Marzo Aprile 2023 - Nefrologo in corsia

Combined extracorporeal CO2 removal and renal replacement therapy in a pregnant patient with COVID-19: a case report

Posted on Download PDF (english version)

Pasquale Esposito

Pasquale Esposito1, Francesca Cappadona1, Filippo Sangregorio1, Elisa Costa1, Laura Mallia1, Valentina Zanetti1, Lorenzo Nescis1, Stefania Bianzina2, Fiorenza Ferrari3, Nicolò Antonino Patroniti4, Giovanni Battista Traverso1, Francesca Viazzi1

1 Clinica Nefrologica, Dialisi, Trapianto, Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genoa, Italy
2 Neonatal and Pediatric Intensive Care Unit, Department of Critical Care and Perinatal Medicine, IRCCS Istituto Giannina Gaslini, Genova, Italy
3 Department of Anesthesia and Intensive Care Unit, I.R.C.C.S., San Matteo Hospital and University of Pavia, Pavia, Italy
4 Anesthesia and Intensive Care, San Martino Policlinico Hospital - IRCCS for Oncology and Neurosciences, Genoa, Italy; Department of Surgical Sciences and Integrated Diagnostics [DISC], University of Genoa, Genoa, Italy

Corresponding author:
Pasquale Esposito
Unit of Nephrology, Dialysis and Transplantation, Department of Internal Medicine, University of Genoa and IRCCS Ospedale Policlinico San Martino, Genova, Italy
E-mail address: pasqualeesposito@hotmail.com

 

Abstract

Background. Pregnant women are at high risk of Coronavirus disease 2019 (COVID-19) complications, including acute respiratory distress syndrome. Currently, one of the cornerstones in the treatment of this condition is lung-protective ventilation (LPV) with low tidal volumes. However, the occurrence of hypercapnia may limit this ventilatory strategy. So, different extracorporeal CO2 removal (ECCO2R) procedures have been developed. ECCO2R comprises a variety of techniques, including low-flow and high-flow systems, that may be performed with dedicated devices or combined with continuous renal replacement therapy (CRRT).
Case description. Here, we report a unique case of a pregnant patient affected by COVID-19 who required extracorporeal support for multiorgan failure. While on LPV, because of the concomitant hypercapnia and acute kidney injury, the patient was treated with an ECCO2R membrane inserted in series after a hemofilter in a CRRT platform. This combined treatment reducing hypercapnia allowed LPV maintenance at the same time while providing kidney replacement and ensuring maternal and fetal hemodynamic stability. Adverse effects consisted of minor bleeding episodes due to the anticoagulation required to maintain the extracorporeal circuit patency. The patient’s pulmonary and kidney function progressively recovered, permitting the withdrawal of any extracorporeal treatment. At the 25th gestational week, the patient underwent spontaneous premature vaginal delivery because of placental abruption. She gave birth to an 800-gram female baby, who three days later died because of multiorgan failure related to extreme prematurity.
Conclusions. This case supports using ECCO2R-CRRT combined treatment as a suitable approach in the management of complex conditions, such as pregnancy, even in the case of severe COVID-19.

Keywords: pregnancy, COVID-19, lung-protective ventilation, hypercapnia, CO2 removal, acute kidney injury, continuous renal replacement therapy

Introduction

Pulmonary involvement in Coronavirus disease 2019 (COVID-19) is highly heterogeneous, with clinical presentation ranging from asymptomatic forms to acute respiratory distress syndrome (ARDS) [1]. This heterogenicity may be explained by demographic factors, history of comorbidities, distinctive genetic background, and pharmacological treatments [2].

Among the different populations of COVID-19 patients, pregnant women deserve specific attention. Indeed, these patients, due to immunological and cardiorespiratory changes occurring in pregnancy, are at risk of the more severe complications of the disease, including ARDS [3, 4].

Most patients with ARDS require mechanical ventilation (MV), and in some cases also extracorporeal respiratory support (ECLS) [5].

These therapies encompass extracorporeal membrane oxygenation (ECMO) and the extracorporeal carbon dioxide removal system (ECCO2R). Briefly, ECMO takes over the gas exchange function of the lungs ensuring full oxygenation and CO2 removal, while ECCO2R is a CO2 removal system that does not affect oxygenation, and whose principal aim is consenting to lung protection (Table 1). 

La visualizzazione dell’intero documento è riservata a Soci attivi, devi essere registrato e aver eseguito la Login con utente e password.