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Table of Contents
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 102-105

Use of single-cannula extracorporeal membrane oxygenation in the pulmonary artery to provide right heart support during respiratory failure in a drowning victim

1 Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine; Department of Jackson, Memorial Hospital, Jackson Health System, Miami, FL, USA
2 Department of Anesthesiology, Perioperative Medicine and Pain Management, University of Miami Miller School of Medicine; Department of Ryder Trauma Center, Jackson Health System, Jackson Health System, Miami, FL, USA

Date of Submission12-May-2020
Date of Acceptance11-Sep-2020
Date of Web Publication29-Jun-2021

Correspondence Address:
Dr. Jack Louro
Department of Anesthesiology, Perioperative Medicine, and Pain Management, University of Miami Miller School of Medicine, 1611 NW 12th Ave. (T-215) Miami, FL 33136
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJCIIS.IJCIIS_68_20

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Acute respiratory distress syndrome (ARDS) and respiratory failure can occur after drowning. Some of these patients do not respond to conventional mechanical ventilation and require extracorporeal membrane oxygenation (ECMO). Patients with severe respiratory failure can also develop acute right heart failure. We describe a case of a young drowning victim who developed ARDS and subsequent right heart failure. The patient was initiated on venovenous ECMO with right atrial to pulmonary artery cannulation of ECMO using the Protek Duo (TandemLife, Pittsburgh, PA, USA). The patient recovered from his ARDS and heart failure and was successfully liberated from ECMO. We will discuss the utility of ECMO in drowning victims and the use of this unique cannulation strategy to support the right ventricle in patients with concomitant respiratory failure.

Keywords: Case report, drowning, extracorporeal membrane oxygenation, respiratory failure

How to cite this article:
Volfson B, Balabanoff Acosta CS, Louro J. Use of single-cannula extracorporeal membrane oxygenation in the pulmonary artery to provide right heart support during respiratory failure in a drowning victim. Int J Crit Illn Inj Sci 2021;11:102-5

How to cite this URL:
Volfson B, Balabanoff Acosta CS, Louro J. Use of single-cannula extracorporeal membrane oxygenation in the pulmonary artery to provide right heart support during respiratory failure in a drowning victim. Int J Crit Illn Inj Sci [serial online] 2021 [cited 2022 Dec 9];11:102-5. Available from: https://www.ijciis.org/text.asp?2021/11/2/102/319782

   Introduction Top

Drowning is a common cause of accidental deaths, especially in young patients.[1] Drowning in saltwater increases the amount of plasma being translocated across the alveolar membrane, leading to an accumulation of fluid in the alveoli and surrounding tissue space and triggering an inflammatory reaction.[2] Aspirated water can also wash away the surfactant, causing alveolar collapse and atelectasis. Bronchospasm from acute emphysema can also arise.[3] The summation of all these can lead to acute respiratory distress syndrome (ARDS).

Patients that are alive upon arrival to the hospital develop symptoms within hours, although radiological studies can lag behind the pathological effect.[4] Biventricular heart failure as well as stunned myocardium can be seen, which could be a result of the metabolic derangements, hypoxia, or postcardiac arrest. The right ventricle (RV) is more sensitive to changes in oxygenation and more prone to failure as hypoxemia can increase pulmonary vascular resistance. The associated alveolar and interstitial infiltrates in ARDS lead to decreased lung compliance, increasing the afterload on the RV. If oxygenation fails after drowning, rescue measures such as prone positioning, use of pulmonary vasodilators, and extracorporeal membrane oxygenation (ECMO) can be initiated. We are presenting a case of a patient who was successfully treated with right atrial to pulmonary artery (PA) cannulation of ECMO to manage postdrowning ARDS and RV failure.

   Case Report Top

A 17-year-old male was brought to the trauma bay after he suffered a drowning event. The previously healthy patient was submerged under seawater for approximately 5 min, was pulseless after extrication, and received cardiopulmonary resuscitation (CPR) at the scene by emergency personnel. Emergency personnel were able to achieve a return of spontaneous circulation (ROSC) doing only chest compression and manual ventilation within minutes of initiating CPR. Multiple unsuccessful attempts at intubation were performed, and a supraglottic airway was placed at the scene. The patient was then transferred to our center with a Glasgow Coma Scale score of 3. On arrival, the patient's heart rate was 107 beats/min with blood pressure of 135/86 mmHg and oxygen saturation of 93%–94% while receiving manual ventilation. The patient was endotracheally intubated on arrival, and the initial trauma survey was negative for other injuries. The initial chest X-ray performed showed a reticular nodular pattern, and bilateral patchy alveolar infiltrates that could be indicative of pulmonary edema [Figure 1].
Figure 1: Initial chest X-ray obtained in resuscitation bay showing reticular nodular pattern and bilateral patchy alveolar infiltrates indicative of pulmonary edema

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A few hours after being admitted, the patient's partial pressure of arterial oxygen (PaO2) began to trend downward. Factors that could explain the suspected respiratory failure were saltwater drowning or postobstructive pulmonary edema after the failed intubation at the scene, which could both contribute to ARDS. Ventilatory support was increased to maintain a PaO2 above 60 mmHg, but inevitably, the patient required high ventilatory support with a positive end-expiratory pressure of 15 cmH2O, respiratory rate of 30 breaths/min, and FiO2 at 100%. Severe ARDS was diagnosed based on a PaO2/FiO2 of 60, the acuity of respiratory deterioration, and the imaging findings consistent with bilateral opacities. At this time, the patient was also initiated on inhaled epoprostenol 0.05 μg/kg/min and required norepinephrine 12 μg/min and vasopressin 2.4 U/h to maintain mean arterial pressures above 65 mmHg. No attempt at proning was made due to the neurological status and the vasopressor requirement.

A bedside transthoracic echocardiogram (TTE) showed reduced RV and left ventricular (LV) function with an ejection fraction of 30%. The RV systolic pressure was estimated at 29 mmHg and flattening of the intraventricular septum suggesting RV pressure overload noted. The ECMO service was consulted, and after multidisciplinary discussion, venovenous (VV) ECMO was initiated approximately 14 h after initial hospital presentation, with bifemoral 23 french cannulas with adequate oxygenation seen upon initiation. Immediately after initiation, the patient was taken to the catheterization laboratory, where a right heart catheterization was performed to rule out pulmonary embolism. During catheterization, the RV was seen to be moderately dilated with reduced function and PA pressures of 31/15 mmHg with pulmonary capillary wedge pressure of 15 mmHg.

The decision was made to convert the bifemoral cannulation strategy to a Protek Duo cannula. The Protek Duo was placed into the right internal jugular vein with the distal tip position in the main PA [Figure 2] under fluoroscopic guidance. Over the next few days, the patient's vasopressor requirements started to drop, and on ECMO day 3, a repeat TTE showed recovery of LV and RV function. The patient's ARDS continued to improve over the next few days and was able to be decannulated from ECMO on day 6.
Figure 2: Chest X-ray performed after placement of the Protek Duo extracorporeal membrane oxygenation cannula with distal tip terminating at the main pulmonary artery

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After decannulation, the patient progressed well, only requiring treatment for a hospital-acquired pneumonia. The patient developed an Enterobacter and Stenotrophomonas pneumonia on hospital day 9 which was successfully treated with cefepime and levofloxacin. He was transferred out of the intensive care unit on hospital day 11 and discharged home on hospital day 21.

   Discussion Top

ECMO serves as a great tool to help improve survival outcomes in patients who were victims of drowning. Several retrospective studies exist that investigated the use of both VV and venoarterial (VA) ECMO in drowning patients across various ages. A common variable associated with lower mortality was whether or not the patient had cardiac arrest, and if so, was ROSC achieved before the initiation of ECMO. A study reviewing Extracorporeal Life Support Organization Registry data of 247 patients who were placed on ECMO due to drowning between 1986 and 2015 found that, of the 127 patients that survived, 47% of patients experienced no cardiac arrest before ECMO, and 38% had cardiac arrest but with ROSC before ECMO initiation.[5] In a single-center study, nine patients were placed on ECMO after drowning during a 5-year period.[6] All of the patients received CPR, and of the nine patients, seven had ROSC before arrival at the hospital. In their study, all patients were successfully weaned from ECMO, and overall mortality was only 22%; however, it was not specified whether or not the two patients who died had ROSC before ECMO initiation.[6] In another study from Paris, a protocol of immediate ECMO initiation upon hospital arrival for drowning victims in cardiac arrest was initiated.[7] Of the 43 patients reviewed, VA ECMO was initiated in twenty of them. The other patients did not receive ECMO either due to cannulation procedure failure, serum potassium above the threshold, or failure of the ECMO machine. Of the twenty patients who received VA ECMO, four survived the first 24 h and only two survived to hospital discharge. This retrospective data seem to support that the use of ECMO in drowning patients may be associated with better outcomes if those patients are not in cardiac arrest at the time of ECMO initiation.

Luckily, our patient achieved ROSC before hospital arrival, which made him a good ECMO candidate for his refractory hypoxemia and ARDS. We diagnosed him with ARDS as the onset was acute, imaging consistent with bilateral infiltrates, and despite shocked myocardium, his LV function and volume status seemed to be more indicative of a respiratory cause. As his hypoxemia worsened, signs of RV dysfunction and pressure overload were noted on bedside ultrasonography prompting the use of pulmonary vasodilators. This was done with the aims of improving RV function as well as oxygenation through improved ventilation-perfusion matching. Epoprostanol was chosen due to it being readily available and as effective as inhaled nitric oxide at improving oxygenation in ARDS patients.[8],[9] Unfortunately, the hypoxemia persisted despite initiating the epoprostanol. Due to the young age of the patient, potential reversibility of the lung pathology, along with a Murray score above 3, the decision was made to proceed with ECMO cannulation.

The associated right heart failure in this patient presented a unique challenge, for which the Protek Duo offered a solution. The Protek Duo provides an added benefit over traditional VV ECMO cannulation as it is able to bypass a failing RV. The cannula is a double lumen catheter that is inserted into the right internal jugular vein, with drainage flow from the right atrium and return flow to the PA. It is usually used as a percutaneous right ventricular assist device, initially studied for right heart failure in fresh postoperative LV assist device (LVAD) recipients.[10] It has been successfully used for short-term RV support in patients who needed a bridge to heart or lung transplant, after LVAD insertion, and postheart transplant RV failure.[11] It offers both oxygenation and right ventricular support while avoiding recirculation as the blood is returned to the patient distal to both the tricuspid and pulmonary valves. The Protek Duo has been used outside of the cardiac failure population to treat pulmonary disorders such as status asthmaticus with associated RV dysfunction.[12]

In conclusion, we believe the use the Protek Duo could be useful for noncardiac patients who have refractory hypoxemia and develop RV failure. We did not find any other case in the literature of Protek Duo utilization in drowning victims. In the future, this device can be considered in those drowning victims that have developed ARDS with concomitant RV failure requiring mechanical support.

Research quality and ethics statement

This case report did not require approval by the Institutional Review Board / Ethics Committee. The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, specifically the CARE guideline, during the conduct of this research project.

Declaration of patient consent

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

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med 2012;366:2102-10.  Back to cited text no. 1
Jin F, Li C. Seawater-drowning-induced acute lung injury: From molecular mechanisms to potential treatments. Exp Ther Med 2017;13:2591-8.  Back to cited text no. 2
Christe A, Aghayev E, Jackowski C, Thali M, Vock P. Drowning–post-mortem imaging findings by computed tomography. Eur Radiol 2008:18:283-90.  Back to cited text no. 3
Noonan L, Howrey R, Ginsburg CM. Freshwater submersion injuries in children: a retrospective review of seventy-five hospitalized patients. Pediatrics 1996;98:368-71.  Back to cited text no. 4
Burke CR, Chan T, Brogan TV, Lequier L, Thiagarajan RR, Rycus PT, et al. Extracorporeal life support for victims of drowning. Resuscitation 2016;104:19-23.  Back to cited text no. 5
Kim Ki, Lee WY, Kim HS, Jeong JH, Ko HH. Extracorporeal membrane oxygenation in near-drowning patients with cardiac or pulmonary failure. Scand J Trauma Resusc Emerg Med 2014;22:77.  Back to cited text no. 6
Champigneulle B, Bellenfant-Zegdi F, Follin A, Lebard C, Guinvarch A, Thomas F, et al. Extracorporeal life support (ECLS) for refractory cardiac arrest after drowning: an 11-year experience. Resuscitation 2015;88:126-31.  Back to cited text no. 7
Ammar MA, Bauer SR, Bass SN, Sasidhar M, Mullin R, Lam SW. Noninferiority of inhaled epoprostenol to inhaled nitric oxide for the treatment of ARDS. Ann Pharmacother 2015;49:1105-12.  Back to cited text no. 8
Torbic H, Szumita PM, Anger KE, Nuccio P, LaGambina S, Weinhouse G. Inhaled epoprostenol vs inhaled nitric oxide for refractory hypoxemia in critically ill patients. J Crit Care 2013;28:844-8.  Back to cited text no. 9
Ravichandran AK, Baran DA, Stelling K, Cowger JA, Salerno CT. Outcomes with the tandem protek duo dual-lumen percutaneous right ventricular assist device. ASAIO J 2018;64:570-2.  Back to cited text no. 10
Nicolais CD, Suryapalam M, O'Murchu B, Bashir R, O'Neill BP, Alvarez R, et al. Use of protek duo tandem heart for percutaneous right ventricular support in various clinical settings: A case series. J Am Coll Cardiol 2018;71 Suppl 11:A1314.  Back to cited text no. 11
Hill GED, Traudt RJ, Durham LA, Pagel PS, Tawil JN. successful treatment of refractory status asthmaticus accompanied by right ventricular dysfunction using a protek duo tandem heart device. J Cardiothorac Vasc Anesth 2019;33:3085-9.  Back to cited text no. 12


  [Figure 1], [Figure 2]


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