Extracorporeal Membrane Oxygenation for Pandemic (H1N1) 2009

To the Editor: As the world struggles with the challenges of infl uenza A pandemic (H1N1) 2009, it is clear that treatment options for critically ill infected patients are suboptimal because deaths continue to be reported in otherwise young and healthy patients. Ex-tracorporeal membrane oxygenation (ECMO) is an established therapeutic option for patients with medically re-fractory cardiogenic or respiratory failure. We describe the successful use of ECMO in a patient with complicated pneumonia and infl uenza A pandemic (H1N1) 2009 virus infection. Our patient, a 21-year-old woman who was 4 months postpartum, had poorly controlled insulin-dependent diabetes (hemoglobin A1C level 13.2 mg/dL). She sought treatment at another hospital after 3 days of respiratory symptoms, a productive cough after working in her garden, and a fever >103°F. Her condition rapidly deteriorated , and she required mechanical ventilation, vasoactive medications, and drotecogin-α (Xigris; Eli Lilly and Company, Indianapolis, IN, USA) for profound shock. The patient was then transferred to Ohio State University Medical Center on August 24, 2009; at admission she exhibited hypotension (83/43 mm Hg) and tachycardia (159 bpm), despite having received high doses of vasoactive medications (norepineph-rine 1.0 μg/kg/min, phenylephrine 2.0 μg/kg/min). A transthoracic echocar-diograph showed severe biventricular failure (ejection fraction 5%–10%); peak tropinin level was 6 mg/dL. Arterial blood gas confi rmed metabolic ac-idosis (pH 7.12, partial carbon dioxide pressure [pCO 2 ] 48 mm Hg, pO 2 117 mm Hg, HCO 3 15.3 mmol/L). Despite fl uid resuscitation and administration of epinephrine (0.06 μg/kg/min), her condition failed to improve, and she was given femoral vein–femoral artery ECMO. A comprehensive search for infectious causes was undertaken. Treatment with broad-spectrum em-piric antimicrobial drugs such as linezolid USA), 150 mg 2×/d, was started. Respiratory cultures were positive for methicillin-sensitive Staphylococcus aureus and Aspergillus glaucus. Naf-cillin and voriconazole were added to the treatment regimen. PCR of a bronchoalveolar lavage specimen later identifi ed pandemic (H1N1) 2009 virus. The patient was weaned from ECMO on hospital day (HD) 10 and extubated on HD11. Repeat cardiovascular evaluation showed normal biventricular function and no coronary disease. She was discharged from hospital for rehabilitation on September 15, 2009 (HD 22), with an oxygen saturation of 98% on room air and is now fully recovered. The use of ECMO is an established option for patients with medically refractory acute and reversible cardiopulmonary failure (1–3) (Table). For isolated respiratory failure, veno– veno support can be used by femoral …