A. Bronco

A. Giuffrida

A. Pesenti

G. Bellani

G. Grasselli

G. Suriano

M. Battistini

M. Pozzi

N. Patroniti

T. Mauri

AIR Universita degli studi di Milano

0675
EFFECTS OF DIFFERENT ECMO GAS FLOWS ON THE BREATHING PATTERN
OF SEVERE ARDS PATIENTS DURING PRESSURE SUPPORT AND NAVA
T. Mauri1,2, G. Suriano1,2, G. Grasselli2, A. Giuffrida2, M. Battistini1,2, A. Bronco1,2, M.
Pozzi1,2, N. Patroniti1,2, G. Bellani1,2, A. Pesenti1,2
1University of Milan Bicocca, Department of Health Sciences, Monza, Italy, 2San Gerardo
Hospital, Department of Emergency Medicine, Monza, Italy
INTRODUCTION. Assisted mechanical ventilation (MV) might improve respiratory
muscles function and gas exchange, decrease sedation needs and weaning time in severe
acute respiratory distress syndrome (ARDS) patients undergoing extracorporeal membrane
oxygenation (ECMO). During assisted MV, tidal volumes (Vt) should remain in the pro-
tective range. However, in ECMO patients, they might depend from physician’s setting of
the ventilator as well as from the amount of CO2 removed by ECMO (1,2).
OBJECTIVES. Aim of this study was to evaluate, in severe ARDS patients, tidal volumes
and other respiratory parameters at different levels of extracorporeal CO2 removal by
ECMO during both pressure support ventilation (PSV) and neurally-adjusted ventilatory
assist (NAVA).
METHODS. We performed a prospective interventional randomized cross-over study on
severe ARDS patients undergoing ECMO and assisted MV. ECMO sweep gas flow (GF)
was decreased from resting conditions (i.e., p0.1 \ 2 cmH2O and RR B 20 bpm) to 50 %-
25 %-0 % during PSV and NAVA (20 min step, random order). Support and NAVA gain
were chosen to obtain, at the highest GF, similar Vt (i.e., & 6 mL/kg) and peak airway
pressure (i.e., \ 25 cmH2O). Continuous recording of airway pressure, flow, esophageal
pressure and electrical activity of the diaphragm were recorded during all study phases and
analyzed off-line by dedicated software. Variables were compared by two-way repeated
measures ANOVA with GF and ventilator mode as co-variates. Data are presented as
median [IQR].
RESULTS. Eight severe ARDS patients (5 male) were recruited: they were on ECMO since
20 days [14-49], age was 51 [40-54] year-old, PEEP was 14 [10-16] cmH2O and Crs 33 [26-
45] mL/cmH2O. During PSV and NAVA, decreasing GF led to a similar decrease in the
amount of CO2 removed by ECMO (Figure 1) and increase of respiratory rate, p0.1 and
electrical activity of the diaphragm (p \ 0.001 for different GF; p = n.s. for ventilation
modes and interaction). Tidal volume (Figure 2), peak airway pressure, minute ventilation
and transpulmonary pressure increased at lower GF, albeit their increase was more pro-
nounced during NAVA than during PSV (p \ 0.05 for different GF and ventilation modes;
p = n.s. for interaction). In facts, when GF was zeroed during NAVA, Vt was [ 6 mL/kg in
90 % of patients and [ 8 mL/kg in 50 %.
CONCLUSIONS. In severe ARDS patients undergoing assisted MV and ECMO,
decreasing CO2 removal by ECMO significantly increases ventilation pressure and volume.
Particular attention should be paid to NAVA settings when changing ECMO gas flow.
REFERENCE(S). 1. T. Mauri et al. Intensive Care Med 2013; 2. T. Langer et al. Crit Care
Med 2014.
GRANT ACKNOWLEDGMENT. MIUR
[Figure 1]
[Figure 2]
0676
INTENSIVIST DELIVERED QUATERNARY SEVERE RESPIRATORY FAILURE
RETRIEVAL SERVICE WITH MOBILE EXTRACORPOREAL MEMBRANE
OXYGENATION (ECMO) CAPABILITIES
P.B. Sherren1, S.J. Shepherd1, G. Glover1, C. Meadows1, C. Langrish1, N. Ioannou1,
K. Daly1, N. Gooby1, A. Agnew1, N.A. Barrett1
1Guy’s and St. Thomas’ NHS Foundation Trust, Critical Care Medicine, London, United
Kingdom
INTRODUCTION. Transfer to an extra-corporeal membrane oxygenation (ECMO)-
capable respiratory failure centre is associated with improvement in disability-free survival
in adult patients with severe respiratory failure (SRF) [1]. However, the secondary inter-
hospital transfer of severely hypoxic/hypercapnic patients poses significant challenges, and
mobile ECMO during retrieval is frequently indicated. Although the use of mobile ECMO is
well established, the ideal make-up of the retrieval teamremains to be demonstrated. Trials
to date predominantly utilise a surgeon and large retrieval team.
OBJECTIVES. We describe the logistics and outcomes for an intensivist (non-surgeon)
delivered SRF retrieval service with mobile ECMO capabilities.
METHODS. Retrospective observational study of all patients retrieved to St Thomas’
hospital between 02/2013 and 01/2014.
RESULTS. Of the 60 patients analysed, 57 % were female and the mean ± SD age was
44.1 ± 13.6 years. The median (IQR) Murray score and mean ± SD PaO2/FiO2 ratio were
3.2 (3-3.5) and 10.2 ± 4.1 kPa respectively. At referral, 16.7 % were receiving protective
lung ventilation according to ARDSnet criteria, 47 were receiving neuromuscular blockers,
eight were ventilated in the prone position, two were on high frequency oscillatory venti-
lation and three were on inhaled nitric oxide.
Forty eight patients (80 %) required venovenous ECMO initiation at the referring centre. All
patients that required ECMO were successfully cannulated. Cannulation techniques were
bifemoral (85.4 %), femoral-jugular (10.4 %) and dual-lumen jugular Avalon cannulation
(4.2 %). There were no cannulation or ECMO related complications. Mean ± SD pump
blood flow and sweep gas flow during transport were 4.5 ± 0.7 and 4.4 ± 1.7 Lmin-1
respectively. One patient with multi-organ failure died prior to transfer.
There were no serious adverse events during retrieval. The mean ± SD lowest SpO2 and
SBP were 91 ± 6 % and 105 ± 19 mmHg respectively. Following retrieval, there was a
significant improvement in PaO2/FiO2 ratio, ventilator FiO2, Pplat, pH and PaCO2
(table 1).
At referral Immediately
following
retrieval
P-value
PaO2/FiO2 ratio mean ± SD, kPa 10.2 ± 4.1 26.2 ± 15.5 \0.0001*
Ventilator FiO2 median (IQR) 1.0 (0.9-1) 0.4 (0.3-0.7) \0.0001*
Pplat mean ± SD, cmH2O 32.8 ± 5.8 23.0 ± 5.5 \0.0001*
pH mean ± SD 7.15 ± 0.16 7.32 ± 0.09 \0.0001*
PaCO2 mean ± SD, kPa 10.6 ± 4.4 6.4 ± 1.7 \0.0001*
[Ventilatory data pre & immediately post-retrieval]
Survival to critical care discharge was 77 % for patients initiated on ECMO and 75 % for
those retrieved conventionally.
CONCLUSIONS. Despite very high illness severity, patients who fail mechanical venti-
lation can be safely transferred to a specialist respiratory failure centre. An intensivist
delivered mobile ECMO service delivers safe patient retrieval and a high survival rate.
REFERENCE(S). 1.Peek GJ et al. Efficacy and economic assessment of conventional
ventilatory support versus extracorporeal membrane oxygenation for severe adult respira-
tory failure (CESAR): a multicentre randomised controlled trial. Lancet. 2009 Oct
17;374(9698):1351-63.
0677
COST ANALYSIS OF THE USE OF EXTRACORPOREAL CARBON DIOXIDE
REMOVAL TO AVOID INTUBATION IN PATIENTS FAILING NON-INVASIVE
VENTILATION
S.A. Braune1, H. Burchardi2, M. Engel3, A. Nierhaus1, H. Ebelt4, S. Rosseau5, S. Kluge1
1University Medical Center Hamburg-Eppendorf, Department of Intensive Care Medicine,
Hamburg, Germany, 2University Goettingen, Bovenden, Germany, 3Klinikum
Bogenhausen, Department of Cardiology and Intensive Care, Munich, Germany, 4Catholic
Hospital ‘St. Johann Nepomuk’, Department of Internal Medicine II, Erfurt, Germany,
5Charite´-Universitaetsmedizin Berlin, Department of Internal Medicine, Infectious Diseases
and Respiratory Medicine, Berlin, Germany
INTRODUCTION. Extracorporeal carbon dioxide removal (ECCO2R) is increasingly
applied in patients with refractory hypercapnia on invasive mechanical ventilation (IMV),
but little is known about the economic impact of this new technology. A new indication for
ECCO2R is its pre-emptive application to avoid IMV altogether.
OBJECTIVES. To evaluate the financial implications of this new treatment strategy.
METHODS. Retrospective ancillary cost analysis using data from a recently published
multicentre case-control-study (1) on the use of ECCO2R to avoid IMV in patients with
acute on chronic ventilatory failure of different aetiology showing a reduction in hospital
length of stay. Cost calculations and comparison between the two treatment groups and
subgroups were based on direct costs of the ECCO2R and on average daily treatment costs
for ICU and normal wards.
RESULTS. In the patient group treated with ECCO2R IMV could be avoided in 90 % of
cases and hospital length of stay (LOS) was shorter than in the matched control group
treated with IMV (median 23 vs. 42 days). The overall average hospital treatment costs did
not differ between the two groups (41.134 vs. 39.366 €, p = 0.8). A subgroup analysis of
each 12 cases and 12 matched controls with chronic obstructive pulmonary disease (COPD)
revealed significantly lower hospital treatment costs for the ECCO2R group (19.610 vs.
46.552, p \ 0.05).
CONCLUSIONS. Avoiding mechanical ventilation by the use of ECCO2R and thereby
reducing hospital LOS was associated with similar treatment costs for a mixed group of
patient with acute on chronic ventilatory failure. In the subgroup of COPD patients treat-
ment costs were even lower, implying that in selected patient groups a strategy of ECCO2R
to avoid intubation may not only hold clinical advantages, but also some beneficial eco-
nomic impact. Further prospective economic analyses in larger patient groups are warranted
to confirm these preliminary results.
27th ANNUAL CONGRESS—BARCELONA, SPAIN—27 SEPTEMBER–1 OCTOBER 2014 S187


Effects of different ECMO gas flows on the breathing pattern of severe ARDS patients during pressure support and nava

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Effects of different ECMO gas flows on the breathing pattern of severe ARDS patients during pressure support and nava

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