A 39-year-old male with no significant past medical history was transferred, intubated and sedated to our burn center, following a 40% TBSA deep partial thickness and full thickness burns to face, head, bilateral upper and lower extremities, perineum, scrotum, and penis. The mechanism of burn was a gasoline fire, following a gasoline container spillage and explosion near a kerosene lamp in a garage.
On admission, the patient underwent an emergent right upper extremity escarotomy with successful return of pulses. Post initial fluid resuscitation, the patient underwent staged grafting of his burns. Following debridement, he underwent xenograft application and partial skin grafting from the trunk to the right arm 32 x 30 cm, right hand size 15 x 15 cm, left hand size 15 x 15 cm, left arm size 20 x 20 cm. He also underwent xenograft application to 30 x 60 cm and to the right leg.
On postoperative day 1, the patient deteriorated into acute respiratory failure. Thick tenacious secretions, prompted an urgent bronchoscopy and bronchoalveolar lavage (BAL). Broad-spectrum antibiotics were initiated to cover for methicillin-resistant Staphylococcus aureus and Gram-negative organism based on the grams stain. The bronchoscopy showed copious secretions in multiple lung fields. The BAL culture had >100,000 CFU streptococcus pneumonia that was resistant to clindamycin. The hypoxemia continued to worsen within hours on volume control (VC) ventilation, pressure regulated volume control (PRVC), pressure control (PC), APRV and on the volumetric diffusive ventilation. A brief summary of the ventilator changes and salient clinical findings are outlined in Table 1. The patient was sedated and neuromuscular blocked once the FiO2 requirements escalated >0.8. The acutely worsening and refractory hypoxemia prompted urgent changes to ventilator management. The FiO2 requirements escalated from 0.5 immediately post-operation to 1.0 over 4 h. The positive end-expiratory pressure (PEEP) was titrated using constant-flow, pressure-volume curve (PVC) method to prescribe optimal PEEP. The PEEP on conventional modes of ventilation was 15 cm H2O before we transitioned to APRV. The peak airway pressures remained >33 cm H2O (mean airway pressures 12-16 cm H2O). The dynamic compliance was <17 ml/cm H2O. 
APRV settings were P high 32, P low 0 and Time high 3.5 s, Time low 0.5 s. Mean airway pressures in APRV were 30 cm H2O. The patient continued to deteriorate on APRV with worsening hypercarbia, hypoxemic and acidemic that prompted the change to the volume diffusive respirator (VDR) or volumetric diffusive ventilation. The VDR settings I:E was 3:1, frequency was 585, VDR peak pressure control was 40 cm H2O.
Hemodynamically, the patient required four units packed cells along with intermittent vasoactive medications to maintain mean arterial pressure (MAP) > 65 mm Hg during the period of deterioration.
Given his single organ failure, a decision was made to initiate V-V ECMO. The ECMO cannulation was done under transesophageal echocardiographic guidance after a quick evaluation that ruled out significant valular dysfunction and showed a preserved left ventricular ejection fraction. V-V ECMO was initiated and managed for 4 days with no complications. Patient was successfully weaned from ECMO on day 7. The patient was ultimately discharged to a skilled care facility on day 27.