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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

Extracorporeal Carbon Dioxide Removal

Yan Wing Wa

Pamela Youde Nethersole Eastern Hospital

4 January 2013

scopes
Scopes
  • What’s it?
    • How does it differ from ECMO?
  • Indications
  • Principles
  • Types available
    • AVCO2R
    • VVCO2R
    • Gas exchange catheter (intracorporeal)
    • Respiratory dialysis
what s it
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
what s it1
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
indications
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
membrane lung
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
membrane lung2
Membrane Lung
  • Non-porous PMP membrane
    • Maquet – Quadrox D
    • Novalung – iLA membrane ventilator
    • Medos – hilite 7000 LT
    • Eurosets – Eurosets ECMO
    • Terumo – Capiox EBS
membrane lung3
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
slide15

Polyurethane

0.6 m2

PMP membrane 1.8 m2

slide16
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
cannulae
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

ecco 2 r
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

ecco 2 r1
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.

ecco 2 r2
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
types of ecco 2 r
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
avco 2 r or pecla1
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
venovenous co 2 removal
Venovenous CO2 Removal
  • VV-ECMO circuit
    • Even with low flow CO2 removal is adequate
  • Novalung: iLA Activve
decap decap smart
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
hemolung
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
gas exchange catheter
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
hattler catheter alung technologies pittsburgh usa
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
gas exchange catheters
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)
respiratory dialysis
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-
respiratory dialysis1
Respiratory dialysis
  • ? Rapid conversion of CO2 back to HCO3
    • NaOH
    • Tromethamine (THAM)
  • Electrolytes, hemolysis, cardiac arrhythmia
  • Still investigational
current studies assessed by www clinicaltrials gov
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