Extra-Corporeal Membrane Oxygenation Case Study

Extra-Corporeal Membrane Oxygenation (ECMO) is a life-saving treatment for severe respiratory failure irresponsive to mechanical ventilation, associated or not with haemodynamic instability, and its application fields are widening to refractory sepsis and also to elective thoracic procedures. ECMO is replacing conventional cardio-pulmonary by-pass (CPB) even during lung transplantation due to its potential advantages: the absence of full-anticoagulation and the possibility of maintaining the extra-corporeal support even in the post-operative period.
An emergent role of ECMO is the intraoperative support during complex trachea-bronchial resection or in situation where the limited respiratory reserve precluded conventional ventilation technique.
He underwent to bronchoscopy for haemoptysis that instead revealed the presence of an endoluminal vegetation of the posterior wall of the left main bronchus, originating 1,5 cm from the carina and extended up for 2 cm to the first bronchial branch. Lymph node metastasis or systemic disease were excluded with whole-body CT-scan and PET-CT-scan (Fig 1). Pre-operative lung function evaluation did not allow a prolonged period of single lung ventilation and moreover we needed a clean operative field to reconstruct the left main bronchus. Then we chose the full-ECMO support in the VA-setting, preventively, for maintaining a haemodynamic stability because the patient had cardiac failure with impaired ejection fraction. After insertion of a thoracic epidural catheter and induction of general anaesthesia, VA-ECMO was established using open approach with the consequential cannulation of the right femoral vessels and ECMO was provided with centrifugal pump and polymethylpentene oxygenator. Veno-arterial ECMO was commenced, maintained at 4,51 l/m with optimal systemic gas exchange and after the mechanical ventilation was stopped. A muscle-sparing postero-lateral left thoracotomy was performed and after the entire mobilization of the pulmonary hilum and under bronchoscopic guidance, the resection of the left main bronchus was performed and then
Other attractive application could be the complex tracheo-bronchial resections both in children and adults [1, 4] and also the elective thoracic surgery in condition of limited respiratory reserve [2]. These situations, both present in our case, makes necessary the use of an extra-corporeal support to complete the resection and reconstruction and in our opinion ECMO has some advantages. First, it consents the apnea, maintaining adequate gas exchanges, with an excellent surgical exposure. The absence of cross-field ventilation allows a clean operating field without probes or tubes and it is especially true for the resection on the left side for the more complex bronchovascular anatomy [4]. The second advantage is the early extubation after surgery avoiding the post-operative mechanical ventilation that is associated with significant respiratory and anastomotic