Crititcal Care Combined Conference Dialysis in Patients with Respiratory Acidosis R4 陳秉民 / VS 吳允升

Crititcal Care Combined Conference Dialysis in Patients with

Respiratory Acidosis

R4 陳秉民 / VS 吳允升

Underlying Disease

1.Chronic respiratory failure status post ETT + MV (2012/3/15~03/28), with difficult weaning, s/p tracheostomy(2012/3/28-)

2.Bronchiolitis obliterans 3.Non-tuberculous mycobacteria infection, treated4.Peripheral T-cell lymphoma, status post auto-PBSCT,

R/T, with transformation to precursor T-lymphobalstic lymphoma/leukemia, status post induction chemotherapy with OPDL, status post Allo-sibling PBSCT, with graft-versus-host disease

History• 29F• 2002/11 Left submandibular LAP, progressed • 2002/03 Core biopsy: peripheral T-cell lymphoma• Partial tonsillectomy • 2013/06 CHOP for six cycles• 2003/10/1 Auto-PBSCT• 2003/12 Radiotherapy 300cGy/15 fractions

History• 2008/06 Submental triangle 1cm small mass• 2008/07 Transformation to precursor T-

lymphobalstic lymphoma/leukemia• 2008/07 Induction chemotherapy with OPDL• 2008/12 Consolidation IV C2• Intrathecal chemotherapy with MTX,

Ara-C, Decadron• 2009/02 Allo-sibling matched PBSCT• Donor lymphocyte infusion *5 on 2009/3/9, 4/9,

5/6, 6/4, 7/2

History• 2009/07 Itchy rash from back to extremities:

GVHD, skin grade 2• 2009/12 Dry cough, dyspnea developed.

Lung function test: Severe obstructive disease. • 2011 /03 Progressive deterioration: CO2 retentionat 60~

90mmHg• 2011/03/06 Intermittent BiPAP • Diagnosis: Brochiolitis obliererans• 2011/11 Lung Transplantation evaluation• Sputum culture: Mycobacterium avium intracellulare

complex 2012/01/04 Treatment for NTM: Ebutol, Rifampin, Klaricid

History

• 2012/03 Dyspnea, persisted despite changing BiPAP setting

• 2012/03/15 Hypercapnic respiratory failure ETT +MV

• 2012/03/28 Tracheostomy• 2012/03 ~ 05 ICU and RCC admission• Failure to wean off ventilator• 2012/5/25 Discharge with home ventilator

History• 2012/12 Dyspnea persisted with CO2 retention noted on

OPD follow-up 7.315/123.6/104.5/ 63.5/37.1 Admitted to 3A2 ICU• AFS: negative *3• Start lung transplantation evaluation• Persisted CO2 retention noted• 2013/1/11• ABG 7.193/155.4/77.0/60.2/31.8• VA-ECMO inserted transfer to SICU for further

treatment

History• 2013/01~ 04 Control infection• 2013/04/04 Bilateral lung transplant + pulmonary

reduction surgery (donor right lower lobectomy + left upper lung wedge resection)

• Ischemic time: right 342 mins, left 474 mins• Blood loss 16000mL

History• Decreased U/O, fluid overload after massive

transfusion• BW 59.4Kg (4/3) 65.4Kg (4/5) • U/O 2390 (4/4) 690 (4/5) 580 (4/6)• FiO2 60~ 80%• 4/6~ 4/13 CAVH U/O 150 ~250mL/day BW 53.9Kg (4/14)• 4/14 Improving AKI, increase U/O

History• 2013/04 Persistent low tidal volume noted <200mL• 2013/04/30 Chest CT RML lobar consolidation, bilateral patchy consolidations Intensive chest care, rehabiliation

History• No obvious improvement• Foamy sputum noted on

bronchoscopy, suspect lung edema

• BW 59.4Kg (4/3) 53.9Kg (4/14) 52.3Kg (5/7)• Start HD for dry lung• U/O 2120mL (5/6)

1110mL (5/7) 310mL (5/8) < 50mL/day

• 5/14 BW 49.5Kg

History• 5/12 BW 48.2Kg• Daily dialysis• 5/6 ~ 6/11

pH pCO2 pO2 HCO3 - BE Dialys.HCO3 -

FiO2 TV

5/7 7.270 67.6 163.3 31.3 4.1 35 55% 135

5/12 7.288 60.7 154.0 29.3 2.4 35 40% 197

5/17 7.285 55.3 109.4 26.5 -0.4 35 40% 1575/22 7.286 67.7 118.1 32.5 5.6 40 40% 1635/23 Hold 7.287 59.9 100.4 28.8 1.9 40% 1685/24 7.255 65.0 105.7 29.1 1.7 35 40% 1695/27 7.271 75.3 94.9 35.0 7.8 35 40% 1375/31 7.138 90.6 110.9 31.0 1.7 35 40% 1096/2 7.119 81.5 96.3 26.7 -3.0 40 40% 1736/6 (PCV) 7.268 76.5 134.1 35.3 8.1 40 45% 1766/11 7.303 61.8 196.4 30.9 4.2 40 45% 1856/13 7.304 62.3 141.5 31.2 4.5 35 40% 204

DiscussionAcute Hypercapnic Respiratory Failure Asscociated

with Hemodilaysis

• 44M• End stage renal disease, HD 4 years, unknown etiology• Severe obese DW 139Kg• Hypertension• Congestive heart failure• LFT: moderate restrictive pattern FVC 62% and FEV 1 /FVC 0.84• Cardiac echo: dilated hypokinetic left ventricle with

left ventricular hypertrophy, enlarged left atrium and calcified mitral annulus

Am J Nephrol 2001 Sep-Oct;21(5):383-5

Intradialytic Hypercapnic Respiratory Failure


• CHF, lung edema, pneumonia admitted to ICU

• 1st HD: Bicarbonate 25 Metabolic acidosis• 2nd HD: Bicarbonate 30• Respiratory acidosis



6366.7

56.6

pH 7.19HCO3 - 21

49.3

pH 7.175HCO3 – 17.5

67.2

HCO3 – 21.2

• Dialysate Bicarbonate 25 for 1week Pre-dialysis respiratory status improved (PCO2 40 mm Hg) Metabolic acidosis (pH 7.27, HCO3 17.9mEq/l)• Dialysate Bicarbonate 30• Small increase in serum bicarbonate 2.5 mEq/l (17.2–19.7 mEq/l)



• Dialysate bicarbonate 25 mEq/L : exacerbation of metabolic acidosis

• Higher dialysate bicarbonate 30 mEq/L: Increase in PCO2 level.



Dialysis & Transplantation 2011; 40(2), 83–85

Acute Hypercapnic Respiratory Failure Associated With Hemodialysis



Acute raise in blood pH : hypoventilation, respiratory depression



Alkalosis: vasoconstriction shift oxygen dissociation curve to the left. Impairing hemoglobin’s ability to release oxygen.



Abrupt reduction H+ Reduce ionized Calcium functional hypocalcemia Neuromuscular impairment Diaphragmatic muscle weakness.

• Vigilant and individualized dialysis prescriptions for kidney failure patients with severe pulmonary dysfunction.

Am J Nephrol 2001 Sep-Oct;21(5):383-5Dialysis & Transplantation 2011; 40(2), 83–85


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Crititcal Care Combined Conference Dialysis in Patients with Respiratory Acidosis R4 陳秉民 / VS 吳允升