Download Template for BMJ Cases - ELSO 2016

TÍTULO DEL CASO
ECMO as a Bridge to Decision. ECMO CPR: ECMO bridge to Transplant. First case in Peru.
Clinica INCA.
RESUMEN
Woman, 42 years. Admission diagnoses: cardiogenic shock, double mitral lesion; dilated
cardiomyopathy with an ejection fraction: 15%, respiratory failure, FMO, left hemiplegia sequela (1
month before admission).
Echocardiography income: compacted myocardium severely decreased heart function. Happen
three episodes of ventricular fibrillation in the third no return to Spontaneous Circulation post
advanced CPR. ECMO Extracorporeal CPR was performed during cardiac massage 60 '.
Performing peripheral cannulation, Biomedicus-550 as ECMO and Thromboelastography console.
Neurologic evaluation is performed at twelve hours on ECMO does not confirm brain death,
finding vestibulo-ocular reflexes and slow corneal reflex.
At 22:00 the day December 19, 2014, heart transplant was performed and the ECMO is removed.
Evolve with Cardiac Output 8.38 lpm. LVEF 53%; Strain by Speckle Tracking Global -23.7%;
SatO2 91%; PA 116 / 65mmHg, 80% FiO2, PaO2 63. Wake up spontaneously 8 hours post
surgery. Discharged the 33 day PO, stable hemodynamics and cognitively.
IMPORTANCIA DEL CASO
Sudden cardiac arrest is a complex, life-threatening event requiring a multidisciplinary approach.
Many strategies have been proposed over time to achieve the return of spontaneous circulation
and to optimize post-resuscitation care in order to ultimately improve survival. These include
medical, organizational, and technical aspects: mild hypothermia, oxygen control, regionalization
to specialized post-resuscitation care centers, and ECMO. As here ECMO may be the only option
for highly selected patients suffering from CA in which conventional treatment failed.
PRESENTACIÓN DEL CASO
Referred patient, who was admitted with diagnoses: mixed shock, respiratory failure, tastorno of
sensorium. Bring history of fatigue, malaise, nausea and vomiting with urine cultures with 80,000
CFU of E coli, was being treated with amikacin unimproved, loose stools and abdominal pain so
the day 12.10.2014 is hospitalized added, inflammatory reaction found in postive stool, they
initiate coverage with ceftriaxone and persistent abdominal pain and oral intolerance will perform
upper endoscopy, during the procedure after premedication has tachycardia and desaturation so
ends the procedure in the shortest time possible but fail to show erosive gastroduodenitis, after
aproximadanente procedure 01 hours later, the patient does not regain consciousness and
Glasgow Coma Scale 7 and 84-89% desaturation proceed to endotracheal intubation and
ventilatory support prior sedation, then presents hemodynamic instability requiring inotropic
support; under these conditions is derived to another hospital where he arrived with PA 0/0, FC
138 x min, with TOT + VM, Glasgow Coma Scale 7 under sedation, dosage of PCR: 0.7, elevated
transaminases, lactate 8.5-10.5, TP extended 3.36 INR, platelet 83000. Ecovision: Global
contractility decreased starting inotropic support with dobutamine and NA during hoapitalizacion
persistently pursuing tachycardia so it gets amiodarone and Cedilanid. Family seeks second
opinion at our institution and requests moved to the same.
INVESTIGACIONES En caso de ser relevante
DIAGNÓSTICO DIFERENCIAL En caso de ser relevante
TRATAMIENTO En caso de ser relevante
RESOLUCIÓN Y SEGUIMIENTO
Paciente fue dada de alta al 33 dia Postoperatorio, estable Hemodinámica y Cognitivamente.
Paciente viva actualmente.
DISCUSIÓN
Tonna JE, Over a third of centers that submitted adult extracorporeal cardiopulmonary
resuscitation cases to ELSO have performed Emergency Department ECMO. These programs are
largely based at academic hospitals, new, and have low volumes. They do not have many formal
inclusion or exclusion criteria, and devices and techniques are variable.
Dalle Ave AL, In order to avoid the fatal error of letting a saveable patient die, safeguards are
necessary. We recommend: (1) the development of internationally accepted termination of
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resuscitation guidelines that would have to be satisfied prior to inclusion of patients in any
uncontrolled donation after circulatory determination of death protocol, (2) the choice regarding
modalities of ongoing resuscitation during transfer should be focused on the primary priority of
attempting to save the life of patients, (3) only centers of excellence in life-saving resuscitation
should initiate or maintain uncontrolled donation after circulatory determination of death programs,
(4) assisted cardiopulmonary resuscitation should be clinically considered first before the initiation
of any uncontrolled donation after circulatory determination of death protocol, and (5) there should
be no discrimination in the availability of access to assisted cardiopulmonary resuscitation.
Mazzeffi MA, extracorporeal cardiopulmonary resuscitation may have a role in younger adult
cardiac surgery patients who experience refractory cardiac arrest. Future studies are needed to
identify patients who will benefit most from extracorporeal cardiopulmonary resuscitation.
PUNTOS DE APRENDIZAJE 3 a 5 puntos.
Decrease the fatal mistake of allowing the death of a patient salvageable.
REFERENCIAS
https://www.elso.org/Portals/0/IGD/Archive/FileManager/6713186745cusersshyerdocumentselsoguidelinesforecprcases1.3.pdf
IMÁGENES O FIGURAS Las imagines o figuras no deben ir en el texto.
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Fecha:30/08/2016
Autor: Gonzales, Hardy1, Mogrovejo, W2.
1. Cardiovascular and Thoracic Surgeon. Heart Transplantation. ECMO. Assistance Mechanical
Circulatory.
Instituto
Neuro
Cardiovascular
de
las
Américas
(INCA).
[email protected]
2. Interventional cardiologist. ECMO coordinator. Instituto Neuro Cardiovascular de las Américas
(INCA). [email protected]
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