Survival from Septic Shock Secondary to Disseminated Group A Streptococcal Infection after Central Extracorporeal Membrane Oxygenation

Abstract

Objective The objective of this study was to describe a case of severe life-threatening acute respiratory distress syndrome (ARDS) and septic shock in a child who responded to a prolonged extracorporeal membrane oxygenation (ECMO) support course utilizing different cannulation techniques depending on the physiological derangement until he recovered.

Design This is a case report.

Setting This study was done at the medical–surgical pediatric intensive care unit in an academic freestanding children's hospital.

Patient A previously healthy 4-year-old boy was presented with respiratory distress and fever. He was diagnosed with respiratory syncytial viral upper respiratory tract infection and group A β-hemolytic Streptococcus septic shock.

Interventions The patient was referred to peripheral ECMO for hemodynamic, ventilatory, and oxygenation support; conversion to central ECMO to augment blood flow; and transition to extracorporeal carbon dioxide removal before successful wean off extracorporeal support.

Measurements and Main Results Patient experienced severe pediatric ARDS and septic shock that were refractory to maximal medical therapy. Patient was able to be decannulated after 75 days of extracorporeal support. He was weaned completely off of mechanical ventilation and oxygen after 6 months. The only neurological deficit he exhibited was poor fine motor skills of his hands for which he continued to receive physical therapy.

Conclusion Central ECMO may benefit children with pediatric ARDS and septic shock who require higher flows than what can be provided from peripheral ECMO. Extracorporeal membrane carbon dioxide removal may be an effective option in children who do not respond to mechanical ventilation alone.

Keywords

central extracorporeal membrane oxygenation - extracorporeal carbon dioxide removal - group A β-hemolytic Streptococcus - intensive care unit - outcomes - pediatric - septic shock

Funding

None.

• References

• 1 O'Loughlin RE, Roberson A, Cieslak PR. , et al; Active Bacterial Core Surveillance Team. The epidemiology of invasive group A streptococcal infection and potential vaccine implications: United States, 2000-2004. Clin Infect Dis 2007; 45 (07) 853-862
• 2 Nizet V, Arnold JC. Streptococcus pyogenes (group A streptococcus). In: Long SS, Pickering LK, Prober CG. , eds. Principles and Practice of Pediatric Infectious Diseases, 4th ed. Chap. 118. China: Elsevier Saunders; 2012: 698-707
• 3 Sande L, Flores AR. Group A, group C, group G beta hemolytic streptococcal infections. In: Cherry J, Demmler-Harrison GJ, Kaplan SL, Steinbach WJ, Hotez P. , eds. Feigin and Cherry's Textbook of Pediatric Infectious Diseases, 7th ed. Chap. 82. Philadelphia, PA: Elsevier Saunders; 2014: 1140-1152
• 4 Lithgow A, Duke T, Steer A, Smeesters PR. Severe group A streptococcal infections in a paediatric intensive care unit. J Paediatr Child Health 2014; 50 (09) 687-692
• 5 American Academy of Pediatrics. Group A streptococcal infections. In: Kimberlin DW, Brady MT, Jackson MA, Long SS. , eds. Red Book®: 2015 Report of the Committee on Infectious Diseases. American Academy of Pediatrics; 2015: 732-744
• 6 Low DE. Toxic shock syndrome: major advances in pathogenesis, but not treatment. Crit Care Clin 2013; 29 (03) 651-675
• 7 Brierley J, Carcillo JA, Choong K. , et al. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine. Crit Care Med 2009; 37 (02) 666-688
• 8 Conrad SA, Dalton HJ. Extracorporeal life support. In: Nichols DG. , ed. Rogers Textbook of Pediatric Intensive Care, 4th ed. Chap. 36. Philadelphia: Lippincott Williams and Wilkins; 2008: 544-563
• 9 Bartlett RH. Extracorporeal support for septic shock. Pediatr Crit Care Med 2007; 8 (05) 498-499
• 10 MacLaren G, Butt W, Best D. Pediatric septic shock guidelines and extracorporeal membrane oxygenation management. Crit Care Med 2009; 37 (06) 2143-2144 , author reply 2144–2145
• 11 Maclaren G, Butt W, Best D, Donath S, Taylor A. Extracorporeal membrane oxygenation for refractory septic shock in children: one institution's experience. Pediatr Crit Care Med 2007; 8 (05) 447-451
• 12 Goldman AP, Kerr SJ, Butt W. , et al. Extracorporeal support for intractable cardiorespiratory failure due to meningococcal disease. Lancet 1997; 349 (9050): 466-469
• 13 Pořízka M, Kopecký P, Prskavec T, Kunstýř J, Rulíšek J, Balík M. Successful use of extra-corporeal membrane oxygenation in a patient with streptococcal sepsis: a case report and review of literature. Prague Med Rep 2015; 116 (01) 57-63
• 14 MacLaren G, Butt W, Best D, Donath S. Central extracorporeal membrane oxygenation for refractory pediatric septic shock. Pediatr Crit Care Med 2011; 12 (02) 133-136
• 15 MacLaren G, Cove M, Kofidis T. Central extracorporeal membrane oxygenation for septic shock in an adult with H1N1 influenza. Ann Thorac Surg 2010; 90 (03) e34-e35
• 16 Richard C, Argaud L, Blet A. , et al. Extracorporeal life support for patients with acute respiratory distress syndrome: report of a Consensus Conference. Ann Intensive Care 2014; 4: 15
• 17 Ryan DP, Doody DP. Treatment of acute pulmonary failure with extracorporeal support: 100% survival in a pediatric population. J Pediatr Surg 1992; 27 (08) 1111-1116 , discussion 1116–1117
• 18 Khemani RG, Smith LS, Zimmerman JJ, Erickson S. ; Pediatric Acute Lung Injury Consensus Conference Group. Pediatric acute respiratory distress syndrome: definition, incidence, and epidemiology: proceedings from the Pediatric Acute Lung Injury Consensus Conference. Pediatr Crit Care Med 2015; 16 (05) (Suppl. 01) S23-S40
• 19 Ferguson ND, Fan E, Camporota L. , et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med 2012; 38 (10) 1573-1582
• 20 Ranieri VM, Rubenfeld GD, Thompson BT. , et al; ARDS Definition Task Force. Acute respiratory distress syndrome: the Berlin Definition. JAMA 2012; 307 (23) 2526-2533