Extracorporeal membrane oxygenation in near-drowning patients with cardiac or pulmonary failure.

BACKGROUND: The aim of this study was to determine the early outcomes of using extracorporeal membrane oxygenation (ECMO) in near-drowning patients with cardiac or pulmonary failure. METHODS: This study was based on data from 9 patients including 2 children (mean age 33; 8 males, 1 female) who received ECMO after near-drowning between 2008 and 2013. Veno-arterial or veno-arteriovenous ECMO was used in 2 patients with sustained cardiac arrest and veno-venous ECMO was used in 7 patients with severe acute respiratory distress syndrome (ARDS). The means of the partial arterial oxygen pressure (PaO2), Murray score, sequential organ failure assessment (SOFA) score, and simplified acute physiology score II (SAPS-II) prior to ECMO were 59.7 ± 9.9 mmHg on 100% oxygen, 3.5 ± 0.6, 11.4 ± 1.9, and 73.0 ± 9.2, respectively. RESULTS: The PaO2 mean improved to 182 ± 152 mmHg within 2 h post-ECMO. The mean of SOFA score and SAPS-II decreased significantly to 8.6 ± 3.2 (p = 0.013) and 46.4 ± 5.1 (p = 0.008), respectively, at 24 h post-ECMO with mean flow rate of 3.9 ± 0.8 l/min. ECMO was weaned at a mean duration of 188 (range, 43-672) h in all patients. Seven patients were discharged home without neurological sequelae, while 2 patients who had hypoxic brain damage died after further referral. The overall survival with favourable neurological outcomes at 3 months was 77.8%. There were no complications related to ECMO. CONCLUSIONS: ECMO was safe and effective for patients with ongoing cardiac arrest or ARDS after a near-drowning incident and can be used as a resuscitative strategy in near-drowning patients with cardiac or pulmonary failure resistant to conventional ventilator therapy.

Drowning in children: Utstein style reporting and outcome.

BACKGROUND: We report the incidence and mortality of paediatric drowning incidents according to 'Utstein Style for Drowning' guidelines. METHODS: Retrospective study including all the drowned children under 16 years of age who were hospitalised or died with or without attempted cardiopulmonary resuscitation (CPR) between 1997 and 2007 in the province of Uusimaa, Finland. Survival rates provided at hospital discharge and after 1-year follow-up period are reported. RESULTS: A total of 58 drowned children were either admitted to the paediatric intensive care unit or died during the study period. The median (interquartile range) age was 5.9 (3.1, 7.8) years. The annual incidence of drowning was 1.9/100,000 and was highest, 2.8/100,000, in children aged between 1 and 4 years. The annual mortality rate was 0.9/100,000. Of all the 58 patients, 14 (24%) died at the scene, 22 (38.1%) before the hospital discharge, and 26 (45%) within the 1 year. The number of non-fatal drownings was 1.2-fold that of fatal drownings. The survival rate of the 26 patients for whom CPR was initiated by emergency medical service (EMS) personnel was 42% at hospital discharge, with the 1-year survival rate being 27%. CONCLUSIONS: The incidence of drowning in children and the survival rate of those children in whom CPR was initiated by EMS personnel was in line with the previously reported. However, the overall mortality rate in drowned children was higher than estimated in previous studies.

Evaluation of freshwater submersion in small animals: 28 cases (1996-2006).

OBJECTIVE: To determine clinical characteristics, treatments, and outcome in dogs and cats evaluated after submersion in freshwater. DESIGN: Retrospective case series. ANIMALS: 25 dogs and 3 cats. PROCEDURES: Medical records were reviewed for signalment; causes, location, and month of submersion; physical examination findings at admission; results of blood gas analysis; treatments administered; duration of hospitalization; and outcome, including evidence of organ failure or compromise. RESULTS: All submersions involved bodies of freshwater. Fourteen animals were submerged in man-made water sources, 13 were submerged in natural water sources, and the body of water was not recorded in 1 case. Twenty (71%) submersions occurred from May through September. Cause was identified in 16 animals and included extraordinary circumstances (n = 6), falling into water (5), breaking through ice (3), and intentional submersion (2). Twelve animals were found submerged in water with unclear surrounding circumstances. Treatment included administration of supplemental oxygen, antimicrobials, furosemide, corticosteroids, and aminophylline and assisted ventilation. Respiratory dysfunction was detected in 21 animals. Neurologic dysfunction was detected in 12 animals, hepatocellular compromise was detected in 6 animals, and cardiovascular dysfunction was detected in 4 animals. Three dogs had hematologic dysfunction, and 2 dogs had acute renal dysfunction. Eighteen (64%) animals survived to hospital discharge, but all of the cats died. In 9 of 10 nonsurvivors, respiratory tract failure was the cause of death or reason for euthanasia. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that submersion is an uncommon reason for veterinary evaluation but is associated with a good prognosis in dogs in the absence of respiratory tract failure.

Near-drowning and clinical laboratory changes.

Opposite to clinical laboratory findings in experimental drowning of animals (erythrocytic lysis, hyperkalemia, and final cardial fibrillation) are the observations in drowned humans (increase of pCO2, hypoxic encephalopathy), which leads to a different pathophysiological interpretation of the drowning process. This process, however, is recently discussed again, therefore an additional study seemed to be recommended. In a retrospective study, 31 cases of near-drowning (23 cases: fresh water; 8 cases: brackish water) clinical laboratory data were analysed. While 21 of the cases were fatal with a delay of up to 180 days, 10 individuals survived the accident, four cases with severe neurological deficits. Data of pH, potassium, sodium, chloride, hemoglobin and total protein were collected during the very early post-drowning period. Nearly all cases (96%) revealed a reduction of pH due to hypoxic acidosis, and only two cases (6.5%) exhibited a slight hyperkalemia. The hemoglobin level was normal in most of the cases (83%) and slightly reduced in the others (17%) while the protein level was slightly reduced in most of the fatalities (80%). As a result of our investigation we have to state the lack of hyperkalemia as well as of an increase of the hemoglobin level indicate that there is no distinct intravascular red cell lysis due to influx of water into the vascular compartment. Therefore the death by drowning in humans in most cases is the result of a hypoxic cerebral process. A comparison with animal experiments obviously is not helpful because the drowning process in humans leads to an aspiration of only 2-4 ml water/kg, while in animal experiments more than 10 ml water/kg will be artificially aspirated leading to red cell lysis as well as to electrolyte disturbances and cardial fibrillation.

Cardiac troponin I as a predictor of mortality for pediatric submersion injuries requiring out-of-hospital cardiopulmonary resuscitation.

BACKGROUND: It is difficult to predict ultimate survivors to hospital discharge in children who are successfully resuscitated after a cardiorespiratory arrest associated with a submersion injury. Serum measurements of organ injury or dysfunction may serve as a surrogate marker of the degree of hypoxic injury. We designed a prospective study whose purpose was to assess the predictive value for outcome of serum cardiac troponin I measurements after submersion injury and cardiorespiratory arrest. METHODS: This is a prospective, observational study of children admitted to a postintensive care unit after experiencing an out-of-hospital cardiorespiratory arrest associated with a submersion event. Cardiac troponin I measurements were examined upon admission to the postoperative intensive care unit after successful emergency department resuscitation. RESULTS: Nine patients were admitted, and 2 patients (22%) survived to hospital discharge. The area under the receiver operating characteristic curve is 0.786 (95% confidence interval, 0.481-1.0). This suggests that cardiac troponin I has a moderate degree of discriminatory power in selecting children who did not survive to hospital discharge.

Extracorporeal membrane oxygenation and CO2 removal in an adult after near drowning.

Near drowning is a common event among otherwise healthy young people. The development of ARDS in the setting may significantly increase mortality. The traditional means of ventilation may lead to barotrauma. Extracorporeal membrane oxygenation (ECMO) is an effective means to improve oxygenation and remove carbon dioxide, while allowing the lungs to recover from the acute insult. It may be especially successful in those victims with single organ injury. We report the use of ECMO in a young adult with ARDS and pneumonia after near drowning.

Near-drowning in the Dead Sea: a retrospective observational analysis of 69 patients.

BACKGROUND: The Dead Sea in Israel has a very high mineral content. Near-drowning in the Dead Sea is expected to result in severe electrolyte abnormalities and respiratory failure. Previous limited studies reported a high mortality rate. OBJECTIVE: To evaluate the clinical and biochemical manifestations and disease outcome of near-drowning in the Dead Sea. METHODS: Data were abstracted from the archives of Soroka University Medical Center. The cohort comprised 69 patients who nearly drowned in the Dead Sea. RESULTS: The median age of the patients was 68 years (range 21-84). There were two major manifestations of near-drowning in the Dead Sea: electrolyte imbalance and acute lung injury. Serum calcium, magnesium and phosphorus (but not sodium, potassium and chloride) were abnormal in most patients. Median serum electrolyte levels (and range) on admission were 10.9 mg/dl (9-24) for calcium, 4.3 mg/dl (1-30) for magnesium, and 4.1 mg/dl (2-9) for phosphorus. These levels quickly normalized with forced diuresis within 24 hours. Acute lung injury--namely, hypoxic bilateral pneumonitis--occurred in 29 patients. Mechanical ventilation was required in 11 patients. Sixty-five patients recovered fully, while the remaining 4 had minor sequelae. CONCLUSIONS: Near-drowning in the Dead Sea is a syndrome of severe electrolyte abnormalities and lung injury. Early treatment with forced diuresis and supportive care results in prompt recovery.

Predicting discharge in uncomplicated near-drowning.

To determine if routine, noninvasive parameters could be measured which predict early (4-6 hour) discharge from the emergency department (ED) in mildly symptomatic and asymptomatic victims of childhood near-drowning, a retrospective cohort study was undertaken. Patients with fresh water near-drowning were studied over a 3-year period who presented with Glascow Come Scale (GCS) > or =13 and required no advanced life support prior to or < or =4 hours after ED presentation. Three groups of patients were found: 39 patients (81%) had normal pulmonary examination (PEx) and normal room air oxygen saturation (RASaO2) by 4 to 6 hours and did not deteriorate during the hospital admission (<24 hours); 5 patients (10%) had normal PEx by 4 to 6 hours and RASaO2 by 8 to 12 hours and did not deteriorate during hospitalization (<24 hours). Four patients (8%) were hospitalized for more than 24 hours. No patient with normal RASaO2 at 6 hours deteriorated while in the hospital (CI 92.3-100%). Children who present to the ED with GCS > or =13 and have normal PEx/respiratory effort and RA-SaO2 more than 95% at 4 to 6 hours after ED presentation can be safely discharged home.

The etiology of pulmonary edema in fresh water near-drowning.

Drowning is a significant cause of death in children and young adults. It is thought to result from the inhalation of either fresh or sea water resulting in lung damage and ventilation-perfusion mismatching. The clinical course, chest roentgenographs, serum electrolytes, alveolar-arterial oxygen gradient, and complete blood count of 10 fresh water drowning victims with pulmonary edema were recorded. Six responded dramatically clinically and radiographically within 24 hours, and most did not have significant alterations of their serum electrolyte levels, especially serum chloride. On the basis of the rapid clearing of the pulmonary edema and the lack of evidence of significant fluid aspiration, neurogenic pulmonary edema is postulated to have played a role in the development of the pulmonary edema in these patients.

Prognostic implications of hyperglycemia and reduced cerebral blood flow in childhood near-drowning.

We retrospectively examined the clinical courses of 20 children with severe near-drowning and divided their outcomes into 3 groups: normal (4), persistent vegetative state (9), and dead (7). We reviewed serial blood glucose levels and cerebral blood flow measured by stable xenon computed tomography within the 1st 48 hours of admission to determine whether they were predictive of outcome. Total, frontal gray, frontal white, and temporal and parietal gray matter cerebral blood flows were significantly decreased in children who died compared with those who completely recovered. Only 1/2 the children surviving in a vegetative state had decreased flows compared with those who recovered. An elevated initial blood glucose was highly predictive of those patients who died (mean, 511 +/- 110 mg%) or those with vegetative survival (465 +/- 104 mg%) compared with those who recovered completely (238 +/- 170 mg%). The predictive value of initial blood glucose alone (68%) or CBF alone (50%) was similar to that of clinical rating scales or immersion/resuscitation times. The combination of blood glucose with CBF improved predictability to 79%. Our results suggest that CBF measurements are predictive of eventual death but cannot differentiate normal from vegetative survival. Combining multiple laboratory studies may be of value in predetermining the eventual outcome in near-drowning.

Drowning and near-drowning: current concepts and neutrophil function studies.

A near-drowning by a young man in an indoor pool is reported, and the current concepts of therapy are discussed. Laboratory studies of the patient's neutrophil function and chemotactic response were performed on the day of admission and on hospital days 2 and 4. Neutrophil function and chemotaxis were equal to control values, indicating no effect of near-drowning on these aspects of the host immune system. Hospital admission and supportive therapy including intubation, positive end-expiratory pressure, steroids, and antibiotics are recommended, if necessary, in management of the nearly drowned patient.