A case report of gadopentetate dimeglumine-induced cardiac arrest: Resuscitation using extracorporeal membrane oxygenation

Gadopentetate dimeglumine (Gd-DTPA) is commonly used for enhancement in magnetic resonance imaging, but rarely causes serious adverse reactions. The patient presented in this report had a cardiac arrest and multiple organ dysfunction syndrome within a short time after administration of Gd-DTPA. Immediately after receiving an intravenous injection of Gd-DTPA, the patient felt nausea and chest tightness, and developed systemic erythema. He was successfully treated using veno-arterial extracorporeal membrane oxygenation (ECMO) combined with continuous renal replacement therapy without any serious complications or neurological deficits. We report a patient who was successfully treated for Gd-DTPA-induced cardiac arrest with ECMO. Thus, ECMO may be an effective treatment for cardiac arrest secondary to anaphylaxis.     

体外膜肺氧合对心脏术后心肺复苏患者的应用

目的:探讨体外膜肺氧合技术(ECMO)在成年心脏手术后心肺复苏(CPR)困难患者的应用经验。方法:回顾分析2010年1月至2012年9月期间,7例心脏手术后因CPR困难应用ECMO救治的成年患者的临床资料,男性4例,女性3例,年龄42～65岁,平均(54±7)岁,其中冠状动脉旁路移植术(CABG)6例,主动脉瓣置换术1例。全部患者均经股动静脉插管建立ECMO辅助。结果:7例患者CPR时间40～65 min,平均(53±7)min,建立ECMO辅助后全部患者均恢复自主心律,ECMO辅助时间36～128 h,平均(85±26)h,监护室停留时间2～8d,平均(5±1)d。辅助24h后患者平均动脉压(MBP)、血乳酸(Lac)及正性肌力药物评分(IS)均明显改善。6例(85.7%)患者成功撤离ECMO辅助,其中3例(42.9%)存活出院,1例患者因无法脱机而死亡,3例成功脱机后因感染及中枢神经系统并发症死亡;4例患者同时应用主动脉内球囊反搏(IABP),3例进行肾替代治疗(CRRT)。结论:体外膜肺心肺复苏(ECPR)可以提供紧急生命支持,挽救部分常规方法复苏困难的心脏术后心脏骤停患者的生命。     

A case report of acquired methemoglobinemia rescued by veno-venous extracorporeal membrane oxygenation

Rationale:Severe methemoglobinemia (Met-Hb) is rare. The delayed diagnosis and treatment often cause further damage. The management of cellular hypoxemia is challenging and the use of extra-corporeal membrane oxygenation (ECMO) has never been reported.Patient concerns:The young patient, healthy with unremarkable past medical history, was sent to emergency room with out-of-hospital circulatory arrest (OHCA) and severe generalized cyanosis. His family reported he ingested sodium nitrite accidentally.Diagnoses:After successful resuscitation and return of spontaneous circulation (ROSC), the paradoxically normal arterial blood gas (ABG) with the unusual brownish blood led to the suspicion of Met-Hb. The lab test confirmed it and showed a very high level of 80%.Interventions:Because of recovered and normal cardiac function, we placed veno-venous extracorporeal membrane oxygenation (VV-ECMO) for tissue hypoxemia in addition to exchange transfusion, vitamin C, and methylene blue.Outcomes:Met-Hb blood level dropped rapidly. After vigorous rehabilitation for weeks, the patient was able to be discharged home without major neurological sequela.Lessons:VV-ECMO can hyper-oxygenate the hypoxemic tissue regardless the etiology and minimize hypoxemia-reperfusion injury while awaiting the definite diagnosis and therapy.     

应用体外膜肺氧合技术治疗胎粪吸入综合征一例及文献复习

目的探讨应用体外膜肺氧合技术（extracorporeal membrane oxygenation,ECMO）救治重症新生儿胎粪吸入综合征的治疗方法。方法报告1例应用ECMO救治重症新生儿胎粪吸入综合征的过程,并进行文献复习。结果患儿病情危重,经使用肺表面活性物质、高频振荡辅助通气及一氧化氮吸入等治疗后效果欠佳,后予ECMO治疗有效。最终治愈出院。结论对于危重症胎粪吸入综合征患儿可适当放宽ECMO治疗指征,及早予ECMO治疗。但需注意术中及术后感染、神经系统损害等相关并发症。     

Successful treatment of severe ARDS caused by accidental inhalation of nitric acid fumes with veno-venous ECMO: A case report and literature review

Rationale:The treatment of severe acute respiratory distress syndrome caused by accidental inhalation of nitric acid fumes is challenging. Few successful cases have been reported in literature. Owing to the development of extracorporeal life support, extracorporeal membrane oxygenation (ECMO) may play an important role in treatment.Patient concerns:A 40-year-old man was accidentally exposed to nitric acid fumes for 10 minutes in a factory. Mild throat irritation and dyspnea occurred 3.5 hours after exposure. Severe dyspnea recurred approximately two hours later. Chest computed tomography revealed bilateral interstitial edema. Tracheal intubation and mechanical ventilation were provided when the non-invasive ventilator failed to support the patient. However, his vital signs, respiratory function, and circulation were aggravated.Diagnosis:Aspiration pneumonia (inhalation of nitric acid fumes), acute respiratory distress syndrome, and hypertension.Interventions:Veno-venous ECMO (VV-ECMO) was started 6 hours after exposure at the intensive care unit. During VV-ECMO, hypoxia improved. However, chest radiography revealed aggravated pulmonary edema. Prone positioning under ultrasound monitoring and high-dose methylprednisolone were administered on the first day. Nebulization and fiberoptic bronchoscopy for airway management were performed on the second day after the exposure. Pulmonary secretions were significantly reduced 48 hours later.Outcomes:The patient was weaned off V-V ECMO after 6 days, achieved the standard of extubation after 9 days, and was discharged without serious pulmonary or infectious complications after 12 days of hospitalization. Three weeks after discharge, the patient’s lung function showed a slight decline in the diffusion function. Two months after discharge, the patient’s lung function returned to normal.Lesson:Early ECMO combined with prone positioning and visualized management through ultrasonography can better improve the prognoses of patients and promote lung function recovery.     

Veno-arterial extracorporeal membrane oxygenation and targeted temperature management in tricyclic antidepressant-induced cardiac arrest: A case report and literature review

Rationale:Cardiotoxicity is a common cause of death in tricyclic antidepressant (TCA) intoxication. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is effective in critically ill poisoned patients who do not respond to conventional therapies, and targeted temperature management (TTM) is associated with improved neurological outcomes and mortality in comatose out-of-hospital cardiac arrest survivors. However, few reports have documented cases of TCA intoxication that required intensive care, including VA-ECMO or TTM.Patient concerns:A 19-year-old Japanese man with a history of depression was brought to our hospital because he was in a comatose state with a generalized seizure. Before admission, he had taken an unknown amount of amitriptyline.Diagnosis:After intubation, the electrocardiogram (ECG) displayed a wide QRS complex tachycardia, and the patient suffered from cardiovascular instability despite intravenous bolus of sodium bicarbonate. At 200 minutes after ingestion, he experienced a TCA-induced cardiac arrest.Interventions:We initiated VA-ECMO 240 minutes after ingestion. The hemodynamic status stabilized, and the ECG abnormality improved gradually. In addition, we initiated targeted temperature management (TTM) with a target temperature of 34°C.Outcomes:Twenty seven hours after starting the pump, the patient was weaned off the VA-ECMO. After completing the TTM, his mental status improved, and he was extubated on day 5. He was discharged on day 15 without neurological impairment, and the post-discharge course was uneventful.Lessons:First, VA-ECMO is effective in patients with TCA-induced cardiac arrest. Second, routine ECG screening during VA-ECMO support is useful for assessing the timing to wean off the VA-ECMO, as well as the degree of cardiotoxicity. Third, TTM is safe in comatose survivors of cardiac arrest caused by severe TCA intoxication.     

Successful treatment of severe myocardial injury complicated with refractory cardiogenic shock caused by AOPP using extracorporeal membrane oxygenation: A case report

Rationale:Acute organophosphorus pesticide poisoning (AOPP) is a common critical illness observed in clinical practice, and severe AOPP can cause serious cardiac toxicity.Patient concerns:This patient was a 43-year-old woman who was admitted to the emergency department with acute respiratory failure and hypotension 13 hours after oral consumption of 300 mL of phoxim pesticide.Diagnoses:Acute organophosphorus pesticide poisoning, cardiogenic shock.Interventions:We conducted veno-arterial extracorporeal membrane oxygenation (VA-ECMO) therapy as the patient did not respond to conventional measures.Outcomes:This patient was successfully rescued with VA-ECMO therapy and discharged.Lessons:We suggest that for patients with severe myocardial injury complicated with cardiogenic shock caused by AOPP, the use of VA-ECMO therapy can improve the prognosis.     

Veno-venous extracorporeal membrane oxygenation support during lung volume reduction surgery for a severe respiratory failure patient with emphysema

The use of extracorporeal membrane oxygenation (ECMO) in adults has increased in popularity and importance for the support of patients with cardiac or pulmonary failure, but rarely been described as a means of support during anaesthesia and surgery. We report the case of a patient who required lung volume reduction because of emphysema where veno-venous ECMO was required both during surgery and for the first four days postoperatively. We describe the anaesthetic management of this patient who had severe respiratory failure, review other alternatives and discuss why ECMO was particularly suited to this case.     

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.     

Lumbosacral plexopathy due to pelvic hematoma after extracorporeal membrane oxygenation: A case report

Rationale:Peripheral nerve injury related to vascular complications associated with extracorporeal membrane oxygenation (ECMO) is perhaps underappreciated. Compared to the well-described central nervous system complications of ECMO, brachial plexopathy and lumbosacral plexopathy have rarely been reported. We report this case to heighten awareness of lumbosacral plexus injury due to pelvic hematoma formation after ECMO.Patient concerns:A 53-year-old woman developed a large pelvic hematoma with significant mass effect on intrapelvic structures after receiving lifesaving venoarterial ECMO for cardiogenic shock following a cardiac arrest. During her hospital course, she developed bilateral foot drop that was attributed to critical illness. Her lack of neurological recovery after 6 months prompted referral to neuromuscular medicine for consultation.Diagnosis:The patient was retrospectively diagnosed with bilateral lumbosacral plexopathy due to the large pelvic hematoma.Intervention:Electromyography/nerve conduction study (EMG/NCS) obtained at the time of referral to neuromuscular medicine localized her neurological deficits to the bilateral lumbosacral plexus and demonstrated no volitional motor unit action potentials in her lower leg muscles.Outcomes:The patient had minimal recovery of strength at the level of the ankles but was ambulatory with solid ankle–foot orthoses due to spared proximal lower extremity strength. Unfortunately, the absence of any volitionally activated motor unit action potentials in her lower leg muscles on EMG performed 6 months after the initial injury was a poor prognostic indicator for successful reinnervation and future neurological recovery.Lessons:Neurological deficits occurring during the course of administration of ECMO require accurate localization. Neurology consultation and/or EMG/NCS may be useful if localization is not clear. Lesions localizing to the lumbosacral plexus should prompt radiographic evaluation with computed tomography of the abdomen and pelvis. Hemostasis of a retroperitoneal hematoma may be achieved with embolization. However, if neurological deficits do not improve, surgical consultation for hematoma evacuation may be warranted.     

Successful treatment of acute fulminant myocarditis with double sets of extracorporeal membrane oxygenation: report of a case and review of the literature

We report a case of acute fulminant myocarditis (AFM) with cardiogenic shock and hemodynamic collapse. We performed emergency extracorporeal life support (ECLS) with right femoral venoarterial cannulation by Seldinger procedure. Because of poor systemic perfusion over the upper trunk with low O? saturation due to inadequate venous return, a second ECLS was applied 16 hours after the first ECLS with right subclavian venoarterial cannulation by cut-down procedure. Total flow of both ECLS sets can achieve a flow of up to 6-8 l/min without massive destruction of blood cells. Combined with supportive intravenous immunoglobulin (IVIG) treatment, cardiac function recovered well and the ECLS sets were removed one-by-one. Follow-up studies one year after admission showed good cardiac systolic function and no sequelae of AFM.     

A case of successful Mitraclip implantation in a patient having a large coaptation gap under extracorporeal membrane oxygenation (ECMO)

Mitraclip is an alternative therapeutic option for severe functional mitral regurgitation (MR) with reduced ejection fraction, especially in patients with high surgical risk. Although the Mitraclip was reported as an effective therapy in patients who fulfilled the anatomical criteria of the EVEREST trial, it is still uninvestigated whether the therapy is also feasible and beneficial in patients outside the indication criteria of the EVEREST II trial. Among them, MR with a large coaptation gap is considered as a challenging anatomy, because the gap makes it difficult to grasp both leaflets with a standard Mitraclip procedure. As two techniques to grasp such a large coaptation gap were reported, there was no report concerning the effectiveness of extracorporeal membrane oxygenation (ECMO) during Mitraclip implantation. Here we present a first case of successful Mitraclip implantation in a patient with a large coaptation gap with the support of ECMO. © 2016 Wiley Periodicals, Inc.     

Massive hollow catheter thrombus in venovenous extracorporeal membrane oxygenation assisted lung transplantation: A case report

Rationale:Catheter-related thrombosis is a serious complication of lung transplantation under venovenous extracorporeal membrane oxygenation (ECMO). Although ECMO-related thrombosis is not uncommon, there are few reports of giant hollow catheter thrombosis in lung transplantation under venovenous ECMO (ECMO). Blood loss and transfusion of coagulation factors may promote ECMO-related thrombosis. Hollow catheter thrombus was not detected on ultrasonography performed after initiation of ECMO. Therefore, it is essential to identify, manage, and reduce or avoid such thrombosis.Patient concerns:We report a rare case of a 43-year-old man with advanced silicosis who developed a massive hollow catheter thrombus during lung transplantation. Anticoagulant therapy did not affect the size of the thrombus.Diagnosis:Giant hollow catheter thrombosis was diagnosed by ultrasonography. Thrombosis from the right external iliac vein to the inferior vena cava was found in the shape of the ECMO pipe.Interventions:Heparin was prescribed as an anticoagulant.Outcomes:Anticoagulant therapy did not affect the size of the thrombus during 2 weeks. The patient developed an infection and died of multiple organ failure.Conclusion:It is uncommon for massive hollow thrombus to occur during venovenous-ECMO-assisted lung transplantation. Fibrinogen and prothrombin complexes promote the formation of thrombus, and the measurement of the wall thickness of ECMO catheter may help to detect such thrombus.     

Induced airway obstruction under extracorporeal membrane oxygenation during treatment of life-threatening massive hemoptysis due to severe blunt chest trauma

Simultaneous improvement in respiratory maintenance and bleeding control increases survival of patients with life-threatening hemoptysis. Endobronchial blockade is an effective method and is preferred for emergency hemostasis. However, when the volume of hemoptysis is high, emergency hemostasis and airway maintenance are impossible due to flooding of blood into the airway. We used extracorporeal membrane oxygenation (ECMO) to overcome these limitations in a patient with massive hemoptysis due to severe blunt trauma and succeeded in saving the life by inducing a near-total airway obstruction.     

静脉-动脉体外膜肺氧合启动后即刻血液稀释对心脏疾病患者器官功能和治疗策略的影响

目的 探讨心脏疾病患者在静脉-动脉体外膜肺氧合(VA-ECMO)辅助启动后血液快速稀释对器官功能改变及临床治疗策略选择的影响。方法 回顾性分析2019年1月至2023年1月于中国人民解放军总医院第一医学中心血管内科重症监护室接受VA-ECMO辅助的50例患者的临床资料。根据VA-ECMO启动后红细胞压积(Hct)下降的程度,将患者分为Hct下降≥30%组(HctΔ30%+组,n=17)和Hct下降<30%组(HctΔ30%-组,n=33)。比较两组患者器官功能相关生物标志物、接受输血、主动脉内球囊反搏(IABP)及持续肾替代治疗(CRRT)情况。采用SPSS 25.0统计软件进行数据分析。根据数据类型,分别采用t检验、Mann-Whitney U 检验、χ²检验或Fisher精确检验进行组间比较。结果 HctΔ30%+组65岁及以上患者占比52.9%(9/17),HctΔ30%-组65岁及以上患者占比36.4%(12/33)。HctΔ30%+组与HctΔ30%-组患者一般临床特征及VA-ECMO辅助前临床指标比较,差异均无统计学意义(P>0.05)。在VA-ECMO启动后,肌酸激酶同工酶、天冬氨酸氨基转移酶及丙氨酸氨基转移酶的峰值在HctΔ30%+组中更高,差异均有统计学意义(P<0.05)。HctΔ30%+组与HctΔ30%-组相比,接受IABP(70.6%和36.4%)和CRRT(64.7%和18.2%)治疗的患者比例更高;HctΔ30%+组患者输注悬浮红细胞和血浆的单位数更多,差异均有统计学意义(P<0.05)。结论 VA-ECMO启动后Hct降低≥30%的患者输血量更大、器官损伤更重,采用IABP或CRRT联合辅助比例更高。VA-ECMO启动后Hct降低≥30%作为一个新的临床指标,为治疗策略的选择及改善预后提供重要参考依据。     

A case report of early application of veno-arterial extracorporeal membrane oxygenation in amniotic fluid embolism

Rationale:Amniotic fluid embolism (AFE) is a rare obstetrical complication and is a leading cause of maternal death in developed countries. Despite the development of supportive therapeutic measures, the mortality rate remains high.Patient concerns:A 38-year-old nulliparous pregnant woman, who underwent in vitro fertilization-embryo transfer, was admitted for labor at 37 weeks’ gestation. Approximately 30 minutes after delivery of the placenta, the puerpera developed postpartum hemorrhage with uterine atony. Soon after, the patient experienced hypotension, repeated cardiac arrest, refectory hypoxia, and disseminated intravascular coagulopathy.Diagnosis:AFE is diagnosed clinically. The pregnant woman in this case fulfilled the diagnostic criteria for AFE: acute hypotension, cardiac arrest, acute hypoxia, and coagulation disorders within approximately 30 minutes after delivery of the placenta.Interventions:The patient was intubated, connected to a ventilator, and was administered a high dose of vasoactive drugs to maintain blood pressure and underwent an emergency hysterectomy. Considering the risk for recurrent cardiac arrest and severe refractory hypoxia, venoarterial extracorporeal membrane oxygenation was initiated and discontinued as soon as cardiac function was restored based on serial bedside ultrasound assessment.Outcomes:The patient stabilized on day 7 in the intensive care unit and was transferred to the obstetrics ward and, 1 week later, was discharged with no complications. Two months later, follow-up revealed that the patient was in good condition.Lesson:Serial bedside ultrasound was crucial for assessing cardiac function and optimal weaning. Timely application of venoarterial extracorporeal membrane oxygenation and weaning was significant to avoid the occurrence of complications and improve long-term outcomes.