ABSTRACT
Aim and background: Since the beginning of COVID-19 pandemic, we have come across a large number of ARDS patients with different presentations and clinical manifestations. The usual management is using a lung-protective ventilatory strategy followed by proning to improve oxygenation. Here, we present a case where the usual management failed to improve oxygenation which led us to think of co-existing alternative diagnosis. Case description: A 59-year-old male with a history of cardiovascular disease, presented with cough and breathing difficulty for 10 days and COVID RT PCR was positive. He was started on remdesivir, steroids, anti-coagulants, and other supportive measures but worsened and had to be intubated and mechanically ventilated. Lung-protective ventilation was initiated but the patient remained hypoxic even at 100% fiO2. Chest X-ray and HRCT did not show much severity and the measured lung compliance was also good. A transesophageal ECHO showed good LV function and no significant diastolic dysfunction. 2 sessions of proning were done and yet the oxygenation did not improve. Repeat HRCT + CTPA was done to look for pulmonary embolism but it instead revealed a pulmonary AV malformation. Coiling of the AV malformation was done. Oxygenation then substantially improved. Further sessions of proning were done and patient was gradually weaned off. Conclusion: There may be several co-existing causes of ventilation-perfusion mismatch which needs to be looked for. Pulmonary AV malformation, though rare, can cause shunting and hence persistent hypoxia.
ABSTRACT
Introduction: Acute respiratory distress syndrome (ARDS) is associated with high mortality despite the use of low-volume, low-pressure ventilation strategies that are aimed at reducing ventilator-induced lung injury. Initiation of ECMO for adult ARDS should be considered when conventional therapy cannot maintain adequate oxygenation. ECMO can stabilize gas exchange and haemodynamic compromise, consequently preventing further hypoxic organ damage. Here, we present a case series of COVID-19 ARDS who were put on VV ECMO in a tertiary care hospital in Kerala and their primary and secondary outcomes. Aims and objectives: The primary outcome is to determine the 28-day mortality from all causes in all COVID-positive patients put on VV ECMO till date. The secondary outcome is the incidence of ventilator-associated pneumonia (VAP) and acute kidney injury (AKI) in all COVID-positive patients put on VV ECMO. Materials and methods: Retrospective continuous case series. Retrospective data were collected from all COVID-positive patients who were put on VV ECMO till date in the hospital and the primary and secondary outcome was analyzed. Results: The mean duration from onset of dyspnea to initiation of ECMO was 11 days. The mean duration of ECMO for a patient was 7 days 19 hours. Out of 14 patients, 9 patients expired within 28 days of initiating ECMO (64.2%). Out of these, 2 patients were weaned off ECMO but died later. 2 patients died due to intracranial haemorrhage while on ECMO. Of all the patients put on ECMO, 6 patients had VAP complicating the course of ECMO (42.8%). Of the organisms isolated, 2 patients had MDR Acinetobacter, 2 patients had MDR Klebsiella, 1 patient had had MDR Acinetobacter, MDR Pseudomonas and MDR Klebsiella, and one patient has Aspergillus sp. Of the total patients, 7 had AKI during the course of ECMO as defined by KDIGO criteria (50%). Of these, 4 had to undergo at least one session of dialysis while the others were managed conservatively. Conclusion: The 28-day mortality was higher than an international multi-centric trial done by De Troy et al. probably because of late referrals to our hospital after many days of NIV and high oxygen requirement. VAP complicated the course of ECMO in many patients which emphasizes strict infection control practices in patients on ECMO. AKI was found in half of the patients and was usually secondary to sepsis.