• Aucun résultat trouvé

CO2 removal: Is a new simplified device could extended the indications?

N/A
N/A
Protected

Academic year: 2021

Partager "CO2 removal: Is a new simplified device could extended the indications?"

Copied!
3
0
0

Texte intégral

(1)

HAL Id: hal-01760110

https://hal.umontpellier.fr/hal-01760110

Submitted on 7 Nov 2018

HAL is a multi-disciplinary open access

archive for the deposit and dissemination of

sci-entific research documents, whether they are

pub-lished or not. The documents may come from

teaching and research institutions in France or

abroad, or from public or private research centers.

L’archive ouverte pluridisciplinaire HAL, est

destinée au dépôt et à la diffusion de documents

scientifiques de niveau recherche, publiés ou non,

émanant des établissements d’enseignement et de

recherche français ou étrangers, des laboratoires

publics ou privés.

CO2 removal: Is a new simplified device could extended

the indications?

Laurent Papazian, Samir Jaber

To cite this version:

Laurent Papazian, Samir Jaber. CO2 removal: Is a new simplified device could extended the

indi-cations?. Anaesthesia Critical Care & Pain Medicine, Elsevier Masson, 2015, 34 (3), pp.131 - 132.

�10.1016/j.accpm.2015.03.001�. �hal-01760110�

(2)

CO

2

removal:

Is

a

new

simplified

device

could

extended

the

indications?

Inthepresentissueofthejournal,Godetetal.[1]reportedinan invivoanimalstudyincluding15pigs,thesafetyandfeasibilityuse ofadevicebasedonaPrismaflex1

platforminremovingCO2from

theblood,thus decreasingPaCO2andacidosis hypercapnia.The

technique wasbased on a standard renal replacement therapy (RRT)platform(Prismaflex1

)thatcanbeeasilyimplementedon existing devices. This strategy used a novel stand alone gas exchangerkitincorporatingahollowfiberchamberwithoutany RRThemofilter.Although,theauthorsevaluatedtheeffectsona shorttermperiod(lessthan2hours)andreportedtheefficiencyby decreasingbloodCO2,theeffectsonalongtermperiodshouldbe

evaluatedinbothanimalandhumanfuturestudiesespeciallyin non-healthylungs.

Invasivemechanicalventilationislifesavingforpatientswith acuterespiratorydistresssyndrome(ARDS).However,weknow forabout30yearsthatpositivepressuremechanicalventilationis abletocreatelunginjuriesandtoworsenpreviouslunginjuries (ventilator-inducedlunginjury;VILI).TominimizetheseVILI,itis generallyrecommendedlimitingtidalvolume(VT)to6mL/kgof predictedbodyweightandplateaupressurelessthan30cmH2O.

However, evidence is accumulating that it may not be fully protectiveagainstVILIandthelesspositivepressureventilationis given,thelessVILIarecreated.ThepricetopaythislimitedVTisa reduction of minute ventilation even if respiratory rate is increased,leadingarespiratoryhypercapniasocalled‘‘permissive hypercapnia’’. The first extracorporeal CO2 removal (ECCO2R)

devicesweredesigned40yearsago.Thetechniqueneverentered into clinical practice, probably because high blood flows were necessary,extracorporealcircuits werenot biocompatible,large catheterswereusedandfullanticoagulationwasrequired.

ECCO2Riscapableofeliminatingatleast50%ofthecalculated

CO2production,withrapidnormalizationofrespiratoryacidosis.

Thishasledtotheattemptofthistechniqueinpatientspresenting withacutehypercapnicrespiratoryfailure(COPDpatients,bridge totransplantlungpatients)[2].ECCO2Rsystemsarenowproposed

toreduceinvasiveness ofmechanicalventilationand, therefore, VILIinARDSpatients[3–7].

Theoldersystemsweredrivenbythearterio-venouspressure gradient; thus, cannulation of an arterial vessel (usually the femoral artery) was necessary for driving the system. Recent pump-drivenveno-venoussystems havebeendesignedandare able to improve respiratory acidosis without requiring arterial cannulation.There arealsosomeattempts toadaptcontinuous renal replacementdevices tobe able toclear CO2 by specially

designedfilters.Clinicalexperiencesuggeststhathighflowrates areneededtocorrectsevererespiratoryacidosis(pH<7.2).Inthis

regard,thephysiologicalrelationshipsbetweencannulasize,blood flow,sweepgasflowandgastransfercapacity,respectively,still remainlargelyunknown.Forthisreason,morephysiologicaldata on these issues are needed before the promising technique of miniaturizedveno-venous ECCO2Rcanbetested inrandomized

controlledtrials(RCTs)aimingtoevaluatethepossiblebeneficial clinicalimpact.Recently,aporcinestudy[7]indicatedthat pump-driven veno-venous ECCO2R required a blood flow of 750 to

1000mL/mintonormalizepHvaluesandreducePaCO2insevere

life-threatening respiratory acidosis under constant ventilatory support. Therefore,usinglow-diametercathetersandlow blood flowrates, pump-drivenveno-venous ECCO2Rmaybeprimarily

feasible inpatients withmild tomoderate respiratoryacidosis. This may be aimed at reducing aggressiveness of invasive ventilation in patients with ARDS. Recently Grasso et al. [6]

showedthattheuseofECCO2Rpermittedtoreducerespiratory

rate from 30 to 14 breaths/min while removing 39% of CO2

production.Interestinglysomecytokines(interleukin-6andtumor necrosis factor-

a

) concentrations were significantly lower in plasma and in bronchoalveolar lavage, suggesting that ECCO2R

isalsocapabletolimitbiotrauma.

Sinceintensivecarespecialistsarefamiliarwithhemodialysis catheters, it is necessary to test whether these catheters also qualify for ECCO2R. The maximal blood flow through these

catheters is usually restricted to approximately 400mL/min. Furthermore, catheters specificallydesigned for ECCO2R aimto

avoidrecirculation(PCO2ofthevenousblood,whichisdirected

towardstheoxygenator,islowerthanarterialPCO2).Recirculation

wasobviouswhenhemodialysiscatheterswereused,evenwith low bloodflow[7].Recirculationhasnotbeenevaluatedinthe Godetetal.study[1].

Using a pumplessextracorporeallungassist, Beinet al.’s[4]

randomized79ARDSpatientswereenrolledtoreceivealowVT ventilation(3mL/kg)combinedwithextracorporealCO2

elimina-tion,ortoaARDS-Netstrategy(6mL/kg)withoutthe extracorpo-realdevice.Ventilator-freedays(VFD)within60 dayswerenot different between the two groups. However, in the more hypoxemicpatients(PaO2/FIO2<150mmHg)VFD-60washigher

intheECCO2Rgroupsuggestingthatnexttrialsshouldfocusonthis

moderatetosevereARDSgroup[4].

TheconceptofECCO2Revolved inresponsetoearlytrials of

ECMOwherethehighincidenceofadverseeventsandmechanical complicationsrelegatedthetherapytoonlythesickestofpatients as a last ditch effort [4,8,9]. Furthermore, the high cost and complexityoftheextracorporealmembraneoxygenation(ECMO) systems limited their use to a small number of high volume

(3)

specializedmedicalfacilities.Asthetechnologyandunderstanding ofextracorporealgasexchangehasimproved,furtherreductionsin theincidenceofadverseeventsandmechanicalfailureshavebeen achievedby:

 advances in hollow fiber membrane technology, in terms of reductions in the fiber diameter and wall thickness, and prevention of plasma leakage to reduce the need for gas exchangerreplacements;

 moresophisticated arrangements of hollow fibermembranes whichreduceprimingvolume,reduceresistancetobothblood and sweep gasflowthrough thedevice,andimprovethegas exchangeefficiencyallowingforreducedfibersurfaceareaand/ orcircuitflowrate;

 the use of centrifugal pumps or non-occlusive pressure controlled roller pumps, which reduces damage tothe blood (hemolysis)andtheincidenceofcircuitrupture;

 biocompatiblecoatings on thefibers and circuit components (suchasheparin),whichreducetheriskofclotformationaswell asthenecessarylevelsofsystemicanticoagulation;

 theuseofsingledual-lumencathetersandpercutaneousvenous cannulation, which reduces the incidence of cannulation-associated adverse events as well as the level of patient discomfort;

 simplificationsinthesystemdesigntoreduceriskofmechanical failureandoperatorerror;

 useofactivemixingofbloodadjacenttothefiberstoincreasegas exchangeefficiency,whichallowsforreducedfibersurfacearea and/orreducedbloodflow;

 useofarterial-to-venouscannulationtoeliminatetheneedfora pump.

Finally, the study of Godet et al. [1] showed that a simple techniquebasedonastandardRRTplatform(Prismaflex1

)could beeasilyimplementedonexistingdevices.Inthefuture,sucha devicecouldbeusedassociatedwiththelungprotectiveor ultra-lung protective ventilation in more ICU patients in extended indications.

Disclosureofinterest

ConflictofinterestofSamirJABER:DrJaberreportsreceiving consultingfeesfromDra¨ger,Hamilton,MaquetandFisherPaykel ConflictofinterestofLaurentPAPAZIAN:LaurentPAPAZIANdo not have any conflicts of interest to declare regarding this manuscript.

References

[1] GodetT,CombesA,ZogheibE,JabaudonM,FutierE,SlutskyAS,etal.NovelCO2 removaldevicedrivenbyarenal-replacementsystemwithouthemofilter.A firststepexperimentalvalidation.AnesthCritCarePainMed 2015.http:// dx.doi.org/10.1016/j.accpm.2014.08.006.

[2]RozeH,RepusseauB,OuattaraA.Extracorporealmembraneoxygenationinadults forsevereacuterespiratoryfailure.AnnFrAnesthReanim2014;33:492–4.

[3]AbramsDC,BrennerK,BurkartKM,AgerstrandCL,ThomashowBM,Bacchetta M,etal.Pilotstudyofextracorporealcarbondioxideremovalto facilitate extubationandambulationinexacerbationsofchronicobstructivepulmonary disease.AnnAmThoracSoc2013;10:307–14.

[4]BeinT,Weber-CarstensS,GoldmannA,MullerT,StaudingerT,BrederlauJ,etal. Lowertidalvolumestrategy(approximately3mL/kg)combinedwith extracor-porealCO2removalversus‘‘conventional’’protectiveventilation(6mL/kg)in severeARDS:theprospectiverandomizedXtravent-study.IntensiveCareMed 2013;39:847–56.

[5]BurkiNK,ManiRK,HerthFJ,SchmidtW,TeschlerH,BoninF,etal.Anovel extracorporealCO2removalsystem:resultsofapilotstudyofhypercapnic respiratoryfailureinpatientswithCOPD.Chest2013;143:678–86.

[6]GrassoS,StripoliT,MazzoneP,PezzutoM,LacitignolaL,CentonzeP,etal.Low respiratoryrateplusminimallyinvasiveextracorporealCO2removaldecreases systemic and pulmonary inflammatory mediators in experimental. Acute RespirDistressSyndrome.CritCareMed2014;42:e451–60.

[7]KaragiannidisC,KampeKA,SipmannFS,LarssonA,HedenstiernaG,Windisch W,etal.Veno-venousextracorporealCO2removalforthetreatmentofsevere respiratoryacidosis:pathophysiologicalandtechnicalconsiderations.CritCare 2014;18:R124.

[8]AzoulayE,CiterioG,BakkerJ,BassettiM,BenoitD,CecconiM,etal.Yearin reviewinIntensiveCareMedicine2013:II.Sedation,invasiveandnoninvasive ventilation,airways,ARDS,ECMO,familysatisfaction,end-of-lifecare,organ donation, informed consent, safety, hematological issues in critically ill patients.IntensiveCareMed2014;40:305–19.

[9]Roncon-AlbuquerqueJrR,CaronaG,NevesA,MirandaF,Castelo-BrancoS, OliveiraT,etal.VenovenousextracorporealCO2removalforearlyextubationin COPDexacerbationsrequiringinvasivemechanicalventilation.IntensiveCare Med2014;40:1969–70.

LaurentPapaziana,*,b aIntensivecareunit‘‘acuterespiratoryfailureandsevereinfections’’,

Assistancepublique–hoˆpitauxdeMarseille, CHUNord,13015Marseille,France

bFaculte´ deme´decine,Aix-Marseilleuniversity,

URMITEUMRCNRS7278,13005Marseille,France SamirJaberc cIntensiveCareUnitandTransplantation,CriticalCareandAnesthesia

Department(DARB),Saint-EloiHospital,UniversityofMontpellier, INSERMU1046,CNRSUMR9214,34295Montpelliercedex5,France

*Correspondingauthor E-mailaddress:laurent.papazian@ap-hm.fr(L.Papazian)

Références

Documents relatifs

contains instruments for measuring meteorological parameters e.g., pressure, temperature, relative humidity, and relative wind speed and an oceanic gondola contains instruments for

De 1965 à 1991, ils ont triplé le volume de leurs exportations totales, mais multiplié par 75 (soit un taux de croissance annuel de 18 %) celui de leurs ventes manufacturières

Increasing the sorption surface (i.e., increasing the cell volume) leads to increase equilibrium time between material (PU foam) and air (up to six times longer than for the 60

application of the standard would thus require strong limitations for the use of both austenitic and duplex stainless steel grades in amine plants. However, even though

Block diagram of the MiscanFor model system showing the methodology for the meteorological data input from the Climate Research Unit historical and future scenario (Mitchell et

Abstract - A device, composed of a thermal light source and an acoustically decoupled photoacoustic non-resonant cell which allows the detection of atmospheric trace gases

Keywords: single wire power, single wire signalling, power through the ground, ground communications, Tesla coil, Tesla transformer, quarter wave resonator.. 1

Switzerland 2 Department of Biology, Institute of Biochemistry ETH Zurich, Zurich, Switzerland Correspondence: Petr Cejka, petr.cejka@irb.usi.ch, phone: +41 91 820 03 42, fax: