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A Journal on Anesthesiology, Resuscitation, Analgesia and Intensive Care
Minerva Anestesiologica 2017 Apr 11
Copyright © 2017 EDIZIONI MINERVA MEDICA
Extracorporeal CO2 removal (ECCO2R) in critically ill patients: a systematic review
Fabio S. TACCONE 1, 13, Maximilian V. MALFERTHEINER 2, 13, Fiorenza FERRARI 3, Matteo DI NARDO 4, 13, Justyna SWOL 5, 13, Lars M. BROMAN 6, 13, Leen VERCAEMST 7, 13, Nicholas BARRETT 8, 13, Federico PAPPALARDO 9, 13, Jan BELOHLAVEK 10, 13, Thomas MUELLER 2, 13, Roberto LORUSSO 11, 13, Mirko BELLIATO 12, 13 ✉
1 Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium; 2 Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany; 3 Intensive Care Unit and International Renal Research Institute (IRRIV), San Bortolo Hospital, Vicenza, Italy; 4 Pediatric Intensive Care Unit, Children’s Hospital Bambino Gesù, IRCCS, Rome, Italy; 5 Department of Intensive Care and Emergency Medicine, HELIOS Frankenwaldklinik Kronach, Kronach, Germany; 6 ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden; 7 Perfusion Department, University Hospital Gasthuisberg, Louvain, Belgium; 8 Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom; 9 Department of Cardiothoracic Anesthesia and Intensive Care, San Raffaele Hospital, Milan, Italy; 10 2nd Department of Medicine, Cardiovascular Medicine, General University Hospital in Prague, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic; 11 Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Hospital, Maastricht, Netherlands; 12 2nd ICU, S.C. Anestesia e Rianimazione 2, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; 13 EuroELSO Workgroup “Innovation on ECMO and ECLS”
INTRODUCTION: The use of extracorporeal CO2 removal (ECCO2R) is increasingly employed in critically ill patients. However, the clinical evidence supporting its efficacy remains currently poor.
EVIDENCE ACQUISITION: A systematic review using MEDLINE via PubMed was performed to identify eligible studies (until 30th September 2016). The amount of CO2 reduction, the effect on the duration of mechanical ventilation and weaning, the impact on patients’ outcome and the occurrence of complications were evaluated. The quality of evidence was evaluated according to the GRADE (Grading of Recommendations Assessment, Development and Evaluation) criteria.
EVIDENCE SYNTHESIS: Six studies were included (3 evaluating patients with COPD; 3 evaluating patients with ARDS), involving 279 adult patients; 142 treated with ECCO2R and 137 controls. No study on pediatric population met the inclusion criteria for analysis. The overall quality of evidence of the 2 randomized trials and 4 case-control studies varied from moderate to very low. PaCO2 was generally reduced by 25-33% within a few hours following ECCO2R initiation. One ARDS study showed a significant decrease in the duration of mechanical ventilation, although this result was only found by post hoc analysis. The 3 studies on COPD demonstrated that some patients supported by ECCO2R devices could avoid endotracheal intubation, however the ICU-LOS and survival was not influenced by ECCO2R when compared to controls.
CONCLUSIONS: In COPD patients, a significantly reduced need for endotracheal intubation was reported. However, the use of ECCO2R has not shown significant improvement on the outcome of critically ill patients in the reviewed studies. Therefore appropriately powered, randomized, controlled studies are urgently needed.
KEY WORDS: Extracorporeal - Removal - Carbon dioxide - Critical illness - Lung protective strategy - ARDS - COPD - Pediatric - ECCO2R - Technology innovation - Low tidal volume - Respiratory dialysis - Protective mechanical ventilation