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      Unusual severe hypoxemia due to unilateral pulmonary edema after conventional cardiopulmonary bypass salvaged by veno-venous extracorporeal membrane oxygenation: a case report

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          Abstract

          Background

          We report a case in which veno-venous extracorporeal membrane oxygenation (V-V ECMO) saved the life of a patient who developed severe hypoxemia due to unusual unilateral pulmonary edema (UPE) after cardiopulmonary bypass (CPB).

          Case presentation

          A 69-year-old man underwent aortic valve replacement and coronary artery bypass grafting. Following uneventful weaning off CPB, he developed severe hypoxemia. The ratio of arterial oxygen tension to inspired oxygen fraction (PaO 2/FiO 2) decreased from 301 mmHg 5 min after CPB to 42 mmHg 90 min after CPB. A chest X-ray revealed right-sided UPE. Immediately established V-V ECMO increased PaO 2/FiO 2 to 170 mmHg. Re-expansion pulmonary edema (REPE) was likely, as the right lung remained collapsed during CPB following the accidental opening of the right chest cavity during graft harvesting.

          Conclusions

          V-V ECMO was effective in improving oxygenation and saving the life of a patient who had fallen into unilateral REPE unusually developing after conventional CPB.

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          Most cited references22

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          Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial.

          Giles J Peek, Miranda Mugford, Ravindranath Tiruvoipati … (2010)
          Severe acute respiratory failure in adults causes high mortality despite improvements in ventilation techniques and other treatments (eg, steroids, prone positioning, bronchoscopy, and inhaled nitric oxide). We aimed to delineate the safety, clinical efficacy, and cost-effectiveness of extracorporeal membrane oxygenation (ECMO) compared with conventional ventilation support. In this UK-based multicentre trial, we used an independent central randomisation service to randomly assign 180 adults in a 1:1 ratio to receive continued conventional management or referral to consideration for treatment by ECMO. Eligible patients were aged 18-65 years and had severe (Murray score >3.0 or pH 30 cm H(2)O of peak inspiratory pressure) or high FiO(2) (>0.8) ventilation for more than 7 days; intracranial bleeding; any other contraindication to limited heparinisation; or any contraindication to continuation of active treatment. The primary outcome was death or severe disability at 6 months after randomisation or before discharge from hospital. Primary analysis was by intention to treat. Only researchers who did the 6-month follow-up were masked to treatment assignment. Data about resource use and economic outcomes (quality-adjusted life-years) were collected. Studies of the key cost generating events were undertaken, and we did analyses of cost-utility at 6 months after randomisation and modelled lifetime cost-utility. This study is registered, number ISRCTN47279827. 766 patients were screened; 180 were enrolled and randomly allocated to consideration for treatment by ECMO (n=90 patients) or to receive conventional management (n=90). 68 (75%) patients actually received ECMO; 63% (57/90) of patients allocated to consideration for treatment by ECMO survived to 6 months without disability compared with 47% (41/87) of those allocated to conventional management (relative risk 0.69; 95% CI 0.05-0.97, p=0.03). Referral to consideration for treatment by ECMO led to a gain of 0.03 quality-adjusted life-years (QALYs) at 6-month follow-up [corrected]. A lifetime model predicted the cost per QALY of ECMO to be pound19 252 (95% CI 7622-59 200) at a discount rate of 3.5%. We recommend transferring of adult patients with severe but potentially reversible respiratory failure, whose Murray score exceeds 3.0 or who have a pH of less than 7.20 on optimum conventional management, to a centre with an ECMO-based management protocol to significantly improve survival without severe disability. This strategy is also likely to be cost effective in settings with similar services to those in the UK. UK NHS Health Technology Assessment, English National Specialist Commissioning Advisory Group, Scottish Department of Health, and Welsh Department of Health.
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            Management of Adult Patients Supported with Venovenous Extracorporeal Membrane Oxygenation (VV ECMO) : Guideline from the Extracorporeal Life Support Organization (ELSO)

            Joseph Tonna, Darryl Abrams, Daniel Brodie … (2021)
            Article 0 comments Cited 148 times – based on 0 reviews     Review now
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              Clinical practice. Acute pulmonary edema.

              Erin B. Ware, Michael Matthay (2005)
              Article 0 comments Cited 135 times – based on 0 reviews     Review now
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                Author and article information

                Contributors
                Izumi Kawagoe:
                ORCID: http://orcid.org/0000-0002-5791-2700
                ikawago@juntendo.ac.jp
                Journal
                Journal ID (nlm-ta): JA Clin Rep
                Journal ID (iso-abbrev): JA Clin Rep
                Title: JA Clinical Reports
                Publisher: Springer Berlin Heidelberg (Berlin/Heidelberg )
                ISSN (Electronic): 2363-9024
                Publication date (Electronic): 7 October 2023
                Publication date PMC-release: 7 October 2023
                Publication date Collection: December 2023
                Volume: 9
                Electronic Location Identifier: 65
                Affiliations
                [1 ]Department of Anesthesiology and Pain Medicine, Juntendo University Hospital, ( https://ror.org/04g0m2d49) Tokyo, 113-8431 Japan
                [2 ]Department of Anesthesia, Fujieda Municipal General Hospital, ( https://ror.org/03q01be91) Shizuoka, Japan
                [3 ]Department of Anesthesiology and Pain Medicine, Juntendo University Shizuoka Hospital, ( https://ror.org/035svbv36) Shizuoka, Japan
                Author information
                http://orcid.org/0000-0002-5791-2700
                Article
                Publisher ID: 656
                DOI: 10.1186/s40981-023-00656-2
                PMC ID: 10558410
                PubMed ID: 37803183
                SO-VID: 145e4dc6-3d59-444a-bdd0-850f28dd6178
                Copyright © © The Japanese Society of Anesthesiologists 2023
                License:

                Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.

                History
                Date received : 4 September 2023
                Date revision received : 25 September 2023
                Date accepted : 26 September 2023
                Categories
                Subject: Case Report
                Custom metadata
                issue-copyright-statement © The Japanese Society of Anesthesiologists 2023

                Keywords: cardiopulmonary bypass,re-expansion pulmonary edema,unilateral pulmonary edema,veno-venous extracorporeal membrane oxygenation
                Data availability:
                Keywords: cardiopulmonary bypass, re-expansion pulmonary edema, unilateral pulmonary edema, veno-venous extracorporeal membrane oxygenation

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