Management
The patient was admitted to
the intensive cardiac care unit due to refractory shock requiring
mechanical circulatory support with VA-ECMO and IABP.
High flow ECMO (3.7-4L)
and aggressive fluid resuscitation were needed in the first few hours to
keep the patient well perfused. Stress steroids were also given. After
48-72 hours the patient presented progressive hemodynamic improvement
until VA-ECMO support could be weaning after five days. Biventricular
function was completely recovered.
Another
problem during admission was severe respiratory failure. Deep sedation,
muscular relaxation, high fraction of oxygen in inspired air (FiO2) and
high requirement of positive end-expiratory pressure was needed to
achieve normoxemia. There was no response to empiric antibiotic therapy
and aggressive negative fluid balance. Suspecting diffuse pulmonary
vasoconstriction with ventilation-perfusion mismatch, inhaled nitric
oxide (NO) was started. An excellent response was achieved with a rapid
improvement of oxygenation allowing to reduce the FiO2 requirements. A
bronchoscopy was performed, isolating a methicillin-resistant
staphylococcus aureus in the cultures with no evidence of complicated
pneumonia in the CT scan.
After seven days of
target antibiotics the patient remained apyrexial without other signs of
infection so treatment was suspended with good evolution.
Neurologically, the
patient evolved without sequelae.
To confirm the
diagnosis of allergic reaction, tryptase levels were determined at the
beginning and 24 hours later. Finally allergy tests were performed
resulting positive for amiodarone and confirming the diagnosis.
One year after the event the patient is asymptomatic with functional
class-I of NYHA, persisting in AF controlled with beta-blocker treatment
and anticoagulated with a direct oral anticoagulant