Extracorporeal carbon dioxide removal as a de-escalation strategy from veno-venous extracorporeal membrane oxygenation in acute respiratory distress syndrome: A case report

Background Extracorporeal carbon dioxide removal (ECCO2R) can be used to wean patients from venovenous extracorporeal membrane oxygenation (ECMO). However, its use remains minimally explored in the literature. This case reports the use of ECCO2R in a patient with acute respiratory distress syndrome (ARDS), an infected ECMO cannula, and persistent hypercapnia. Case summary A 39-year-old man placed on venovenous ECMO for ARDS secondary to viral pneumonia developed acute kidney injury, circuit air embolism, and pulmonary hemorrhage during his course. After 80 days on ECMO support, purulent discharge was noted at the femoral cannula site, and the patient remained dependent on sweep gas despite multiple weaning attempts. ECMO support was subsequently de-escalated to ECCO2r and he was decannulated after improvement in blood gases parameters. Conclusion ECCO2R successfully facilitated de-escalation of respiratory support from venovenous ECMO in this complicated case of persistent hypercapnia. The optimal timing and safety of transitioning to ECCO2R still need to be evaluated in larger studies.