Extracorporeal CO&lt;sub&gt;2&lt;/sub&gt; Removal Integrated within a Continuous Renal Replacement Circuit Offers Multiple Advantages

Redant, Sébastien; Bels, David De; Barbance, Océane; Loulidi, Ghalil; Honoré, Patrick M.

doi:10.1159/000507875

Cited by 5 publications

(13 citation statements)

References 40 publications

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“…Based on that finding, those investigators recommended placing the ECCO 2 R device proximal to the CVVH device based on its higher efficacy of dissolved CO2 removal. Others 12 have recently questioned this contention, stating “there is no demonstrated benefit” of placing the ECCO 2 R device proximal to the CVVH device.…”

Section: Discussionmentioning

confidence: 99%

Modeling acid‐base balance for in‐series extracorporeal carbon dioxide removal and continuous venovenous hemofiltration devices

et al. 2021

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Patients with acute respiratory distress syndrome and acute kidney injury (AKI) treated by kidney replacement therapy may also require treatment with extracorporeal carbon dioxide removal (ECCO2R) devices to permit protective or ultraprotective mechanical ventilation. We developed a mathematical model of acid‐base balance during extracorporeal therapy using ECCO2R and continuous venovenous hemofiltration (CVVH) devices applied in series for the treatment of mechanically ventilated AKI patients. Published data from clinical studies of mechanically ventilated AKI patients treated by CVVH at known infusion rates of substitution fluid without ECCO2R were used to adjust the model parameters to fit plasma levels of arterial partial pressure of carbon dioxide (PaCO2), arterial plasma bicarbonate concentration ([HCO3]), and plasma pH (as well as certain other unmeasured physiological variables). The effects of applying ECCO2R at an unchanged and a reduced tidal volume on PaCO2, [HCO3] and plasma pH were then simulated assuming carbon dioxide removal rates from the ECCO2R device measured in the clinical studies. Agreement of such model predictions with clinical data was good whether the ECCO2R device was positioned proximal or distal to the CVVH device in the extracorporeal circuit. Although carbon dioxide removal rates from the ECCO2R device measured in one previous clinical study were higher when it was placed proximal to the CVVH device, suggesting that such in‐series positioning was optimal, the current mathematical model demonstrates that proximal positioning of the ECCO2R device also results in lower bicarbonate (and, therefore, total carbon dioxide) removal from the distal CVVH device. Thus, the removal of total carbon dioxide by such extracorporeal circuits is relatively independent of the position of the in‐series devices. It is concluded that the described mathematical model has quantitative accuracy; these results suggest that the overall acid‐base balance when using ECCO2R and CVVH devices in a single extracorporeal circuit will be similar, independent of their in‐series position.

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Section: Discussionmentioning

confidence: 99%

Modeling acid‐base balance for in‐series extracorporeal carbon dioxide removal and continuous venovenous hemofiltration devices

et al. 2021

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“…Furthermore, given the high rate of acute renal failure in patients with respiratory failure, a modular extracorporeal technique to provide simultaneous respiratory and renal organ support would be of great clinical relevance. The integration of ECCO 2 R and continuous renal replacement therapy (CRRT) in one device has already been reported and clinically applied (23)(24)(25)(26)(27)(28)(29)(30)(31). Nevertheless, the currently available devices combining the two therapies only provide limited CO 2 removal and clinical efficacy, especially when regional citrate anticoagulation is applied and the blood flow is reduced (24,29,32,33).…”

Section: E469mentioning

confidence: 99%

“…The integration of ECCO 2 R and continuous renal replacement therapy (CRRT) in one device has already been reported and clinically applied (23)(24)(25)(26)(27)(28)(29)(30)(31). Nevertheless, the currently available devices combining the two therapies only provide limited CO 2 removal and clinical efficacy, especially when regional citrate anticoagulation is applied and the blood flow is reduced (24,29,32,33). An enhanced CO 2 removal could allow achieving high CO 2 extraction combined with regional anticoagulation.…”

Section: E469mentioning

confidence: 99%

A Minimally Invasive and Highly Effective Extracorporeal CO2 Removal Device Combined With a Continuous Renal Replacement Therapy

Zanella

Pesenti

Busana

et al. 2022

Critical Care Medicine

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OBJECTIVES:Extracorporeal carbon dioxide removal is used to treat patients suffering from acute respiratory failure. However, the procedure is hampered by the high blood flow required to achieve a significant CO 2 clearance. We aimed to develop an ultralow blood flow device to effectively remove CO 2 combined with continuous renal replacement therapy (CRRT).DESIGN: Preclinical, proof-of-concept study.SETTING: An extracorporeal circuit where 200 mL/min of blood flowed through a hemofilter connected to a closed-loop dialysate circuit. An ion-exchange resin acidified the dialysate upstream, a membrane lung to increase Pco 2 and promote CO 2 removal. PATIENTS: Six, 38.7 ± 2.0-kg female pigs. INTERVENTIONS:Different levels of acidification were tested (from 0 to 5 mEq/ min). Two l/hr of postdilution CRRT were performed continuously. The respiratory rate was modified at each step to maintain arterial Pco 2 at 50 mm Hg. MEASUREMENTS AND MAIN RESULTS:Increasing acidification enhanced CO 2 removal efficiency of the membrane lung from 30 ± 5 (0 mEq/min) up to 145 ± 8 mL/min (5 mEq/min), with a 483% increase, representing the 73% ± 7% of the total body CO 2 production. Minute ventilation decreased accordingly from 6.5 ± 0.7 to 1.7 ± 0.5 L/min. No major side effects occurred, except for transient tachycardia episodes. As expected from the alveolar gas equation, the natural lung Pao 2 dropped at increasing acidification steps, given the high dissociation between the oxygenation and CO 2 removal capability of the device, thus Pao 2 decreased. CONCLUSIONS:This new extracorporeal ion-exchange resin-based multipleorgan support device proved extremely high efficiency in CO 2 removal and continuous renal support in a preclinical setting. Further studies are required before clinical implementation.

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“…In a recently published consensus, 40 A clever approach is to apply ECCO 2 R and CRRT integrating both extracorporeal circuits. 4,41 Fourth-generation CRRT machines 1 are prepared for this strategy and the stewardship of a dedicated perfusionist is not required. Recently, Jonckheer et al, demonstrated that RCA for CRRT is not associated with worsening in PaCO 2 , since CO 2 generated in the Krebs cycle from citrate metabolism is rapidly swept from the blood during its passage through the dialyzer.…”

Section: E X Tr Acorp Ore Al C Arbon Dioxide Removalmentioning

confidence: 99%

“…As a means to provide ultra-protective ventilation, 39,40 extracorporeal carbon dioxide removal (ECCO 2 R) was started using a combined ECCO 2 R-CRRT system. 4,41 The dialysis membrane applied was able to remove both cytokines and endotoxins. [42][43][44][45] In parallel and through another venous access, hemoperfusion for endotoxin removal [46][47][48][49][50] was carried out for 2 h, followed by hemoperfusion for cytokine removal [51][52][53] for 12 h, in two consecutive days.…”

mentioning

confidence: 99%

Continuous renal replacement therapy and extended indications

Ronco

Reis

2021

Seminars in Dialysis

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Initially developed to replace kidney function in severely ill newborns/infants, and then diverted to severely ill adult patients, 1 continuous renal replacement therapy (CRRT) is now applied to support different organs apart from the kidney in a myriad of clinical conditions such as sepsis, 2 acute liver failure (ALF), 3 acute respiratory distress syndrome (ARDS), 4-6 and cardiogenic shock. 7 The extended indications for CRRT and the concept of sequential extracorporeal therapies 8 are intrinsically related. The individualization of care and selection of treatment candidates based on clinical and molecular phenotypes increases the probability of benefit for each of the proposed blood purification techniques 9-15 (Figure 1).In sepsis, the removal of damage-associated molecular patterns (e.g. cytokines) and pathogen-associated molecular patterns (e.g. endotoxins) might reduce the burden of the disease. 16 In liver failure, CRRT reduces the risk of ammonia-related neurotoxicity while artificial liver support systems effectively reduce bilirubin and bile acids concentrations. 3 In ARDS, extracorporeal CO 2 removal (ECCO 2 R) allows the application of ultra-protective ventilation avoiding deleterious consequences of hypercapnia and reducing the risk of ventilator-associated lung injury. [17][18][19] In cardiogenic shock and cardiac surgery in which shifts in fluid balance are poorly tolerated, CRRT might mitigate further myocardial damage. 20,21

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Extracorporeal CO<sub>2</sub> Removal Integrated within a Continuous Renal Replacement Circuit Offers Multiple Advantages

Cited by 5 publications

References 40 publications

Modeling acid‐base balance for in‐series extracorporeal carbon dioxide removal and continuous venovenous hemofiltration devices

Modeling acid‐base balance for in‐series extracorporeal carbon dioxide removal and continuous venovenous hemofiltration devices

A Minimally Invasive and Highly Effective Extracorporeal CO2 Removal Device Combined With a Continuous Renal Replacement Therapy

Continuous renal replacement therapy and extended indications

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