extracorporeal gas exchange for ards patients · extracorporeal gas exchange for ards patients ......
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Extracorporeal gas exchange for ARDS patients
Prof. Alain Combes Service de Réanimation iCAN, Institute of Cardiometabolism and Nutrition Hôpital Pitié-Salpêtrière, AP-HP, Paris Université Pierre et Marie Curie, Paris 6 www.reamedpitie.com [email protected]
Conflict of interest
¢ Principal Investigator: HEROICS trial l HVHF after complicated heart surgery l NCT01077349 l Sponsored by GAMBRO
¢ Principal Investigator: EOLIA trial l VV ECMO in ARDS l NCT01470703 l Sponsored by MAQUET, Getinge Group
¢ Received honoraria from MAQUET, Getinge Group, ALung
The evolving paradigm…
¢ ARDSnet strategy might not protect against tidal hyperinflation when Pplat remains >28-30 cm H2O
¢ Further decrease of Vt l From 6 to 5, 4 or 3 ml/kg IBW l To decrease Pplat <25 cm H2O l To further reduce VILI l With sufficient PEEP to prevent lung derecruitment
¢ Induced Hypercapnia controlled by extracorporeal CO2 removal l “CO2 dialysis” l Low-flow devices
25% Incidence of complications and side effects
Limb ischemia due to arterial canulation +++
Need for IV norepinephrine
A Strategy of UltraProtective lung ventilation With Extracorporeal CO2 Removal for
New-Onset moderate to seVere ARDS
The SUPERNOVA trial
NEJM, 1972
¢ 24 yrs old male ¢ Blunt thoracic
trauma ¢ « Shock Lung » ¢ VA ECMO for 75h ¢ Fully recovered
¢ UK, 2001-2006 ¢ ECMO provided only at the Glenfield Hospital,
Leicester ¢ Entry criteria:
l Adult patients (18-65 years) l Severe, but potentially reversible ARDS l Murray score ≥3.0, or l Uncompensated hypercapnia: pH <7.20
¢ Primary outcome measure l Death or severe disability 6 months
The French REVA H1N1 ECMO cohort
¢ 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
SDRA lié à la grippe H1N1
Recommandations pour la ventilation
A. Mercat, J-C.M. Richard, A. Combes, J. Chastre, J.D. Ricard, D. Dreyfuss, L. Brochard
Réseau de Recherche en Ventilation Artificielle
(REVA)
ECMO : potential indications
• Refractory hypoxemia: PaO2/FiO2 < 50, persistent *
Despite: FiO2 > 80 %, PEEP (≤ 20 cmH2O)
Targeting Pplat = 32 cmH2O, prone position +/- NOi
• Plateau Pressure ≥ 35 cmH2O
despite reducing PEEP to 5 cmH2O
AND Vt to 4 ml/kg with pH remaining ≥ 7,15 * : Should also account for disease’s type and evolution
Auteur Pham Noah Davies Patroniti Schmidt Takeda Holzgraef Bonastre Roch
Pays France UK Aus/NZ Italy France Japon Suède Espagne France Nombre de malades 123 80 (69) 68 49 36 14 13 9 9
Nombre de centres 33 4 15 14 3 12 1 5 1
Age 42 [32-53] 34 [28-46] 36 [27-45] 39 [32-46] 39 (28-53) 54 (43–60) 31 (25-50) 36 [28-42] 49 (26-57)
BMI 30.5±8 29 [23-36] 27 [24-35] 29 (25-36) - 35 (31-42) - 30 (25-30)
SOFA 9.5 ± 4.0 9 (7-10) - 7 (6-9) 11 (9-14) 16 (12–19) - - 9 (8-10)
VM-ECMO, j 2 [1-5] 4 [2-7] 2 (1-5) 2 [1-5] 2 (0-5) 5.0 (0.8–8.5) 1 (0-7) 5 (2-7) 0.5 (0.25-4)
PaO2/FiO2 59 [51-71] 55 [46-63] 56 [48-63] 63 [56-79] 50 (41-55) 50 (40–55) 52 (38-60) 66 (64-102) 52 (50-60)
Durée d’ECMO, j 11 [8-22] 9 [6-12] 10 [7-15] 10 [7-17] 20 (9-38) 9 (4–11) 16 (9-30) 6 (5-22) 9 (4-14)
Mortalité 36% 28% 25% 29% 17% 64% 15% 56% 56%
A(H1N1)v09, published series
A(H1N1)v09, published series
0 10 20 30 40 50 60 70 80
0 5 10 15 20 Number of patient/center
Mor
talit
y
The minimum annual case load most significantly associated with lower mortality was 22 (95% CI, 22–28)
0-19
20-49
>49
Where to perform VV-ECMO?
¢ Experienced centers in both ARDS and ECMO ¢ Better if cardiac and respiratory ECMO combined
on the same site l With experienced intensivists, heart surgeons,
perfusionists, nurses…. l Minimum of 20 total ECMO runs per year
¢ ECMO programs should include a mobile ECMO referral team l Available 24H/7D l Nationwide or regional EMCO networks necessary
EOLIA: ECMO to rescue Lung Injury in severe ARDS
¢ Multicenter international randomized controlled trial ¢ Best care possible in the ECMO arm
l ECMO initiated asap for every patient randomized • Using the most recent ECMO technology
l Transport of randomized patients to the referral center UNDER ECMO
l ECMO managed only in highly experienced centers l “Highly protective” MV
• Plateau pressure limited to ≤ 24 cm H2O
EOLIA: ECMO to rescue Lung Injury in severe ARDS
¢ Best care possible in the control arm l MV protocolized using the
“high PEEP – high recruitment” strategy of the EXPRESS trial
l To limit plateau pressure <28-30 cm H2O • Vt limited to 6 ml/kg IBW
l Including Prone positioning l “Ethical” cross-over option to ECMO if the patient
develops refractory hypoxemia