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