Background: Refractory hypoxia and hypercapnia are a rare and severe dangerous complication of acute respiratory distress syndrome (ARDS) leading to mortality and morbidity. Venovenous extracorporeal membrane oxygenation (VV ECMO) is reported as one of the rescue treatments for this life-threatening hypoxia and hypercapnia. Case presentation: A 12-year-old boy with refractory ARDS managed with mechanical ventilation but complicated by bilateral pneumothorax and cardiac arrest. Venovenous extracorporeal membrane oxygenation was initiated because of severe hypoxia and hypercapnia due to his worst lung condition shifted to a lung transplant center on ECMO. The patient was weaned successfully on day 60th and discharged on the 90th day of admission without the need for lung transplantation. Conclusion: Venovenous extracorporeal membrane oxygenation can be considered for supportive therapy in refractory severe acute respiratory failure after failing all conventional measures. To get the best results, ECMO should be initiated as early as possible in refractory ARDS patients.

Aim and background: Tracheal stenosis, arising from intubation-related trauma, poses challenges in management, particularly during rigid bronchoscopy (RB). This case explores the effective use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) during tracheal stent placement for central airway obstruction. Case description: A 44-year-old male chronic obstructive pulmonary disease (COPD) patient with postcardiac arrest presented with worsening respiratory symptoms. Diagnosed with postintubation tracheal stenosis (PITS), initial flexible bronchoscopy attempts failed. Rigid bronchoscopy with tracheal stenting was planned. Due to comorbidities, VA-ECMO was initiated before the procedure. Upon arrival in the operating room (OR), ECMO was initiated under local anesthesia. Cannulation involved a 29 Fr venous cannula and a 17 Fr arterial cannula. Systemic anticoagulation was maintained. Anesthesia was induced, and the patient was intubated with a 4.5-size rigid bronchoscope. Stenotic segment dilation and 12-mm silicone tracheal stent placement were performed. Postprocedure, ECMO was gradually weaned, and the patient maintained stable hemodynamics. The patient underwent successful stenting with ECMO support, resulting in improved oxygenation and obstruction resolution. Conclusion: Tracheal stenosis poses challenges in therapeutic strategies, with stenting carrying inherent risks. In this case, VA-ECMO provided continuous oxygenation during the procedure, aligning with recent studies favoring its use in central airway obstruction. The successful application of VA-ECMO in our case supports its safety and effectiveness. Clinical significance: This case underscores the successful utilization of VA-ECMO in managing PITS during tracheal stenting. The decision to employ ECMO should involve a multidisciplinary approach. Acknowledging potential complications, our findings emphasize the need for further research. Integrating VA-ECMO in tracheal stenosis interventions ensures collaborative airway management, ensuring patient safety and optimal outcomes.

Acute respiratory distress syndrome (ARDS) due to viral or bacterial lower respiratory tract infections is a common indication for mechanical ventilatory support in children. Common viruses involved include Influenza A or B, Parainfluenza, Adenovirus, Coronavirus, and Measles. While the standard respiratory support for pediatric ARDS (pARDS) includes conventional ventilatory support along with non-ventilatory measures, a minority of patients develop refractory hypoxemia and warrant higher forms of ventilation like high-frequency oscillatory ventilation (HFOV) and occasionally extracorporeal membranous oxygenation (ECMO). Extracorporeal life support organization (ELSO) guidelines have recommended the use of ECMO in reversible refractory hypoxemia. Here, we describe a toddler with severe ARDS and air leak, who was managed with veno-venous ECMO (VV ECMO) and bronchoscopy toilets.

Acute poisoning is a common problem faced by physicians working in emergency units all across the globe. Severe acute toxicity can be life-threatening or fatal. The death can either be due to cardiovascular or respiratory failure. These toxicities can be accidental, homicidal, or suicidal. Cardiac arrhythmias leading to fatal cardiac arrest, seizures, hypotension, and respiratory depression are some of the features of acute poisoning and can lead to the death of the patient if not treated in a timely manner. The poison profile varies all over the world; with the causative agents being widely different from one part of the world to another. For example, cardiotoxic drugs are common poisons in our country, while pesticides and other household toxins are common in various other domains. Some commonly used patterns of toxicity which are frequently encountered in clinical practice are overdose of medications, drug abuse, ingestion of household or industrial chemicals, and poisoning by plant or animal toxins. In our country, irrespective of the nature of the toxin, the patients affected are relatively young and usually healthy with most of them being bread earners of their families. Extracorporeal life support (ECLS) is increasingly being used as a bridge therapy in the management of acute severe ALP poisoning-induced cardiac arrest or cardiogenic shock. The basic principles in the management of intoxication include decreasing further absorption and increasing elimination of the toxin, administration of antidote, and general supportive measures. The rationale for using ECMO in such cases is to enhance the toxin metabolism and maintenance of adequate cardiac output/oxygenation and tissue perfusion. Despite the evidence of favorable outcomes with ECMO, there are no clear guidelines for the timeline for treatment with ECMO in the existing literature. Hence, it is still not widely used clinically for ALP poisoning. The Extracorporeal Life Support Organization (ELSO) may help in resolving some of these issues since it supports worldwide data collection for the use of ECMO in acute intoxication.

Introduction: Children on extracorporeal membrane oxygenation (ECMO) support need adequate sedation and analgesia for optimal care. Often, they need neuromuscular blocking agents (NMBAs). These drugs are associated with adverse consequences. The current survey was done to identify the sedation practices in children on ECMO support. Materials and methods: An online survey was conducted via Google form in December 2023. The Google form was circulated among the members of the ECMO Society of India and personal contacts. ECMO specialists and pediatric intensivists performing pediatric ECMO were requested to respond. The survey had 29 questions in five domains: demographics, drug details, protocols, sedation withdrawal, and outcomes. Results: There were 19 responses in the survey from across eight states, and were predominantly from non-government organizations. All except one used a combination of sedatives and analgesics for optimal sedation; midazolam and fentanyl were the most common combination (44%). About 37% of the respondents used dexmedetomidine as the first-line sedative agent. Two thirds of the respondents reported that children on ECMO have greater difficulty in achieving adequate sedation and 42% used sedative and analgesic doses higher than the usual doses. About 37% of all children received NMBAs. Two-thirds of the respondents never practice awake ECMO. Ramsay sedation scale (RSS) (36.8%) and richmond agitation sedation scale (RASS) (31.6%) were commonly used for sedation assessment and withdrawal assessment tool (WAT-1) (63.2%) was the most commonly used withdrawal scale. Nearly 80% of the respondents reported that sedation-related adverse events (SRAEs) affect the overall outcomes including the duration of ventilation or duration of pediatric intensive care unit (PICU) stay or duration of hospital stay in children on ECMO. Conclusion: In this survey, we observed that a combination of benzodiazepines and opioids was the preferred agent with increasing use of dexmedetomidine as a first-line agent in children on ECMO. A greater proportion of children on ECMO have difficulty in achieving optimal sedation and need for higher doses or NMBAs. Future studies should focus on reporting sedation practices, effects on outcomes, and methods to improve outcomes related to sedation in children on ECMO. Clinical significance: Sedation in children on ECMO poses a challenge and optimal sedation strategies to be employed for best results minimizing adverse consequences.