
DOI: 10.1055/s-0040-1716637
A 92 Days Run of Venovenous Extracorporeal Membrane Oxygenation
Fundings Nil.
Abstract
Background Venovenous extracorporeal membrane oxygenation (VV-ECMO) is an established life-saving procedure for severe acute respiratory failure due to various causes. In general, the duration of ECMO ranges from 1 to 2 weeks, with withdrawal recommended if no improvement is noted. We report a case of respiratory failure due to acute respiratory distress syndrome (ARDS) following influenza A infection, supported with a long ECMO run and the lessons learned from this experience.
Case Report A 40-year-old female weighing 120 kg with pneumonia following H1N1 influenza was transferred to our hospital on mechanical ventilation for worsening respiratory distress. On admission, she presented with bilateral diffuse infiltrates on chest X-ray and severe hypoxemia with a partial pressure of oxygen in arterial blood/fraction of inspired oxygen concentration ratio (PaO2/FiO2) of 85 at FiO2 of 0.8 on endotracheal intubation and mechanical ventilation. Acinetobacter Baumannii was isolated from respiratory secretions; antibiotics were revised as per sensitivity. Her respiratory status further deteriorated over next 96 hours in spite of maximally optimized mechanical ventilation. VV-ECMO was established on 4th day of mechanical ventilation in our hospital. Thereafter, she underwent a prolonged ECMO run with respiratory improvement starting to show some promise only by 86th day of ECMO. Weaning process was initiated gradually. However, on 88th day of ECMO the patient had an episode of seizure followed by low Glasgow Coma Scale (GCS) score (3T/15). The patient did not recover from the cerebral insult and based on clinical neurological examination including apnea test, brain death was determined within next 48 hours and the ECMO was called off.
Conclusions Prolonged ECMO therapy poses many challenges and might be considered if the primary cause of respiratory failure necessitating ECMO is expected to resolve or a feasibility of lung transplantation is contemplated. Good team dynamics and appropriate counselling to the family are of utmost importance managing the patients on prolonged ECMO.
Keywords
H1N1 influenza - acute respiratory distress syndrome - venovenous extracorporeal membrane oxygenationPublication History
Publication Date:
08 October 2020 (online)
© 2020. Official Publication of The Simulation Society (TSS), accredited by International Society of Cardiovascular Ultrasound ISCU. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/.)
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References
- 1 ELSO guidelines. Extracorporeal Life Support Organization (ELSO) Guidelines for Adult Respiratory Failure; Ver 1.4: August, 2017. Available at: https://www.elso.org/Portals/0/ELSO%20Guidelines%20For%20Adult%20Respiratory%20Failure%201_4.pdf. Accessed March 21, 2020
- 2 Peek GJ, Mugford M, Tiruvoipati R. et al. CESAR trial collaboration. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009; 374 (9698) 1351-1363
- 3 Mendiratta P, Tang X, Collins II RT, Rycus P, Brogan TV, Prodhan P. Extracorporeal membrane oxygenation for respiratory failure in the elderly: a review of the Extracorporeal Life Support Organization registry. ASAIO J 2014; 60 (04) 385-390
- 4 Combes A, Hajage D, Capellier G. et al. EOLIA Trial Group, REVA, and ECMONet. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med 2018; 378 (21) 1965-1975
- 5 Goligher EC, Tomlinson G, Hajage D. et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome and posterior probability of mortality benefit in a Post Hoc Bayesian analysis of a randomized clinical trial. JAMA 2018; 320 (21) 2251-2259
- 6 Munshi L, Walkey A, Goligher E, Pham T, Uleryk EM, Fan E. Venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis. Lancet Respir Med 2019; 7 (02) 163-172
- 7 Zapol WM, Snider MT, Hill JD. et al. Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA 1979; 242 (20) 2193-2196
- 8 Posluszny J, Rycus PT, Bartlett RH. et al. ELSO Member Centers. Outcome of adult respiratory failure patients receiving prolonged (14 Days) ECMO. Ann Surg 2016; 263 (03) 573-581
- 9 Noah MA, Peek GJ, Finney SJ. et al. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). JAMA 2011; 306 (15) 1659-1668
- 10 Peek GJ, Moore HM, Moore N, Sosnowski AW, Firmin RK. Extracorporeal membrane oxygenation for adult respiratory failure. Chest 1997; 112 (03) 759-764
- 11 Kolla S, Awad SS, Rich PB, Schreiner RJ, Hirschl RB, Bartlett RH. Extracorporeal life support for 100 adult patients with severe respiratory failure. Ann Surg 1997; 226 (04) 544-564, discussion 565–566
- 12 Pierrakos C, Karanikolas M, Scolletta S, Karamouzos V, Velissaris D. Acute respiratory distress syndrome: pathophysiology and therapeutic options. J Clin Med Res 2012; 4 (01) 7-16
- 13 Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med 2000; 342 (18) 1334-1349
- 14 Ali AS, Yosri M, Abouelwafa M. et al. One hundred forty six days on ECMO: our longest ECMO run. Egypt J Crit Care Med 2018; 6: 113-121
- 15 Umei N, Ichiba S, Sakamoto A. Idiopathic pulmonary fibrosis patient supported with extracorporeal membrane oxygenation for 403 days while waiting for a lung transplant: a case report. Respir Med Case Rep 2018; 24: 86-88
- 16 Davies A, Jones D, Bailey M. et al. Australia and New Zealand Extracorporeal Membrane Oxygenation (ANZ ECMO) Influenza Investigators. Extracorporeal membrane oxygenation for 2009 Influenza A(H1N1) acute respiratory distress syndrome. JAMA 2009; 302 (17) 1888-1895
- 17 Chang Y, Lee SO, Shim TS. et al. Lung transplantation as a therapeutic option in acute respiratory distress syndrome. Transplantation 2018; 102 (05) 829-837
- 18 Weill D. Lung transplantation: indications and contraindications. J Thorac Dis 2018; 10 (07) 4574-4587
- 19 Kim EJ, Paik HC, Park MS. et al. One hundred and seven days of ECMO as a bridge to lung transplantation: the longest duration among elderly patients. Korean. J Crit Care Med 2014; 29 (01) 48-51
- 20 Raza T. 300 plus days on ECMO - Lessons Learned. Qatar Medical Journal, 4th Annual ELSO-SWAC Conference Proceedings 2017: 49
- 21 Lorusso R, Gelsomino S, Parise O. et al. Neurological injury in adults supported with venovenous extracorporeal membrane oxygenation for respiratory failure: findings from Extracorporeal Life Support Organization Database. Crit Care Med 2017; 45 (08) 1389-1397
- 22 Lie SA, Hwang NC. Challenges of brain death and apnea testing in adult patients on extracorporeal membrane oxygenation-a review. J Cardiothorac Vasc Anesth 2019; 33 (08) 2266-2272