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ECCO₂R therapy in the ICU: consensus of a European round table meeting.

ABSTRACT:

Background

With recent advances in technology, patients with acute respiratory distress syndrome (ARDS) and severe acute exacerbations of chronic obstructive pulmonary disease (ae-COPD) could benefit from extracorporeal CO₂ removal (ECCO₂R). However, current evidence in these indications is limited. A European ECCO₂R Expert Round Table Meeting was convened to further explore the potential for this treatment approach.

Methods

A modified Delphi-based method was used to collate European experts' views to better understand how ECCO₂R therapy is applied, identify how patients are selected and how treatment decisions are made, as well as to identify any points of consensus.

Results

Fourteen participants were selected based on known clinical expertise in critical care and in providing respiratory support with ECCO₂R or extracorporeal membrane oxygenation. ARDS was considered the primary indication for ECCO₂R therapy (n = 7), while 3 participants considered ae-COPD the primary indication. The group agreed that the primary treatment goal of ECCO₂R therapy in patients with ARDS was to apply ultra-protective lung ventilation via managing CO₂ levels. Driving pressure (≥ 14 cmH₂O) followed by plateau pressure (P_plat; ≥ 25 cmH₂O) was considered the most important criteria for ECCO₂R initiation. Key treatment targets for patients with ARDS undergoing ECCO₂R included pH (> 7.30), respiratory rate (< 25 or < 20 breaths/min), driving pressure (< 14 cmH₂O) and P_plat (< 25 cmH₂O). In ae-COPD, there was consensus that, in patients at risk of non-invasive ventilation (NIV) failure, no decrease in PaCO₂ and no decrease in respiratory rate were key criteria for initiating ECCO₂R therapy. Key treatment targets in ae-COPD were patient comfort, pH (> 7.30-7.35), respiratory rate (< 20-25 breaths/min), decrease of PaCO₂ (by 10-20%), weaning from NIV, decrease in HCO₃^- and maintaining haemodynamic stability. Consensus was reached on weaning protocols for both indications. Anticoagulation with intravenous unfractionated heparin was the strategy preferred by the group.

Conclusions

Insights from this group of experienced physicians suggest that ECCO₂R therapy may be an effective supportive treatment for adults with ARDS or ae-COPD. Further evidence from randomised clinical trials and/or high-quality prospective studies is needed to better guide decision making.

SUBMITTER: Combes A

PROVIDER: S-EPMC7412288 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:BackgroundBy controlling hypercapnia, respiratory acidosis, and associated consequences, extracorporeal CO2 removal (ECCO2R) has the potential to facilitate ultra-protective lung ventilation (UPLV) strategies and to decrease injury from mechanical ventilation. We convened a meeting of European intensivists and nephrologists and used a modified Delphi process to provide updated insights into the role of ECCO2R in acute respiratory distress syndrome (ARDS) and to identify recommendations for a future randomized controlled trial.ResultsThe group agreed that lung protective ventilation and UPLV should have distinct definitions, with UPLV primarily defined by a tidal volume (VT) of 4-6 mL/kg predicted body weight with a driving pressure (ΔP) ≤ 14-15 cmH2O. Fourteen (93%) participants agreed that ECCO2R would be needed in the majority of patients to implement UPLV. Furthermore, 10 participants (majority, 63%) would select patients with PaO2:FiO2 > 100 mmHg (> 13.3 kPa) and 14 (consensus, 88%) would select patients with a ventilatory ratio of > 2.5-3. A minimum CO2 removal rate of 80 mL/min delivered by continuous renal support machines was suggested (11/14 participants, 79%) for this objective, using a short, double-lumen catheter inserted into the right internal jugular vein as the preferred vascular access. Of the participants, 14/15 (93%, consensus) stated that a new randomized trial of ECCO2R is needed in patients with ARDS. A ΔP of ≥ 14-15 cmH2O was suggested by 12/14 participants (86%) as the primary inclusion criterion.ConclusionsECCO2R may facilitate UPLV with lower volume and pressures provided by the ventilator, while controlling respiratory acidosis. Since recent European Society of Intensive Care Medicine guidelines on ARDS recommended against the use of ECCO2R for the treatment of ARDS outside of randomized controlled trials, new trials of ECCO2R are urgently needed, with a ΔP of ≥ 14-15 cmH2O suggested as the primary inclusion criterion.

Project description:BackgroundBurnout remains a significant health concern within the healthcare sector. Numerous studies have explored burnout among gastroenterologists. However, as far as we are aware, there is currently no documented research specifically focused on burnout for specialists in the field of inflammatory bowel disease (IBD).ObjectiveThe aim of our study was to assess the extent of burnout, its determinants, and to analyze potential risk factors among European healthcare professionals who provide care to patients with IBD.MethodsWe carried out a cross-sectional pilot study involving healthcare professionals responsible for the treatment of patients with IBD. A total of 102 participants (56.9% male, average age 48 ± 10.6) completed the anonymous multiple question open web survey. The survey consisted of four distinct psychological constructs (burnout, depression, somatization, and well-being), along with inquiries associated with sociodemographic, health-related, and work-related factors.ResultsIn our study, we observed that 47.1% of professionals specializing in IBD experienced burnout. When considering all three factors of burnout simultaneously, 5.9% of participants fell within the moderate range. Among these, depersonalization (DP) was the most prevalent factor, with 48% at a medium level and 47.1% at a high level. Depression, somatization, and well-being correlated with emotional exhaustion (EE) and DP, while only depression correlated with personal accomplishment (PA). Furthermore, age, physical activity, total time spent in healthcare, and time spent as an IBD specialist were correlated with EE. Multiple linear regression analysis revealed that depression was the most dominant predictor of both PA and DP. In terms of work-related factors, we observed that having endoscopic access had a detrimental impact on burnout, while the presence of a dedicated IBD outpatient unit and opportunities to participate in multidisciplinary meetings had a positive effect on mitigating burnout.ConclusionsOur pilot study underscores the importance of burnout among IBD professionals in Europe, with a specific emphasis on DP. Subsequent studies may help to uncover the way underlying factors contribute to burnout, potentially laying the foundation for international support and prevention initiative programs.

Project description:BackgroundFocal therapy as a treatment option for localized prostate cancer (PCa) is an increasingly popular and rapidly evolving field.ObjectiveTo gather expert opinion on patient selection, interventions, and meaningful outcome measures for focal therapy in clinical practice and trial design.Design, setting, and participantsFifteen experts in focal therapy followed a modified two-stage RAND/University of California, Los Angeles (UCLA) Appropriateness Methodology process. All participants independently scored 246 statements prior to rescoring at a face-to-face meeting. The meeting occurred in June 2013 at the Royal Society of Medicine, London, supported by the Wellcome Trust and the UK Department of Health.Outcome measurements and statistical analysisAgreement, disagreement, or uncertainty were calculated as the median panel score. Consensus was derived from the interpercentile range adjusted for symmetry level.Results and limitationsOf 246 statements, 154 (63%) reached consensus. Items of agreement included the following: patients with intermediate risk and patients with unifocal and multifocal PCa are eligible for focal treatment; magnetic resonance imaging-targeted or template-mapping biopsy should be used to plan treatment; planned treatment margins should be 5mm from the known tumor; prostate volume or age should not be a primary determinant of eligibility; foci of indolent cancer can be left untreated when treating the dominant index lesion; histologic outcomes should be defined by targeted biopsy at 1 yr; residual disease in the treated area of ≤3 mm of Gleason 3+3 did not need further treatment; and focal retreatment rates of ≤20% should be considered clinically acceptable but subsequent whole-gland therapy deemed a failure of focal therapy. All statements are expert opinion and therefore constitute level 5 evidence and may not reflect wider clinical consensus.ConclusionsThe landscape of PCa treatment is rapidly evolving with new treatment technologies. This consensus meeting provides guidance to clinicians on current expert thinking in the field of focal therapy.Patient summaryIn this report we present expert opinion on patient selection, interventions, and meaningful outcomes for clinicians working in focal therapy for prostate cancer.

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ECCO₂R therapy in the ICU: consensus of a European round table meeting.