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Safety and efficacy of extracorporeal CO2 removal combined with continuous renal replacement therapy in patients presenting both acute respiratory distress syndrome and acute kidney injury

Introduction

Pulmonary overdistension has been observed in 33% of patients with acute respiratory distress syndrome (ARDS) despite low tidal volume (6 ml/kg ideal body weight) ventilation [1]. Tidal volume (VT) reduction from 6 to 4 ml/kg attenuates overdistension but is associated with hypercarbia [2]. We thought to combine extracorporeal CO2 removal (ECCO2R) with continuous renal replacement therapy (CRRT) through the insertion of an oxygenator membrane within the hemofiltration circuit in patients presenting both ARDS and acute kidney injury (AKI).

Methods

A first set of measurement was performed at 6 ml/kg before and after ECCO2R. Twenty minutes later, VT was reduced to 4 ml/kg for the remainder of the study period (72 hours). Ventilator settings were those of the ARMA trial. The CRRT mode was hemofiltration with 33% of predilution. Ultrafiltration was adjusted to achieve a filtration fraction of 15%. Sweep gas flow was constant at 8 l/minute. The primary endpoint was a 20% reduction of PaCO2 at 20 minutes after initiation of ECCO2R.

Results

Eight patients were studied. Age was 69 ± 11 years, SAPS II was 68 ± 9 and SOFA score was 13 ± 4 at inclusion. Blood flow, at the inlet of the oxygenator membrane, was 400 ± 4 ml/minute. CO2 removal rate was 84 ± 4 ml/minute. Initiating ECCO2R, at 6 ml/kg, induced a mean PaCO2 reduction of 17% (41 ± 5.5 to 33.9 ± 5.6 mmHg, P < 0.001). Then, lowering the VT to 4 ml/kg induced a mean PaCO2 increase of 25% (33.9 ± 5.6 to 42.6 ± 8 mmHg) and a mean PaO2/FIO2 ratio increase of 8% (176 ± 63 to 190 ± 61). Minute ventilation decrease from 7.4 ± 1.6 to 5 ± 1.2 l/minute. Respiratory system compliance did not vary. No major complications were observed.

Conclusion

Combining ECCO2R and CRRT in patients with ARDS and AKI is safe and feasible through the insertion of an oxygenator membrane within a RRT circuit.

References

  1. 1.

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Allardet-Servent, J., Castanier, M., Signouret, T. et al. Safety and efficacy of extracorporeal CO2 removal combined with continuous renal replacement therapy in patients presenting both acute respiratory distress syndrome and acute kidney injury. Crit Care 19, P275 (2015). https://doi.org/10.1186/cc14355

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Keywords

  • Tidal Volume
  • Acute Kidney Injury
  • Acute Respiratory Distress Syndrome
  • Continuous Renal Replacement Therapy
  • Ideal Body Weight