INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is a rescue modality for patients with refractory hypoxemic respiratory failure.
CASE PRESENTATION: A 29 year old female with a past medical history of Sickle cell disease (HbSS) was admitted with generalized body aches. Two days into her hospitalization she rapidly developed hypoxemic respiratory failure and required mechanical ventilation. The PaO2/FiO2 ratio was 121 and normal left ventricular function was documented on trans-thoracic echocardiography. Her chest radiograph showed bilateral alveolar infiltrates and a subsequent CT of the chest showed extensive bilateral ground glass attenuations. She was treated with broad spectrum antibiotics, but all her cultures came back negative. She underwent exchange transfusions for a diagnosis of acute chest syndrome. Despite the latter therapy, her hypoxemia worsened (PaO2 52 mm Hg, P/F ratio 52) and was refractory to increase in PEEP to 15 cm H2O and inhaled nitric oxide. Veno-venous ECMO was initiated with improvement in oxygenation (PaO2 85, P/F ratio 212). ECMO was weaned over seven days and discontinued. Tracheostomy was performed and after a lengthy ICU stay complicated by multiple pneumothoraces, the patient was weaned from mechanical ventilation, decannulated and transferred to rehab.
DISCUSSION: ECMO is experiencing a resurgence secondary to use during the recent H1N1 influenza pandemic and the publication of the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial. To date there has been one published report of the use of ECMO in the treatment of adult acute chest syndrome (reference 1). In the pediatric population 17 published case reports (reference 2) suggest that ECMO is both feasible and has similar outcomes to ECMO in ARDS (50% survival to discharge) (reference 3)
CONCLUSIONS: Initiation of ECMO or transfer to a center with ECMO capability should be considered for patients with refractory hypoxemic respiratory failure secondary to the acute chest syndrome. This case illustrates the use of ECMO for temporary support of severe, but potentially reversible hypoxemic respiratory failure.
Reference #1 Gillett DS, Gunning KE, Sawicka EH, Bellingham AJ, Ware RJ. Life threatening sickle chest syndrome treated with extracorporeal membrane oxygenation. Br Med J (Clin Res Ed) 1987;294:81
Reference #2 Pelidis MA, Kato GJ, Resar LM, Dover GJ et al. Successful treatment of life-threatening acute chest syndrome of sickle cell disease with venovenous extracorporeal membrane oxygenation. J Pediatr Hematol Oncol. 1997 Sep-Oct;19(5):459-61.
Reference #3 Brogan TV, Thiagarajan RR, Rycus PT, Bartlett RH, Bratton SL. Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med. 2009;35(12):2105-2114.
DISCLOSURE: The following authors have nothing to disclose: Muralikrishna Gopal, Deborah Orsi, Michael Khilkin, Alina Dulu, Ricardo Bello, Theo Trandafirescu, Peter Dicpinigaitis, Wilma Lopez, Vladimir Kvetan
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