GUILLAIN-BARRÉ SYNDROME AS A COMPLICATION OF EXTRACORPOREAL MEMBRANE OXYGENATION

Abstract

SESSION TITLE: Critical Care Devices SESSION TYPE: Med Student/Res Case Report PRESENTED ON: 10/23/2019 8:45 AM - 9:45 AM INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is considered the highest form of life support. Despite its expanded use and improved success, adverse issues including hemostatic, thrombotic and hemolysis still occur at high rates. Guillain-Barre syndrome (GBS), a demyelinating polyneuropathy, is not documented in the literature as an adverse issue. We present a case of massive pulmonary embolism (PE) requiring ECMO complicated by GBS. CASE PRESENTATION: A 54-year-old female with a history of breast cancer in remission, deep vein thrombosis formerly on rivaroxaban, discontinued after cancer remission, presented with acute onset severe chest pain. She was in severe respiratory distress, tachycardic and in shock. She was intubated with cardiac arrest soon after, with successful resuscitation. Computed-tomography angiography (CTA) scan confirmed massive bilateral PE and she was administered tenecteplase. Her hemodynamics worsened necessitating maximal vasopressor support. Labs showed an acute drop in hematocrit from 32% to 14% with increasing abdominal distension, rigidity and decreased bowel sounds alarming for compartment syndrome. Bedside ultrasound revealed signs of retroperitoneal bleed, an adverse effect of tenecteplase. Despite massive transfusion protocol, she continued to worsen necessitating venous-arterial ECMO to support cardiogenic shock. Within 30 minutes of ECMO support, vasopressors were weaned and underwent exploratory laparotomy for abdominal compartment syndrome. She remained on ECMO for 17 days with improvement. While on ECMO, she developed progressive ascending lower extremity weakness. Lumbar puncture was done, with a WBC of 0, Glucose 107 mg/dL and Protein 77 mg/dL with cytoalbumincytologic dissociation. Magnetic resonance imaging showed diffuse nerve root and cord enhancement, findings consistent with GBS. She subsequently received full treatment of intravenous immunoglobulin with improvement in her symptoms. DISCUSSION: GBS has a pathogenesis related to aberrant immune response against the peripheral nervous system. Infections are known to be a cause, but there is literature about surgery as a potential trigger, often spinal surgery. One study cited an attributable risk of 4.1 cases per 100000 surgeries with most attributed to spinal surgery. To our knowledge this is the first case of GBS with ECMO exclusive of preceding infection. Initiation of ECMO is associated with an immediate inflammatory reaction. As blood enters the circuit, levels of pro-inflammatory cytokines increase causing leukocyte activation. Simultaneously, there is antigen release and autoimmunization to antigens, similar to GBS in surgical patients. CONCLUSIONS: As ECMO patients are critically ill, they are more prone to develop critical care neuropathy. It is important that in patients with neuromuscular weakness in the setting of ECMO use, that GBS be amongst the differential of critical care neuropathy. Reference #1: Dowling JR, Dowling TJ. A Rare Axonal Variant of Guillain-Barré Syndrome following Elective Spinal Surgery. Case Rep Orthop. 2018;2018:2384969. Published 2018 Aug 7. https://doi.org/10.1155/2018/2384969 Reference #2: Millar JE, Fanning JP, McDonald CI, McAuley DF, Fraser JF. The inflammatory response to extracorporeal membrane oxygenation (ECMO): a review of the pathophysiology. Crit Care. 2016;20(1):387. https://doi.org/10.1186/s13054-016-1570-4. DISCLOSURES: No relevant relationships by Abhas Khurana, source=Web Response No relevant relationships by Gaurav Manek, source=Web Response No relevant relationships by Varun Tandon, source=Web Response No relevant relationships by Aysha Tandon, source=Web Response