Christopher Ull

Extremely obese patients treated with venovenous ECMO—an intensivist’s challenge

Obesity, defined according to bodymass index (BMI N 30 kg/m), is an increasing problem in theworld’s population. The proportion of extremely obese patients (BMI N 40 kg/m) in intensive care units varies between 2.8% and 6.8 %. We report on 2 surgical patients (BMI N 70 kg/m) with postoperative acute respiratory distress syndrome (ARDS) treated with extracorporeal membrane oxygenation (ECMO). The first patient developed severe pneumonia with ARDS on the fourth day postsurgical intervention, and venovenous ECMO was performed. At 6-month follow-up after successful weaning from extracorporeal lung support and mechanical ventilation, the patient was well but required noninvasive ventilation. The second patient developed ARDS because of severe sepsis after treatment of necrotizing fasciitis. Extracorporeal lung support took 19 days. A sacral decubitus caused secondary sepsis and resulted in lethal multiorgan failure. These 2 case reports showed that venovenous ECMO represents a challenge for the entire intensive care unitteam and is feasible for extremely obese patients but not always successful. Obesity (bodymass index [BMI] N 30 kg/m) is an increasing problem in the world’s population. In 2014, 26% of adults worldwide were obese [1]. The proportion of extremely obese patients (BMI N 40 kg/m) in intensive care units varies between 2.8% and 6.8% [2–7]. A BMI higher than 40 kg/m seems to be associated with an increased risk of developing acute respiratory distress syndrome (ARDS) along with greater morbidity, length of stay, and duration of mechanical ventilation in the intensive care unit (ICU) [8]. However, extreme obesity is not a risk factor for hospital mortality in patients with acute lung failure and is not a contraindication for venovenous extracorporeal membrane oxygenation (vv ECMO) implantation [9,10].We report on 2 cases of surgically treated patients (BMI N 70 kg/m) with postoperative ARDS and ECMO support. The first patient was a 45-year-old man (180 cm tall, 250 kg, BMI 77 kg/m) with a distal tibial and fibular shaft fracture on the left side and an ankle fracture on the right, which were operatively treated with open reduction and internalfixation. The patient developed severe pneumonia with ARDS on the fourth day of hospitalization. Because of an episode of hypercapnia, intubation and mechanical ventilation were necessary. Hypercapnic lung failure persisted after 24 hours of mechanical ventilation, and vv ECMO was indicated. The cannulation was performed via the right femoral and jugular veins with 23F and 19F cannulae. The CardioHelp HLS (Maquet, Raststatt, Germany) was used. Recovery was prolonged by 2 episodes of intestinal bleeding, which were treated successfully with endoscopic clipping. The patient ☆ Conflict of interest: None http://dx.doi.org/10.1016/j.ajem.2015.03.065 0735-6757/© 2015 Elsevier Inc. All rights reserved. Please cite this article as: Ull C, et al, Extremely obese patients treated with challenge, Am J Emerg Med (2015), http://dx.doi.org/10.1016/j.ajem.2015 was able to be weaned off the respirator. Six months after his discharge from the hospital, hewaswell but still required noninvasive ventilation. The second patient was a 34-year-old man (180 cm tall, 287 kg, BMI 88.6 kg/m) with necrotizing fasciitis on his lower left limb, which was surgically treated with extensive debridement. The patient required hemofiltration because of acute kidney failure. Furthermore, he developed ARDS as a result of severe sepsis. Severe hypoxemia and hypercapnia occurred, and vv ECMO was indicated. The cannulation was performed via the right femoral and jugular veinswith 23F and 21F cannulae. Extracorporeal membrane oxygenation was removed 19 days after implantation. Oxygenation significantly improved, and the patient wasweaned off the respirator. A sacral decubitus caused secondary sepsis and resulted in lethal multiorgan failure. The treatment of extremely obese patients with vv ECMOposes a special challenge for intensivists. Radiological diagnostics are limited because tables have weight restrictions of 200 kg. It makes the use of a doublelumen cannulation not available. Percutaneous cannulation venovenous femoral-jugular is associated with several pitfalls: anatomical landmarks are difficult tofind, the blood vessels cannot be visualized sonographically, and at least 4 people from the ICU team help for patient positioning. Both patients were successfully weaned from ECMO and later from invasive ventilation. These case reports showed that extracorporeal lung support is a feasible treatment option for extremely obese patients with ARDS, a finding that was previously described [9,10]. After weaning from ECMO, 1 patient required noninvasive ventilation support; the other died of multiorgan failure due to secondary sepsis. It also demonstrated as well how difficult it is to make accurate predictions about the outcome of ECMO in patients with extreme obesity. Several studies tried to determine the risk factors associated with ECMO treatment. In an analysis of preoperative risk factors in cardiac ECMO, Wagner et al [11] showed a positive association between preoperative SvO2 and survival. Later, they [12] found that poor renal function before ECMO resulted in a higher mortality rate for patients with pulmonary failure. This association was seen in the second patient, who required hemofiltration because of acute kidney failure. Another study revealed a lowermortality rate in younger and nondiabetic patients who experienced cardiogenic shock [13]. Formica et al [14] identified a high blood lactate level (N3mmol/L) at 48 hours as a significant predictor of 30-day hospital mortality for patients with cardiogenic shock. A higher survival rate of younger patients and those with a normal blood lactate level after 24 hours of ECMO treatment was confirmed by Pham et al [15] in a study with 123 adults with ARDS caused by influenza A (H1N1). Those risk factors could not be found in either of the patients. The study by Rastan et al [16] was the only trial that identified obesity as a risk factor for hospital mortality in adult patients treated with ECMO for refractory postcardiotomy cardiogenic shock. venovenous extracorporeal membrane oxygenation—an intensivist’s .03.065 2 C. Ull et al. / American Journal of Emergency Medicine xxx (2015) xxx–xxx This case report supports the findings of previous studies in this regard that treatmentwith vv ECMO in extremely obese patients presents special challenges for the entire ICU team. Extreme obesity should not be seen as a contraindication for ECMO treatment, but the procedure should be performed by experienced hands.

Effect of body mass index on the outcome of surgical patients receiving extracorporeal devices (VV ECMO, pECLA) for respiratory failure

Introduction To determine whether obese surgical patients are at a significant disadvantage in terms of outcomes after extracorporeal device (ECD) support, such as veno-venous extracorporeal membrane oxygenation (VV ECMO) or pumpless extracorporeal lung assist (pECLA), for respiratory failure, the relationship between body mass index (BMI) and hospital outcomes was analyzed. Methods This retrospective study included data on patients who were supported with an ECD between January 1, 2008 and December 31, 2014. The analysis included 89 patients (74 male). Results The median BMI was 30 kg/m2 (19–88.5). The median duration of the ECD support was 9.0 days, with a maximum of 37.1 days. The median LOS (length of stay) in the intensive care unit (ICU) was 21 days (range 0.06–197.6). The median hospital LOS was 34.9 days (range 0.1–213.8). VV ECMO was performed 72 times, and pECLA was performed 18 times. The number of patients successfully weaned off the ECD was 54 (60.6%). Survival at the discharge from the hospital was 48.3%. Conclusions 54 (60.6%) patients were successfully weaned off the ECD; 43 (48.3%) patients survived and were discharged from the hospital. The analysis of correlations between BMI and outcomes of surgical patients treated with ECD showed no association between BMI and mortality. Complications (especially oxygenator clotting) were not more frequent in obese and extremely obese patients. We hypothesized that patients with higher or morbid BMIs would have increased mortality after ECD support. A BMI of 30.66 kg/m2 corresponded to the desired sensitivity and specificity to predict mortality. This finding applied only to the study group. Treatment with ECD in obese patients presents unique challenges, including percutaneous cannulation and increased staff requirements. However, based on these data, obesity should not be an exclusion criterion for ECD therapy.

Die beidseitige proximale Humerusfraktur – eine seltene Kombination mit hoher Komplikationsrate nach operativer Versorgung

INTRODUCTION Bilateral acute proximal humerus fractures are rare. There are no data available about these bilateral injuries. The aim of the study was to analyse bilateral proximal humerus fractures retrospectively in terms of incidence, complications and revisions. METHODS All bilateral proximal humerus fractures were evaluated retrospectively using the institutions database, with the focus on cause of the injury, fracture severity and the clinical course compared to published information on monolateral proximal humerus fractures. Bilateral posterior dislocation fractures were excluded, because these fractures are a separate entity. RESULTS Between 2005 and 2016, n = 17 patients were primarily treated within our hospital for an acute proximal humerus fracture on both sides (n = 12 female, n = 5 male, average age: 68 years; overall 34 proximal humerus fractures). The general trauma mechanism was a fall on both arms (82% [18% polytrauma]). There were 65% displaced 3-/4-part proximal humerus fractures. Angle-stable plate osteosynthesis was performed predominantly (64%), followed by fracture prosthesis (18%; tension wiring: 3%; non-operatively: 15%). Overall, n = 10 patients (59%) or n = 18 (53%) proximal humerus fractures developed a complication, primarily with loss of reduction or implant loosening (44%). In n = 14 (78%) of the complications further operations were necessary. Alcohol abuse was increasingly found in 29% of the cases within the bilateral patient cohort compared to patients with monolateral fractures. CONCLUSION Bilateral proximal humerus fractures are mainly associated with comminuted displaced fractures and a higher complication rate in comparison to monolateral fractures after surgical treatment.

Differences between primary and secondary osteosynthesis for fractures of the lower limb with acute compartment syndrome

Aims and Objectives: To analyze the differences between primary and secondary osteosynthesis for fractures of the lower limb with acute compartment syndrome (ACS). Materials and Methods: From our trauma database, we indentified a total number of 107 patients with 126 fractures of AO/OTA type 41 to 44 and 120 ACS from January 01, 2001 to December 31, 2015 who were treated with primary or secondary osteosynthesis after compartment incision. Results: 71 patients with 77 fractures of AO/OTA classification type 41 to 44 suffering ACS received primary osteosynthesis after compartment incision (POCI) and were compared to 36 patients with 49 fractures of AO/OTA type 41 to 44 and ACS, who were treated by secondary osteosynthesis after compartment incision (SOCI). Patients with POCI showed a significantly shorter length of stay in the hospital with significantly less necessary surgeries for definitive treatment of the fractures and the soft tissue closure than SOCI patients (p < 0,001). The overall rate of infections in both groups were 13% without any difference between POCI and SOCI. Conclusion: The POCI of AO/OTA fractures type 41 to 44 with ACS is a safe and effective procedure for unilateral und single fractures of the lower limb without an increasing infection rate.

Successful non-surgical management of pleuroparenchymal fistula following cervical intraspinal empyema

Pulmonary infections are life-threatening complications in patients with spinal cord injuries. In particular, paraplegic patients are at risk if they are ventilator-dependent. This case history refers to a spinal cord injury with a complete sensorimotor tetraplegia below C2 caused by a septic scattering of an intraspinal empyema at C2-C5 and T3-T4. A right-sided purulent pneumonia led to a complex lung infection with the formation of a pleuroparenchymal fistula. The manuscript describes successful, considerate, non-surgical management with shortterm separate lung ventilation. Treatment aimed to achieve the best possible result without additional harm. A variety of surgical and conservative strategies for the treatment of pleuroparenchymal fistula (PPF) have been described with different degrees of success. We detail the non-surgical management of a persistent PPF with temporary separate lung ventilation (SLV) via a double-lumen tube (DLT) in combination with talc pleurodesis as an approach in patients who are unable to undergo surgical treatment.

Blunt Pancreatic Injury in Major Trauma: Decision-Making between Nonoperative and Operative Treatment

Blunt trauma injuries to the pancreas are rare but are associated with significant overall mortality and a high complication rate. Motor vehicle collisions are the leading cause of blunt pancreatic trauma, followed by falls, and sports injuries. We discuss the decision-making process used during the clinical courses of 3 patients with life-threatening blunt pancreatic injuries caused by traumatic falls. We also discuss the utility of the American Association for the Surgery of Trauma Organ Injury Scale (AAST-OIS), which provides a system for grading pancreatic trauma. Retrospectively, the cases reviewed were classified as AAST-OIS grade II, III, and IV in each one patient. Although the nonoperative approach was initially preferred, surgery was required in each case due to pseudocyst formation, pancreatic necrosis, and posttraumatic pancreatitis. In each case, complete healing was achieved through exploratory laparotomy with extensive lavage and placement of abdominal drains for several weeks postoperatively. These cases show that nonoperative management of pancreatic ductal trauma results in poor outcomes when initial therapy is less than optimal.

Veno-venous ECMO as a safe bridge to recovery in a patient with severe peripartum cardiomyopathy – learning from errors:

Peripartum cardiomyopathy (PPCM) is a rare disorder of unknown etiology and pathogenesis. The most important tool for diagnostic confirmation is transthoracic echocardiography. The recommended management of PPCM in pregnancy is summarized by the European Society of Cardiology Heart Failure Guidelines. Few data exist on the treatment of patients with fulminant PPCM and the need for extracorporeal membrane oxygenation (ECMO) in this context. We report on a young multiparous woman with cardiogenic shock caused by severe PPCM who was successfully, but atypically, supported with veno-venous ECMO as a bridge to recovery immediately after the birth of her third child.