PRONE POSITIONING IN AXILLARY INTRA-AORTIC BALLOON PUMP COUNTERPULSATION: FIRSTIN-HUMAN CASE REPORT

ABSTRACT

Background: Acute respiratory distress syndrome (ARDS) is characterized by hypoxemia and non-hydrostatic pulmonary edema. While ARDS is associated with a high mortality rate, its conjunction with cardiogenic shock (CS) can lead to devastating outcomes. ARDS is managed via lung protective ventilation with low tidal volumes and positive end expiratory pressures. Prone positioning has emerged as a supplementary strategy with beneficial effects on gas exchange, respiratory mechanics, and hemodynamics. Our case underlines the feasibility of intra-aortic balloon pump counterpulsation (IABP) with concurrent prone positioning in a patient with ARDS and CS. Case 71-year-old male with history of coronary artery disease, hypertension, hyperlipidemia, and chronic kidney disease, presented to the emergency department with new onset chest pain. EKG showed ST-segment elevations in leads V1-V2 consistent with acute anterior wall myocardial infarction. Patient underwent percutaneous coronary intervention to the left anterior descending artery.Due to worsening hemodynamics and CS, it was decided to place a left axillary IABP. Hospital course was further complicated by acute pulmonary edema and ARDS requiring emergent intubation and mechanical ventilation. Patient was also started on renal replacement therapy given progression of renal failure. Decision-making Given the onset of ARDS, the patient was placed in prone position for 12-16 hours/day for 5 days. There was no special technique required during proning, other than additional staff to ensure IABP stability. Gradual improvement in hemodynamics was attained, including an increase in cardiac index from 2.1 to 3.4, and a decrease in pulmonary vascular congestion. Conclusion: With the emergence of COVID-19 pandemic, the incidence of ARDS has increased significantly, with simultaneous occurrence of CS in some of these patients. Prone positioning has become one of the main therapeutic modalities in the management of ARDS. Our case highlights the feasibility of axillary IABP while implementing prone positioning in patients with concomitant ARDS and CS.