P005: USE OF VENOVENOUS ECMO AS INTRAOPERATIVE OXYGENATION FOR RIGHT-SIDED ESOPHAGEAL AND LEFT-SIDED BRONCHIAL INJURY REPAIRS AFTER MULTIPLE GSW'S
Adriana Grossman, MD, MPH, MHA1; Aryana Gharagozloo, BA2; Maria Rathore, MD1; Daniel Perez, MD1; 1University of Miami Department of Anesthesia; 2University of Miami Miller School of Medicine
Introduction/Background: The patient is a 39 year-old male who presented to Ryder Trauma Center as a part of a mass casualty incident. Upon arrival patient was found to have multiple gunshot wounds (GSW) to the chest, arm, and buttock but was otherwise stable. The patient was intubated in the resuscitation bay for airway protection and a left chest tube was placed. After CT, the patient was promptly taken for exploratory laparotomy where the patient underwent splenectomy, stomach repair, and diaphragmatic repair. The patient was postoperatively admitted to SICU. Pneumomediastinum was then noted on repeat CT and the patient was scheduled for a right-sided thoracotomy on suspicion of a possible esophageal and/or tracheal injury. The Cardiothoracic (CT) Surgery service was consulted and was present for diagnostic esophageal scope at bedside revealing a right-sided through and through esophageal injury. The patient then underwent preoperative right internal jugular (RIJ) central line placement in SICU. During transport to OR, the patient developed worsening hypoxia, requiring 100% FiO2 to maintain saturations in low 90’s along with new and acute pressor requirements. Upon arrival to OR, right-sided breath sounds were found to be diminished, thus the surgical team placed a right chest tube with immediate improvement of SpO2 and hemodynamics. Due to the subsequent very high index of suspicion for tracheal or mainstem bronchus injury, the anesthesia team then performed diagnostic flexible bronchoscopy. Upon inspection, bronchoscopy demonstrated a linear defect in the left mainstem bronchus about two centimeters from the carina that was seen to have intermittent bubbling of air concerning for a possible injury.
Methods: Considering access to the right chest for repair of the esophageal injury would involve single lung ventilation on the left, but such intervention would present prohibitive risk due to the left mainstem bronchus injury, venovenous (VV) ECMO was presented as the safest means of oxygenation for the surgical repairs. The patient underwent VV ECMO cannulation with RIJ and left femoral vein access, after which the CT Surgery followed with right posterolateral thoracotomy for esophageal and left mainstem bronchus repair. ABG’s were drawn and evaluated throughout the case as well as serial TEG’s, which remained stable.
Results: Patient was post-operatively transferred to the TICU for further management where he was extubated after 6 days of mechanical ventilation and, subsequently, was decannulated from VV ECMO with 17 days of ECMO run. Patient was discharged approximately 1 month from admission.
Discussion/Conclusion: Intraoperative VV ECMO has predominately been used for bilateral lung transplantation and in patients with ARDS following GSW’s to the lung parenchyma. However, in conditions where airway injury on the opposing thoracic side of another intrathoracic injury requiring single lung ventilation for repair, VV ECMO presents a viable and safe means of intraoperative oxygenation.