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Crititcal Care Combined Conference Dialysis in Patients with Respiratory Acidosis

Crititcal Care Combined Conference Dialysis in Patients with Respiratory Acidosis. R4 陳秉民 / VS 吳允升. Underlying Disease. 1.Chronic respiratory failure status post ETT + MV (2012/3/15~03/28), with difficult weaning, s/p tracheostomy(2012/3/28-) 2.Bronchiolitis obliterans

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Crititcal Care Combined Conference Dialysis in Patients with Respiratory Acidosis

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  1. Crititcal Care Combined Conference Dialysis in Patients with Respiratory Acidosis R4 陳秉民 / VS 吳允升

  2. Underlying Disease 1.Chronic respiratory failure status post ETT + MV (2012/3/15~03/28), with difficult weaning, s/p tracheostomy(2012/3/28-) 2.Bronchiolitis obliterans 3.Non-tuberculous mycobacteria infection, treated 4.Peripheral T-cell lymphoma, status post auto-PBSCT, R/T, with transformation to precursor T-lymphobalstic lymphoma/leukemia, status post induction chemotherapy with OPDL, status post Allo-sibling PBSCT, with graft-versus-host disease

  3. History • 29F • 2002/11 Left submandibular LAP, progressed • 2002/03 Core biopsy: peripheral T-cell lymphoma • Partial tonsillectomy • 2013/06 CHOP for six cycles • 2003/10/1 Auto-PBSCT • 2003/12 Radiotherapy 300cGy/15 fractions

  4. History • 2008/06 Submental triangle 1cm small mass • 2008/07 Transformation to precursor T-lymphobalstic lymphoma/leukemia • 2008/07 Induction chemotherapy with OPDL • 2008/12 Consolidation IV C2 • Intrathecal chemotherapy with MTX, Ara-C, Decadron • 2009/02 Allo-sibling matched PBSCT • Donor lymphocyte infusion *5 on 2009/3/9, 4/9, 5/6, 6/4, 7/2

  5. History • 2009/07 Itchy rash from back to extremities: GVHD, skin grade 2 • 2009/12 Dry cough, dyspnea developed. Lung function test: Severe obstructive disease. • 2011 /03 Progressive deterioration: CO2 retentionat 60~ 90mmHg • 2011/03/06 Intermittent BiPAP • Diagnosis: Brochiolitis obliererans • 2011/11 Lung Transplantation evaluation • Sputum culture: Mycobacterium avium intracellulare complex  2012/01/04 Treatment for NTM: Ebutol, Rifampin, Klaricid

  6. History • 2012/03 Dyspnea, persisted despite changing BiPAP setting • 2012/03/15 Hypercapnic respiratory failure ETT +MV • 2012/03/28 Tracheostomy • 2012/03 ~ 05 ICU and RCC admission • Failure to wean off ventilator • 2012/5/25 Discharge with home ventilator

  7. History • 2012/12 Dyspnea persisted with CO2 retention noted on OPD follow-up 7.315/123.6/104.5/ 63.5/37.1 Admitted to 3A2 ICU • AFS: negative *3 • Start lung transplantation evaluation • Persisted CO2 retention noted • 2013/1/11 • ABG 7.193/155.4/77.0/60.2/31.8 • VA-ECMO inserted  transfer to SICU for further treatment

  8. History • 2013/01~ 04 Control infection • 2013/04/04 Bilateral lung transplant + pulmonary reduction surgery (donor right lower lobectomy + left upper lung wedge resection) • Ischemic time: right 342 mins, left 474 mins • Blood loss 16000mL

  9. History • Decreased U/O, fluid overload after massive transfusion • BW 59.4Kg (4/3)  65.4Kg (4/5) • U/O 2390 (4/4)  690 (4/5) 580 (4/6) • FiO2 60~ 80% • 4/6~ 4/13 CAVH U/O 150 ~250mL/day BW 53.9Kg (4/14) • 4/14 Improving AKI, increase U/O

  10. History • 2013/04 Persistent low tidal volume noted <200mL • 2013/04/30 Chest CT RML lobar consolidation, bilateral patchy consolidations Intensive chest care, rehabiliation

  11. History • No obvious improvement • Foamy sputum noted on bronchoscopy, suspect lung edema • BW 59.4Kg (4/3)  53.9Kg (4/14)  52.3Kg (5/7) • Start HD for dry lung • U/O 2120mL (5/6)  1110mL (5/7)  310mL (5/8) < 50mL/day • 5/14 BW 49.5Kg

  12. History • 5/12 BW 48.2Kg • Daily dialysis • 5/6 ~ 6/11

  13. DiscussionAcute Hypercapnic Respiratory Failure Asscociated with Hemodilaysis

  14. IntradialyticHypercapnicRespiratory Failure • 44M • End stage renal disease, HD 4 years, unknown etiology • Severe obese DW 139Kg • Hypertension • Congestive heart failure • LFT: moderate restrictive pattern FVC 62% and FEV 1 /FVC 0.84 • Cardiac echo: dilated hypokinetic left ventricle with left ventricular hypertrophy, enlarged left atrium and calcified mitral annulus Am J Nephrol 2001 Sep-Oct;21(5):383-5

  15. IntradialyticHypercapnicRespiratory Failure • CHF, lung edema, pneumonia admitted to ICU • 1st HD: Bicarbonate 25 Metabolic acidosis • 2nd HD: Bicarbonate 30 • Respiratory acidosis Am J Nephrol 2001 Sep-Oct;21(5):383-5

  16. 66.7 67.2 63 56.6 49.3 pH 7.19 HCO3 - 21 HCO3 – 21.2 pH 7.175 HCO3 – 17.5 Am J Nephrol 2001 Sep-Oct;21(5):383-5

  17. Intradialytic Hypercapnic Respiratory Failure • Dialysate Bicarbonate 25 for 1week Pre-dialysis respiratory status improved (PCO2 40 mm Hg) Metabolic acidosis (pH 7.27, HCO3 17.9mEq/l) • Dialysate Bicarbonate 30 • Small increase in serum bicarbonate 2.5 mEq/l (17.2–19.7 mEq/l) Am J Nephrol 2001 Sep-Oct;21(5):383-5

  18. Intradialytic Hypercapnic Respiratory Failure • Dialysate bicarbonate 25 mEq/L : exacerbation of metabolic acidosis • Higher dialysate bicarbonate 30 mEq/L: Increase in PCO2 level. Am J Nephrol 2001 Sep-Oct;21(5):383-5

  19. Acute Hypercapnic Respiratory Failure Associated With Hemodialysis Dialysis & Transplantation 2011; 40(2), 83–85

  20. Acute Hypercapnic Respiratory Failure Associated With Hemodialysis Acute raise in blood pH : hypoventilation, respiratory depression Dialysis & Transplantation 2011; 40(2), 83–85

  21. Acute Hypercapnic Respiratory Failure Associated With Hemodialysis Alkalosis: vasoconstriction shift oxygen dissociation curve to the left. Impairing hemoglobin’s ability to release oxygen. Dialysis & Transplantation 2011; 40(2), 83–85

  22. Acute Hypercapnic Respiratory Failure Associated With Hemodialysis Abrupt reduction H+ Reduce ionized Calcium  functional hypocalcemiaNeuromuscular impairment Diaphragmatic muscle weakness. Dialysis & Transplantation 2011; 40(2), 83–85

  23. Intradialytic Hypercapnic Respiratory Failure • Vigilant and individualized dialysis prescriptions for kidney failure patients with severe pulmonary dysfunction. Am J Nephrol 2001 Sep-Oct;21(5):383-5 Dialysis & Transplantation 2011; 40(2), 83–85

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