Extracorporeal multiorgan support including CO₂-removal with the ADVanced Organ Support (ADVOS) system for COVID-19: A case report

Abstract

A substantial part of COVID-19-patients suffers from multi-organ failure (MOF). We report on an 80-year old patient with pulmonary, renal, circulatory, and hepatic failure. We decided against the use of extracorporeal membrane oxygenation (ECMO) due to old age and a SOFA-score of 13. However, the patient was continuously treated with the extracorporeal multi-organ- “ADVanced Organ Support” (ADVOS) device (ADVITOS GmbH, Munich, Germany). During eight 24h-treatment-sessions blood flow (100–300 mL/min), dialysate flow (160–320 mL/min) and dialysate pH (7.6–9.0) were adapted to optimize arterial PaCO2 and pH. Effective CO2 removal and correction of acidosis could be demonstrated by mean arterial- versus post-dialyzer values of pCO2 (68.7 ± 13.8 vs. 26.9 ± 11.6 mmHg; p < 0.001). The CO2-elimination rate was 48 ± 23mL/min. The initial vasopressor requirement could be reduced in parallel to pH-normalization. Interruptions of ADVOS-treatment repeatedly resulted in reversible deteriorations of paCO2 and pH. After 95 h of continuous extracorporeal decarboxylating therapy the patient had markedly improved circulatory parameters compared to baseline. In the context of secondary pulmonary infection and progressive liver failure, the patient had a sudden cardiac arrest. In accordance with the presumed patient will, we decided against mechanical resuscitation. Irrespective of the outcome we conclude that extracorporeal CO2 removal and multiorgan-support were feasible in this COVID-19-patient. Combined and less invasive approaches such as ADVOS might be considered in old-age-COVID-19 patients with MOF.

The role of the ADVanced Organ Support (ADVOS) system in critically ill patients with multiple organ failure

“…Moreover, the COVID pandemic has accelerated the obtention of results regarding extracorporeal CO 2 removal and lung support. Recent case reports have presented the possibilities of ADVOS in the management of COVID‐related respiratory failure 34,35 . In the case series by Allescher and colleagues, a median CO 2 removal of 49 ml/min was reported using ADVOS with elevated dialysate pH 8.5–9.0, blood flows around 300 ml/min, and regional citrate anticoagulation.…”

“…Extra‐corporeal CO 2 removal with ADVOS has recently been appraised first in a case report and then in a case series with nine COVID‐19 patients. In the case report by Huber and colleagues, an 80‐year‐old male patient with COVID‐19 infection was treated with ADVOS for progressive ARDS and multi‐organ failure characterized by renal dysfunction, septic shock, hepatic injury, and mixed acidosis 34 . ADVOS proved effective at CO 2 removal with mean estimated CO 2 elimination rate of 48 ± 23 ml/min, and significant differences between mean arterial and post‐dialyser pCO 2 (69 ± 14 vs. 27 ± 12 mm Hg, p < 0.001).…”

Registry on extracorporeal multiple organ support with the advanced organ support (ADVOS) system

“…[ 20 , 21 ] A recent publication from his group reported a median CO 2 removal of 48 ml/minutes in a COVID-19 patient with multiple organ failure. [ 33 ]…”

Extracorporeal carbon dioxide removal with the Advanced Organ Support system in critically ill COVID‐19 patients

“…This basic chemical principle, which is also physiologically employed by the kidney for acidosis compensation, 31,32 is the proposed mechanism for CO 2 removal and acid-base balance correction during ADVOS treatments, as described in detail elsewhere. 20,33 Baseline The efficiency of the process was correlated with three major aspects, which had been underlined in previous in vitro analyses 20 : Firstly, the starting CO 2 levels (high levels of CO 2 resulted in a higher removal). Secondly, the dialysate pH setting (the CO 2 removal is more effective with a dialysate pH >8.5) and thirdly, the blood flow (the higher the blood flow the higher the removal).…”

“…3 ), thus supporting the renal compensation of respiratory acidosis. 20,[31][32][33] The question here is to decide whether an AKI diagnosis is necessary if the kidney is not able to provide an adequate renal compensation. Moreover, the need of CO 2 removal is independent of the triggering cause of ARDS.…”