key: cord-0969684-2rctomye
authors: Voelker, Maria T.; Laudi, Sven; Henkelmann, Jeanette; Bercker, Sven
title: ECMO and perfluorocarbon in a therapy refractory case of Acute Respiratory Distress Syndrome
date: 2021-08-18
journal: Ann Thorac Surg
DOI: 10.1016/j.athoracsur.2021.07.045
sha: 3cc7bd2902732c9ccc09037f2b31f45af0a98fc6
doc_id: 969684
cord_uid: 2rctomye

Perfluorocarbons are oxygen-carrying, dense liquids initially intended for the use in partial or total liquid ventilation in patients with severe acute respiratory distress syndrome (ARDS), but did not show beneficial effects in clinical studies. However, perfluorocarbons may be used for lung lavage in severe alveolar proteinosis. In ARDS, oxygenation may be so severely compromised that the use of non-oxygenated perfluorocarbons may not be possible. We report of a case of severe non-resolving ARDS treated with extracorporeal membrane oxygenation (ECMO) to secure oxygenation, using perfluorocarbon in a single instillation to aid the clearance of debris and proteinacous edema.

We report of a case of severe acute respiratory distress syndrome in a young patient. Venovenous ECMO had to be initiated. Despite adequate and extensive supportive treatment, ARDS was not resolving. Perfluorocarbon (PFC) was used in a single instillation technique to help clear debris from the lung. This was possible only by the simultaneous use of ECMO to ensure oxygenation as perfluorocarbon was not used for ventilation but only instilled once.

As perfluorocarbon evaporated from the lung, bilateral infiltrations and consecutively oxygenation improved. This case report displays a feasible and practical way to use perfluorocarbon to clear lungs from debris in persistent ARDS without the danger of hypoxemia by the simultaneous application of ECMO.

A 20-year-old male refugee from Iraq, non-smoker with a history of type one diabetes, presented with cough and fatigue to a tertiary care hospital eight days after arriving in Germany. Calculated antibiotic treatment was started with meropenem. The condition worsened quickly and the patient was admitted to the intensive care unit and intubated 2 days after admittance. Despite lung-protective ventilation, fluid restriction and intermittent prone positioning gas exchange deteriorated rapidly (paO2 40mmHg at FiO2 1.0) and he was presented for transfer to our center two days later. With a paO2 of 40mmHg at an FiO2 of 1.0 and aggressive ventilation, our ARDS retrieval team decided on on-site initiation of ECMO before transportation. The patient received a 21 French multistage draining cannula into the right femoral vein and a 19 French returning cannula into the right jugular vein. ECMO was started (blood flow: 4 liters/ minute, gas flow 3 liters/ minute) and ventilation could be Ultimately, PFC may be used as rescue therapy in non-resolving ARDS to aid clearance of cell debris and edema 6 .

Total liquid ventilation is technically challenging and expensive as adequate circulation of oxygenated PFC must be provided to ensure oxygen delivery into the lung. However, in patients with severe hypoxemia due to ARDS, partial liquid ventilation cannot be used safely without risking hypoxemia due to the reduced tidal volume immediately after instillation. In this case we saw a completely opaque lung. After the use of PFC aeration was restored quickly. We Postulate, that this was induced by supporting alveolar clearance of cell debris and proteniacous secretion leading to supernatant above the PFC In this unfortunate course of the patient presenting with disseminated cerebral infarctions two days after the removal of the ECMO cannulas and 13 days after the application of PFCwe cannot exclude that these infarctions were a thromboembolic complication of ECMO or caused by PFC therapy. However, the fact that the patient was fully awake between ECMO and infarction and the long interval between PFC treatment and infarction provide some arguments against this hypothesis. From a pathophysiological point of view PFC as a cause at least seems implausible. Unfortunately, the definite reason remained unclear. 

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