Case Report

Rescue a drowning patient by prolonged extracorporeal membrane oxygenation support for 117 days^?

Abstract

Drowning is one of the most common causes of accidental events. Here we report a drowning patient who experienced acute respiratory distress syndrome after hospitalization. Although the compliance of lung was as poor less as 5 mL/cm H₂O, this patient was eventually rescued and recovered by extraprolonged extracorporeal membrane oxygenation support for 117 days.

Drowning is one of the most common causes of accidental events. According to the reports from World Health Organization, an estimated 376 000 people drowned world- wide in 2002 and is the third leading cause of unintentional injury death [1].

Here we report a drowning patient who experienced Acute respiratory distress syndrome after hospitalization and was rescued successfully by extraprolonged extracorpo- real membrane oxygenation (ECMO) support for 117 days. In July 2007, a 26-year-old man fell into a pond due to drunkenness. Basic life support was started within minutes by his friend and the local emergency medical service team. On arrival at the emergency department in the local hospital, the patient was conscious with tachypnea and hypoxia. His chest x-ray revealed bilateral lung infiltra- tions; therefore, tracheal intubation was performed for mechanical ventilation. The initial arterial blood gas after mechanical ventilation showed a pH of 7.342, PaCO2 of

29.9 mm Hg, and PaO2 of 79 mm Hg under a FiO2 of 60%.

Empirical antibiotic was administered for high fever and potential Aspiration pneumonia.

Nevertheless, the progressive pulmonary infiltrations deteriorated the young man‘s oxygenation. On the day 7, even with a positive end-expiratory pressure of 15 cm H₂O and a FiO2 of 100%, the arterial saturation was only 73% by conventional ventilation; therefore, the ECMO team of National Taiwan University Hospital was consulted for assessment of this clinical situation.

^? Conflict of interest statement: All authors participating in this article have no potential conflicts of interest that might cause a bias in the article.

Venovenous ECMO (VV ECMO) was accomplished by percutaneously accessing the Right internal jugular vein with a 17-French arterial catheter and right femoral vein with a 21-French venous catheter (Fig. 1A). This patient, supported by ECMO with 2.5 L/min, was transported to National Taiwan University Hospital by ground ambulance. The details of the transport protocol were described in our previous report [2]. On day 4 of ECMO support, due to persistent low SpO2 detected by oxymetry on the ear, an additional 17-French arterial catheter was inserted into right axillary artery, and the VV ECMO was converted to veno- venoarterial ECMO (V-VA ECMO) with a total pump flow rate of 5 L/min by separate pumps and oxygenators. On ECMO day 6, another 17-French arterial catheter was inserted into left femoral artery, and the ECMO circuits were separated into 2 VA ECMO systems, to provide better oxygenation for both upper and lower body. Appropriate antibiotics were prescribed by infectious disease specialists according to culture results. Minimizing of the Ventilator settings was attempted; however, right and left pneumotho- rax developing respectively on ECMO days 14 and 16 worsened the oxygenation and complicated the ventilator settings. The patient underwent tracheostomy on ECMO day 21 for better airway hygiene. On ECMO day 34, the catheter of right axillary artery was decannulated because of thrombus and the 2 VA ECMO systems were modified to V-VA ECMO. Bronchoscopic examinations were performed for airway hygiene as needed. The leakage of bilateral pneumothoraces gradually healed, and the compliance and oxygenation of lung improved in 60 and 80 days, respectively, after ECMO support (Fig. 2). The V-VA ECMO system was converted to VV system only on ECMO day 87. The VV ECMO operated for further 30 days, and “trail off” ECMO was performed by increasing the ventilator settings again. Decannulation of ECMO was attempted successfully on day 117 of ECMO support.

After 5 weeks after decannulation of ECMO, the mecha-

nical ventilation was disconnected and the tracheostomy was closed thereafter. The patient was discharged 197 days after the accident without any permanent complications of ECMO.

Two months after hospital discharge, the follow-up chest x-ray showed only mild fibrosis (Fig. 1B) and the patient went back to labor as a porter.

Drowning is the third leading cause of unintentional injury death worldwide [1]. If the victims are rescued by basic life

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Fig. 1 Chest x-ray on ECMO day 1 (A) and 2 months after discharge (B).

support on the scenes and transported to medical services, ARDS after drowning accidents is one of the most common causes of death in hospitalized drowning victims [3].

Limited data exist on the roles of ECMO in the drowning patients and mostly emphasize the hypothermic or pediatric patients [4,5]. However, because Taiwan is located in the subtropical zone and the temperature of the natural water in summer is usually around 20?C, we seldom encounter

Fig. 2 Pulmonary oxygenation (PaO2/FiO2) and compliance.

hypothermia that resulted from drowning. Instead, ARDS or Multiorgan dysfunction after drowning complicates our hospitalized drowning patients.

In this report, we demonstrate the successful treatment of an adult ARDS after drowning by extraprolonged (117 days) ECMO support. During ECMO days 20 to 40, the compliance of the lung was as poor less as 5 mL/cm H₂O (as shown in Fig. 2). In other words, the tidal volume was less than 100 mL under a plateau inspiratory pressure of 20 cm H₂O. However, the lung function eventually recovered after ECMO support for 117 days. Our patient implied the possibility of autorepair of the lung after a major damage.

In conclusion, we report a drowning patient who experienced acute respiratory distress syndrome after hospitalization and was rescued successfully by extraprolonged ECMO support for 117 days.

Chih-Hsien Wang MD Department of Surgery and Traumatology National Taiwan University Hospital

Taipei 100, Taiwan

Chun-Chih Chou MD

Department of Surgery and Traumatology National Taiwan University Hospital Yun-Lin Branch

Yun-Lin County 640, Taiwan

Wen-Je Ko MD, PhD Yung-Chie Lee MD, PhD

Department of Surgery and Traumatology National Taiwan University Hospital

Taipei 100, Taiwan E-mail address: kowj@ntu.edu.tw

doi:10.1016/j.ajem.2009.11.011

Case Report

References

1. World Health Organization-Violence and Injury Prevention and Disability. Drowning. http://www.who.int/violence_injury_prevention/ other_injury/drowning 2009.
2. Huang SC, Chen YS, Chi NH, Hsu J, Wang CH, Yu HY, et al. Out-of- center extracorporeal membrane oxygenation for adult cardiogenic shock patients. Artif Organs 2006;30:24-8.

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