Extracorporeal carbon dioxide removal (ECCO2-R) over a membrane lung is a new therapy for patients with adult respiratory distress syndrome (ARDS) who frequently suffer from lung complications caused by long-term artificial ventilation and who may require major thoracic surgery. This is a report of 76 patients with severe ARDS who were treated by ECCO2-R. Twenty-six of these 76 patients required thoracotomy: 19 for pneumothorax and pneumatocele, and seven for haemothorax, infected lung necrosis or oesophagotracheal fistula. Most pneumothoraces were bilateral. Ten of these 26 patients required reoperation, usually for extensive persisting alveolar air leaks. Sixteen (62 per cent) of the 26 patients who had a thoracotomy and 22 (44 per cent) of the 50 patients without surgery survived. These results demonstrate that performing a thoracotomy, if necessary, does not diminish the survival chance of high-risk patients with severe ARDS.

Continuous hemofiltration is used widely in the management of patients with acute renal failure, but administration guidelines for many drugs have yet to be established. In this study, the pharmacokinetics of ceftriaxone were compared in patients with normal renal function (n = 9), mild renal insufficiency (n = 5), and acute renal failure receiving continuous veno-venous hemofiltration (n = 6). Pharmacokinetic parameters were determined under steady state conditions. Patients with mild renal insufficiency had a significantly lower renal clearance and longer half-life of ceftriaxone; however, drug recovery in the ultrafiltrate with continuous veno-venous hemofiltration was similar to that in the urine of patients with normal renal function. Pharmacokinetic parameters for renal, nonrenal, and systemic clearance and for volume of distribution and half-life were also similar between patients receiving continuous veno-venous hemofiltration and those with normal renal function. The sieving coefficient (S) of ceftriaxone (0.69) significantly exceeded the expected free fraction in plasma, confirming previous reports that protein binding does not limit the sieving of this compound. The results suggest that a reduction in the usual daily dose of ceftriaxone is not required in patients with acute renal failure receiving continuous veno-venous hemofiltration.

Extracorporeal CO2 removal combined with low-frequency positive pressure ventilation (ECCO2-R LFPPV) is a new therapeutic approach in treatment of ARDS. The main problem during long-term extracorporeal support is anticoagulation and related bleeding problems. We conducted a prospective, randomized and controlled clinical trial in 18 patients to compare the effect of the non-heparin-coated (Scimed = group 1) with the heparin-coated (Carmeda = group 2) extracorporeal circuit on clinical course and complication rate. In group 2 the daily blood loss, the amount of substituted red cells and the i.v. heparin dose were significantly lower than in group 1. Bleeding complications were less and more patients survived in group 2. The disadvantage of the hollow fiber oxygenators in the heparin-coated system was plasma leakage, which was more frequent in patients with pancreatitis and hyperbilirubinemia.

Summary:The time-dependent concentrations of hyaluronan, aminoterminal propeptide of type III procollagen, and laminin were determined in sera of 16 patients with severe adult respiratory distress syndrome during treatment with an extracorporeal CO 2 removal device. Patients were classified according to lung Parameters äs responders (n = 10) and non-responders (n = 6) to extracorporeal CO 2 removal. At the beginning of treatment strongly elevated serum concentrations of all studied extracellular matrix components were found. During the first 6-11 days of treatment the concentrations of aminoterminal propeptide of type III procollagen and hyaluronan increased further in non-responders but decreased in the majority of responders, while laminin decreased in both groups. No significant correlations were found between the serum concentrations of connective tissue components and the parameters of lung function. By non-parametric analysis of variance, significant differences between responders and non-responders according to treatment time could be established. By analysing the time course of the serum concentrations of hyaluronan and aminoterminal propeptide of type III procollagen, a total differentiation between responders and nonresponders was made pössible by the trends of these analytes äs early äs three days after the Start of treatment. The determination of aminoterminal propeptide of type III procollagen and hyaluronan in serum of patients with adult respiratory distress syndrome might therefore have prognostic significance in extracorporeal CO 2 removal. unfavourable rapid development of pulmonary fibroThe adult respiratory distress syndrome is a severe sis within about 2 weeks (5, 6), characterized by an condition of life-threatening organ failure, character-increase in fibroblast numbers and accelerated collaized by tachypnoea, hypoxaemia, diffuse interstitial gen metabolism (7,8). mfiltrates, alveolar oedema, and loss of lung compliance (l, 2). The syndrome develops in response to a Components of the extracellular matrix have been primary attack on lung cells like inhalation of toxins, determined in blood of patients with fibrotic lung aspiration of gastric contents (3) or äs a consequence diseases, but in contrast to e. g. liver fibrosis there of systemicdisorders like septicshock and multiorgan seems to be only a weak association between the trauma. Severe, progressive cases are associated with concentrations of such analytes in blood and the a mortality rate of up to 90% (4). One sequel of adult activity and/or grade of the fibrosing process in the respiratory distress syndrome is the prognostically lung (9).