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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 67-70

Complex necrotizing soft-tissue infections managed with extra-corporeal membrane oxygenation: 10-year follow-up


1 Department of Surgery, Summa Akron City Hospital, Akron, USA
2 Diamond Hill Capital Management, Columbus, USA
3 Department of Surgery, The Medical Center of Aurora, Aurora, CO; Department of Surgery, Northeast Ohio Medical Universities, Rootstown, OH, USA

Date of Submission08-Jul-2018
Date of Acceptance08-Jul-2018
Date of Web Publication23-Apr-2019

Correspondence Address:
Dr. Melissa E Pastoressa
Department of Surgery, Summa Health System, 55 Arch Street, Suite 2F, Akron, OH 44304-1423
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJAM.IJAM_26_18

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  Abstract 


The use of extracorporeal membrane oxygenation (ECMO) was initially used to support patients in acute cardiopulmonary failure, but its utility has expanded to include a broadspectrum of patients with complex medical conditions. As a growing number of cases continue to mount to prove its successes, ECMO has emerged as a versatile treatment modality in a wide range of clinical scenarios. While the literature documents many successes regarding short-term outcomes, long-term data are lacking. We previously reported two separate cases of profound septic shock where ECMO was implemented as rescue therapy and both patients were able to be successfully discharged. We now provide an update to one of those cases to demonstrate long-term meaningful outcomes in a case where ECMO was utilized successfully.
The following core competencies are addressed in this article: Medical knowledge, Patient care and procedural skills, and Systems-based practice.

Keywords: Extracorporeal membrane oxygenation, necrotizing soft-tissue infection, septic shock


How to cite this article:
Pastoressa ME, Haxton B, Firstenberg MS. Complex necrotizing soft-tissue infections managed with extra-corporeal membrane oxygenation: 10-year follow-up. Int J Acad Med 2019;5:67-70

How to cite this URL:
Pastoressa ME, Haxton B, Firstenberg MS. Complex necrotizing soft-tissue infections managed with extra-corporeal membrane oxygenation: 10-year follow-up. Int J Acad Med [serial online] 2019 [cited 2019 Sep 22];5:67-70. Available from: http://www.ijam-web.org/text.asp?2019/5/1/67/256798




  Introduction Top


Extracorporeal membrane oxygenation (ECMO) provides circulatory and respiratory support for patients in severe acute cardiopulmonary failure refractory to traditional treatment. Initial applications to treat neonates with severe respiratory failure have been shown to be successful with good short- and long-term outcomes. With growing experiences and successes, the use of ECMO has broadened to include adult patients with significant cardiopulmonary compromise from acute respiratory distress syndrome (ARDS), as a bridge to cardiothoracic transplantation, and acute cardiogenic shock of varying causes.[1] Furthermore, with growing successes, clinically, unusual and complex cases continue to be reported in the medical literature illustrating potentially expanding applications and indications.[2] We have previously reported our short-term experience with septic shock due to necrotizing soft-tissue infections (NSTIs) that were successfully treated with ECMO in conjunction with aggressive surgical debridement and antibiotics.[3] NSTIs involve infections of any layer of the soft-tissue compartment and are associated with widespread necrosis and systemic toxicity.[4] If not recognized and treated early, NSTIs are associated with significant mortality with the cause of death typically from overwhelming sepsis, shock, and multisystem organ failure.[3] In our two cases, both patients were suffering from profound septic shock with cardiopulmonary compromise. After implementation of ECMO and eventual successful decannulation, both patients were able to be discharged to rehabilitation facilities. At initial follow-up, both were home and doing well. While one was lost to follow-up over the years, we are now presenting our 10 years update on the other case to illustrate long-term meaningful recovery.


  Case Report Top


At the time of initial presentation, the patient was an 18-year-old, previously-healthy athletic male who presented to an outside hospital with flu such as symptoms, fevers, and pain in his right calf. He was active on his high school's rowing (crew) team and was pursuing athletic scholarship opportunities. He underwent an extensive workup and was diagnosed with an NSTI. He became progressively hemodynamically unstable and was taken emergently to the operating room for aggressive surgical debridement. Intraoperatively, he continued to deteriorate and eventually sustained a cardiopulmonary arrest. As previously reported in detail, with cardiopulmonary resuscitation in progress, he was then placed on percutaneous salvage veno-arterial ECMO with cannulation of the right femoral vein and left femoral artery, followed by a right guillotine above the knee amputation. He stabilized and was then transferred to our facility for further management. Antibiotic therapy consisted of clindamycin and a continuous infusion of penicillin. His open amputation site required further debridement of necrotic tissue and a new site of necrosis was evident on his right upper extremity that also required debridement. While on ECMO he also underwent exploratory laparotomy for a presumed retroperitoneal extension of his soft-tissue infection as suggested by computed tomography which demonstrated retroperitoneal air from gas-forming agents—however, the intraoperative exploration, tissue gram stains, and cultures were all negative. His hospital course was further complicated by a clinically ischemic left leg that ultimately required above the knee amputation. Continuous renal replacement therapy was also required. His blood and tissue cultures grew beta hemolytic Group A streptococci, and he was maintained on penicillin G and clindamycin for a total of 21 days. After 5 days, following aggressive surgical debridement of all infected tissues, he was able to be weaned off ECMO. He subsequently required additional surgical debridement of his right lower extremity, gluteal tissue and ultimately required high above the knee amputation of his left leg. During his hospitalization, he also required emergent surgical management of dehiscence of his abdominal midline incision and right femoral artery reconstruction for an acute disruption of an infected pseudoaneurysm (note: this was not the site of his ECMO arterial cannulation). A tracheostomy and feeding tube were placed, and on hospital day 55, he was stable enough to be discharged to a rehabilitation facility. He required over 35 separate operative procedures. A follow-up echocardiogram was performed before his discharge which demonstrated normal biventricular function. After six weeks of rehabilitation, he was able to be discharged home with his family – his tracheostomy and feeding tube had been removed.[3] Two months later, he started his undergraduate education at The Ohio State University (Main Campus, Columbus, Ohio, USA) and graduated 4 years later with a bachelor's degree in finance. He subsequently enrolled in The Ohio State University Moritz College of Law and graduated with a Juris Doctor degree in 2016. While pursuing his academic interests, he remained an active member of the athletic community. Despite his bilateral amputations, extensive surgical debridements, severe deconditioning, and prolonged recovery, he resumed competitive rowing and his key accomplishments are listed in [Table 1]. Currently, approximately 10 years after his initial illness and not having had any other hospitalizations since he continues to work full-time as an investment analyst. He also serves as a motivational speaker and advocates for clinical patient-safety initiatives.
Table 1: Individual Accomplishments of our Patient After Successful Treatment with ECMO

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  Discussion Top


ECMO is a growing tool for ARDS and cardiogenic shock, and its role in severe sepsis is also become increasingly evident. Currently, the use of ECMO is limited to major centers due to perceived poor short- and long-term outcomes, the need for comprehensive multidisciplinary teams, and there are still poorly defined guidelines and protocols regarding intervention. However, ongoing advances in all aspects of ECMO management have resulted in better tools for patient selection and a substantial increase in clinical cases and programs that offer ECMO. Nevertheless, extremely complex and high-risk cases, such as the one we describe, continue to challenge the quest for better outcomes.[3]

The use of ECMO as a therapeutic tool has been well documented in cases of severe ARDS and its use has been increasing substantially since 2009. Evidence suggests that patients with severe ARDS who cannot maintain adequate oxygenation can benefit from ECMO have superior short-term (i.e., <180 days) outcomes when compared to conventional ventilator therapies.[5] The utility of venoarterial ECMO in patients with cardiogenic shock is well established and can be used as a bridge to recovery in those who have a severe biventricular cardiac failure, as was the case with our patient. It is a very versatile treatment modality that has become increasingly useful worldwide, and its indications for use continue to broaden to include severely septic patients, among others; however, long-term outcome data are lacking. A study by Bréchot et al. aimed to assess the outcomes and long-term quality of life in adult patients with refractory cardiac and hemodynamic failure during severe septic shock that were supported by venoarterial ECMO. Although a small, retrospective observational study, their results showed that ECMO rescued more than 70% of patients who were in severe bacterial septic shock and that their survivors reported good long-term quality of life.[6] The CESAR trial was a randomized, multicenter trial that allocated adults with acute respiratory failure to receive consideration for ECMO or conventional management. They determined that 63% of the patients who were considered for ECMO survived to 6 months without disability compared to the 47% of patients that had received conventional management. The study also found that those patients who were referred to ECMO received a gain of 0.03 quality-adjusted life years at their 6-month follow-up. These results demonstrated that ECMO could significantly improve survival without severe disability.[7]

Nevertheless, despite clinical perceptions, long-term outcome studies beyond the immediate recovery phase (i.e., 6 months) is lacking, especially studies that demonstrate some of the longer-term physiologic, neurologic, and functional outcomes. While commonly used clinical testing has not been performed in our patient, and hence, a limitation of this report, it is difficult to argue that his independent quality of life, intellectual, and athletic accomplishments (despite his obvious disability from his amputation) reflect any degree of objective impairment.

The use of ECMO in patients with severe cardiopulmonary failure is well documented in the literature. Its application to a variety of clinical scenarios has broadened significantly as a means to rescue patients with refractory acute cardiopulmonary failure and septic shock. As the indications for its use continue to grow, and more health-care providers and institutions begin to take advantage of such a valuable treatment modality, more research is needed to determine the long-term outcomes of those patients treated with ECMO. Hopefully, our dramatic case, with long-term follow-up, illustrates the huge potential value in this rapidly growing, but complex, therapeutic tool.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Ethical conduct of research

Nil.



 
  References Top

1.
Chang CH, Chen HC, Caffrey JL, Hsu J, Lin JW, Lai MS, et al. Survival analysis after extracorporeal membrane oxygenation in critically ill adults: A nationwide cohort study. Circulation 2016;133:2423-33.  Back to cited text no. 1
    
2.
Maclaren G, Butt W. Extracorporeal membrane oxygenation and sepsis. Crit Care Resusc 2007;9:76-80.  Back to cited text no. 2
    
3.
Firstenberg MS, Abel E, Blais D, Louis LB, Steinberg S, Sai-Sudhakar C, et al. The use of extracorporeal membrane oxygenation in severe necrotizing soft tissue infections complicated by septic shock. Am Surg 2010;76:1287-9.  Back to cited text no. 3
    
4.
Mishra SP, Singh S, Gupta SK. Necrotizing soft tissue infections: Surgeon's prospective. Int J Inflam 2013;2013:609628.  Back to cited text no. 4
    
5.
Aokage T, Palmér K, Ichiba S, Takeda S. Extracorporeal membrane oxygenation for acute respiratory distress syndrome. J Intensive Care 2015;3:17.  Back to cited text no. 5
    
6.
Bréchot N, Luyt CE, Schmidt M, Leprince P, Trouillet JL, Léger P, et al. Venoarterial extracorporeal membrane oxygenation support for refractory cardiovascular dysfunction during severe bacterial septic shock. Crit Care Med 2013;41:1616-26.  Back to cited text no. 6
    
7.
Peek GJ, Clemens F, Elbourne D, Firmin R, Hardy P, Hibbert C, et al. CESAR: Conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure. BMC Health Serv Res 2006;6:163.  Back to cited text no. 7
    



 
 
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