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Extracorporeal membrane oxygenation for interhospital transfer of a patient with severe ARDS
American Journal of Emergency Medicine 31 (2013) 640.e1–640.e2
Contents lists available at SciVerse ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Extracorporeal membrane oxygenation for interhospital transfer of a patient with severe ARDS Abstract Conventional transportation of unstable patients with acute respiratory distress syndrome (ARDS) may not always be safely possible. In such cases, extracorporeal membrane oxygenation (ECMO) implantation in the referral hospital should be considered to enable safe transportation. We report the case of a 41-year-old woman who developed fulminant secondary ARDS. Two days before, she presented at our emergency department with constant left flank pain and was diagnosed with pyelonephritis because of a proximal ureteral stone. In the course, she developed severe urosepsis and secondary ARDS with rapidly progressive bilateral pulmonary infiltrates and was transferred to the intensive care unit. Eighteen hours after intensive care unit admission, endotracheal intubation was necessary because of refractory hypoxemic and hypercapnic respiratory failure. Mechanical ventilation was difficult because of severely limited pulmonary compliance and lung protective ventilation could not be achieved. We planned to refer our patient to a tertiary ECMO center. The air transportation had to be cancelled because it was impossible to oxygenate and ventilate the patient sufficiently with the transport ventilator. The heart surgery team (cardiac surgeon and perfusionist) of the tertiary care hospital was called in to install a veno-venous ECMO at our institution. They arrived within 90 minutes and successfully installed the ECMO so that the patient could safely be transported by road to the tertiary centre. The patient remained on ECMO for 7 days and fully recovered from ARDS. A 41-year-old woman presented with constant left flank pain at our emergency department. The diagnosis of pyelonephritis due to a proximal 4-mm ureteral stone was made. Analgesic and empirical antibiotic therapy with ceftriaxone was initiated. After 2 days, the patient became tachycardic and tachypnoeic and showed decreased oxygen saturation. She developed severe urosepsis with partial respiratory insufficiency (PaO2, 8.7 kPa) and metabolic acidosis (base excess, − 5.0 mmol/L; lactate, 2.8 mmol/L) as well as activated coagulation and was transferred to the intensive care unit (ICU). As a result of the severe sepsis, the patient developed secondary acute respiratory distress syndrome (ARDS) with evidence of rapidly progressive bilateral pulmonary infiltrates (see Fig.). At first, oxygen saturation over 90% could be maintained with 6 L of nasal oxygen delivery. Within the following 16 hours, oxygen content had to be increased to 100% using a high flow oxygen cannula, and 18 hours
0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
after ICU admission, endotracheal intubation was necessary because of refractory hypoxemic and hypercapnic respiratory failure (see Fig.). As expected, mechanical ventilation was difficult because of severely limited pulmonary compliance. Despite optimization of the ventilator settings, lung protective ventilation could not be achieved. End-inspiratory plateau pressure remained at 37 mbar, and progressive respiratory acidosis with pH of 7.17 developed. Because of an impossible lung protective ventilation 12 hours after intubation, we planned to refer our patient to a tertiary extracorporeal membrane oxygenation (ECMO) center, and it was foreseen to transfer her by air ambulance (REGA). Unfortunately, the air transportation had to be cancelled because it was impossible to oxygenate and ventilate the patient sufficiently with the transport ventilator of the air ambulance; we saw rapid desaturation to SpO2 of 20% and bradycardia. To install a veno-venous ECMO (Maquet Cardiopulmonary AG, Rastatt, Germany) at our institution, the heart surgery team (cardiac surgeon and perfusionist) of the tertiary care hospital was called in. Meanwhile, we prepared the right jugular vein for the ECMO implantation by changing the central venous catheter from the right jugular vein to the left side. Within 90 minutes, the heart surgery team arrived at our institution, and the ECMO was successfully installed, so that the patient could be safely transported by road to the tertiary center. Our patient remained on ECMO for 7 days and was extubated after 11 days (see Fig.). She fully recovered from the ARDS, left the ICU after 2 weeks, and was admitted to the general ward, from where she was sent to a rehabilitation center. Acute respiratory distress syndrome is defined as an acute hypoxemic respiratory failure with bilateral radiographic opacities without evidence of left heart failure [1]. It is caused by direct or indirect lung injury. For indirect lung injury, sepsis is the most common cause [2]. Lung protective ventilation is needed to avoid ventilator-associated lung injury and oxygen toxicity. By using volume- and pressurelimited ventilation with permissive hypercapnia overdistension of the alveoli can be avoided. Positive end-expiratory pressure is needed to maintain alveolar patency and prevent the lung from injurious forces generated during repeated collapsing and reopening of small bronchioles and alveoli. In addition, the use of supplemental inspired oxygen should be minimized [3]. Indications of ECMO are severe hypoxemia, uncompensated hypercapnia with acidemia, and excessively high end-inspiratory plateau pressure, despite the best accepted standard of care for management with a ventilator [3]. A multicenter randomized controlled trial showed a significantly higher survival rate for patients with severe ARDS treated with ECMO [4].
640.e2
Case Report / American Journal of Emergency Medicine 31 (2013) 640.e1–640.e2
Fig. Left side: Chest x-ray at ICU admission. Middle: Chest x-ray after intubation (18 hours later). Right side: Chest x-ray after 7 days at ECMO explantation.
Conventional interhospital transportation of severely hypoxemichypercapnic patients with ARDS is a high-risk procedure, and critically ill patients are at increased risk for morbidity and mortality during transport. Risk can be minimized with careful planning, adequate pretransport stabilization, and selection of appropriate equipment. Extracorporeal membrane oxygenation implantation in the referring hospital by an experienced ECMO transport team may be necessary to make the transport of these high-risk critically ill patients feasible under stable vital gas exchange conditions. A 5-year experience of ECMO implantation at the referral hospital was lately published, which showed that use of veno-venous ECMO enables safe road transportation of patients with severe ARDS to tertiary care institutions with a very low rate of complications. This mode of transport allows more advanced care of these patients and probably may even improve survival [5]. In conclusion, conventional transportation, either by air or by road, of unstable patients with ARDS may not always be safely possible. In such cases, ECMO implantation by an experienced team should be considered as a means of enabling transportation. Our case shows that an ECMO can successfully be implanted at a referring hospital and the patient may then be safely transported even by road. Caroline Schaer MD Interdisciplinary Intensive Care Unit, Buelach Hospital, CH-8180 Buelach, Switzerland E-mail address: [email protected]
Alexander Klarer MD Medical Intensive Care Unit, University Hospital Zuerich, CH-8091 Zuerich, Switzerland Christoph Starck MD Clinic of Cardiac and Vascular Surgery, University Hospital Zuerich CH-8091 Zuerich, Switzerland Bernd Yuen MD Interdisciplinary Intensive Care Unit, Buelach Hospital, CH-8180 Buelach, Switzerland http://dx.doi.org/10.1016/j.ajem.2012.10.033 References [1] Rubenfeld GD, Herridge MS. Epidemiology and outcomes of acute lung injury. Chest 2009;131:554-62. [2] Ware LB. Pathophysiology of acute lung injury and the acute respiratory distress syndrome. Semin Respir Crit Care Med 2006;27:337-49. [3] Brodie D, Bacchetta M. Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med 2011;365:1905-14. [4] Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009;374:1351-63. [5] Isgrò S, Patroniti N, Bombino M, et al. Extracorporeal membrane oxygenation for interhospital transfer of severe acute respiratory distress syndrome patients: a 5-year experience. Int J Artif Organs 2011;34(11):1052-60.
Contents lists available at SciVerse ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Extracorporeal membrane oxygenation for interhospital transfer of a patient with severe ARDS Abstract Conventional transportation of unstable patients with acute respiratory distress syndrome (ARDS) may not always be safely possible. In such cases, extracorporeal membrane oxygenation (ECMO) implantation in the referral hospital should be considered to enable safe transportation. We report the case of a 41-year-old woman who developed fulminant secondary ARDS. Two days before, she presented at our emergency department with constant left flank pain and was diagnosed with pyelonephritis because of a proximal ureteral stone. In the course, she developed severe urosepsis and secondary ARDS with rapidly progressive bilateral pulmonary infiltrates and was transferred to the intensive care unit. Eighteen hours after intensive care unit admission, endotracheal intubation was necessary because of refractory hypoxemic and hypercapnic respiratory failure. Mechanical ventilation was difficult because of severely limited pulmonary compliance and lung protective ventilation could not be achieved. We planned to refer our patient to a tertiary ECMO center. The air transportation had to be cancelled because it was impossible to oxygenate and ventilate the patient sufficiently with the transport ventilator. The heart surgery team (cardiac surgeon and perfusionist) of the tertiary care hospital was called in to install a veno-venous ECMO at our institution. They arrived within 90 minutes and successfully installed the ECMO so that the patient could safely be transported by road to the tertiary centre. The patient remained on ECMO for 7 days and fully recovered from ARDS. A 41-year-old woman presented with constant left flank pain at our emergency department. The diagnosis of pyelonephritis due to a proximal 4-mm ureteral stone was made. Analgesic and empirical antibiotic therapy with ceftriaxone was initiated. After 2 days, the patient became tachycardic and tachypnoeic and showed decreased oxygen saturation. She developed severe urosepsis with partial respiratory insufficiency (PaO2, 8.7 kPa) and metabolic acidosis (base excess, − 5.0 mmol/L; lactate, 2.8 mmol/L) as well as activated coagulation and was transferred to the intensive care unit (ICU). As a result of the severe sepsis, the patient developed secondary acute respiratory distress syndrome (ARDS) with evidence of rapidly progressive bilateral pulmonary infiltrates (see Fig.). At first, oxygen saturation over 90% could be maintained with 6 L of nasal oxygen delivery. Within the following 16 hours, oxygen content had to be increased to 100% using a high flow oxygen cannula, and 18 hours
0735-6757/$ – see front matter © 2013 Elsevier Inc. All rights reserved.
after ICU admission, endotracheal intubation was necessary because of refractory hypoxemic and hypercapnic respiratory failure (see Fig.). As expected, mechanical ventilation was difficult because of severely limited pulmonary compliance. Despite optimization of the ventilator settings, lung protective ventilation could not be achieved. End-inspiratory plateau pressure remained at 37 mbar, and progressive respiratory acidosis with pH of 7.17 developed. Because of an impossible lung protective ventilation 12 hours after intubation, we planned to refer our patient to a tertiary extracorporeal membrane oxygenation (ECMO) center, and it was foreseen to transfer her by air ambulance (REGA). Unfortunately, the air transportation had to be cancelled because it was impossible to oxygenate and ventilate the patient sufficiently with the transport ventilator of the air ambulance; we saw rapid desaturation to SpO2 of 20% and bradycardia. To install a veno-venous ECMO (Maquet Cardiopulmonary AG, Rastatt, Germany) at our institution, the heart surgery team (cardiac surgeon and perfusionist) of the tertiary care hospital was called in. Meanwhile, we prepared the right jugular vein for the ECMO implantation by changing the central venous catheter from the right jugular vein to the left side. Within 90 minutes, the heart surgery team arrived at our institution, and the ECMO was successfully installed, so that the patient could be safely transported by road to the tertiary center. Our patient remained on ECMO for 7 days and was extubated after 11 days (see Fig.). She fully recovered from the ARDS, left the ICU after 2 weeks, and was admitted to the general ward, from where she was sent to a rehabilitation center. Acute respiratory distress syndrome is defined as an acute hypoxemic respiratory failure with bilateral radiographic opacities without evidence of left heart failure [1]. It is caused by direct or indirect lung injury. For indirect lung injury, sepsis is the most common cause [2]. Lung protective ventilation is needed to avoid ventilator-associated lung injury and oxygen toxicity. By using volume- and pressurelimited ventilation with permissive hypercapnia overdistension of the alveoli can be avoided. Positive end-expiratory pressure is needed to maintain alveolar patency and prevent the lung from injurious forces generated during repeated collapsing and reopening of small bronchioles and alveoli. In addition, the use of supplemental inspired oxygen should be minimized [3]. Indications of ECMO are severe hypoxemia, uncompensated hypercapnia with acidemia, and excessively high end-inspiratory plateau pressure, despite the best accepted standard of care for management with a ventilator [3]. A multicenter randomized controlled trial showed a significantly higher survival rate for patients with severe ARDS treated with ECMO [4].
640.e2
Case Report / American Journal of Emergency Medicine 31 (2013) 640.e1–640.e2
Fig. Left side: Chest x-ray at ICU admission. Middle: Chest x-ray after intubation (18 hours later). Right side: Chest x-ray after 7 days at ECMO explantation.
Conventional interhospital transportation of severely hypoxemichypercapnic patients with ARDS is a high-risk procedure, and critically ill patients are at increased risk for morbidity and mortality during transport. Risk can be minimized with careful planning, adequate pretransport stabilization, and selection of appropriate equipment. Extracorporeal membrane oxygenation implantation in the referring hospital by an experienced ECMO transport team may be necessary to make the transport of these high-risk critically ill patients feasible under stable vital gas exchange conditions. A 5-year experience of ECMO implantation at the referral hospital was lately published, which showed that use of veno-venous ECMO enables safe road transportation of patients with severe ARDS to tertiary care institutions with a very low rate of complications. This mode of transport allows more advanced care of these patients and probably may even improve survival [5]. In conclusion, conventional transportation, either by air or by road, of unstable patients with ARDS may not always be safely possible. In such cases, ECMO implantation by an experienced team should be considered as a means of enabling transportation. Our case shows that an ECMO can successfully be implanted at a referring hospital and the patient may then be safely transported even by road. Caroline Schaer MD Interdisciplinary Intensive Care Unit, Buelach Hospital, CH-8180 Buelach, Switzerland E-mail address: [email protected]
Alexander Klarer MD Medical Intensive Care Unit, University Hospital Zuerich, CH-8091 Zuerich, Switzerland Christoph Starck MD Clinic of Cardiac and Vascular Surgery, University Hospital Zuerich CH-8091 Zuerich, Switzerland Bernd Yuen MD Interdisciplinary Intensive Care Unit, Buelach Hospital, CH-8180 Buelach, Switzerland http://dx.doi.org/10.1016/j.ajem.2012.10.033 References [1] Rubenfeld GD, Herridge MS. Epidemiology and outcomes of acute lung injury. Chest 2009;131:554-62. [2] Ware LB. Pathophysiology of acute lung injury and the acute respiratory distress syndrome. Semin Respir Crit Care Med 2006;27:337-49. [3] Brodie D, Bacchetta M. Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med 2011;365:1905-14. [4] Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009;374:1351-63. [5] Isgrò S, Patroniti N, Bombino M, et al. Extracorporeal membrane oxygenation for interhospital transfer of severe acute respiratory distress syndrome patients: a 5-year experience. Int J Artif Organs 2011;34(11):1052-60.