Management of severe ARDS due to SARS-CoV-2 pneumonia using low-flow extracorporeal CO2 extraction,Critical Care

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Management of severe ARDS due to SARS-CoV-2 pneumonia using low-flow extracorporeal CO2 extraction
Critical Care ( IF 15.1 ) Pub Date : 2021-10-18 , DOI: 10.1186/s13054-021-03777-1
Rosario Molina Lobo _{1,

2} , Beatriz Lobo-Valbuena _{1,

2} , Federico Gordo _{2,

3}

Affiliation

Extracorporeal CO₂ extraction (ECCO₂R) is a technique that uses an extracorporeal device to extract excess CO₂ from the blood by passing it through an air exchange membrane using low blood flows and requiring systemic anticoagulation for its use. The main technical difference with extracorporeal membrane oxygenation system (ECMO) is the reduced blood flow (between 300 and 500 ml/min), achieving the elimination of most of the CO₂ produced by metabolism, thanks to the greater solubility of this gas in plasma.

This technique emerged from the need to decouple the oxygenation support from the ventilation support provided by ECMO with the main objective of optimising lung protection during mechanical ventilation (MV) [1]. There is currently no strong evidence regarding the benefit provided by the use of ECCO₂R in this clinical context [2].

We present a series of 8 cases of patients with severe global respiratory failure due to COVID-19, admitted in ICU between December 2020 and May 2021. Regarding patients’ characteristics, we highlight mean values of ICU stay of 45.8 days (± standard deviation 15.8), PaFi of 75.1 (± 10.4) and pH 7.25 (± 0.03), despite endotracheal intubation (ETI) and protective MV with Pplat 29.1 (± 1.61). Prone position was necessary in all cases, both before and after ECCO₂R placement. The mean number of days in prone position prior to ECCO₂R was 3.75 days (± 1.08). Mean number of days from the start of ETI to the start of ECCO₂R was 14.5 days, PaO2/FiO2 of 75.1 and SOFA score 6.6. Transfer to ECMO was not possible in any of the 8 cases, following to the current recommendations of the receiving centres [3].

All cases had positive SARS-CoV-2 polymerase-chain-reaction detection and severe respiratory failure without severe dysfunction of other organs or documented infections.

During ICU admission, selected patients presented persistent hypoxaemia and hypercapnia refractory to lung protective measures (TV 6–8 ml/kg, Pplat < 30) and proning. ECCO₂R support was considered then, preserving the level of lung protection and correcting the expected deterioration of ventilation with worsening respiratory acidosis obtained after achieving an increase in PEEP. Our objectives were also to decrease Pplat in a range of less than 28, to decrease respiratory rate under 25 bpm and to decrease TV (under 7 ml/kg).

Table 1 shows the respiratory status prior to initiation of therapy, and Table 2 shows the results obtained 12–24 h after initiation of the ECCO₂R.

Table 1 Characteristics

Full size table

Table 2 Data before and after 24-h initiating ECCO₂R

Full size table

The therapeutic objectives of ProLUNG® (blood flow 400 ml/min and air flow 15 L/min), with a rise in pH (7.32–7.35), were achieved in the first 12 h of treatment. Results are shown in Table 2. Regarding technical complications, thrombocytopenia not induced by heparin was observed in one of the cases, requiring withdrawal of treatment after 5 days.

Regarding the outcome data on the ECCO₂R device, the mean duration of therapy was 5.25 days, with a mean blood flow of 400 ml/min and air flow of 12 lpm. Fifty percentage of the patients survived, with an ICU discharge of 25 days (average value) after disconnection from the ECCO₂R. Case number 8 died within a day after removal of the CO₂ extractor.

These cases, as in previous studies, show us the possible usefulness of applying ECCO₂R based on individual clinical and physiological criteria [4], without development of serious complications, although other known published series report relevant complications [5].

ECCO₂R system could be applied as a tool to optimise the degree of lung protection, essential in patients with severe ARDS. In our experience, ECCO₂R is a simple and feasible therapeutic option for patients with severe respiratory diseases in whom conventional treatment has been maximised. Further studies are needed to strengthen the scientific evidence in this context [6].

All data generated or analysed during this study are included in this published article.

1.
Combes A, Auzinger G, Capellier G, et al. ECCO2R therapy in the ICU: consensus of a European round table meeting. Crit Care. 2020;24:490. https://doi.org/10.1186/s13054-020-03210-z.
Article PubMed PubMed Central Google Scholar
2.
Combes A, Schmidt M, Hodgson CL, et al. Extracorporeal life support for adults with acute respiratory distress syndrome. Intensive Care Med. 2020;46:2464–76. https://doi.org/10.1007/s00134-020-06290-1.
CAS Article PubMed Google Scholar
3.
https:www.care-statement.org
4.
Romay E, Ferre R. Eliminación extracorpórea de CO2: fundamentos fisiológicos y técnicos y principales indicaciones. Medicina Intensiva. 2016;40(1):33–8. https://doi.org/10.1016/j.medin.2015.06.001.
CAS Article PubMed Google Scholar
5.
Combes A, Fanelli V, Pham T, et al. Feasibility and safety of extracorporeal CO2 removal to enhance protective ventilation in acute respiratory distress syndrome: the SUPERNOVA study. Intensive Care Med. 2019;45:592–600. https://doi.org/10.1007/s00134-019-05567-4.
Article PubMed Google Scholar
6.
Kearsley R, Daly Guris R, Miles LF, Shelton CL. Case reports in the COVID-19 pandemic: first responders to an emergency in evidence-based medicine. Anaesthesia Rep. 2021;9(1):1–7. https://doi.org/10.1002/anr3.12088.
Article Google Scholar

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We would like to thank all clinical members of the ICU team at H.U del Henares, who actively helped gather the data for the present article.

No financial support was required for the study. Financial support will be available in case of publication (through Fundación para la Investigación e Innovación Biomédica of Hospital Universitario Infanta Sofia and Hospital Universitario del Henares; Director: Marta Neira Álvarez).

Affiliations

Intensive Care Unit. Hospital Universitario del Henares, Coslada-Madrid, Spain
Rosario Molina Lobo & Beatriz Lobo-Valbuena
Grupo de Investigación en Patología Crítica, Facultad de Ciencias de La Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain
Rosario Molina Lobo, Beatriz Lobo-Valbuena & Federico Gordo
Intensive Care Unit Head of Department, Hospital Universitario del Henares, Coslada, Madrid, Spain
Federico Gordo

Authors

Rosario Molina LoboView author publications
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Beatriz Lobo-ValbuenaView author publications
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Contributions

RML did investigation, writing original draft; BLV was involved in writing—reviewing and editing. FG performed methodology, project administration, supervision and validation. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Federico Gordo.

Ethical approval and consent to participate

Informed consent from patients or family member for the inclusion of medical data in our prospective ICU Registry was obtained. This study was conducted in accordance with the amended Declaration of Helsinki. Local institutional review boards and independent ethics committees (Healthcare Ethics Committee of the Francisco de Vitoria University) approved the protocol, and written informed consent was obtained from all patients.

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Consent for publication was forwarded by next of akin / family member through informed consent.

Competing interests

Authors declare no potential financial or ethical conflicts of interest.

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Molina Lobo, R., Lobo-Valbuena, B. & Gordo, F. Management of severe ARDS due to SARS-CoV-2 pneumonia using low-flow extracorporeal CO₂ extraction. Crit Care 25, 362 (2021). https://doi.org/10.1186/s13054-021-03777-1

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Received: 18 June 2021
Accepted: 29 September 2021
Published: 18 October 2021
DOI: https://doi.org/10.1186/s13054-021-03777-1

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Keywords

ARDS
Coronavirus infection
Respiratory failure
Extracorporeal circulation
Patient outcome assessment

中文翻译：

使用低流量体外 CO2 提取管理由 SARS-CoV-2 肺炎引起的严重 ARDS

体外 CO ₂提取 (ECCO ₂ R) 是一种使用体外装置通过使用低血流量的空气交换膜从血液中提取过量 CO ₂并需要全身抗凝才能使用的技术。与体外膜肺氧合系统 (ECMO) 的主要技术区别是血流量减少（300 至 500 毫升/分钟），由于这种气体在血浆中的溶解度更大，因此可以消除代谢产生的大部分 CO ₂ .

该技术的出现源于需要将 ECMO 提供的通气支持与氧合支持分离，其主要目标是优化机械通气 (MV) 期间的肺保护 [1]。目前没有强有力的证据表明在这种临床背景下使用 ECCO ₂ R 所提供的益处[2]。

我们展示了一系列 8 例因 COVID-19 导致严重全身性呼吸衰竭的患者，他们在 2020 年 12 月至 2021 年 5 月期间入住 ICU。关于患者的特征，我们强调了 ICU 住院天数的平均值为 45.8 天（± 标准差 15.8 )，PaFi 为 75.1 (± 10.4) 和 pH 7.25 (± 0.03)，尽管气管插管 (ETI) 和保护性 MV 与 Pplat 29.1 (± 1.61)。在所有情况下，无论是放置ECCO ₂ R之前还是之后，都需要俯卧位。ECCO ₂ R之前俯卧位的平均天数为 3.75 天 (± 1.08)。从 ETI 开始到 ECCO ₂开始的平均天数R 为 14.5 天，PaO2/FiO2 为 75.1，SOFA 评分为 6.6。根据接收中心的当前建议 [3]，在 8 个病例中的任何一个都无法转移到 ECMO。

所有病例均呈阳性 SARS-CoV-2 聚合酶链反应检测和严重呼吸衰竭，无其他器官严重功能障碍或有感染记录。

在入住 ICU 期间，部分患者出现持续性低氧血症和高碳酸血症，对肺保护措施（TV 6-8 ml/kg，Pplat < 30）和俯卧撑无效。然后考虑支持ECCO ₂ R，以保持肺保护水平并纠正在实现 PEEP 增加后呼吸性酸中毒恶化的预期通气恶化。我们的目标也是将 Pplat 降低到小于 28 的范围，将呼吸频率降低到 25 bpm 以下并降低 TV（低于 7 ml/kg）。

表 1 显示了开始治疗前的呼吸状态，表 2 显示了开始 ECCO ₂ R后 12-24 小时获得的结果。

表 1 特性

全尺寸表

表 2 启动 ECCO ₂ R前后 24 小时的数据

全尺寸表

ProLUNG® 的治疗目标（血流量 400 毫升/分钟和空气流量 15 升/分钟）在治疗的前 12 小时内实现，pH 值升高（7.32-7.35）。结果见表2。关于技术并发症，其中1例出现非肝素引起的血小板减少症，需在5天后停药。

关于 ECCO ₂ R 设备的结果数据，平均治疗持续时间为 5.25 天，平均血流量为 400 毫升/分钟，空气流量为 12 lpm。50% 的患者存活，在与 ECCO ₂ R断开连接后 ICU 出院时间为 25 天（平均值）。病例 8 在移除 CO ₂提取器后一天内死亡。

这些案例与之前的研究一样，向我们展示了根据个体临床和生理标准应用 ECCO ₂ R的可能有用性[4]，而不会出现严重并发症，尽管其他已知的已发表系列报告了相关并发症 [5]。

ECCO ₂ R 系统可用作优化肺保护程度的工具，这对严重 ARDS 患者至关重要。根据我们的经验，ECCO ₂ R 是一种简单可行的治疗选择，适用于常规治疗已最大化的严重呼吸系统疾病患者。需要进一步研究以加强这方面的科学证据[6]。

本研究期间生成或分析的所有数据都包含在这篇已发表的文章中。

1.
Combes A、Auzinger G、Capellier G 等。ICU 中的 ECCO2R 治疗：欧洲圆桌会议的共识。暴击护理。2020；24:490。https://doi.org/10.1186/s13054-020-03210-z。
文章 PubMed PubMed Central Google Scholar
2.
Combes A、Schmidt M、Hodgson CL 等。成人急性呼吸窘迫综合征的体外生命支持。重症监护医学。2020；46：2464-76。https://doi.org/10.1007/s00134-020-06290-1。
CAS 文章 PubMed Google Scholar
3.
https:www.care-statement.org
4.
Romay E, Ferre R. Eliminación extracorpórea de CO2：fundamentos fisiológicos y técnicos y principales indicaciones。重症医学。2016;40(1):33-8。https://doi.org/10.1016/j.medin.2015.06.001。
CAS 文章 PubMed Google Scholar
5.
Combes A、Fanelli V、Pham T 等。体外 CO2 去除以增强急性呼吸窘迫综合征保护性通气的可行性和安全性：SUPERNOVA 研究。重症监护医学。2019；45：592-600。https://doi.org/10.1007/s00134-019-05567-4。
文章 PubMed Google Scholar
6.
Kearsley R、Daly Guris R、Miles LF、Shelton CL。COVID-19 大流行中的病例报告：循证医学紧急情况的第一响应者。麻醉代表 2021；9(1):1-7。https://doi.org/10.1002/anr3.12088。
文章谷歌学术

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我们要感谢 HU del Henares ICU 团队的所有临床成员，他们积极帮助收集本文的数据。

该研究不需要财政支持。出版时将获得财政支持（通过Fundación para la Investigación e Innovación Biomédica of Hospital Universitario Infanta Sofia 和 Hospital Universitario del Henares；主任：Marta Neira Álvarez）。

隶属关系

重症监护室。Hospital Universitario del Henares, Coslada-Madrid, 西班牙
罗萨里奥·莫利纳·洛博和比阿特丽斯·洛博-瓦尔布埃纳
Grupo de Investigación en Patología Crítica, Facultad de Ciencias de La Salud, Universidad Francisco de Vitoria, Pozuelo de Alarcón, 马德里, 西班牙
罗萨里奥·莫利纳·洛博、比阿特丽斯·洛博-瓦尔布埃纳和费德里科·戈多
西班牙马德里科斯拉达 Universitario del Henares 医院重症监护室主任
费德里科·戈多

作者

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贡献

RML做了调查，写了原稿；BLV 参与了写作——审查和编辑。FG 执行方法论、项目管理、监督和验证。所有作者阅读并认可的终稿。

通讯作者

与费德里科·戈多的通信。

道德批准和同意参与

获得了患者或家属的知情同意，同意将医疗数据纳入我们的前瞻性 ICU 登记处。本研究是根据修订后的赫尔辛基宣言进行的。当地机构审查委员会和独立伦理委员会（Francisco de Vitoria 大学医疗伦理委员会）批准了该方案，并获得了所有患者的书面知情同意。

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出版同意书由近亲/家庭成员通过知情同意转发。

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Molina Lobo, R.、Lobo-Valbuena, B. 和 Gordo, F. 使用低流量体外 CO ₂提取管理由 SARS-CoV-2 肺炎引起的严重 ARDS 。暴击护理 25, 362 (2021)。https://doi.org/10.1186/s13054-021-03777-1

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