544486 research-article2014
PRF0010.1177/0267659114544486PerfusionChan-Dominy et al.
Original paper
Extracorporeal membrane modality conversions
Perfusion 2015, Vol. 30(4) 291–294 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659114544486 prf.sagepub.com
ACF Chan-Dominy,1 M Anders,1 J Millar,1 S Horton,2 D Best,1 C Brizard,2 Y D’Udekem,2 A Hilton3 and W Butt1
Abstract We report the case of a patient with cardiovascular and respiratory failure due to severe anaphylaxis requiring multiple extracorporeal membrane oxygenation (ECMO) cannulation strategies to provide adequate oxygen delivery and ventilatory support during a period of rapid physiological change. ECMO provides partial or complete support of oxygenation-ventilation and circulation. The choice of which ECMO modality to use is governed by anatomical (vessel size, cardiovascular anatomy and previous surgeries) and physiological (respiratory and/or cardiac failure) factors. The urgency with which ECMO needs to be implemented (emergency cardiopulmonary resuscitation (eCPR), urgent, elective) and the institutional experience will also influence the type of ECMO provided. Here we describe a 12-year-old schoolgirl who, having been resuscitated with peripheral veno-venous (VV) ECMO for severe hypoxemia due to status asthmaticus in the setting of acute anaphylaxis, required escalation to peripheral veno-arterial (VA) ECMO for precipitous cardiovascular deterioration. Insufficient oxygen delivery for adequate cellular metabolic function and possible cerebral hypoxia due to significant differential hypoxia necessitated ECMO modification. After six days of central (transthoracic) VA ECMO support and 21 days of intensive care unit (ICU) care, she made a complete recovery with no neurological sequelae. The use of ECMO support warrants careful consideration of the interplay of a patient’s pathophysiology and extracorporeal circuit dynamics. Particular emphasis should be placed on the potential for mismatch between cardiovascular and respiratory support as well as the need to meet metabolic demands through adequate cerebral, coronary and systemic oxygenation. Cannulation strategies occasionally require alteration to meet and anticipate the patient’s evolving needs. Keywords ECMO; extracorporeal membrane oxygenation; anaphylaxis; status asthmaticus; shock; resuscitation
Case Description A 12-year-old, 40 kg, female patient with a known history of asthma and peanut allergy developed severe bronchospasm upon accidental ingestion of a peanut– containing sandwich. After salbutamol inhaler therapy, the school nurse administered two doses of intramuscular epinephrine. On arrival of the paramedical team, the child was semi-conscious, with a pulse and cardiac output present. Pulse oximetry was 74% on bag-mask ventilation (FiO2 1.0) and, after four doses of intravenous (iv) 10 µg/kg epinephrine for worsening bronchospasm, there was a loss of cardiac output, therefore, cardiopulmonary resuscitation (CPR) was initiated. The return of spontaneous circulation occurred after 11 minutes, during which she was intubated and received five further doses of iv 25 µg/kg epinephrine. En route to the nearest tertiary hospital, an epinephrine infusion was started in addition to multiple epinephrine boluses (each 25 µg/kg,
totalling 20 mg) for recurrent bradycardia and severe bronchospasm. On arrival at the hospital, the mean arterial pressure was over 60 mmHg on epinephrine 10 1Intensive
Care Unit, Royal Children’s Hospital, Melbourne, VIC 3052, Australia 2Department of Cardiac Surgery, Royal Children’s Hospital, Melbourne, VIC 3052, Australia 3Department of Intensive Care, Austin Hospital, Melbourne, VIC 3084, Australia Corresponding author: Marc Anders Paediatric Intensive Care Unit Royal Children’s Hospital Melbourne VIC 3052 Australia. Email: [email protected]
292
µg/kg/min. Multimodal asthma-directed therapy was instituted with corticosteroid, salbutamol (5 µg/kg), magnesium (20 mmol), aminophylline (10 mg/kg), neuromuscular blockade (vecuronium 30 mg) and morphine infusion. The patient failed to respond to conventional medical treatment and ventilation strategies (FiO2 1.0, peak inspiratory pressure 45 cmH2O, positive end-expiratory pressure 10 cmH2O, mean airway pressure 18 cmH2O, frequency 10 – 20), with the pH 6.48, pCO2 236 mmHg, pO2 443 mmHg, base excess -18.2 and lactate 14.6 mmol/L. Echocardiography showed mild impairment of biventricular function and no inter-atrial communication. Percutaneous femoro-femoral VV ECMO support with 19Fr drainage and return cannulae was commenced, allowing epinephrine wean. Extracorporeal blood flow was titrated up to 4 L/min (Jostra Rotaflow Pump, Maquet Cardiopulmonary AG, Hechingen, Germany with Maquet Quadrox Pediatric Oxygenator, Maquet Cardiopulmonary AG) and sweep gas flow to 4 L/min of oxygen. However, the patient developed intractable ventricular fibrillation refractory to defibrillation and amiodarone 5 mg/kg, needing CPR and escalation to VA ECMO support. With both venous femoral drainage and arterial return cannulae positions confirmed by transthoracic echocardiography and X-ray and ECMO flow of 3 L/min, the child was expediently retrieved by our paediatric ECMO transport team. On peripheral VA ECMO, there was substantial differential hypoxia (right hand pulse oximetry less than 10%, left hand pulse oximetry 84%), ongoing severe cardiorespiratory instability with substantial inotropic and ventilation requirements and severe limb ischaemia with the bifemoral cannulae in situ. Conversion to central (transthoracic) VA ECMO by sternotomy was performed with the placement of a 28Fr right atrial drainage cannula and a 20Fr aortic return cannula. Extracorporeal blood flow was increased to 5 L/min and sweep gas flow up to 4 L/min (Medos HiLite 7000, Medos Medizintechnik, Stolberg, Germany), then continuous renal replacement was commenced via the ECMO circuit for anuric renal failure. Her metabolic markers gradually improved, with blood gas acid-base profile normalised by 24 hours, lactate 10 years old were cannulated via the carotid artery for VA ECMO support. However, there was increased risk of carotid artery territory cerebral infarction with carotid cannulation compared with femoral artery cannulation. In addition, this approach would risk increasing the cardiac afterload due to upper and lower aortic return, which could constrain myocardial recovery. This option would also bear the risk of worsening limb ischaemia. (2) As a variation of (1) for VV-AA ECMO support, a subclavian artery return cannula could have been inserted as auxiliary return to the existing femoral artery cannula, whilst using the existing femoral venous cannulae for drainage. Again, this approach would risk increasing the cardiac afterload and worsening limb ischaemia. (3) VenoVeno-ArterioVenous (VV-AV) ECMO (Option 2) would require the insertion of a jugular vein cannula as auxillary to the existing femoral artery cannula for return, while using the existing femoral venous cannulae for drainage. This option would have provided the obvious advantage with improving differential hypoxia while maintaining cardiovascular VA ECMO support. This approach would not have altered the risk of limb ischaemia; however, it would have improved venous and arterial oxygen saturation, but may have necessitated the continuation of substantial cardiovascular medication with the attendant risks of high doses of inotropic drugs.
(4) As a variation of (3), there was a potential hybrid VV-AV ECMO option considered, with the insertion of a bicaval, double-lumen cannula into the jugular vein. Zhao and co-workers have described, through an animal model,4 the potential advantage of improved differential hypoxia through additional superior vena and inferior vena cava drainage and return flow into the right atrium. The disadvantage of this method is similar to (3) as there is the risk of limb ischaemia and further substantial cardiovascular medication may have been needed. ECMO provides partial or complete support of ventilation, oxygenation and circulation. The choice of which ECMO modality to use is governed by anatomical (vessel size, cardiovascular anatomy and/or previous surgeries) and physiological (respiratory and/or cardiac failure) factors. The urgency with which ECMO needs to be implemented (eCPR, urgent, elective) and the institutional experience will also influence the type of ECMO employed. The use of ECMO support warrants careful consideration of the interplay of the anticipated patient’s pathophysiology and extracorporeal circuit dynamics, as well as evolving pertubations. Particular emphasis should be placed on the potential for mismatch between cardiovascular and respiratory support as well as the need to meet metabolic demands through adequate cerebral, coronary and systemic oxygenation. Our priority was to improve cerebral oxygen delivery, prevent any further cerebrovascular or peripheral vascular insult and maximise cardiovascular support in a
294
patient with ongoing severe haemodynamic and respiratory instability despite peripheral VA ECMO support. Various alternative ECMO options may have been feasible to achieve this. In order not to delay definitive treatment, given our extensive experience with central ECMO, we chose to convert to open-chest, central (trans-thoracic), atrio-aortic VA ECMO with large multi-stage venous drainage cannulae and large arterial cannulae placed into the ascending aorta. Although this is more invasive than peripheral cannulation, the benefits of maintaining substantially higher circuit blood flow and patient oxygen delivery, as well as avoiding the potentially detrimental effects of deoxygenated left ventricular blood entering the aorta in the presence of severe lung disease, could be assured for this patient. We have used this technique, for similar reasons, as the preferred site for ECMO in patients with septic shock.4 At our institution, this cannulation strategy is standard in small children after cardiac surgery, reliably supported by our composite cardiac surgical service, with much experience in managing the problems inherent in this technique. The problems with this strategy include increased risk of local and generalised bleeding and excessive mediastinal clot formation with the activation of thrombolysis. An open sternum facilitates repeated surgical haemostasis and/or clot removal, required over the first 48 hours. Our clear anticoagulation protocol is to enforce safe management of these patients. During central cannulation, the myocardium appeared stunned, but as the left heart showed no signs of dilatation, no elective left heart vent was inserted, in line with our standard ECMO practice. The existing femoral cannulae were removed and the vessels surgically reconstructed. Albeit the most invasive option,
Perfusion 30(4)
central (trans-thoracic) cannulation afforded the most appropriate support for this child at our institution. The achievement of high ECMO flows allayed multi-organ failure, allowing the patient to move from myocardial stunning and lung compliance failure to full recovery. Declaration of Conflicting Interest The authors declare that there is no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Pettignano R, Fortenberry JD, Heard ML, et al. Primary use of the venovenous approach for extracorporeal membrane oxygenation in pediatric acute respiratory failure. Pediatr Crit Care Med 2003; 4: 291–298. 2. Grasselli G, Pesenti A, Marcolin R, et al. Percutaneous vascular cannulation for extracorporeal life support (ECMO): a modified technique. Int J Artif Organs 2010; 33: 553–557. 3. Rollins M, Hubbard A, Zabrockic L, Barnharta D, Bratton S. Extracorporeal membrane oxygenation cannulation trends for pediatric respiratory failure and central nervous system injury. J Pediatr Surg 2012; 47: 68–75. 4. Zhao J, Wang D, Zhou X, Ballard-Croft C, Rosenstein K, Zwischenberger J. Hybrid ECMO using AvalonElite DLC for circulatory support guarantees adequate heart/ brain oxygen supply. J Heart Lung Transpl 2013; 3: S117–S118. 5. MacLaren G, Butt W, Best D, Donath S, Taylor A. Extracorporeal membrane oxygenation for refractory septic shock in children: one institution’s experience. Pediatr Crit Care Med 2007; 8: 447–451.
Copyright of Perfusion is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
PRF0010.1177/0267659114544486PerfusionChan-Dominy et al.
Original paper
Extracorporeal membrane modality conversions
Perfusion 2015, Vol. 30(4) 291–294 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659114544486 prf.sagepub.com
ACF Chan-Dominy,1 M Anders,1 J Millar,1 S Horton,2 D Best,1 C Brizard,2 Y D’Udekem,2 A Hilton3 and W Butt1
Abstract We report the case of a patient with cardiovascular and respiratory failure due to severe anaphylaxis requiring multiple extracorporeal membrane oxygenation (ECMO) cannulation strategies to provide adequate oxygen delivery and ventilatory support during a period of rapid physiological change. ECMO provides partial or complete support of oxygenation-ventilation and circulation. The choice of which ECMO modality to use is governed by anatomical (vessel size, cardiovascular anatomy and previous surgeries) and physiological (respiratory and/or cardiac failure) factors. The urgency with which ECMO needs to be implemented (emergency cardiopulmonary resuscitation (eCPR), urgent, elective) and the institutional experience will also influence the type of ECMO provided. Here we describe a 12-year-old schoolgirl who, having been resuscitated with peripheral veno-venous (VV) ECMO for severe hypoxemia due to status asthmaticus in the setting of acute anaphylaxis, required escalation to peripheral veno-arterial (VA) ECMO for precipitous cardiovascular deterioration. Insufficient oxygen delivery for adequate cellular metabolic function and possible cerebral hypoxia due to significant differential hypoxia necessitated ECMO modification. After six days of central (transthoracic) VA ECMO support and 21 days of intensive care unit (ICU) care, she made a complete recovery with no neurological sequelae. The use of ECMO support warrants careful consideration of the interplay of a patient’s pathophysiology and extracorporeal circuit dynamics. Particular emphasis should be placed on the potential for mismatch between cardiovascular and respiratory support as well as the need to meet metabolic demands through adequate cerebral, coronary and systemic oxygenation. Cannulation strategies occasionally require alteration to meet and anticipate the patient’s evolving needs. Keywords ECMO; extracorporeal membrane oxygenation; anaphylaxis; status asthmaticus; shock; resuscitation
Case Description A 12-year-old, 40 kg, female patient with a known history of asthma and peanut allergy developed severe bronchospasm upon accidental ingestion of a peanut– containing sandwich. After salbutamol inhaler therapy, the school nurse administered two doses of intramuscular epinephrine. On arrival of the paramedical team, the child was semi-conscious, with a pulse and cardiac output present. Pulse oximetry was 74% on bag-mask ventilation (FiO2 1.0) and, after four doses of intravenous (iv) 10 µg/kg epinephrine for worsening bronchospasm, there was a loss of cardiac output, therefore, cardiopulmonary resuscitation (CPR) was initiated. The return of spontaneous circulation occurred after 11 minutes, during which she was intubated and received five further doses of iv 25 µg/kg epinephrine. En route to the nearest tertiary hospital, an epinephrine infusion was started in addition to multiple epinephrine boluses (each 25 µg/kg,
totalling 20 mg) for recurrent bradycardia and severe bronchospasm. On arrival at the hospital, the mean arterial pressure was over 60 mmHg on epinephrine 10 1Intensive
Care Unit, Royal Children’s Hospital, Melbourne, VIC 3052, Australia 2Department of Cardiac Surgery, Royal Children’s Hospital, Melbourne, VIC 3052, Australia 3Department of Intensive Care, Austin Hospital, Melbourne, VIC 3084, Australia Corresponding author: Marc Anders Paediatric Intensive Care Unit Royal Children’s Hospital Melbourne VIC 3052 Australia. Email: [email protected]
292
µg/kg/min. Multimodal asthma-directed therapy was instituted with corticosteroid, salbutamol (5 µg/kg), magnesium (20 mmol), aminophylline (10 mg/kg), neuromuscular blockade (vecuronium 30 mg) and morphine infusion. The patient failed to respond to conventional medical treatment and ventilation strategies (FiO2 1.0, peak inspiratory pressure 45 cmH2O, positive end-expiratory pressure 10 cmH2O, mean airway pressure 18 cmH2O, frequency 10 – 20), with the pH 6.48, pCO2 236 mmHg, pO2 443 mmHg, base excess -18.2 and lactate 14.6 mmol/L. Echocardiography showed mild impairment of biventricular function and no inter-atrial communication. Percutaneous femoro-femoral VV ECMO support with 19Fr drainage and return cannulae was commenced, allowing epinephrine wean. Extracorporeal blood flow was titrated up to 4 L/min (Jostra Rotaflow Pump, Maquet Cardiopulmonary AG, Hechingen, Germany with Maquet Quadrox Pediatric Oxygenator, Maquet Cardiopulmonary AG) and sweep gas flow to 4 L/min of oxygen. However, the patient developed intractable ventricular fibrillation refractory to defibrillation and amiodarone 5 mg/kg, needing CPR and escalation to VA ECMO support. With both venous femoral drainage and arterial return cannulae positions confirmed by transthoracic echocardiography and X-ray and ECMO flow of 3 L/min, the child was expediently retrieved by our paediatric ECMO transport team. On peripheral VA ECMO, there was substantial differential hypoxia (right hand pulse oximetry less than 10%, left hand pulse oximetry 84%), ongoing severe cardiorespiratory instability with substantial inotropic and ventilation requirements and severe limb ischaemia with the bifemoral cannulae in situ. Conversion to central (transthoracic) VA ECMO by sternotomy was performed with the placement of a 28Fr right atrial drainage cannula and a 20Fr aortic return cannula. Extracorporeal blood flow was increased to 5 L/min and sweep gas flow up to 4 L/min (Medos HiLite 7000, Medos Medizintechnik, Stolberg, Germany), then continuous renal replacement was commenced via the ECMO circuit for anuric renal failure. Her metabolic markers gradually improved, with blood gas acid-base profile normalised by 24 hours, lactate 10 years old were cannulated via the carotid artery for VA ECMO support. However, there was increased risk of carotid artery territory cerebral infarction with carotid cannulation compared with femoral artery cannulation. In addition, this approach would risk increasing the cardiac afterload due to upper and lower aortic return, which could constrain myocardial recovery. This option would also bear the risk of worsening limb ischaemia. (2) As a variation of (1) for VV-AA ECMO support, a subclavian artery return cannula could have been inserted as auxiliary return to the existing femoral artery cannula, whilst using the existing femoral venous cannulae for drainage. Again, this approach would risk increasing the cardiac afterload and worsening limb ischaemia. (3) VenoVeno-ArterioVenous (VV-AV) ECMO (Option 2) would require the insertion of a jugular vein cannula as auxillary to the existing femoral artery cannula for return, while using the existing femoral venous cannulae for drainage. This option would have provided the obvious advantage with improving differential hypoxia while maintaining cardiovascular VA ECMO support. This approach would not have altered the risk of limb ischaemia; however, it would have improved venous and arterial oxygen saturation, but may have necessitated the continuation of substantial cardiovascular medication with the attendant risks of high doses of inotropic drugs.
(4) As a variation of (3), there was a potential hybrid VV-AV ECMO option considered, with the insertion of a bicaval, double-lumen cannula into the jugular vein. Zhao and co-workers have described, through an animal model,4 the potential advantage of improved differential hypoxia through additional superior vena and inferior vena cava drainage and return flow into the right atrium. The disadvantage of this method is similar to (3) as there is the risk of limb ischaemia and further substantial cardiovascular medication may have been needed. ECMO provides partial or complete support of ventilation, oxygenation and circulation. The choice of which ECMO modality to use is governed by anatomical (vessel size, cardiovascular anatomy and/or previous surgeries) and physiological (respiratory and/or cardiac failure) factors. The urgency with which ECMO needs to be implemented (eCPR, urgent, elective) and the institutional experience will also influence the type of ECMO employed. The use of ECMO support warrants careful consideration of the interplay of the anticipated patient’s pathophysiology and extracorporeal circuit dynamics, as well as evolving pertubations. Particular emphasis should be placed on the potential for mismatch between cardiovascular and respiratory support as well as the need to meet metabolic demands through adequate cerebral, coronary and systemic oxygenation. Our priority was to improve cerebral oxygen delivery, prevent any further cerebrovascular or peripheral vascular insult and maximise cardiovascular support in a
294
patient with ongoing severe haemodynamic and respiratory instability despite peripheral VA ECMO support. Various alternative ECMO options may have been feasible to achieve this. In order not to delay definitive treatment, given our extensive experience with central ECMO, we chose to convert to open-chest, central (trans-thoracic), atrio-aortic VA ECMO with large multi-stage venous drainage cannulae and large arterial cannulae placed into the ascending aorta. Although this is more invasive than peripheral cannulation, the benefits of maintaining substantially higher circuit blood flow and patient oxygen delivery, as well as avoiding the potentially detrimental effects of deoxygenated left ventricular blood entering the aorta in the presence of severe lung disease, could be assured for this patient. We have used this technique, for similar reasons, as the preferred site for ECMO in patients with septic shock.4 At our institution, this cannulation strategy is standard in small children after cardiac surgery, reliably supported by our composite cardiac surgical service, with much experience in managing the problems inherent in this technique. The problems with this strategy include increased risk of local and generalised bleeding and excessive mediastinal clot formation with the activation of thrombolysis. An open sternum facilitates repeated surgical haemostasis and/or clot removal, required over the first 48 hours. Our clear anticoagulation protocol is to enforce safe management of these patients. During central cannulation, the myocardium appeared stunned, but as the left heart showed no signs of dilatation, no elective left heart vent was inserted, in line with our standard ECMO practice. The existing femoral cannulae were removed and the vessels surgically reconstructed. Albeit the most invasive option,
Perfusion 30(4)
central (trans-thoracic) cannulation afforded the most appropriate support for this child at our institution. The achievement of high ECMO flows allayed multi-organ failure, allowing the patient to move from myocardial stunning and lung compliance failure to full recovery. Declaration of Conflicting Interest The authors declare that there is no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Pettignano R, Fortenberry JD, Heard ML, et al. Primary use of the venovenous approach for extracorporeal membrane oxygenation in pediatric acute respiratory failure. Pediatr Crit Care Med 2003; 4: 291–298. 2. Grasselli G, Pesenti A, Marcolin R, et al. Percutaneous vascular cannulation for extracorporeal life support (ECMO): a modified technique. Int J Artif Organs 2010; 33: 553–557. 3. Rollins M, Hubbard A, Zabrockic L, Barnharta D, Bratton S. Extracorporeal membrane oxygenation cannulation trends for pediatric respiratory failure and central nervous system injury. J Pediatr Surg 2012; 47: 68–75. 4. Zhao J, Wang D, Zhou X, Ballard-Croft C, Rosenstein K, Zwischenberger J. Hybrid ECMO using AvalonElite DLC for circulatory support guarantees adequate heart/ brain oxygen supply. J Heart Lung Transpl 2013; 3: S117–S118. 5. MacLaren G, Butt W, Best D, Donath S, Taylor A. Extracorporeal membrane oxygenation for refractory septic shock in children: one institution’s experience. Pediatr Crit Care Med 2007; 8: 447–451.
Copyright of Perfusion is the property of Sage Publications, Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
