Successful management of COVID-19-induced ards using vv ecmo in a patient with a bmi of 73 kg/m2

ABSTRACT

INTRODUCTION: With the SARS-CoV2 adversely affecting outcomes in obese patients, extracorporeal membrane oxygenation (ECMO) as a therapeutic option is increasingly being considered and used, however, no cutoff value for body mass index (BMI) has been identified. We present a unique case of acute respiratory distress syndrome (ARDS) successfully treated with veno-venous (VV) ECMO in a young patient with body mass index (BMI) 73.9 kg/m2 with COVID-19 infection. To our best knowledge this represents the highest BMI patient with COVID-19 successfully managed with VV ECMO to date. METHODS: An 18-year-old male with history of asthma, obstructive sleep apnea, and super morbid obesity, weighing 540 pounds presented with complaints of dyspnea. On admission he was afebrile, conscious and in mild respiratory distress. Initial laboratory findings showed troponinemia with peak levels 66.45ng/ml with signs of inferior wall ST elevation myocardial infarction in electrocardiogram for which thrombolytics were administered. Later COVID-19 test returned positive. Within less than 24 hours of admission, patient developed worsening hypoxic respiratory failure necessitating emergent endotracheal intubation. The patient continued to have hypoxia on 85% FIO2, positive end expiratory pressure (PEEP) 16 cm H2O. Neuromuscular blockade was initiated and the ECMO team was consulted. Patient was cannulated via the right internal jugular vein using a 32-French Crescent VV double-lumen bicaval ECMO cannula by the cardiac critical care team. During the course, patient encountered many challenges particularly with a difficult airway while maintaining infection control precautions, loss of airway pre- and post- cannulation while positioning, refractory hypoxemia owing to shunting due to high endogenous CO up to 20 liters/minute (treated with beta blockers) and septic shock after successful decannulation on day 20 of ECMO needing catecholamine, vasopressin and angiotensin II support. After few days on high ventilatory support post decannulation, he underwent tracheostomy and after 95 days of total hospital stay, was discharged home. RESULTS: Our multi-disciplinary critical care team along with anesthesiology, hospital medicine and nursing played an integral and crucial role in a good outcome for this super morbidly obese patient.