Wei Wang, MD
Pediatric Critical Care Medicine Fellow
University of Florida
Gainesville, Florida
Disclosure information not submitted.
Daniel Moas, MD
Pediatric Critical Care Medicine Fellow
University of Florida, United States
Disclosure information not submitted.
Shruthi Mahadevaiah, MD
Pediatric Critical Care Medicine
University of Florida, United States
Disclosure information not submitted.
Carolina Maciel, MD, MS
Neurology and Neurosurgery
University of Florida, United States
Disclosure information not submitted.
Philip Chang, MD
Pediatric Cardiology
University of Florida, United States
Disclosure information not submitted.
Jason Blatt, MD
Pediatric Neurosurgery
University of Florida, United States
Disclosure information not submitted.
Giles Peek, MD
Pediatric Cardiology and Cardiothoracic Surgery
University of Florida, United States
Disclosure information not submitted.
Desiree Machado, MD
Pediatric Critical Care Medicine
University of Florida, United States
Disclosure information not submitted.
Title: Extracorporeal Membrane Oxygenation for Ventricular Tachycardia After Hemicraniectomy
Introduction: Arrhythmias post neurological injury have been attributed to sympathetic surge in subarachnoid hemorrhage and traumatic brain injury. Extracorporeal membrane oxygenation (ECMO) in the postoperative neurosurgical patient can be controversial due to high bleeding risk with systemic anticoagulation. ECMO for neurogenically induced arrhythmias in the setting of neuro-infectious disease has not been well described.
Description: A 13-year-old male with sinusitis was admitted post craniotomy for left subdural empyema (SDE) evacuation. Left decompressive hemicraniectomy (DHC) was performed on postoperative day (POD) 3 for refractory intracranial hypertension. On POD1 after DHC, he developed repeated episodes of pulseless ventricular tachycardia (VT) refractory to electrolyte replacements with limited antiarrhythmic options due to QT prolongation, though lidocaine and amiodarone were used with no efficacy. His echocardiogram revealed a structurally normal heart with normal biventricular systolic function. There was no family history suggestive of inheritable arrhythmia conditions. The patient progressed to cardiac arrest requiring veno-arterial ECMO cannulation with a 25Fr venous, a 17Fr arterial and a 12Fr distal perfusion cannula on his left femoral site. Bivalirudin was used for anticoagulation to a goal aPTT of 60-80. He was maintained on neuroprotective measures and broad-spectrum antibiotics. Intravenous diltiazem was incorporated for VT suppression with resolution of arrhythmias the next day. He was decannulated after four days on ECMO without significant bleeding events. There were no significant differences between pre- and post-ECMO brain MRI scans. His post-ECMO course involved protracted ventilation with tracheostomy (TT), rhabdomyolysis, renal replacement therapy, deconditioning, and gastrostomy (GT)-associated nutritional support. He was transferred to a rehabilitation facility after 55 hospital days with recovery of physical and cognitive abilities, with TT and GT removed and cranial bone flap reinserted after two months.
Discussion: To our knowledge, this is the first report of successful ECMO support of a child with neuro-infection induced arrhythmias. ECMO following neurosurgical procedures is challenging but can be life saving with careful patient selection and anticoagulation management.