Patient 4, a 21-year-old male, had the most remarkable clinical course with acute kidney failure and need of renal replacement therapy on day 2 and initiation of V-V-ECMO therapy due to severe ARDS on day 6 after 75% TBSA deep dermal to full-thickness burn and inhalation injury. Prior, prone positioning and inhalative NO therapy had not been successful in improving respiratory function.
After successful ECMO weaning and removal on day 19, the patient developed severe Candida sepsis with respiratory insufficiency and a PO2/FiO2 of 59 mmHg and pH of 6.99 and required emergency recannulation for veno-venous ECMO therapy on day 40 after admission. Albeit, exhausting the settings of the ECMO with maximum blood and oxygen flow, the patient still showed systemic hypoxia, which we attributed to the hyperdynamic septic circulatory situation, where ECMO blood flow relative to the cardiac output is insufficient, a phenomenon described in the literature.
For this reason, we decided to insert an additional arterial outflow cannula in the brachiocephalic trunk to oxygenate the brain, resulting in a V-V-A-ECMO setup (Fig. 1b). Afterwards, we saw a rapid decline in lactate as marker of ischemia and later an improvement in systemic oxygenation.
The patient could be weaned from ECMO successfully by day 62 and later discharged to a rehabilitation facility after 172 days of inpatient treatment.