ecmo/ecco2r in acute respiratory failure...influence of sweep gas flow schmidt et al, intensive care...
TRANSCRIPT
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ECMO/ECCO2R in Acute Respiratory Failure
Alain Combes, MD, PhDCardiology Institute, Hôpital Pitié-Salpêtrière, AP-HP
Inserm UMRS 1166, iCAN, Institute of Cardiometabolism and Nutrition
Sorbonne Pierre et Marie Curie University, Paris, [email protected]
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Conflict of interest
• Principal Investigator: EOLIA trial• VV ECMO in ARDS• NCT01470703 • Sponsored by MAQUET, Getinge Group
• Received honoraria for lectures from • MAQUET, XENIOS, BAXTER
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ECMO/ECCO2RThe rationale…For ARDS patients…To decrease the intensity of MV?
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The evolving paradigm…• ARDSnet strategy might not protect against tidal hyperinflation
• When Pplat remains >28-30 cm H2O • Further decrease of Vt to reduce VILI
• From 6 to <2 ml/kg IBW• To decrease Pplat <25 cm H2O• To decrease ∆P < 12-14 cm H2O• With sufficient PEEP to prevent lung derecruitment?
• To decrease RR to <20… <15… <10?????• Extracorporeal gas exchange for
• Blood Oxygenation/Decarboxylation• Decrease the intensity of MV…
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What areECMO and ECCO2R?Same Technology
Different Objectives…
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Membrane lung O2/CO2 transfer
O2 transferCO2 transfer
ECMO for oxygenation
ECCO2R for Decarboxylation
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Influence of ECMO flow
Schmidt et al, Intensive Care Med, 2013
Adequate Oxygenation
Qecmo > 60% Qco
PaO2 mmHg
SaO2, %
PaCO2 mmHg
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Influence of Sweep Gas Flow
Schmidt et al, Intensive Care Med, 2013
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ECMO and ECCO2R
ECMO• Large cannulas
• High extracorporeal flow• >5000 ml/min
• Large membrane oxygenator
• Full blood oxygenation
• Full blood decarboxylation
• High technicity, ECMO center
ECCO2R• Double lumen catheter• Low flow, respiratory dialysis
• 250-1000 ml/min
• Medium size oxygenator• No blood oxygenation• Partial blood
decarboxylation• Regular ICU
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ECMO and ECCO2R…What is the Evidence?
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Results of series of VV-ECMO in ARDS patients
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The CESAR trial
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• UK, 2001-2006
• ECMO provided only at the Glenfield Hospital, Leicester
• Entry criteria:
• Adult patients (18-65 years) • Severe, but potentially reversible ARDS• Murray score ≥3.0, or • Uncompensated hypercapnia: pH <7.20
• Primary outcome measure
• Death or severe disability 6 months
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Time from randomization to death
Log rank p = 0.03
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17 (25%)
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Et al…
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Et al…
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• The French REVA Registry collected data of patients hospitalized in ICUs
• For H1N1-associated ARDS
• Analysis of factors associated with death among 123 patients who received ECMO
• Case-control study with matching on a propensity score to receive ECMO
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Why early ECMO?
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0
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MV <7 days before ECMO
MV >7 days before ECMO
P <0.005, log-rank
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0 0
Driving Pressure Tidal Volume Plateau Pressure
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Results ECCO2R seriesin ARDS patients
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40 ECCO2R Strategy
39 Conventional Strategy
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A Strategy of UltraProtective lung ventilation
With Extracorporeal CO2 Removal for
New-Onset moderate to seVere ARDS
The SUPERNOVA trial
Pilot feasibility and safety studyMarco Ranieri and Alain Combes, on behalf of
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Flow chart
95 in the analysis
MAQUET
N=28
NOVALUNG
N=34
ALUNG
N=33
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AT ENROLLMENT
• 95 patients in 7 countries• Belgium, Canada, France,
Italy, Germany, Netherlands, Spain
• 23 centers
• 3 [1-5] patients per center
• Male: 67%
• Age: 60±14
• SAPS II: 45.9 ±15.5
• SOFA: 7.4 ±3.2
• Bilateral opacities: 92 (97%)
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Cause of ARDS (%)
0
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50
Pneumonia(bacterial)
Pneumonia(Flu)
Inhalation Otherpneumonia
Nonplumonary
sepsis
Pancreatitis Pulmonarycontusion
Extra-corporalcirculation
Other
82%
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During run-in time (2 hrs)• Minute ventilation: 10.3±2.5
• VT: 6.1±0.7 (387.4±72.6)
• RR: 27.2±5.3
• PEEP: 12.1±4.3
• PIP: 34.6±7.0
• Pplat: 26.2±5.2
• DELTA P: 13.2±5.1
• FiO2: 60 [50-70]
• PF: 153±40
• pH: 7.3±0.1
• PCO2: 47.5±7.9
• Bicarbonate: 25.6±4.7
• Lactate: 1.6±1.1
• HR:92.3±21.8
• MAP: 76.5±11.4
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Tidal Volume
98% REACHED THE TARGET OF4.0 ml/kg (+/- 20%)
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PplatPplat decreased:
From 26±5 to 23±3, p<0.0173% had a decreased Pplat
Percentage of decrease: -11% [-20 to 0]
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PEEPPEEP INCREASED:
From 12±4 to 14±4cmH2O,p<0.01(29±58 % baseline vs. 4 ml/Kg)
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Driving PressureDeltaP decreased:
from 13±5 to 9±4 cmH2O, p<0.0133±16 % baseline vs. 4 ml/Kg
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PaCO2
NO SIGNIFICANT CHANGES
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pH
NO SIGNIFICANT CHANGES
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PaO2/FiO2
NO SIGNIFICANT CHANGES
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Survival at D28
69/95 = 73%
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Probability of being on ECCO2R
ECCOR duration: 5 [3-8] days
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Serious adverse events
2 patients• HEMORRAGIC SHOCK RELATED TO AN ARTERIAL
BLEEDING IN THE CAECUM, NO SURGERY BECAUSE OF THE LACK OF RESPIRATORY IMPROVEMENT IN THE LAST 3 WEEKS, MINIMAL DOSES OF ANTICOAGULATION BUT POSSIBLE PLATELETS DYSFUNCTION RELATED TO ECCOR
• CEFOTAXIM BLOOD LEVEL < 0,1 MG/ML
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Device-related mechanical events
• PUMP CLOTTING: N=6• Change circuit ECCO2R n=1• Discontinue ECCO2R N=5
• DERECRUITMENT/HYPOXIA: N=2 • Increased VT
• HEMOLYSIS: N=3• HEMORRHAGE AT CANNULA INSERTION POINT: N=4• PNEUMOTHORAX: N=1• HYPOTHERMIA: N=1
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“In God we (may) trust; all others
must bring data…”W. Edwards Deming
(1900-1993)
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EOLIA: ECMO to rescue Lung Injury in severe ARDS
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EOLIA: ECMO to rescue Lung Injury in severe ARDS
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EOLIA… A new trial of ECMO
for severe ARDS249 patients randomized…
YESWECAN
YESWECAN
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A Strategy of UltraProtective lung ventilation
With Extracorporeal CO2 Removal for
New-Onset moderate to seVere ARDS
The SUPERNOVA trial
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