A 53-year-old reportedly healthy African American male was admitted with 25% TBSA partial and full thickness burns to his upper extremities, chest and back following a flash burn from a grease fire. After burn shock resuscitation, he underwent excision/debridement/grafting of his back, upper extremities and chest. His hands and forearms were autografted and upper arms were covered with xenograft.
His post-graft clinical course was complicated by new onset pulmonary infiltrates; fevers and vasopressor dependent septic shock 96 h post admission. His post recovery from vasopressor-dependent shock was complicated by episodes of delirium, early onset pneumonia (Gram-positive cocci) and late onset fevers (day 10-15) of ill-defined etiology (multiple microbiology cultures, fungal cultures were negative but the serum procalcitonin remained positive). His indolent clinical picture and microbiological profile were not aligned. This prompted concern that the source of infection had not cleared with the rounds of antibiotics or we were not adequate covering all pathogens. The infectious disease recommendation was that he completes a course of 14 days of broad-spectrum antibiotics. He was on broad-spectrum antibiotics up to his deterioration.
The mechanical ventilatory course was also rocky for this patient. He was ventilator dependant from day 3 to 14 on a complex trajectory of escalating and deescalating ventilator support. He was weaned to pressure support on day 12 with settings of 20 cm pressure over PEEP and PEEP of 10 cm H2O. He continued to be tachypneic with respiratory rates in the upper 20 and 30 ranges. It is worth noting that the patient was extubated for < 24 h prior to his acute deterioration on day 16.
Less than 24 h, post extubation (day 17), the patient deteriorated rapidly requiring urgent re-intubation and high degree of mechanical ventilator support. The patient was neuromuscularly blocked once we transitioned to pressure control ventilation on FiO2 1.0 early in the deterioration episode. Post intubation, he deteriorated rapidly with severely reduced pulmonary dynamic compliance < 8 ml/cm H2O (normal > 50 ml/cm H2O). Resultant peak pressure were >45 mm Hg.
We cycled through low tidal volume ventilation using VC, PC, PRVC, ARPV, and a trial of prone positioning for twelve hours. This ranged from conventional ventilation (SIMV, PC) to PRVC and APRV. High PEEP prescriptions of 12-16 cm H2O, and high FiO2 0.6 -1.0. APRV settings were P high 33, P low 0 and Time high 3.5 s, Time low 0.5 s. Mean airway pressures on APRV were 28 cm H2O. The ongoing refractory hypoxemia that was not responding to the ventilator changes precluded longer trials of prone positioning or alternate rescue modes of ventilation like VDR.
He was progressively acidemic from hypercarbia and we could not improve the PaO2 > 45 mm Hg on FiO2 1.0 during the prone position trail. He however maintained his hemodynamics and did not require vasopressors at this point in time. Given his isolated respiratory failure we decided to trial him on V-V ECMO. ECMO was successfully initiated and managed for 24 days. The patient was successfully weaned off ECMO and off mechanical ventilation post tracheostomy and was discharged to a nursing facility on hospital day 54.