Central Extracorporeal Membrane Oxygenation for Septic Shock in an Adult With H1N1 Influenza

doi:10.1016/j.athoracsur.2010.06.019

The Annals of Thoracic Surgery

Volume 90, Issue 3, September 2010, Pages e34-e35

https://doi.org/10.1016/j.athoracsur.2010.06.019 Get rights and content

Extracorporeal membrane oxygenation has been used as rescue therapy for respiratory failure caused by pandemic hemagglutanin-1 and neuroaminadase-1 (H1N1) influenza, but it is unclear as to whether it can be also used for refractory circulatory failure. A previously healthy 29-year-old woman presented with pneumonitis and septic shock. She deteriorated, despite multiple pharmacologic and ventilatory strategies, so she was placed on central (atrio-aortic) extracorporeal membrane oxygenation for 4 days. After a protracted intensive care stay, she recovered and is undergoing rehabilitation. In particularly severe cases of H1N1 influenza, central extracorporeal membrane oxygenation can completely supplant both cardiac and pulmonary function until the patient recovers from the infection.

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The patient was referred for ECMO very late in the course of her illness, which may account for its severity and complexity and her protracted recovery. One possible differential diagnosis considered at the time was H1N1 influenza myocarditis. However, the preservation of high cardiac output measured on both pressure waveform analysis and echocardiography, coupled with the absence of any histologic features suggestive of myocarditis, would seem more likely to support a diagnosis of distributive

References (6)

Pandemic (H1N1) 2009 – update 91
A. Davies et al.
Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome
JAMA
(2009)
Clinical management of human infection with pandemic (H1N1) 2009: revised guidance

There are more references available in the full text version of this article.

Cited by (25)

Septic Shock in Low-Cardiac-Output Patients With Heart and Lung Transplantation: Diagnosis and Management Dilemma
2017, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
If ECMO is in use before the onset of sepsis after thoracic organ transplantation, its discontinuation and decannulation require careful consideration based on the existing oxygenation status and myocardial function. Nevertheless, ECMO has been used in adult refractory septic shock with a variable success rate.50–55 The unpredictability associated with isolation of the organism, the frequent presence of atypical microorganisms, and shared clinical and biochemical manifestations mandate refinement in the diagnostic criteria of sepsis and septic shock.
Extracorporeal membrane oxygenation resuscitation in adult patients with refractory septic shock
2013, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
The present study found age was the only recognized prognostic variable in adults with refractory septic shock, and no patient aged 60 years or older survived to hospital discharge. This is in line with previous case reports5-8 that demonstrated successful rescue of refractory septic shock by ECMO in patients aged 18 to 46 years. Age is an unchangeable characteristic and predicts the outcome of various diseases.17-19
Experience with extracorporeal membrane oxygenation for adult patients with refractory septic shock remains limited. We aimed to study the clinical features and outcomes of this patient group in an extracorporeal membrane oxygenation referral center in Taiwan.
From January 2005 to December 2010, all adult patients in refractory septic shock and requiring venoarterial extracorporeal membrane oxygenation for circulatory support were included in the present study. The variables analyzed included patient demographics; comorbidities; smoking status; hemodynamic, ventilatory, and laboratory parameters just before extracorporeal membrane oxygenation support; clinical course; extracorporeal membrane oxygenation details; complications; microbiology results; and outcomes. The primary endpoint was survival to hospital discharge.
A total of 52 patients, 39 men and 13 women, were included during a 6-year period. Their median age and body mass index was 56.8 years and 24.1 kg/m², respectively. Of the 52 patients, 39 (75%) had failure of at least 3 organ systems and 21 (40%) had developed cardiac arrest and received cardiopulmonary resuscitation at extracorporeal membrane oxygenation implantation. Of these 52 patients, 8 (15%) survived to hospital discharge. The nonsurvivors were significantly older than the survivors (59.3 vs 43.8 years; P = .009), and all 20 patients (38%) aged 60 years or older died.
In our single-center experience with extracorporeal membrane oxygenation for adults with refractory septic shock, the outcomes of these patients remain unsatisfactory. From our findings, we suggest that if extracorporeal membrane oxygenation were to be used in this patient population, age 60 years or older might be a contraindication. Also, central extracorporeal membrane oxygenation could possibly be beneficial according to the favorable pediatric experience in published studies.
To ventilate, oscillate, or cannulate?
2013, Journal of Critical Care
Citation Excerpt :
However, these criteria may not always identify a true need for ECMO because in the CESAR trial, about 20% of patients who met these criteria were successfully managed with CV. Rarely, VV ECMO may not suffice in a patient with severe cardiorespiratory failure who is in extremis and may necessitate advanced extracorporeal life support with venoarterial ECMO [79]. Although outcomes in such patients are likely to be poor, such decisions at best are to be made on a case-by-case basis.
Ventilatory management of acute respiratory distress syndrome has evolved significantly in the last few decades. The aims have shifted from optimal gas transfer without concern for iatrogenic risks to adequate gas transfer while minimizing lung injury. This change in focus, along with improved ventilator and multiorgan system management, has resulted in a significant improvement in patient outcomes. Despite this, a number of patients develop hypoxemic respiratory failure refractory to lung-protective ventilation (LPV). The intensivist then faces the dilemma of either persisting with LPV using adjuncts (neuromuscular blocking agents, prone positioning, recruitment maneuvers, inhaled nitric oxide, inhaled prostacyclin, steroids, and surfactant) or making a transition to rescue therapies such as high-frequency oscillatory ventilation (HFOV) and/or extracorporeal membrane oxygenation (ECMO) when both these modalities are at their disposal. The lack of quality evidence and potential harm reported in recent studies question the use of HFOV as a routine rescue option. Based on current literature, the role for venovenous (VV) ECMO is probably sequential as a salvage therapy to ensure ultraprotective ventilation in selected young patients with potentially reversible respiratory failure who fail LPV despite neuromuscular paralysis and prone ventilation. Given the risk profile and the economic impact, future research should identify the patients who benefit most from VV ECMO. These choices may be further influenced by the emerging novel extracorporeal carbon dioxide removal devices that can compliment LPV. Given the heterogeneity of acute respiratory distress syndrome, each of these modalities may play a role in an individual patient. Future studies comparing LPV, HFOV, and VV ECMO should not only focus on defining the patients who benefit most from each of these therapies but also consider long-term functional outcomes.
Survival of septic adults compared with nonseptic adults receiving extracorporeal membrane oxygenation for cardiopulmonary failure: A propensity-matched analysis
2013, Journal of Critical Care
Citation Excerpt :
However, use of VA-ECMO for this indication in the adults is rare. Five such cases reports comprise a patient with prosthesis-related osteomyelitis, 2 with necrotizing fasciitis, 1 with novel H1N1 influenza, and one with sternal wound infection, all of them had left ventricular ejection fraction less than 35% [9,12,16,31]. The hemodynamic responses of these patients were similar to those seen in septic young children (Supplement Table 5).
Limited data on the outcomes of adults with active sepsis undergoing extracorporeal membrane oxygenation (ECMO) exist.
We analyzed our prospective database for adults undergoing their first ECMO from 2001 to 2009. Patients with preexisting sepsis had newly emerging or uncontrolled infections precipitating refractory respiratory and/or circulatory failure within 7 days preceding ECMO. Propensity score matching was performed to equalize potential prognostic factors between patients with and patients without sepsis.
Of the 514 adults receiving their first ECMO, 108 with preexisting sepsis were matched with 108 without sepsis by propensity score. Overall survival to discharge did not differ between those with (28.7%) and those without sepsis (37.0%; P = .192). When venovenous ECMO and venoarterial ECMO were considered separately, survival tended to be worse for septic patients on venoarterial ECMO (24.4%) compared with nonseptic adults on venoarterial ECMO (34.9%; P = .147). After adjustments for age, stroke, acute myocarditis, inter-extracorporeal cardiopulmonary resuscitation, and post-ECMO renal and neurologic deficits by multivariate analysis, the increased risk of mortality persisted for septic adults receiving venoarterial ECMO (hazard ratio, 2.54; 95% confidence intervals, 1.75-3.70; P < .01). Patients on venovenous ECMO had similar outcomes regardless of preexisting sepsis.
Preexisting sepsis is not a contraindication for ECMO. However, venoarterial ECMO should be used with caution, given active sepsis.
A novel strategy to improve systemic oxygenation in venovenous extracorporeal membrane oxygenation: The "χ-configuration"
2011, Journal of Thoracic and Cardiovascular Surgery
Citation Excerpt :
Different experimental20-23 and clinical4,24 reports show that VILI also causes renal, cardiac, liver failure, and other systemic consequences, probably owing to inflammatory mediators delivered from the damaged lung when high-pressure mechanical ventilation is continued.21 During ECMO, obtaining an optimal blood oxygenation level is possible only if the VV-ECMO technique permits it: our new cannula setting, the χ-configuration, reduces recirculation and permits a very high ECMO flow related to the patient’s CO, avoiding invasive surgical methods, which are to date the only methods that permit similar results.18,25 Although percutaneous VA-ECMO permits a higher and more consistent oxygen delivery, VV-ECMO reduces invasiveness and major complications related to arterial cannulation, impaired cardiac performance, decreased coronary and cerebral oxygen transport and autoregulation, altered regional blood flow to vital organ, increased pulmonary resistance, and more.3,8,10,16
Venovenous extracorporeal membrane oxygenation (VV-ECMO) is used in refractory acute respiratory distress syndrome where lung recovery is the primary goal. For its achievement, adequate extracorporeal blood flow and a maximal separation between oxygenated (inflow) and deoxygenated (outflow) blood flow are essential for reducing the recirculation phenomenon. We introduce the χ-configuration, a new cannulation strategy for VV-ECMO.
We report our experience with 30 VV-ECMO consecutive patients: in 16 patients (group NS) we applied the χ-configuration, which consists of a particular right atrial cannula arrangement and a self-made modified inflow cannula, consisting of an outflow multihole venous cannula that was inserted percutaneously through the right femoral vein, into the right atrium, just below on the superior vena cava, and a self-made modified curved inflow cannula (inserted percutaneously through the right internal jugular vein) that, in its terminal segment, permitted the tip to be positioned close to the tricuspid valve. In 14 patients (group C) we applied the standard femoro-jugular VV-ECMO 2-cannula setting. In both groups, efficacy of blood oxygenation was obtained by gas–blood analysis, by blood samples obtained at arterial, central venous, and pulmonary artery lines, and by ECMO inflow and outflow lines. The recirculation fraction was obtained by a specific bedside formula.
No differences were noted between groups regarding the pre-ECMO patient characteristics. No complications during cannulation were recorded. In group NS, on-ECMO time, post-ECMO mechanical ventilation time, and ECMO overall results were significantly better than in group C. During high-flow VV-ECMO, pulmonary and systemic arterial oxygen saturation and arterial oxygen tension were significantly higher in group NS, and blood recirculation fraction was significantly lower.
Our data indicate that χ-configuration can be safe, feasible, and more effective than conventional VV-ECMO. It permits near complete drainage of the desaturated blood and a preferential oxygenated blood inflow toward the tricuspid valve, resulting in a significant reduction of recirculation, thereby improving the patient’s oxygenation. Our innovative strategy reduces on-ECMO and post-ECMO mechanical ventilation time, gives a faster and better pulmonary recovery, improves survival, and can reduce hospital costs.
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2011, Annals of Thoracic Surgery

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Case reportCentral Extracorporeal Membrane Oxygenation for Septic Shock in an Adult With H1N1 Influenza

Section snippets

Comment

Pandemic (H1N1) 2009 – update 91

Extracorporeal membrane oxygenation for 2009 influenza A(H1N1) acute respiratory distress syndrome

JAMA

Clinical management of human infection with pandemic (H1N1) 2009: revised guidance

Case report
Central Extracorporeal Membrane Oxygenation for Septic Shock in an Adult With H1N1 Influenza