Successful extracorporeal membrane oxygenation therapy as a bridge to sequential bilateral lung transplantation for a patient after severe paraquat poisoning

Case report: Lung transplantation for treatment of paraquat intoxication: timing of transplantation

Objective: To analyze the optimal timing of lung transplantation and summarize postoperative complications and their management after paraquat poisoning. Methods: Here, we present the clinical course of a 17-year-old boy with paraquat poisoning, in whom bilateral lung transplantation (LT) was performed. We reviewed the eight previously published articles relevant to LT after paraquat poisoning to summarize the therapeutic strategy. Results: A 17-year-old boy was admitted to the hospital after ingestion of 30-50 mL 25% paraquat. Mechanical ventilation was initiated on the 25th day after intoxication. Venovenous extracorporeal membrane oxygenation was initiated on the 26th day. Sequential bilateral LT was performed on the 27th day. Several complex postoperative complications occurred and the patient was discharged on the 50th day postoperatively. Eight case reports were included in the literature review, including 11 patients with paraquat poisoning undergoing LT. Three patients died due to paraquat poisoning leading to fibrosis in the transplanted lungs or postoperative complications. Eight patients survived during follow-up. Conclusion: LT after herbicide poisoning should be planned when hepatorenal function starts to recover, and waiting for complete recovery is unnecessary. Prevention of infection before surgery is important to reduce the incidence of postoperative infection. Complex perioperative complications caused by the herbicide itself or the late timing of transplantation can be successfully managed by a multidisciplinary team.

Lung transplantation in a woman with paraquat poisoning that led to pulmonary fibrosis-Widely reported by the media: A case report

RATIONALE

Paraquat is an extremely toxic herbicide with a high mortality rate on poisoning. It can damage vital organs, such as the lungs, liver, heart, and kidneys. In this study, we report a case of pulmonary fibrosis after paraquat poisoning in a patient who underwent a lung transplant procedure after preoperative administration of corticosteroids and immunosuppressive agents and continuous noninvasive ventilation support therapy.

PATIENT CONCERNS

An 18-year-old student was hospitalized owing to diarrhea, chest pain, and gradually evolving dyspnea.

DIAGNOSES

Owing to the inability to estimate the intake concentration and dose, paraquat was only detected in the urine on the 13th day, resulting in rapid progression of the disease and severe pulmonary fibrosis.

INTERVENTIONS

Extensive media coverage has attracted the attention of all sectors of society. The patient received financial assistance; thus, she could receive a double-lung transplant with extracorporeal membrane oxygenation (ECMO) support on the 34th day after the poisoning.

OUTCOMES

Postoperatively, the girl was actively rehabilitated, adhered to anti-rejection medication, followed up regularly, and had a good prognosis.

LESSONS

Lung transplantation is currently the most effective treatment for pulmonary fibrosis, and mass media campaigns can provide economic support, influence potential organ donation, and provide such patients more chances to survive.

Case Report: Delayed Lung Transplantation With Intraoperative ECMO Support for Herbicide Intoxication-Related Irreversible Pulmonary Fibrosis: Strategy and Outcome

Background: Lung transplantation is recognized as the only therapeutic option for patients who develop irreversible pulmonary fibrosis after herbicide intoxication. Methods: We have collected and presented clinical course and outcome of four patients who received lung transplantation due to paraquat and diquat intoxication from 2018 to 2021. Another patient who received initial lung transplantation due to paraquat intoxication and re-transplantation due to chronic lung allograft dysfunction in 2019, was further reported. Patients were admitted in lung transplantation centers, including the 1^st affiliated hospital of Zhengzhou University and Wuxi Lung transplantation center. Previous reported cases from Europe, Canada and China were also summarized as benchmark. Results: During the period from the year of 2018 to 2021, there have been four patients in China, who received lung transplantation due to herbicide intoxication. Median age of the four patients was 37 (IQR 34.5, 39.75) years old. Median time from intoxication to lung transplantation was 27.5 (IQR 27, 30.5) days. Bilateral lung transplantation was performed in three patients, while one single lung transplantation was performed in an urgent listed patient. Extracorporeal Membrane Oxygenation (ECMO) and hemopurification support were used in all patients (100%). Details of the cases with follow-ups were further presented and analyzed. Conclusions: Late timing of bilateral lung transplantation can be performed successfully for pulmonary fibrosis after paraquat or diquat intoxication. The survival of patients with complex perioperative conditions can be achieved with a multidisciplinary team to manage the irreversible effects of intoxication.

Unexpected survival after deliberate phosphine gas poisoning: An Australian experience of extracorporeal membrane oxygenation rescue in this setting

Phosphine poisoning is responsible for hundreds of thousands of deaths per year in countries where access to this pesticide is unrestricted. Metal phosphides release phosphine gas on contact with moisture, and ingestion of these tablets most often results in death despite intensive support. A 36-year-old woman presented to a regional hospital after ingesting multiple aluminium phosphide pesticide tablets and rapidly developed severe cardiogenic shock. In this case, serendipitous access to an untested Extracorporeal Membrane Oxygenation (ECMO) service of a regional hospital effected a successful rescue and prevented the predicted death. We discuss the toxicology, management and the evidence for and against using ECMO in this acute poisoning.

Extracorporeal membrane oxygenation use in poisoning: a narrative review with clinical recommendations

CONTEXT

Poisoning may lead to respiratory failure, shock, cardiac arrest, or death. Extracorporeal membrane oxygenation (ECMO) may be used to provide circulatory support, termed venoarterial (VA) ECMO; or respiratory support termed venovenous (VV) ECMO. The clinical utility of ECMO in poisoned patients remains unclear and guidelines on its use in this setting are lacking.

OBJECTIVES

To perform a literature search and narrative review on the use of ECMO in poisonings. Additionally, to provide recommendations on the use of ECMO in poisonings from physicians with expertise in ECMO, medical toxicology, critical care, and emergency medicine.

METHODS

A literature search in Ovid MEDLINE from 1946 to October 14, 2020, was performed to identify relevant articles with a strategy utilizing both MeSH terms and adjacency searching that encompassed both extracorporeal life support/ECMO/Membrane Oxygenation concepts and chemically-induced disorders/toxicity/poisoning concepts, which identified 318 unique records. Twelve additional manuscripts were identified by the authors for a total of 330 articles for screening, of which 156 were included for this report.

NARRATIVE LITERATURE REVIEW

The use of ECMO in poisoned patients is significantly increasing over time. Available retrospective data suggest that patients receiving VA ECMO for refractory shock or cardiac arrest due to poisoning have lower mortality as compared to those who receive VA ECMO for non-poisoning-related indications. Poisoned patients treated with ECMO have reduced mortality as compared to those treated without ECMO with similar severity of illness and after adjusted analyses, regardless of the type of ingestion. This is especially evident for poisoned patients with refractory cardiac arrest placed on VA ECMO (termed extracorporeal cardiopulmonary resuscitation [ECPR]).

INDICATIONS

We suggest VA ECMO be considered for poisoned patients with refractory cardiogenic shock (continued shock with myocardial dysfunction despite fluid resuscitation, vasoactive support, and indicated toxicologic therapies such as glucagon, intravenous lipid emulsion, hyperinsulinemia euglycemia therapy, or others), and strongly considered for patients with cardiac arrest in institutions which are structured to deliver effective ECPR. VV ECMO should be considered in poisoned patients with ARDS or severe respiratory failure according to traditional indications for ECMO in this setting.

CONTRAINDICATIONS

Patients with pre-existing comorbidities with low expected survival or recovery. Relative contraindications vary based on each center's experience but often include: severe brain injury; advanced age; unrepaired aortic dissection or severe aortic regurgitation in VA ECMO; irreversible organ injury; contraindication to systemic anticoagulation, such as severe hemorrhage.

CONCLUSIONS

ECMO may provide hemodynamic or respiratory support to poisoned patients while they recover from the toxic exposure and metabolize or eliminate the toxic agent. Available literature suggests a potential benefit for ECMO use in selected poisoned patients with refractory shock, cardiac arrest, or respiratory failure. Future studies may help to further our understanding of the use and complications of ECMO in poisoned patients.

Orthotopic foetal lung tissue direct injection into lung showed a preventive effect against paraquat-induced acute lung injury in mice

OBJECTIVES

Lung transplantation is the only effective therapy for patients with end-stage lung disease but an organ shortage crisis necessitates the development of alternative therapies. Recent studies have highlighted the potential of foetal tissue transplantation to facilitate the regeneration of vital organs such as liver that have been damaged by lethal diseases. Herein, with the aim of restoring pulmonary function, we hypothesized that allogenic foetal lung tissue implantation would attenuate severe respiratory failure.

METHODS

Lung tissue from the foetuses of pregnant green fluorescent protein-C57BL/6 mice at 13.5 days of gestation was injected into the left lungs of recipient mice. Severe lung injury was induced by paraquat, and we analysed the survival rate and pathohistological findings after 1 month.

RESULTS

The survival rate of the therapy group was 39%, which was significantly higher than the vehicle group at 5.9% (P = 0.034). Immunochemical staining showed that positive cytoplasmic stained cells with anti-interleukin-10 antibody were identified in the gland-like structure of embryonic day 13.5 foetal lung. At 4 weeks after orthotopic implantation, haematoxylin and eosin staining showed reduced lung inflammatory cells, reduced lung oedema and increased active cell proliferation of foetal lung cells. Lung injury score showed that the airway septal thickening revealed statistically significant differences between vehicle and foetal lung therapy (P < 0.001).

CONCLUSIONS

Immature foetal lungs improved the survival rate of mice with paraquat-induced severe lung injury, establishing the need for systematic follow-up studies. The anti-inflammatory cytokine in the tissue from embryonic day 13.5 foetal lung might suppress severe lung injury.

The herbicide paraquat-induced molecular mechanisms in the development of acute lung injury and lung fibrosis

The herbicide paraquat (PQ; 1,1'-dimethyl-4,4'-bipyridylium dichloride) is a highly toxic organic heterocyclic herbicide that has been widely used in agricultural settings. Since its commercial introduction in the early 1960s, numerous cases of fatal PQ poisonings attributed to accidental and/or intentional ingestion of PQ concentrated formulations have been reported. The clinical manifestations of the respiratory system during the acute phase of PQ poisoning mainly include acute lung injury (ALI)/acute respiratory distress syndrome (ARDS), followed by pulmonary fibrosis in a later phase. The focus of this review is to summarize the most recent publications related to PQ-induced lung toxicity as well as the underlying molecular mechanisms for PQ-mediated pathologic processes. Growing sets of data from in vitro and in vivo models have demonstrated the involvement of the PQ in regulating lung oxidative stress, inflammatory response, epigenetics, apoptosis, autophagy, and the progression of lung fibrosis. The article also summarizes novel therapeutic avenues based on a literature review, which can be explored as potential means to combat PQ-induced lung toxicity. Finally, we also presented clinical studies on the association of PQ exposure with the incidence of lung injury and pulmonary fibrosis.

Influence of strengthened hemoperfusion combined with continuous venovenous hemofiltration on prognosis of patients with acute paraquat poisoning: SHP + CVVH improve prognosis of acute PQ patients

Background

The success rate of rescue is extremely low in acute paraquat poisoning. This study aimed to assess whether strengthened hemoperfusion (SHP) combined with continuous venovenous hemofiltration (CVVH) improves prognosis in patients with acute paraquat poisoning.

Methods

Patients from January 2005 to December 2018 were enrolled retrospectively. All selected patients were administered conventional therapy. They were divided according to the received treatments in the conventional therapy, hemoperfusion (HP), CVVH, SHP and SHP + CVVH groups. Follow-up was implemented until the 90th day after poisoning. Other outcomes included all-cause mortality on the 15th day after poisoning, and the percentages of respiratory failure and mechanical ventilation use.

Results

The study included 487 patients,and 211 died in all. Mortality rate in the SHP + CVVH group on the 90th day after poisoning was significantly decreased compared with those of other groups (p<0.001). Survival curves of all groups showed significant differences (p<0.001). SHP combined with CVVH was an independent factor reducing mortality risk (p<0.001). Mortality rate in the SHP + CVVH group on the 15th day after poisoning was also significantly decreased (p < 0.05). The proportions of patients in the SHP + CVVH group with acute respiratory failure and mechanical ventilation were significantly lower than those of other groups (p < 0.05).

Conclusions

SHP with CVVH may decrease the mortality rate of patients with acute paraquat poisoning on the 90th day after poisoning and improve the prognosis.

Paraquat: The Poison Potion

Paraquat is a commonly used herbicide in India that has lethal consequences even on minimal consumption. The case fatality rate for this poisoning is high and there is dearth of evidence-based recommendation for the treatment of this poison. This review article explores the diagnosis and management of paraquat poisoning with an emphasis on recent advances in treatment. Though immunosuppressants and antioxidants are conventionally used, there is a gap in evidence to prove survival benefit of these treatment regimens. There are also some data showing the use of hemoperfusion (with toxin-specific cartridges) as an early intervention, i.e., within 4 hours of exposure to the poison. The recent drug, Edaravone, has also shown promise in the prevention of renal and hepatic injury in paraquat poisoning. Though it did not reduce pulmonary fibrosis in patients with paraquat poisoning, it delays the generation and development of pulmonary fibrosis. However, there is a need for more clinical and experimental studies to validate its use in paraquat poisoning.

HOW TO CITE THIS ARTICLE

Sukumar CA, Shanbhag V, Shastry AB. Paraquat: The Poison Potion. Indian J Crit Care Med 2019;23(Suppl 4):S263-S266.

Ventilator settings and outcome of respiratory failure in paraquat-induced pulmonary injury

Paraquat is a nonselective contact herbicide that has significant importance in clinical toxicology due to its high mortality rate. The cause of mortality in the acute phase of poisoning is a multi-organ failure while in the sub-acute phase is alveolar injury and lung fibrosis. The aim of this study was to evaluate the advantages and drawbacks of mechanical ventilation (MV) in paraquat-induced pulmonary injury and its consequential respiratory failure (PIPI-CRF). This retrospective descriptive analytical study was done to investigate the outcome of patients who had developed PIPI-CRF and underwent conventional treatments with invasive MV in three teaching hospitals in Shiraz, Iran, from March 2010 to February 2015. In total, 44 patients (mean age of 27.9 ± 9.98 years) had undergone MV due to PIPI-CRF. None of the patients had a successful wean off from the ventilator. Although all the patients’ were on aggressive life support and full efforts to resuscitate were carried out in case of cardiac arrest, all of them expired. We suggest that in the case of conventional treatment of paraquat poisoning, only noninvasive ventilation should be applied. However, considering the chance of patient’s survival performing novel treatments, such as extracorporeal membrane oxygenation (ECMO), lung protective ventilation with optimal positive end-expiratory pressure (PEEP) could be applied only in such circumstances.

Successful extracorporeal membrane oxygenation support for severe acute diquat and glyphosate poisoning: A case report

RATIONALE

Because of the lack of an antidote or effective treatment, patients with severe acute diquat and glyphosate poisoning always died within a few hours. Extracorporeal membrane pulmonary oxygenation (ECMO), as an artificial heart-lung supporting system, can be applied to support lung that is expected to recover from reversible pathological damage. However, to our knowledge, the application of ECMO for patients with diquat and glyphosate poisoning has not been reported.

PATIENT CONCERNS

A 40-year-old man ingested in 100 ml of diquat (20 g/100 ml) and 400 ml glyphosate (41 g/100 ml) was admitted to the intensive care unit (ICU), immediately complicated by the development of ventricular fibrillation, respiratory failure, renal failure, and multi-organ failure.

DIAGNOSIS

Diquat and glyphosate poisoning were diagnosed by stated ingestion history, and the diagnostic criteria for acute respiratory distress syndrome (ARDS) and multi-organ dysfunction syndrome were also met.

INTERVENTIONS

He was treated with veno-venous ECMO.

OUTCOMES

He was successfully transferred out of the ICU on day 46 and discharged on day 67. The computed tomography scan showed no obvious pulmonary fibrosis 2 months after poisoning.

LESSONS

ECMO may be effective in the treatment of patients with severe ARDS caused by diquat and glyphosate poisoning when conventional management does not work.

Examining the role of extracorporeal membrane oxygenation in patients following suspected or confirmed suicide attempts: A case series

The decision to offer extracorporeal membrane oxygenation (ECMO) is based on a risk/benefit assessment and the likelihood of a treatable underlying condition or the feasibility of destination therapy (durable mechanical support or thoracic organ transplantation) should heart-lung function fail to improve. Patients who present following suspected suicide attempts who fail medical therapy may pose a dilemma for clinicians. An assessment to determine if a patient has a high likelihood of psychiatric recovery such that bridging with ECMO or ultimately destination therapy could or should be offered is not always feasible in the setting of critical illness. This case series reviews our institution's experience with ECMO in the management of five patients who presented following suspected or confirmed suicide attempts. All five patients survived to hospital discharge. Two had subsequent psychiatric admissions, one following a repeat suicide attempt. A discussion of these cases demonstrates the effectiveness of ECMO in supporting this group of patients in the short-term. The self-limited natural history of many psychiatric episodes, poisonings and traumatic injuries makes the use of ECMO a potentially reasonable support strategy. However, careful consideration must be given to psychiatric history and follow-up given the substantial commitment of resources, potential for complications and for stranding patients on extracorporeal therapy without definitive destination therapy.

Continuous venovenous hemofiltration in the management of paraquat poisoning: A meta-analysis of randomized controlled trials

BACKGROUND

Paraquat (PQ) poisoning is a widespread occurrence, especially in underdeveloped areas. The treatment of PQ poisoning has always been difficult, and there is currently no definite effective treatment. Continuous venovenous hemofiltration (CVVH) treatment for PQ poisoning has been widely used in clinical practice; however, its effect remains uncertain. Accordingly, the purpose of this meta-analysis was to evaluate the efficacy of CVVH in the treatment of PQ poisoning.

METHODS

We searched for relevant trials using PubMed, Embase, the Cochrane Library, and 3 Chinese databases, the Chinese BioMedical Literature Database, National Knowledge Infrastructure Database, and Wanfang Database. We included all qualified randomized controlled trials (RCTs) of CVVH treatment for patients with PQ poisoning. The primary outcome was mortality, while the secondary outcomes included the survival time and constituent ratios of death due to respiratory failure and circulatory failure.

RESULTS

Three RCTs involving 290 patients were included. The mortality rates of the intervention and control groups were 57.9% and 61.0%, respectively. Pooled analysis demonstrated no significant difference in mortality between the CVVH treatment and control groups (risk ratio [RR] 0.94, 95% confidence interval [CI]: 0.78-1.15, P = .56), with a low level of heterogeneity (X = 1.75, I = 0%). However, the CVVH group was associated with a longer survival time compared to the control group (weighted mean difference 1.73, 95% CI: 0.56-2.90, P = .004). Respiratory failure as the cause of death was more common in the CVVH group, as compared with the control group (RR 1.66, 95% CI: 1.24-2.23, P = .0008), whereas patients in the control group were more likely to die from circulatory failure than in the CVVH group (RR 0.56, 95% CI: 0.40-0.81, P = .002).

CONCLUSION

Although CVVH treatment might not noticeably reduce mortality for patients with PQ poisoning, it can prolong the survival time of the patients and improve the stability of the circulatory system, thereby enabling further treatment.

Adult venovenous extracorporeal membrane oxygenation for severe respiratory failure: Current status and future perspectives

Extracorporeal membrane oxygenation (ECMO) for severe acute respiratory failure was proposed more than 40 years ago. Despite the publication of the ARDSNet study and adoption of lung protective ventilation, the mortality for acute respiratory failure due to acute respiratory distress syndrome has continued to remain high. This technology has evolved over the past couple of decades and has been noted to be safe and successful, especially during the worldwide H1N1 influenza pandemic with good survival rates. The primary indications for ECMO in acute respiratory failure include severe refractory hypoxemic and hypercarbic respiratory failure in spite of maximum lung protective ventilatory support. Various triage criteria have been described and published. Contraindications exist when application of ECMO may be futile or technically impossible. Knowledge and appreciation of the circuit, cannulae, and the physiology of gas exchange with ECMO are necessary to ensure lung rest, efficiency of oxygenation, and ventilation as well as troubleshooting problems. Anticoagulation is a major concern with ECMO, and the evidence is evolving with respect to diagnostic testing and use of anticoagulants. Clinical management of the patient includes comprehensive critical care addressing sedation and neurologic issues, ensuring lung recruitment, diuresis, early enteral nutrition, treatment and surveillance of infections, and multisystem organ support. Newer technology that delinks oxygenation and ventilation by extracorporeal carbon dioxide removal may lead to ultra-lung protective ventilation, avoidance of endotracheal intubation in some situations, and ambulatory therapies as a bridge to lung transplantation. Risks, complications, and long-term outcomes and resources need to be considered and weighed in before widespread application. Ethical challenges are a reality and a multidisciplinary approach that should be adopted for every case in consideration.