Fatal Sepsis in Extracorporeal Membrane Oxygenation: Case Report of the H1N1 Treated Elderly Patient

Abstract

Background: Extracorporeal membrane oxygenation (ECMO) for severe acute respiratory distress syndrome (ARDS) has aroused a growing interest over the past decades with promising results during the 2009 (H1N1) influenza epidemic. ECMO is still marred by frequent and significant complications such as bleeding and nosocomial infections. Here we describe our experience in H1N1-induced ARDS followed by ECMO support. The patient was successfully weaned from ECMO but later died because of refractory Acinetobacter baumannii chest infection. Introduction: A 58-year-old man, known case of type 2 diabetes mellitus and hypertension, was shifted from other hospital with H1N1 pneumonia and ARDS. The patient was hemodynamically unstable, on mechanical ventilator, and hemodialysis. He was started on broad-spectrum antibiotics, oseltamivir, and other supportive measures. His Murray score was 4, so he was taken on venovenous ECMO. Initial endotracheal tube cultures showed A. baumannii infection. His liver function tests (LFTs) were deranged with high direct bilirubin. Imaging did not show any obstructive bile duct pathology. Sepsis was considered to be the main cause of cholestasis. Antibiotics were modified to meropenem, polymyxin B, and sulbactam. Three times fiberoptic bronchoscopic alveolar lavage was done, which showed persistent A. baumannii infection. Gradually his chest X-ray improved. ECMO was successfully weaned off after 10 days. Later, percutaneous tracheostomy was done. Tracheal secretion cultures continued to show A. baumannii. Rifampicin was added. The patient was weaned to pressure support ventilation (PSV) trials. Later his chest infection worsened with signs of sepsis. He developed multiorgan failure with deranged liver and renal function test. He became comatosed, hemo-dynamically unstable, and needed high ventilatory support and hemodialysis. Finally, the patient died of sepsis and multiorgan failure after 33 days of treatment. Conclusion: Though ECMO is now becoming the modality of choice for H1N1 pneumonia and severe ARDS, but complete aseptic precautions must be kept throughout the treatment to achieve successful outcome.