A CASE OF NEAR DROWNING WITH ARDS TREATED WITH EXTRA-CORPOREAL MEMBRANOUS OXYGENATION

Abstract

SESSION TITLE: Critical Care 3 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Per World Health Organization data, more than 500,000 deaths each year and 0.7% of all deaths worldwide occur due to unintentional drowning. Outcome of such patients is related mainly to anoxic brain injury and acute respiratory distress syndrome (ARDS). A study of 1699 adult drowning patients quotes 1.7% survival if they had cardio-respiratory failure on initial presentation and only 0.7% of those with a favorable neurological outcome at 1 month (1). We present a case of patient with altered mental status and ARDS refractory to mechanical ventilation after near drowning episode who drastically improved on Extra-corporeal membranous oxygenation (ECMO) CASE PRESENTATION: 19-year-old male with no known medical history presented following a diving accident after striking his head in a swimming pool. He lost consciousness for approximately 1-2 minutes,EMS responded, he was appropriately resuscitated and reportedly was responsive but not following commands. On arrival to the emergency department, he was hypoxic with oxygen saturation (SpO2) ranging from 85-88%. Initial Arterial Blood gas(ABG) revealed pH of 6.96, pCO2 of 109, pO2 of 112 on a non re-breather mask. Imaging revealed ARDS but trauma series was otherwise without injuries. Urine drug screen was positive for cocaine. He was intubated and eventually had to be placed on Airway Pressure Release Ventilation due to continued hypoxia which only improved to a saturation of 90% with ABG revealing pH of 7.01 pCO2 of 90 and pO2 of 100. Patient also became hypotensive requiring vasopressors. He was transferred to a facility with ECMO and was started on it approximately 7-8 hours after his drowning episode. He was transitioned off ECMO the next day and was extubated. He was discharged on hospital day 7 with no complications up to 6 months of follow up. DISCUSSION: Patients with severe ARDS after drowning are conventionally treated with mechanical ventilation. However, this may not effectively improve the respiratory failure and may further cause ventilator associated lung injury. Kim et al. demonstrated in a retrospective observational study that ECMO improved survival rate and neurological outcomes at 3 months indicating that early application can improve clinical outcomes(2). The CESAR trial identified higher 6 month survival rate in patients transferred to an ECMO center versus patients treated with conventional therapy(3). The EOLIA trial is currently underway investigating early ECMO within 3 hours of initiation of mechanical ventilation for patients with severe ARDS. In our case, ECMO dramatically improved patient's condition and he also did well after discharge. CONCLUSIONS: Currently, there are no data to support ECMO as anything other than a rescue therapy. Future research may spur increased utilization of ECMO especially in ARDS, and early referral to ECMO centers akin to Acute Coronary Syndrome patients being taken to PCI centers. Reference #1: Nitta M, Kitamura T, Iwami T, et al. Out-of-hospital cardiac arrest due to drowning among children and adults from the Utstein Osaka Project. Resuscitation. 2013;84(11):1568-1573. https://doi.org/10.1016/j.resuscitation.2013.06.017. Reference #2: Kim KI, Lee WY, Kim HS, Jeong JH, Ko HH. Extracorporeal membrane oxygenation in near-drowning patients with cardiac or pulmonary failure. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2014;22:77. https://doi.org/10.1186/s13049-014-0077-8. Reference #3: Peek GJ, Clemens F, Elbourne D, et al. CESAR: conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure. BMC Health Services Research. 2006;6:163. https://doi.org/10.1186/1472-6963-6-163. DISCLOSURES: No relevant relationships by Abhas Khurana, source=Web Response No relevant relationships by Rohini Manaktala, source=Web Response No relevant relationships by Gaurav Manek, source=Web Response No relevant relationships by Ahmed Zaghloul, source=Web Response