Management of carbon monoxide poisoning-induced cardiac failure and multiorgan dysfunction with combined respiratory and circulatory extracorporeal membrane oxygenation

AA Rabie; A Asiri; M Alsherbiny; W Alqassem; M Rajab; S Mohamed; W Hazem I Alenazi; L Ariplackal

doi:10.4103/2543-1854.259471

REVIEW ARTICLE

Year : 2019 | Volume : 3 | Issue : 1 | Page : 12-14

Management of carbon monoxide poisoning-induced cardiac failure and multiorgan dysfunction with combined respiratory and circulatory extracorporeal membrane oxygenation

AA Rabie, A Asiri, M Alsherbiny, W Alqassem, M Rajab, S Mohamed, W Hazem I Alenazi, L Ariplackal
Department of Critical Care, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia

Date of Web Publication

30-May-2019

Correspondence Address:
A A Rabie
Department of Critical Care, Prince Mohammed Bin Abdulaziz Hospital, Riyadh
Saudi Arabia

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2543-1854.259471

Abstract

Carbon monoxide (CO) is an odorless, colorless, and nonirritant gas; it is the most common cause of poisoning and poisoning-related death. The main mechanism of CO toxicity is ischemic hypoxia secondary to hypoxemia. The heart is the major target organ of acute CO poisoning. Cardiac failure is the most common cardiac presentation; however, other cardiovascular manifestations include arrhythmia, pulmonary edema, and myocardial infarction. Recovery time from CO-induced cardiomyopathy varies from 4 days to 6 weeks. To our knowledge, there are a limited number of reported cases that demonstrated successful extracorporeal membrane oxygenation (ECMO) in adult and pediatric patients with CO poisoning and multiple organ failure. We present our experience with a case we think that it is the first case to be published for a patient with acute CO poisoning received both circulatory and respiratory support (hybrid venoarterial-venous ECMO).

Keywords: Carbon monoxide poisoning, extracorporeal membrane oxygenation, venoarterial-venous extracorporeal membrane oxygenation

How to cite this article:
Rabie A A, Asiri A, Alsherbiny M, Alqassem W, Rajab M, Mohamed S, I Alenazi W H, Ariplackal L. Management of carbon monoxide poisoning-induced cardiac failure and multiorgan dysfunction with combined respiratory and circulatory extracorporeal membrane oxygenation. Saudi Crit Care J 2019;3:12-4

How to cite this URL:
Rabie A A, Asiri A, Alsherbiny M, Alqassem W, Rajab M, Mohamed S, I Alenazi W H, Ariplackal L. Management of carbon monoxide poisoning-induced cardiac failure and multiorgan dysfunction with combined respiratory and circulatory extracorporeal membrane oxygenation. Saudi Crit Care J [serial online] 2019 [cited 2023 Jun 4];3:12-4. Available from: https://www.sccj-sa.org/text.asp?2019/3/1/12/259471

Introduction

Carbon monoxide (CO) is the most common cause of poisoning and poisoning-related death, resulting in 20,000 emergency department visits and 450 fatalities each year in the United States.^[1]

CO is an odorless, colorless, and nonirritant gas.^[2],[3],[4] The main mechanism of CO toxicity is ischemic hypoxia secondary to hypoxemia.^[1],[3],[4] Specifically, the heart is the major target organ of acute CO poisoning.^[5],[6] Cardiac failure is a common presentation in patients with acute CO poisoning.^[7],[8] Other reported cardiovascular manifestations include arrhythmia, pulmonary edema, and myocardial infarction.^[9],[10] Previous reports have shown that the recovery time from CO-induced cardiomyopathy varied from 4 days to 6 weeks.^[7],[11] To our knowledge, a limited number of reported cases (4 cases) demonstrated successful use of extracorporeal membrane oxygenation (ECMO) in adult and pediatric patients with CO poisoning and multiple organ failure, with one of these cases being supported with respiratory ECMO and the remaining cases being supported with circulatory ECMO.^[12],[13] We present here our experience with a case we think that it is the first case to be published for a patient with acute CO poisoning received both circulatory and respiratory support.

Case Report

A 27-year-old female patient, not known to have any medical illness, presented to the emergency room (ER) of a nearby hospital. She had been found by her brother with one of her relative after 5 h of sleep in a closed room exposed to a fire source; both the patient and her relative were unconscious. On arrival to the ER, both patients started to regain consciousness gradually until they became fully conscious. Our patient presented a carboxyhemoglobin (COHb) level of 13.8. Because hyperbaric oxygen therapy was not available, she was treated with oxygen at FiO₂ of 100%. Six hours later, she started to develop shortness of breath with progressive hypotension; chest X-ray showed diffuse bilateral infiltrates [white lungs, [Figure 1]. She was started on inotropic support, was intubated, and was mechanically ventilated with high settings reaching FiO₂100% and PEEP 15 mmHg. However, she continued to have progressive refractory hypotension on maximum doses of inotropic support (adrenaline 1 mcg/kg/min, noradrenaline 1 mcg/kg/min, vasopressin 0.03 mcg/kg/min, and dopamine 25 mcg/kg/min) with mean arterial pressure of 60 mmHg and lactate level of 18 mmol/dl. Echocardiography examination revealed global hypokinesia with ejection fraction (EF) 10%. A request was sent to our center for possible ECMO support by our ECMO retrieval team. After multidisciplinary discussion, it was decided to provide respiratory and circulatory support on ECMO. On arrival of the team to the referring hospital, the patient condition had worsened further. Immediately, ECMO cannulation was started with three ECMO cannula being inserted percutaneously; the first was a drainage left femoral vein cannula (Maquet from Getinge Co, 25 Fr 38 cm), the second was a return internal jugular venous cannula (Maquet from Getinge Co, 23 Fr 15 cm), and the third was a return left femoral artery cannula (Medtronic Next Generation 19 Fr) in addition to a distal perfusion cannula (8 Fr). The cannula position was secured; HLS cardiohelp circuit was reconstructed with hybrid venoarterial-venous (V-AV) configuration [Figure 1] where returned blood was divided into arterial circulation (two-third of pump flow) and venous circulation (one-third of pump flow) by means of Y connector, using Hoffman tubing clamp [Figure 2]. With ECMO initiation, the required inotropic support decreased dramatically; the patient was prepared and transferred successfully to our extracorporeal life support unit. The patient hospital course was complicated; however, her heart gradually recovered, pulmonary edema improved the 2^nd day to ECMO support; 4 days later, she was successfully weaned and de-cannulated. Neurologically, she had decreased level of consciousness with normal CT brain but became fully conscious later on with conservative treatment. She was successfully extubated and was successfully discharged from the intensive care unit after 12 days with complete heart function recovery with EF 55%. Follow-up 2 months later, the patient was discharged home with good health status without disability.

Figure 1: Venoarterial-venous extracorporeal membrane oxygenation configuration, return cannula in the internal jugular venous and arterial in the common femoral artery controlled by Hoffman clamp. DPC: Distal perfusion cannula

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Figure 2: Hoffman tubing clamp

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Discussion

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 ECMO.^[13] We found too much limited data on ECMO utilization in CO poisoning. Two cases are reported: the first for an adult patient with CO poisoning supported on venoarterial (VA) ECMO^[11] and the second case for a pediatric patient with CO poisoning supported on venovenous (VV) ECMO; both cases had favorable outcome.^[12] Another article provided a retrospective review of cases with acute poisoning supported on ECMO reported to the American College of Medical Toxicology's Toxicology Investigators Consortium since its inception in 2010 to December 31, 2013. A total of 10 patients during the study period received ECMO for a toxicological exposure, two pediatric cases of 10 exposed to CO and smoke inhalation. A 4-year-old patient had a COHb concentration of 29.6%. A cyanide concentration was not obtained, but the patient had a peak lactate concentration of 13.8 mmol/l. A 7-month-old patient had smoke inhalation injury and a COHb of 5.7% with a peak lactate of 8 mmol/l. Cyanide concentration was not obtained. Both patients were placed on VA ECMO for ARDS and poor ventilation by conventional and high-frequency mechanical ventilation modalities.^[13] Although a femoral VA ECMO configuration may provide both respiratory and circulatory support, in the setting of severely compromised gas exchange with recovering native cardiac function, the ability to deliver oxygenated blood to the coronary and carotid arteries may be compromised.^[14],[15] Biscotti et al.^[16] described hybrid V-AV configuration to provide concomitant respiratory and circulatory support and reported directing two-thirds of the reinfusion blood flow toward the arterial limb using Hoffman tubing clamp. The concept behind that is to provide circulatory support through the retrograde blood flow to the arterial circulation; on the other hand, the remaining one-third of the blood flow was directed to the venous side to provide oxygenation to coronaries and cerebral arteries which might be affected due to compromised native lung function and distally located mixed zone (water-shedding) to the heart by retrograde flow from the arterial reinfusion limb and native antegrade blood flow from the native heart function. This complex modality is used in case of VA ECMO support complicated by Harlequin syndrome or VV ECMO support complicated by cardiogenic shock or septic cardiomyopathy. In our case, we preferred to support the patient using V-AV ECMO for two reasons; the first was the severely critical condition of the patient complicated with severe respiratory and circulatory failure, and the second was the need to transport this patient to our ECMO center.

Please review the video demonstrating echocardiography of cardiac function recovery in our educational channel on youtube https://www.youtube.com/watch?v=1VhlROJRNBE.

Conclusions

ECMO can be safely and effectively used to support patients with severe CO. Hybrid VAV configuration may be preferred than other ECMO modalities in case of concomitant cariogenic shock with refractory hypoxemia. However, it should be carried out by an expert team in a specialized center.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Centers for Disease Control and Prevention (CDC). Nonfatal, unintentional, non – Fire-related carbon monoxide exposures – United States, 2004-2006. MMWR Morb Mortal Wkly Rep 2008;57:896-9.
2.	Ernst A, Zibrak JD. Carbon monoxide poisoning. N Engl J Med 1998;339:1603-8.
3.	Raub JA, Mathieu-Nolf M, Hampson NB, Thom SR. Carbon monoxide poisoning – A public health perspective. Toxicology 2000;145:1-4.
4.	Jung YS, Lee JS, Min YG, Park JS, Jeon WC, Park EJ, et al. Carbon monoxide-induced cardiomyopathy. Circ J 2014;78:1437-44.
5.	Gandini C, Castoldi AF, Candura SM, Locatelli C, Butera R, Priori S, et al. Carbon monoxide cardiotoxicity. J Toxicol Clin Toxicol 2001;39:35-44.
6.	Fitzgerald RS, Dehghani GA, Kiihl S. Autonomic control of the cardiovascular system in the cat during hypoxemia. Auton Neurosci 2013;174:21-30.
7.	Yanir Y, Shupak A, Abramovich A, Reisner SA, Lorber A. Cardiogenic shock complicating acute carbon monoxide poisoning despite neurologic and metabolic recovery. Ann Emerg Med 2002;40:420-4.
8.	Satran D, Henry CR, Adkinson C, Nicholson CI, Bracha Y, Henry TD. Cardiovascular manifestations of moderate to severe carbon monoxide poisoning. J Am Coll Cardiol 2005;45:1513-6.
9.	Choi IS. Carbon monoxide poisoning: Systemic manifestations and complications. J Korean Med Sci 2001;16:253-61.
10.	Gomes Serrao M, Nascimento R, Santos N, Pereira A, Decio Pereir AB, Alamda Cardoso A. Miocardiopatia transitória secundária aomonóxido de carbono. Rev Port Cardiol 2008;27:833-8.
11.	Teerapuncharoen K, Sharma NS, Barker AB, Wille KM, Diaz-Guzman E. Successful treatment of severe carbon monoxide poisoning and refractory shock using extracorporeal membrane oxygenation. Respir Care 2015;60:e155-60.
12.	Baran DA, Stelling K, McQueen D, Pearson M, Shah V. Pediatric veno-veno extracorporeal membrane oxygenation rescue from carbon monoxide poisoning. Pediatr Emerg Care 2018. [In Press]
13.	Wang GS, Levitan R, Wiegand TJ, Lowry J, Schult RF, Yin S, et al. Extracorporeal membrane oxygenation (ECMO) for severe toxicological exposures: Review of the Toxicology Investigators Consortium (ToxIC). J Med Toxicol 2016;12:95-9.
14.	Stulak JM, Dearani JA, Burkhart HM, Barnes RD, Scott PD, Schears GJ. ECMO cannulation controversies and complications. Semin Cardiothorac Vasc Anesth 2009;13:176-82.
15.	Field ML, Al-Alao B, Mediratta N, Sosnowski A. Open and closed chest extrathoracic cannulation for cardiopulmonary bypass and extracorporeal life support: Methods, indications, and outcomes. Postgrad Med J 2006;82:323-31.
16.	Biscotti M, Lee A, Basner RC, Agerstrand C, Abrams D, Brodie D, et al. Hybrid configurations via percutaneous access for extracorporeal membrane oxygenation: A single-center experience. ASAIO J 2014;60:635-42.