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Extracorporeal decarboxylation in patients with severe traumatic brain injury and ARDS enables effective control of intracranial pressure.

Munoz-Bendix C, Beseoglu K, Kram R - Crit Care (2015)

Bottom Line: To evaluate effects on ICP, the volume of daily cerebrospinal fluid (CSF) drainage needed to maintain the set ICP threshold was compared pre- and postimplant.In spite of this improved lung-protective ventilation, carbon dioxide pressure decreased from 46.6 ± 3.9 mmHg to 39.7 ± 3.5 mmHg (p = 0.005).The volume of daily CSF drainage needed to maintain ICP at 20 mmHg decreased significantly from 141.5 ± 103.5 ml to 62.2 ± 68.1 ml (p = 0.037).

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany. christopher.munoz@med.uni-duesseldorf.de.

ABSTRACT

Introduction: Acute respiratory distress syndrome (ARDS) with concomitant impairment of oxygenation and decarboxylation represents a complex problem in patients with increased intracranial pressure (ICP). Permissive hypercapnia is not an option to obtain and maintain lung-protective ventilation in the presence of elevated ICP. Pumpless extracorporeal lung assist (pECLA) devices (iLA Membrane Ventilator; Novalung, Heilbronn, Germany) can improve decarboxylation without aggravation associated with invasive ventilation. In this pilot series, we analyzed the safety and efficacy of pECLA in patients with ARDS and elevated ICP after severe traumatic brain injury (TBI).

Methods: The medical records of ten patients (eight male, two female) with severe ARDS and severe TBI concurrently managed with external ventricular drainage in the neurointensive care unit (NICU) were retrospectively analyzed. The effect of pECLA on enabling lung-protective ventilation was evaluated using the difference between plateau pressure and positive end-expiratory pressure, defined as driving pressure (ΔP), during the 3 days preceding the implant of pECLA devices until 3 days afterward. The ICP threshold was set at 20 mmHg. To evaluate effects on ICP, the volume of daily cerebrospinal fluid (CSF) drainage needed to maintain the set ICP threshold was compared pre- and postimplant.

Results: The ΔP values after pECLA implantation decreased from a mean 17.1 ± 0.7 cm/H2O to 11.9±0.5 cm/H2O (p = 0.011). In spite of this improved lung-protective ventilation, carbon dioxide pressure decreased from 46.6 ± 3.9 mmHg to 39.7 ± 3.5 mmHg (p = 0.005). The volume of daily CSF drainage needed to maintain ICP at 20 mmHg decreased significantly from 141.5 ± 103.5 ml to 62.2 ± 68.1 ml (p = 0.037).

Conclusions: For selected patients with concomitant severe TBI and ARDS, the application of pECLA is safe and effective. pECLA devices improve decarboxylation, thus enabling lung-protective ventilation. At the same time, potentially detrimental hypercapnia that may increase ICP is avoided. Larger prospective trials are warranted to further elucidate application of pECLA devices in NICU patients.

No MeSH data available.


Related in: MedlinePlus

Changes in carbon dioxide pressure (pCO2), pH, mean arterial pressure (MAP), oxygen pressure to fraction of inspired oxygen (pO2/FiO2) ratio, and respiratory rate after implant of the pumpless extracorporeal lung assist device. a After implant (post) of the pumpless extracorporeal lung assist (pECLA) device, pCO2 was significantly reduced compared with before (pre)implant. b Simultaneously, pH increased significantly postimplant as compared with preimplant. The pO2/FiO2 ratio (c), MAP (d), and respiratory rate (e) remained unchanged before and after implant of the pECLA device.
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Fig1: Changes in carbon dioxide pressure (pCO2), pH, mean arterial pressure (MAP), oxygen pressure to fraction of inspired oxygen (pO2/FiO2) ratio, and respiratory rate after implant of the pumpless extracorporeal lung assist device. a After implant (post) of the pumpless extracorporeal lung assist (pECLA) device, pCO2 was significantly reduced compared with before (pre)implant. b Simultaneously, pH increased significantly postimplant as compared with preimplant. The pO2/FiO2 ratio (c), MAP (d), and respiratory rate (e) remained unchanged before and after implant of the pECLA device.

Mentions: Implant of the pECLA device facilitated a significant decrease of pCO2 from 46.6 ± 3.9 mmHg to 39.7 ± 3.5 mmHg (p = 0.005), and pH rose from 7.42 ± 0.04 to 7.46 ± 0.03 (p = 0.021) (Fig. 1a, b). The pO2/FiO2 ratio remained unchanged after implant of the pECLA device (Fig. 1c). MAP was kept stable over the treatment period (Fig. 1d), and fluid was kept at a positive balance of 1500–2000 ml daily to stabilize patients’ hemodynamics. Respiratory rate showed no significant change, but a slight decrease was seen (Fig. 1e).Fig. 1


Extracorporeal decarboxylation in patients with severe traumatic brain injury and ARDS enables effective control of intracranial pressure.

Munoz-Bendix C, Beseoglu K, Kram R - Crit Care (2015)

Changes in carbon dioxide pressure (pCO2), pH, mean arterial pressure (MAP), oxygen pressure to fraction of inspired oxygen (pO2/FiO2) ratio, and respiratory rate after implant of the pumpless extracorporeal lung assist device. a After implant (post) of the pumpless extracorporeal lung assist (pECLA) device, pCO2 was significantly reduced compared with before (pre)implant. b Simultaneously, pH increased significantly postimplant as compared with preimplant. The pO2/FiO2 ratio (c), MAP (d), and respiratory rate (e) remained unchanged before and after implant of the pECLA device.
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4627375&req=5

Fig1: Changes in carbon dioxide pressure (pCO2), pH, mean arterial pressure (MAP), oxygen pressure to fraction of inspired oxygen (pO2/FiO2) ratio, and respiratory rate after implant of the pumpless extracorporeal lung assist device. a After implant (post) of the pumpless extracorporeal lung assist (pECLA) device, pCO2 was significantly reduced compared with before (pre)implant. b Simultaneously, pH increased significantly postimplant as compared with preimplant. The pO2/FiO2 ratio (c), MAP (d), and respiratory rate (e) remained unchanged before and after implant of the pECLA device.
Mentions: Implant of the pECLA device facilitated a significant decrease of pCO2 from 46.6 ± 3.9 mmHg to 39.7 ± 3.5 mmHg (p = 0.005), and pH rose from 7.42 ± 0.04 to 7.46 ± 0.03 (p = 0.021) (Fig. 1a, b). The pO2/FiO2 ratio remained unchanged after implant of the pECLA device (Fig. 1c). MAP was kept stable over the treatment period (Fig. 1d), and fluid was kept at a positive balance of 1500–2000 ml daily to stabilize patients’ hemodynamics. Respiratory rate showed no significant change, but a slight decrease was seen (Fig. 1e).Fig. 1

Bottom Line: To evaluate effects on ICP, the volume of daily cerebrospinal fluid (CSF) drainage needed to maintain the set ICP threshold was compared pre- and postimplant.In spite of this improved lung-protective ventilation, carbon dioxide pressure decreased from 46.6 ± 3.9 mmHg to 39.7 ± 3.5 mmHg (p = 0.005).The volume of daily CSF drainage needed to maintain ICP at 20 mmHg decreased significantly from 141.5 ± 103.5 ml to 62.2 ± 68.1 ml (p = 0.037).

View Article: PubMed Central - PubMed

Affiliation: Department of Neurosurgery, Medical Faculty, Heinrich-Heine-University Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany. christopher.munoz@med.uni-duesseldorf.de.

ABSTRACT

Introduction: Acute respiratory distress syndrome (ARDS) with concomitant impairment of oxygenation and decarboxylation represents a complex problem in patients with increased intracranial pressure (ICP). Permissive hypercapnia is not an option to obtain and maintain lung-protective ventilation in the presence of elevated ICP. Pumpless extracorporeal lung assist (pECLA) devices (iLA Membrane Ventilator; Novalung, Heilbronn, Germany) can improve decarboxylation without aggravation associated with invasive ventilation. In this pilot series, we analyzed the safety and efficacy of pECLA in patients with ARDS and elevated ICP after severe traumatic brain injury (TBI).

Methods: The medical records of ten patients (eight male, two female) with severe ARDS and severe TBI concurrently managed with external ventricular drainage in the neurointensive care unit (NICU) were retrospectively analyzed. The effect of pECLA on enabling lung-protective ventilation was evaluated using the difference between plateau pressure and positive end-expiratory pressure, defined as driving pressure (ΔP), during the 3 days preceding the implant of pECLA devices until 3 days afterward. The ICP threshold was set at 20 mmHg. To evaluate effects on ICP, the volume of daily cerebrospinal fluid (CSF) drainage needed to maintain the set ICP threshold was compared pre- and postimplant.

Results: The ΔP values after pECLA implantation decreased from a mean 17.1 ± 0.7 cm/H2O to 11.9±0.5 cm/H2O (p = 0.011). In spite of this improved lung-protective ventilation, carbon dioxide pressure decreased from 46.6 ± 3.9 mmHg to 39.7 ± 3.5 mmHg (p = 0.005). The volume of daily CSF drainage needed to maintain ICP at 20 mmHg decreased significantly from 141.5 ± 103.5 ml to 62.2 ± 68.1 ml (p = 0.037).

Conclusions: For selected patients with concomitant severe TBI and ARDS, the application of pECLA is safe and effective. pECLA devices improve decarboxylation, thus enabling lung-protective ventilation. At the same time, potentially detrimental hypercapnia that may increase ICP is avoided. Larger prospective trials are warranted to further elucidate application of pECLA devices in NICU patients.

No MeSH data available.


Related in: MedlinePlus