P013: MECHANICAL THROMBECTOMY REQUIRING EXTRACORPOREAL MEMBRANE OXYGENATION IN A PATIENT WITH STEVEN JOHNSON SYNDROME
Jessica M Alonso, MD; Emily Chung, MD; Raul Bermudez-Velez, MD
HCA Florida Kendall Hospital
A 31-year-old male was transferred to HCA Florida Kendall Hospital from an outside facility for evaluation by the plastic surgery service due to concerns of Steven Johnson Syndrome/Toxic Epidermal Necrolysis. Patient reported to have developed a fever and sore throat a few days prior to admission, and having taken expired Amoxicillin provided by a family member. On arrival patient was found to have a diffuse blistering rash with devitalized epidermis and (+) Nikolsky’s sign on the oral mucosa, face, arms, legs, and penis (approximately 30% total body surface area). Patient underwent surgical debridement of skin lesions and remained intubated post-operatively, with successful extubation on post-operative day 1. On post-operative day 3, patient became acutely diaphoretic, developed atrial fibrillation with rapid ventricular response (heart rate 190-200s bpm), and became hypotensive (requiring norepinephrine vasopressor support) and hypoxemic (SaO2 ~80% which improved with non-rebreather mask at 15L/min). Emergent CT angiogram of the chest confirmed bilateral pulmonary embolism (PE) and right lower lobe pulmonary infarct, consistent with massive PE.
Interventional radiology (IR) was consulted for emergent mechanical embolectomy. Due to high risk of clinical decompensation during the procedure, the decision was made to pharmacologically manage the patient with thrombolytic therapy (heparin infusion) and consult the cardiothoracic surgery service for venoarterial extracoporeal membrane oxygenation (VA ECMO) prior to embolectomy. The patient was placed on VA ECMO via femoral vein-femoral artery cannulation and was then taken to IR for mechanical embolectomy, where a large amount of mixed acuity thrombi were removed from the pulmonary arteries. Post-embolectomy, hemodynamic stability significantly improved, vasopressors were discontinued, and patient was successfully extubated. VA ECMO decannulation was performed 48 hours post-procedure.
Venoarterial extracoporeal membrane oxygenation (VA ECMO) is a life-saving cardiopulmonary bypass technique that can be used in cases of severe cardiac and/or respiratory failure. It can be used as a temporary measure while bridging to definitive therapies in multiple disease states, including cardiogenic shock, cardiac arrest secondary to refractory arrhythmias, and severe biventricular heart failure. With this technique, venous access is obtained via the femoral or internal jugular vein, while arterial access is obtained via the femoral or subclavian artery. Blood is shunted away from the heart via a large-bore cannula to the ECMO machine where a pump provides mechanical circulatory support to maintain blood flow, and an oxygenator acts as the lungs, oxygenating the blood and removing carbon dioxide. Another large-bore cannula then returns blood back into the systemic circulation.
Criteria for diagnosis of massive PE includes severe hemodynamic instability requiring vasopressor support and cardiac arrest secondary to complete obstruction of pulmonary flow. Obstructive shock secondary to massive PE can result in acute right heart failure. The increased right ventricular afterload and increased pulmonary vascular resistance leads to right ventricular dilation and dysfunction, as well as decreased left ventricular preload. VA ECMO can offer temporary cardiopulmonary support during the treatment of pulmonary embolism. Its use in managing massive pulmonary embolism should be considered in cases of severe hemodynamic instability that hinder immediate medical intervention.