one case needs help , died on ECMO

[SAMIR gami]

21 year old male

No comorbities

 

Taken “Alpos” Two tables on 23 march at 10.30 pm, admitted at one physician nursing home, he was treated with IV fluids & magnesium.

He started developing hypotension on 24^th afternoon and given an option of ECMO by physician in evening. He reached our hospital at 9.30 PM and ECMO initiated in 45 minutes. Right femoral artery cannulated easily with 16 fr cannula, but unfortunately left femoral vein was toygh and couldn’t cannulate after surgical open than cannulated with 19 fr cannula and after that left IJV with 16 fr cannula. With this flow is maintained.

His Myocardium was 10% ejecting and rhythm sinus tachycardia on very high dose noradrenalin, adrenalin , vaso pressin

Pt treated with 3.5 l flow and SLED . he was improving ABG and clinically also

Following is chart of ABG

Initiall lactate is 16.1

Nect day morning 17.1

Increased flow to 4

After 6 hr lactate 4.8 – ionotropes started tappering

Than another 6 hrs lactate 1.5

After 36 hrs myocardium improved and ejecting 25 %

He was off ionotropes on Sunday morning

On Sunday 26^th march at 3.30 he was on cpap and counscious suddenly complain of chest pain severe left sided. And rhythm changes to junctional rhythm  

Refractory hypotension and ionotropes started (which was off since almost 10 hrs), not responding anything , flow was also going down

Echo suggestive of LV again 5% and hardly moving rhythm never came back to normal

And at 10.30 no heart beating and gone.

 

Points need to be discussed...

1, can phosfin gas once detaching from myocardium can do secondary effect ? means myocarditis again

2,  can it be a coronary embolism ?

3, if it coronary embolism what measures can we take more?

Regards

Dr Samir Gami

Chest Physician & Intensivist

+91 9925276708

[vijil rahulan]

Just a question, was ECMO weaned off by then, if so why so early as myocarditis needs time to recover

Dr vijil Rahulan

Global Hosp 

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[SAMIR gami]

nope ECMO was on till last it was not weaned off

only flow was 3 l per min

ECO was on 

Dr Samir Gami

Chest Physician & Intensivist

+91 9925276708

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[vijil rahulan]

3 lit flow may not give full cardiovascular support, may need 4 lit flow at the least. Looks like heart was fully shot and hardly ejecting

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[SAMIR gami]

i am telling 3 l flow on sunday morning when EF was 25 and pts right radial BP was 130/80 off ionotropes

and after making that flow also his lactate was 1.5 and pt fully vounscious with normal cerebral perfusion and his SpO2 on rt and left hand was 100%

he developed this acute event at 3.30 all of sudden pain and hypotension. his BP was normal from saturday night to sunday afternoon 3.30 pm 

Dr Samir Gami

Chest Physician & Intensivist

+91 9925276708

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[drpran...@gmail.com]

Sameer, unlikely. To be coronary embolism. We can think of either pulmonary embolism or sepsis. I have not heard of recycling of alphos so far

Pranay

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From: SAMIR gami Sent: Wednesday 29 March 2017 4:38 PM To: ecmosocie...@googlegroups.com Reply To: ecmosocie...@googlegroups.com Subject: Re: {ESOI} one case needs help , died on ECMO

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[SAMIR gami]

sir he was on heparin and ACT was around 180

and when his ef was down we were continuously seeing echo RA RV was normal at all

dont know reason as pt was so fine and this event occurs in fraction of minutes

so i thought i ask some advice from seniors

Dr Samir Gami

Chest Physician & Intensivist

+91 9925276708

On Wed, Mar 29, 2017 at 8:01 PM, <drpran...@gmail.com> wrote:

Sameer, unlikely. To be coronary embolism. We can think of either pulmonary embolism or sepsis. I have not heard of recycling of alphos so far

Pranay

Sent from my BlackBerry 10 smartphone.

From: SAMIR gami Sent: Wednesday 29 March 2017 4:38 PM

To: ecmosocietyofindia@googlegroups.com Reply To: ecmosocietyofindia@googlegroups.com