2001 OPEN FORUM Abstracts
Elective useof ECMO for Complex Tracheal Reconstruction
Douglas R. HansellBS, RRT, William F. McGuirt Jr. MD, Michael H. Hines MD FACS
INTRODUCTION: Congenitaltracheal stenosis, though rare, presents unique challenges to the surgeon becauseof the perioperative airway management, complexity of the repair and the sizeof the infant. Previous complications have included breakdown and leakage fromthe tracheal suture line, as well as the added difficulty of performing therepair around an endotracheal tube. We describe our technique in four patientsused to address complex tracheal repairs with elective ECMO support (?ElECMO?)for the procedure as well as for post-operative healing.
Methods: We have used ECMOsupport for the repair of complex tracheal lesions in 4 newborns with long segmenttracheal stenosis and complete tracheal rings, diagnosed with rigid bronchoscopyand CT scans, ranging in weight from 2.2-4.3kg. One patient also had completeagenesis of the left lung, and a second child was a quadruplet with double outletright ventricle and pulmonic stenosis. All four patients had had difficult airwaymanagement requiring either heavy sedation or paralysis. All patients underwentsimilar procedures with exposure through a median sternotomy with mobilizationof the great vessels and trachea including a suprahyoid release in three ofthe four. The patients underwent placement on VA ECMO using a right internaljugular double lumen cannula for venous return and an ascending aortic cannulafor arterial inflow after appropriate systemic heparinization and initiationof antifibrinolytics. The trachea was divided obliquely and the endotrachealtube withdrawn out of the field of the repair. Ventilation was ceased. The incisionswere extended up and down along opposite sides longitudinally essentially spatulatingboth ends. The two sides of the trachea were then brought together and sewnin ?side to side? fashion with a continuous absorbable suture creating a ?slidingtracheoplasty?. Prior to completing the suture line the endotracheal tube wasadvanced under direct vision to stent the repair, and the suture line completed.The repair was covered with a pericardial flap. The patient was converted toVV ECMO using the double lumen IJ cannula, and the arterial cannula removed.The heparin was partially reversed and the mediastinum drained and the sternumclosed. The patients were transported to the pediatric intensive care unit onVV ECMO, with ventilator settings utilizing very low tidal volumes and ratesto minimize trauma to the newly reconstructed airway. After several days of?airway rest? and appropriate diuresis, the lungs were gently re-expanded andthe patient taken off ?ElECMO? at 4, 5, 8 and 9 days. All patients were thentaken electively to the operating room for rigid bronchoscopy to evaluate theairway.
Results: All patients had patentairways with excellent healing of the tracheal suture line with minimal to nogranulation tissue. None of the patients had problems with post-operative bleedingdespite having their sternums closed while still anticoagulated on ECMO. Thepatients were subsequently weaned toward extubation. Three of the patients survivedalthough one child required eventual tracheostomy for congenital laryngeal anomalies,and a second child required a later run of ECMO for ARDS and toxic shock syndrome.The fourth child with the congenital heart disease died one month later withhepatorenal failure.
CONCLUSION: VA and VV ECMOsupport provide an excellent environment for complex tracheal reconstructionin newborns, as well as allowing time for tracheal healing by minimizing theuse of, and therefore trauma to, the fragile airway.