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J Thorac Cardiovasc Surg 2001;121:542-551
© 2001 The American Association for Thoracic Surgery

Cardiopulmonary Support and Physiology

Percutaneous extracorporeal arteriovenous carbon dioxide removal improves survival in respiratory distress syndrome: A prospective randomized outcomes study in adult sheep

From the Departments of Surgery,^a Anesthesiology,^b and Medicine,^c The University of Texas Medical Branch and Shriners Hospitals for Children, Galveston, Tex.

Supported in part by Shriners Hospitals for Children (grant No. 8530) and the Constance Marsili Shafer Research Fund.

Presented in part at the American College of Surgeons Surgical Forum.

Received for publication May 4, 2000. Revisions requested June 12, 2000; revisions received Sept 29, 2000. Accepted for publication Nov 8, 2000. Address for reprints: Joseph B. Zwischenberger, MD, Division of Cardiothoracic Surgery, The University of Texas Medical Branch, 301 University Blvd, Galveston, TX 77555-0528 (E-mail: jzwische{at}utmb.edu).

Objective: Arteriovenous carbon dioxide removal (AVCO₂R) uses a simple arteriovenous shunt for CO₂ removal to minimize barotrauma/volutrauma from mechanical ventilation. We performed a prospective randomized outcomes study of AVCO₂R in our new, clinically relevant model of respiratory distress syndrome.
Methods: Adult sheep (n = 18) received an LD₅₀ severe smoke inhalation and 40% third-degree burn. When respiratory distress syndrome developed (PaO₂/FIO₂ < 200 at 40 to 48 hours), animals were randomized to the AVCO₂R (n = 9) or sham group (n = 9) for 7 days. Ventilator management protocols mandated reductions in minute ventilation, first tidal volume to peak inspiratory pressure less than 30 cm H₂O, then respiratory rate when PaCO₂ was less than 40 mm Hg. PaO₂ was kept above 60 mm Hg by adjusting FIO₂. When FIO₂ was 0.21, animals were weaned.
Results: The study required 2946 animal-hours of critical care with 696 AVCO₂R hours. One died in each group during model development. AVCO₂R flow from 820 mL/min to 970 mL/min (11% to 14% cardiac output) removed CO₂ at a rate of 92 to 116 mL/min (mean 103 mL/min; 93%-97% of CO₂ production). Heart rate, mean arterial pressure, cardiac output, and pulmonary arterial wedge pressure remained relatively constant. Within 48 hours, AVCO₂R allowed significant ventilator reductions versus baseline in the following measurements: tidal volume (420 to 270 mL), peak inspiratory pressure (25 to 14 cm H₂O), minute ventilation (13 to 5 L/min), respiratory rate (26 to 16 breaths/min), and FIO₂ (0.88 to 0.35). Ventilator-free days with AVCO₂R were 3.9 versus 0.2 (P < .01) for sham animals, and ventilator-dependent days with AVCO₂R were 2.4 versus 6.2 (P < .01) for the 3 sham survivors. All 8 AVCO₂R animals and 3 of 8 sham animals survived 7 days after randomization.
Conclusions: Percutaneous AVCO₂R achieved significant reduction in airway pressures, increased ventilator-free days, decreased ventilator-dependent days, and improved survival in a sheep model of respiratory distress syndrome.

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