Butzko Ryan, Narasimhan Mangala
Department of Pulmonary, Critical Care and Sleep Medicine, Northwell Health, Long Island Jewish Medical Center, New Hyde Park, NY, USA.
Perfusion. 2022 Jul;37(5):530-532. doi: 10.1177/02676591211003874. Epub 2021 Mar 26.
Point-of-care ultrasound (POCUS) is widely utilized to make timely decisions regarding patient care. This approach allowed us to diagnose the cause of acutely rising transaminases in a patient in severe ARDS secondary to influenza pneumonia requiring veno-venous extracorporeal membrane oxygenation (VV-ECMO).
A 36-year-old female presented with acute hypoxemic respiratory failure secondary to influenza A infection. Within 24 hours, she required intubation and met severe ARDS criteria with a PaO/FiO ratio of 62. She was managed with high PEEP and low tidal volume ventilation strategy, however her clinical status continued to deteriorate and the decision was made to pursue VV-ECMO. Within hours of cannulation her aspartate aminotransferase (AST) dramatically increased from 736 to 4512 µ/L, with concurrent mild increases in alanine aminotransferase (ALT) and creatine phosphokinase (CPK). Point-of-care ultrasound was performed which revealed a complete absence of flow in the hepatic vein, secondary to acute obstruction by an 25-French drainage catheter for the ECMO circuit. The catheter was exchanged with a smaller French catheter and the patient's transaminases and CPK levels quickly decreased and returned to normal within several days.
Budd-Chiari syndrome (BCS) is a rare but potentially life-threatening condition caused by acute obstruction of hepatic vein blood flow that can lead to fulminant liver failure if left untreated. BCS is usually caused by a hepatic vein thrombus, however any mechanical obstruction can lead to the same pathology. Point-of-care ultrasound lead to a prompt diagnosis and allowed for quick action to correct the obstruction. Although BCS is not a common problem with VV-ECMO, the syndrome should always be on the differential of any patient on VV-ECMO with acutely rising transaminases.
Ultrasound played an integral role in providing a crucial diagnosis of BCS secondary to obstruction by an ECMO drainage catheter.
床旁超声（POCUS）被广泛用于就患者护理做出及时决策。这种方法使我们能够诊断出一名因流感肺炎继发严重急性呼吸窘迫综合征（ARDS）且需要静脉 - 静脉体外膜肺氧合（VV - ECMO）治疗的患者急性转氨酶升高的原因。
一名36岁女性因甲型流感感染出现急性低氧性呼吸衰竭。在24小时内，她需要插管，并符合严重ARDS标准，动脉血氧分压/吸入氧分数值（PaO/FiO）为62。她接受了高呼气末正压（PEEP）和低潮气量通气策略治疗，然而她的临床状况持续恶化，于是决定采用VV - ECMO治疗。插管后数小时内，她的天冬氨酸转氨酶（AST）从736急剧升至4512µ/L，同时丙氨酸转氨酶（ALT）和肌酸磷酸激酶（CPK）略有升高。进行了床旁超声检查，结果显示肝静脉完全无血流，这是由于ECMO回路的一根25法式引流导管急性阻塞所致。将该导管更换为较小法式导管后，患者的转氨酶和CPK水平迅速下降，并在数天内恢复正常。
布加综合征（BCS）是一种罕见但可能危及生命的疾病，由肝静脉血流急性阻塞引起，如果不治疗可导致暴发性肝衰竭。BCS通常由肝静脉血栓形成引起，然而任何机械性阻塞都可导致相同的病理改变。床旁超声检查促成了快速诊断，并使得能够迅速采取行动纠正阻塞。虽然BCS在VV - ECMO治疗中并非常见问题，但对于任何接受VV - ECMO治疗且转氨酶急性升高的患者，该综合征都应列入鉴别诊断范围。
超声在对ECMO引流导管阻塞继发的BCS进行关键诊断方面发挥了不可或缺的作用。
