Use of an Extracorporeal Membrane Oxygenation (ECMO) Circuit as a Bridge to Salvage a Major Upper Extremity Replant in a Critically Ill Patient
Patrick J. Greaney, Jr., M.D., Michael Cordisco, CCP, Daniel Rodriguez, CCP, Jordanna Newberger, CCP, Alan D. Legatt, M.D., Ph. D., Evan S. Garfein, M.D..
Montefiore Medical Center, Bronx, NY, USA.
Purpose: Major replantation of the upper extremity is defined as replantation at or above the level of the wrist. Selection of appropriate candidates is complex and requires consideration of many patient and injury associated factors. With respect to age, younger patients, are deemed to have an advantage over more elderly patients due to improved nerve regeneration, and many advocate making every effort to replant this population. Herein we describe the use of an extracorporeal membrane oxygenation (ECMO) circuit as a bridge for short term preservation of the extremity in a young patient with an acute, concomitant systemic illness. In the authors’ opinion, use of ECMO perfusion is a viable means of maintaining extremity perfusion over hours or days and may lead to broadened replant criteria in patients with associated injuries.
Case report: A 19 year-old, right-hand dominant female presented after being ejected as an unrestrained rear seat passenger from a car. The patient sustained an amputation of the right upper extremity at the level of the proximal humerus. Although replantation was performed, the patient suffered a cardiac arrest postoperatively, most likely as the result of a transfusion reaction. Cardiopulmonary resuscitation was successful, however, with ongoing blood/capillary fluid loss from the extremity in the face of hemodynamic instability, the decision was made to clamp the reconstructed blood vessels supplying the replanted extremity.
Due to the age of the patient and since an identifiable cause for the arrest had been found and addressed, an ECMO circuit was deemed a possible means to preserve the extremity while the patient was stabilized. The extremity remained connected to the ECMO circuit for approximately 72 hours and was cooled to approximately thirty degrees Fahrenheit to decrease metabolic demand. Hand and finger viability, as determined by capillary refill, remained excellent during the duration. Some areas of proximal arm muscle as well as volar forearm muscle near the fracture sites proceeded to demarcate. In light of moderate muscle demarcation and developing fungemia, further attempts at replanting the extremity were abandoned after discussing the matter with the patient’s family.
Conclusions: While achieving functional recovery in the replanted upper extremity can be challenging, the associated morbidity related to the loss of an extremity is significant. Every effort should be made to reattach the arm of a young patient, especially if restoration of function is possible. Nevertheless, replantation efforts should not jeopardize the chances of survival (“life before limb”) of the patient. In the case of patients who have significant concomitant injuries, replantation may have to be delayed until the patient is stable enough to undergo a lengthy procedure that is accompanied by major blood loss and a high transfusion requirement. This delay may extend beyond the time limit for replantation due to irreversible muscle and nerve ischemia. The use of extracorporeal circulation is possible in this situation and may provide a means to extend the time-window for replantation of the extremity in the setting of the unstable patient.
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