Scientific Letter
Extracorporeal membrane oxygenation to resuscitate a 14-year-old boy after 43min drowning
Oxigenación de la membrana extracorpórea para resucitar a un niño de 14 años después de 43 minutos de ahogamiento
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"apellidos" => "Zangrillo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Vita-Salute San Raffaele University, Milan, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "S.C. Sala Operativa Regionale, Emergenza Urgenza Metropolitana, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Oxigenación de la membrana extracorpórea para resucitar a un niño de 14 años después de 43 minutos de ahogamiento" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">More than 500,000 people die each year for unintentional drowning, accounting for near 0.7% of all deaths worldwide.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> If not promptly resolved, drowning rapidly causes asphyxia and subsequent cardiac arrest which drastically reduces survival possibilities and worsens neurological outcome.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Many factors influence the overall prognosis, especially age.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Duration of submersion and water temperature are other critical aspects to consider since survival is extremely rare and full neurological recovery near impossible if submersion is longer than 30<span class="elsevierStyleHsp" style=""></span>min in water warmer than 6<span class="elsevierStyleHsp" style=""></span>°C.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Hypothermia induced by cold water has a protective effect on the brain possibly allowing a better neurological prognosis even after a prolonged submersion.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Cooling rapidity could be more important than the body temperature itself in predicting survival after drowning.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This case report will discuss the management of a young boy, drowned in an Italian river during spring who had 43<span class="elsevierStyleHsp" style=""></span>min of documented drowning followed by 85<span class="elsevierStyleHsp" style=""></span>min of ineffective advanced life support for cardiac arrest who had recovery of cardiac function after extracorporeal membrane oxygenation (ECMO) and full neurological recovery.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case report</span><p id="par0020" class="elsevierStylePara elsevierViewall">An Italian 14-year-old healthy boy drowned and was trapped two meters under water in a river near Milan.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The firefighters extracted him from water 43<span class="elsevierStyleHsp" style=""></span>min after drowning and 29<span class="elsevierStyleHsp" style=""></span>min after the activation of the emergency system. Water temperature was 15<span class="elsevierStyleHsp" style=""></span>°C. The ECG showed the presence of asystole, Glasgow Coma Scale (GCS) score was three, skin was cyanotic, pupils were symmetrically midriatic, nasopharyngeal temperature was 29.5<span class="elsevierStyleHsp" style=""></span>°C. Cardiopulmonary resuscitation (CPR) was performed with manual chest compressions, orotracheal intubation performed, and epinephrine administered via an intraosseous access. Transient return of spontaneous circulation (ROSC) with junctional rhythm was obtained after 25<span class="elsevierStyleHsp" style=""></span>min of advanced life support (ALS). The patient was thus transferred on a helicopter and transported to our hospital. During the flight, refractory ventricular fibrillation occurred and ALS immediately re-started. The patient arrived at our institute at 6:46 pm, 100<span class="elsevierStyleHsp" style=""></span>min after the emergency system activation, under manual chest compression and directly transferred to the Cardiothoracic Intensive Care Unit (ICU). At 7:00 pm, extracorporeal life support (ECLS) was started at a flow of 3<span class="elsevierStyleHsp" style=""></span>L/min, after the percutaneous cannulation of the right femoral vein and artery under transesophageal guidance. For the persistence of ventricular fibrillation, a direct current shock was delivered and atrial fibrillation achieved. Intra-aortic balloon pump (IABP) was placed via the left femoral artery and a continuous infusion of inotropes was started to facilitate ventricular unloading.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Propofol, remifentanil, and mannitol infusions were started. He was progressively rewarmed to 36<span class="elsevierStyleHsp" style=""></span>°C in 14<span class="elsevierStyleHsp" style=""></span>h via the heat-exchange connected to the ECMO circuit.</p><p id="par0035" class="elsevierStylePara elsevierViewall">First arterial blood gas analysis, performed immediately after ECMO start, showed pH 7.26, pO<span class="elsevierStyleInf">2</span> 176<span class="elsevierStyleHsp" style=""></span>mmHg, pCO<span class="elsevierStyleInf">2</span> 43<span class="elsevierStyleHsp" style=""></span>mmHg, HCO<span class="elsevierStyleInf">3</span><span class="elsevierStyleSup">−</span> 9.6<span class="elsevierStyleHsp" style=""></span>mmol/L, base excess −20, lactate higher than the upper limit detectable by the analyzer, potassium 2.7<span class="elsevierStyleHsp" style=""></span>mEq/L, sodium 147<span class="elsevierStyleHsp" style=""></span>mEq/L, glucose 311<span class="elsevierStyleHsp" style=""></span>mg/dL.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Starting immediately after ICU admission, overt disseminated intravascular coagulation (hemoglobin: 11.5<span class="elsevierStyleHsp" style=""></span>g/dL, platelets count: 87,000/mm<span class="elsevierStyleSup">3</span>, INR: 1.70, aPTT: 42.5<span class="elsevierStyleHsp" style=""></span>s, D-dimer: >20<span class="elsevierStyleHsp" style=""></span>μg/mL, fibrinogen: 123<span class="elsevierStyleHsp" style=""></span>mg/dL) with massive bleeding (more than 2500<span class="elsevierStyleHsp" style=""></span>mL of bloody material aspirated from respiratory, gastrointestinal and urinary tract) was managed with multiple transfusions of red blood cells and fresh frozen.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Fourteen hours after ICU admission, propofol and remifentanil administration was stopped to allow the first neurological assessment which showed the patient comatose, areflexic, with muscular hypertonia at both lower extremities and at the right arm. Only the ciliospinal reflex was evocable after intense stimulation. Propofol infusion was thus restarted.</p><p id="par0050" class="elsevierStylePara elsevierViewall">The second day, acute renal failure requiring renal replacement therapy (highest value of serum creatinine registered<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>2.83<span class="elsevierStyleHsp" style=""></span>mg/dL) and acute liver failure (highest transaminase value<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>4925<span class="elsevierStyleHsp" style=""></span>U/L; highest total bilirubin value<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>6.29<span class="elsevierStyleHsp" style=""></span>mg/dL) were evident. On the third day of hospitalization, propofol infusion was stopped again to permit a second neurological assessment that showed the patient with open eyes and able to obey to simple orders. After four days, in light of myocardial recovery, ECMO and IABP were removed. The fifth day, brain magnetic resonance was performed and showed thalamic ischemia and signs of reduced cortical diffusion and intracranial hypertension. Furthermore, during the same day amputation of the right leg was performed since irreversible ischemia of the right inferior limb occurred. Pharmacological inotropic support was stopped ten days after hospital admission. On the same day, the patient was transferred to the neurosurgical ICU.</p><p id="par0055" class="elsevierStylePara elsevierViewall">Neurological status progressively improved, after 13 days of hospitalization the patient was awake and neurologically intact, reaching a complete recovery after 37 days of hospitalization, the day in which he was discharged at home. After few months, he went back to school and he speaks the four languages he spoke before the accident.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Patient's relatives signed a written consent for the scientific use of the patient's data. Ethics committee approval was waived according to Italian law.</p><p id="par0065" class="elsevierStylePara elsevierViewall">This is the longest mild hypothermic drowning with excellent neurological recovery reported in literature. Indeed, the patient had near one hour and a half CRP before ECMO start; water temperature was 15<span class="elsevierStyleHsp" style=""></span>°C and patient's body was found at 29.5<span class="elsevierStyleHsp" style=""></span>°C. Furthermore, the two years follow up confirmed the absence of neurological deficits. The only report with longer duration of submersion (83<span class="elsevierStyleHsp" style=""></span>min estimated) happened in icy water with the patient retrieved at 13.8<span class="elsevierStyleHsp" style=""></span>°C (profound hypothermia).<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> The authors described an excellent neurological outcome even though ten months after the episode described the patient had generalized seizures requiring antiepileptic therapy initiation. Furthermore, in this case the patient was first treated with cardiopulmonary by-pass and only subsequently with ECMO.</p><p id="par0070" class="elsevierStylePara elsevierViewall">This report questions the borders of futility of extracorporeal CPR and when “to stop” it. As a matter of fact, strict cooperation of emergence medical service and ECMO unit allowed this boy “back to life”.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Source of funding</span><p id="par0075" class="elsevierStylePara elsevierViewall">The manuscript was supported by departmental funds only.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Source of funding" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 4 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Drowning" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "D. Szpilman" 1 => "J.J. Bierens" 2 => "A.J. Handley" 3 => "J.P. Orlowski" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMra1013317" "Revista" => array:6 [ "tituloSerie" => "N Engl J Med" "fecha" => "2012" "volumen" => "366" "paginaInicial" => "2102" "paginaFinal" => "2110" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22646632" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Extracorporeal life support (ECLS) for refractory cardiac arrest after drowning: an 11-year experience" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Champigneulle" 1 => "F. Bellenfant-Zegdi" 2 => "A. Follin" 3 => "C. Lebard" 4 => "A. Guinvarch" 5 => "F. Thomas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.resuscitation.2014.11.023" "Revista" => array:6 [ "tituloSerie" => "Resuscitation" "fecha" => "2015" "volumen" => "88" "paginaInicial" => "126" "paginaFinal" => "131" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25484021" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Impact of age, submersion time and water temperature on outcome in near-drowning" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "P. Suominen" 1 => "C. Baillie" 2 => "R. Korpela" 3 => "S. Rautanen" 4 => "S. Ranta" 5 => "K.T. 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Park" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.resuscitation.2009.04.007" "Revista" => array:6 [ "tituloSerie" => "Resuscitation" "fecha" => "2009" "volumen" => "80" "paginaInicial" => "778" "paginaFinal" => "783" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19443097" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Excellent outcome with extracorporeal membrane oxygenation after accidental profound hypothermia (13.8<span class="elsevierStyleHsp" style=""></span>°C) and drowning" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.S. Romlin" 1 => "H. Winberg" 2 => "M. Janson" 3 => "B. Nilsson" 4 => "K. Björk" 5 => "A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 38 | 32 | 70 |
| 2024 September | 46 | 26 | 72 |
| 2024 August | 76 | 46 | 122 |
| 2024 July | 82 | 19 | 101 |
| 2024 June | 74 | 56 | 130 |
| 2024 May | 51 | 31 | 82 |
| 2024 April | 57 | 34 | 91 |
| 2024 March | 54 | 23 | 77 |
| 2024 February | 63 | 42 | 105 |
| 2024 January | 66 | 30 | 96 |
| 2023 December | 56 | 35 | 91 |
| 2023 November | 67 | 37 | 104 |
| 2023 October | 67 | 33 | 100 |
| 2023 September | 94 | 35 | 129 |
| 2023 August | 62 | 20 | 82 |
| 2023 July | 108 | 24 | 132 |
| 2023 June | 86 | 13 | 99 |
| 2023 May | 69 | 33 | 102 |
| 2023 April | 66 | 18 | 84 |
| 2023 March | 88 | 29 | 117 |
| 2023 February | 75 | 28 | 103 |
| 2023 January | 83 | 22 | 105 |
| 2022 December | 98 | 29 | 127 |
| 2022 November | 60 | 35 | 95 |
| 2022 October | 86 | 36 | 122 |
| 2022 September | 68 | 39 | 107 |
| 2022 August | 65 | 37 | 102 |
| 2022 July | 55 | 41 | 96 |
| 2022 June | 37 | 42 | 79 |
| 2022 May | 71 | 33 | 104 |
| 2022 April | 57 | 34 | 91 |
| 2022 March | 80 | 38 | 118 |
| 2022 February | 57 | 27 | 84 |
| 2022 January | 59 | 40 | 99 |
| 2021 December | 57 | 44 | 101 |
| 2021 November | 73 | 37 | 110 |
| 2021 October | 151 | 67 | 218 |
| 2021 September | 77 | 31 | 108 |
| 2021 August | 53 | 41 | 94 |
| 2021 July | 31 | 31 | 62 |
| 2021 June | 55 | 27 | 82 |
| 2021 May | 58 | 62 | 120 |
| 2021 April | 130 | 122 | 252 |
| 2021 March | 111 | 42 | 153 |
| 2021 February | 87 | 27 | 114 |
| 2021 January | 79 | 21 | 100 |
| 2020 December | 74 | 15 | 89 |
| 2020 November | 63 | 18 | 81 |
| 2020 October | 48 | 29 | 77 |
| 2020 September | 48 | 13 | 61 |
| 2020 August | 48 | 16 | 64 |
| 2020 July | 70 | 14 | 84 |
| 2020 June | 32 | 7 | 39 |
| 2020 May | 32 | 12 | 44 |
| 2020 April | 40 | 15 | 55 |
| 2020 March | 28 | 7 | 35 |
| 2020 February | 70 | 29 | 99 |
| 2020 January | 34 | 24 | 58 |
| 2019 December | 50 | 23 | 73 |
| 2019 November | 40 | 24 | 64 |
| 2019 October | 43 | 18 | 61 |
| 2019 September | 37 | 19 | 56 |
| 2019 August | 38 | 17 | 55 |
| 2019 July | 82 | 27 | 109 |
| 2019 June | 23 | 15 | 38 |
| 2019 May | 43 | 25 | 68 |
| 2019 April | 28 | 24 | 52 |
| 2019 March | 14 | 12 | 26 |
| 2019 February | 0 | 5 | 5 |
| 2019 January | 0 | 5 | 5 |
| 2018 December | 1 | 0 | 1 |
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