1 Department of Anesthesiology, Mayo Clinic Hospital, Phoenix, USA. 2 Department of Cardiothoracic Surgery, Mayo Clinic Hospital, Phoenix, USA. 3 Department of Neurosurgery, Mayo Clinic Hospital, Phoenix, USA.
Background: Extracorporeal membrane oxygenator (ECMO) use is dramatically increasing in recent years. This case report describes a patient on veno-venous (VV) ECMO for H1N1 who underwent emergent craniotomy twice for intracranial hemorrhage. Case presentation: A 38-year-old male presented to a community hospital for worsening shortness of breath. He had experienced cough, malaise and fatigue for two weeks prior to presentation. On arrival, his arterial oxygen saturation was 64%. He was placed on oxygen via non-rebreather mask and started on Tamiflu plus antibiotics. He was intubated for worsening respiratory failure. Despite maximal ventilator settings, the arterial oxygen saturation was approximately 90%. He was placed in the prone position and nitric oxide was initiated. Severe acute respiratory distress syndrome (ARDS) secondary to influenza was diagnosed by viral PCR, clinical presentation, and diagnostic imaging. Within 24 hours of his intubation, a decision was made to initiate veno-venous (V-V) ECMO for respiratory support. Five days following the initiation of ECMO, asymmetric pupils and a nonreactive right pupil were noted. A massive right frontal intraparenchymal hemorrhage with midline shift and downward uncal herniation was found on computed tomography (CT). A decision was made to surgically intervene. He was taken to the operating room for immediate right frontal craniotomy and clot evacuation under general anesthesia. Conclusion: With the dramatic increase in ECMO use, anesthesiologists are encountering patients on ECMO in the operating room with more frequency. When the situation does arise, it is imperative that the anesthesiologist is knowledgeable about ECMO and how to appropriately administer anesthesia for these critically ill patients. Challenges confronting the anesthesiologist with ECMO patients include managing bleeding or coagulopathy, ventilation and oxygenation, volume status, transporting and positioning these patients, and altered pharmacokinetics of anesthetic drugs.
Kraus, M. , Weis, R. , Alwardt, C. , Lanza, L. , Birch, B. and Ramakrisna, H. (2015) Veno-Venous Extracorporeal Membrane Oxygenation: Anesthetic Management for Massive Intracranial Hemorrhage in H1N1 Infection. Open Journal of Anesthesiology, 5, 251-256. doi: 10.4236/ojanes.2015.512045.
[1] Jain, S., Kamimoto, L., Bramley, A.M., Schmitz, A.M., Benoit, S.R., Louie, J., Sugerman, D.E., Druckenmiller, J.K., Ritger, K.A., Chugh, R. et al. (2009) Hospitalized Patients with 2009 H1N1 Influenza in the United States, April-June 2009. The New England Journal of Medicine, 361, 1935-1944.
http://dx.doi.org/10.1056/NEJMoa0906695
[2] Davies, A., Jones, D., Bailey, M., Beca, J., Bellomo, R., Blackwell, N., Forrest, P., Gattas, D., Granger, E., Herkes, R., et al. (2009) Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. JAMA, 302, 1888-1895.
http://dx.doi.org/10.1001/jama.2009.1535
[3] Paden, M.L., Rycus, P.T. and Thiagarajan, R.R. (2014) Update and Outcomes in Extracorporeal Life Support. Seminars in Perinatology, 38, 65-70.
http://dx.doi.org/10.1053/j.semperi.2013.11.002
[4] Villar, J., Winston, B. and Slutsky, A.S. (1990) Non-Conventional Techniques of Ventilatory Support. Critical Care Clinics, 6, 579-603.
[5] Marasco, S.F., Preovolos, A., Lim, K. and Salamonsen, R.F. (2007) Thoracotomy in Adults While on ECMO Is Associated with Uncontrollable Bleeding. Perfusion, 22, 23-26.
http://dx.doi.org/10.1177/0267659106074789
[6] Muehrcke, D.D., McCarthy, P.M., Stewart, R.W., Seshagiri, S., Ogella, D.A., Foster, R.C. and Cosgrove, D.M. (1995) Complications of Extracorporeal Life Support Systems Using Heparin-Bound Surfaces. The Risk of Intracardiac Clot Formation. Journal of Thoracic and Cardiovascular Surgery, 110, 843-851.
http://dx.doi.org/10.1016/S0022-5223(95)70119-2
[7] Marasco, S.F., Lukas, G., McDonald, M., McMillan, J. and Ihle, B. (2008) Review of ECMO (Extra Corporeal Membrane Oxygenation) Support in Critically Ill Adult Patients. Heart, Lung and Circulation, 17, S41-S47.
http://dx.doi.org/10.1016/j.hlc.2008.08.009
[8] Kasirajan, V., Smedira, N.G., McCarthy, J.F., Casselman, F., Boparai, N. and McCarthy, P.M. (1999) Risk Factors for Intracranial Hemorrhage in Adults on Extracorporeal Membrane Oxygenation. European Journal Cardio-Thoracic Surgery, 15, 508-514.
http://dx.doi.org/10.1016/S1010-7940(99)00061-5
[9] Stallion, A., Cofer, B.R., Rafferty, J.A., Ziegler, M.M. and Ryckman, F.C. (1994) The Significant Relationship between Platelet Count and Haemorrhagic Complications on ECMO. Perfusion, 9, 265-269.
http://dx.doi.org/10.1177/026765919400900404
[10] Robinson, T.M., Kickler, T.S., Walker, L.K., Ness, P. and Bell, W. (1993) Effect of Extracorporeal Membrane Oxygenation on Platelets in Newborns. Critical Care Medicine, 21, 1029-1034.
http://dx.doi.org/10.1097/00003246-199307000-00018
[11] Linden, V., Palmer, K., Reinhard, J., Westman, R., Ehren, H., Granholm, T. and Frenckner, B. (2000) High Survival in Adult Patients with Acute Respiratory Distress Syndrome Treated by Extracorporeal Membrane Oxygenation, Minimal Sedation, and Pressure Supported Ventilation. Intensive Care Medicine, 26, 1630-1637.
http://dx.doi.org/10.1007/s001340000697
[12] Tulman, D.B., Stawicki, S.P., Whitson, B.A., Gupta, S.C., Tripathi, R.S., Firstenberg, M.S., Hayes Jr., D., Xu, X. and Papadimos, T.J. (2014) Veno-Venous ECMO: A Synopsis of Nine Key Potential Challenges, Considerations, and Controversies. BMC Anesthesiology, 14, 65.
http://dx.doi.org/10.1186/1471-2253-14-65
[13] Chauhan, S. and Subin, S. (2012) Extracorporeal Membrane Oxygenation—An Anaesthesiologist’s Perspective—Part II: Clinical and Technical Consideration. Annals of Cardiac Anaesthesia, 15, 69-82.
http://dx.doi.org/10.4103/0971-9784.91485
[14] Shekar, K., Roberts, J.A., Welch, S., Buscher, H., Rudham, S., Burrows, F., Ghassabian, S., Wallis, S.C., Levkovich, B., Pellegrino, V., et al. (2012) ASAP ECMO: Antibiotic, Sedative and Analgesic Pharmacokinetics during Extracorporeal Membrane Oxygenation: A Multi-Centre Study to Optimise Drug Therapy during ECMO. BMC Anesthesiology, 12, 29.
http://dx.doi.org/10.1186/1471-2253-12-29
[15] Harthan, A.A., Buckley, K.W., Heger, M.L., Fortuna, R.S. and Mays, K. (2014) Medication Adsorption into Contemporary Extracorporeal Membrane Oxygenator Circuits. Journal of Pediatric Pharmacology and Therapeutics, 19, 288-295.
[16] Alwardt, C.M., Wilson, D.S., Alore, M.L., Lanza, L.A., Devaleria, P.A. and Pajaro, O.E. (2015) Performance and Safety of an Integrated Portable Extracorporeal Life Support System for Adults. Journal of Extra-Corporeal Technology, 47, 38-43.