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Efficacy of "Awake ECMO" for critical respiratory failure after pediatric open-heart surgery
Akihiko Higashida1, Takaya Hoashi2, Koji Kagisaki1
1Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan.
Insights
This case study highlights the successful use of awake extracorporeal membrane oxygenation (ECMO) in a pediatric patient with complex congenital heart disease who developed acute respiratory distress syndrome (ARDS). The novel approach facilitated lung recovery and successful weaning from mechanical support.
Area of Science:
- Pediatric Cardiology
- Cardiothoracic Surgery
- Critical Care Medicine
Background:
- A 4-year-old boy with complex congenital heart defects, including atrioventricular discordance and double-outlet right ventricle, underwent extensive surgical repair.
- Postoperatively, the patient developed acute respiratory distress syndrome (ARDS), attributed to mechanical ventilation strategies.
Observation:
- Irreversible hypercapnia and respiratory acidosis necessitated veno-arterial extracorporeal membrane oxygenation (ECMO) support.
- Pulmonary interstitial inflammation improved with ECMO, but massive pulmonary hemorrhage complicated ventilation.
- Transitioning to "Awake ECMO" enabled effective respiratory physical therapy and improved tidal volume.
Findings:
- Awake ECMO facilitated lung rest and recovery, leading to a regained cough reflex.
- The patient was successfully weaned from ECMO after 5 days.
- Significant improvement in respiratory function was observed, allowing for eventual discharge.
Implications:
- Awake ECMO represents a viable strategy for managing severe respiratory failure in pediatric cardiac surgery patients.
- This approach may enhance recovery by allowing active participation in respiratory therapy.
- Successful ECMO management can lead to positive long-term outcomes without neurological sequelae.
Abstract:
A 4-year-old boy with atrioventricular discordance, double-outlet right ventricle, pulmonary stenosis, and mitral regurgitation, was undergoing anatomical repair consisting of Senning, Rastelli, Damus-Kaye-Stansel procedures, and a mitral valve repair, complained of post-operative excessive airway tract secretion, which ultimately developed into acute respiratory distress syndrome (ARDS) 28 days after the operation. The cause of the ARDS was thought to be frequent manual positive pressure recruitment and prolonged inhalation of pure oxygen. At 45 days after the operation, hypercapnia and respiratory acidosis turned out to be irreversible, and therefore, veno-arterial extracorporeal membrane oxygenation (ECMO) was established utilizing the Endumo(®)4000 system. Pulmonic interstitial inflammation gradually improved while resting the lung under ECMO support; however, effective ventilation volume decreased critically because a massive pulmonary hemorrhage occurred at 2 and 9 days after the initiation of ECMO. To maximize the effectiveness of respiratory physical therapy, "Awake ECMO" was started and tidal volume dramatically increased with a regained cough reflex. Five days later, he was successfully weaned off from ECMO, and discharged 7 months after the operation without any neurological and physiological sequelae.
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