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REPORT: It can be challenging to calculate the risks versus benefits of a potential Extracorporeal Membrane Oxygenation (ECMO) pediatric candidate. A patient with an oncologic comorbidity and an increased potential of needing near-future surgical interventions carries higher ECMO risks. We report a successful VA ECMO run of a newly diagnosed acute lymphoblastic leukemia (ALL) adolescent with Clostridium septicum necrotizing fasciitis. A previously healthy 16-year-old male was diagnosed with pre-B cell ALL after having an ileocolic intussusception and a Clostridium septicum blood infection. He underwent successful surgical intussusception reduction, started induction chemotherapy, and completed a ten-day course of antibiotics. On hospital day (HD) 15, he experienced significant abdominal pain and profound septic shock. His abdominal CT scan was concerning for air and fat stranding within the anterior abdominal wall. He was taken to the OR, where he was found to have necrotizing fasciitis and underwent debridement and silo placement. He returned to the Pediatric Intensive Care Unit on multiple high-dose vasoactive infusions with hemodynamic instability refractory to aggressive volume resuscitation. His instability and lactic acidosis progressed quickly in the 60 minutes after arriving from the OR, and thus, careful consideration was given to his ECMO candidacy. The prognosis for survival from ALL is 60-90% in adolescents (1,2). Repeat blood cultures had not speciated at the time of our patient’s hemodynamic decline, but necrotizing fasciitis survival in pediatrics ranges from 60-90% (3-6). Early surgical intervention increases the survival rate of myonecrosis, but future interventions would be complicated by anticoagulation on ECMO (7-9). Little more than a few case studies have been reported on the outcomes of ECMO patients with active necrotizing fasciitis (10,11). Compared to other pediatric ECMO patients, immunocompromised and oncological patients on ECMO have historically higher mortality rates. However, current survival reports have been improving (12-15). Ultimately, he was determined to be an ECMO candidate. While the team mobilized, he suffered a 16-minute bradycardic arrest but was successfully cannulated to VA-ECMO. Bivalirudin was used in anticipation of surgical procedures considering its short half-life. Chemotherapy was held, and antimicrobials were broadened. Repeat surgical debridement happened on ECMO day 2. Heparin neutralized partial thromboplastin time (PTT) measured at 69 seconds, so no anticoagulation adjustments were made for the procedure. He received alternating 1.1x plasma exchanges and granulocyte infusions during the first week of ECMO. A large volume GI bleed complicated his ECMO run, but he was able to be successfully decannulated on ECMO day 8. He was discharged home on HD 54 neurologically intact and is currently in the Interim Maintenance I stage of his pre-B ALL treatment. He has been home for six months at the time of this report. (Discharged 5/11/2022) While more centers are reporting their individual ECMO experiences in high-risk oncologic pediatric populations, the data is lacking for pediatric ECMO cases with multiple comorbidities and surgical intervention needs while on ECMO. Our approach required surgical collaboration and would be necessary for any future patients such as this. ECMO candidacy should not be ruled out for these patients, and case-by-case candidacy determinations should be undertaken. Understanding outcomes of the underlying disease and acute processes could improve with increased data collection and sharing.
Critical Care | Pediatrics
Orrick, Johanna I.; Rouchou, Brittany; Holton, Cara; and Miller, Jenna, "Successful VA ECMO for a pre-B cell acute lymphoblastic leukemia patient with necrotizing faciitis from Clostridium septicum" (2023). Posters. 331.