Life‐saving use of extracorporeal membrane gas exchange in severe, acute respiratory failure

Abstract

SummaryA 41-year-old man developed acute respiratory failure in association with thoracotomy and decortication for a persisting pleural collection secondary to a stab injury. The use of veno-venous extracorporeal membrane gas exchange proved life-saving. Key words Surgery; thoracic.Complications; acute ventilatory failure. Extracorporeal membrane oxygenation. Case historyA 41-year-old Caucasian male was admitted to hospital complaining of malaise, shortness of breath and weight loss, having sustained a stab wound to the left chest one month previously. He had undergone exploratory thoracotomy in another hospital immediately after the assault and had been discharged after 9 days with residual haemothorax. He was readmitted there 3 weeks later with a large collection in the left pleural space. This was evacuated incompletely by insertion of a chest drain and the patient was referred to this hospital for thoracotomy and decortication.On examination he was pale and dyspnoeic with the clinical and radiological signs of a left basal fluid collection and a purulent discharge via the chest drain.The patient was given papaveretum and hyoscine preoperatively on the ward. Anaesthesia was induced with thiopentone, and a large, right, Robertshaw double-lumen tube was inserted after administration of suxamethonium. Anaesthesia was maintained by ventilation of the dependent right lung with nitrous oxide, oxygen and isoflurane. Muscle relaxation was achieved with atracurium and fentanyl was given to provide analgesia during the procedure. Monitoring included electrocardiography, continuous direct blood pressure (BP) measurement via a radial artery cannula and arterial oxygen saturation (Spo,) with a pulse oximeter.The findings at thoracotomy were a collection of blood clot and serosanguinous fluid, a left hemidiaphragmatic defect with adherent, prolapsing omentum and a healed laceration of the upper pole of the spleen, all of which appeared to have been caused by the original injury. Evacuation of clot and fluid, decortication and diaphragmatic repair were performed.Surgery and anaesthesia proceeded uneventfully for 20 minutes with mild hypotension (systolic BP 80-100 mmHg) and Spo, > 95% on one-lung ventilation until, without significant blood loss, and for no apparent reason, the patient became profoundly hypotensive and hypoxic (Spo, 60%). Inspired oxygen fraction (Ro,) was increased to 1.0, correct position of the Robertshaw tube confirmed and continued, adequate ventilation of the dependent lung assured. Rapid infusion of one litre of Gelofusine restored the blood pressure but Spo, remained variably depressed at 80-90% despite the application of positive end-expiratory pressure (PEEP) to the lower lung and insufflation of the upper lung with oxygen. Ventilation of both lungs was resumed with Ro, 0.6 and Spo, improved to 93%. The patient was haemodynamically stable but peripherally cool