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Application of veno-arterial-venous extracorporeal membrane oxygenation in differential hypoxia.

Choi JH, Kim SW, Kim YU, Kim SY, Kim KS, Joo SJ, Lee JS - Multidiscip Respir Med (2014)

Bottom Line: A 39-year-old man received cardiopulmonary resuscitation from a cardiac arrest due to acute myocardial infarction.Even after more than 30 min of resuscitation, spontaneous circulation had not resumed.While an echocardiogram revealed improvements in myocardial function, a follow up chest radiograph showed increasing massive parenchymal infiltrations, and gas analysis of blood from the right radial artery revealed severe hypoxemia.

View Article: PubMed Central - PubMed

Affiliation: Deparment of Cardiology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea.

ABSTRACT
Veno-arterial extracorporeal membrane oxygenation (ECMO) through the femoral vein and artery may cause differential hypoxia, i.e., lower PaO2 in the upper body than in the lower body, because of normal cardiac output with severe impairment of pulmonary function. Hereby, we report the diagnosis and the treatment of differential hypoxia caused by veno-arterial ECMO. A 39-year-old man received cardiopulmonary resuscitation from a cardiac arrest due to acute myocardial infarction. Even after more than 30 min of resuscitation, spontaneous circulation had not resumed. Next, we performed veno-arterial ECMO through the femoral artery and vein, and the patient recovered consciousness on the second day of ECMO. On day 5 of ECMO, he lost consciousness again and presented a generalized tonic-clonic seizure, and an electroencephalogram showed delta waves suggesting diffuse cerebral cortical dysfunction. While an echocardiogram revealed improvements in myocardial function, a follow up chest radiograph showed increasing massive parenchymal infiltrations, and gas analysis of blood from the right radial artery revealed severe hypoxemia. These findings indicated a definite diagnosis of differential hypoxia, and therefore, we inserted a 17-Fr cannula into the left subclavian vein as a return cannula. The patient's consciousness and pulmonary infiltrations were improved 2 days after veno-arterial-venous ECMO, and the electroencephalogram showed normal findings. To our knowledge, this is the first report of successful clinical management of differential hypoxia. We suggest that veno-arterial-venous ECMO could be the treatment of choice for differential hypoxia resulting from veno-arterial ECMO.

No MeSH data available.


Related in: MedlinePlus

Conversion of electroencephalogram. At the time of admission electroencephalogram showed generalized reactive theta slowing (A). On the fifth day of extracorporeal membrane oxygenation support, generalized delta activity with superimposed beta frequency was evident (B). The electroencephalogram returned to normal configurations after veno-arterial venous extracorporeal membrane oxygenation (C).
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Fig2: Conversion of electroencephalogram. At the time of admission electroencephalogram showed generalized reactive theta slowing (A). On the fifth day of extracorporeal membrane oxygenation support, generalized delta activity with superimposed beta frequency was evident (B). The electroencephalogram returned to normal configurations after veno-arterial venous extracorporeal membrane oxygenation (C).

Mentions: Pulmonary infiltrates were observed, which may be due to pulmonary edema resulting from cardiac arrest, considering that no history of suspicious pneumonia, idiopathic pulmonary fibrosis, or vasculitis was present. Furthermore, his chief complaint was chest pain, not dyspnea, and severe left ventricular systolic dysfunction was found by echocardiography. The patient showed stuporous mentality. An electroencephalogram (EEG) revealed bilateral theta waves of 5 to 6 Hz (FigureĀ 2A). On the second day of ECMO, the patient regained consciousness, and inotropic agents were reduced. The arterial gas analysis of blood from the right radial artery revealed normal results (PaO2 76 mmHg, O2 saturation 96.2%). Therefore, the ventilator settings were as follows: pressure control mode, inspired oxygen fraction 0.4, positive end-expiratory pressure 5 cm H2O, inspiratory pressure 16 cm H2O, and respiratory rate 14 breaths/minutes.Figure 2


Application of veno-arterial-venous extracorporeal membrane oxygenation in differential hypoxia.

Choi JH, Kim SW, Kim YU, Kim SY, Kim KS, Joo SJ, Lee JS - Multidiscip Respir Med (2014)

Conversion of electroencephalogram. At the time of admission electroencephalogram showed generalized reactive theta slowing (A). On the fifth day of extracorporeal membrane oxygenation support, generalized delta activity with superimposed beta frequency was evident (B). The electroencephalogram returned to normal configurations after veno-arterial venous extracorporeal membrane oxygenation (C).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4226883&req=5

Fig2: Conversion of electroencephalogram. At the time of admission electroencephalogram showed generalized reactive theta slowing (A). On the fifth day of extracorporeal membrane oxygenation support, generalized delta activity with superimposed beta frequency was evident (B). The electroencephalogram returned to normal configurations after veno-arterial venous extracorporeal membrane oxygenation (C).
Mentions: Pulmonary infiltrates were observed, which may be due to pulmonary edema resulting from cardiac arrest, considering that no history of suspicious pneumonia, idiopathic pulmonary fibrosis, or vasculitis was present. Furthermore, his chief complaint was chest pain, not dyspnea, and severe left ventricular systolic dysfunction was found by echocardiography. The patient showed stuporous mentality. An electroencephalogram (EEG) revealed bilateral theta waves of 5 to 6 Hz (FigureĀ 2A). On the second day of ECMO, the patient regained consciousness, and inotropic agents were reduced. The arterial gas analysis of blood from the right radial artery revealed normal results (PaO2 76 mmHg, O2 saturation 96.2%). Therefore, the ventilator settings were as follows: pressure control mode, inspired oxygen fraction 0.4, positive end-expiratory pressure 5 cm H2O, inspiratory pressure 16 cm H2O, and respiratory rate 14 breaths/minutes.Figure 2

Bottom Line: A 39-year-old man received cardiopulmonary resuscitation from a cardiac arrest due to acute myocardial infarction.Even after more than 30 min of resuscitation, spontaneous circulation had not resumed.While an echocardiogram revealed improvements in myocardial function, a follow up chest radiograph showed increasing massive parenchymal infiltrations, and gas analysis of blood from the right radial artery revealed severe hypoxemia.

View Article: PubMed Central - PubMed

Affiliation: Deparment of Cardiology, Jeju National University Hospital, Jeju National University School of Medicine, Jeju, Korea.

ABSTRACT
Veno-arterial extracorporeal membrane oxygenation (ECMO) through the femoral vein and artery may cause differential hypoxia, i.e., lower PaO2 in the upper body than in the lower body, because of normal cardiac output with severe impairment of pulmonary function. Hereby, we report the diagnosis and the treatment of differential hypoxia caused by veno-arterial ECMO. A 39-year-old man received cardiopulmonary resuscitation from a cardiac arrest due to acute myocardial infarction. Even after more than 30 min of resuscitation, spontaneous circulation had not resumed. Next, we performed veno-arterial ECMO through the femoral artery and vein, and the patient recovered consciousness on the second day of ECMO. On day 5 of ECMO, he lost consciousness again and presented a generalized tonic-clonic seizure, and an electroencephalogram showed delta waves suggesting diffuse cerebral cortical dysfunction. While an echocardiogram revealed improvements in myocardial function, a follow up chest radiograph showed increasing massive parenchymal infiltrations, and gas analysis of blood from the right radial artery revealed severe hypoxemia. These findings indicated a definite diagnosis of differential hypoxia, and therefore, we inserted a 17-Fr cannula into the left subclavian vein as a return cannula. The patient's consciousness and pulmonary infiltrations were improved 2 days after veno-arterial-venous ECMO, and the electroencephalogram showed normal findings. To our knowledge, this is the first report of successful clinical management of differential hypoxia. We suggest that veno-arterial-venous ECMO could be the treatment of choice for differential hypoxia resulting from veno-arterial ECMO.

No MeSH data available.


Related in: MedlinePlus