Question on a patient (ECMO vs Mechanical ventilation)

[Cytarabine]

Pt is an older adolescent w/severe ARDS 2/2 aspiration, about 3 weeks on the vent, transferred from OSH about a week ago. Outside of present illness, nonsignificant PMHx. Hemodynamically stable, resolved AKI. Recently had some significant barotrauma, PTX x3 now w/ b/l chest tubes, extensive pneumomediastinum/subQ emphysema. MAPs have been in the teens, peak pressures around 30, PaO2:FiO2 high 70's, OI low 20's. Compensated hypercapnea. SIMV/PRVC. PEEP is 14 (only 15 prior to barotrauma), O2 requirement of >90% if we try to wean PEEP further, still on 5 of nitric we were trying to wean until the barotrauma and increased O2 requirements. There was a bit of a disagreement between our CT surg and intensivist about ECMO (assuming VV) vs continuing w/mechanical ventilation. Interested in getting y'alls opinions on the matter. Can provide additional info as requested, tried to pick out the highlights

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[jdh71]

You have plenty of room to oxygenate this guy. Pressure aren't that high. Only 0.7 fio2. Turn off the freaking nitric already. Trach the guy. And wait it out.

Is the thought that his lungs won't heal on positive pressure ventilation as fast and he's young?? I would consider that argument.

 

[Cytarabine]

You have plenty of room to oxygenate this guy. Pressure aren't that high. Only 0.7 fio2. Turn off the freaking nitric already. Trach the guy. And wait it out.

Is the thought that his lungs won't heal on positive pressure ventilation as fast and he's young?? I would consider that argument.

He came on 10 of nitric. We've tried to wean off the 5 for a while but has had different things come up each time (increased O2 requirement after bronch, Pseudomonas PNA, etc.). We tried to trach, ENT's on board, anesthesia nixed it due to the extent of his ARDS, wanted to let him medically improve a bit first. We want the trach badly, he's been really agitated/uncomfortable to the point where we now just have him snowed for the time being, RASS -4 to -5. Would love to have him trached and more conscious. There's definitely room to oxygenate. CT surg is the one pushing for ECMO, point of view seems primarily to be that he's had 3 weeks on vent and now has significant barotrauma, says that's an indication in it's own right. The subQ emphysema is very impressive. Still has a small trickle of air coming out the chest tubes (days 2 and 3 for them), but no significant new pneumo that BID CXR's has picked up, though it's possible the chest tubes are masking. Intensivist thinks he'll have a bad outcome on ECMO, he's driving age, so not THAT young as far as good ECMO outcomes go (at least, my knowledge of ECMO outcomes, thought that was more for prepubertal).

 

[jdh71]

He came on 10 of nitric. We've tried to wean off the 5 for a while but has had different things come up each time (increased O2 requirement after bronch, Pseudomonas PNA, etc.). We tried to trach, ENT's on board, anesthesia nixed it due to the extent of his ARDS, wanted to let him medically improve a bit first. We want the trach badly, he's been really agitated/uncomfortable to the point where we now just have him snowed for the time being, RASS -4 to -5. Would love to have him trached and more conscious. There's definitely room to oxygenate. CT surg is the one pushing for ECMO, point of view seems primarily to be that he's had 3 weeks on vent and now has significant barotrauma, says that's an indication in it's own right. The subQ emphysema is very impressive. Still has a small trickle of air coming out the chest tubes (days 2 and 3 for them), but no significant new pneumo that BID CXR's has picked up, though it's possible the chest tubes are masking. Intensivist thinks he'll have a bad outcome on ECMO, he's driving age, so not THAT young as far as good ECMO outcomes go (at least, my knowledge of ECMO outcomes, thought that was more for prepubertal).

You can turn up the O2 to wean the nitric? Then do it. And I don't think he'd have a bad outcome on ECMO. Based on what? Old studies of a much older iteration of the modality? VV is pretty sweet and will allow you barely put any pressure in the kid. It's not an
Unreasonable option. Will delay trach though.

 

[deleted547339]

You can turn up the O2 to wean the nitric? Then do it. And I don't think he'd have a bad outcome on ECMO. Based on what? Old studies of a much older iteration of the modality? VV is pretty sweet and will allow you barely put any pressure in the kid. It's not an
Unreasonable option. Will delay trach though.

Dude, they won't trach any kid where I'm at.

 

[Cytarabine]

You can turn up the O2 to wean the nitric? Then do it. And I don't think he'd have a bad outcome on ECMO. Based on what? Old studies of a much older iteration of the modality? VV is pretty sweet and will allow you barely put any pressure in the kid. It's not an
Unreasonable option. Will delay trach though.

Our general plan for vent wean was goals sats of 88, wean FiO2 to 60 -> wean nitric 1 q6, adjust FiO2 prn to maintain goal sats -> wean FiO2 to 60, repeat to nitric off. The process was going slowly as he'd require FiO2's in the 80's-90's after each nitric wean, though he has no pulm HTN per echo. The various other incidences of increased O2 requirement came up, most recently the PTX's, and essentially the nitric wean just got put on hold while trying to keep his sats up and preventing further barotrauma.

With regard to my comment about ECMO, I very well may be working off outdated data. On a little more reading, it looks like CESAR trial may be showing favorable results even for adults with ARDS receiving ECMO rather than conventional mechanical ventilation. It sounds like if he did go for ECMO though, it would be with a trach to facilitate rehab while on ECMO (not sure if the ECMO facility has its own ENT/anesthesia to facilitate that though, since our anesthesiology wasn't on board with the trach idea).

 

[jdh71]

Our general plan for vent wean was goals sats of 88, wean FiO2 to 60 -> wean nitric 1 q6, adjust FiO2 prn to maintain goal sats -> wean FiO2 to 60, repeat to nitric off. The process was going slowly as he'd require FiO2's in the 80's-90's after each nitric wean, though he has no pulm HTN per echo. The various other incidences of increased O2 requirement came up, most recently the PTX's, and essentially the nitric wean just got put on hold while trying to keep his sats up and preventing further barotrauma.

With regard to my comment about ECMO, I very well may be working off outdated data. On a little more reading, it looks like CESAR trial may be showing favorable results even for adults with ARDS receiving ECMO rather than conventional mechanical ventilation. It sounds like if he did go for ECMO though, it would be with a trach to facilitate rehab while on ECMO (not sure if the ECMO facility has its own ENT/anesthesia to facilitate that though, since our anesthesiology wasn't on board with the trach idea).

Kid has a strong heart I'm sure. Don't pay too much attention to the peripheral sat. Use your measured sat to calculate an oxygen delivery if you're above 300-350 without an elevation in lactate you're fine. Wean nitric, wean PEEP - though peaks of 30 aren't that high. Run the O2 high if you need too. "Oxygen poisoning" is nonsense. Though it has been dogma for a long long time.

 

[Cytarabine]

Kid has a strong heart I'm sure. Don't pay too much attention to the peripheral sat. Use your measured sat to calculate an oxygen delivery if you're above 300-350 without an elevation in lactate you're fine. Wean nitric, wean PEEP - though peaks of 30 aren't that high. Run the O2 high if you need too. "Oxygen poisoning" is nonsense. Though it has been dogma for a long long time.

Thanks for the input / education. Pt ended up going down for ecmo yesterday evening after a family / staff discussion. Students / residents are going to be hands off while he's in the CCU.

 

[bigtuna]

This is a really difficult case. Unfortunately - there are a significant number of people who do not recover from ARDS this severe that has not begun to resolve after 3 weeks. However, the data on survival on VV-ECMO after a week to 10 days of mechanical ventilation is very poor (down to about 10% i believe). My institution usually will not consider vv-ecmo in someone that has been on the vent for more than 1 week. However, we might make an exception for an otherwise healthy teenager.

I think ideally this pt should be transferred to a center with lots of ECMO experience and a lung transplant program (reading between the lines it seems like this is not the case at your institution?). If his condition declines at all - put on VV-ECMO with goal to trach and improve mental status/mobility etc to the point where he might be a transplant candidate. You could make a case for putting on VV-ECMO with the inability to wean nitric, the barotrauma, and even the inability to do a track but you need to prepared for a long run (weeks/months). I have seen several similar cases where the pt was put on ECMO and the lungs essentially shriveled up and never recovered at all. One of these was a 16 y/o that subsequently survived a high risk lung transplant.

 

[Cytarabine]

This is a really difficult case. Unfortunately - there are a significant number of people who do not recover from ARDS this severe that has not begun to resolve after 3 weeks. However, the data on survival on VV-ECMO after a week to 10 days of mechanical ventilation is very poor (down to about 10% i believe). My institution usually will not consider vv-ecmo in someone that has been on the vent for more than 1 week. However, we might make an exception for an otherwise healthy teenager.

I think ideally this pt should be transferred to a center with lots of ECMO experience and a lung transplant program (reading between the lines it seems like this is not the case at your institution?). If his condition declines at all - put on VV-ECMO with goal to trach and improve mental status/mobility etc to the point where he might be a transplant candidate. You could make a case for putting on VV-ECMO with the inability to wean nitric, the barotrauma, and even the inability to do a track but you need to prepared for a long run (weeks/months). I have seen several similar cases where the pt was put on ECMO and the lungs essentially shriveled up and never recovered at all. One of these was a 16 y/o that subsequently survived a high risk lung transplant.

We do a lot of ECMO in the NI, and we're set up to do it on older kids, but we're definitely nothing close to high volume there, and that we do isn't in the form of the ECMO with extensive concurrent targeted rehab, at least not to my knowledge. As far as transplants, we do BMT, hearts, and kidneys, no lungs AFAIK

 

[Stitch]

This is a really difficult case. Unfortunately - there are a significant number of people who do not recover from ARDS this severe that has not begun to resolve after 3 weeks. However, the data on survival on VV-ECMO after a week to 10 days of mechanical ventilation is very poor (down to about 10% i believe). My institution usually will not consider vv-ecmo in someone that has been on the vent for more than 1 week. However, we might make an exception for an otherwise healthy teenager.

I pretty much agree. The chance for ECMO was 2+ weeks ago, and he should have been transferred to an ECMO center then. I do know of people who will put someone on after 3 weeks, but at this point a lot of damage has been done. Were the previous OIs higher? Usually an OI of 20 wouldn't get you on at the places I've been, but there are of course other factors. It's also unlikely anyone will put lungs into him unless you rehab him. In that case, getting him on ECMO, extubating him (with or without a trach) and doing some rehab may get him somewhere. What he has going for him is that he seems otherwise very healthy. We don't generally let kids die from single organ failure (unless it's brain), so if this works, it's worth writing up as evidence that 10-14 days of ventilation isn't a hard 'rule.' I once put a kid on after 18 days of mechanical ventilation with MRSA sepsis and pneumonia with pneumatocoeles. He went home on room air, so I'm always skeptical when people say 'irreversible' lung disease in younger people. I'm working on that case report now.

 

[Stitch]

Also, what's his fluid status? We run CRRT on nearly all of our ECMO patients. Usually when you cannulate this far out, there has been significant fluid overload and ECMO will definitely add to it with the blood product load. Better to get on it right away, even if you're just running even.

What kind of cannula did the surgeons put in?

 

[Cytarabine]

I pretty much agree. The chance for ECMO was 2+ weeks ago, and he should have been transferred to an ECMO center then. I do know of people who will put someone on after 3 weeks, but at this point a lot of damage has been done. Were the previous OIs higher? Usually an OI of 20 wouldn't get you on at the places I've been, but there are of course other factors. It's also unlikely anyone will put lungs into him unless you rehab him. In that case, getting him on ECMO, extubating him (with or without a trach) and doing some rehab may get him somewhere. What he has going for him is that he seems otherwise very healthy. We don't generally let kids die from single organ failure (unless it's brain), so if this works, it's worth writing up as evidence that 10-14 days of ventilation isn't a hard 'rule.' I once put a kid on after 18 days of mechanical ventilation with MRSA sepsis and pneumonia with pneumatocoeles. He went home on room air, so I'm always skeptical when people say 'irreversible' lung disease in younger people. I'm working on that case report now.

Out of curiosity, an issue that had come up in debating ecmo and his OI in the 20's was that using OI (or the "cutoff" of 40) was an inappropriate extrapolation of data originating in studies on neonates. How much validity is there to using OI or specific OI cutoffs in older populations (vs barotrauma, oxygenation/ventilation failure on HFMV)? For his OI's, while under our care they've fluctuated a but never gotten into the high 20s. At OSH, I'm not sure. Certainly higher, as he was on osc at one point, but in general record weren't conducive to calculating it daily

Also, what's his fluid status? We run CRRT on nearly all of our ECMO patients. Usually when you cannulate this far out, there has been significant fluid overload and ECMO will definitely add to it with the blood product load. Better to get on it right away, even if you're just running even.

What kind of cannula did the surgeons put in?

Managing his fluid status was a bit of a hassle. Long story short, we felt he was near euvolemic going into ecmo, we took off several liters from transfer to our facility. ECMO set up looks like VV jug/fem per films. As far as writing him up, I'm going to continue to follow him up through EMR, but I'm going off service tomorrow and the reason for resident/student hands off seems to be a bit of interdepartmental drama, and I don't particularly want to press my way into that as it's been a bit of a frustrating situation for me as well (eg surgery starting a norcuron drip for clearly undersedated agitation). Has been a good learning case though. Appreciate all of your comments

Edit: took a peek in the room today, looks like a dual IJ

 

[Stitch]

Managing his fluid status was a bit of a hassle. Long story short, we felt he was near euvolemic going into ecmo, we took off several liters from transfer to our facility. ECMO set up looks like VV jug/fem per films. As far as writing him up, I'm going to continue to follow him up through EMR, but I'm going off service tomorrow and the reason for resident/student hands off seems to be a bit of interdepartmental drama, and I don't particularly want to press my way into that as it's been a bit of a frustrating situation for me as well (eg surgery starting a norcuron drip for clearly undersedated agitation). Has been a good learning case though. Appreciate all of your comments

I hear you, and thanks for sharing this case ('thank you for this interesting consult'). I'd love an update on how the case unfolds.

Edit: took a peek in the room today, looks like a dual IJ

The real question was whether he had an Avalon catheter or not. There's no reason you'd know that as a student, but I was curious. VV is usually done with a dual lumen from the neck (either an Origin or an Avalon catheter), but you can add drainage catheters from cephalad or femoral or even sub xyphoid.

Out of curiosity, an issue that had come up in debating ecmo and his OI in the 20's was that using OI (or the "cutoff" of 40) was an inappropriate extrapolation of data originating in studies on neonates. How much validity is there to using OI or specific OI cutoffs in older populations (vs barotrauma, oxygenation/ventilation failure on HFMV)? For his OI's, while under our care they've fluctuated a but never gotten into the high 20s. At OSH, I'm not sure. Certainly higher, as he was on osc at one point, but in general record weren't conducive to calculating it da

There's not really an OI cutoff per se, and I think most data is extrapolated from neonates. Aren't adults just big kid? The idea was that an OI of 40 represented an 80% mortality in neonates. Obviously that may not compare. But OI of 30 for several hours would lead me to cannulate. Also if this patient's air leak is particularly bad, the only way it may heal is by clamping the ET tube and putting him on ECMO for a few weeks. It's multifactorial, and I don't know what the CT scans of his lungs look like, nor what the pulm guys think his liklihood of lung recovery is. In general, kids heal. But there are multiple ways of handling this situation, and I don't think there's good data to say one way is right and the other is wrong.

 

[Cytarabine]

I hear you, and thanks for sharing this case ('thank you for this interesting consult'). I'd love an update on how the case unfolds.


The real question was whether he had an Avalon catheter or not. There's no reason you'd know that as a student, but I was curious. VV is usually done with a dual lumen from the neck (either an Origin or an Avalon catheter), but you can add drainage catheters from cephalad or femoral or even sub xyphoid.



There's not really an OI cutoff per se, and I think most data is extrapolated from neonates. Aren't adults just big kid? The idea was that an OI of 40 represented an 80% mortality in neonates. Obviously that may not compare. But OI of 30 for several hours would lead me to cannulate. Also if this patient's air leak is particularly bad, the only way it may heal is by clamping the ET tube and putting him on ECMO for a few weeks. It's multifactorial, and I don't know what the CT scans of his lungs look like, nor what the pulm guys think his liklihood of lung recovery is. In general, kids heal. But there are multiple ways of handling this situation, and I don't think there's good data to say one way is right and the other is wrong.

I thought you may be referring to the brand, but I figured I'd answer the information I knew on the chance that was what you were looking for. He did get a CT while he was here, but it was a CT angio looking for a tracheal erosion. Don't remember how much of the lungs happened to be in field or the read on them, but I imagine you'd want a high res CT regardless. Thanks for the information! I'm going off service today, but he's actually coming back up to the PI so I should be able to get some resolution on his outcome at some point

 

[Cytarabine]

Was able to check in briefly today. Looks like he's coded a couple times and brain took a hard anoxic hit, but he's still churning away on ECMO. Not sure what the status is on a withdrawing care discussion