Trenton Wray, MD,
Assistant Professor; Emergency Medicine, Critical Care
University of New Mexico
Albuquerque, New Mexico
Disclosure information not submitted.
Jessica Mitchell, MD
Associate Professor of Emergency Medicine and Critical Care
University of New Mexico, United States
Disclosure information not submitted.
Richard Miskimins, MD
Assistant Professor of Surgery
University of New Mexico, United States
Disclosure information not submitted.
Title: Extracorporeal membrane oxygenation and colonic lavage for septic shock from clostridium difficile
Introduction: Source control is a key component in the management of intraabdominal sepsis. However, patients who develop refractory shock may not make it to operative intervention. The use of venoarterial extracorporeal membrane oxygenation (VA ECMO) is controversial for septic shock and there are no cases to report its use as a bridge to surgical intervention in septic shock. We present a case where VA ECMO was initiated for severe undifferentiated shock, and was then used as a bridge to surgical management of fulminant C. Difficile Infection (CDI).
Case: We present the case of a 49-year-old male with a history of schizophrenia, alcohol use who presented with undifferentiated shock. He was intubated for respiratory support and vasopressors were initiated. Imaging was not obtained due to patient instability. Despite maximal medical therapy he became progressively unstable. Echocardiogram was performed which showed a dilated right ventricle with septal flattening and an underfilled left ventricle, and the decision was made to place the patient on peripheral VA ECMO for refractory shock due to presumed pulmonary embolism (PE). Once VA ECMO was initiated vasopressors were able to be weaned and lactic acid down trended. Shortly after cannulation a CT was performed which did not show a PE, but did show colitis with ileus. Testing for C. difficile confirmed the diagnosis of fulminant CDI. There was significant concern from family given the patient’s psychosocial barriers and ability to care for a permanent ileostomy. With these concerns, we elected to perform diverting loop ileostomy and colonic lavage as described by Neal, et al. Vancomycin was continued via nasogastic tube and anterograde through the distal limb of the ileostomy. On post-operative day 2 the patient was able to be decannulated from ECMO. After 10 days of antibiotics, a fecal transplant performed via the ileostomy. One week later the ileostomy was closed and the patient was discharged.
Discussion: The use of VA ECMO for septic shock remains controversial. This case demonstrates that extracorporeal support may give time for a patient in extremis to obtain definitive diagnosis and surgical management. To our knowledge this is the first use of VA ECMO for severe CDI and is the first to utilize a fecal transplant prior to ileostomy closure.