PURPOSE: Asthma remains a common chronic illness in children and adults. Management has improved greatly with the advent of long acting beta-agonists and inhaled steroids, however, asthmatics admitted to the intensive care unit continue to have high mortality (reported as high as 22%). AVCO2R utilizes commercially available products and requires percutaneously placed cannulae into the femoral artery and vein by Seldinger technique. AVCO2R utilizes the arterial-venous pressure difference to push blood through a gas exchanger using 10-15% of cardiac output so produced CO2 is removed and a small amount of oxygen is added as blood is returned to the venous system. An 11 YO girl was transferred in status asthmaticus. She arrived intubated and requiring high peak inspiratory pressures (>45cm H2O) to maintain the pH >7.0 (last gas prior to transfer 7.00/100/564/24). Upon arrival, her asthma remained refractory to all conventional therapy (terbutaline, ketamine, versed, and vecuronium drips, continuous nebulizer treatments, IV magnesium, steroids,antibiotics and isoflurane).
METHODS: For AVCO2R a 12 F cannula was placed in the right femoral artery, and a 15 F cannula was placed in her right femoral vein to create an AV circuit with an Affinity® oxygenator generating flow averaging between 800-1000 ml/min.
RESULTS: All vasopressors were weaned with discontinuation of the isoflurane and the shunt was well tolerated. PaCO2 levels were normalized within 8 hours and ventilatory support was reduced. She remained on AVCO2R for 130 hours without complications. She was extubated 10 days following AVCO2R and transferred to the floor 2 days later. She was discharged in good condition after 21 days in the hospital.
CONCLUSION: Extracorporeal membrane oxygenation (ECMO) has previously been described as a therapy of last resort in patients with life threatening asthma. ECMO is complicated and labor intensive. AVCO2R proved to be an alternative to ECMO in this child with unresponsive status asthmaticus.
CLINICAL IMPLICATIONS: AVCO2R is an alternative in the treatment of acute CO2 syndromes in patients who have failed aggressive conventional management.
DISCLOSURE: James Lynch, None.