Adult Intensive Care Services, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD, Australia.
University of Queensland, Brisbane, QLD, Australia.
Perfusion. 2023 Jul;38(5):1062-1079. doi: 10.1177/02676591221096225. Epub 2022 Jun 2.
A strategy that limits tidal volumes and inspiratory pressures, improves outcomes in patients with the acute respiratory distress syndrome (ARDS). Extracorporeal carbon dioxide removal (ECCOR) may facilitate ultra-protective ventilation. We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of venovenous ECCOR in supporting ultra-protective ventilation in moderate-to-severe ARDS.
MEDLINE and EMBASE were interrogated for studies (2000-2021) reporting venovenous ECCOR use in patients with moderate-to-severe ARDS. Studies reporting ≥10 adult patients in English language journals were included. Ventilatory parameters after 24 h of initiating ECCOR, device characteristics, and safety outcomes were collected. The primary outcome measure was the change in driving pressure at 24 h of ECCOR therapy in relation to baseline. Secondary outcomes included change in tidal volume, gas exchange, and safety data.
Ten studies reporting 421 patients (PaO:FiO 141.03 mmHg) were included. Extracorporeal blood flow rates ranged from 0.35-1.5 L/min. Random effects modelling indicated a 3.56 cmHO reduction (95%-CI: 3.22-3.91) in driving pressure from baseline ( < .001) and a 1.89 mL/kg (95%-CI: 1.75-2.02, < .001) reduction in tidal volume. Oxygenation, respiratory rate and PEEP remained unchanged. No significant interactions between driving pressure reduction and baseline driving pressure, partial pressure of arterial carbon dioxide or PaO:FiO ratio were identified in metaregression analysis. Bleeding and haemolysis were the commonest complications of therapy.
Venovenous ECCOR permitted significant reductions in ∆P in patients with moderate-to-severe ARDS. Heterogeneity amongst studies and devices, a paucity of randomised controlled trials, and variable safety reporting calls for standardisation of outcome reporting. Prospective evaluation of optimal device operation and anticoagulation in high quality studies is required before further recommendations can be made.
一种限制潮气量和吸气压力的策略，可以改善急性呼吸窘迫综合征（ARDS）患者的预后。体外二氧化碳去除（ECCOR）可能有助于实现超保护性通气。我们进行了系统评价和荟萃分析，以评估在中重度 ARDS 患者中支持超保护性通气的静脉-静脉 ECCOR 的疗效和安全性。
检索 MEDLINE 和 EMBASE 数据库，以获取 2000 年至 2021 年期间报告静脉-静脉 ECCOR 用于中重度 ARDS 患者的研究。纳入报告≥10 例成人患者的英文期刊研究。收集 ECCOR 治疗开始后 24 小时的通气参数、设备特征和安全性结果。主要结局指标是 ECCOR 治疗 24 小时后驱动压与基线相比的变化。次要结局包括潮气量、气体交换和安全性数据的变化。
纳入了 10 项研究，共 421 例患者（PaO：FiO 141.03mmHg）。体外血液流速范围为 0.35-1.5L/min。随机效应模型表明，与基线相比，驱动压降低了 3.56cmHO（95%-CI：3.22-3.91）（<0.001），潮气量降低了 1.89mL/kg（95%-CI：1.75-2.02，<0.001）。氧合、呼吸频率和 PEEP 保持不变。荟萃回归分析未发现驱动压降低与基线驱动压、动脉血二氧化碳分压或 PaO：FiO 比值之间的显著相互作用。出血和溶血是治疗中最常见的并发症。
静脉-静脉 ECCOR 可显著降低中重度 ARDS 患者的 ∆P。由于研究和设备之间存在异质性、随机对照试验较少以及安全性报告的差异，需要标准化结局报告。在提出进一步建议之前，需要在高质量研究中评估最佳设备操作和抗凝的效果。
