ABSTRACTS ECMO – IJECMO2023

VV ECMO Assisted Tracheal Stenting

M Ravi Krishna¹, Ch Bharat², V Rakesh³

¹Critical Care Department, KIMS Icon Hospital, Vishakapatnam, Andhra Pradesh, India

²Department of Pulmonology, KIMS Icon Hospital, Vishakapatnam, Andhra Pradesh, India

³Critical Care Department, Gemcare Hospital, Kurnool, Andhra Pradesh, India

DOI: 10.5005/jaypee-journals-11011-0018.1

Keywords: VV ECMO, Tracheal stenting, Respiratory failure

The use of extracorporeal membrane oxygenation (ECMO) can be beneficial when conventional ventilation methods are unsuccessful. Here, we successfully managed a patient with advanced tracheal malignancy and impending airway obstruction by implementing veno-venous ECMO (VV-ECMO) before performing a critical endotracheal procedure. The VV-ECMO was securely established through the right jugular vein and the left femoral vein, under local anesthesia. The placement of a tracheal stent was then performed under the guidance of a rigid bronchoscope and fluoroscopy. ECMO effectively maintained adequate oxygenation and ventilation. VV-ECMO serves as a valuable tool in supporting airway interventions for complex tracheal pathologies, especially when conventional ventilation may not be sufficient or feasible.

References

1. Malpas G, Hung O, Gilchrist A, et al. CWCJ, 2018 undefined. The use of extracorporeal membrane oxygenation in the anticipated difficult airway: a case report and systematic review. search.proquest. comG Malpas, O Hung, A Gilchrist, C Wong, K Blaine, GM Hirsch, RD HartCanadian Journal of Anesthesia, 2018•search.proquest. com [Internet]. [cited 2023 Nov 23]; Available from: https://search.proquest.com/openview/ec46daffa80cec489f446dacc90d3887/1?pq-origsite=gscholar&cbl=326357.

2. Surgery GHJTJ of cardiovascular, 1986 undefined. The impossible intubation–what next? europepmc.orgGL Hicks JrThe Journal of cardiovascular surgery, 1986•europepmc.org [Internet]. [cited 2023 Nov 23]; Available from: https://europepmc.org/article/med/3782283.

3. Ayers ML, Beamis JF. Rigid bronchoscopy in the twenty-first century. Clin Chest Med. 2001; 22(2):355–64.

Multi-slice Contrast – Enhanced CT Imaginig in Periphrral VA ECMO: How I Do It?

Saibal Tripathy¹, Sourav Dalal², Avik Dhar³, Dipayan Chakraborty⁴, Pranabesh Paria⁵, Deblal Pandit⁶, Dipanjan Chatterjee⁷, Kunal Sarkar⁸

DOI: 10.5005/jaypee-journals-11011-0018.2

Keywords: Computed tomography, ECMO, Contrast

Introduction: Extracorporeal membrane oxygenation (ECMO) is a modified cardiopulmonary bypass to support life, permitting further treatment and recovery during severe cardiac or pulmonary failure. Computed tomography (CT) is widely applied in the assessment of critical conditions, such as clinical suspicion of complications or an unexplained delay in improvement on ECMO.

Methods: Specific hemodynamic changes associated with patients on ECMO determine the patterns and the route of contrast use in CT(computed tomography). Different possible venous route for contrast delivery were used on VA-ECMO patient to get proper coronary view as used in non ECMO patients which encountered complication for proper imaging.

Results: If a CT angiogram is being performed on these type of VA-ECMO patients to evaluate the coronary status, an optimal image can be obtained by lowering the flow rate of the ECMO circuit or by disabling the circuit for the duration of image acquisition.

Conclusion: Therefore it is important that in ECMO centers perfusionists are well aware of the imaging pitfalls associated with the use of CT in ECMO cases.It is also important to apply well-designed imaging protocols in ECMO centers and familiarize themselves with post-contrast CT imaging findings in patients on ECMO.

Reviving the Unrecoverable: Outcomes of Veno-arterial ECMO In 14 Severe Celphos Poisoning Cases, Highlighting The Role of Multidisciplinary Management and Future Implications

Amit Mehta¹, Vijayant Solanki², Shailesh Jhawar³, Geetesh Mangal⁴

^1–4Apex Hospital, Jaipur, India

DOI: 10.5005/jaypee-journals-11011-0018.3

Introduction: Celphos poisoning, common and often fatal in North India, lacks a specific antidote, with cardiogenic shock as the primary cause of death.¹ This case series examines 14 high-risk Celphos poisoning cases treated with VA-ECMO at our hospital (October 2021-August 2023), resulting in a 78.5% survival rate. Establishing a new ECMO center presented challenges, and post-liberation, some patients needed prolonged care, emphasizing the need for comprehensive, long-term management. Despite hurdles, the successful outcomes demonstrates VA-ECMO’s efficacy in severe Celphos poisoning.

Case series: Patients who met the inclusion criteria for high-risk Celphos poisoning, includes left ventricular myocardial dysfunction with an ejection fraction of ≤35% or severe metabolic acidosis with a pH ≤ 7.0 and/or refractory shock with a systolic blood pressure <80 mmHg despite conventional medical therapies, were considered for VA-ECMO therapy.²

Discussions: In 23 high-risk Celphos poisoning cases, average presentation time was 7 hours, with 6 grams ingestion on average. 14 patients received VA ECMO. All cannulation was done ultrasound guidance. VA-ECMO recipients showed a 78.5% survival rate. Mechanical ventilation, renal replacement therapy, bleeding, and thrombosis were observed in varying cases. Limb ischemia occurred in two, psychiatric symptoms in one, and four developed sepsis. The average door to cannulation time was 40 minutes. VA-ECMO duration averaged 48 hour, contributing to reduced vascular access complications, blood transfusions, and overall cost-effectiveness and safety.

Conclusion: VA-ECMO therapy may be a promising intervention for severe Celphos poisoning cases with cardiogenic shock. Multidisciplinary management is crucial for the successful management of these patients in a new center. Our experience highlights the importance of collaborative management and may have important implications for future management.

References

1. Proudfoot AT. Aluminium and zinc phosphide poisoning. Clin Toxicol (Phila). 2009;47:89–100.

2. Bishav Mohan, Bhupinder Singh. Outcome of patients supported by extracorporeal membrane oxygenation for aluminum phosphide poisoning: an observational study. indianheartjournal682016295-301.

A Successful Case of VA-ECMO For an Antenatal Woman with Aluminium Phosphide Poisoning

Vijayashanthi S¹, Aruna A², Gautham Ganapathy³, Ganapathy Nagarajan⁴

^1–4Dhanvantri Institute of Medical Education and Research, Erode, Tamil Nadu, India

DOI: 10.5005/jaypee-journals-11011-0018.4

Introduction: Aluminium phosphide poisoning has high mortality of 80-100% which causes refractory cardiogenic shock and multiorgan dysfunction syndrome. Maternal mortality has always been a major medical concern. The effects of aluminium phosphide toxicity on both mother and fetus should be treated and the classical treatment may be controversial at certain circumstances. Among population who were ingested aluminium phosphide tablets, antenatal women were rare and have higher risks.

Case presentation: We present a case of 21-year-old antenatal woman who was consumed aluminium phosphide tablets (3g) in suicidal intent. On primary survey, her airway was patent, blood pressure was 100/60 mm Hg with heart rate of 105/min. Routine investigations and POCUS were done. POCUS revealed reduced LVEF-25%. As the time progressed her blood pressure started falling (90/60 mm Hg) and lactate levels were raising (10.5 mmol/L). Hence, she was started on inotropes. Inspite of increasing her vasopressor and inotropic support her hemodynamics remained unstable. In view of refractory cardiogenic shock secondary to lactic acidosis due to aluminium phosphide poisoning, VA ECMO was planned. Elective intubation was done. Obstetrician opinion was obtained regarding morbidity and mortality of the fetus. After obtaining high risk consent, peripheral VA ECMO was initiated. Gradually after 4 hours of initiation her lactate levels started decreasing and her hemodynamics were improved. Serial POCUS monitoring was done. After 62 hours, her cardiac function improved and the fetal viability remained intact. Hence, she was successfully weaned off from ECMO.

Discussion: This case illustrates the prompt and appropriate choice of treatment in an antenatal woman with aluminium phosphide poisoning will increase the survival rate of both mother and fetus.

A Successful Case of VV ECMO Complicated by Membrane Thrombosis and Airway Haemorrhage

Kalla SujithKumar

Head of ECMO’s & Clinical Heart Failure Coordinator, AIG Hospital, Gachibowli, Hyderabad, India

DOI: 10.5005/jaypee-journals-11011-0018.5

Objective: Despite increasing use and promising outcomes Veno- Venous ECMO introduces the risk of a number of complications across the spectrum of ECMO care. This describe the variety of complication that can occur during treatment with ECMO and how patient selection and management decisions may influence the risk of these complication. ECMO has emergedasapromising intervention that may provide more efficacious supportive care to these patients. Improvements in technology have made ECMO safer and easier to use, allowing for the potential of more widespread application in patients with Acute Respiratory Failure.

Methods: Femoral-IJV cannulation with adequate flows was used to perform a Veno-Venous ECMOon a 60-year-old male patient who had been diagnosed with ARDS and developed pneumonia. From there, we faced numerous challenges for almost 36 days of ECMO, including a coagulation factor, failure of the oxygenator, an active internal bleed at the lung, aspirations from the Ryles tube, regular lab work, X-rays, ACT for hourly sometimes.

Conclusion: VVECMO is the treatment of choice for patient with respiratory failure refractory to optimal mechanical ventilation and conventional medical treatment. A baseline echo evaluation of paramount importance in such critically ill patient to rule out the presence of concomitant cardiac dysfunction. Technological advances have improved the safety and simplicity of ECMO for patients with Acute Respiratory Failure and may represent an important advance in the management of these patient. VV-ECMO is a form of mechanical circulatory support that has been shown to be effective in temporarily managing patients with profound respiratory failure.

Role of Respiratory Therapist is Essential during VV-ECMO

R Rosheeni

Apollo University, Chittor, Andhra Pradesh, India

DOI: 10.5005/jaypee-journals-11011-0018.6

Role of Respiratory therapist is essential during VV-ECMO, because mechanical ventilation is still required due to reasons that are:

• (1) ECMO blood flow rate is usually not enough and in hyperdynamic status a substantial proportion of blood still passed via native lung, not having gone through the artificial lung first;

• (2) lung should be mildly ventilated and kept open.

Role of VA-ECMO in Dengue Myocarditis

Girish IR

DOI: 10.5005/jaypee-journals-11011-0018.7

Dengue is an acute viral illness caused by a RNA virus of the family Flaviviridae and spread by the Aedes mosquito. Cardiac manifestations of Dengue fever vary from mildly raised cardiac enzymes to severe myocarditis, congestive heart failure, arrhythmia’s, cardiogenic shock and death. We present a case of 19 year old female who presented to us with cardiogenic shock and was found to be NS1 and IG M positive. She had a Mobitz type II block on her electrocardiogram (ECG) with bradycardia on arrival to the emergency room and a temporary pacemaker was placed via a femoral vein approach. She was initiated on central veno-arterial extracorporeal membrane oxygenation (VA-ECMO) with an apical left ventricular (LV) vent as a bridge to recovery. A myocardial biopsy was done at this stage. Apart from thrombocytopenia needing platelet transfusion her stay in intensive care was unremarkable. She passed the RAMP test on VA-ECMO day 5 and eventually weaned off VA-ECMO on day 7 and was successfully decannulated. Her abnormal ECG rhythm persisted and she was reviewed by the electro-physiology team. The ECG finding was deemed a conginental block, not needing a permanent pacemaker insertion. The myocardial biopsy which was done while initiating VA-ECMO showed evidence of necrotic myocardial tissue with lymphoid infiltration which cemented the diagnosis of viral myocarditis. In this case report we highlight the successful usage of VA-ECMO as a bridge to recovery in a patient with cardiogenic shock caused by viral myocarditis.

Victorious VV-ECMO in a Post Cardiac Arrest Pediatric Patient with ARDS and Bilateral Pneumothorax

Raghavendra Vagyannavar¹, BP Singh², Rajeev Gupta³

^1,2Consultant, Department of Critical Care Medicine

³Head of Department Pulmonary Critical Care Medicine, Midland Healthcare & Research Center Lucknow, Uttar Pradesh, India

DOI: 10.5005/jaypee-journals-11011-0018.8

A 12 years boy admitted with fever, dry cough for 3 days and breathlessness 1 day managed in pediatric IPD discharged on 7th day. On next day patient readmitted with breathlessness, shifted to ICU in view of hypoxic with arterial oxygen tension (PaO2) of 58mm Hg on 15L/min of oxygen via mask with a reservoir, requiring non-invasive positive pressure mode of ventilation to maintain arterial oxygen saturation. HRCT thorax showed diffuse bilateral ground glass opacities with extensive consolidation, RTPCR for covid 19 negative. The patient received empirical antibiotics, steroids for 2 days but there is no improvement in respiratory status so we took on mechanical ventilator support with intubation. Unfortunately developed bilateral pneumothorax on 5th day, managed with bilateral intercostal drains. On 7th day patient developed hypoxemia refractory to mechanical ventilation, ABG analysis showed persistent hypoxemia (PaO2 of 48mm Hg, pCO2 79, Ph7.1, lactate 3) on 100% fraction of inspired oxygen (FiO2) with positive end expiratory pressure (PEEP) of 12 cm H2O in spite of proning. On 8th day patient had cardiac arrest, ROSC achieved after 3 minutes of CPR, due to hemodynamically stable and refractory hypoxemia with respiratory acidosis (po2-33, pco2 98, Ph 7, lactate 7) decision was made to treat the patient with venous-venous ECMO. He was subsequently initiated with circuit flow of 1.2L/min and sweep gas of 4.0L/min of oxygen (FiO2 of 100%,3000RPM) with lung protective ventilation and antibiotics based on cultures. On day 13th patient shifted to KIMS Hospitals Secunderabad on ECMO in view of lung transplant, Patient weaned successfully on day 60th and discharged on 90th day of admission without need of lung transplantation. To the best of our knowledge, this is the first pediatric case report of the successful use of prolonged VV-ECMO for bilateral pneumothorax with post CPR survivor from refractory ARDS.

Haemoperfusion in Parquat Posioning

Dharanindra Moturu¹, Yelanati Ramesh²

^1,2Critical Care Department, Aster Ramesh Hospital, Vijayawada, India

DOI: 10.5005/jaypee-journals-11011-0018.9

Keywords: Paraquat, Hemoperfusion, Urine dithionite, Resin-based cartridges

Background: Paraquat (PQ) is a highly toxic weedicide when ingested causes multiple organ dysfunction followed by death if treatment is delayed. Interventions to reduce mortality were less beneficial in many case series and only a few studies have documented the use of urine dithionite tests (UDT) with hemoperfusion in prognosticating the outcomes. We aimed to determine the outcomes of hemoperfusion (HA 230) guided by UDT in patients with PQ poisoning in terms of presentation time.

Methods: This retrospective observational study involved 15 patients presented with paraquat ingestion. UDT was performed to confirm paraquat severity in all patients. Data on the ingested quantity, presentation time, complications developed, diagnostic results and treatment prognosis were collected and analysed.

Results: Of the 15 patients treated, hemoperfusion (HP) (with HA 230) was performed in 12 patients who tested positive for paraquat on UDT. The overall mortality rate was 40%. All patients presented early. (<4h) (n=6) were successfully managed. Seventy-five percent (n=3) of late presenters succumbed to death despite HP therapy. The UDT was strongly positive (+++) in all non-survivors (p<0.05). Non-survivors had higher serum creatinine and bilirubin levels at postfinal HP compared to survivors. Complications like respiratory dysfunction, hepatic failure and multiorgan dysfunction syndrome (MODS) were significantly higher in the non-survivors (p<0.05). The survival rate in patients treated with HP was higher 66.7%.

Conclusion: Early presentation and timely hemoperfusion (with HA 230) with diagnostic UDT guidance increases survival with fewer complications in cases with paraquat intoxication.

References

1. Pillay VV. Modern Medical Toxicology. Jaypee Brothers Medical Publishers (P) Ltd; 2013, :398–406.

2. Pillay VV. Paraquat: the underestimated lethal pesticide. J Indian Soc Toxicol 2007; 3(2):11–4.

3. Iyyadurai R, Mohan J, Jose A, Das S, Johnson J, Gunasekaran K. Paraquat poisoning management. Current Medical Issues. 2019 Apr 1; 17(2):34–7. 10.4103/cmi.cmi.

Intraoperative ECMO and Anesthesia Management in Challenging Airway Cases: A Comprehensive Case Series

Krishna Kumar¹, Aditya Joshi², Rajeev Nair³, Amit Lall⁴

^1–4Army Hospital Research and Referral, New Delhi, India

DOI: 10.5005/jaypee-journals-11011-0018.10

Introduction: This case series investigates the application of intraoperative extracorporeal membrane oxygenation (ECMO) and anesthesia management in three challenging airway scenarios: a) tracheal stenosis requiring resection and anastomosis, b) pulmonary alveolar proteinosis necessitating bronchoalveolar lavage, and c) intratracheal tumor leading to intratracheal stenosis managed with stenting.

Methods: A retrospective analysis was conducted on patients undergoing these intricate airway procedures between Jan 2023 and Dec 2023. The study focuses on delineating the unique challenges encountered during surgery, outlining perioperative complications, and evaluating critical care outcomes associated with using ECMO and tailored anesthesia approaches.

Results: In tracheal stenosis cases, the study underscores the nuances of resection and anastomosis, emphasizing the role of ECMO in ensuring adequate oxygenation during airway reconstruction. Pulmonary alveolar proteinosis cases highlight the significance of ECMO support in maintaining hemodynamic stability, and gas exchange during bronchoalveolar lavage. Intratracheal tumor cases with stenting explore the complexities of managing intratracheal stenosis, showcasing the critical role of ECMO in facilitating surgery and mitigating complications.

Conclusion: This case series offers valuable insights into the multifaceted challenges of intraoperative ECMO and anesthesia management in diverse airway pathologies. By addressing the specific intricacies of tracheal stenosis, pulmonary alveolar proteinosis, and intratracheal tumor with stenting, the study contributes to the evolving understanding of perioperative strategies, complications, and critical care outcomes. The findings provide practical insights for clinicians navigating complex airway interventions, guiding future approaches, and enhancing overall patient care in similar challenging scenarios.

References

1. Campo I, Luisetti M, Griese M, Trapnell BC, Bonella F, Grutters J, et al. Whole lung lavage therapy for pulmonary alveolar proteinosis: A global survey of current practices and procedures. Orphanet J Rare Dis [Internet]. 2016; 11(1):1–10. Available from: http://dx.doi.org/10.1186/s13023-016-0497-9.

2. Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, et al. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement from the Society of Cardiovascular Anesthesiologists - Part I, Technical Aspects of Extracorporeal Membrane Oxygenation. Anesth Analg. 2021 Dec 1; 133(6):1459–77.

3. Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, et al. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement from the Society of Cardiovascular Anesthesiologists - Part II, Intraoperative Management and Troubleshooting. Anesth Analg. 2021 Dec 1; 133(6):1478–93.

Prevalence and Outcomes of RV Dysfunction in VV ECMO

Ravi Krishna¹, V Gupta², V Rakesh³, K Venkatraman⁴, JV Krishna⁵, G Sricharan⁶

¹KIMS Icon hospital, critical care medicine, Visakhapatnam, India

²Hero DMC Heart Institute, Ludhiana, India,

³Gemcare Hospital, Critical Care Medicine, Hyderabad, India

⁴Yashoda Hospital, Hyderabad, India

⁵Gemcare Hospital, Hyderabad, India

DOI: 10.5005/jaypee-journals-11011-0018.11

Background: Extracorporeal membrane oxygenation (ECMO), also known as extracorporeal life support, was initially developed to extend the support provided by the cardiopulmonary bypass machine. Its use in adults has increased due to the H1N1 ARDS pandemic in 2009 and the COVID-19 ARDS pandemic in 2020. Severe acute respiratory distress syndrome can lead to acute right ventricular (RV) dysfunction, which occurs in 22 to 50% of cases. Many factors contributing to RV dysfunction in ARDS can be improved with better oxygenation and VV-ECMO implementation. However, the presence and impact of RV dysfunction after VV-ECMO cannulation are not well understood.

Aims and Objectives: To determine the prevalence and prognostic value of post-cannulation RV dysfunction, as measured by transthoracic echocardiography, in patients treated with VV-ECMO for severe ARDS.

Materials and Methods: A retrospective cohort study design was used to include consecutive patients treated with VV-ECMO between January 2013 and December 2021 at a single quaternary medical center. The institutional electronic medical record was used to identify clinical variables, comorbidities. Clinical test results, and outcomes.

Results: Out of the 37 patients, 9 patients (24.3%) survived to discharge. In terms of RV dysfunction, out of the 37 patients, 26 (70.27%) did not have RV dysfunction. Among them, 6 patients were discharged (23.1%) and 20 patients died (76.9%). On the other hand, 11 patients had RV dysfunction, with 3 patients being discharged (27.3%) and 8 patients dying (72.7%). The mortality was similar in both groups although not statistically significant (P-value 0.786).

Conclusion: RV dysfunction is prevalent even after initiation of VV ECMO (29.7%). The temporal sequence of RV function and its effects on outcomes should be evaluated with further studies in this population. Prospective multicenter studies are needed to validate alternative forms of temporary.

Transportation on ECMO: Challenges, Strategies, and Best Practices

M Dharanindra

Consultant and In charge Medical ICU at Aster Ramesh Hospital, Vijayawada, Andhra Pradesh, India

DOI: 10.5005/jaypee-journals-11011-0018.12

The transportation of patients supported with Extracorporeal Membrane Oxygenation (ECMO) poses unique challenges that demand careful coordination, specialized equipment, and a skilled transport team. This review traces the historical evolution of ECMO transportation since the pioneering work of Dr. Robert Bartlett in the 1970s and highlights the exponential growth in ECMO indications over the years. the heightened complexity associated with transporting critically ill patients on ECMO support, whether for interhospital transfers or rescues at outside facilities. The necessity for meticulous risk assessment and consideration of potential benefits is crucial during the selection of ground or air transportation methods. Ground and air transport involve adaptations of in-house ECMO support circuits and equipment, with a focus on addressing the distinctive aspects of mobile care.¹ While limited evidence guides ECMO-supported patient transport, recommendations stress the importance of well-prepared teams familiar with mobile transport. The need for ECMO transport arises from the hazards associated with conventional transfers of mechanically ventilated patients to ECMO centers, with recent studies indicating improved outcomes in centers with higher annual ECMO treatment volumes.² The means of transport, whether ground or air, introduces various advantages and challenges. Air transport, especially fixed-wing flights, offers shorter travel times but requires careful consideration of logistical challenges such as airport accessibility. Ground transport, facilitated by specialized ECMO ambulances, ensures stability in diverse weather conditions but may have limitations on maximum distance coverage.³ The composition of ECMO transport teams to be build in such a way that emphasizing the flexibility needed to handle the high complexity task with time constraints, and environmental pressures involved. Team members, including a lead, cannulating provider, ECMO specialist, and medical transport professionals, play specific roles to ensure safe and effective ECMO transport.⁴ The definition and systems of ECMO transport, as outlined by the Extracorporeal Life Support Organization (ELSO), include primary, secondary, tertiary, and intra-facility scenarios. Each scenario demands unique considerations and coordination between referring and accepting institutions. Cannulation and equipment strategies have changed widely drawing data from recent studies during the COVID-19 pandemic. A preferred cannulation strategy, utilizing specific cannula sizes and configurations, is discussed to enhance simplicity during transport and daily ICU management. In conclusion, the challenges, strategies, and best practices associated with ECMO transport are evolving greatly offering valuable insights for healthcare professionals involved in the critical task of transporting patients on ECMO support.

References

1. Labib, Ahmed*; August, Erin†; Agerstrand, Cara‡; Frenckner, Bjorn§; Laufenberg, De’ann¶; Lavandosky, Gerald||; Fajardo, Christian#; Gluck, Jason A.**; Brodie, Daniel††. Extracorporeal Life Support Organization Guideline for Transport and Retrieval of Adult and Pediatric Patients with ECMO Support. ASAIO Journal 68(4):p 447-455, April 2022. | DOI: 10.1097/MAT.0000000000001653.

2. Barbaro RP, Odetola FO, Kidwell KM, Paden ML, Bartlett RH, Davis MM, Annich GM. Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality. Analysis of the extracorporeal life support organization registry. American journal of respiratory and critical care medicine. 2015 Apr 15;191(8):894-901.

3. Lebreton G, Sanchez B, Isetta C, Hennequin JL, Mnif MA, Pécout F, Villain-Coquet L, Clerel M, Combes A, Leprince P, Roques F. Transportation of patients under extracorporeal membrane oxygenation support on an airliner: Flying bridge to transplantation. Archives of Cardiovascular Diseases. 2023 May 24.

4. Automotive industry standards committee under central motor vehicle rules – technical standing committee set-up by ministry of road transport and highways (department of road transport and highways) government of India.

Challenges Faced by an ECMO Patient – A Case Report

R Sree Sahitya¹, K Subba Reddy², Sudeep Sirga³, Niranjan Panigrahi⁴, Saranya Devi Datla⁵

^1–5Apollo Hospital, Hyderabad, India

DOI: 10.5005/jaypee-journals-11011-0018.13

Keywords: ECMO, COVID, cell free hemoglobin,hemolysis,CMV, CANDIDA AURIS

Objective: To Elaborate the challenges faced by an ECMO Patient and the issues to be overcome and how to address them and combat with the help of a multidisciplinary team.

Introduction: Severe ARDS is associated with very high mortality leads to death in 46% of cases. VV ECMO has become a frequent modality in recent years if all other rescue therapies fail. Therapy with ECMO buys time for lung recovery/transplantation and delivers lung protective ventilation meanwhile. During VV ECMO therapy venous blood is drained through a large bore cannula into an extracorporeal circuit. A pump drives the blood through a membrane oxygenator and finally oxygenated and decarboxylated blood is infused back in to a large vein of the circulation. Intravascular hemolysis is side effect of blood circulating through extracorporeal systems and membrane oxygenator. Current literature reports an incidence of 18% in patients treated with ECMO. Evidence suggests role of hemolysis in sepsis and ARDS where increased concentration of cell free hemoglobin might be associated with increased mortality. Plasma hemoglobin scavenges endothelial derived nitric oxide inducing vasoconstriction and hypertension. It also triggers proinflammatory signaling pathways. Patients receiving ECMO are at highest risk of developing nosocomial infections including fungal and viral infections due to underlying immune dysregulation and prolonged hospitalisations. Management of these infections is very challenging due to the potential for microorganisms colonization of devices, unpredictable antibiotic pharmacokinetics and challenges in removing cannulas for source control, we lose our patients to refractory sepsis most of the times. Here we present a case scenario of a young patient who witnessed all the forementioned complications and had long hospitalization stay and came out of all odds due to prompt detection and treatment and holistic approach.

Case presentation: This is a case of 34 year old male patient without any comorbidities tested positive for covid on 08/07/21 who was on home quarantine for for 8 days and reported to hospital on 16/07 in view of breathlessness, was started on oxygen, bipap and tried on remdesevir, steroids and tocilizumab and baricitinib. Patient was not maintaining saturations and was intubated on 26/07/21 and as there was refractory hypoxaemia was initiated on ECMO on the next day. Patient was started on ceftazidime and levoflox along with voricanozole as serum galactomann was positive and ET cultures showed strephonomonas maltophilia. Patient was tracheostomized on 01/08 and was keeping well till 12/08 when there were episodes of desaturation and tachypnoea and blood culture showed candida auris and BAL culture showed chryseobacterium and MDR klebsiella with NDM, OXA -48 AND VIM + Patient developed septic shock and required dual vasopressors. BAL galactomann had titres of 4.5 and patient was initiated on a mixture of ceftazidime -avibactum, aztreonam, voriconazole and anidulafungin suspecting MDR bacterial and dual fungal infection. Patient started having hemoglobinuria, high coloured urine and was quantified using plasma concentrations of cell free hemoglobin and plasma LDH. Subsequently acute kidney injury secondary to this and required 3 sessions of dialysis and the whole ECMO circuit was changed. Improvement in the parameters followed with normalization of cell free hemoglobin, blood pressure and urine output. When there was a sigh of relief as the things were getting normal patient started having heavy bouts of tracheal bleeding and bronchoscopy done again with endobronchial biopsy showing CMV endobronchitis with focal ulceration and was started on ganciclovir. Patient had high viral loads more than 1,00,000 copies. There were maleana episodes too which normalized after initiation of antivirals and CMV enterocolitis was suspected to be the cause. Patient responded to the treatment and was decannulated after multiple hurdles and events.

Conclusion: Initiating ECMO triggers a number of hematologic and inflammatory consequences. Forecasting those complications and treating them pragmatically would reverse the potential devastating consequences and improve outcomes despite numerous challenges in the journey.

Veno-venous Extracorporeal Membrane Oxygenation in Bronchopleural Fistula – A Case Report

Snehal Gokhale¹, Ashwini Jahagirdar²

¹Junior Consultant, Sahyadri Super specialty Hospital, Pune, India

²Senior Consultant & HOD, Sahyadri Super specialty Hospital, Pune, India

DOI: 10.5005/jaypee-journals-11011-0018.14

Keywords: Bronchopleural Fistula, Differential lung ventilation, VV-ECMO.

Introduction: The use of Veno-venous Extracorporeal Membrane Oxygenation in severe pneumonia is very well known when lungs are extensively damaged and conventional management has failed. In this case report, we demonstrate successful use of VV-ECMO in a patient with severe necrotizing MRSA pneumonia with Bronchopleural Fistula.

Case presentation: 42 years old man with flu like symptoms for 7 days presented to the hospital with lower respiratory tract infection with sepsis initially managed on noninvasive ventilation for a day, later required endotracheal intubation and mechanical ventilation. Respiratory biofire grew influenza and MRSA – treated with inj. Ceftaroline, inj. Linezolid, fluvir and other supportive treatment. Course complicated with spontaneous pneumothorax with bronchopleural fistula on left side required intercostal drain insertion. Bronchoscopy with instillation of glue was done for broncho pleural fistula, but leak persisted. Double lumen endotracheal tube inserted, and differential lung ventilation attempted for 12 hours but peak pressures worsened, with severe type 2 respiratory failure. Considering worsened lung mechanics-not responding to conventional treatment, VV ECMO was initiated on day 7 th of hospital admission. Complete lung rest with minimum PEEP strategy for mechanical ventilation was used. Course complicated with XDR pseudomonas ventilator associated pneumonia -treated with cefepime -zidebactum. In view of anticipated prolonged ventilation, tracheostomy was performed. blood gases and patient condition gradually improved so ECMO support weaned after 14 days. Pneumothorax and leak through ICD persisted-so patient underwent thoracoscopic decortication. There was gradual improvement and tracheostomy was decannulated on 43rd day of admission. Patient was shifted to stepdown unit and then discharged on 65 th day of admission.

Conclusion: In this case report we report the successful use of VV ECMO in 42-yrars old man with severe MRSA necrotizing pneumonia with bronchopleural fistula, given high mortality rate of necrotizing pneumonia with BPF, this case report provided evidence for use of VV ECMO as supportive care in such patients.

Successful Management of 1gm Amlodipine Poisoning with the Combination of VA-ECMO and Plasmapheresis

Balasubrahmanyam CH¹, Nisheeth TP², Ajith BR³, Varun R⁴, Dilip Khaddar⁵

^1–5Department of Critical Care Medicine, Miot International Hospitals, Chennai, Tamil Nadu, India

DOI: 10.5005/jaypee-journals-11011-0018.15

Keywords: Amlodipine overdose, VA ECMO,Plasmapheresis.

Introduction: As per the 2022 Annual Report of the National Poison Data System® the first-ranked substance was pharmaceutical in 2,250 (85.8%) of the 2,622 fatalities and of the 2,250 first-ranked pharmaceuticals 266 were cardiovascular drugs and among them, 105 were of amlodipine overdose.¹ High efficacy, low metabolic clearance, high volume of distribution, and long half-life make amlodipine a highly toxic substance if ingested in high amounts.

Case report: A 28-year-old Pediatric resident from Pondicherry presented to our emergency with a history of ingestion of 100 tablets of 10 mg of amlodipine {1000mg} along with 60 tablets of 2 mg diazepam 20 hours before presenting to our hospital. He was taken to a nearby nursing home within 4hrs of suspicion of consumption where he was intubated and was started on vasopressors and inotropes for worsening shock and oliguria. His initial ABG revealed metabolic acidosis {HCO3- 12 mmol/L and lactates of 8mmol/L. ECG showed sinus tachycardia. He was rushed to our centre because of worsening hemodynamics. On arrival, he was tachycardic(122/min) and hypotensive 84/38 mm Hg on noradrenaline infusion of 0.5 ug/kg/min. Spo2 was 90 % on fio2 of 100%. His blood gas revealed worsening metabolic acidosis with lactates of 16 and a Pa02/Fio2 ratio of 122. His Systemic vascular resistance index was 544 dynes-sec/cm², Extravascular lung water was 1260 and Cardiac index of 1.8. His screening 2D ECHO revealed global LV hypokinesia with an EF of 20% and lung USG showed B profiling. He was started on IV glucagon, High dose insulin -euglycemia therapy {HIET}and IV lipid emulsion but despite these aggressive measures his hemodynamics continued to worsen drastically over the next few hours requiring supranormal doses of vasopressors (noradrenaline 3.33 ug/kg/min, adrenaline 1.88 ug/ kg/min vasopressin 0.04Units/min and phenylephrine 0.42 ug/kg/ min) respectively just to maintain a MAP target of 65 mmHg and progressively became anuric. Given his worsening clinical condition, he was initiated on Vf-Af ECMO 21 fr arterial cannula and 29 fr venous cannula. distal perfusion with 8 fr sheath distal perfusion cannula surgically placed. The blood flow rate was 3.5 L/min, the sweep gas flow rate was 3.0 L/min and the fraction of delivered oxygen was 1.0. he received one session of plasmapheresis for 4 hours exchanging one and a half times plasma volume. Within a few hours of starting ECMO, arterial blood gas variables began improving lactates trended down to 5.8 mmol/l. Pao2 238mmhg. After 6 hours on the ECMO, the patient started to produce urine which reached normal levels after about 12 hours. Patient hemodynamics gradually improved with the progressive decline of vasopressors and inotropes and were completely stopped on the 5th day. On the 5th day he was started on ECMO weaning trial and on the 6th day he was successfully decannulated. He was found to have a floating thrombus in the right proximal femoral vein and was started on rivaroxaban Patient was shifted out of ICU after 8 days to the ward and was subsequently discharged. Wienberg et al² in similar circumstances were able to wean the patient ECMO after 8 days which could be due to the persistence of the drug in the system. Amlodipine is a highly protein-binding drug and therefore not dialyzable. On the other hand, the same property can be utilized to remove it from the system by plasma exchange. A significant amount of drug can be removed from the body by one plasma volume exchange.³ This very likely allowed for rapid return of vasomotor tone and rapid weaning of the ECMO compared to Wienberg et al who had to use ECMO for 8 days with half the amount of drug consumed which is 500 mg compared to 1000mg as in our case.

Conclusion: We like to report this case as it is probably the first instance where both ECMO and Plasmapheresis were successfully combined to revive a near-fatal amlodipine overdose.

References

1. Gummin David D.,Mowry James B.,Beuhler Michael C.,Spyker, Daniel A.Rivers, Laura J.Feldman, RyanBrown, KaitlynPham, Nathaniel P.T.Bronstein & Alvin C.DesLauriers Carol (2023) 2022 Annual Report of the National Poison Data System® (NPDS) from America’s Poison Centers®: 40th Annual Report, Clinical Toxicology, 61:10, 717-939, DOI: 10.1080/15563650.2023.2268981.

2. Weinberg RL1, Bouchard NC, Abrams DC, Bacchetta M, Dzierba AL, Burkart KM, Brodie D. Venoarterial extracorporeal membrane oxygenation for the management of massive amlodipine overdose. Perfusion. 2014 Jan;29(1):53-6.

3. Ezidiegwu C, Spektor Z, Nasr MR, Kelly KC, Rosales LG. A case report on the role of plasma exchange in the management of a massive amlodipine besylate intoxication. Ther Apher Dial. 2008 Apr;12(2):180-4.

Extracorporeal Cardiopulmonary Resuscitation (ECPR): Are We There Yet?” – Challenges Faced by a Tertiary Care Center—A Case Series Analysis

Krishna Kumar Mylavarapu¹, Aditya Joshi², Rajeev Nair³, Neha Bhardwaj⁴, Apoorva Magu⁵, Amit Lall⁶, Ankit Sinha⁷

^1,2Faculty Critical Care Medicine

³Consultant Prof & HOD Anaesthesiology and Critical Care

^4–7Senior Registrar Critical Care Medicine, India

^1–7Dept of Anaesthesiology and Critical Care, Army Hospital Research and Referral, Delhi Cantt, New Delhi, India

DOI: 10.5005/jaypee-journals-11011-0018.16

Keywords: Code Blue/Cardiac Arrest, CPR, ACLS, ECPR.

Introduction: Extracorporeal Cardiopulmonary Resuscitation (ECPR) is a revolutionary approach utilizing extracorporeal life support (ECLS) for circulatory and respiratory support during cardiac arrest. Unlike traditional CPR, ECPR extends resuscitative efforts, acting as a potential bridge to definitive treatment and significantly improving survival rates. Rapid extracorporeal membrane oxygenation (ECMO) initiation is crucial for sustaining vital organ perfusion, making ECPR a dynamic intervention that revolutionizes outcomes for patients in cardiac arrest.^1–2

Objectives: This case series explores the application of ECPR across diverse cases, aiming to identify specific challenges inherent to ECPR for refining protocols and improving patient outcomes.³

Materials and Methods: A retrospective analysis was conducted on 328 code blue activated in a busy 1000-bed tertiary care public sector teaching hospital in Northern India from January to December 2023. Challenges faced were a) lack of knowledge in patient selection for ECPR among the postgraduate residents trained in ACLS, the right time to activate ECPR b) patient age, number of comorbidities, location of code blue event (ward vs emergency unit), CPR duration, peri-arrest cardiac rhythms, availability of trained manpower, resource limitations e.g., PLS kits, and end-of-life care. ECMO parameters considered were circuit priming, the need for an automated CPR device, initiation and maintenance, cannulation complexities and complications, imaging choices, post-ECPR patient transport to the cardiac Cath lab on ECMO, the futility of care, and ethical considerations.

Results: Of the 328-code blues, only 3 (0.92%) were converted to ECPR. The mean duration on VA-ECMO was 3.67 days. One patient presented to the emergency department after 20 min of cardiac arrest with refractory Ventricular tachycardia following anterior wall MI, the remaining two were admitted to the cardiology unit, with a patient posted for transcatheter aortic valve replacement (TAVR) presented with cardiac arrest and the third was a female patient presented with cardiac arrest following severe myocarditis 03 days post illness, both within 20-30 minutes after the activation of the code. The complications and outcomes are shown in Table 1.

Conclusions: The study highlights the need for comprehensive training, meticulous logistics support, resource augmentation, futility of care, and continuous refinement of institutional protocols impacting ECPR success and safety for future implementation.⁴

References

1. Wengenmayer T, Tigges E, Staudacher DL. Extracorporeal cardiopulmonary resuscitation in 2023. Vol. 11, Intensive Care Medicine Experimental. Springer Nature; 2023.

2. Abrams D, MacLaren G, Lorusso R, Price S, Yannopoulos D, Vercaemst L, et al. Extracorporeal cardiopulmonary resuscitation in adults: evidence and implications. Vol. 48, Intensive Care Medicine. Springer Science and Business Media Deutschland GmbH; 2022.

3. Kumar KM. ECPR—extracorporeal cardiopulmonary resuscitation. Vol. 37, Indian Journal of Thoracic and Cardiovascular Surgery. Springer; 2021. p. 294–302.

4. Gulla KM, Sahoo T, Pooboni SK, Oza P. Extracorporeal cardio-pulmonary resuscitation in Indian scenario: A web-based survey. Indian Journal of Critical Care Medicine. 2021 Jun 1; 25(6):675–9.

Extracorporeal Toxin Removal (ECTR) in Paraquat Poisoning – The Broad Spectrum Use of Extracorporeal Life Support in Developing Countries

Y Ramesh¹, M Dharanindra², Dinesh G³, Manindra Reddy B⁴

¹Consultant, Nephrologist, Aster Ramesh Hospital Vijayawada, Andhra Pradesh, India

²Consultant, Critical Care Medicine and Incharge Medical ICU at Aster Ramesh Hospital, Vijayawada, Andhra Pradesh, India

³Consultant, Critical Care Medicine, Aster Ramesh Hospital, Vijayawada, Andhra Pradesh, India

⁴Critical Care Medicine Resident, Aster Ramesh, Vijayawada, Andhra Pradesh, India

DOI: 10.5005/jaypee-journals-11011-0018.17

Keywords: Paraquat, hemoperfusion, urine dithionite, resin-based cartridges

Background: Paraquat (PQ) is a highly toxic weedicide when ingested causes multiple organ dysfunction followed by death if treatment is delayed.1 Interventions to reduce mortality were less beneficial in many case series and only a few studies have documented the use of urine dithionite tests (UDT) with hemoperfusion in prognosticating the outcomes.2–3 We aimed to determine the outcomes of hemoperfusion (HA 230) guided by UDT in patients with PQ poisoning in terms of presentation time.

Methods: This retrospective observational study involved 15 patients presented with paraquat ingestion. UDT was performed to confirm paraquat severity in all patients.4–5 Data on the ingested quantity, presentation time, complications developed, diagnostic results and treatment prognosis were collected and analysed.

Results: Of the 15 patients treated, hemoperfusion (HP) (with HA 230) was performed in 12 patients who tested positive for paraquat on UDT. The overall mortality rate was 40%. All patients presented early. (<4h) (n = 6) were successfully managed. Seventy-five percent (n = 3) of late (Table 1) presenters succumbed to death despite HP therapy. The UDT was strongly positive (+++) in all non-survivors (p < 0.05). Non-survivors had higher serum creatinine and bilirubin levels at postfinal HP compared to survivors. Complications like respiratory dysfunction, hepatic failure and multiorgan dysfunction syndrome (MODS) were significantly higher in the non-survivors (p<0.05). The survival rate in patients treated with HP was higher 66.7%.

Conclusion: Early presentation and timely hemoperfusion (with HA 230) with diagnostic UDT guidance increases survival with fewer complications in cases with paraquat intoxication.

References

1. Pillay VV. Modern Medical Toxicology. Jaypee Brothers Medical Publishers (P) Ltd; 2013, :398-406.

2. Pillay VV. Paraquat: the underestimated lethal pesticide. J Indian Soc Toxicol 2007;3(2):11-4.

3. Iyyadurai R, Mohan J, Jose A, Das S, Johnson J, Gunasekaran K. Paraquat poisoning management. Current Medical Issues. 2019 Apr 1;17(2):34-7. 10.4103/cmi.cmi_29_19.

4. Li LR, Chaudhary B, You C, Dennis JA, Wakeford H. Glucocorticoid with cyclophosphamide for oral paraquat poisoning. Cochrane Database of Systematic Reviews. 2021(6).

5. Baud FJ, Houze P, Bismuth C, Scherrmann JM, Jaeger A, Keyes C. Toxicokinetics of paraquat through the heart—lung block six cases of acute human poisoning. Journal of Toxicology: Clinical Toxicology. 1988 Jan 1;26(1-2):35-50.

ECMO Bridge to Lung Transplantation Single Center Experience

M Lalani¹, V Rakesh², O Tisekar³, V Rahulan⁴, S Devi⁵, S Attawar⁶, P Dutta⁷, M Negigowda⁸, A Kamath⁹, U Shah¹⁰, M Menander¹¹, Mahesh BN¹²

^1–12Krishna Institute of Medical Sciences, Institute of Heart and Lung Transplantation, Secunderabad, India, Sir HN Reliance Hospitals, Mumbai, Maharashtra, India

DOI: 10.5005/jaypee-journals-11011-0018.18

Keywords: ECMO, ARDS, Acute Exacerbation of ILD

Purpose: Extracorporeal membrane oxygenation (ECMO) is a life-saving technique that provides respiratory and/or circulatory support to patients with end- stage lung disease who are awaiting lung transplantation. However, the outcomes of ECMO as a bridge to lung transplantation are not well studied in India. This study aimed to evaluate the clinical characteristics and survival of patients who underwent ECMO as a bridge to lung transplantation in a single centre in India.

Method: This was a retrospective analysis of 29 patients who required veno-venous ECMO as a bridge to lung transplantation from November 2021 to July 2023. Data on demographics, primary diagnosis, duration of ECMO per and post transplantation, length of hospital stay, and survival were collected and analyzed.

Results: The mean age of the patients was 55.4 years (range 28-75), and 23 (79.3%) were male. The primary diagnosis was acute respiratory distress syndrome in 6 (20.7%) patients and acute exacerbation of interstitial lung disease in 23 (79.3%) patients. The median duration of ECMO was 17.3 days (range 2-60), and the median length of hospital stay post-transplantation was 57 days (range 24-132). Of the 29 patients, 11 (37.9%) died while waiting for an organ, and 18 (62.1%) received a lung transplant. Of the 18 transplant recipients, 4 (22.2%) patients required continuation of VV ECMO post transplantation for Primary Graft Dysfunction. 14 (77.8%) survived at day 30 and 13 (72.2%) at day 180. Survival was significantly lower in patients who had ECMO duration more than 10 days compared to those who had less than or equal to 10 days (p<0.05).

Conclusion: Our study showed that VV ECMO can be used as a bridge to lung transplantation in selected patients with severe lung failure. However, the mortality rate is high among patients who require prolonged ECMO support before transplantation. Our study also highlight’s an urgent need to increase the availability of donor organs, strategies to optimize donor and reduce waiting time are needed to improve the outcomes of this population.

References

1. Iyengar, A.Eisenring, C.DePasquale, E.Ross, D.Ardehali, A. (836) - ECMO as a Bridge to Lung Transplantation: An Analysis of the UNOS Database, The Journal of Heart and Lung Transplantation, Volume 35, Issue 4, Supplement, 2016.

2. Biscotti M, Sonett J, Bacchetta M. ECMO as bridge to lung transplant. Thorac Surg Clin. 2015;25(1):17-25.DOI: 10.1016/j.thorsurg.2014.09.010. PMID: 25430426.

3. Todd EM, Biswas Roy S,Hashimi AS,Serrone R,Panchanathan R,Kang P,Varsch KE,Steinbock BE,Huang J,Omar A,Patel V,Walia R,Smith MA,Bremner RM. Extracorporeal membrane oxygenation as a bridge to lung transplantation: A single-center experience in the present era. J Thorac Cardiovasc Surg. 2017 Nov;154(5):1798-1809. DOI: 10.1016/j.jtcvs.2017.06.063. Epub 2017 Jul 31. PMID: 29042051.

False Prognostic Sign in A Patient Following ECPR – An Interesting Case Report

Bharath K Pamulapati¹, Bala S Chandrabhatla², Sasidhar Puvvula³, Sumayya U Roohi⁴, Manisha C⁵, Santosh K Paiaulla⁶, Palepu B Gopal⁷

^1–7Critical Care Department, Citizens Specialty Hospital, Hyderabad, India

DOI: 10.5005/jaypee-journals-11011-0018.19

Keywords: VA ECMO, e-CPR, Pressure natriuresis

Background: The ability of the kidney to alter urine flow and sodium excretion in response to acute changes in renal perfusion pressure – Pressure natriuresis. This is the central component that acts a feedback system for long term control of extra cellular fluid volume and blood pressure.¹ It is a non-adaptive mechanism where increased blood pressure leads to osmotically driven diuresis.²

Case Report: We would like to report a unique and rare scenario that occurred in patient on VA ECMO which was initiated as e-CPR. The patient was a 51-year-old male, known diabetic, hypertensive, post PTCA status (2021), who presented to our ER in a state of cardiogenic shock (SCAI stage C i.e. extensive rales on NIV requiring vasopressors with Lactate > 2mmol/L), quickly progressing to SCAI stage D and E leading to cardiac arrest at the time of performing PCI.High quality CPR was immediately started and converted to eCPR with VA ECMO support being initiated within 30 minutes. About an hour into the initiation of ECMO, though the vital parameters started to stabilize, the patient started to pour out urine in the range of 1500-2000 ml per hour with the total volume of exceeding 20 liters within a span of 16-18 hours. Given the background of post CPR status, we were led to believe that it was probably cranial diabetes insipidus and almost painted a grave prognosis to the family. However, the neurological examination findings and investigative results were not much in favor of a central pathology. A thorough literature review enlightened us about the fact that the positioning of the arterial cannula in relation to the renal vasculature may lead to an increased GFR and thus an increased output.³ Performing certain interventions lead to the resolution of the polyuria picture and motivated us to continue with ECMO support instead of withdrawing based on misleading signs.

Conclusion: we would like to highlight this rare scenario and an interesting solution to counter any undue withdrawal of supports.

References

1. Granger JP, Alexander BT, Llinas M. Mechanisms of pressure natriuresis. Curr Hypertens Rep. 2002 Mar;4(2):152–9.

2. Díaz-Morales N,Baranda-Alonso EM,Martínez-Salgado C,López-Hernández FJ. Renal sympathetic activity: A key modulator of pressure natriuresis in hypertension. Biochem Pharmacol. 2023 Feb;208:115386.

3. Rosen RJ, Stevens JS, Canetta PA, Siddall E. Polyuria due to Pressure Natriuresis in Venoarterial Extracorporeal Membrane Oxygenation. ASAIO Journal. 2022 Jul 28;68(7):e124–7.

H1N1 Influenza Induced Acute Respiratory Distress Syndrome With Severe Right Ventricular Dysfunction Rescued by Veno- Venous Extracorporeal Membrane Oxygenation : A Case Report

R Diptasree¹, C Dipanjan²

^1,2Department of Cardiac Anaesthesia and ECMO Services, Medica Superspecialty Hospital, Kolkata, India

DOI: 10.5005/jaypee-journals-11011-0018.20

Keywords: ARDS, HINI Influenza, Right heart failure, VV ECMO

Introduction: Extracorporeal Membrane Oxygenator is an upcoming revolutionary technology for potentially reversible severe respiratory failure cases resistant to conventional therapy. The 2009 pandemic of swine flue revealed the lethal effects of H1N1 viral infection with a hospital mortality ranging between 29 and 32%. Severe ARDS is frequently complicated by right ventricular failure associated with high mortality and influencing the choice of ECMO modes. There is limited literature on management of RV failure during VV ECMO support.

Case presentation: We report a case of 34 years old male patient, with respiratory pannel test positive for Influenza A virus, presenting with fever for one day, respiratory distress along with one episode of ventricular tachycardia which got controlled by cardioversion. Refractory hypoxia, inspite of full ventilation and proning-trial, necessitated the initiation of rescue femoral-femoral VV ECMO and was transferred to our institute on ECMO transport. He had echocardiography revealing severe right ventricular dysfunction and tricuspid regurgitation, acute kidney injury, deranged liver function and increased lipase with USG revealing hepatomegaly and bulky pancreas. He required several cycles of hemodialysis after which urine output got improved, was put on antiviral therapy along with broad spectrum antibiotics, underwent early tracheostomy and maintained hemodynamics with inotropic support, antiarrythmic medication along with lung protective ventilation and supportive management. Gradually his symptoms improved, was taken off ECMO and gradually inotropes were tapered off. However, he developed right sided hemiparesis with worsening sensorium and absent seizures, MRI brain showing left middle cerebral artery and left posterior cerebral artery territory infarct possibly resulting from embolic stroke — a complication of ECMO. He was put on neuroprotective medication, and after gradual weaning from ventilatory support and prolonged rehabilitation he was discharged in a stable condition with regular follow-up.

Conclusion: VV ECMO is an effective salvage yet complicated and high-risk therapy when provided early in ARDS patients at specialised reference centre with adequate trained staff.

Anesthesia Management for Complex Airway Cases with Intraoperative ECMO: A Panacea or Challenge? – A Comprehensive Case Series

Krishna Kumar Mylavarapu¹, BC Nambiar², Rajeev Nair³, Manish Dhawan⁴, Aditya Joshi⁵, Shyam Madabushi⁶

^1–4Dept of Anaesthesiology and Critical Care, Army Hospital Research and Referral, Delhi Cantt, New Delhi, India

^1,4Faculty Critical Care Medicine2 Consultant Anaesthesiology

³Consultant & HOD Anaesthesiology and Critical Care

DOI: 10.5005/jaypee-journals-11011-0018.21

Keywords: Intraoperative ECMO, Bifemoral VV ECMO, Difficult airway

Introduction: Administering anesthesia for procedures involving complex airways is inherently challenging. The integration of intraoperative Extracorporeal Membrane Oxygenation (ECMO) is a rare and distinct challenge to the field of anesthesia. Effectively managing the complexities of advanced life support through ECMO requires a comprehensive understanding of both these intricate domains.¹

Methods: A retrospective analysis was conducted on patients undergoing intricate airway procedures between Jan 2023 and Dec 2023. The study focuses on the unique challenges encountered during surgery, outlining perioperative complications, and evaluating critical care outcomes associated with using ECMO and tailored anesthesia approaches, in three challenging airway scenarios: a) Tracheal stenosis requiring resection and anastomosis, b) pulmonary alveolar proteinosis necessitating bronchoalveolar lavage under one-lung ventilation, managed with VV ECMO under general anaesthesia and c) intratracheal tumor for resection and placement of self-expanding metal (SEMS) stent-under Awake VV- ECMO.

Results: The mean duration of perioperative ECMO was 4 days. The study underscores the role of ECMO in maintaining hemodynamic stability, and gas exchange during intratracheal tumor resection and stenting done in awake patient and in bronchoalveolar lavage in pulmonary alveolar proteinosis both done in Jugular-femoral configuration and airway reconstruction in a case of tracheal stenosis for resection and anastomosis done in Bifemoral ECMO (see Fig 1 & 2). There were no complications in all three cases and were discharged uneventfully.

Conclusion: The study has limitations as these cases are rare; however, it offers valuable insights into the multifaceted challenges of intraoperative ECMO and anesthesia management in diverse airway pathologies.^2–3 By addressing the specific intricacies of using intraoperative ECMO in tracheal stenosis, pulmonary alveolar proteinosis, and intratracheal tumor with stenting, the study contributes to the evolving understanding of perioperative strategies, complications, and critical care outcomes. The findings provide practical insights to anesthesiologists in the perioperative period navigating complex airway interventions, guiding future approaches, and enhancing overall patient care in similar challenging scenarios.

References

1. Campo I, Luisetti M, Griese M, Trapnell BC, Bonella F, Grutters J, et al. Whole lung lavage therapy for pulmonary alveolar proteinosis: A global survey of current practices and procedures. Orphanet J Rare Dis [Internet]. 2016; 11(1):1–10. Available from: http://dx.doi.org/10.1186/s13023-016-0497-9.

2. Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, et al. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement from the Society of Cardiovascular Anesthesiologists - Part I, Technical Aspects of Extracorporeal Membrane Oxygenation. Anesth Analg. 2021 Dec 1; 133(6):1459–77.

3. Mazzeffi MA, Rao VK, Dodd-O J, Del Rio JM, Hernandez A, Chung M, et al. Intraoperative Management of Adult Patients on Extracorporeal Membrane Oxygenation: An Expert Consensus Statement from the Society of Cardiovascular Anesthesiologists - Part II, Intraoperative Management and Troubleshooting. Anesth Analg. 2021 Dec 1; 133(6):1478–93.

Neonatal ECMO in India – Another Ray of Hope

Parvathy S Menon¹, Vasanth Kumar², Parth Devendrabhai Dalal³, Suchitra Ranjit⁴, Rajeshwari N⁵, Priyavarthini-V⁶, Chidambaram L⁷, K Madhan Kumar⁸, Thangaraj Paul Ramesh⁹, Immanuel Rajasingh¹⁰

^1,3Academic Registrar, PICU, Apollo Children’s Hospital, Chennai, Tamil Nadu, India

^2,7,8Consultant, PICU, Apollo Children’s Hospital Chennai, Tamil Nadu, India

⁵Senior Consultant and HOD, Department of Paediatric Critical Care, Apollo Children’s Hospital Chennai, Tamil Nadu, India

⁶Senior Consultant, PICU, Apollo Children’s Hospital Chennai, Tamil Nadu, India

^8,9Senior Consultant Department of Cardiothoracic, ECMO, VAD and Transplant surgery, Apollo Hospital Chennai, Tamil Nadu, India

¹⁰Senior Perfusionist, Apollo Hospital Chennai, Tamil Nadu, India

DOI: 10.5005/jaypee-journals-11011-0018.22

Keywords: ECMO, MAS, PPHN.

Introduction: ECMO (Extra Cardiovascular Membrane Oxygenation) is used to treat newborns with severe respiratory and/or cardiac failure with a probable reversible aetiology when conventional therapies have failed. Currently, neonatal cases account for < 10% of all ECMO runs. The majority of newborn ECMO cases (78%) are with a primary respiratory diagnosis. Common neonatal diagnoses include Congenital Diaphragmatic Hernia (CDH), Meconium aspiration syndrome (MAS) and Persistent pulmonary hypertension of newborn (PPHN), which account for approximately 75% of all newborn respiratory ECMO cases.¹

Case presentation: We describe a case of a newborn with severe MAS with PPHN that was successfully treated with Veno-arterial ECMO. It is one of the rare cases of neonatal ECMO transport in India. The baby was born to a primi mother with history of fever and amniotic fluid leakage for 2 days. An emergency LSCS was performed due to thick meconium-stained liquor. The baby had APGAR scores of 8 at 1’ and 9 at 5’and developed respiratory distress soon after birth. Chest X-ray revealed bilateral white out lungs. She was intubated in 4 hours of life and initiated on mechanical ventilation. Empirical antibiotic therapy-Piperacillin-tazobactam, Amikacin was commenced. Echocardiography revealed pulmonary hypertension; hence Sildenafil, Milrinone and inhaled nitric oxide was started. She was initiated on high frequency oscillatory ventilation on post-natal day 3 to address refractory hypoxia. She also required noradrenaline, dobutamine and dopamine infusions for shock. Veno-arterial ECMO was initiated on post-natal day 4 for severe MAS/ PPHN. Indications for VA-ECMO were refractory hypoxemia despite maximum respiratory support and 100 % FiO2 (oxygenation index > 40), pulmonary hypertension and catecholamine refractory shock. ECMO cannulation was done by our team in referral hospital. We used peripheral canulation strategy. By open technique right internal jugular vein as the drainage and right common carotid artery as return were cannulated with 12 Fr and 8 Fr canula respectively (Cannula position – Fig 1). After initiation of ECMO she was safely transported to our centre. In our centre she was initiated on full ECMO flows and kept on rest lung settings. Anticoagulation with heparin was initiated with an aPTT target of 40 - 60. i NO was continued; Levosimendan and milrinone cycling was used for pulmonary afterload reduction. She also had fluid overload while on ECMO for which CRRT-CVVHDF was initiated with drainage pre-oxygenator and return to pre-pump. CRRT was done for 4 days. She developed Stenotrophomonas bacteremia on day 5 of ECMO which was managed with Levofloxacin and Cotrimoxazole. She was decannulated on day 6 of ECMO after reaching 30 % ECMO flows and extubated to HFNC on day 11 of admission. She was discharged home on day 29 of life. She had celebrated her first birthday recently and is developmentally normal.

Conclusion: Neonatal ECMO for MAS is associated with good outcome if initiated appropriately. Thus, neonates with MAS refractory to conventional modalities should be evaluated as a possible ECMO candidate. Timely referral, following appropriate patient selection and exclusion criteria will help in optimising outcomes.

References

1. ELSO-2017-Guidelines-Neonatal-Respiratory-Failure.pdf [Internet]. [cited 2023 Dec 20]. Available from: https://www.heartuniversity.org/wp-content/uploads/ELSO-2017-Guidelines-Neonatal-Respiratory-Failure.pdf.

2. Louis D, Sundaram V, Mukhopadhyay K, Dutta S, Kumar P. Predictors of mortality in neonates with meconium aspiration syndrome. Indian Pediatr. 2014 Aug;51(8):637–40.

3. Oza P, Goyal V. Portable ECMO and Transport. J Pediatr Crit Care. 2017 Jun;4(2):82.

Persistent Burkholderia Cenocepacia Bacteremia in VV ECMO – Clearing The Clutter

Parvathy S Menon¹, Vasanth Kumar², Suchitra Ranjit³, Rajeshwari N⁴, Priyavarthini--V⁵, Chidambaram L⁶, K Madhan Kumar⁷, Thangaraj Paul Ramesh⁸, Immanuel Rajasingh⁹

¹Academic Registrar, PICU, Apollo Children’s Hospital, Chennai, Tamil Nadu, India

^2,5,6Consultant, PICU, Apollo Children’s Hospital Chennai, Tamil Nadu, India

³Senior Consultant and HOD, Department of Paediatric Critical Care, Apollo Children’s Hospital Chennai, Tamil Nadu, India

^7,8Senior Consultant, PICU, Apollo Children’s Hospital Chennai, Tamil Nadu, India

⁵Senior Consultant Department of Cardiothoracic, ECMO, VAD and Transplant surgery, Apollo Hospital Chennai, Tamil Nadu, India

⁹Senior Perfusionist, Apollo Hospital Chennai, Tamil Nadu, India

DOI: 10.5005/jaypee-journals-11011-0018.23

Keywords: Burkholderia cenocepacia, persistent infection, ECMO

Introduction: ECMO has been used as a successful rescue modality for pediatric ARDS. Patients on ECMO are at risk for infectious complications. The most common organism causing sepsis in ECMO patients were coagulase-negative staphylococcus followed by Candida and Pseudomonas species. Early identification of sepsis, source control and optimal antibiotic therapy is the key to better patient outcome.¹

Case description: A 4-year-old girl with human metapneumovirus pneumonia/ severe ARDS was referred to our centre on day 7 of mechanical ventilation. Considering severe viral pneumonia with secondary infection, Ceftazidime-avibactam, Aztreonam, Vancomycin and Micafungin were commenced. She was initiated on VV-ECMO as refractory hypoxemia and hypercarbia persisted despite maximum ventilatory support. Peripheral canulation strategy with right femoral vein as drainage and right internal jugular vein as return was used (Fig 1). Blood cultures taken at admission were reported positive for Burkholderia cenocepacia. Thus, antibiotic therapy with IV Cotrimoxazole was initiated and Ceftazidime was continued. Blood cultures were repeated every 48 hours. Despite dual antibiotic therapy, blood cultures remained positive for Burkholderia. Thus, Cotrimoxazole dose was increased and changed to oral route considering circuit sequestration of IV antibiotics. Venous doppler and echocardiography seeking for thrombus and vegetations were negative. Considering ECMO circuit colonisation, pre- and post-membrane blood cultures were sent. Oxygenator colonisation was identified with pre-oxygenator cultures being sterile and post-oxygenator showing burkholderia. Hence, oxygenator was changed on ECMO day 10. Antibiotics were discontinued on day 18 of ECMO in view of clinical improvement and bacteraemia clearance. On day19 of ECMO, she had worsening lung infiltrates (Fig 2) and thrombocytopenia. Repeat Blood cultures revealed Burkholderia cenocepacia; hence combination therapy with oral Cotrimoxazole, IV Ceftazidime and IV Minocycline was commenced. As pulmonary status improved, she was weaned off ECMO and decannulated on day 26 of ECMO. Repeat Blood cultures on day 6 after decannulation showed no growth. Antibiotics were discontinued after 7 days of documented bacteraemia clearance.

Conclusion: This case highlights the importance of early identification and initiation of appropriate antibiotic therapy in presumed sepsis. Antibiotic strategies in persistent bacteraemia include combination therapy, usage of higher dose and considering oral route and prolonged duration of therapy. These strategies may help in clearance of bacteraemia till definite source control is done

References

1. Jain A, Mehta Y. Sepsis Associated with Extracorporeal Membrane Oxygenation. J Card Crit Care TSS. 2022 Jul;06(02):146–50.

2. Cheng V, Abdul-Aziz MH, Roberts JA, Shekar K. Optimising drug dosing in patients receiving extracorporeal membrane oxygenation. J Thorac Dis. 2018 Mar;10(Suppl 5):S629–41.

3. Gomez F, Veita J, Laudanski K. Antibiotics and ECMO in the Adult Population-Persistent Challenges and Practical Guides. Antibiot Basel Switz. 2022 Mar 4;11(3):338.

Exploring The Role of ECMO - A Single Center Experience

Sumayya Uzma Roohi¹, Balasubrahmanyam CH², Santosh Kumar Paiulla³, Bharath Kumar Pamulapati Paiulla⁴, Sasidhar P⁵, PBN Gopal⁶

DOI: 10.5005/jaypee-journals-11011-0018.24

Keywords: Cardiogenic shock, ARDS, DVT, Neuropraxia

Introduction: ECMO has become an essential tool in management of cardio respiratory failure where other interventions collapse.

Objective: This study aims to present a single center experience with ECMO, focusing on the clinical outcomes, patient selection criteria, and the role of ECMO in various patient populations.

Methodology: A retrospective, observational study of patients who received ECMO in one year at Citizens speciality hospital, Hyderabad from November 2022 to November 2023. In our study, we encountered a total of 14 cases of ECMO usage, with VA ECMO being performed in 10 cases of carcinogenic shock across various case scenarios, and VV ECMO being utilised in 4 cases. Indication of VV ECMO included severe acute respiratory distress syndrome refractory to conventional ventilator management and recruitment manoeuvres. Decision to initiate ECMO was based on several factors including the severity of cardiac dysfunction, refractory hypotension,and inadequate response to conventional therapies such as medication and IABP support. Additionally, one case of VV ECMO was used in the context of extracorporeal cardiopulmonary resuscitation (ECPR).

Results: The mortality rate was measured as 50% (2 deaths in 4 cases) for VV ECMO and 50% (5 deaths in 10 cases) for VA ECMO. When comparing the outcomes of patients using various common scoring systems such as RESP, PRESERVE, and PRESET in VV ECMO, and SAVE and PREDICT in VA ECMO, none of these scores correlated with the outcome of our patients. The most frequently observed complications included deep vein thrombosis (DVT) at a rate of 28.57%, bleeding at a rate of 14.28%, and neuropraxia at a rate of 14.28%. Other significant issues that were addressed included brain death and withdrawal from extracorporeal membrane oxygenation (ECMO).

References

1. Pratt, E.H.,Morrison, S.,Green, C.L. et al. Ability of the respiratory ECMO survival prediction (RESP) score to predict survival for patients with COVID-19 ARDS and non-COVID-19 ARDS: a single-center retrospective study. j intensive care 11, 37 (2023).

2. Pillai AK, Bhatti Z, Bosserman AJ, Mathew MC, Vaidehi K, Kalva SP. Management of vascular complications of extra-corporeal membrane oxygenation. Cardiovasc Diagn Ther. 2018 Jun;8(3):372-377. DOI: 10.21037/cdt.2018.01.11. PMID: 30057883; PMCID: PMC6039794.

3. Sahu MK, Vaswani P, Bipin C, Singh SP, Hadda V. Enigma of apnea test for brain death on ECMO-an ongoing discussion-case study and review of literature. Indian J Thorac Cardiovasc Surg. 2021 Mar;37(2):188-191. DOI: 10.1007/s12055-020-01008-w. Epub 2020 Sep 1. PMID: 32904971; PMCID: PMC7462103.

The Role of Dual Lumen Single Cannula (DLSC) in ECMO Patients - Our Experience–A Case Series

Paul Ramesh Thangaraj¹, Madhan Kumar Kuppusamy², Thirugnanasambandan Sunder³, Kalimuthu Balasubramanian Sriraman⁴, Chinnasamy Selvi⁵, Srinivasan Yasvanth Kumar⁶

^1–6Department of Cardiothoracic Surgery at Apollo Hospital, Greams road, Chennai, Tamil Nadu, India

DOI: 10.5005/jaypee-journals-11011-0018.25

Keywords: Dual lumen single cannula (DLSC), V-V ECMO, Early mobilization in ECMO patients

Introduction: The Dual Lumen Single Cannula (DLSC) ECMO aims to redefine and offer an efficient solution for enhanced cardiopulmonary support. This technology, with single cannula housing dual lumens, combines venous drainage and reinfusion pathways.

Objectives: DLSC ECMO helps avoid groin cannulation and as such is expected to help with early mobilization and better patient compliance (1) typical for patients requiring venovenous extracorporeal membrane oxygenation (V-V ECMO. However, flow rates are comparably less than traditional dual cannula VV ECMO. We analyze our experience over 12 years to see its role in VV ECMO.

Methodology: A single-center retrospective study was conducted on all patients supported with ECMO using a DLSC from June 2011 to December 2023.

Results: Out of 208 ECMOs, 10 patients (4.81%) were treated using the DLSC ECMO method. Among these 10 patients, 1 patient underwent V-PA ECMO. The median age of the patients was 52 years, consisting of 40% females and 60% males. The primary cause of the DLSC - ECMO treatment was ARDS due to Covid pneumonia in 4 out of 10 patients (40%), followed by ARDS due to atypical pneumonia in 1 out of 10 patients (10%), ILD exacerbation in 2 out of 10 patients (10%), IPF exacerbation in 1 out of 10 patients (10%), hypercapnic respiratory failure (S/P LVAD, RVAD and Impella) in 1 out of 10 patients (10%) and Paraquat poisoning induced Lung fibrosis in 1 out of 10 patients (10%). 6 out of 10 patients (60%) were extubated during ECMO, 1 / 10 (10%) underwent tracheostomy. 5 out of the 10 patients (50%) were mobilized while on ECMO. The in-hospital survival rate was 60% (6 out of 10).

Conclusion: Only a small fraction of patients were eligible for DLSC (2). In general patients considered as high risk or who required high flows of who had a background of sepsis did not benefit from DLSC. However, in patients in whose flow was adequate to maintain gas exchange, it was useful in early mobilization.

References

1. Noe C, Rottmann FA, Bemtgen X, Supady A, Wengenmayer T, Staudacher DL. Dual lumen cannulation and mobilization of patients with venovenous extracorporeal membrane oxygenation. Artif Organs. 2023; 47(10):1654–62.

2. Bazan VM, Taylor EM, Gunn TM, Zwischenberger JB. Overview of the bicaval dual lumen cannula. Indian J Thorac Cardiovasc Surg. 2021 Apr 1; 37(2):232–40.

Surgical Cutdown and Semi-Seldinger Technique for Placing Distal Perfusion Cannula After Percutaneous Placement of Arterial Return Cannula In VA ECMO- Our Experience

MuhammedShereef K¹, Dipanjan Chatterjee²

CardiacAnaesthesia and ECMO Services, Medica Superspecialty Hospital, Kolkata, India

DOI: 10.5005/jaypee-journals-11011-0018.26

Background: Extracorporeal Membrane oxygenation has become a revolutionary technology for cardiopulmonary failure refractory to conventional management. Placement of femoral percutaneous arterial cannula is preferred as lesser invasive and faster technique but may lead to cannulation related limb complications in 10 to 70% of cases. To preserve distal limb perfusion, distal perfusion cannula (DPC) is usually being obtained before placing the main arterial cannula. But it can be challenging after main arterial cannulation especially when the patient is in shock. Our aim was to compare the technical benefits and time consumed for cannulating distal perfusing artery by surgical dissection and semi- Seldinger technique under direct vision in difficult cases while looking for the possible peri-procedural complications.

Method: After unsuccessful attempts for anterograde placement of guide-wire via superficial femoral artery (SFA) under USG-guidance; ECMO physician would directly proceed with percutaneous placement of arterial return cannula at common femoral artery (CFA) and ECLS would be initiated. Vascular surgeon would be called to dissect SFA and cannulate using 6-8Fr distal perfusion sheath by semi- Seldinger technique under direct vision within 1-2 hours of arterial cannulation. Side arm of the sheath was connected to the side port of the arterial cannula after de-airing and maintained flow at 150-200ml/min. In the subsequent hours distal perfusion was checked by clinical examination of the limb viz. warmth, colour change, stiffness of the joints and Doppler assessment of the arterial system of lower limbs.

Results: In 17 cases where ECMO physician failed to place distal perfusion cannula; arterial cannulation and ECMO initiation got delayed approximately by 15 minutes and 30 minutes respectively. Surgeon took less than 15 minutes to dissect out SFA and cannulated under direct vision within 5 minutes and achieved distal limb perfusion by 20 seconds without any surgical complications like bleeding, hematoma or infection.

Conclusion: Thus in instances where patient is in circulatory shock and need an urgent ECLS with difficult vascular access, primary arterial cannulation and ECLS initiation followed by surgical exploration of SFA and semi-seldinger technique of cannulation for distal perfusion can be tried with minimal ischemic and vascular complications.