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J Thorac Cardiovasc Surg 2007;133:1673-1674
© 2007 The American Association for Thoracic Surgery
Brief Communication |
a Department of General Thoracic Surgery, Hospital of Cuneo, Cuneo, Italy
b Department of Cardiac Surgery, Hospital of Cuneo, Cuneo, Italy
c Department of Cardiovascular Anesthesia and Intensive Care, Hospital of Cuneo, Cuneo, Italy.
Received for publication January 17, 2007; accepted for publication February 17, 2007. * Address for reprints: Andrea Campione, MD, Hospital of Cuneo, General Thoracic Surgery, Via Michele Coppino 26, Cuneo 12100, Italy. (Email: andikampione{at}yahoo.it).
Extracorporeal membrane oxygenation (ECMO) may offer lifesaving treatment in severe pulmonary contusion or acute respiratory distress syndrome when conventional treatments have failed.1,2
Although ECMO has become the standard treatment for neonatal severe respiratory failure, interest in adult ECMO weakened because of the high mortality until investigators3 began dictating that it should be used in children and in adult respiratory failure.
Use in trauma is restricted4,5 because of the risk of systemic anticoagulation in patients with multiple trauma.
A 14-year-old boy experienced a serious blunt thoracic trauma during a go-cart race.
On admission to the emergency department, he was awake and spontaneously breathing but dyspneic with hemoptysis and severe hypoxemia (SAO 2 < 50%). As soon as endotracheal ventilation was started, the gas exchange rapidly worsened with subcutaneous emphysema and cardiac arrest, which necessitated resuscitation and urgent chest drainage for the onset of a hypertensive right pneumothorax.
Oxygen saturation levels worsened, and continuous massive air leakage was present. A bronchoscopy was mandatory, but it failed to reveal injuries in the trachea and main stem bronchi. An endobronchial tube with left intubation was inserted (Robertshaw n.35), but the gas exchange did not improve dramatically. Emergency chest and abdomen computed tomography scans showed a suspicious lower right bronchial tear with bilateral pulmonary contusion, a large quantity of abdominal fluid, and a mild left pneumothorax. After another chest tube was inserted on the left, drainage on the left gas exchange remained stable with an SAO 2 of 50%.
A team of cardiothoracic surgeons and anesthesiologists recommended a venovenous ECMO, because they agreed that the boy would not survive.
Regardless of the trauma, the patient was placed on an extracorporeal circuit (Bio-Medicus; Medtronic Inc, Minneapolis, Minn) with venous access achieved through the right jugular vein and right femoral vein using a percutaneous Seldinger technique.
Anticoagulation with intravenous heparin was set to activated clotting times between 250 and 300 seconds.
Heparinized blood was extracted from the internal jugular vein and through a centrifugal pump (Bio-Medicus; Medtronic Inc) reached a membrane oxygenator (Affinity, Avecor Cardiovascular, Plymouth, Minn) and heat exchanger (Biotherm; Medtronic Inc) and returned through the femoral vein.
With a blood flow of 2.5 L/min and an FIO 2 of 60%, the oxygenation saturation increased and the patient maintained good oxygen levels averaging 95%; thus, surgical intervention was possible.
An exploratory laparotomy showed a large amount of ascites without intraperitoneal or retroperitoneal visceral injury, and a right posterolateral thoracotomy confirmed the large pulmonary contusion with multiple parenchymal tears and a transverse disruption in the intermediate bronchus.
The location of the injury, size of the bronchial tree, and presence of irregular borders did not allow a conservative approach to bronchus without the risk of subtotal stenosis; therefore, a lower bilobectomy was performed.
Three days later, after a short period of coagulopathy that was treated with fresh-frozen plasma, the patient was successfully weaned from ECMO.
In the postoperative course, a tracheostomy was planned, and the patient was then successfully discharged from any kind of ventilatory support within 4 weeks and referred to a rehabilitation center. Two years after the accident, the boy is doing well.
In trauma victims with possible intracranial and abdominal bleeding, and long bones and pelvic fractures, ECMO should be performed only as a last resort.
The successful outcome of this case is most likely attributable to the young age of the patient, early institution of ECMO, and aggressive surgical intervention after cardiopulmonary stabilization.
Ascites was probably associated with prolonged mesenteric hypoxemia.
References
This article has been cited by other articles:
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  D. Wise, D. Chalkley, and K. Amhed 6 Assessment of breathing--thoracic injuries ODR Major Trauma, November 1, 2010; 1(1): med-9780199543328-chapter - med-9780199543328-chapter. [Full Text]
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