Validation of RESP and PRESERVE score for ARDS patients with pumpless Extracorporeal Lung Assist (pECLA)

Abstract Background: RESP score and PRESERVE score have been validated for veno-venous Extracorporeal Membrane Oxygenation in severe ARDS to assume individual mortality risk. ARDS patients with low-flow Extracorporeal Carbon Dioxide Removal, especially pumpless Extracorporeal Lung Assist, have also a high mortality rate, but there are no validated specific or general outcome scores. Methods: In a retrospective single center cohort study we calculated and evaluated RESP, PRESERVE, and SOFA score for 73 ARDS patients with pumpless Extracorporeal Lung Assist. Additionally, demographic data and hospital mortality as well as ventilator settings, hemodynamic parameters, and blood gas measurement before and during extracorporeal therapy were recorded. Results: Pumpless Extracorporeal Lung Assist of mechanical ventilated ARDS patients resulted in an optimized lung protective ventilation, significant reduction of PaCO2, and compensation of acidosis. Scoring showed a mean score of alive versus deceased patients of 3 ± 1 versus -1 ± 1 for RESP (p < 0.01), 3 ± 0 versus 6 ± 0 for PRESERVE (p < 0.05) and 8 ± 1 versus 10 ± 1 for SOFA (p < 0.05). Using receiver operating characteristic curves, area under the curve (AUC) was 0.78 (95 % confidence interval (CI) 0.67 – 0.89, p < 0.01) for RESP score, 0.80 (95 % CI 0.70 – 0.90, p < 0.0001) for PRESERVE score and 0.66 (95 % CI 0.53 – 0.79, p < 0.05) for SOFA score. Conclusions: RESP and PRESERVE scores were superior to SOFA, as non-specific critical care score. Although scores were developed for veno-venous ECMO, we could validate RESP and PRESERVE score for pumpless Extracorporeal Lung Assist. In conclusion, RESP and PRESERVE score are suitable to estimate mortality risk of ARDS patients with an arterio-venous pumpless Extracorporeal Carbon Dioxide Removal.

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Validation of RESP and PRESERVE score for ARDS patients with pumpless Extracorporeal Lung Assist (pECLA)

10.21203/rs.2.17989/v2 ◽

2020 ◽

Author(s):

Jan Petran ◽

Thorsten Muelly ◽

Rolf Dembinski ◽

Niklas Steuer ◽

Jutta Arens ◽

...

Keyword(s):

Carbon Dioxide ◽

Mortality Risk ◽

Sofa Score ◽

Carbon Dioxide Removal ◽

Low Flow ◽

Risk Scores ◽

Lung Protective Ventilation ◽

Extracorporeal Carbon Dioxide Removal ◽

Extracorporeal Lung Assist ◽

Pumpless Extracorporeal Lung Assist

Abstract Background RESP score and PRESERVE score have been validated for veno-venous Extracorporeal Membrane Oxygenation in severe ARDS to assume individual mortality risk. ARDS patients with low-flow Extracorporeal Carbon Dioxide Removal, especially pumpless Extracorporeal Lung Assist, have also a high mortality rate, but there are no validated specific or general outcome scores. This retrospective study tested whether these established specific risk scores can be validated for pumpless Extracorporeal Lung Assist in ARDS patients in comparison to a general organ dysfunction score, the SOFA score. Methods In a retrospective single center cohort study we calculated and evaluated RESP, PRESERVE, and SOFA score for 73 ARDS patients with pumpless Extracorporeal Lung Assist treated between 2002 and 2016 using the XENIOS iLA Membrane Ventilator. 6 patients had a mild, 40 a moderate and 27 a severe ARDS according to the Berlin criteria. Demographic data and hospital mortality as well as ventilator settings, hemodynamic parameters, and blood gas measurement before and during extracorporeal therapy were recorded. Results Pumpless Extracorporeal Lung Assist of mechanical ventilated ARDS patients resulted in an optimized lung protective ventilation, significant reduction of PaCO2, and compensation of acidosis. Scoring showed a mean score of alive versus deceased patients of 3 ± 1 versus -1 ± 1 for RESP (p < 0.01), 3 ± 0 versus 6 ± 0 for PRESERVE (p < 0.05) and 8 ± 1 versus 10 ± 1 for SOFA (p < 0.05). Using receiver operating characteristic curves, area under the curve (AUC) was 0.78 (95 % confidence interval (CI) 0.67 – 0.89, p < 0.01) for RESP score, 0.80 (95 % CI 0.70 – 0.90, p < 0.0001) for PRESERVE score and 0.66 (95 % CI 0.53 – 0.79, p < 0.05) for SOFA score. Conclusions RESP and PRESERVE scores were superior to SOFA, as non-specific critical care score. Although scores were developed for veno-venous ECMO, we could validate RESP and PRESERVE score for pumpless Extracorporeal Lung Assist. In conclusion, RESP and PRESERVE score are suitable to estimate mortality risk of ARDS patients with an arterio-venous pumpless Extracorporeal Carbon Dioxide Removal.

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Validation of RESP and PRESERVE score for ARDS patients with pumpless Extracorporeal Lung Assist (pECLA)

10.21203/rs.2.17989/v3 ◽

2020 ◽

Author(s):

Jan Petran ◽

Thorsten Muelly ◽

Rolf Dembinski ◽

Niklas Steuer ◽

Jutta Arens ◽

...

Keyword(s):

Carbon Dioxide ◽

Mortality Risk ◽

Sofa Score ◽

Carbon Dioxide Removal ◽

Low Flow ◽

Risk Scores ◽

Lung Protective Ventilation ◽

Extracorporeal Carbon Dioxide Removal ◽

Extracorporeal Lung Assist ◽

Pumpless Extracorporeal Lung Assist

Abstract Background RESP score and PRESERVE score have been validated for veno-venous Extracorporeal Membrane Oxygenation in severe ARDS to assume individual mortality risk. ARDS patients with low-flow Extracorporeal Carbon Dioxide Removal, especially pumpless Extracorporeal Lung Assist, have also a high mortality rate, but there are no validated specific or general outcome scores. This retrospective study tested whether these established specific risk scores can be validated for pumpless Extracorporeal Lung Assist in ARDS patients in comparison to a general organ dysfunction score, the SOFA score.Methods In a retrospective single center cohort study we calculated and evaluated RESP, PRESERVE, and SOFA score for 73 ARDS patients with pumpless Extracorporeal Lung Assist treated between 2002 and 2016 using the XENIOS iLA Membrane Ventilator. 6 patients had a mild, 40 a moderate and 27 a severe ARDS according to the Berlin criteria. Demographic data and hospital mortality as well as ventilator settings, hemodynamic parameters, and blood gas measurement before and during extracorporeal therapy were recorded.Results Pumpless Extracorporeal Lung Assist of mechanical ventilated ARDS patients resulted in an optimized lung protective ventilation, significant reduction of PaCO2, and compensation of acidosis. Scoring showed a mean score of alive versus deceased patients of 3 ± 1 versus -1 ± 1 for RESP (p < 0.01), 3 ± 0 versus 6 ± 0 for PRESERVE (p < 0.05) and 8 ± 1 versus 10 ± 1 for SOFA (p < 0.05). Using receiver operating characteristic curves, area under the curve (AUC) was 0.78 (95 % confidence interval (CI) 0.67 – 0.89, p < 0.01) for RESP score, 0.80 (95 % CI 0.70 – 0.90, p < 0.0001) for PRESERVE score and 0.66 (95 % CI 0.53 – 0.79, p < 0.05) for SOFA score. Conclusions RESP and PRESERVE scores were superior to SOFA, as non-specific critical care score. Although scores were developed for veno-venous ECMO, we could validate RESP and PRESERVE score for pumpless Extracorporeal Lung Assist. In conclusion, RESP and PRESERVE score are suitable to estimate mortality risk of ARDS patients with an arterio-venous pumpless Extracorporeal Carbon Dioxide Removal.

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Carbon dioxide removal using low bicarbonate dialysis in rodents

Perfusion ◽

10.1177/0267659119839284 ◽

2019 ◽

Vol 34 (7) ◽

pp. 578-583 ◽

Cited By ~ 3

Author(s):

Lien H Vu ◽

John A Kellum ◽

William J Federspiel ◽

Matthew E Cove

Keyword(s):

Carbon Dioxide ◽

In Vitro Study ◽

Blood Gases ◽

Carbon Dioxide Removal ◽

Low Flow ◽

Sprague Dawley ◽

Bicarbonate Concentration ◽

Extracorporeal Carbon Dioxide Removal ◽

Arterial Ph

Background: Extracorporeal carbon dioxide removal may be used to manage hypercapnia, but compared to dialysis, it’s not widely available. A recent in vitro study showed that dialysis with low bicarbonate dialysates removes CO2. Objective: To show that bicarbonate dialysis removes CO2 in an animal model to validate in-vitro findings and quantify the effect on arterial pH. Methods: Male Sprague-Dawley hypercapnic rats were dialyzed with either a conventional dialysate (PrismasolTM) or a bicarbonate-free dialysate (Bicarb0). The effect of dialysis on standard blood gases and electrolytes was measured. Results: Partial pressure of CO2 and bicarbonate concentration in blood decreased significantly after exposure to Bicarb0 compared to PrismasolTM (filter outflow values 12.8 vs 81.1 mmHg; p < 0.01 for CO2 and 3.5 vs 22.0 mmol/L; p < 0.01 for bicarbonate). Total CO2 content of blood was reduced by 459 mL/L during dialysis with Bicarb0 (filter inflow 546 ± 91 vs filter outflow 87 ± 52 mL/L; p < 0.01), but was not significantly reduced with PrismasolTM. Conclusions: Bicarbonate dialysis removes CO2 at rates comparable to existing low-flow ECCO2R.

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Noninvasive ventilation and low-flow veno-venous extracorporeal carbon dioxide removal as a bridge to lung transplantation in a child with refractory hypercapnic respiratory failure due to bronchiolitis obliterans*

Pediatric Critical Care Medicine ◽

10.1097/pcc.0b013e3181b0123b ◽

2010 ◽

Vol 11 (1) ◽

pp. e8-e12 ◽

Cited By ~ 15

Author(s):

Andrea Moscatelli ◽

Giancarlo Ottonello ◽

Laura Nahum ◽

Elisabetta Lampugnani ◽

Franco Puncuh ◽

...

Keyword(s):

Carbon Dioxide ◽

Respiratory Failure ◽

Lung Transplantation ◽

Noninvasive Ventilation ◽

Bronchiolitis Obliterans ◽

Carbon Dioxide Removal ◽

Low Flow ◽

Extracorporeal Carbon Dioxide Removal ◽

Hypercapnic Respiratory Failure

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Regional Blood Acidification Enhances Extracorporeal Carbon Dioxide Removal

Anesthesiology ◽

10.1097/aln.0000000000000099 ◽

2014 ◽

Vol 120 (2) ◽

pp. 416-424 ◽

Cited By ~ 29

Author(s):

Alberto Zanella ◽

Paolo Mangili ◽

Sara Redaelli ◽

Vittorio Scaravilli ◽

Marco Giani ◽

...

Keyword(s):

Carbon Dioxide ◽

Blood Flow ◽

Lactic Acid ◽

Blood Flow Rate ◽

Carbon Dioxide Removal ◽

Low Flow ◽

Extracorporeal Carbon Dioxide Removal ◽

Membrane Lung ◽

Extracorporeal Blood ◽

Patients At Risk

Abstract Background: Extracorporeal carbon dioxide removal has been proposed to achieve protective ventilation in patients at risk for ventilator-induced lung injury. In an acute study, the authors previously described an extracorporeal carbon dioxide removal technique enhanced by regional extracorporeal blood acidification. The current study evaluates efficacy and feasibility of such technology applied for 48 h. Methods: Ten pigs were connected to a low-flow veno-venous extracorporeal circuit (blood flow rate, 0.25 l/min) including a membrane lung. Blood acidification was achieved in eight pigs by continuous infusion of 2.5 mEq/min of lactic acid at the membrane lung inlet. The acid infusion was interrupted for 1 h at the 24 and 48 h. Two control pigs did not receive acidification. At baseline and every 8 h thereafter, the authors measured blood lactate, gases, chemistry, and the amount of carbon dioxide removed by the membrane lung (VCO2ML). The authors also measured erythrocyte metabolites and selected cytokines. Histological and metalloproteinases analyses were performed on selected organs. Results: Blood acidification consistently increased VCO2ML by 62 to 78%, from 79 ± 13 to 128 ± 22 ml/min at baseline, from 60 ± 8 to 101 ± 16 ml/min at 24 h, and from 54 ± 6 to 96 ± 16 ml/min at 48 h. During regional acidification, arterial pH decreased slightly (average reduction, 0.04), whereas arterial lactate remained lower than 4 mEq/l. No sign of organ and erythrocyte damage was recorded. Conclusion: Infusion of lactic acid at the membrane lung inlet consistently increased VCO2ML providing a safe removal of carbon dioxide from only 250 ml/min extracorporeal blood flow in amounts equivalent to 50% production of an adult man.

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Update on extracorporeal carbon dioxide removal: a comprehensive review on principles, indications, efficiency, and complications

Perfusion ◽

10.1177/0267659120906048 ◽

2020 ◽

Vol 35 (6) ◽

pp. 492-508

Author(s):

Thomas Staudinger

Keyword(s):

Carbon Dioxide ◽

Carbon Dioxide Removal ◽

Low Flow ◽

Chronic Obstructive ◽

Extracorporeal Carbon Dioxide Removal ◽

Obstructive Pulmonary Disease ◽

Blood Flows ◽

Non Invasive ◽

Non Invasive Ventilation ◽

Exchange Membrane

Technology: Extracorporeal carbon dioxide removal means the removal of carbon dioxide from the blood across a gas exchange membrane without substantially improving oxygenation. Carbon dioxide removal is possible with substantially less extracorporeal blood flow than needed for oxygenation. Techniques for extracorporeal carbon dioxide removal include (1) pumpless arterio-venous circuits, (2) low-flow venovenous circuits based on the technology of continuous renal replacement therapy, and (3) venovenous circuits based on extracorporeal membrane oxygenation technology. Indications: Extracorporeal carbon dioxide removal has been shown to enable more protective ventilation in acute respiratory distress syndrome patients, even beyond the so-called “protective” level. Although experimental data suggest a benefit on ventilator induced lung injury, no hard clinical evidence with respect to improved outcome exists. In addition, extracorporeal carbon dioxide removal is a tool to avoid intubation and mechanical ventilation in patients with acute exacerbated chronic obstructive pulmonary disease failing non-invasive ventilation. This concept has been shown to be effective in 56-90% of patients. Extracorporeal carbon dioxide removal has also been used in ventilated patients with hypercapnic respiratory failure to correct acidosis, unload respiratory muscle burden, and facilitate weaning. In patients suffering from terminal fibrosis awaiting lung transplantation, extracorporeal carbon dioxide removal is able to correct acidosis and enable spontaneous breathing during bridging. Keeping these patients awake, ambulatory, and breathing spontaneously is associated with favorable outcome. Complications: Complications of extracorporeal carbon dioxide removal are mostly associated with vascular access and deranged hemostasis leading to bleeding. Although the spectrum of complications may differ, no technology offers advantages with respect to rate and severity of complications. So called “high-extraction systems” working with higher blood flows and larger membranes may be more effective with respect to clinical goals.

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