Rewarming for Refractory Accidental Hypothermia Using Extracorporeal Membrane Oxygenation. HitoshiHirose, MD; Harrison T. Pitcher, MD; Qing Yang, MD; Nicholas Cavarocchi, MD. Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA.
Introduction
Case Report
Accidental hypothermia complicated by cardiac arrest carries a high mortality rate in urban areas. For moderate hypothermia cases conventional rewarming methods are usually adequate, however in severe cases extracorporeal membrane oxygenation (ECMO) is known to provide the most efficient rewarming with complete cardiopulmonary support. We report a case of severe hypothermia complicated by prolonged cardiac arrest successfully resuscitated using ECMO.
A 45 year old female was brought to our emergency department with a core body temperature < 25oC. Shortly after arrival she had witnessed cardiac arrest in the department. Resuscitative efforts were started immediately including conventional rewarming techniques, followed by ECMO support. ECMO was used successfully in this case to resuscitate this patient from prolonged arrest when conventional techniques likely would have failed. After a prolonged hospital course this patient was discharged with her baseline mental and physical capacities intact. Time line of the patient 17:48
45yo F with Down syndrome was brought to ED due to lethargy by care giver. Unknown activity at shared home, outside temp: -10 o C (14F). GCS: 8, BP: 94/47, HR: 30, Sat: 94% at room air. Body temp: unobtainable (< 25o C) due to limitation of the thermostat, Pt was “icy cold.” Warming blanket was placed.
18:40
Warm saline via central line was started. Remained junctional rhythm 30s, lethargic but responsible, atropine was given. Elective intubation due to declining mental status and airway protection
19:08 19:12
PEA code, CPR started. Warm saline lavage via NG tube. Core temp 28 o C (28F). Wide open drips including Epi, Dopamine, and Norepinephrine.
19:50
No gag reflex, no corneal reflex, Dilated pupil without light reflex. Unable to declare brain death due to hypothermia. CPR continued. ECMO consult for re-warming. Echo showed no cardiac activity. CPR continued.
20:00 20:40
21:00
VA ECMO started. CPR stopped (total CPR time 88 min) Telemetry: agonal rhythm, Body core temp: 26.8 o C (80F). Epi, Dopamine and Norepinephrine were discontinued as soon as ECMO started. Circuit temp setting: 37 o C (98.6F). Maintain MAP 65 mm Hg. ECMO flow 4 L/min. EKG showed junctional rhythm 60s.
22:40
Arterial wave form showed cardiac activity.
23:50
Core temp: 36.5 o C (99F). Echo showed normal cardiac function. Pt followed commands.
00:00
Weaning trial of ECMO (ECMO flow 0.5 L/min), BP 100/58, HR 100 SR, Sat 99%.
01:25
ECMO decannulation. Total ECMO time 3h 45min.
03:00
Transferred to ICU, Normal head CT.
POD#3 POD#23 POD#60
Extubated. Transferred to floor. (delay was due to aspiration, self removal of peg tube etc..) Discharged to shared home with baseline mental status.
Conclusion This case demonstrates the advantages of advanced internal rewarming techniques, such as ECMO, for quick and efficient rewarming of severely hypothermic patients. This case supports the use of ECMO in severely hypothermic patients as an option of care.
Contact Information Dr. Hitoshi Hirose:
[email protected]
