肺（体外二氧化碳清除）和肾（连续性肾脏替代治疗）支持：超保护性策略在新型冠状病毒肺炎和非新型冠状病毒肺炎所致急性呼吸窘迫综合征中的作用。一项病例对照研究。
Lung (extracorporeal CO removal) and renal (continuous renal replacement therapy) support: the role of ultraprotective strategy in Covid 19 and non-Covid 19 ARDS. A case-control study.
作者信息
Pasero Daniela, Pistidda Laura, Piredda Davide, Liperi Corrado, Cossu Andrea, Esposito Raffaella, Muroni Angela, Mereu Cristiano, Rum Carlino, Branca Gian Pietro, Mulas Franco, Puci Mariangela, Sotgiu Giovanni, Terragni Pierpaolo
机构信息
Anesthesia and General Intensive Care Unit, AOU Sassari, Sassari, Italy.
Department of Medicine, Surgery and Pharmacy, University of Sassari, A.O.U Sassari, Viale San Pietro 43, 07100, Sassari, Italy.
出版信息
J Anesth Analg Crit Care. 2024 Apr 27;4(1):27. doi: 10.1186/s44158-024-00164-4.
BACKGROUND
Preliminary studies suggest that moderate ARDS and acute renal failure might benefit from extracorporeal CO removal (ECCOR) coupled with CRRT. However, evidence is limited and potential for this coupled treatment may need to be explored. The aim of the present study was to evaluate whether a protective driving pressure was obtained applying low-flow ECCOR plus CRRT in patients affected by moderate ARDS with COVID-19 compared to an historical group without COVID-19.
METHODS
A case-control study has been conducted comparing a group of consecutive moderate ARDS patients presenting AKI and affected by COVID-19, who needed low-flow ECCOR plus CRRT to achieve an ultra-protective ventilatory strategy, with historical group without COVID-19 that matched for clinical presentation and underwent the same ultra-protective treatment. V was set at 6 mL/kg predicted body weight then ECCOR was assessed to facilitate ultra-protective low V ventilation to preserve safe Pplat and low driving pressure.
RESULTS
ECCOR+CRRT reduced the driving pressure from 17 (14-18) to 11.5 (10-15) cmHO (p<0.0004) in the fourteen ARDS patients by decreasing V from 6.7 ml/kg PBW (6.1-6.9) to 5.1 (4.2-5.6) after 1 hour (p <0.0001). In the ARDS patients with COVID-19, the driving pressure reduction was more effective from baseline 18 (14-24) cmHO to 11 (10-15) cmHO (p<0.004), compared to the control group from 15 (13-17) to 12(10-16) cmHO (p< 0.03), after one hour. ECCOR+CRRT did not affected 28 days mortality in the two groups, while we observed a shorter duration of mechanical ventilation (19 {7-29} vs 24 {22-38} days; p=0.24) and ICU length of stay (19 {7-29} vs 24 {22-78} days; p=0.25) in moderate ARDS patients with COVID-19 compared to control group.
CONCLUSIONS
In moderate ARDS patients with or without COVID-19 disease, ECCOR+CRRT may be and effective supportive treatment to reach protective values of driving pressure unless severe oxygenation defects arise requiring ECMO therapy initiation.
背景
初步研究表明，中度急性呼吸窘迫综合征（ARDS）和急性肾衰竭可能受益于体外二氧化碳清除（ECCOR）联合连续性肾脏替代治疗（CRRT）。然而，证据有限，这种联合治疗的潜力可能需要探索。本研究的目的是评估与无新型冠状病毒肺炎（COVID-19）的历史对照组相比，在患有中度ARDS的COVID-19患者中应用低流量ECCOR加CRRT是否能获得保护性驱动压。
方法
进行了一项病例对照研究，将一组连续的患有急性肾损伤（AKI）且受COVID-19影响的中度ARDS患者与无COVID-19的历史对照组进行比较，这些患者需要低流量ECCOR加CRRT以实现超保护性通气策略，历史对照组临床表现匹配且接受相同的超保护性治疗。潮气量（V）设定为预测体重的6 mL/kg，然后评估ECCOR以促进超保护性低V通气，以维持安全的平台压（Pplat）和低驱动压。
结果
在14例ARDS患者中，ECCOR + CRRT使驱动压从17（14 - 18）cmH₂O降至11.5（10 - 15）cmH₂O（p < 0.0004），1小时后V从6.7 ml/kg预计体重（PBW）（6.1 - 6.9）降至5.1（4.2 - 5.6）（p < 0.0001）。在患有COVID-19的ARDS患者中，驱动压从基线的18（14 - 24）cmH₂O降至11（10 - 15）cmH₂O更有效（p < 0.004），而对照组从15（13 - 17）cmH₂O降至12（10 - 16）cmH₂O（p < 0.03），1小时后。ECCOR + CRRT对两组28天死亡率无影响，而我们观察到与对照组相比，患有COVID-19的中度ARDS患者机械通气时间较短（19 {7 - 29}天对24 {22 - 38}天；p = 0.24），重症监护病房（ICU）住院时间较短（19 {7 - 29}天对24 {22 - 78}天；p = 0.25）。
结论
在患有或不患有COVID-19疾病的中度ARDS患者中，除非出现严重氧合缺陷需要启动体外膜肺氧合（ECMO）治疗，ECCOR + CRRT可能是达到驱动压保护值的有效支持治疗。
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