Posted: August 1st, 2022
Utilization of Veno-arterial extra-corporeal membrane oxygenation (ECMO) for a 15 years old female as case of sepsis
A15 years old female free medical history referred from ALHAYAT national hospital to King ABDULLAH Medical City (KAMC) as case of post appendectomy complication. referred for extra-corporeal membrane oxygenation (ECMO) secondary to septic shock and septic cardiomyopathy as part of sepsis.
Introduction add some reference and rewrite it
ECMO is a modified cardiopulmonary bypass circuit that serves as an artificial membrane lung and blood pump to provide gas exchange and systemic perfusion when heart and lungs are unable to function adequately. initiation of Veno-arterial ECMO has emerged as a salvage intervention in patients with cardiogenic shock.
Sepsis is defined as a life-threatening organ dysfunction due to a dysregulated immune response to an infection, and has become one of the top ten leading causes of death in developed and developing countries, with a mortality rate as high as 30%.
Septic shock is defined as hypotension with lactic acid >2 mmol/L after adequate fluid resuscitation.
Cardiomyopathy (SCM) is an acute cardiac disorder caused by sepsis, and increasingly recognized as a potential complication of septic shock.
The subject of our case study is a15 years old Saudi female referred from Almadinh Hayat National hospital to King Abdullah Medical City (KAMC) on 24/3/2022 as case of post appendectomy complicated with intra-abdominal collection, enterocutanous fistula septic shock, metabolic acidosis, acute hepatitis, coagulopathy, and bilateral pleural effusions referred for ECMO.
On assessment she was Intubated with Endotracheal tube (ETT) size 7 at 19 cm lip level, on Acute respiratory distress syndrome (ARDS) protocol, fully sedated, on inotropic support and computed tomography scan (CT) Showed Lung parenchyma are entirely replaced by consolidation/hemorrhage.
On 23/3/2022 V-A ECMO initiated secondary to septic shock and septic cardiomyopathy as part of sepsis.
initial setting on mechanical ventilation (MV) were as follows: pressure control (PCMV) mode, Pressure control (PC)10, Positive end expiratory pressure (PEEP) 10, Respiratory Rate (RR) 12, Fraction of inspired oxygen (Fio2) 45%.
Arterial Blood gas (ABG) results: PH 7,44- Pco2 40,1 – Po2 535 – Hco3 27.5 – Lactate 24).
Initial ECMO setting: flow 3L – Sweep gas(SG) 3,5 L – Fio2 100 %).
On Chest x-ray(figure1) ETT was far from carina so pushed 1cm
On 25/3/22 lactate decreased to 18, the plan for ECMO to wean Fio2 gradually and keep flow to avoid clotting.
On the next day the plan was to decannulate ECMO once flow reached 1L, SG 1.5 and accepted hemodynamics.
ABG result was: PH 7.64 -PCo2 36 -sO2 94 -PO2 52 -Hco3 43 -lactate 3.
Prior to ECMO decannulation the patient developed shunt and gab as shown in po2 and So2 due to fast and high ECMO flow which affected blood that passed through the ECMO oxygenator.
On 27/3/2022 ECMO decannulation done, after decannulation the ABG and shunt improved as result showed (PH7.54 -pCo2 47.6 -sO2 100 -PO2 343 -Hco3 40 -lactate 2.3). Next day she was shifted to PRVC initial setting was: tidal volume (Vt) 230, RR 24, PEEP 12, Fio2 65%), she still on ARDS protocol and the plan was to wean MV gradually.
On 30/3/2022 She was weaned to Adaptive Support Ventilation (ASV) initial setting: set minute ventilation (MV)100%, PEEP 8, Fio2 39%.
Weaning of MV continued until 4/4/2022, She was tolerated Pressure support mode (PS) PS 7, PEEP 5, Fio2 30% with Accepted ABG, chest x-ray (figure2) and stable hemodynamics extubation done in the same day to nasal cannula 3 L.
After two days of extubation She was desating therefore shifted to simple face mask (SFM) then to low flow nasal cannula (LFNC) 25L/70%, then electively re-intubated due to decreased Level of consciousness and difficulty to protect her airway, she was intubated with ETT size 7 lip level 20 cm on PC 14, PEEP 8, RR 16, Fio2 70%, ABG post intubation was: (PH 7.48, Pco2 25.9, Po2 84.2, Hco3 21, Lactate 1.4), on minimal settings for MV.
After 8 days GCS improved; so she was extubated to high flow nasal cannula (HFNC) 50 LPM/ 40% Fio2). ABG was (PH: 7.42, Pco2: 46.4, Po2 104, Hco3 29.6) After patient became stable she transferred to ward. On 21/3/2022 upon auscultation diminished air entry was heard from right side and chest x-ray revealed increased right pneumothorax (figure 3), Right chest tube inserted. After 15 days right CT removed.
Patient diagnosed with Crohn’s disease and stay for long time until discharge on 21/6/2022.
Write the challenge of diagnosing, transferring and treating patient
1-Paolone S. Extracorporeal Membrane Oxygenation (ECMO) for Lung Injury in Severe Acute Respiratory Distress Syndrome (ARDS): Review of the Literature. Clin Nurs Res. 2017 Dec;26(6):747-762. doi: 10.1177/1054773816677808. Epub 2016 Nov 11. PMID: 27836935.
2- Rao P, Khalpey Z, Smith R, Burkhoff D, Kociol RD. Venoarterial Extracorporeal Membrane Oxygenation for Cardiogenic Shock and Cardiac Arrest. Circ Heart Fail. 2018 Sep;11(9):e004905. doi: 10.1161/CIRCHEARTFAILURE.118.004905. PMID: 30354364.
3- Lin H, Wang W, Lee M, Meng Q, Ren H. Current Status of Septic Cardiomyopathy: Basic Science and Clinical Progress. Front Pharmacol. 2020;11:210. Published 2020 Mar 3. doi:10.3389/fphar.2020.00210
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