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Tuesday Case Conference

History. 23 yr old man with cystic fibrosis, requiring multiple hospitalizations. Admitted for bilateral lung transplant.Symptoms are at baseline. Has SOB at rest and 2 block DOE. Has a cough which is productive of yellow sputum. Requires 3 liters home O2 with exertion. ROS o/w negative.. PMHx:

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Tuesday Case Conference

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    1. Tuesday Case Conference

    2. History 23 yr old man with cystic fibrosis, requiring multiple hospitalizations. Admitted for bilateral lung transplant. Symptoms are at baseline. Has SOB at rest and 2 block DOE. Has a cough which is productive of yellow sputum. Requires 3 liters home O2 with exertion. ROS o/w negative.

    3. PMHx: Cystic fibrosis FEV1=1.0 (24%) FVC=1.8 (36%) Pancreatic insufficiency Appendectomy PEG tube placement SHx: No tobacco/EtOH FHx: n/c

    4. Labs: 13.5 66% PMNs 10.5 230 43.2 135 97 14 4.1 33 0.5 LFTs normal Coags normal Exam: T37.0 BP99/50 P92 RR22 89% on 2 liters nc 50 kg Gen: Thin NAD A+Ox3 HEENT: WNL No palpable LN CV: RRR no M/G/R Lungs: bilat wheeze & rhonchi Abd: SNTND, nl BS, PEG Ext: clubbing, no edema Neuro: WNL

    6. Hospital Course: Patient goes to the OR early the next morning for bilateral lung transplant. Requires cardiopulmonary bipass for appoximately 60 minutes. Requires multiple blood products including 10 PRBCs, 10 FFP, 10 cryo, 10 platelets. Patient is noted to have increased O2 requirement, by end of operation patient is on FiO2 of 0.7.

    7. Hospital Course (continued): Patient is transferred to the ICU. O2 requirement continues to increase, now requiring FiO2 of 1.0 AC 12 TV 750 PEEP 8 FiO2 1.0 PIP 32 Ve 8.9 ABG 7.28 / 65 / 45

    9. Hospital Course (continued): DDx and therapeutic interventions? Despite efforts to improve oxygenation, including adjusting PEEP, tidal volume, rate, mode of ventilation and diuresis patient continues to require an FiO2 of 1.0 with repeat ABG 7.26 / 55 / 49. CXR repeated

    11. Hospital Course (continued): On POD #1 patient is started on ECMO for presumed reperfusion edema.

    12. Extracorporeal Membrane Oxygenation

    30. Does ECMO work?

    31. Does ECMO work? Neonates: YES Pediatric: Probably Adults: Maybe

    32. Randomized Trial of Neonatal ECMO

    33. Randomized Trial of Neonatal ECMO

    34. ECMO for Pediatric Patients with Acute Respiratory Failure

    35. ECMO for Pediatric with Respiratory Failure Result of Three Different Analyses

    36. ECMO in Severe Adult Respiratory Failure Randomized, prospective, multi-center trial 90 patients with ARDS enrolled All had low pO2 despite high FiO2 42 Patients treated with ECMO 48 Patients treated with conventional management

    37. ECMO in Severe Acute Respiratory Failure Survival over Time

    38. ECMO in Severe Acute Respiratory Failure Survival by Category

    39. ECMO in Severe Adult Respiratory Failure Problems with the Study Mortality in both groups higher than anticipated Some centers had no prior experience with ECMO Over aggressive anticoagulation Ventilator management may have been suboptimal

    40. ECMO in Severe Adult Respiratory Failure Problems with the Study Mortality in both groups higher than anticipated Some centers had no prior experience with ECMO Over aggressive anticoagulation Ventilator management may have been suboptimal So several centers have continued to use ECMO for adults with severe acute respiratory disease.

    41. Extracoporeal Life Support The University of Michigan Experience

    42. ECMO at University of Michigan Survival Results by Group

    43. 100 Adults with Severe Respiratory Failure Baseline Characteristics

    44. 100 Adults with Severe Respiratory Failure Survival After Support with ECMO

    45. 100 Adults with Severe Respiratory Failure Survival After Support with ECMO

    46. 100 Adults with Severe Respiratory Failure Survival After Support with ECMO

    48. ECMO After Lung Transplant Estimated 15-30% of lung transplants will be complicated by early graft dysfunction (aka reperfusion edema, reimplantation response, primary graft failure). Early graft dysfunction characterized by diffuse pulmonary infiltrates, impaired oxygenation and diffuse alveolar damage on biopsy. In one series of 444 lung transplants, 12 were placed on ECMO for severe early graft dysfunction.

    49. ECMO After Lung Transplant Early Physiological Response

    50. ECMO After Lung Transplant Survival to Hospital Discharge

    51. ECMO After Lung Transplant Survival to Hospital Discharge

    52. Hospital Course (continued): On POD #1 patient is started on ECMO (venovenous) with a flow rate of 3 L/min. His oxygen requirement decreases and his CXR is improved. After 5 days he is weaned off ECMO and decanulated. FiO2 of 0.6 with a pO2 of 120. Patient has complicated hospital course but ultimately discharged 3 months after his transplant. He remains alive and well now almost one year post-transplant.

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