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Resuscitaton in near drowning with

extracorporeal membrane oxygenation
Article in The Annals of Thoracic Surgery September 2001
DOI: 10.1016/S0003-4975(00)02307-9 Source: PubMed

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Resuscitaton in near drowning with extracorporeal membrane oxygenation

Markus Thalmann, Ernst Trampitsch, Norbert Haberfellner, Elisabeth Eisendle,
Raimund Kraschl and Georg Kobinia
Ann Thorac Surg 2001;72:607-608

The online version of this article, along with updated information and services, is located
on the World Wide Web at:
http://ats.ctsnetjournals.org/cgi/content/full/72/2/607

The Annals of Thoracic Surgery is the official journal of The Society of Thoracic Surgeons and the
Southern Thoracic Surgical Association. Copyright 2001 by The Society of Thoracic Surgeons.
Print ISSN: 0003-4975; eISSN: 1552-6259.

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Ann Thorac Surg

2001;72:607 8

CASE REPORT
THALMANN ET AL
RESUSCITATION IN NEAR DROWNING

defect using suture, autologous materials, or prosthetic

materials [2].
Often thoracoscopic ports are created bluntly, the
intercostal defect is large, and trocars are not used. The
interspace at the site of a thoracoscopy port is often not
sutured. In high-risk patients, minimizing port size, using small trocars, creating small intercostal defects and
closing the intercostal space, and repairing fascial defects
may lessen the future occurrence of this complication.

References
1. Van Den Bossche M, Leman G, Ballaux K, Himpens J. Videoassisted thoracoscopic repair of an intercostal pulmonary
hernia. Surg Endosc 1999;13:1667.
2. Sonett J, OShea M, Caushaj P, Kulkarni M, Sandstrom S.
Hernia of the lung: case report and literature review. Ir J Med
Sci 1994;163:4102.
3. Jacka M, Luison F. Delayed presentation of traumatic
parasternal lung hernia. Ann Thorac Surg 1998;65:11501.
4. Konecny J, Grosso M, Fernandez J, Murphy D, McGrath L.
Herniation of emphysematous bulla through a chest tube site.
Ann Thorac Surg 1999;68:584.
5. Ross R, Burnett C. Atraumatic lung hernia. Ann Thorac Surg
1999;67:14967.

Resuscitaton in Near Drowning

With Extracorporeal Membrane
Oxygenation
Markus Thalmann, MD, Ernst Trampitsch, MD, Norbert
Haberfellner, ECCP, Elisabeth Eisendle, MD, Raimund
Kraschl, MD, and Georg Kobinia, MD
Departments of Cardiothoracic Surgery and Anesthesiology
and Intensive Care, General Hospital Klagenfurt, Klagenfurt,
Austria

We report a case of near drowning of a 3-year-old girl,

who was admitted to our emergency room with a core
temperature of 18.4C. After rewarming on cardiopulmonary bypass and restitution of her circulation, respiratory
failure resistant to conventional respiratory therapy prohibited weaning from cardiopulmonary bypass. Therefore, we instituted extracorporeal membrane oxygenation
(ECMO). Fifteen hours later, she could be weaned from
ECMO but required assisted ventilation for another 12
days. Twenty months later there are no neurologic deficits.
(Ann Thorac Surg 2001;72:607 8)
2001 by The Society of Thoracic Surgeons

ear drowning associated with deep hypothermia is a

clinical setting associated with poor outcome [1].
Because important data of the accident and prognostic
predictors generally are not known to the resuscitation

Accepted for publication July 16, 2000

Address reprint requests to Dr Thalmann, Department of Cardiothoracic
Surgery, c/o General Hospital Klagenfurt, St. Veiterstrasse 47, A-9026
Klagenfurt, Austria; e-mail: herz-thorax.abteilung@lkh-klu.at.

607

team, prolonged resuscitation efforts including extracorporeal circulation are the current state of the art [2]. If
the victim could breath during the cooling-down period,
the prognosis would be superior to immediate (warm)
suffocation. Severe aspiration of water, however, may
impair the lung function to the point that it will not
recover during the warm-up period, necessitating the
termination of the resuscitation efforts. We, therefore,
report a patient in whom ventilatory function recovered
only after ECMO, a method previous reported only in
one patient for this application [3].
A 3-year-old unobserved girl fell into a fishpond with a
water temperature of 8C. She was found at the bottom of
the pond by her parents after approximately 30 minutes.
They initiated cardiopulmonary resuscitation according
to the directions of the emergency doctor given by
telephone. Eight minutes later, the emergency team
arrived and initiated professional resuscitation. At this
time, the girl was comatose and asystolic, had dilated
pupils, and a tympanic membrane temperature of 18.7C.
Under continuous cardiopulmonary resuscitation, the
girl was flown to our department by helicopter for
rewarming on cardiopulmonary bypass. Flight time was
25 minutes. Upon arrival, she was immediately taken to
the operating room. Under continuous mechanical resuscitation, we cannulated the right groin with a 12F arterial
cannula (BARD) and a 18F venous cannula (RMI). In the
meantime, a central venous catheter was inserted by way
of the right subclavian vein. An arterial pressure line was
inserted surgically in the left groin. It took 20 minutes
from the landing to initiate extracorporeal bypass; total
time of cardiorespiratory arrest must have been about 90
minutes. We used our conventional preconnected adult
oxygenator set, constantly preprepared for emergency
cases, consisting of a hollow-fiber membrane oxygenator
(Monolyth Sorin Biomedica, Saluggia, Italy), a roller
pump (Stockert, Munich, Germany), an arterial line filter
(Affinity Avecor; Medtronic, Minneapolis, MN) and a 1/2
inch polyvinylchloride (PVC) tubing.
Immediately after going on bypass, the arterial blood
gas analysis revealed a pH of 6.72, standard bicarbonate
2.4 mmol/L, base excess 28.1 and K 5.7. With a mean
blood flow ranging from 1.2 L/min to 1.6 L/min and a gas
flow ranging from 0.5 L to 1.0 L, oxygenation was satisfactory and the pH could be raised to 7.38 within 40
minutes. We performed rewarming with 3C per hour
and reached a temperature of 37C after 6 hours on
cardiopulmonary bypass. At 24C, the girl developed
spontaneous sinus rhythm. When we reached 32C as
measured by the esophageal probe, severe lung edema
occurred, intractable even to jet ventilation and bronchoscopic application of surfactant factor. Because we had no
evidence of severe neurologic injury and the girl demonstrated insufficient oxygen saturation without oxygenator
support, it was decided to temporarily replace the function of the lung with extracorporeal membrane oxygenation (ECMO). Because we dont have a pediatric cardiac
surgery and it is well known that the adequate positioning of the cervical canulas can be difficult [4], we decided

2001 by The Society of Thoracic Surgeons

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608

CASE REPORT
DAY AND WALESBY
SPONTANEOUS DUCTAL ANEURYSM

to use a thoracic cannulation, a technique well known to

us from adult cardiac surgery. Thus, we performed a
median sternotomy and cannulated the ascending aorta
with a 14F cannula (Dideco; Mirandola, Italy) and the
right atrium with a 22F cannula (RMI). The tubing for
ECMO was assembled while opening the chest. We used
the Medtronic Biopump (Medtronic, Minneapolis, MN)
with a Carmeda (heparin-) coated tubing system, the
Maxima PRF membrane oxygenator (Medtronic, Minneopolis, MN) and a centrifugal pump head (CB BP 80).
The ventilating gas mixture was warmed up to 39C to
prevent plasma leakage by condensed water.
When we initiated ECMO, the groin was decannulated.
The chest was left open, covered with a plastic foil. With
this setup, the girl was transferred to the intensive care
unit. Simultaneously, conventional ventilation with positive end-expiratory pressure and repeated endobronchial administration of surfactant was performed. After
15 hours, the girl could be weaned from ECMO. The
patient required sedation and ventilation with biphasic
positive airway pressure as well as positive inotropic
support with dopamine, dobutamine and arterenol for
the next 7 days. Our sedation and analgesic regimen
consisted of sufentanyl, midazolam, and propofol. On the
first postoperative day, we performed a computer tomography of the cerebrum, which showed mild cerebral
edema. Thereafter, an intracerebral pressure line was
inserted and therapy was aimed at maintaining a cerebral perfusion pressure of at least 40 mm Hg. After
respiratory and neurologic improvement, she could be
weaned from mechanical ventilation and was extubated
on day 12. Other than a moderate weakness of the right
leg and the left arm, there were no further neurologic
deficits. During the next 6 months, she had physiotherapeutic support and logopedic training. By the control
examination 20 months after the accident, she was doing
well and was developing without any neurologic
abnormalities.

Comment
Institution of cardiopulmonary bypass to warm up a
near-drowned child is a standard procedure in every
heart center. The most important factor influencing the
neurologic outcome is the speed of cooling and the
length of time during which the victim still had the
capability of breathing. If the victim can breathe during
cooling, the prognosis is better than immediate suffocation. Similarities exist to the pathophysiology and management of persons buried in an avalanche, demonstrating the prognostic importance of an air pocket, but only
limited role of hypothermia [5]. In addition to neurologic
problems, respiratory complications and pulmonary failure are very common in near-drowned patients and may
also prevent successful outcome. Extended resuscitation
with the ECMO can be a successful procedure in individuals with prolonged pulmonary insufficiency secondary to near-drowning. Therefore, pulmonary failure secondary to a warm-up procedure with extracorporeal
circulation resistant to ventilatory treatment may be an

Ann Thorac Surg

2001;72:608 9

appropriate indication for ECMO and may result in an

event-free outcome.

References
1. Spack L, Gedeit R, Splaingard M, Havens PL. Failure of
aggressive therapy to alter outcome in pediatric near drowning. Pediatr Emerg Care 1997;13:98 102.
2. Christensen DW, Jansen P, Perkin RM. Outcome and acute
care hospital costs after warm water near drowning in children. Pediatrics 1997;99:71521.
3. Foltan M, Philipp A, Kobuch R, Lemberger P, Rodig G,
Birnbaum DE. Extrakorporale Wiedererwarmung eines hypothermen Kleinkindes nach Beinahe-Ertrinken ein Fallbericht. Kardiotechnik 1999;2:29 31.
4. Irish MS, OToole SJ, Kapur P, Bambini DA, Azizkhan RG.
Cervical ECMO cannula placement in infants, and children
recommendations for assessment of adequate positioning,
and function. J Pediatr Surg 1998;33:92931.
5. Brugger H, Falk M, Adler-Kastner L. Avalanche emergencies.
New perspectives on the pathophysiology and management
of persons buried in an avalanche. Wien Klin Wochenschr
1997;109:14559.

A Spontaneous Ductal Aneurysm

Presenting With Left Recurrent
Laryngeal Nerve Palsy
Jonathan R. S. Day, MRCS, and Robin K. Walesby, FRCS
Department of Cardiothoracic Surgery, Middlesex Hospital,
London, England

A 76-year-old man was found to have a left recurrent

laryngeal nerve palsy, due to a spontaneous patent ductus arteriosus aneurysm. Ortners syndrome (left recurrent laryngeal nerve palsy caused by cardiovascular pathology) secondary to patent ductus arteriosus aneurysm
has not previously been described in the literature. We
present a case, illustrated with surface rendering computer tomogram reconstructions.
(Ann Thorac Surg 2001;72:608 9)
2001 by The Society of Thoracic Surgeons

rtners syndrome is the clinical entity of hoarseness

due to left recurrent laryngeal nerve palsy caused
by cardiovascular pathology. We present a case of patent
ductus arteriosus aneurysm presenting with Ortners
syndrome.
A 76-year-old man with severe rheumatoid arthritis and
peripheral vasculitis presented to hospital with gradual
onset hoarseness. Fiber optic laryngoscopy showed leftsided vocal cord palsy, and a chest radiograph revealed a
mediastinal mass adjacent to the aortic knuckle. A contrast computed tomography (CT) scan of the thorax
demonstrated a saccular aneurysm of a patent ductus
arteriosus partially occluded by thrombus (Figs 1 and 2).

Accepted for publication Aug 17, 2000.

Address reprint requests to Dr Day, Gruinart, Tullibardine Crescent,
Auchterarder, Perthshire PH 3 ILY UK; e-mail: jrsday@hotmail.com.

2001 by The Society of Thoracic Surgeons

Published by Elsevier Science Inc

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PII S0003-4975(00)02403-6

Resuscitaton in near drowning with extracorporeal membrane oxygenation

Markus Thalmann, Ernst Trampitsch, Norbert Haberfellner, Elisabeth Eisendle,
Raimund Kraschl and Georg Kobinia
Ann Thorac Surg 2001;72:607-608
Updated Information
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References

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