Two hundred and sixty-two days on single cannula vv-ecmo in a patient with severe pulmonary coccidioidomycosis: insights to successful management

SESSION TITLE: Critical Care Case Report Posters 64 SESSION TYPE: Case Report Posters PRESENTED ON: 10/11/2023 12:00 pm - 12:45 pm INTRODUCTION: Prolonged extracorporeal membrane oxygenation (ECMO) support is becoming more common. Currently, there are no randomized trials comparing single versus dual cannulation for veno-venous (VV) ECMO. Complications can arise from either cannulation strategies. We report our institutional experience utilizing dual-lumen (DL) single cannulation for VV-ECMO in a patient cannulated for 262 days up until his hospital transfer for lung transplant. CASE PRESENTATION: A 27-year-old male with severe pulmonary coccidioidomycosis underwent elective right lower lobectomy. Post-operatively, the patient developed ARDS following an aspiration event, necessitating intubation for respiratory failure. Despite optimal medical management, his condition continued to deteriorate so we elected to rescue the patient with VV-ECMO on ventilator day 1. A jugular single-venous VV-ECMO was implemented with placement of a 30-French dual-lumen catheter. Anticoagulation was managed with bivalirudin. The patient underwent tracheostomy on ventilator day 14. Unfortunately, the patient did not tolerate weaning of sweep gas flow. The patient had a complicated 8-month hospitalization course with multi-drug resistant ventilator-associated pneumonia (4 recurrences), intolerance to antifungals, Staphylococcus epidermidis bacteremia from ECMO-related cannulation (first occurrence on ECMO day 51), organizing pneumonia, adrenal insufficiency and cor pulmonale. Cannula tip dislodgement did not occur. Pressure gradient across the cannula remained stable. Serial echocardiograms showed normalization of right ventricular systolic function. Due to his prior lobectomy and ongoing infections, he was deemed a poor surgical candidate by many transplant centers. Therefore, aggressive anti-infective measures were implemented to improve the patient's candidacy. We started the patient on prophylactic minocycline for suppressive therapy with no evidence of recurrent bacteremia. After 4 months on ECMO, the patient was weaned to a tracheostomy collar. He was safely air transported to an outside facility for lung transplant with no complications during transit. DISCUSSION: Early initiation of VV-ECMO in this patient proved to be life-saving. Traditional ventilator management can fail in patients like ours with unilateral cavitary lung disease. The affected lung being relatively stiffer, remains underinflated and prone to atelectrauma causing profound hypoxemia. ECMO-related complications make prolonged runs difficult. Although a single cannula inserted through the neck theoretically reduces the risk of catheter-related bloodstream infection, bacteremia can still occur. There is a lack of high-quality evidence to guide ECMO line management practices. Fortunately, daily prophylactic administration of minocycline prevented recurrent bacteremia for our patient. DL single cannula configuration also offered several advantages. Single cannulation avoids recirculation and reduces the chance of inadvertent cannula dislodgement. Inspection of the cannulation site occurred every 2 hours as part of routine nursing care, with as needed resuturing to maintain placement. Single cannulation is also potentially easier for patient mobilization, which we believe is crucial in mitigating deconditioning for these patients while they await transplant. Despite its superiority, DL single cannulation has not been increasingly utilized as per ELSO International Report. CONCLUSIONS: Our experience shows that DL single cannula VV-ECMO is as efficient and less invasive than two cannula ECMO in carefully selected patients. REFERENCE #1: Lorusso, R., Belliato, M., Mazzeffi, M. et al. Neurological complications during veno-venous extracorporeal membrane oxygenation: Does the configuration matter? A retrospective analysis of the ELSO database. Crit Care 25, 107 (2021). https://doi.org/10.1186/s13054-021-03533-5 REFERENCE #2: Extracorporeal Life Support Organization. ELSO guidelines for cardiopulmonary extracorporeal life support, Version 1.4. Ann Arbor, MI, USA: Extracorporeal Life Support Organisation; 2017. Available from: https://www.elso.org/Resources/Guidelines.aspx. REFERENCE #3: Crotti S, Iotti GA, Lissoni A, et al. Organ allocation waiting time during extracorporeal bridge to lung transplant affects outcomes. Chest. 2013;144(3):1018-1025. doi:10.1378/chest.12-1141 DISCLOSURES: No relevant relationships by Zachary Hernandez No relevant relationships by Ivy Liu No relevant relationships by Walter Migotto No relevant relationships by Daniel Puebla Neira No relevant relationships by Andrew Talon No relevant relationships by Suresh Uppalapu