E C O S” Extra Corporal Organ Support

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“E C O S”

Extra Corporal Organ Support

Dr. dr. Faisal Muchtar, Sp.An-KIC

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Mortality

What went wrong?

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Extracorporeal organ support (ECOS) is being employed to describe all forms of therapies entailing blood extraction and

further processing it in specifically

designed circuits and devices

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DOI: 10.1007/s00134-018-5329-z

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Bleumink GS, Knetsch AM, Sturkenboom MC, Straus SM, Hofman A, Deckers JW, Witteman JC, et al. Quantifying the heart failure epidemic: prevalence, incidence rate, lifetime risk and prognosis of heart failure:

The Rotterdam Study,European Heart Journal, Volume 25, Issue 18, 1 September 2004, Pages 1614–1619, https://doi.org/10.1016/j.ehj.2004.06.038

Ortiz, Justin R.; Neuzil, Kathleen M.; Rue, Tessa C.; Zhou, Hong; Shay, David K.; Cheng, Po-Yung; Cooke, Colin R.; Goss, Christopher H. (2013). Population-based Incidence Estimates of Influenza- associated Respiratory Failure Hospitalizations, 2003 to 2009. American Journal of Respiratory and Critical Care Medicine, 188(6), 710–715. doi:10.1164/rccm.201212-2341OC

Behrendt CE. Acute respiratory failure in the United States: incidence and 31-day survival. Chest. 2000 Oct;118(4):1100-5. doi: 10.1378/chest.118.4.1100. PMID: 11035684.

Pump Failure

Exchange Failure

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DOI: 10.1007/s00134-018-5329-z Pump

Support Exchange

Support

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DOI: 10.1007/s00134-018-5329-z

Mode of ECLS CO2 Removal Oxygenation Support

Right Ventricular Support

Full

Hemodynamic Support

Low-flow VV

ECMO Yes No No No

High-flow VV

ECMO Yes Yes No No

VA ECMO Yes Yes Yes Yes

AV ECMO

(pumpless) Yes No No No

PA-LA Novalung

(pumpless) No No Yes No

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Bréchot N, Hajage D, Kimmoun A, Demiselle J, Agerstrand C, Montero S, Schmidt M, Luyt CE, Lebreton G, Hékimian G, Flecher E, Zogheib E, Levy B, Slutsky AS, Brodie D, Asfar P, Combes A; International ECMO Network.

Venoarterial extracorporeal membrane oxygenation to rescue sepsis-induced cardiogenic shock: a retrospective, multicentre, international cohort study. Lancet. 2020 Aug 22;396(10250):545-552. doi: 10.1016/S0140- 6736(20)30733-9. PMID: 32828186.

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Detoxification

Failure

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Husain-Syed, Faeq; Ricci, Zaccaria; Brodie, Daniel; Vincent, Jean-Louis; Ranieri, V. Marco; Slutsky, Arthur S.; Taccone, Fabio Silvio; Gattinoni, Luciano; Ronco,

Claudio (2018). Extracorporeal organ support (ECOS) in critical illness and acute kidney injury: from native to artificial organ crosstalk. Intensive Care Medicine,

(), –. doi:10.1007/s00134-018-5329-z

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Anna Kanjo;Klementina Ocskay;Noémi Gede;Szabolcs Kiss;Zsolt Szakács;Andrea Párniczky;Steffen Mitzner;Jan Stange;Péter Hegyi;Zsolt Molnár; (2021). Efficacy and safety of liver support devices in acute and hyperacute liver failure: a systematic review and network meta-analysis . Scientific Reports, (), –. doi:10.1038/s41598-021-83292-z

Surface under the cumulative ranking curves (SUCRA%) values of in-hospital mortality.

• Higher the SUCRA value, the higher the probability for the interventions to be the best option.

HVPE, high-volume plasma exchange;

SMT, standard medical therapy;

Ch-HP, Charcoal hemoperfusion;

ET, exchange transfusion.

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Anna Kanjo;Klementina Ocskay;Noémi Gede;Szabolcs Kiss;Zsolt Szakács;Andrea Párniczky;Steffen Mitzner;Jan Stange;Péter Hegyi;Zsolt Molnár; (2021). Efficacy and safety of

liver support devices in acute and hyperacute liver failure: a systematic review and network meta-analysis . Scientific Reports, (), –. doi:10.1038/s41598-021-83292-z

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Lameire, Norbert; Van Biesen, Wim; Vanholder, Raymond (2006). The changing epidemiology of acute renal failure. Nature Clinical Practice Nephrology, 2(7), 364–

377. doi:10.1038/ncpneph0218

Cockwell, Paul; Fisher, Lori-Ann (2020). The global burden of chronic kidney disease. The Lancet, (), S0140673619329770–. doi:10.1016/S0140-6736(19)32977-0 Chen A, Zou M, Young CA, Zhu W, Chiu H-C, Jin G and Tian L (2021) Disease Burden of Chronic Kidney Disease Due to Hypertension From 1990 to 2019: A Global Analysis. Front. Med. 8:690487. doi: 10.3389/fmed.2021.690487

Filtration Failure

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DOI: 10.1007/s00134-018-5329-z

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DOI: 10.1007/s00134-018-5329-z

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DOI:10.1001/jama.2017.10108

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DOI: http://10.1007/s00134-018-5329-z

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DOI: http://10.1007/s00134-018-5329-z

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DOI: http://10.1007/s00134-018-5329-z

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Choosing RRT Modality

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q Critically ill patients with AKI in the context of MODS require a complex and articulated therapeutic approach that includes pharmacological and organ-specific preventive and supportive strategies

q Extracorporeal lung support (VV-ECMO and ECCO2R) and mechanical circulatory support (MCS, such as VA- ECMO)

q More than 70% of patients receiving ECMO develop AKI :

• Underlying disease and severity

• comorbid conditions

• pre-existing kidney injury and

• possible adverse effects of lung

support and MCS on renal

function

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1. Fluid balance in ECMO: ultrafiltration

2. Mediator removal in ECMO : Blood-purification techniques such as high-volume haemofiltration, plasma adsorption, plasma filtration, high cut-off haemofiltration and haemoperfusion

3. Hypercapnic acidosis in protective lung ventilation : ECO 2 R + RRT

4. Hemodynamic instability: CRRT

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Common indications for RRT during ECMO include :

• Fluid overload (43%),

• AKI (35%),

• Prevention of fluid overload (16%) and

• Electrolyte disturbances (4%)

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q Anticoagulation : In the presence of systemic

anticoagulation, additional anticoagulation for the RRT circuit during ECMO/ ECCO2R is usually unnecessary

q Antibiotics and other medications :

o Lipophilic medications with a large volume of distribution are markedly sequestered in the circuit (e.g. voriconazole, propofol, fentanyl, midazolam )

o Hydrophilic medications with a small volume of distribution are dialysed and adsorbed less by the membrane (e.g. piperacillin–

tazobactam, vancomycin, aminoglycosides )

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But all conclusions were derived with low certainty

Comparing Renal Replacement Therapy Modalities in Critically Ill Patients With Acute Kidney Injury: A Systematic Review and

Network Meta-Analysis

Ye Z, Wang Y, Ge L, et al. Comparing Renal Replacement Therapy Modalities in Critically Ill Patients With Acute Kidney Injury: A Systematic Review and Network Meta-Analysis. Critical Care Explorations. 2021 May;3(5):e0399. DOI: 10.1097/cce.0000000000000399. PMID:

34079944; PMCID: PMC8162503

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Winters, Jeffrey L. (2012). Plasma exchange: concepts, mechanisms, and an overview of the American Society for Apheresis guidelines. Hematology, 2012(1),

7–12. doi:10.1182/asheducation.v2012.1.7.3797920

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Replacement Fluid/Albumin/Plasma

Patient Blood

Plasma

Toxin

Inflammatory Mediators Antibodies Immunoglobulins

Water Protein RBC

Winters, Jeffrey L. (2012). Plasma exchange: concepts, mechanisms, and an

overview of the American Society for Apheresis guidelines. Hematology,

2012(1), 7–12. doi:10.1182/asheducation.v2012.1.7.3797920

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Ranganathan D, John G T. Therapeutic plasma exchange in renal disorders. Indian J Nephrol 2019;29:151-9

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Ranganathan D, John G T. Therapeutic plasma exchange in renal disorders. Indian J Nephrol 2019;29:151-9

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Ranganathan D, John G T. Therapeutic plasma exchange in renal disorders. Indian J Nephrol 2019;29:151-9

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Hildebrand AM, Huang SH, Clark WF. Plasma exchange for kidney disease: what is the best evidence? Adv Chronic Kidney Dis. 2014 Mar;21(2):217-27. doi:

10.1053/j.ackd.2014.01.008. PMID: 24602471.

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• There are a lot of ECOS options available

• Delaying ECOS in AKI might put the patient at risk to develop CKD

• ADVOS might be needed in the future

• TPE might offer benefits in managing unwanted substance-

induced kidney injury and MOF

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