MIOT’s Multidisciplinary Team saves a Poly-trauma patient against failing ventilator support using ECMO

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MIOT’s Multidisciplinary Team saves a Poly-trauma patient against failing ventilator support using ECMO

16th Sep 2017

Mrs. Vidya, from Pondicherry was brought to MIOT by her husband in a badly injured state on 30th March, 2017. Mrs. Vidya (29yrs old) mother to 1.5 yr old girl. She is a school teacher by profession. Her husband, Mr. Guru is working as the Nursing officer at JIPMER, Pondicherry.

On 29th march, 2017, around 1:00pm while Mrs. Vidya was on her way home on a two-wheeler for lunch, she met with a road traffic accident. A car travelling behind her at high speed, lost control, hit an auto and toppled over Mrs. Vidya, severely injuring her abdomen, pelvis, head and face.

She was immediately rushed to the nearby Villaiyanoor Primary health centre and primary first-aid was done. Within half an hour, she was shifted to JIPMER, where primary resuscitation was given. Her husband, being aware of the intensity of the problem, decided to shift Mrs. Vidya to MIOT.  By the next day Mrs. Vidya was at MIOT, Chennai.

Press Photo - MIOT Hospitals
Seen in the photograph from left to right: Dr. Nisheeth TP, Director – Critical Care, MIOT International, Mrs. Mallika Mohandas, Chairman – MIOT International, Patient Mrs. Vidya, Mrs. Vidya’s husband, Dr. Vijit K. Cherian, Director – Adult Cardiothoracic Surgery, MIOT International. (Press meet event on 16th Sep 2017 at MIOT)

Emergency care at MIOT:

As soon as she arrived at MIOT, she was attended by the Critical Care Team. She was found to have low blood pressure with difficulty in breathing and immediately needed ventilator for stabilization along with fluid and resuscitation with blood.  She was found to have major pelvic injury with damage to the nerve to leg, injury in the abdomen with tear of the blood vessel that supplies the intestine known as mesenteric tear.

 Note: ventilator is a machine designed to move breathable air into and out of the lungs, to provide breathing for a patient who is physically unable to breathe, or breathing insufficiently.

Over the next 12 hours her condition was deteriorating with falling Blood pressure in spite of resuscitation.  She had to be taken up for emergency abdomen Surgery. The surgeon identified that a tear in the blood vessel had stopped the blood supply to certain parts of the intestine. This had resulted in death of the tissues in that particular segment which had to be cut and removed. Post operatively in the ICU , She was placed on Continuous Cardiac Output Monitor, an advanced form of monitoring where precise amount of fluids and Blood pressure medicines can be given based on their needs, rather than blindly. Within the next 48 hours, her Blood pressure was stabilizing and, Mrs. Vidya showed a positive change in her condition.

In most of the cases, the patient is removed from ventilator by 3rd or 4th day once the condition stabilizes, which was not possible for Mrs. Vidya. The lungs were not ready to breathe by itself. Tracheostomy (A hole in the wind pipe) was done in view of her needing ventilator for a longer duration. By day 7, her ventilator requirement and oxygen requirement was going high. X-ray started showing patches developing in the lungs, all suggestive of a new problem, “ARDS (Acute Respiratory Distress Syndrome)”. CT Imaging confirmed the diagnosis of ARDS. This happens in case of major trauma, long bone injury, infections, pneumonia, etc.

On day 13, her ventilator requirement had reached its maximum safe levels. Oxygen levels in the body were reducing, blood pressure falling and there was failure of multiple organs. Something needed to be done. The doctors decided to put her on the next level of life support, the ECMO (Extra Corporeal Membrane Oxygenation).

ECMO (Extra Corporeal Membrane Oxygenation)

ECMO is a treatment used, when our lungs fail completely. It is a device that pumps blood through an artificial lung and back into the body. The purpose of ECMO is to provide oxygen, while allowing time for the lungs and heart to rest or heal. It’s done by inserting a tube into the neck Vein and in a large leg Vein. Blood drawn from one end goes through the machine, which adds oxygen and removes carbon-di-oxide. The re-oxygenated blood enters the body from other port.

Within 24hours on ECMO, things started changing; Mrs. Vidya oxygen levels had become normal. Blood pressure started stabilizing.

“The challenge is not putting a patient on ECMO, but it’s seeing her through” which can only be done by an expert team. The main problem associated with ECMO is bleeding from multiple sites; lungs, nose, mouth, surgical operative sites, etc. This is because of a drug called heparin that needs to be administered, to prevent the blood from clotting inside the tubes and keep machine working. Handling this requires precision.

During the course of our ECMO Mrs. Vidya too had bleeding from multiple sites which were handled, however the worst episode was the lung bleed. This Bleeding took us back by few days in her lung recovery. Subsequently when bleeding stopped, the blood clots from the lungs were removed.  She took quiet a longer time, than usual and we had to change her ECMO cassette once.

 Step-down from ECMO support to ventilator:

After 20 days on ECMO support, she was weaned out of ECMO and continued on ventilator support. With care, she continued to improve over time and was finally breathing without the ventilator by the 37th day. She required a dedicated physiotherapy and rehabilitative team to work on her.

Discharged after 56 day:

After 50 days in the ICU, she was shifted to ward. She was able to stand, walk and started taking normal food. After 56 days of hospitalization, she was discharged and was back with her family and little son. 2 weeks later she came for review. Her Chest X-ray was totally clear. She is recovering very fast and will be back to work in a couple of weeks.

Conclusion:

ECMO is reliable and important treatment in patients with failing lungs or failing heart. ECMO comes with unique challenges which require expertise, a huge team effort & infrastructure to run successfully. So being at the right place at the right time becomes very crucial.

 Team Effort:

“Talent wins games, but teamwork wins championships”, a very famous saying by Michael Jordan best suits our team of doctors at MIOT. It was not the effort of 1 doctor or a department, but an umbrella of doctors & multidisciplinary team effort starting from Critical & Intensive care, Cardio thoracic, Trauma & Emergency Care, Surgical Team, Pulmonology, Radiology, Blood bank and Microbiology. But not to forget our nurses and the Physiotherapist who worked hand in hand to make the impossible, possible today.