Ann Thorac Surg 2009;87:e4-e5. doi:10.1016/j.athoracsur.2008.07.077
© 2009 The Society of Thoracic Surgeons
Case Reports
Use of Extracorporeal Membrane Oxygenation in the Management of Septic Shock With Severe Cardiac Dysfunction After Ravitch Procedure
Hunaid A. Vohra, MRCS, MD,
Louise Adamson, MRCS,
David F. Weeden, FRCS,
Marcus P. Haw, FRCS(CTh)*
Wessex Cardiothoracic Centre, Southampton University Hospitals NHS Trust, Southampton, United Kingdom
Accepted for publication July 25, 2008.
* Address correspondence to Dr Haw, Wessex Cardiothoracic Centre, Southampton University Hospitals NHS Trust, Southampton General Hospital, Tremona Rd, Southampton, S016 6YD, United Kingdom (Email: marcus.haw{at}suht.nhs.uk).
 |
Abstract
|
|---|
We report the case of an 18-year-old patient who underwent Ravitch procedure for pectus carinatum and subsequently had septic shock develop with severe cardiac dysfunction requiring treatment with extracorporeal membrane oxygenation. We advocate the use of extracorporeal membrane oxygenation in adult patients with intractable cardiorespiratory failure due to sepsis post-thoracic surgery unresponsive to conventional therapy.
|
Introduction
|
|---|
Repair of pectus carinatum can be undertaken by several surgical methods, the standard approach being the Ravitch procedure. This involves subperichondrial excision of the overgrown costal cartilages, remodeling of the sternum, and stabilization of the anterior chest wall. Repair of pectus deformity is a safe procedure with low morbidity and no reported mortality [1]. This report describes the case of an 18-year-old patient who underwent the Ravitch procedure and subsequently had septic shock develop with severe cardiac dysfunction requiring treatment with extracorporeal membrane oxygenation (ECMO).
An 18-year-old student was admitted to our unit for a Ravitch procedure. He had no significant, past medical history. An uncomplicated Ravitch procedure was performed. He made good recovery for the first 3 days. His chest roentgenogram was unremarkable and the drains were removed. On postoperative day 4, the patient had a fever (38°C) develop; his sinus tachycardia was 110 per minute, and he had slight dysuria. The white cell count was 6.6 x 109/L and the C-reactive protein was 223 mg/L. Oral trimethoprim was commenced for suspected urinary tract infection. However, on postoperative day 6, his condition deteriorated rapidly with severe hypotension refractory to fluid resuscitation. A transthoracic echocardiogram demonstrated mildly hypokinetic right and left ventricles. The temperature at this stage was 39.5°C, and the white cell count was 43.1 x 109/L. Blood cultures were taken, and intravenous meropenem was empirically started. Biochemistry showed acute renal dysfunction (urea 17.2 mmol/L and creatinine 460 µmol/L), and arterial blood analysis revealed lactate of 12 mmol/L with a base deficit of –12 mEq/L. On the same day, the patient had oliguria develop that was transferred to the intensive care unit. Noradrenaline was commenced and the patient was mechanically ventilated. A computed tomographic pulmonary angiogram was performed that did not show any evidence of pulmonary embolism, but there was a very small retrosternal collection. On day 7, continuous veno-venous hemofiltration was commenced for acute renal failure through the right subclavian vein. A transesophageal echocardiography on the same day showed severe biventricular dysfunction and an ejection fraction of 5% to 10%. On the same day, an intra-aortic balloon pump was inserted and due to continuing deterioration, veno-arterial ECMO was initiated through the right femoral vein and the right femoral artery. Blood flow was maintained at 2.2 to 2.6 L/min. Perfusion was evaluated by correction of acidosis, arterial oxygen saturation > 90% and mixed venous oxygen saturation > 65%. Intravenous heparin infusion was used to achieve an activated clotting time of 150 to 200 seconds. On ECMO, the mechanical ventilator settings were reduced to minimize iatrogenic lung damage (positive end-expiratory pressure, 10 cm H2O, fraction of inspired oxygen, 0.21 to 0.3; peak inspiratory pressure < 25 cm H2O, 10 breaths per minute). Inotropes were stopped once adequate systemic perfusion was achieved.
At this stage on postoperative day 7, a small amount of pus was evacuated from the lower sternal wound. A repeat transesophageal echocardiography was performed 24 hours after commencing ECMO on postoperative day 8, which showed an improvement in ejection fraction (20% to 25%). Staphylococcus aureus, sensitive to flucloxacillin and fusidic acid was isolated from both the blood and the sternal wound. Hence, the patient was switched over from meropenem to these antibiotics on postoperative day 9. The ECMO was discontinued 72 hours after commencement on postoperative day 10, and the intra-aortic balloon pump counter-pulsation was weaned and discontinued 48 hours later on postoperative day 12. A VAC Therapy System (KCI Medical Ltd, Kidlington, United Kingdom) was applied to the lower sternal wound. The patient returned to the ward on the postoperative day 26. The wound was regularly dressed, and he was discharged on postoperative day 53. The oral antibiotics were continued for another 6 weeks. He was readmitted for sternal wound closure and a satisfactory cosmetic result was achieved.
|
Comment
|
|---|
The ECMO has historically been used almost exclusively in neonates and children, although cases of successful use of ECMO in adults have recently been reported in the literature [2]. This report highlights the successful application of ECMO therapy in an adult patient with septic shock resulting in severe cardiac dysfunction after thoracic surgery. The ECMO has been shown to provide adequate tissue oxygen delivery in neonatal patients suffering cardiac and respiratory failure, or both [3]. Since its introduction in 1975, the application of ECMO has expanded to include pediatric and adult patients, although no randomized controlled trials have as yet been carried out in these populations. Sepsis, once considered a contraindication for ECMO, has not been shown to independently influence survival in pediatric ECMO [4]. Moreover, adults with sepsis of varying cause have been successfully treated by this method [2]. The role of ECMO has also been proposed as a bridge to recovery in patients with severe sepsis who would otherwise die as a result of either hypoxemia or inadequate cardiac output. The potential benefits of ECMO in sepsis are a result of provision of temporary cardiovascular and respiratory support, improving peripheral perfusion and oxygenation in the presence of cardiovascular collapse until septicemia and detrimental consequences of the inflammatory response subside.
The indication for ECMO in our case was severe cardiac dysfunction resulting from staphylococcal septic shock. A case series by Ferdman and colleagues [5] reports favorable outcomes in 3 children who presented with gram-positive sepsis and significant cardiovascular compromise, including left ventricular dilatation with the use of aggressive therapy. Another article reported in 9 pediatric patients with culture proven refractory septic shock reported that the use of inotropes could be stopped within 24 hours of starting ECMO [6]. Five children survived to live normal lives in this series.
A review by Fortenberry and Paden [7] found good outcomes for the use of ECMO in neonatal sepsis, but overall survival in septic patients needing ECMO was not different from survival in nonseptic patients needing the therapy. However, they reported that data was lacking to determine whether outcomes were improved when ECMO was initiated for sepsis as a primary indication. The American College of Critical Care Medicine has presented a consensus on indications for ECMO [8]. For neonates, they recommend ECMO for refractory shock, unresponsive to catecholamines. For pediatric patients, based on the evidence, they recommend only considering the use of ECMO for persistent catecholamine-resistant shock-failing, directed therapies. There are currently no universally agreed guidelines for the use of ECMO in adults. However, criteria published by experienced centers recommend ECMO in patients with combined cardiorespiratory compromise that is life threatening [9].
In conclusion, we recommend that ECMO should be strongly considered in every adult patient with septic shock with concomitant severe cardiac dysfunction leading to refractory hypotension. The present case report highlights the need for further investigation into the potential of ECMO to treat adults with refractory septic shock leading to cardiogenic shock.
|
References
|
|---|
- Jaroszewski DE, Fonkalsrud EW. Repair of pectus chest deformities in 320 adult patients: 21 year experience Ann Thorac Surg 2007;84:429-433.[Abstract/Free Full Text]
- Maclaren G, Pellegrino V, Butt W, Preovolos A, Salamonsen R. Successful use of ECMO in adults with life-threatening infections Anaesth Intensive Care 2004;32:707-710.[Medline]
- Hansell DR. Extracorporeal membrane oxygenation for perinatal and pediatric patients Respir Care 2003;48:352-362.[Medline]
- Meyer DM, Jessen ME. Results of extracorporeal membrane oxygenation in children with sepsis. The Extracorporeal Life Support Organization. Ann Thorac Surg 1997;63:756-761.[Abstract/Free Full Text]
- Ferdman B, Jureidini SB, Gale G, Mink R. Severe left ventricular dysfunction and arrhythmias as complications of gram-positive sepsis: rapid recovery in children Pediatr Cardiol 1998;19:482-486.[Medline]
- Beca J, Butt W. Extracorporeal membrane oxygenation for refractory septic shock in children Pediatrics 1994;93:726-729.[Abstract/Free Full Text]
- Fortenberry JD, Paden ML. Extracorporeal therapies in the treatment of sepsis: experience and promise Semin Pediatr Infect Dis 2006;17:72-79.[Medline]
- Carcillo JA, Fields A. American College of Critical Care Medicine Task Force Clinical practice parameters for hemodynamic support of neonatal and pediatric patients in septic shock Crit Care Med 2002;30:1365-1378.[Medline]
- Egan T, Duffin J, Glynn M, et al. Ten-year experience with extracorporeal membrane oxygenation for severe respiratory failure Chest 1988;94:681-687.[Abstract/Free Full Text]
Top
Abstract
Introduction
