A 31-year-old male was admitted to the emergency room after being found unconscious in a dirty river. He was intubated and placed on VV-ECMO for severe ARDS. Over the following days, he developed septic shock, multiple organ failure, and worsening infection despite broad-spectrum antibiotics. His condition continued to deteriorate and he suffered cardiac arrest on November 14, 2015. The cause of death was determined to be septic shock and multiple organ failure resulting from aspiration pneumonia and infection.

1. Morbidity & Mortality ConferenceMorbidity & Mortality Conference
Septic Shock after Aspiration
Pneumonia & ARDS Rescued by
ECMO
心臟血管外科 陳勁辰 醫師
台北慈濟醫院
02/24/2016

2.  Sex: MaleSex: Male
 Age: 31 yearsAge: 31 years
 Date of admission: 11/09/2015Date of admission: 11/09/2015
 Dates of surgery: 11/09/2015Dates of surgery: 11/09/2015
 Date of death: 11/14/2015Date of death: 11/14/2015
Patient data

3.  CC: Drunk and fell into dirty river from 5-meterCC: Drunk and fell into dirty river from 5-meter
height (face down, vomiting)height (face down, vomiting)
 PH: UnremarkablePH: Unremarkable
 Course:Course:
 11/09/2015: ER11/09/2015: ER
 11/09/2015: VV-ECMO11/09/2015: VV-ECMO
 11/10/2015: MOF & Septic shock11/10/2015: MOF & Septic shock
 11/14/2015: Mortality11/14/2015: Mortality
Brief summary

4. ER (3am, 11/09/2015)
 Cons: comatose, GCS=E3M4V2Cons: comatose, GCS=E3M4V2
 VS: BP=93/54, HR=112, BT=35C, RR=26VS: BP=93/54, HR=112, BT=35C, RR=26
 Multiple A/W, right hand burnMultiple A/W, right hand burn
 EKG: sinus, 112/minEKG: sinus, 112/min
 Lab: EtOH=223, Hb=14.6, WBC=16k, Cre=1.0,Lab: EtOH=223, Hb=14.6, WBC=16k, Cre=1.0,
ABG=7.11/57/65/20/-11ABG=7.11/57/65/20/-11
 Trauma team! ETT intubationTrauma team! ETT intubation

5. CourseCourse
 BP=72/52, Dopamine IV pump, BT=38.6CBP=72/52, Dopamine IV pump, BT=38.6C
 GCS=E1M1V1-> M4, Pupils 3.0(-)/3.5(+)GCS=E1M1V1-> M4, Pupils 3.0(-)/3.5(+)
 Abx: TapiAbx: Tapi
 Brain CT: Spine C3,4,5 fracture dislocationBrain CT: Spine C3,4,5 fracture dislocation
 Abd CT: no internal bleedingAbd CT: no internal bleeding
 FAST echo: minimal ascitesFAST echo: minimal ascites
 SpO2=60% with MV max supportSpO2=60% with MV max support

6. Brain CT (11/09/2015)

7. Abd CT (11/09/2015)

8. CXR (11/09/2015)

10. VV-ECMOVV-ECMO
 Indication: ARDSIndication: ARDS
 Method: FV & FV punctureMethod: FV & FV puncture
 Procedures: RFV 21F outflow (35cm), LFV 19FProcedures: RFV 21F outflow (35cm), LFV 19F
inflow (50cm), bad outflow upon pump on,inflow (50cm), bad outflow upon pump on,
RFV old CVP wire exchange to 21F cannula asRFV old CVP wire exchange to 21F cannula as
outflow, pump resumedoutflow, pump resumed
 Findings: ECMO initial flow=3-4 L/min,Findings: ECMO initial flow=3-4 L/min,
SpO2=99% as flow upSpO2=99% as flow up

11. CXR (11/09/2015)

12. Course (11/09)Course (11/09)
 WBC=1.3k, Hb=7.9, PLT=48k, Cre=2.1WBC=1.3k, Hb=7.9, PLT=48k, Cre=2.1
 GCS=E1M5Vt, pupils 3.0(-)/3.5(-)GCS=E1M5Vt, pupils 3.0(-)/3.5(-)
 Swan-Ganz catheter: CCO=8.3, PAP=56/38Swan-Ganz catheter: CCO=8.3, PAP=56/38
(46), CVP=31, PCWP=30 -> R/O hypervolemia?(46), CVP=31, PCWP=30 -> R/O hypervolemia?
 Cre=3.9, UO=0, Lac=7.3, CRP=13.5Cre=3.9, UO=0, Lac=7.3, CRP=13.5
 CVVH began as nephrologist suggestedCVVH began as nephrologist suggested

13. CXR (11/10/2015)

14. Course (11/10)Course (11/10)
 Heart echo: LVEF=61%, no PCEHeart echo: LVEF=61%, no PCE
 Lac=10.3, WBC=6.5k, PLT=72k, AST=144Lac=10.3, WBC=6.5k, PLT=72k, AST=144
 VV-ECMO flow=7 L/min, SpO2=100%VV-ECMO flow=7 L/min, SpO2=100%
 Levophed use, BP=125/63, HR=111, EKG sinusLevophed use, BP=125/63, HR=111, EKG sinus
 CVVH & Lasix useCVVH & Lasix use
 MV PEEP=12, FiO2=60%MV PEEP=12, FiO2=60%
 Abx: Vanco & TapiAbx: Vanco & Tapi

15. Course (11/11~12)Course (11/11~12)
 Hypoglycemia (min=45) with D50W useHypoglycemia (min=45) with D50W use
 NPO, NG drained 400cc/dayNPO, NG drained 400cc/day
 WBC=10.6k, Hb=12.6, PLT=23k, Cre=3.8,WBC=10.6k, Hb=12.6, PLT=23k, Cre=3.8,
Lac=6.7, CRP=34.2Lac=6.7, CRP=34.2
 GCS=E1M1Vt, pupils 2.0(+-)/2.0(+-)GCS=E1M1Vt, pupils 2.0(+-)/2.0(+-)
 Abd: hypo, NG free drainAbd: hypo, NG free drain

16. CXR (11/11/2015)

17. Course (11/13)Course (11/13)
 Lac=12.3, Cre=2.8, CRP=39.18, WBC=17.3,Lac=12.3, Cre=2.8, CRP=39.18, WBC=17.3,
Hb=10.8, PLT=47k, Bil(T)=3.2Hb=10.8, PLT=47k, Bil(T)=3.2
 Infection breakthrough?Infection breakthrough?
 Abx: Targo + Mepem + Fluconazole (Anti-Abx: Targo + Mepem + Fluconazole (Anti-
fungal added)fungal added)
 AST/ALT=352/68, BUN/Cre=56/2.8AST/ALT=352/68, BUN/Cre=56/2.8
 Abd: soft, NG D5W slow feedingAbd: soft, NG D5W slow feeding

18. CXR (11/13/2015)

19. Course (11/14)Course (11/14)
 Shock worsenedShock worsened
 Bosmin, Levephed, Dopamine useBosmin, Levephed, Dopamine use
 GCS=E1M1Vt, pupils 3.0(-)/3.5(-)GCS=E1M1Vt, pupils 3.0(-)/3.5(-)
 Family agreed DNRFamily agreed DNR
 EKG: asystole at 12:00EKG: asystole at 12:00

20. Possible Causes of Mortality
Septic shock, pathogen?
Non-bacterial infection: fungus, protozoa?
Multiple organ failure

21. 手術適應症是否恰當 --> Yes
手術前評估是否完整 --> Yes
手術中麻醉是否洽當 --> N/A
加護病房之照護洽當否 --> Yes
死亡原因之根本分析 ?
Septic shock
整體而言 , 本案例可以改進之處為何 ?
Earlier anti-fungal or anti-protozoa?
本案例學到什麼 ?
Non-bacterial septic shock
How to do better?

28. My VV-ECMO (ARDS) CasesMy VV-ECMO (ARDS) Cases
 02/27/2016, 39F, alive (6107)02/27/2016, 39F, alive (6107)
 11/09/2015, 31M, dead11/09/2015, 31M, dead
 10/08/2015, 58F, alive10/08/2015, 58F, alive
 07/29/2015, 70F, dead07/29/2015, 70F, dead
 07/29/2015, 75F, alive07/29/2015, 75F, alive
 07/08/2015, 22F, alive07/08/2015, 22F, alive
 05/28/2015, 48F, dead05/28/2015, 48F, dead
 05/09/2015, 43F, dead05/09/2015, 43F, dead
 01/16/2015, 69M, dead01/16/2015, 69M, dead
 => Survival rate= 4/9=44%=> Survival rate= 4/9=44%