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The Use of Venovenous-ECMO for Refractory Hypoxemia Following Liver Transplantation in a Patient With Hepatopulmonary Syndrome
Critical Care SESSION TITLE: Critical Care 3 SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Sunday, October 29, 2017 at 04:30 PM - 05:30 PM
The Use of Venovenous-ECMO for Refractory Hypoxemia Following Liver Transplantation in a Patient With Hepatopulmonary Syndrome Anish Geevarghese* Akmal Sarwar Amy Chi and James Dargin Lahey Hospital & Medical Center, Burlington, MA INTRODUCTION: Up to 21% of patients with hepatopulmonary syndrome (HPS) develop severe, post-operative hypoxemia, which carries a 45% mortality rate. There are few reports of the successful use of vv-ECMO for severe hypoxemia following liver transplantation. CASE PRESENTATION: A 64-year-old male with end stage liver disease due to hepatitis C presented with severe hypoxemia. Arterial blood gas showed a PaO2 of 58mmHg on room air. A chest CT with contrast did not show AV malformations, but demonstrated dilated vessels in the bilateral lower lobes. (Figure 1). Transthoracic “bubble study” echocardiogram revealed a large right-to-left intrapulmonary shunt, consistent with the diagnosis of HPS. The patient underwent deceased donor liver transplantation. The immediate post-operative course was complicated by severe hypoxemia with a PaO2 of 57mmHg on 100% FiO2 and 10cmH20 of PEEP. Chest x-ray and CT angiogram showed no significant infiltrates or pulmonary embolism. The patient was treated with Trendelenburg positioning, inhaled nitric oxide and intravenous methylene blue with no significant improvement. He was subsequently placed on VV-ECMO with improvement in oxygenation. Eleven days later, his hypoxemia had improved and he was taken off ECMO support. He required tracheostomy and was liberated from mechanical ventilation. He was discharged from the hospital six weeks post-liver transplantation. Five months post-operatively, the patient was discharged home. His tracheostomy was decannulated and he had a room air oxygen saturation of 99%.
CRITICAL CARE
DISCUSSION: Liver transplantation cures HPS in 80% of cases, but resolution of hypoxemia can take up to 14 months. Up to 20% of patients may develop severe post-operative hypoxemia, which may be related to changes in vascular mediators in the lung following transplantation. Inhaled vasodilators, such as nitric oxide, have been used successfully to treat severe post-operative hypoxemia. Methylene blue may cause vasoconstriction of dilated pulmonary vessels and has also been used with some success in treating post-operative hypoxemia. Here we report the successful use of VV-ECMO in a patient with HPS and severe postoperative hypoxemia that was refractory to inhaled nitric oxide and methylene blue. CONCLUSIONS: VV-ECMO may be used as a bridge to recovery in patients with HPS who develop severe, post-operative hypoxemia following liver transplantation. Reference #1: Nayyar et al. Proposed Management Algorithm for Severe Hypoxemia After Liver Transplantation in the HPS. Am J Transplant 2015; 15: 903-13. DISCLOSURE: The following authors have nothing to disclose: Anish Geevarghese, Akmal Sarwar, Amy Chi, James Dargin No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.312
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
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The Use of Venovenous-ECMO for Refractory Hypoxemia Following Liver Transplantation in a Patient With Hepatopulmonary Syndrome Anish Geevarghese* Akmal Sarwar Amy Chi and James Dargin Lahey Hospital & Medical Center, Burlington, MA INTRODUCTION: Up to 21% of patients with hepatopulmonary syndrome (HPS) develop severe, post-operative hypoxemia, which carries a 45% mortality rate. There are few reports of the successful use of vv-ECMO for severe hypoxemia following liver transplantation. CASE PRESENTATION: A 64-year-old male with end stage liver disease due to hepatitis C presented with severe hypoxemia. Arterial blood gas showed a PaO2 of 58mmHg on room air. A chest CT with contrast did not show AV malformations, but demonstrated dilated vessels in the bilateral lower lobes. (Figure 1). Transthoracic “bubble study” echocardiogram revealed a large right-to-left intrapulmonary shunt, consistent with the diagnosis of HPS. The patient underwent deceased donor liver transplantation. The immediate post-operative course was complicated by severe hypoxemia with a PaO2 of 57mmHg on 100% FiO2 and 10cmH20 of PEEP. Chest x-ray and CT angiogram showed no significant infiltrates or pulmonary embolism. The patient was treated with Trendelenburg positioning, inhaled nitric oxide and intravenous methylene blue with no significant improvement. He was subsequently placed on VV-ECMO with improvement in oxygenation. Eleven days later, his hypoxemia had improved and he was taken off ECMO support. He required tracheostomy and was liberated from mechanical ventilation. He was discharged from the hospital six weeks post-liver transplantation. Five months post-operatively, the patient was discharged home. His tracheostomy was decannulated and he had a room air oxygen saturation of 99%.
CRITICAL CARE
DISCUSSION: Liver transplantation cures HPS in 80% of cases, but resolution of hypoxemia can take up to 14 months. Up to 20% of patients may develop severe post-operative hypoxemia, which may be related to changes in vascular mediators in the lung following transplantation. Inhaled vasodilators, such as nitric oxide, have been used successfully to treat severe post-operative hypoxemia. Methylene blue may cause vasoconstriction of dilated pulmonary vessels and has also been used with some success in treating post-operative hypoxemia. Here we report the successful use of VV-ECMO in a patient with HPS and severe postoperative hypoxemia that was refractory to inhaled nitric oxide and methylene blue. CONCLUSIONS: VV-ECMO may be used as a bridge to recovery in patients with HPS who develop severe, post-operative hypoxemia following liver transplantation. Reference #1: Nayyar et al. Proposed Management Algorithm for Severe Hypoxemia After Liver Transplantation in the HPS. Am J Transplant 2015; 15: 903-13. DISCLOSURE: The following authors have nothing to disclose: Anish Geevarghese, Akmal Sarwar, Amy Chi, James Dargin No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2017.08.312
Copyright ª 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
286A
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152#4S CHEST OCTOBER 2017
]