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Ann Thorac Surg 2001;72:607-608
© 2001 The Society of Thoracic Surgeons

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Case report

Resuscitaton in near drowning with extracorporeal membrane oxygenation

^a Departments of Cardiothoracic Surgery and Anesthesiology and Intensive Care, General Hospital Klagenfurt, Klagenfurt, Austria

Accepted for publication July 16, 2000.

Address reprint requests to Dr Thalmann, Department of Cardiothoracic Surgery, c/o General Hospital Klagenfurt, St. Veiterstrasse 47, A-9026 Klagenfurt, Austria
e-mail: herz-thorax.abteilung{at}lkh-klu.at

	Abstract

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We report a case of near drowning of a 3-year-old girl, who was admitted to our emergency room with a core temperature of 18.4°C. After rewarming on cardiopulmonary bypass and restitution of her circulation, respiratory failure resistant to conventional respiratory therapy prohibited weaning from cardiopulmonary bypass. Therefore, we instituted extracorporeal membrane oxygenation (ECMO). Fifteen hours later, she could be weaned from ECMO but required assisted ventilation for another 12 days. Twenty months later there are no neurologic deficits.

	Introduction

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Near drowning associated with deep hypothermia is a clinical setting associated with poor outcome [1]. Because important data of the accident and prognostic predictors generally are not known to the resuscitation team, prolonged resuscitation efforts including extracorporeal circulation are the current "state of the art" [2]. If the victim could breath during the cooling-down period, the prognosis would be superior to immediate (warm) suffocation. Severe aspiration of water, however, may impair the lung function to the point that it will not recover during the warm-up period, necessitating the termination of the resuscitation efforts. We, therefore, report a patient in whom ventilatory function recovered only after ECMO, a method previous reported only in one patient for this application [3].

A 3-year-old unobserved girl fell into a fishpond with a water temperature of 8°C. She was found at the bottom of the pond by her parents after approximately 30 minutes. They initiated cardiopulmonary resuscitation according to the directions of the emergency doctor given by telephone. Eight minutes later, the emergency team arrived and initiated professional resuscitation. At this time, the girl was comatose and asystolic, had dilated pupils, and a tympanic membrane temperature of 18.7°C. Under continuous cardiopulmonary resuscitation, the girl was flown to our department by helicopter for rewarming on cardiopulmonary bypass. Flight time was 25 minutes. Upon arrival, she was immediately taken to the operating room. Under continuous mechanical resuscitation, we cannulated the right groin with a 12F arterial cannula (BARD) and a 18F venous cannula (RMI). In the meantime, a central venous catheter was inserted by way of the right subclavian vein. An arterial pressure line was inserted surgically in the left groin. It took 20 minutes from the landing to initiate extracorporeal bypass; total time of cardiorespiratory arrest must have been about 90 minutes. We used our conventional preconnected adult oxygenator set, constantly preprepared for emergency cases, consisting of a hollow-fiber membrane oxygenator (Monolyth Sorin Biomedica, Saluggia, Italy), a roller pump (Stöckert, Munich, Germany), an arterial line filter (Affinity Avecor; Medtronic, Minneapolis, MN) and a 1/2 inch polyvinylchloride (PVC) tubing.

Immediately after going on bypass, the arterial blood gas analysis revealed a pH of 6.72, standard bicarbonate -2.4 mmol/L, base excess -28.1 and K⁺ 5.7. With a mean blood flow ranging from 1.2 L/min to 1.6 L/min and a gas flow ranging from 0.5 L to 1.0 L, oxygenation was satisfactory and the pH could be raised to 7.38 within 40 minutes. We performed rewarming with 3°C per hour and reached a temperature of 37°C after 6 hours on cardiopulmonary bypass. At 24°C, the girl developed spontaneous sinus rhythm. When we reached 32°C as measured by the esophageal probe, severe lung edema occurred, intractable even to jet ventilation and bronchoscopic application of surfactant factor. Because we had no evidence of severe neurologic injury and the girl demonstrated insufficient oxygen saturation without oxygenator support, it was decided to temporarily replace the function of the lung with extracorporeal membrane oxygenation (ECMO). Because we don’t have a pediatric cardiac surgery and it is well known that the adequate positioning of the cervical canulas can be difficult [4], we decided to use a thoracic cannulation, a technique well known to us from adult cardiac surgery. Thus, we performed a median sternotomy and cannulated the ascending aorta with a 14F cannula (Dideco; Mirandola, Italy) and the right atrium with a 22F cannula (RMI). The tubing for ECMO was assembled while opening the chest. We used the Medtronic Biopump (Medtronic, Minneapolis, MN) with a Carmeda (heparin-) coated tubing system, the Maxima PRF membrane oxygenator (Medtronic, Minneopolis, MN) and a centrifugal pump head (CB BP 80). The ventilating gas mixture was warmed up to 39°C to prevent plasma leakage by condensed water.

When we initiated ECMO, the groin was decannulated. The chest was left open, covered with a plastic foil. With this setup, the girl was transferred to the intensive care unit. Simultaneously, conventional ventilation with positive end-expiratory pressure and repeated endobronchial administration of surfactant was performed. After 15 hours, the girl could be weaned from ECMO. The patient required sedation and ventilation with biphasic positive airway pressure as well as positive inotropic support with dopamine, dobutamine and arterenol for the next 7 days. Our sedation and analgesic regimen consisted of sufentanyl, midazolam, and propofol. On the first postoperative day, we performed a computer tomography of the cerebrum, which showed mild cerebral edema. Thereafter, an intracerebral pressure line was inserted and therapy was aimed at maintaining a cerebral perfusion pressure of at least 40 mm Hg. After respiratory and neurologic improvement, she could be weaned from mechanical ventilation and was extubated on day 12. Other than a moderate weakness of the right leg and the left arm, there were no further neurologic deficits. During the next 6 months, she had physiotherapeutic support and logopedic training. By the control examination 20 months after the accident, she was doing well and was developing without any neurologic abnormalities.

	Comment

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Institution of cardiopulmonary bypass to warm up a near-drowned child is a standard procedure in every heart center. The most important factor influencing the neurologic outcome is the speed of cooling and the length of time during which the victim still had the capability of breathing. If the victim can breathe during cooling, the prognosis is better than immediate suffocation. Similarities exist to the pathophysiology and management of persons buried in an avalanche, demonstrating the prognostic importance of an air pocket, but only limited role of hypothermia [5]. In addition to neurologic problems, respiratory complications and pulmonary failure are very common in near-drowned patients and may also prevent successful outcome. Extended resuscitation with the ECMO can be a successful procedure in individuals with prolonged pulmonary insufficiency secondary to near-drowning. Therefore, pulmonary failure secondary to a warm-up procedure with extracorporeal circulation resistant to ventilatory treatment may be an appropriate indication for ECMO and may result in an event-free outcome.

	References

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1. Spack L., Gedeit R., Splaingard M., Havens P.L. Failure of aggressive therapy to alter outcome in pediatric near drowning. Pediatr Emerg Care 1997;13:98-102.[Medline]
2. Christensen D.W., Jansen P., Perkin R.M. Outcome and acute care hospital costs after warm water near drowning in children. Pediatrics 1997;99:715-721.[Abstract/Free Full Text]
3. Foltan M., Philipp A., Kobuch R., Lemberger P., Rödig G., Birnbaum D.E. Extrakorporale Wiedererwärmung eines hypothermen Kleinkindes nach Beinahe-Ertrinken–ein Fallbericht. Kardiotechnik 1999;2:29-31.
4. Irish M.S., O’Toole S.J., Kapur P., Bambini D.A., Azizkhan R.G. Cervical ECMO cannula placement in infants, and children recommendations for assessment of adequate positioning, and function. J Pediatr Surg 1998;33:929-931.[Medline]
5. Brugger H., Falk M., Adler-Kastner L. Avalanche emergencies. New perspectives on the pathophysiology and management of persons buried in an avalanche. Wien Klin Wochenschr 1997;109:145-159.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Markus Thalmann Norbert Haberfellner Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Thalmann, M. Articles by Kobinia, G. Search for Related Content PubMed PubMed Citation Articles by Thalmann, M. Articles by Kobinia, G. Related Collections Extracorporeal circulation