Venoarterial ECMO Cannula Placement – IVC/IJ | Emergency Medicine
Okay, here’s a breakdown of the provided text, focusing on the patient’s condition and treatment, along with key details. I’ll organize it for clarity.
patient Presentation & Initial Findings
* Initial Condition: The patient presented in extremely critical condition, requiring urgent transfer to the ICU after interventional procedures.
* Initial Assessment (ICU Admission):
* Shallow coma and tachypnea (rapid breathing).
* Heart Rate (HR): 133 bpm
* Respiratory Rate (RR): 27 breaths/min
* Blood Pressure (BP): 131/71 mmHg (maintained with norepinephrine)
* Oxygen Saturation (SpO2): 68%
* Cyanosis (bluish discoloration of lips)
* Coarse lung sounds
* Arrhythmia (irregular heartbeat)
* Imaging (Figure 1): Showed scattered filling defects in the main pulmonary arteries and branches, predominantly in the right pulmonary artery. An inferior vena cava (IVC) filter was also present.
Initial Interventions & Deterioration
* Emergency Intubation & Ventilation: the patient was intubated and placed on invasive mechanical ventilation (SIMV mode with high FiO2, tidal volume, PEEP).
* Vasopressor Support: Norepinephrine was administered to maintain blood pressure.
* Initial arterial Blood Gas (ABG): Revealed severe acidosis (pH 6.95), hypoxemia (PaO2 71 mmHg), hypercapnia (PaCO2 67 mmHg), and elevated lactate (9.4 mmol/L).
* Sodium Bicarbonate: Administered to correct the acidosis, initially improving SpO2 to 90%.
* Further Deterioration: SpO2 declined to 84%, and BP dropped to 80/60 mmHg despite continued norepinephrine.
* Repeat ABG: Showed improved pH (7.23) but worsening hypoxemia (PaO2 50 mmHg) and persistent hypercapnia (PaCO2 62 mmHg).Lactate remained elevated (6.7 mmol/L).
Further Investigation & Decision for ECMO
* Transthoracic Echocardiogram (TTE): revealed right ventricular (RV) dilation with a RV/LV ratio > 1. (supplementary Videos 1 & 2)
* Additional Findings: Concomitant hematuria (blood in urine), prolonged PT and APTT (indicating coagulopathy/bleeding risk).
* Decision: Due to the high risk of bleeding and the severity of the condition, the decision was made to initiate Venous-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) after obtaining informed consent.
ECMO Cannulation
* Percutaneous Cannulation: Ultrasound-guided placement of a 22-French right internal jugular vein (IJV) drainage catheter and a 19-French femoral artery return catheter.
* Catheter Positioning: Drainage catheter tip positioned above the hepatic vein confluence in the IVC. Confirmed by chest X-ray and echocardiography (Figure 2, Supplementary Video 3).
* Initial ECMO Flow: Was set (the specific flow rate isn’t mentioned in this excerpt).
In essence, the patient presented with a severe pulmonary embolism (suggested by the filling defects in the pulmonary arteries), leading to acute respiratory distress, right heart failure, and shock. Despite initial interventions, the patient continued to deteriorate, necessitating emergency VA-ECMO support.