Veno-Venous Extracorporeal Membrane Oxygenation: Anesthetic Management for Massive Intracranial Hemorrhage in H1N1 Infection

摘要

Background: Extracorporeal membrane oxygenator (ECMO) use is dramatically increasing in recent years. This case report describes a patient on veno-venous (VV) ECMO for H1N1 who underwent emergent craniotomy twice for intracranial hemorrhage. Case presentation: A 38-year-old male presented to a community hospital for worsening shortness of breath. He had experienced cough, malaise and fatigue for two weeks prior to presentation. On arrival, his arterial oxygen saturation was 64%. He was placed on oxygen via non-rebreather mask and started on Tamiflu plus antibiotics. He was intubated for worsening respiratory failure. Despite maximal ventilator settings, the arterial oxygen saturation was approximately 90%. He was placed in the prone position and nitric oxide was initiated. Severe acute respiratory distress syndrome (ARDS) secondary to influenza was diagnosed by viral PCR, clinical presentation, and diagnostic imaging. Within 24 hours of his intubation, a decision was made to initiate veno-venous (V-V) ECMO for respiratory support. Five days following the initiation of ECMO, asymmetric pupils and a nonreactive right pupil were noted. A massive right frontal intraparenchymal hemorrhage with midline shift and downward uncal herniation was found on computed tomography (CT). A decision was made to surgically intervene. He was taken to the operating room for immediate right frontal craniotomy and clot evacuation under general anesthesia. Conclusion: With the dramatic increase in ECMO use, anesthesiologists are encountering patients on ECMO in the operating room with more frequency. When the situation does arise, it is imperative that the anesthesiologist is knowledgeable about ECMO and how to appropriately administer anesthesia for these critically ill patients. Challenges confronting the anesthesiologist with ECMO patients include managing bleeding or coagulopathy, ventilation and oxygenation, volume status, transporting and positioning these patients, and altered pharmacokinetics of anesthetic drugs.