2004 OPEN FORUM Abstracts
CRITICAL CARE MANAGEMENT OF AN ADOLESCENT WITH ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
Donelly, RRT, Peter Betit, RRT, Robert Pascucci, MD. Children's
Hospital, Boston and Harvard Medical School, Boston, MA
Introduction: Although ECMO can provide full cardiopulmonary support in infants and small children, in larger patients ECMO may only provide partial cardiorespiratory support. Other components of care equally important in the management of ARDS on ECMO include cardiovascular support and a variety of ventilator and ECMO strategies. ELSO reports 60% and 47% for patient survival for pediatric and adult ECMO respectively. Boston Children’s Hospital’s patient survival for ARDS with ECMO is 67% in the pediatric population and 50% in the adult population.
Case Summary: We report a previously healthy 15 yo 60 kg F, with a history of cough, dyspnea, and fever who presented to local ER with a room air SpO2 of 80%. Patient was transferred to CH ED for further management of her presumed pneumonia. Due to her severe hypoxia and respiratory distress, she was intubated shortly upon arrival to our ED. Manual ventilation with inflation pressures >40 cmH20 were needed to achieve visible chest rise and a maximum SpO2 of 94%. The patient was stabilized and admitted to our MSICU. CXR indicated worsening infiltrates consistent with ARDS and a R apical pneumothorax. Patient ‘s oxygen index (OI) was .3 on conventional ventilation (28/8 x12) and was placed on HFOV-B (MAP 28 cmH20, Hz 6, P 60 cmH20, OI=.56) at hour 7 in the ICU. OI was unimproved despite the initiation of HFOV. The patient was placed in the prone postion and 80 ppm INO was started with no improvement in OI. Veno-venous ECMO was initiated at hour 22, but ventilator and vasopressor support could not be weaned and she was converted to veno-arterial ECMO at hour 30. ECMO flows were maintained at 50-70ml/kg. A ventilator strategy for lung recruitment included inspiratory hold maneuvers and maintaining PEEP levels from 8-12 cm H20. Blood cultures were positive for Streptococcus Group G and antibiotic coverage was tailored. The patients’s cardiopulmonary status improved over 7 days and she was successfully decannulated. Post-ECMO ventilator settings were PCV+PSV (30/10 x 14, 60%). She developed bilateral pneumothoraces and prompt cardiopulmonary decompensation shortly after decannulation, and was temporarily ventilated on HFOV during pleurocentesis. Air leak and sanguineous drainage continued to be an ongoing problem for several days, requiring almost daily manipulations of the chest tubes. A steroid regimen was initiated for treatment of late fibroproliferative ARDS. Over the next week her ventilatory support was weaned and she was extubated on hospital day 14 to 100% aerosol mask. Despite recurrent air leak syndrome post extubation, she was successfully rehabilitated over the next three weeks and discharged with no oxygen requirement and no neurologic sequelae. She has resumed all normal activities including swimming and dance.
Discussion: In this case report, ECMO alone did not guarantee patient survival. Prompt patient interventions and the institution of advanced technologies before and after her ECMO course proved successful. The experience and expertise of several disciplines contributed to the critical management of her ARDS that ultimately led to her survival.