Scientific Letter
Extracorporeal CO2 removal in combination with continuous renal replacement therapy
Sistema combinado de depuración de CO
Marta López-Sánchez
, M. Isabel Rubio-López
Corresponding author
Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain
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Isabel Rubio-López" "autores" => array:2 [ 0 => array:4 [ "nombre" => "Marta" "apellidos" => "López-Sánchez" "email" => array:1 [ 0 => "marta.lopezs@scsalud.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "M. Isabel" "apellidos" => "Rubio-López" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Marqués de Valdecilla, Santander, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sistema combinado de depuración de CO" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Extracorporeal carbon dioxide removal (ECCO<span class="elsevierStyleInf">2</span>R) systems are devices that provide partial respiratory support. They work with a blood flow of 250–1500<span class="elsevierStyleHsp" style=""></span>ml/min, less than that required for extracorporeal membrane oxygenation (ECMO), and use a smaller membrane surface (0.33–0.67<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>). This system was first described in the 1980s by Gattinoni et al.,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> while in 1990, Terragni et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> published the first combined ECCO<span class="elsevierStyleInf">2</span>R system. Using a neonatal membrane lung with a total membrane surface of 0.33<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> coupled with a continuous hemofiltration system in 32 patients with acute respiratory distress syndrome, they succeeded in reducing tidal volume (Vt) to less than 6<span class="elsevierStyleHsp" style=""></span>ml/kg ideal weight, achieving normalization of hypercapnia and a reduction of cytokines in bronchoalveolar lavage at 72<span class="elsevierStyleHsp" style=""></span>h, reflecting a reduction in mechanical ventilator-induced lung injury.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In patients with acute respiratory distress syndrome, these systems remove CO<span class="elsevierStyleInf">2</span>, allowing Vt to be reduced, so that protective or ultraprotective mechanical ventilation (MV) (Vt<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>6<span class="elsevierStyleHsp" style=""></span>ml/kg or Vt 3–4<span class="elsevierStyleHsp" style=""></span>ml/kg, respectively) can be efficiently applied. These findings have been demonstrated in a recent international multicenter prospective study.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> A greater reduction in Vt and plateau pressure would prevent alveolar overdistension, reduce mechanical ventilator-induced lung injury, and may reduce mortality in patients with acute respiratory distress syndrome.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> These systems have several potential indications in hypercapnic patients.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a> In COPD, they could help avoid the use of MV, act as an alternative if non-invasive MV fails, or facilitate extubation.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> In the bridge to lung transplant, they can improve physical conditions, obviating the complications derived from MV.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Several ECCO<span class="elsevierStyleInf">2</span>R systems are available, most of which are of the veno-venous type.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The use of this system combined with continuous renal replacement techniques (CRRT) has been shown to decrease vasopressor requirements,<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> in addition to sparing vascular access.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We report a case in which we used a combined ECCO<span class="elsevierStyleInf">2</span>R-CRRT system, describe the effects, and discuss the most important technical aspects.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Our patient was a 61-year-old woman admitted for an asthma exacerbation with progressive hypercapnia, who was intubated and connected to MV. On admission to the ICU, she had a pressure plateau of 35 cmH<span class="elsevierStyleInf">2</span>O and a peak pressure of 52 cmH<span class="elsevierStyleInf">2</span>O. Arterial blood gases with inspired oxygen fraction of 0.4 showed pH 7.3, PaCO<span class="elsevierStyleInf">2</span> 120<span class="elsevierStyleHsp" style=""></span>mmHg, PaO<span class="elsevierStyleInf">2</span> 96<span class="elsevierStyleHsp" style=""></span>mmHg, bicarbonate 28.1<span class="elsevierStyleHsp" style=""></span>mmol/l, base deficit −7<span class="elsevierStyleHsp" style=""></span>mmol/l, and oxygen saturation 98%. She developed acute renal failure with urea 107<span class="elsevierStyleHsp" style=""></span>mg/dl and creatinine 1.36<span class="elsevierStyleHsp" style=""></span>mg/dl.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Antibiotic therapy, both empirical and targeted at pulmonary aspergillosis, was started, and she received corticosteroids, salbutamol, ipratropium, ketamine, and magnesium. MV was optimized by starting ECMO with ultraprotective MV, which was withdrawn on day 11. After 1 week, the patient’s status deteriorated, with pH 7.32; PaCO<span class="elsevierStyleInf">2</span>, 83<span class="elsevierStyleHsp" style=""></span>mmHg; PaO<span class="elsevierStyleInf">2</span>, 181<span class="elsevierStyleHsp" style=""></span>mmHg; and bicarbonate, 37<span class="elsevierStyleHsp" style=""></span>mmol/l. A 13.5 Fr femoral Shaldon catheter was inserted for a combined ECCO<span class="elsevierStyleInf">2</span>R-CRRT system, with an 0.9 m<span class="elsevierStyleSup">2</span> AN69 hemofilter, and CO<span class="elsevierStyleInf">2</span> membrane lung with surface area of 0.32 m<span class="elsevierStyleSup">2</span>, blood flow of 350<span class="elsevierStyleHsp" style=""></span>ml/min, air 10<span class="elsevierStyleHsp" style=""></span>l/min, and anticoagulation with sodium heparin for an activated partial thromboplastin time (aPTT) of 2.1. After starting therapy, respiratory acidosis was corrected, with development of respiratory alkalosis after effective reduction of PaCO<span class="elsevierStyleInf">2</span> to 30<span class="elsevierStyleHsp" style=""></span>mmHg in the first 3<span class="elsevierStyleHsp" style=""></span>h, allowing us to start protective MV with a Vt of 5<span class="elsevierStyleHsp" style=""></span>ml/kg and PEEP 8 cmH<span class="elsevierStyleInf">2</span>O. In the following hours, blood flow was reduced to 300<span class="elsevierStyleHsp" style=""></span>ml/min due to the development of alkalosis, and the fraction of inspired oxygen was reduced. Despite aPTT remaining within a good range, the hemofilter clotted at 24<span class="elsevierStyleHsp" style=""></span>h, so the system had to be removed. The patient died in the following 24<span class="elsevierStyleHsp" style=""></span>h due to severe global respiratory failure caused by pulmonary aspergillosis and septic shock, after ruling out the reintroduction of extracorporeal respiratory support systems, although no complications derived from the use of the system were observed.</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the case described, CO<span class="elsevierStyleInf">2</span> removal was effective in the first hour, with maximum effect at 3<span class="elsevierStyleHsp" style=""></span>h, but effectiveness was later lost due to hemofilter clotting. It is important to emphasize that ECCO<span class="elsevierStyleInf">2</span>R systems contribute only marginally to the improvement of oxygenation by several mechanisms.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The diffusing capacity of CO<span class="elsevierStyleInf">2</span> is 20 times higher than that of oxygen, and these systems are theoretically able to eliminate 200–250<span class="elsevierStyleHsp" style=""></span>ml/min of CO<span class="elsevierStyleInf">2</span> in an adult with a flow of 500<span class="elsevierStyleHsp" style=""></span>ml/min.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> Hypercapnia should be corrected slowly<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> to avoid secondary alkalosis, as occurred in our case.</p><p id="par0040" class="elsevierStylePara elsevierViewall">The main determining factor in CO<span class="elsevierStyleInf">2</span> removal is airflow: up to a maximum of 10<span class="elsevierStyleHsp" style=""></span>l/min is recommended for most devices.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a> However, blood flow has also been studied as a related factor, and some authors determine that it should be increased in cases of severe respiratory acidosis (pH<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>7.2).<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">13,14</span></a> The membrane surface area seems to play a less critical role in CO<span class="elsevierStyleInf">2</span> clearance, although a membrane of 0.8<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> proved more effective than one of 0.4<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> in a bovine animal model.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The surface area of our polymethylpentene membrane was 0.32<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>, similar to that used by Terragni et al.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">These ECCO<span class="elsevierStyleInf">2</span>R-CRRT systems can provide respiratory support alone, or both respiratory and renal support. This is important, because 60% of patients who suffer multiple organ failure and require MV also develop acute renal failure. In these patients, volume overload and increased alveolar permeability derived from acute renal failure negatively affect the lungs and, similarly, MV and biotrauma diminish renal function.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Systemic anticoagulation is needed to maintain the whole system (hemofilter and ECCO<span class="elsevierStyleInf">2</span>R), maintaining an aPTT ratio of 1.5–2 to balance the risk of bleeding and/or clotting. In our case, clotting of the hemofilter (but not of the membrane lung) occurred after 24<span class="elsevierStyleHsp" style=""></span>h despite maintaining aPTT within the range, and this limited treatment. This complication has been previously described and may be related to the hemofilter surface.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> Clotting of the membrane lung occurs in 14%–16.7% of cases.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,10,11</span></a> These thrombotic complications in veno-venous ECCO<span class="elsevierStyleInf">2</span>R systems are the most feared, since they require the system to be changed, or treatment to be discontinued, as in our case.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In summary, this combined ECCO<span class="elsevierStyleInf">2</span>R-TRRC system at a flow of less than 400<span class="elsevierStyleHsp" style=""></span>ml/min was very effective for CO<span class="elsevierStyleInf">2</span> removal, but limited by rapid clotting of the hemofilter.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: López-Sánchez M, Rubio-López MI. Sistema combinado de depuración de CO<span class="elsevierStyleInf">2</span> y reemplazo renal continuo. Arch Bronconeumol. 2019;55:665–666.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Low-frequency positive-pressure ventilation with extracorporeal CO<span class="elsevierStyleInf">2</span> removalin severe acute respiratory failure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Gattinoni" 1 => "A. Pesenti" 2 => "D. Mascheroni" 3 => "R. Marcolin" 4 => "R. Fumagalli" 5 => "F. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 6 | 3 | 9 |
| 2024 October | 73 | 20 | 93 |
| 2024 September | 58 | 17 | 75 |
| 2024 August | 75 | 32 | 107 |
| 2024 July | 61 | 28 | 89 |
| 2024 June | 69 | 40 | 109 |
| 2024 May | 105 | 27 | 132 |
| 2024 April | 50 | 31 | 81 |
| 2024 March | 68 | 22 | 90 |
| 2024 February | 39 | 25 | 64 |
| 2024 January | 3 | 0 | 3 |
| 2023 December | 12 | 2 | 14 |
| 2023 November | 15 | 1 | 16 |
| 2023 October | 8 | 2 | 10 |
| 2023 September | 16 | 5 | 21 |
| 2023 August | 2 | 0 | 2 |
| 2023 July | 10 | 0 | 10 |
| 2023 June | 8 | 0 | 8 |
| 2023 May | 3 | 0 | 3 |
| 2023 April | 11 | 1 | 12 |
| 2023 March | 27 | 7 | 34 |
| 2023 February | 74 | 17 | 91 |
| 2023 January | 39 | 46 | 85 |
| 2022 December | 67 | 33 | 100 |
| 2022 November | 53 | 21 | 74 |
| 2022 October | 65 | 38 | 103 |
| 2022 September | 63 | 30 | 93 |
| 2022 August | 55 | 48 | 103 |
| 2022 July | 47 | 45 | 92 |
| 2022 June | 42 | 43 | 85 |
| 2022 May | 52 | 32 | 84 |
| 2022 April | 53 | 33 | 86 |
| 2022 March | 35 | 36 | 71 |
| 2022 February | 42 | 34 | 76 |
| 2022 January | 44 | 31 | 75 |
| 2021 December | 41 | 48 | 89 |
| 2021 November | 4 | 0 | 4 |
| 2020 April | 1 | 0 | 1 |
| 2020 March | 13 | 0 | 13 |
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