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Extracorporeal Carbon Dioxide Removal

Extracorporeal Carbon Dioxide Removal. Yan Wing Wa Pamela Youde Nethersole Eastern Hospital 4 January 2013. Scopes. What ’ s it? How does it differ from ECMO? Indications Principles Types available AVCO 2 R VVCO 2 R Gas exchange catheter (intracorporeal) Respiratory dialysis.

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Extracorporeal Carbon Dioxide Removal

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  1. Extracorporeal Carbon Dioxide Removal Yan Wing Wa Pamela Youde Nethersole Eastern Hospital 4 January 2013

  2. Scopes • What’s it? • How does it differ from ECMO? • Indications • Principles • Types available • AVCO2R • VVCO2R • Gas exchange catheter (intracorporeal) • Respiratory dialysis

  3. What’s it? • ECMO • Add oxygen to blood + • Remove CO2 from blood • Higher flow needed • O2 is carried mainly through Hb, not plasma • 1.36 x Hb x (SaO2-SvO2) = O2 ml /l blood1.36 x 120 x (1.00 to 0.72) = 46 ml/l blood • One needs ~ 240ml O2 /min  ~ 5 L/min flow

  4. What’s it? • ECCO2R • Lower flow need • CO2 mainly carried by plasma (dissolved bicarbonate) • Linear kinetics without saturation • 1 L blood carry > 500 ml CO2 • CO2 removal rate < 1 L/min blood flow • CO2 diffuses more readily than O2 across extracorporeal membrane

  5. Indications * The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000, 342:1301-1308 #Terragni PP et al, Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal carbon dioxide removal. Anesthesiology 2009, 111:826-835. • ARDS with lung protective ventilation (LPV) • Tidal volume ~6 ml/kg*, • Evidence ~< 4 ml/kg (ultra protective ventilation)# even better than 6 ml/kg • Hypercapnia (Permissive hypercapnia) • Raised ICP • R heart failure • Immunosuppression • Impaired pulmonary epithelial repair • COPD exacerbation or Status Asthmaticus • Bridge to lung transplant

  6. Principles

  7. Membrane Lung • Past: coiled silicon rubber, low efficiency and high resistance • Present: hollow fibre membrane • Microporous polypropylene – plasma leak • Nonporous poly-4-methyl-1-pentene (PMP) • No plasma leak • Efficient with superior gas exchange • inc. biocompatibility

  8. Membrane Lung blood

  9. Membrane Lung • Non-porous PMP membrane • Maquet – Quadrox D • Novalung – iLA membrane ventilator • Medos – hilite 7000 LT • Eurosets – Eurosets ECMO • Terumo – Capiox EBS

  10. Membrane Lung • Coating to improve biocompatibility and decrease clotting • Bioline: Maquet - Quadrox D • Rheoparin: Medos – hilite 7000LT • Carmeda Bioactive Surface: Medtronic • X coating: Terumo – Capiox EBS • Phosphorylcholine: Sorin – Phisio; Euromed -Eurosets

  11. Membrane Lung: Medos hilite 7000LT

  12. Membrane Lung: iLA Membrane Ventilator(Novalung, GmbH, Germany)

  13. Membrane Lung: Maquet Quadrox D

  14. Polyurethane 0.6 m2 PMP membrane 1.8 m2

  15. Pump • Types: • Centrifugal pump • Diagonal pump: centrifugal + axial pump • +/- shaft or bearings • Medtronic – Biomedicus • Impellors suspended by electromagnetic field • Maquet – Rotaflow • Levotronix – Centrimag • Sorin – Cobe-Revolution

  16. Pump

  17. Cannulae Avalon Bicaval Dual Lumen catheter Fr. 20/23/27/31, 31cm jugular Novaport Twin Fr. 18/22, 17cm jugular Fr. 24, 27cm femoral Separate access and return cannulae Dual lumen

  18. Novaport Twin(Novalung GmbH, Germany)

  19. ECCO2R First introduced in 1978 Gattinoni L, Kolobow T, Tomlinson T, Iapichino G, Samaja M, White D, Pierce J; Low-frequency positive pressure ventilation with extracorporeal carbon dioxide removal (LFPPV-ECCO2R): an experimental study. Anesth Analg 1978, 57:470-477

  20. ECCO2R Gattinoni L, Pesenti A, Mascheroni D, Marcolin R, Fumagalli R, Rossi F, Iapichino G, Romagnoli G, Uziel L, Agostoni A, et al.: Low-frequency positivepressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. JAMA 1986, 256:881-886 Brunet F, Mira JP, Belghith M, Monchi M, Renaud B, Fierobe L, Hamy I, Dhainaut JF, Dall’ava-Santucci J: Extracorporeal carbon dioxide removal technique improves oxygenation without causing overinflation. Am J Respir Crit Care Med 1994, 149:1557-1562.

  21. ECCO2R • Morris AH, etal, Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med 1994, 149:295-305 • No survival benefit however, • Very high complication rate, 33% discontinued therapy because of bleeding, 20% because of circuit clotting • VA support for lung failure with high ventilatory tidal volume • some centres lack of experience in ECCO2R therapy

  22. Types of ECCO2R • Arteriovenous CO2 Removal (AVCO2R) • Pumpless Extracorporeal Lung Assist (PECLA) • Venovenous CO2 Removal (VVCO2R) • Typical ECMO set up • ILA Activve • Decap/Decapsmart • Hemolung • Gas-exchange catheter • Respiratory dialysis

  23. AVCO2R or PECLA

  24. AVCO2R or PECLA • Novalung: interventional Lung Assist (iLA) membrane ventilator • Hemodynamic should be stable, with MAP >60mmHg • Risk of distal limb ischemia • Indications • LPV for ALI/ARDS or severe asthmaticus • Bridge to lung transplantation

  25. Venovenous CO2 Removal • VV-ECMO circuit • Even with low flow CO2 removal is adequate • Novalung: iLA Activve

  26. Decap / Decap Smart(Hemodec, Salerno, Italy)

  27. Decap / Decap Smart Terragni PP, Gattinoni L, Ranieri VM et al: Tidal volume lower than 6 ml/kg enhances lung protection: role of extracorporeal carbon dioxide removal. Anesthesiology 2009, 111:826-835 • Allow CO2 removal + RRT • Roller pump + hemofilter & membrane lung connected in series • Infusing Uf back to membrane lung • Inc. membrane lung pressure • Inc. CO2 removal • Smaller lung (0.3 to 1.35 m2) • Neonate Medos Hilite 800 LT • Lower blood flow rate, 300 - 500 ml/min

  28. Hemolung(Alung Technologies, Pittsburgh, USA)

  29. Hemolung Burki N etal: A novel extracoporeal CO2 removal system: application of the hemolung in patients with hypercapnic respiratory failure. Am J Respir Crit Care Med Med 2011, 183:A1697 • Centrifugal pump + membrane lung together • Rotating core impeller pushing blood to the surrounding fibre bundle • Active mixing • CO2 removal is efficient & with smaller area • Blood flow 400 – 600 ml/min • Gas flow to membrane lung is under negative pressure to prevent risk of gas embolism

  30. Gas exchange catheter • Intravenocaval gas exchanger (IVOX) • Hollow fibre (spiral) membrane lung  catheter <15mmф • Intracorporeal catheter in IVC flow 2-3 L/min • Therefore, not flow dependent • Gas flow is applied under negative pressure to prevent gas embolism (in case of fibre breaks) • High complication rate: bleeding & thrombosis • Conflicting clinical results • Facilitated lower ventilator settings in some studies but not all

  31. Hattler catheter(Alung Technologies, Pittsburgh, USA) • ~ IVOX catheter • Hollow fibres bundle ~ 1,000 • + IABP (helium filled balloon) • Active mixing • IVC • 300 beats / min • Efficient CO2 removal

  32. Gas exchange catheters • Dynamic intravascular lung assist device (D-ILAD) • Rotating fibres • May damage vessel wall • Modified Hattler catheter • Balloon replaced by a series of small impellers • CO2 exchange further improved by covalent immobilization of carbonic anhydrase to the surface of membrane fibres (CO2 more readily generated from blood soluble HCO3)

  33. Respiratory dialysis Carbonic anhydrase • Using dialysis to remove CO2 in the form of HCO3 • Easy to remove HCO3 but difficult to maintain pH (hyperchloremic acidosis) • Venous blood contains 52ml CO2/dl blood (within which 65% in plasma fraction) • > 500 ml/min • CO2 +H2O H+ + HCO3-

  34. Respiratory dialysis • ? Rapid conversion of CO2 back to HCO3 • NaOH • Tromethamine (THAM) • Electrolytes, hemolysis, cardiac arrhythmia • Still investigational

  35. Current studies assessed by www.clinicaltrials.gov • Pulmonary And Renal Support During Acute Respiratory Distress Syndrome • Fresenius Multifiltrate Kit 7 CVVH circuit + Medos Hilite 800 LT • France • Extracorporeal CO2 Removal in COPD Exacerbation • Decap Smart • Italy • Flow-flow ECCO2-R and 4 ml/kg Tidal Volume vs. 6 ml/kg Tidal Volume to Enhance Protection From VILI in Acute Lung Injury • Randomized multi-centre trial • D28 ventilator free days • Italy

  36. Thank you.

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