Benefits of extracorporeal membrane oxygenation for hydrocarbon pneumonitis

Utilizing extracorporeal membrane oxygenation and surfactant in the management of severe acute respiratory distress syndrome due to hydrocarbon pneumonitis

Severe cases of hydrocarbon aspiration requiring Extracorporeal Membrane Oxygenation (ECMO) are rarely reported in pediatrics, and 90% of hospitalized patients have a relatively benign clinical course. We describe a 14 month-old female with accidental hydrocarbon ingestion and aspiration due to organic makeup brush cleaner that suffered severe ARDS and multiorgan failure, successfully managed with ECMO and surfactant. She was decannulated after a total of 72 hours on ECMO, extubated on hospital day 15 (HD 15), and discharged home in her normal state of health after one month in the hospital. ECMO and adjunctive therapies such as surfactant may be helpful in the management of severe hydrocarbon pneumonitis and there are limited reports of ECMO as a supportive method for these pediatric patients.

A case report of recreational use of inhaled Freon leading to acute hypoxemic respiratory failure salvaged by veno-venous extracorporeal membrane oxygenation

BACKGROUND

Freon™ is a halogenated hydrocarbon often used as a refrigerant. When inhaled recreationally, it has the desired effects of euphoria and intoxication. Toxic effects include cardiovascular and neurologic insults such as arrhythmias and seizures, and less well-described toxicities include airway and lung injury. The treatment in general is primarily supportive.

CLINICAL FEATURES

We present the case of a 42-yr-old previously healthy male who developed acute bronchiolitis and pneumonitis following inhalation of Freon leading to severe respiratory failure. He was supported by veno-venous extracorporeal membrane oxygenation and managed with high-dose corticosteroids.

CONCLUSION

To our knowledge, this is the first case report of an inhaled Freon exposure resulting in acute lung injury refractory to conventional therapy that was salvaged by vv-ECMO as a bridge towards a full recovery.

The Recommendation and Use of Extracorporeal Membrane Oxygenation (ECMO) in Cases Reported to the California Poison Control System

INTRODUCTION

Antidotes are available to treat some specific poisonings; however, the mainstay of treatment for the poisoned patient remains supportive care. Extracorporeal membrane oxygenation (ECMO) is one of the most aggressive supportive measures available to manage poisoned patients.

OBJECTIVE

To characterize the recommendation and use of ECMO in cases reported to the California Poison Control System (CPCS).

METHODS

This retrospective chart review queried the CPCS database from 1997 to 2016 for cases containing the American Association of Poison Control Centers (AAPCC) code for ECMO, and "ECMO" and "ECLS" free-text searches. The collected data included year, age, gender, substances involved, route of exposure, clinical effects, treatments, and medical outcome.

RESULTS

A total of 94 cases discussed ECMO as a supportive option with 16 cases utilizing ECMO. Cases where ECMO was discussed rose from one case in 1997 to 13 cases in 2016. Of the 94 cases where ECMO was discussed, 38 cases (40%) involved toxicity from a cardiovascular agent(s) and 33 cases (35%) involved exposure to hydrocarbons. Of the 16 cases where ECMO was performed, 13 (81%) involved males. The median age was 17 years (range 1 month-54 years). Ten cases (63%) involve patients under the age of 18. In this series, 13 of 16 ECMO-supported patients survived (81%).

CONCLUSIONS

ECMO is being recommended more often for treatment of acute poisoning cases by the CPCS. All caregivers involved in the treatment of poisoning should gain a working knowledge of the potentially lifesaving technology of ECMO, its indications for use, adverse effects, and drug or poison interactions.

Extracorporeal Membrane Oxygenation (ECMO) for Severe Toxicological Exposures: Review of the Toxicology Investigators Consortium (ToxIC)

Although there have been many developments related to specific strategies for treating patients after poisoning exposures, the mainstay of therapy remains symptomatic and supportive care. One of the most aggressive supportive modalities is extracorporeal membrane oxygenation (ECMO). Our goal was to describe the use of ECMO for toxicological exposures reported to the American College of Medical Toxicology (ACMT) Toxicology Investigators Consortium (ToxIC). We performed a retrospective review of the ACMT ToxIC Registry from January 1, 2010 to December 31, 2013. Inclusion criteria included patients aged 0 to 89 years, evaluated between January 2010 through December 2013, and received ECMO for toxicological exposure. There were 26,271 exposures (60 % female) reported to the ToxIC Registry, 10 (0.0004 %) received ECMO: 4 pediatric (< 12 years), 2 adolescent (12-18 years), and 4 adults (>18 years). Time of initiation of ECMO ranged from 4 h to 4 days, with duration from 15 h to 12 days. Exposures included carbon monoxide/smoke inhalation (2), bitter almonds, methanol, and several medications including antihistamines (2), antipsychotic/antidepressant (2), cardiovascular drugs (2), analgesics (2), sedative/hypnotics (2), and antidiabetics (2). Four ECMO patients received cardiopulmonary resuscitation (CPR) during their hospital course, and the overall survival rate was 80 %. ECMO was rarely used for poisoning exposures in the ACMT ToxIC Registry. ECMO was utilized for a variety of ages and for pharmaceutical and non-pharmaceutical exposures. In most cases, ECMO was administered prior to cardiovascular failure, and survival rate was high. If available, ECMO may be a valid treatment modality.

Respiratory complications following hydrocarbon aspiration in children

Accidental hydrocarbon ingestion may lead to aspiration and chemical pneumonitis in children. In this review article, the clinical course of hydrocarbon pneumonitis, chest radiographic abnormalities, complications, and treatment interventions are summarized. Most children remain asymptomatic and without complications following ingestion of a hydrocarbon. In approximately 15% of ingestions, aspiration pneumonitis occurs and evolves over the first 6-8 hr presenting with fever, tachypnea, hypoxemia, and tachycardia. A symptom zenith is reached within 48 hr followed by progressive improvement. Up to 5% of pneumonitis cases progress rapidly to acute respiratory failure. Chest radiographic abnormalities develop by 4-8 hr after ingestion, but they are not always predictive of clinical pneumonitis. Patients with history of hydrocarbon ingestion should be monitored for 6-8 hr in the emergency department and a chest radiogram should be obtained at the end of the observation period. Spontaneous or induced emesis and gastric lavage have been related to aspiration pneumonitis. Children who are symptomatic are admitted to the hospital for cardiorespiratory status monitoring and supportive care. Approximately 90% of hospitalized patients have a benign clinical course. Increased work of breathing with or without altered sensorium and seizures are indications for admission to the intensive care unit. Hypoxemia unresponsive to supplemental oxygen and/or severe central nervous system involvement require mechanical ventilation. Corticosteroids do not seem to offer any benefit and antibiotics are administered in cases of bacterial superinfection. Pneumatoceles may become evident after the first 6-10 days of symptoms on follow-up chest radiograms and they resolve up to 6 months later. Pediatr Pulmonol. 2016;51:560-569. © 2016 Wiley Periodicals, Inc.

Available extracorporeal treatments for poisoning: overview and limitations

Poisoning is a significant public health problem. In severe cases, extracorporeal treatments (ECTRs) may be required to prevent or reverse major toxicity. Available ECTRs include intermittent hemodialysis, sustained low-efficiency dialysis, intermittent hemofiltration and hemodiafiltration, continuous renal replacement therapy, hemoperfusion, therapeutic plasma exchange, exchange transfusion, peritoneal dialysis, albumin dialysis, cerebrospinal fluid exchange, and extracorporeal life support. The aim of this article was to provide an overview of the technical aspects, as well as the potential indications and limitations of the different ECTRs used for poisoned patients.

Pulse steroid therapy in adult respiratory distress syndrome following petroleum naphtha ingestion

CASE REPORT

A suicide attempt by a 23-year-old woman involved ingestion of 1000 mL of petroleum naphtha. Early chemical pneumonitis was complicated by life-threatening, diffuse interstitial lung consolidation with pneumatoceles. Pulse steroid therapy beginning on day 17 was associated with remarkable resolution of interstitial consolidation, although an enlarging secondarily infected pneumatocele ruptured to produce a bronchopleural fistula. Thoracic surgery and antibiotic therapy resulted in improvement of the patient's respiratory condition, and she was discharged with no residual respiratory symptoms. High-dose corticosteroid therapy appears to be a useful addition to aggressive supportive treatment in late adult respiratory distress syndrome following hydrocarbon ingestion.