VV-ECMO Resistant Hypoxia and RV Failure in a case of PVL-MSSA Community Acquired Pneumonia
Dr James Wilson, Dr Francisca Caetano, Dr Richard Fisher, Dr James Doyle, Dr ShahanaUddin, Prof Susanna Price; AICU, Royal Brompton Hospital, London
•Panton-Valentine leucocidinis acytotoxinproduced by certain Staphylococcus aureus
•Causessevere tissue necrosis, including the lung .
•Affects ~2%% of staphylococcal community acquired pneumonia 
•54-year-old type 2 diabetic admitted for community acquired pneumonia; sputum positive for methicillin-sensitive Staphylococcus aureus(MSSA) subsequently found to be PVL positive
•Admitted to ICU but despite appropriate medical treatment continued deterioration. Referred for retrieval on VV-ECMO
Initial management at ECMO Centre
•Admission CT (Figure 1) showed extensive consolidation of both lungs. Transthoracic echocardiogram (TTE) demonstrated normal biventricular function but signs of elevated pulmonary vascular resistance.
•Despite adequate VV-ECMO flows and circuit change patient remained consistently hypoxic (PaO2 8.7kPa)
•Additional strategies considered (including utilising a secondary oxygenator) but started to show improvement on standard VV-ECMO. Target PaO2> 6kPa (saturations >80%) accepted.
•On day 7: ECG demonstrated new RBBB -> TTE found low cardiac output state due to acute cor-pulmonale with severe right ventricular (RV) dilatation(Figure 2) -> Milrinone started.
•Underlyinglung pathology slowly improved, allowing weaning of VV-ECMO, milrinone and vasopressor support.
•Serial TTE showed partial resolution of the acute RV failure but persistent pulmonary hypertension -> sildenafil started.
•Tracheostomy inserted and on sedation hold neurological examination normal.
•Decannulated from VV-ECMO on day 43and was repatriated to his local hospital at day 47.
Summary & Discussion
•While use of VV-ECMO in treatment of PVL pneumonia has been described previously [2,3], in this case:
- The severity proved resistant to VV-ECMO support and so relative hypoxaemia was accepted
- The degree of acute RV dysfunction reflected the severity of the underlying pulmonary pathology, highlighting the importance of regular TTEin patients with severe respiratory conditions such as these.
•Despite the critical illness patient made a good clinical recovery with no gross signs of neurological deficit.
Figure 1: CT Thorax
Saggitalsection of CT Thorax in case of PVL-MSSA demonstrating extensive consolidation and lung destruction. Ao; aorta, LPA; left pulmonary artery, RPA; right pulmonary artery, C; cavity, ECMO; extracorporeal membrane oxygenation cannulae(arrowed)
Figure 2: Transthoracic echocardiogram
Transthoracic echocardiogram (parasternal short axis view) in a patient with acute cor-pulmonale relating to PVL-MSSA. LV; left ventricle, RV; right ventricle, IVS; inter-ventricular septum, coll; pericardial collection
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