Case Report

Hypothermia with extracorporeal membrane oxygenation for sudden cardiac death and submersion

Abstract

A case of successful recovery from cardiopulmonary arrest and submersion is reported. The victim collapsed due

to ventricular fibrillation owing to acute coronary syndrome with double coronary vessel occlusion and was found nearly drowned in a hot bathtub. Although he was resuscitated, he had been hypoxic because of aspiration. Two hours after return of spontaneous circulation, he was transferred to our institution with hypoxia. No attempt of Cerebral protection was done before admission. Therapeutic hypothermia was

Fig. 1 (Left panel) Twelve-lead ECG on admission. (Right panel) Coronary angiography of left anterior oblique view. (Top) Left anterior descending (LAD) and circumflex (LCX) arteries were occluded. No collateral vessel existed. (Bottom) Two coronary arteries were revascularized by aspiration of thrombus and direct stenting.

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initiated with a veno-venous extracorporeal membrane oxygenation system by direct cooling of circulating blood. Not only effective oxygenation but also accuRate control of the body temperature during 5 days of hypothermia were obtained. In addition, coronary bailout was successfully performed under hypothermia. After 3 weeks of intensive care, he regained consciousness and presented with complete Neurologic recovery. Despite delayed initiation of more than 2 hours, therapeutic hypothermia with veno-venous extra- corporeal membrane oxygenation was effective for cerebral protection in a case of cardiopulmonary arrest with subsequent submersion.

A resuscitated case with protracted hypoxia due to acute coronary syndrome complicated by submersion in a hot spa is demonstrated. Delayed initiation of therapeutic hypother- mia with veno-venous extracorporeal membrane oxygena- tion (VV-ECMO) system provided successful outcome for this case.

A 67-year-old man was found submerged underwater in a Japanese hot spa facility. Up to 10 minutes have passed since he collapsed. Bystanders pulled him out of the bathtub and recognized that he was breathless and pulseless. The automated external defibrillator recognized ventricular fibrillation and delivered shocks 2 times. Despite endotra- cheal intubation, oxygen saturation stayed around 40% at most. Moreover, he was diagnosed with acute coronary

syndrome (Fig. 1A). He was transferred to our institution about 2 hours after return of spontaneous circulation with comatose state (Glasgow coma scale, 3). Poor neurologic signs were recognized (unreactive pupils, flaccid limbs, and decorticate posture evoked by pain stimulation). Mechanical ventilation was impossible because of massive aspirated water in the endotracheal tube. We decided to use the VV- ECMO system for oxygenation and hypothermia for postarrest coma. The Right internal jugular vein was cannulated using a 15F return catheter (BioMedicus Cannula, Medtronic Inc, Minneapolis, MN), and the right femoral vein was also cannulated with a 20F drainage catheter (NSH Heparinization Cannula, TOYOBO Co Ltd, Shiga, Japan) using a percutanous technique (Fig. 2A). The VV-ECMO was initiated via these 2 catheters with the use of a centrifugal pump (Gyro-pump JP0005, Kyocera Co Ltd, Kyoto, Japan) of a percutaneous cardiopulmonary bypass circuit and an artificial lung (Platinum Cube NCVC6000, Edwards Life- sciences Co Ltd, Tokyo, Japan). An arterial blood gas analysis provided pH of 7.300, PO2 of 68.6 mm Hg, and PCO2 of 45.2 mm Hg at a flow rate of 1.8 L/min with 100% of oxygen at 10 L/min by VV-ECMO and a mechanical ventilator with 6.0 L of minute volume and 100% of oxygen. Therapeutic hypothermia was done by blood cooling in the ECMO circuit with the heat exchanger. Target blood temperature (34?C) was obtained within 10 minutes after the initiation of the system. Coronary angiography revealed

Fig. 2 (A) A chest X-ray was shown on the day of admission. ECMO return catheter was inserted via the right juglar vein. The distal of the return catheter is placed in the right atrium. The drainage catheter was inserted via the right femoral vein (not shown). (B) A Chest CT scan demonstrated bilateral pulmonary infiltration with congestive appearance and massive consolidation that denotes aspiration as well as pulmonary edema. (C) Blood Temperature control during therapeutic hypothermia. Blood temperature was measured with Swan-Ganz catheter. Abbreviation: IABP=intraaortic balloon pumping.

Fig. 3 Clinical course after admission. Therapeutic hypothermia was performed with VV-ECMO system for initial 72 hours and CHDF system for the last 24 hours. Chest X ray demonstrated recovery of respiratory distress and ICD in his left chest wall. Abbreviations: MEPM = meropenem, CLDM = clindamycin, AM-SB = ampicillin-sulbactam, CHDF = continuous hemodiafiltration, VT = ventricular tachycardia, ICD = Implantable cardioverter defibrillator.

double-vessel total occlusion of the mid left ascending (LAD) and the mid circumflex (LCX) arteries Percutaneous coronary interventions (PCIs) were performed for LAD and LCX lesion (Fig. 1B). A chest computed tomography scan showed bilateral Ground glass opacities and massive consolidation suggesting pulmonary edema and aspiration mainly in lower lobes (Fig. 2B). In addition, Legionella pneumonia was complicated. For the respiratory distress, oxygenation was maintained by the ECMO system as well as mechanical ventilation. For postarrest coma, therapeutic Mild hypothermia was maintained for 48 hours [1] with deep sedation by intravenous administration of midazolam and vecuronium for suppression of shivering. Rewarming was done at a rate of 0.5?C increase in every 12 hours (Fig. 2C). The VV-ECMO and intraaortic balloon pumping were withdrawn on day 5. A continuous hemodiafiltration was also performed for the progressive renal failure until obtaining adequate urination on day 8. Mechanical ventila- tion was discontinued on day 20. On day 21, the patient regained consciousness (Glasgow coma scale, 15). He recovered completely after 1 month of rehabilitation. An Implantable cardioverter-defibrillator was implanted for his recurrent nonsustained ventricular tachycardia with reduced left ventricular function (left ventricular ejection fraction = 40%) (Fig. 3). No residual neurologic complication was recognized.

out-of-hospital cardiopulmonary arrest patients who remain unconscious after resuscitation still have a poor prognosis [2]. Poor neurologic outcome is related with the “reperfusion injury” [3] of brain cells after return of spontaneous circulation. Several authors reported favorable

outcomes of submersion with “accidental hypothermia” [4-7]. Successful outcomes in published cases resulted from the protective effect of accidental hypothermia by the submersion in low-temperature water. On the other hand, the victim in the present case was submerged in 40?C of spa water, and asphyxia was also complicated. Thus, neither accidental hypothermia nor effective oxygenation was expected. We speculated that VV-ECMO resolved the critical condition of the present case in the following 3 aspects. First, it provided accurate temperature control as well as oxygenation. Although a dog model study demon- strated that delayed hypothermia more than 15 minutes after reperfusion did not improve functional outcome [8], hypothermia with VV-ECMO was effective for Cerebral hypoxia over 2 hours in the present case despite the presentation of poor prognostic signs on admission. Second, the system provided successful management of respiratory distress by oxygenizing and minimizing alveolar over- distension injury by mechanical ventilation. Third, complete revascularization by an ad hoc PCI contributed to successful outcome as well. Because transfer of the patient for repeat PCI procedure would destabilize the temperature control for cerebral protection and simultaneous total occlusion of 2 or 3 coronary arteries would be extremely fatal [9], complete revascularization at initial procedure resulted in a favorable outcome. Therapeutic hypothermia with the VV-ECMO system should be considered for resuscitated victims. Especially, It would be of great use for near-drowned or aspirated victims in terms of strict temperature control during several days of therapeutic hypothermia and manage- ment of subsequent respiratory distress.

Masahiro Mizobuchi MD Shigeru Nakamura MD Hiromi Muranishi MD Makoto Utsunomiya MD Atsushi Funatsu MD Tomoko Kobayashi MD Yoshihisa Enjoji MD Cardiovascular center Kyoto-Katsura Hospital

Nishikyo-ku, Kyoto 615-8256, Japan E-mail address: [email protected]

doi:10.1016/j.ajem.2009.03.011

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