The use of life-saving extracorporeal membrane oxygenation (ECMO) for pregnant woman with status asthmaticus

Introduction: Status asthmaticus can develop into a life-threatening disorder that requires mechanical ventilation. Severe respiratory failure during pregnancy can worsen maternal and fetal outcomes. Previous case studies have demonstrated extracorporeal membrane oxygenation (ECMO) as a life-saving measure for pregnant women with acute respiratory distress syndrome (ARDS) as well as non-pregnant patients with status asthmaticus. Case study: A 25-year-old woman, who was 5 weeks pregnant, was admitted with status asthmaticus and severe hypercapnic respiratory failure. Despite rescue therapies such as pressure control ventilation with high inspiratory pressures, inhaled beta2 agonists and antimuscarinic drugs, intravenous salbutamol, methylprednisolone and magnesium sulfate, her condition gradually deteriorated. Veno-venous ECMO was initiated for respiratory support and the patient's clinical condition as well as the gas exchange improved within the next few days. ECMO was removed and the patient was extubated after 2 days. Sonography, however, revealed a retrochorial hematoma; the patient was diagnosed with abortus imminens and successfully treated with magnesium substitution and bed rest. Finally, she gave birth to a healthy boy at 38 weeks of gestation. Conclusions: This is the first case report on the successful use of ECMO in a pregnant woman with severe respiratory insufficiency due to status asthmaticus, who failed to respond to invasive mechanical ventilation and maximum pharmacological treatment. Despite this life-threatening condition, the use of ECMO in our patient has greatly improved the chance of survival for the mother and the baby, who was born without any complications.     

Complications of intermittent prone positioning in pediatric patients receiving extracorporeal membrane oxygenation for respiratory failure

STUDY OBJECTIVE: To describe the safety and risks of placing pediatric patients in the prone position during extracorporeal membrane oxygenation (ECMO) for the treatment of respiratory failure. DESIGN: Single-center retrospective cohort study. SETTING: Tertiary pediatric ICUs. PATIENTS: All patients admitted to the pediatric ICU who required ECMO for respiratory failure from 1995 to 2000. INTERVENTIONS: None. Measurements and results: Medical records for 93 patients representing 95 ECMO runs for treatment of respiratory failure were reviewed. Of these, 63 patients (66%) received intermittent prone positioning. Demographic data and clinical information were recorded. The median age was 12 months, and the median weight was 9.8 kg. There were 962 position changes. Complications surveyed for included bleeding from appliance insertion sites, appliance dislodgment, unplanned extubation, cutaneous pressure ulceration, corneal abrasion, and extreme hemodynamic instability. These complications were noted as to whether they were present prior to the initiation of prone positioning or whether they developed after prone positioning began. Twenty-four percent of patients had bleeding from cannulation sites prior to prone positioning, and 18% of patients had bleeding begin after prone positioning was initiated. Two patients had chest tubes dislodge after prone positioning began, but neither patient had bleeding occur or required reinsertion of the chest tube. There were no unplanned extubations, appliance displacements, development of cutaneous pressure ulcerations, or corneal abrasions associated with prone-positioning maneuvers. No patient had ECMO support removed secondary to the surveyed complications. Eighty-two percent of children who received prone positioning during ECMO for treatment of respiratory failure survived to hospital discharge. CONCLUSION: We found that prone positioning may be used in pediatric ECMO patients without increasing the risk of complications. A multi-institutional, prospective, randomized, controlled study would better evaluate the efficacy of this practice and whether it is associated with a shorter length of ECMO or shorter post-ECMO ventilation and outcome.     

Successful use of recombinant factor VIIa in a patient with intractable bleeding during extracorporeal membrane oxygenation

Bleeding is still the most common complication during extracorporeal membrane oxygenation (ECMO) for temporary cardio-circulatory support. We present a case of a young man suffering from intractable hemorrhage during ECMO support, who was pre-treated with glycoprotein IIb/IIIa receptor antagonist Tirofiban due to a suspicion of myocardial ischemia. After failure of conventional hemostatic means, hemostasis was achieved by the donation of recombinant Factor VIIa (rFVIIa). Aspects of bleeding control during extracorporeal circulatory support, the use of Tirofiban and rFVIIa are discussed.     

体外膜肺氧合治疗心脏手术后急性心功能衰竭的疗效

目的总结体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)治疗心脏外科术后出现严重心功能衰竭的应用经验。方法选择自2009年10月至2013年2月在中山市人民医院进行心脏外科手术,且术后出现急性心功能衰竭而应用ECMO治疗的22例患者为研究对象,总结其应用ECMO治疗的临床情况。结果上机维持时间为(100.0±89.2)h。因心脏功能无法恢复,无法撤机并死亡4例;成功撤机18例,其中4例顺利撤机,但仍最终死亡;顺利恢复并出院14例。辅助过程中主要并发症为出血和感染。结论 ECMO的应用有利于辅助心肺功能和防治并发症,对于心脏术后心功能衰竭的治疗疗效肯定。     

Postpartum extracorporeal membrane oxygenation of a woman with COVID-19-related acute respiratory distress syndrome: A case report

Introduction:Patients with coronavirus disease (COVID-19) may develop acute respiratory distress syndrome (ARDS). There have been few reports of postpartum woman with ARDS secondary to COVID-19 who required respiratory support using veno-venous extracorporeal membrane oxygenation (ECMO). We present the case of a 31-year-old woman who was admitted to hospital at 35 weeks gestation with ARDS secondary to COVID-19 and required ECMO during the postpartum period.Patient concerns:The patient had obvious dyspnea, accompanied by chills and fever. Her dyspnea worsened and her arterial oxygen saturation decreased rapidly.Diagnosis:ARDS secondary to COVID-19.Interventions:Emergency bedside cesarean section. Medications included immunotherapy (thymosin α 1), antivirals (lopinavir/ritonavir and ribavirin), antibiotics (imipenem-cilastatin sodium and vancomycin), and methylprednisolone. Ventilatory support was provided using invasive mechanical ventilation. This was replaced by venous-venous ECMO 5 days postpartum. ECMO management focused on blood volume control, coagulation function adjustment, and airway management.Outcomes:The patient was successfully weaned for ECMO and the ventilator and made a good recovery.Conclusion:Special care, including blood volume control, coagulation function adjustment, and airway management, should be provided to postpartum patients with ARDS secondary to COVID-19 who require ECMO support.     

Contrast-enhanced echocardiographic detection of severe aortic insufficiency in venoarterial extracorporeal membrane oxygenation

Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) support is an increasingly used temporizing therapy for patients with refractory cardiogenic shock. Contrast-enhanced echocardiography plays a critical role in the diagnosis and management of diseases that precipitate severe cardiac failure. In this case report, we describe a previously healthy 60-year-old woman who presented with dyspnea on exertion, and whose hospital course was complicated by ventricular fibrillation, emergent coronary artery bypass surgery (CABG), and ECMO support. Her contrast-enhanced ECMO images demonstrated a unique pattern of opacification of three of the four cardiac chambers, which led to a diagnosis of severe aortic insufficiency.     

Awake extracorporeal membrane oxygenation in patients with severe postoperative acute respiratory distress syndrome

Background

A clinical trial of extracorporeal membrane oxygenation (ECMO) as an alternative ventilator tool is being performed as a new indication for ECMO. The purpose of this study was to evaluate the feasibility of awake ECMO to increase the success rate of weaning patients from ECMO and ventilator care during treatment of postoperative severe acute respiratory distress syndrome (ARDS).

Methods

We retrospectively analyzed the clinical reports of 10 patients who underwent awake ECMO due to postoperative ARDS between August 2012 and May 2015. We analyzed patient history, the partial arterial pressure of oxygen (PaO₂)/fraction of inspired oxygen (FiO₂) ratio, and patient outcome.

Results

Seven patients (70%) were weaned from ECMO without difficulty; one patient failed to maintain awake ECMO, was re-intubated after 2 days of awake ECMO, and was re-tried on awake ECMO after 4 days of ventilator care. We weaned that patient from ECMO 2 days later. We weaned a total of eight patients (80%) from awake ECMO. The ECMO duration of surviving patients was 9.13±2.2 days (range, 6–12 days), and mean ventilator use duration was 6.8±4.7 days (range, 2–16 days). Two cases failed awake ECMO and died due to disease aggravation.

Conclusions

Awake ECMO was a useful weaning strategy after severe postoperative ARDS, as it avoids long-duration use of mechanical ventilation. Additionally, it is possible for patients to breathe spontaneously, which might prevents respiratory muscle dystrophy.     

Protocol-driven daily optimisation of venovenous extracorporeal membrane oxygenation blood flows: an alternate paradigm?

Venovenous extracorporeal membrane oxygenation (VV ECMO) is now an established modality of support for patients with the who are failing evidence-based conventional therapies. Minimising ventilator-induced lung injury is the guiding principle behind patient management with VV ECMO. Patients with acute respiratory distress syndrome (ARDS) supported with VV ECMO are liberated from ECMO at a stage when native lungs have recovered sufficiently to support physiologic demands and the risks of iatrogenic lung injuries after discontinuation of ECMO are perceived to be small. However, native lung recovery is a dynamic process and patients rely on varying degrees of contributions from both native lungs and ECMO for gas exchange support. Patients often demonstrate near total ECMO dependence for oxygenation and decarboxylation early in the course of the illness and this may necessitate higher ECMO blood flow rates (EBFRs). Although, reliance on high EBFR for oxygenation support may remain variable over the course of ECMO, blood flow requirements typically diminish over time as native lungs start to recover. Currently, protocol-driven modulation of the EBFR based on changing physiologic needs is not common practice and consequently patients may remain on higher than physiologically necessary EBFR. This exposes the patient to potential risks because maintaining higher blood flows often requires a less restrictive fluid balance and deeper sedation. Both may be harmful in the setting of recovery from ARDS. In this article, we propose a strategy that involves daily assessments of native lung function and a protocol-driven daily optimisation of EBFR. This is followed by optimisation of sweep gas flow rate (SGFR) and the fraction of delivered oxygen in the sweep gas (FdO₂). This staged approach to weaning VV ECMO allows us to fully utilise the “decoupling” of oxygenation and decarboxylation that is possible only during extracorporeal support. This approach may benefit patients by allowing for greater fluid restriction, more aggressive fluid removal, expedited weaning of sedation and neuromuscular blocking agents (NMBAs), and early physical rehabilitation. Ultimately, prospective studies are needed to evaluate optimal VV ECMO weaning practices     

The intersection of bronchoscopy and extracorporeal membrane oxygenation

Central airway obstruction (CAO), which results from malignant, benign or iatrogenic etiologies, causes significant morbidity and mortality and can be seen in both the pediatric and adult patient population. Patients frequently present to the hospital with dyspnea, stridor, and respiratory distress, indicating impending respiratory failure. Heliox is used to help alleviate symptoms while procedural planning takes place. A multidisciplinary approach to airway management is often needed. Interventional pulmonologists treat CAO with rigid of flexible bronchoscopy in order to deliver therapeutic interventions under general anesthesia. In severe CAO where there is concern for total loss of the airway creating a life-threatening situation for the patient during procedural intervention, short term extracorporeal membrane oxygenation or ECMO has been successfully reported in the literature to provide ventilation and oxygenation support throughout the procedure. Venoarterial ECMO can be used to augment cardiac output in cases of central tumors with cardiac involvement. ECMO can also be used for the removal of tracheal stents when there is a concern that ventilation will be interrupted for a prolonged period of time. ECMO has also been reported as a salvage measure for patients with life threatening hemoptysis until more definitive interventions can be performed. Short term ECMO cannulation can be used with limited associated morbidity and a heparin-free approach can be pursued when there is a concern for bleeding. We will briefly review the anesthetic considerations in CAO as well as review cases of CAO where ECMO was employed to safely alleviate the airway compromise.     

机械循环辅助装置治疗围手术期急性心肺功能衰竭

目的:观察心室辅助(VAD)、体外膜式氧合(ECMO)及主动脉内气囊反搏(IABP)等机械循环辅助装置治疗围手术期急性心肺功能衰竭的疗效。方法:回顾2005年1月至2006年12月我院心脏外科监护病房224例围手术期进行循环辅助患者临床资料,VAD4例、ECMO47例及IABP173例。结果:VAD死亡2例(50%),ECMO死亡23例(48.9%),IABP死亡49例(28.3%)。并发症为感染27例、肾功能衰竭需要透析26例、出血23例、下肢缺血15例及脑并发症7例。结论:机械辅助是救治围手术期急性心肺功能衰竭的有效方法,应根据患者病情选择适合的辅助方式并及早放置,防治并发症对提高成功率非常重要。     

不同病因导致急性呼吸窘迫综合征应用体外膜式氧合治疗体会

目的:观察不同病因引起急性呼吸窘迫综合征(ARDS)的患者,应用体外膜式氧合(ECMO)的治疗效果。方法:回顾性分析2007年6月至2008年8月我院3例ARDS应用ECMO病例。发生原因分别是重症肺炎、胸腹联合创伤后合并呼吸机相关性肺炎(VAP)、以及肺栓塞肺动脉内膜血栓剥脱术后灌注肺;观察应用ECMO前基础状态(Base)、用后8 h、24 h、48 h及72 h动脉血气分析、血压、脉搏和呼吸机调整参数。结果:应用ECMO后,例1重症肺炎患者8 h、24 h、48 h及72 h血压、脉搏及氧合等项指标平稳,但ECMO参数下调时,缺氧状态无缓解,最终ECMO辅助14 d后死亡;例2胸腹联合创伤后VAP合并ARDS患者和例3肺栓塞术后灌注肺患者,ECMO辅助8 h、24 h、48 h、72 h血压、脉搏、氧合等项指标明显改善,分别于ECMO辅助4 d后和24 h后停机。结论:不同病因导致的ARDS应用ECMO后可能结果有所不同。ECMO能改善ARDS患者氧合和气体交换,减轻肺部病理损伤,减轻机体因低氧血症带来的多器官损伤,为治疗原发病赢得时间。     

Influenza A-induced cardiogenic shock requiring temporary ECMO support and urgent heart transplantation

We report a case of a child with familial cardiomyopathy who contracted H1N1 influenza followed by cardiovascular collapse requiring immediate arteriovenous ECMO support. Despite the lack of experience with heart transplantation (HTx) soon after H1N1 infection, HTx was considered as an exit strategy since restoration of cardiac function was considered unlikely. In contrast to the most common indication for ECMO use in patients with H1N1 infection, early ECMO support in cases with infection-induced myocardial decompensation may be lifesaving. Additionally, this report shows that urgent heart transplantation in a patient on ECMO support can be performed safely after recent H1N1 infection and simultaneous heparin-induced thrombocytopenia, which has not been reported before. This case also indicates that H1N1 vaccination should be considered for potential transplantation candidates to prevent severe infection.     

Case report: atrial septostomy as a bridge to lung transplantation in a patient with venovenous extracorporeal membrane oxygenation

Introduction:Advances in critical care management have led to the recent increase in the use of extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation (LT). Patients with respiratory failure requiring venovenous ECMO usually experience progressive right ventricular (RV) failure. Diagnosis and treatment of RV failure during ECMO are essential for improving the prognosis of patients.Patient concerns:A 28-year-old female patient underwent allogeneic hematopoietic stem cell transplantation (HSCT) from a matched unrelated donor for acute myeloid leukemia presenting with progressive dyspnea.Diagnoses:Computed tomography revealed multifocal patchy peribronchial and subpleural ground-glass opacities in both lungs, and the patient was clinically diagnosed with cryptogenic organizing pneumonia.Interventions and outcomes:Despite intensifying systemic corticosteroid therapy, her symptoms deteriorated, and mechanical ventilation and ECMO were applied. During treatment, her respiratory failure continued to progress, and systemic hypotension developed. An echocardiogram showed evidence of RV failure, and percutaneous atrial septostomy was performed for RV decompression. After a balloon atrial septostomy was performed, RV failure of the patient improved, and LT was successfully performed.Lessons:We report the first case of atrial septostomy as a successful bridge to LT in a HSCT recipient with venovenous ECMO. Atrial septostomy could be an option for management of RV failure during ECMO. Further studies need to be conducted to validate the effect of atrial septostomy in patients with RV failure during ECMO.     

Observation of retrieved ceramic-on-ceramic articular surface: a case of revised total hip arthroplasty due to failure of the support ring

We report the case of a 63-year-old woman who required revision surgery for ceramic-on-ceramic total hip arthroplasty (THA) due to failure of the support ring. We retrieved the ceramic cup and head, observed it macroscopically and measured it to determine its shape condition (sphere diameter, sphericity, and circularity) and surface condition (surface roughness by scanning electronic microscopy). Although abrasion was not found at the sliding surface of either the cup or head, it was observed at the edges of the cup and at one part of the head. We point out the risk of the edge contact and conclude the possibility of micro-motion between the cup and the head during walking or loading in vivo, and that contact had taken place at such parts.     

Use of extracorporeal membrane oxygenation in cystic fibrosis in an Australian cystic fibrosis centre

Extracorporeal membrane oxygenation (ECMO) support is used in selected patients with cystic fibrosis (CF) as a bridge to transplantation. Our aim was to describe briefly treatment and outcomes of six CF patients who received ECMO. One patient received a lung transplant and another recovered from acute respiratory failure. Four died despite ECMO support. Lack of timely availability of suitable donor lungs and patient selection are contributing factors.     

Successful use of factor VIIa to control life-threatening post-operative haemorrhage in a patient on extra-corporeal membrane oxygenation

Recombinant Factor VII (Novoseven) is gaining recognition as an established treatment option for post-cardiac surgery bleeding. However, little information is available on its use in patients being maintained on Extra-Corporeal Membrane Oxygenation (ECMO) support, particularly in the adult population. We present the first case of the successful use of Factor VIIa to control bleeding in an adult patient on ECMO post cardiac surgery.     

Pulmonary sequelae at six months following extracorporeal membrane oxygenation.

Mechanical assisted ventilation for neonatal respiratory failure is associated with residual lung disease. Because ECMO rests the lungs, it has been suggested that ECMO will prevent chronic lung disease in survivors. To determine whether or not ECMO survivors have evidence of pulmonary sequelae, we studied 19 infants who were treated with ECMO for neonatal respiratory failure. Ten infants still required supplemental oxygen or pulmonary medications or both to treat clinical lung disease during the first six months of life. Thoracic gas volume was normal. Pulmonary mechanics in ECMO survivors were compared with those of 13 preterm infants with BPD at similar age. We conclude that a significant proportion of ECMO survivors have residual abnormalities in pulmonary mechanics at 6 months of age. We speculate that neonatal lung injury due to meconium aspiration and other causes is a more important determinant of abnormal pulmonary sequelae than the method of treatment.     

Extracorporeal membrane oxygenation as a rescue of intractable ventricular fibrillation and bridge to heart transplantation

Extracorporeal membrane oxygenation (ECMO) systems have undergone rapid technological improvements and are now feasible options for medium‐term support of severe cardiac or pulmonary failure. Intractable ventricular arrhythmia is a rare but well‐established indication for heart transplantation. We report a case of persistent ventricular fibrillation (VF) that was rescued by insertion of peripheral veno‐arterial ECMO during cardiopulmonary resuscitation, which provided support for 30 h of continuous VF and subsequently permitted urgent heart transplantation.     

体外膜肺氧合在心脏危重症患者救治中的应用

目的:总结体外膜肺氧合(ECMO)辅助在心脏危重症患者中的临床救治经验与体会。方法:回顾性分析7例因药物治疗和/或主动脉内球囊反搏(IABP)无效而行ECMO辅助的心源性休克或血流动力学障碍患者的临床资料。ECMO辅助的主要原因:急性心肌梗死后心源性休克4例(57.1%),暴发性心肌炎1例(14.3%),心脏骤停2例(28.6%)。结果:7例患者ECMO平均辅助时间(4.7±3.2)d(范围:1~9 d),6例(85.7%)顺利撤除ECMO,3例行经皮冠状动脉介入治疗。主要并发症包括:出血2例(28.6%),肢体缺血1例(14.3%),急性肾衰竭1例(14.3%),多器官功能衰竭2例(28.6%)。1例在ECMO辅助情况下放弃治疗死亡,2例在成功撤除ECMO后死亡。其中,1例死于严重出血,2例死于多器官功能衰竭。其余4例(57.1%)好转存活出院。结论:ECMO能暂时性为心肺功能提供有效的支持,有利于稳定心脏危重患者的血流动力学,为心功能的恢复创造机会,减少ECMO相关并发症的发生可能会改善心脏危重患者预后。     

Oxygenated right ventricular assist device with a percutaneous dual-lumen cannula as a bridge to lung transplantation

BackgroundOxygenated right ventricular assist device (oxyRVAD) placement has become more streamlined with the introduction of the dual-lumen pulmonary artery cannula. Peripherally cannulated oxyRVAD may provide oxygenation support with right heart support as an alternative to venoarterial extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplantation.MethodsA single-institution, retrospective analysis was performed on patients placed on oxyRVAD with a dual-lumen pulmonary artery cannula with the intention of bridging to lung transplantation in 2019.ResultsFour patients with idiopathic pulmonary fibrosis were placed on oxyRVAD as a bridge to transplantation. Two patients were extubated and ambulated while waiting for a lung offer, and two patients required conversion to venoarteriovenous ECMO (VAV ECMO) from oxyRVAD. The median waiting time for extracorporeal life support (ECLS) was 42 h. All patients underwent double lung transplantation. Two patients stayed on oxyRVAD, and one patient was placed on venovenous ECMO (VV ECMO) after transplantation. Primary graft dysfunction score at 72 h after transplantation was grade 1 in three patients and grade 3 in one patient.ConclusionsPeripherally cannulated oxyRVAD with percutaneous dual-lumen venous cannula could be an ambulatory bridge for lung transplantation. It is unknown whether oxyRVAD is feasible as a long-term bridge to lung transplantation.