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A5257 - ECMO CPR for Hypoxic Respiratory Failure Associated Refractory Cardiac Arrest: A Success Story
Author Block: A. Bhardwaj1, D. Gorman1, A. A. Hameed2, M. W. Sims3, J. T. Gutsche4; 1Medicine, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, PA, United States, 2Medicine, Mercy Catholic Medical Center, Darby, PA, United States, 3Univ of Pennsylvania Hosp, Philadelphia, PA, United States, 4Anesthesiology, University of Pennsylvania, Penn Presbyterian Medical Center, Philadelphia, PA, United States.
Introduction:
High quality CPR, early defibrillation and prompt administration of ACLS medications are all important components in chain of survival after cardiac arrest. Despite timely intervention, some patients end up in refractory cardiac arrest state. In such scenarios, Extracorporeal Cardiopulmonary Resuscitation (ECPR) offers hope. We present a case of a 48-year-old man who had complete neurological recovery post ECPR after cardiac arrest.
Description:48-year-old male with history of diabetes, hypertension, chronic kidney disease and morbid obesity presented to an outside hospital with acute onset shortness of breath requiring mechanical ventilation (MV). Patient was ruled out for myocardial infarction, pulmonary embolism and sepsis. His chest X-ray demonstrated pulmonary edema and ECHO showed an EF of 65%, normal RV and PASP of 43. Patient was started on a Lasix drip and was transferred to our hospital for management of refractory hypoxemic respiratory failure and worsening renal failure. He was cautiously diuresed and was started on inhaled epoprostenol. Patient's oxygenation improved over the next few days and he was extubated.
Twelve-hour post extubation, patient became acutely hypoxic requiring MV again. Despite optimization of MV with high PEEP and 100% FiO2, patient stayed persistently hypoxemic eventually leading to a PEA arrest. While patient intermittently responded to initial CPR and transiently achieved return of spontaneous circulation(ROSC), over the period of next 70 minutes he re-arrested four times due to refractory hypoxemia. ECMO team cannulated the patient at bedside while CPR continued. VV-ECMO was initiated and post ECMO ABG was 7.25/40/441/18/99% resolving hypoxemic state. Sustained ROSC was noted. Patient's CXR again demonstrated pulmonary edema and he was started on continuous renal replacement therapy. Patient also underwent targeted temperature management. Patient required VV-ECMO support for 72 hours. He underwent tracheostomy and was gradually weaned from the ventilator. He left the hospital with a CPC 1 score and on hemodialysis.
Discussion:Early recognition of refractory cardiac arrest state and prompt ECMO use along with high quality CPR followed by Targeted Temperature Management offers an opportunity for good neurological outcome as seen in our patient. Our case also highlights that in cases of refractory hypoxemia related refractory cardiac arrest, VV-ECMO is an alternative to the conventional use of VA-ECMO post arrest. To our knowledge this is the first reported case of VV-ECMO use for refractory cardiac arrest from hypoxic respiratory failure. Comparative effectiveness studies between VV vs VA-ECMO in cases of hypoxic cardiac arrest are needed.