ECMO in acute respiratory failure
Venkat Goyal
Mr. RR, 49 year old young gentleman not a diabetic and normotensive, not a smoker and ethnolic presented with symptoms of URTI for 5 days on 25th of July. Gradually progressive to LRTI and admitted with respiratory distress and high oxygen requirement. He was suspected H1N1 noval swinflu infection but PCR from throat swab was negative. Serology of atypical pneumonia was non-contributory. Haemogram and biochemistry was also normal.
Chest X-ray revealed mild lung volume reduction and ground glass opacity. A day passes his oxygen requirement increased as patient put on initial on oxygen mask to Non-rebreathing face mask, within two day patient put on NIV support and Invasive ventilation support on 27th July. Bronchoscopy revealed Klebseilla and pseudomonas. Connective tissue work up was non-contributory. CRP was reduced 515 to 143 in initial days. Patient was extubated on 5th August and put on NIV, HRCT shows interstitial pneumonitis during 1st week of august. Patient was not sustain NIV support and again reintubated on 9th of August and Tracheostomy done on same day.
Repeat HRCT revealed more of fibrosis and pneumotecele of right lung. Day by day patient was deteriorating and further bronchoscopy revealed same organism. 27th august patient further deteriorate, chest x-ray revealed right side tension pneumothorax, ICD was inserted, next day morning another ICD was inserted in-view of non-expanding of lung.
Patient was shifted in sterling hospital on 31st August.
Now patient on PRVC mode with 450 ml tidal volume, but peak pressure around 23 cm H2O as most of the air is leaking through BPF. He is maintaining SPo2 around 88 with Fio2 1.
His ABC shows moderate hypoxia PO2 54 mmHg with hypercarbia PCO2 62 mmHg.
Patient relative were explained about ECMO, its initiation, complication and prolongation of treatment and outcome.
Indications for ECMO –
Barotrauma – Air leak syndrome, PO2/FiO2 ratio ~ 50
Goal –
To give rest to the lungs with minimum ventilator settings so that lung recovers & BPF seals off
Discussion –
There was a lot of concern about whether to take this patient for ECMO or not, as we know ECMO is to prolong the life & not to prolong death. The issues were patient on ventilator for almost 30 days, HRCT showing ground glass appearance with some fibrotic areas interspersed, Pneumothorax & BPF. At the other end patient is young, no premorbid illness, behaving as a Single organ failure so far, Hard ventilator settings (FiO2 100%) since 4 to 5 days. After a detailed discussion with the relatives regarding the possible outcome, it was decided to give him at least one week trial of ECMO & then see how lungs improves & if there is no improvement then do lung biopsy & decide further course of action.
Patient was put on VV ECMO with 29 F venous cannula in femoral vein for drainage & 19 F arterial cannula in right internal jugular vein for return. The circuit was primed with crystalloid & albumin. Cannulation was done by seldinger’s technic. ECMO was started on 2/09/11 at 2 am
Day 1 ON ECMO –
Findings & parameters –
ECMO setting – FiO2 – 100%, blood flow – 3.7l/min, sweep gas flow – 5.5 l/min,
Ventilator setting – rest setting PCMV, FiO2 – 30%, PEEP – 05, Peak IP – 20, I:E 1:2
Heparin requirement – 8000 iv bolus at cannulation then drip started after 4 hrs with 1000u/hr.
Saturation – 90%, PO2 – 52.5, PCO2 – 46, pH – 7.42, HCO3 – 29.8
Output – ~ 100 ml/hr
MAP ~ 100
Blood requirement –
Packed cell or whole blood – 5 blood (Hb at the time of starting ECMO was 10 gm%)
Platelets – nil
Plasma – nil
Interpretation –
After initiation of ECMO, ventilator support was reduced to rest settings, negative suction applied. PEEP of 5 was kept to promote healing of BPF & as the disease is long standing with fibrosis so higher PEEP may not be of much use. Initially hemoglobin was 10 he required 5 transfusion.
Day 2 on ECMO –
Findings & parameters –
ECMO setting – FiO2 – 100%, blood flow – 3.5l/min, sweep gas flow – 5l/min,
Ventilator setting – rest setting PCMV, FiO2 – 30%, PEEP – 5, Peak IP – 20, I:E 1:2
Heparin requirement – ~ 1000u/hr
Saturation – 84.9%, PO2 – 45, PCO2 – 37.5, pH – 7.4,
Output – ~ 100 ml/ hr
MAP – 110, with NTG ~ 3 µg/min
Blood requirement –
Packed cell or whole blood – nil
Platelets – nil
Plasma – nil
Interpretation –
X ray fully expanded but haziness worsened (ECMO Lung) probably SIRS reaction. His sats used to remain 85% inspite of flow of 4l/min & there was no improvement on saturation even by increasing flow. Possibility of recirculation was thought & pre oxygenator & SVO2 was done & recirculation was 50%. Rt IJV was looking to deep in RA & was probably facing the IVC. IJV was pulled slightly & saturation improved
Day 3 on ECMO –
Findings & parameters –
ECMO setting – FiO2 – 100%, blood flow – 3.6 l/min, sweep gas flow – 5.5l/min,
Ventilator setting – rest setting PCMV, FiO2 – 30%, PEEP – 5, Peak IP – 20, I:E 1:2
Heparin requirement – ~ 800u/hr
Saturation – 86.2%, PO2 – 49, PCO2 – 47, pH – 7,24
Output – ~ 125 ml/hr
MAP – 120
Blood requirement –
Packed cell or whole blood – 1
Platelets – nil
Plasma – nil
Interpretation –
Patient stable
Day 4 on ECMO –
Findings & parameters –
ECMO setting – FiO2 – 100%, blood flow – 3.5 l/min, sweep gas flow – 5.2l/min,
Ventilator setting – rest setting PCMV, FiO2 – 30%, PEEP – 5, Peak IP – 20, I:E 1:2
Heparin requirement – ~ 800 u/hr
Saturation ~ 87, PO2 – 51 PCO2 - 46, pH – 7.4,
Output – ~ 125 ml/hr
MAP – 110,
Blood requirement –
Packed cell or whole blood – 1
Platelets – nil
Plasma – nil
Interpretation –
Stable, uneventful day
Day 5 on ECMO –
Findings & parameters –
ECMO setting – FiO2 – 100%, blood flow 3.2 l/min, sweep gas flow – 5l/min,
Ventilator setting – rest setting PCMV, FiO2 – 30%, PEEP – 5, Peak IP – 20, I:E 1:2
Heparin requirement – 1000 u/hr
Saturation – 87.5%, PO2 – 50, PCO2 - 40, pH – 7.4,
Output – ~ 100 ml/hr,
MAP – 100,
Blood requirement –
Packed cell or whole blood – nil
Platelets – nil
Plasma –
Interpretation –
ECMO flow reduced to 3.2l/min, negative suction was stopped for some time but pneumothorax redeveloped.
Day 6 on ECMO –
Findings & parameters –
ECMO setting – FiO2 – 100%, blood flow – 2.5 l/min, sweep gas flow – 4 l/min,
Ventilator setting – rest setting PCMV, FiO2 – 40%, PEEP – 5, Peak IP – 20, I:E 1:2
Heparin requirement – 1000 u/hr
Saturation – 91%, PO2 – 56.3, PCO2 – 35.6, pH – 7.4,
Output – ~ 125 ml / hr,
MAP – 100
Blood requirement –
Packed cell or whole blood – nil
Platelets – nil
Plasma – nil
Interpretation –
Clinically better, alert, sedation reduced. ECMO flow decreased to 2.5 l/min inview of negative pre pump pressure & improved oxygenation
Day 7 on ECMO –
Findings & parameters –
ECMO setting – FiO2 – 100%, blood flow – 2.5 l/min, sweep gas flow – 4 l/min,
Ventilator setting – rest setting PCMV, FiO2 – 40%, PEEP – 5, Peak IP – 20, I:E 1:2
Heparin requirement – 1000 u/hr
Saturation – 87.8%, PO2 – 52, PCO2 – 43.8, pH – 7.4,
Output – ~ 150 ml / hr,
MAP – 78
Blood requirement –
Packed cell or whole blood – 1
Platelets – nil
Plasma – nil
Interpretation –
Patient had a dark coloured urine Coca-Cola urine s/o haemolysis, as the prepump pressures were ok hence suction is unlikely to be the culprit. The possibilities are either pump induced or oxygenator related. The pump related causes are clot in the pump, too much of heat generated by old pump or breaking of one of the bearing of the pump while oxygenator induced is always the clot in oxygenator. In his case as pump is already 7 days old we decided to change the pump. Pump showed blood clots at the base of the pump. The Coca-Cola urine disappeared in hrs.
Overall patient is doing well but worry is how much the lung will improve.
Plan is to do broncoscopy & try to seal off BPF with glue, give rest for 2 more days & then if lungs improve reduce ECMO FiO2 up to 50% & then think of giving loads to lung & weaning.
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Dr Venkat Goyal