A respiratory case on ECMO

[Venkatesh Gopal]

Dear sir,

any further feedback on the resporatory case on ECMO

thanks

[venkat]

Case history –

46 yrs/M, was admitted with 11/2 month back with giddiness, vomiting with altered LFT & was diagnosed to have alcoholic hepatitis. He was discharged after 7 days but developed fever & require rehospitalization in 2 days. At the time of hospitalization had convulsion & was investigated & daignosed to be TBM & was treated with AKT with steroids. He gradually improved with fully conscious , no FND & steroid was tappered. He became breathless 10 days back & was diagnosed to have Hospital acquired pnemonia with ARDS. HE was put on
ventilator 7 days back & was maintaining gases with moderate ventilator settings. but his gases deteriorated since 2 days & ventilatory requirement increased. he developed Pneumomediastinum & surgical emphysema & requiring FiO2 100% for more than 24 hrs. His PO2 was 48 with 100% FiO2 with PEEP 0f 10. His PaO2/FiO2 ratio was 48 with OI of 46. He was considered for ECMO & we were called in. Indication for ECMO was PaO2/FiO2 ratio - 48, OI - 46 (< 35), gradually worsening ventilatory parameter, Barotrauma & relatively
behaving like single organ failure. At the time of initiation of ECMO he had SPO2 for 85% with FiO2 100%., haemodynamically stable on noradrenaline support of 0.05mics/kg/min &
surgical emphysema with peak pressure of 46 - 48. He was taken for VVECMO.(draining cannula - 29F, rt femoral vein, returning cannula - 19 RT IJV) with blood flow of 2.3l/min, sweep gas flow 1:1. Patient's gases improved with in 15 - 20 mins & was on rest lung settings.At present he is haemodynamically atable with noradrenaline of 0.03 mics/kg/min. SPO2 98% with FiO2 of 40. u/o ~ 1.5 ml/kg/hr
Dr Pranay
NB – Circuit priming was done with albumin 20% - 100cc, 1 unit of whole blood & calcium.
Day 1 ON ECMO –
Findings & parameters –
ECMO setting – FiO2 – 100%, blood flow – 2.5l/min, sweep gas flow – 4l/min,
Ventilator setting – rest setting PCMV, FiO2 – 40%, PEEP – 12, Peak IP – 28, I:E 1:1
Heparin requirement – 5000 iv bolus at cannulation then drip started after 12 hrs with 500u/hr
Saturation – 94%, PO2 - 70, PCO2 – 26.6, pH – 7.38,
Output – ~ 50 ml/hr
MAP – 74 on Nor ad. ~ 0.4 µg/kg/min (was there before ECMO)
Blood requirement –
Packed cell or whole blood – 5 blood (Hb at the time of starting ECMO was 9 gm%)
Platelets – nil
Plasma – nil
Interpretation –
After initiation of ECMO, ventilator support was reduced to rest settings & surgical emphysema remained same not worsening. As there was altered coagulatory parameters, heparin requirement was less & as hemoglobin was 9 he required 5 transfusion.
Day 2 on ECMO –
Findings & parameters –
ECMO setting – FiO2 – 100%, blood flow – 2.5l/min, sweep gas flow – 4l/min,
Ventilator setting – rest setting PCMV, FiO2 – 40%, PEEP – 12, Peak IP – 28, I:E 1:1
Heparin requirement – ~ 750u/hr
Saturation – 94%, PO2 – 68, PCO2 – 43, pH – 7.35,
Output – ~ 100 ml/ hr with Lasix 40 mg/hr
MAP – 70, with nor ad – 0.6 µg/kg/min & Dopamine ~ 4 µg/kg/min
Blood requirement –
Packed cell or whole blood – 1
Platelets – 4
Plasma – nil
Interpretation –
Supports & fluid requirement increased can be SIRS reaction or developing sepsis. He had mild SIRS reaction & mild transient renal dysfunction. Lasix drip started to maintain U/o ~ 2- 3ml/kg/hr, as some haemolysis is bound to be there.
Surgical emphysema reducing
PCT increasing, antibiotics stepped up
Day 3 on ECMO –
Findings & parameters –
ECMO setting – FiO2 – 100%, blood flow – 3 l/min, sweep gas flow – 4.5l/min,
Ventilator setting – rest setting PCMV, FiO2 – 40%, PEEP – 12, Peak IP – 28, I:E 1:1
Heparin requirement – ~ 400u/hr
Saturation – 96%, PO2 – 73.6, PCO2 – 39.9, pH – 7.35,
Output – ~ 125 ml/hr with Lasix of 40 mg/hr
MAP – 80 with nor ad – 0.4 µg/kg/min & dopamine – 4 µg/kg/min
Blood requirement –
Packed cell or whole blood – nil
Platelets – nil
Plasma – nil
Interpretation –
Patient stabilized supports requirement decreases, X ray improving
Day 4 on ECMO –
Findings & parameters –
ECMO setting – FiO2 – 90%, blood flow – 3 l/min, sweep gas flow – 4.5l/min,
Ventilator setting – rest setting PCMV, FiO2 – 40%, PEEP – 12, Peak IP – 28, I:E 1:1
Heparin requirement – ~ 500 u/hr
Saturation ~ 94, PO2 – 77.7, PCO2 - 39, pH – 7.35,
Output – ~ 125 ml/hr with Lasix 40 mg/hr
MAP – 80, nor ad tapered off, Dopamine – 3 µg/kg/min
Blood requirement –
Packed cell or whole blood – 1
Platelets – 4
Plasma – nil
Interpretation –
Stable supports started reducing
Day 5 on ECMO –
Findings & parameters –
ECMO setting – FiO2 – 90%, blood flow 3 l/min- , sweep gas flow - ,
Ventilator setting – rest setting PCMV, FiO2 – 40%, PEEP – 12, Peak IP – 28, I:E 1:1
Heparin requirement – 400 u/hr
Saturation – 93%, PO2 – 65.3, PCO2 - 46, pH – 7.3,
Output – ~ 150 ml/hr, Lasix tapered to 20 mg/kg/mr
MAP – 76, Dopamine 2 µg/kg/min
Blood requirement –
Packed cell or whole blood – nil
Platelets – nil
Plasma –
Interpretation –
ECMO parameters stable lungs shows signs of improvement, blood culture send before initiation of ECMO grow candida hence started on Caspofungin ( as he was already on flucon), surgical emphysema disappeared
Day 6 on ECMO –
Findings & parameters –
ECMO setting – FiO2 – 90%, blood flow – 3 l/min, sweep gas flow – 4.5 l/min,
Ventilator setting – rest setting PCMV, FiO2 – 40%, PEEP – 12, Peak IP – 28, I:E 1:1
Heparin requirement – 300 u/hr
Saturation – 94%, PO2 – 69, PCO2 – 45, pH – 7.3,
Output – ~ 125 ml / hr, Lasix tapered to 10 mg/hr
MAP – 74, Dopamine – 2 µg/kg/min
Blood requirement –
Packed cell or whole blood – 1
Platelets – 4
Plasma – nil
Interpretation –
Clinically, biochemical parameters & radiologically improving. PCT showing declining trend

Overall patient is doing well but worry is about the comorbid factors like alcoholic liver (non cirrhotic), TBM, general poor health (low albumin, haemoglobin, hospitalized almost since 2 – 3 months)
Plan is to reduce ECMO FiO2 up to 50% & then think of giving loads to lung & weaning.

Sent from my BlackBerry® smartphone

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From: Venkatesh Gopal <venkates...@gmail.com>

Sender: ecmosocie...@googlegroups.com

Date: Wed, 24 Aug 2011 10:08:07 +0530

To: <ecmosocie...@googlegroups.com>

ReplyTo: ecmosocie...@googlegroups.com

Subject: {ESOI} A respiratory case on ECMO

Dear sir,

any further feedback on the resporatory case on ECMO

thanks

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