Mortality and Morbidity

Conference
Dr Himanshu Patel, MD
Dr Vindhya Koneru, MD
Dr Robert G Smith, MD
08/06/2020
HPI
• 25 yo female presented to the ER with 2 day history of shortness of breath.
Neurology/Stroke was activated for altered mental status.

• After admission, she had 3 bouts of emesis for which she was given phenergan and
ativan. She then became hypoxic with a SpO2 of 70%. CERT was called. She was placed on
BiPAP with improvement in SaO2 to 95% which also improved her mentation. On bedside
evaluation, no new focal deficits were noted except for chronic bilateral foot drop. Patient
was alert, oriented and able to move BUE.

CTH done that did not show any acute changes. 

HPI
• PMH: ASD, Pulmonary Hypertension, vWF inhibitor disorder.
• PSH : Cesarean section, cardiac catheterization.
• Social H: Not a smoker, no alcohol or drug abuse.
• Family H: None significant.
• Allergies : Vancomycin – Red man syndrome.
• Medications: Macitentan, Adcirca, Treprostinil, warfarin, norethindrone, digoxin.
•VITAL SIGNS:
BP: 98/59, Heart Rate:  88, Respiratory Rate:  25, SpO2:  92 %, T:  96.4 °F

•GENERAL EXAMINATION:
Constitutional:             Well-developed
Eyes:                           No scleral icterus.
HENT:                         Normocephalic/Atraumatic. 
Neck/Back:                  Supple w/ full range of motion.
Cardiovascular:           Regular rate and rhythm. 
Respiratory:                 No stridor, no respiratory distress.
Gastrointestinal:          Soft. Mild distension, no tenderness
Musculoskeletal:         + pedal  edema   
Skin:                            Warm and dry.
Psychiatric:                 Insight adequate, mood anxious. 
 
NEUROLOGICAL EXAMINATION
Mental status:              A/OX3 (partial to date). Follows complex commands, able to cross
midline.
Language/speech:      Fluent w/o dysarthria. Comprehension intact. 
Cranial nerves:            VFs full. PERRL, no APD.
                                     Gaze conjugate w/o deviation. EOMI. No
nystagmus  
                                     V1-3 equal to light touch. 
                                    No facial droop.
                                     Hearing equal bilaterally to finger rub.
                                     Symmetric palate rise .
                                     SCM/Trapezius 5/5
                                     Tongue midline. Movement intact.
 
NEUROLOGICAL EXAMINATION
Motor system:          Normal appearance of the muscles.
                                    Normal muscle tone. No pronator drift.
                                    RUE: antigravity, 3/5(+pain IV)
                                    LUE:  antigravity, 4/5
                                    RLE:  3/5 proximal and 2/5 distal muscle groups
                                    LLE:  3/5 proximal and 1/5 distal muscle groups
                                    Plantars unreliable
Sensory:                     Intact sensation to LT
Coordination:            No tremor. FTN intact.
Gait:                            Not tested due to weakness, acuity

• D3 Note : Strength :  RUE: proximal 4/5, distal 4/5

                                    LUE: proximal 4/5, distal 4/5
                                     RLE: proximal 4/5, distal 2/5
                                     LLE: proximal 4/5, distal 1/5
• Patient reported that she developed bilateral foot drop 5 years ago.
Going back 5 years… At 20 years of age
• Patient was admitted to the hospital for hemoptysis. She has a history of
pulmonary hypertension. She is at 25 weeks gestation. G1P0. She was admitted in
MICU. She was seen by obstetrician who started betamethasone and magnesium
sulphate to prepare her for delivery.

• Next day, at approximately 7:15pm, OBG residents were called to the bedside to
evaluate the patient as the RN was unable to find FHTs.  The tracing was
obtained for approximately 5 minutes. So bedside ultrasound was performed
which showed slowed FHTs at approximately 100 to 110 beats per minute. This
was a change from her baseline of 120 beats per minute. FHTs showed moderate
variability with accelerations and no decelerations.  The fetal heart tracings were
felt to be non-reassuring fetal bradycardia for approximately 3 to 5 minutes. So
the patient was taken for emergency C-section.
OBG OP NOTE
General anesthesia was then given without any difficulty.  The patient was intubated without any difficulty
and the Foley catheter was already placed in the bladder.  She was then prepped and draped in the usual
sterile fashion.  A vertical skin incision was made with a knife.  This was carried down to the rectus fascia
bluntly and the rectus muscle separated bluntly.  The peritoneum was entered and stretched.  Bladder
blade was inserted.  The knife was used to make a classical uterine incision on the uterus then stretch was
accomplished, the infant's breech was delivered, the remainder of the baby was delivered without any
difficulty.  The cord was clamped x2 and cut.  The infant was handed off to the waiting neonatologist.  A
segment of cord was clamped and given off so that blood gases could be obtained.  We then exteriorized
the uterus.  The placenta was removed and the uterine incision was then repaired quickly with 0 Vicryl
suture in 2 layers.  The second layer being a baseball stitch.  Hemostasis was confirmed.  At this point, right
as we closed the hysterotomy, the patient went into cardiac arrest.  Thus, CPR was started and chest
compressions were initiated by anesthesia and the cardiac team came to resuscitate.  Please see their
separate dictation for there is part of the procedure.  After the patient was resuscitated and placed on
ECMO and the CV surgeon performed an emergency pericardial window enclosure.
Vascular Surgery Note
After C-section, she had cardiopulmonary arrest requiring CPR and
emergent placement of VA ECMO.  The venous side was placed on the
left and arterial side was placed on the right. She subsequently was
able to recover and sent to the FICU for recovery.  At the same time
also during this procedure, she also underwent a pericardial window
due to concerns for tamponade.  She was transferred back to the FICU
after completion of the procedure and during that time, she was noted
to have decreased signals in the right lower extremity.  We were
consulted for antegrade sheath placement.
Vascular Surgery OP Note
• This is a 20-year-old female with VA ECMO (secondary to cardiopulmonary arrest) with decreased perfusion to right lower extremity due to secondary small
vessels and a large cannula.  Our team has been asked to place antegrade arterial sheath. We attempted multiple attempts at percutaneous placement with
ultrasound guidance and we were unsuccessful.  At this time, we opted to do cutdown.  Once we passed the wire and placed a dilator with a 5-French sheath
into the vessel directly through the skin and confirmed its placement with backbleeding as well as with visualization.
EMG/ NCS : 7/21/2020
• Nerve conduction studies: 
1. Normal motor conductions for the left upper extremity. Normal upper
extremity F wave latencies. 
2. Lower extremity F wave and H reflex responses are absent. 
3. Absent peroneal conductions bilaterally, with absent Rt tibial and Rt peroneal
TA conductions. Severely reduced Lt tibial and peroneal TA CMAP responses
with normal motor conduction velocities for for size of CMAP response. Lower
extremity H reflex is slowed on the Lt and absent on the Rt. 
4. No conduction block was noted, while temporal dispersion was best observed
in Rt peroneal TA response. 
5. Sensory conductions are largely present, and normal, except for the
superficial peroneal responses, which are slightly reduced on the Lt side, and
absent on the Rt. 

Repetitive nerve stimulation:  Not performed 

EMG
• Electromyography: 
Intramuscular recordings were evaluated from the Lt upper and bilateral lower extremities using a 37
mm monopolar AMBU needle. There is widespread active chronic denervation with variable
reinnervation affecting most tested distal lower extremity muscles. Denervation is generally more
severe the farther distally we assess the Lt lower extremity; the right lower extremity is more severely
affected, apparently involving the sciatic nerve and posterior compartment on the right, potentially
producing nerve ischemia, while either compression was more distal on the left or less severe. Motor
greater than sensory involvement suggests that compression/ischemia caused selective motor damage
initially, since the opposite response should be observed at this time after injury (preferential motor
reinnervation is typical of peripheral nervous system regeneration following injury). 
• Impression: Abnormal Study 
• 1) Late effects of bilateral compartment syndrome or distal steal syndrome following ECMO
placement (see Ayden S, et al, Arch Neuropsych 2019;56:75-78 for more information), with evidence
of severe distal sciatic nerve dysfunction on the right and less severe, more tibial nerve selective
distal motor dysfunction on the left side, noted both on nerve conduction studies and needle exam. 
• 2) Clinical evidence of right foot extensor contraction, 
• Here is a young 20 year old woman who underwent an emergent
procedure AV- ECMO and then developed distal weakness in both
lower extremities.

• What could be done differently to prevent this morbidity?

Discussion
Extracorporeal membrane oxygenation
• Temporary mechanical
cardiopulmonary
supportive therapy
that sustains life while
bridging to decision,
organ recovery or
transplant
• Peripheral veno-
arterial ECMO (VA
ECMO)
Incidence of neuropathy with ECMO
• Health‐related quality of life after extracorporeal membrane
oxygenation: a single center's experience
• University of North Norway, 74 patients from 1988–2015, VA=64, VV=10.
• Peripheral neural injuries were registered in 10 of 34 survivors (29%).
• Peripheral neuropathies were most often foot drop or critical illness
polyneuropathies.
• Peripheral neurological sequelae were documented in 6 of 20 (30%)
survey responders at an average time from ECMO of 6.5 years.
Pathophysiology of Neuropathy with ECMO
• 1) distal limb ischemia
• 2) compartment syndrome
• 3) compression of peroneal nerve

• In ischemic monomelic neuropathy, distal axonal infarction can occur without significant
muscle necrosis, supporting the hypothesis that in humans the distal nerve fibers are more
vulnerable than muscle to acute noncompressive limb ischemia.
• Peroneal nerve palsy may be a result of prolonged immobilization and external compression
during ECMO. In VA-ECMO, limb compartment syndrome can cause irreversible tissue damage
and permanent neuropathies. Whereas compartment syndrome is initiated by limb ischemia,
it is aggravated by other factors such as reperfusion injury and secondary tissue inflammation
and swelling. Limb ischemia may be due to inadequate ECMO flow to the affected limb or due
to the precipitating event.
Incidence of distal limb ischemia with ECMO
• Distal limb ischemia is a well documented complication with femoral VA-
ECMO cannulation, however its true incidence remains underreported.
• A large meta‐analysis of 12 studies involving almost 1800 patients
showed an incidence of 10% for limb ischemia.
• A literature review involving 28 studies found an incidence ranging from
10 to 70%. This highly variable incidence is due to studies performed in
populations that are different in baseline characteristics, ECMO
indications, cannulation techniques, limb ischemia definition, detection
tools, and distal perfusion cannulation modalities and timing of insertion.
Distal limb ischemia and Compartment
syndrome
• Acute compartment syndrome can develop as a result of limb ischemia or
reperfusion during ECMO
• Proinflammatory phase: Reduced arteriovenous gradient results in limb ischemia and
thus hypoxic damage to vascular endothelium. This induces peripheral leukocytosis
and inflammatory mediator release causing further microvascular impairment. WBC
migrate into interstitium and thus risk of reperfusion injury is increased.
• Reperfusion phase: Reperfusion of ischemic tissue causes reactive oxygen species
and enzyme cofactors to reach the ischemic tissue. There is reduced vascular
permeability due to interstitial inflammatory cells resulting in no-reflow phenomenon.
Blood flow is not fully restored after reperfusion. Increased platelet-leukocyte
aggregation and interstitial fluid accumulation result in target organ damage.
• Potassium, AST, and myoglobin showed peak values at about 10-16 hours after ECMO
disconnection.
Mechanisms of limb ischemia in ECMO
Clinical Manifestation of distal limb ischemia
• Distal limb ischemia manifests as one or more of the “six P's”:
pulselessness, poikilothermia, pallor, pain, paresthesia, and paralysis.
• Pain, paresthesia, and paralysis may be difficult to assess in sedated
or unconscious patients.
• Capillary return of less than 5 seconds is considered normal.
• Significant temperature difference between two extremities may
herald ischemia.
• Calf firmness may be a sign of compartment syndrome.
Monitoring
• Near-infrared spectroscopy (NIRS) monitors
difference between oxy- and deoxy-hemoglobin
and reflects oxygen uptake in the tissue bed and
is defined as regional oxygen saturation (rSO2).
• rSO2 drop below 40 or more than 25% from
baseline is clinically significant requiring
intervention.
• All patients with clinical evidence of limb
ischemia had rSO2 below 50% for longer than 4 
min, and a positive predictive value of 86% was
calculated
Options to reduce distal limb ischemia
(Prevention vs. Treatment)
• Smaller bore systemic outflow cannula (blood will flow around the cannula to
distally perfuse the limb)
• Vessel-sparing cannulation (prosthetic graft stitched to the femoral artery)
• Distal perfusion cannula (antegrade vs. retrograde perfusion)
• Via Cannula
• Via Introducer Sheath (5-8 Fr)
• Conservative management of distal limb ischemia by increasing ECMO flow,
decreasing vasopressor infusion, external limb warming, treating cause of
circulatory shock, vasodilator infusion (epoprostenol).
• Revascularization vs. Amputation.
Preventing distal limb ischemia
• If Seldinger technique is used, avoid placing the arterial and venous
cannula on the same side in order to avoid venous congestion from
compression of the femoral vein by the adjacent arterial cannula.
• The best way to decrease distal ischemia is to insert the arterial
cannula into an end-to-side graft or inserted a DPC to perfuse the
distal extremity at the time of ECMO insertion. The earlier the
intervention, the better: don’t wait for compartment syndrome to
develop to perform fasciotomy.
Distal perfusion catheter size and Outcome
• Distal limb perfusion was achieved with an introducer sheath or with a distal-
perfusion cannula. Incidence of limb ischemia (30.6% vs. 15.6%) and limb
ischemia requiring surgical intervention (15.4% vs. 6.25%) were significantly
higher for the introducer sheath compared with distal-perfusion cannula.
• Moreover patients supported on ECMO with a distal-perfusion cannula spent
a significantly longer time on ECMO compared to those with an introducer
sheath (11.9 vs 7.7 days).
• The mean cannula size was significantly greater than the mean introducer
sheath size (11.1 vs. 7.0 Fr). The cannula can ensure adequate and smooth
perfusion of the limb owing to its large caliber, its less turbulent flow, the
ability it provides to monitor the flow, and the option to attach a side port.
 Healthcare Matrix: Care of Patient(s) with….
Aims
Competencies
SAFE TIMELY EFFECTIVE EFFICIENT EQUITABLE PATIENT-CENTERED

Assessment
Yes Yes, vascular Yes, primary goal Yes, institution Yes Yes, family updated
PATIENT CARE
(Overall Assessment)
surgery notified of life preservation of ECMO in
Yes/No when pulse not with ECMO was timely fashion
detected achieved
 Yes, ECMO  …in a timely  …that was effective in  ECMO initiated in  Yes  Yes
MEDICAL KNOWLEDGE evaluation initiated manner preserving the emergency situation
(What must we know) patient’s life

Yes  Yes  Yes  Yes  Yes  Yes

INTERPERSONAL AND
COMMUNICATION SKILLS
(What must we say)

 Yes  Yes  Yes  Yes  Yes  Yes

PROFESSIONALISM
(How must we act)

 Yes, ACLS followed  Yes  Yes  Yes  Yes  Yes

SYSTEM-BASED PRACTICE and ECMO consulted
(What is the Process? appropriately
On whom do we depend and who
depends on us)

Improvement
N/A There are  Unclear if placement Knowing that young  N/A  N/A
PRACTICE-BASED LEARNING AND monitoring of introducer sheath is females with
IMPROVEMENT strategies which can associated with pulmonary disease
(What have we learned, what will we be employed for significant reduction in are at higher risk,
improve) early detection of limb ischemia DPC could have been
limb ischemia placed initially

© 2004 Bingham, Quinn Vanderbilt University

References
• Mohite PN, Fatullayev J, Maunz O, et al. Distal limb perfusion: Achilles' heel in peripheral
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580. doi:10.5535/arm.2014.38.4.575
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oxygenation. Ann Transl Med. 2017;5(5):103. doi:10.21037/atm.2017.03.01
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