When a rectal tube saves a life in an ECMO patient

Abstract

Abstract Background: This article shows the concrete possibility to resolve important hypotension during assistance with ECMO by doing simple maneuvers. The abdominal fluid overload and hypertension is a problem probably a little underestimated and underestimated during the post-cardiac arrest reperfusion phase. Our clinical case shows how an important intra-abdominal hypertension developed and how it was treated just a few hours after the implantation of the post refractory cardiac arrest ECMO. Case presentation We describe a case of cardiac arrest in a 47-year-old male, 80kg, with history of moderate hypertension. Cardiac arrest happened in the patient’s house, in the presence of his wife. She immediately called for aid. 1 minute after the event cardiopulmonary resuscitation (CPR) was started by a policeman (BLS performer). 20 minutes later the Emergency Medical Service (EMS) arrived. The cardiac rhythm of presentation was a ventricular fibrillation (VF). Forty minutes after the event, the EMS arrived with a declared ongoing CPR protocol at the cath-lab at Angel’s Hospital in Mestre (Venice). 50 min after the event a veno-arterial ECMO support was started. 3 hours after the admission in the ICU, we observed a sudden hemodynamic instability, characterized by hypotension, MAP < 60 mmHg, increase in lactates, drastic decrease in ECMO blood flow (1,5-1,8 lpm) despite > 3000rpm. The abdomen was expanded and stiff. The intra-abdominal pressure (IAP) (measured by Unometer Abdopressure Convatec USA) was 18 cmH2O. A naso-gastric tube and a rectal tube (Rectal tube, Bicakcilar- Istanbul, Turkye) were placed. The drainage from the rectal tube was 2500ml of liquid stools in 2 hours. The IAP dropped to 9 cmH2O, and ECMO blood flow raised to 3.2 lpm. The drainage gave to the ECMO a correct blood flow returns from the cannulas and the return to a normal BF. Conclusion We recommend is a careful assessment of intra-abdominal pressure in the first 24 hours after the ECMO implant to prevent any drops in flow and systemic pressure.