2004 OPEN FORUM Abstracts
CRITICAL CARE MANAGEMENT OF AN ADOLESCENT WITH ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)
Daria
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.