Case study: Transfer without ECMO of a patient critically ill with pancreatitis and ARDS

The assessment at the time of activation (day 3 after admission into the ICU) was:

• Severe ARDS (acute respiratory distress syndrome) with PaO₂/FiO₂ ratio of less than 100. The patient was sedated with midazolam, propofol, and remifentanil. He did not receive a neuromuscular blocking agent. He received invasive ventilation with positive end-expiratory pressure (PEEP) 10, fraction of inspired oxygen (FiO₂) 80%, tidal volume (VT) 470mL (VT / kilogram of ideal body weight (IDW) 6.2mL/kg), respiratory rate of 22 breaths per minute
• Abdominal compartment syndrome was suspected (large amount of free liquid in the abdominal cavity, necrosis of pancreas tail) but no abdominal pressure was available
• Acute kidney injury KDIGO 1
• Hemodynamic shock supported by continuous intravenous (IV) noradrenaline (0.1µg/kg/min). No heart failure.
• The patient was transported at day 4 after admission in our Falcon 900EX, with a fully trained ICU/ECMO team (cardiac surgeon, ICU physician, ICU nurse, ECMO nurse).

The assessment before leaving the hospital was:

• ARDS with PaO₂/FiO₂ 122, FiO₂ 80% (ground altitude), plateau pressure 22, tidal volume 6mL/kg IBW, RR 22, PEP 10
• Stable kidney injury (KDIGO 1), no need for renal replacement therapy
• Hemodynamic support by noradrenaline (0.1µg/kg/min). Transthoracic echocardiography found a normal function, without pericardial effusion, no sign of fluid overload.
• The decision was made to transport the patient without ECMO to the aircraft, after discussion with the treating medical team, as the patient had been stable / slightly improving for 48hrs.

In case of a deterioration, our medical team had several measures to improve the patient’s medical condition before ECMO:

• Neuromuscular blocking agents
• PEP titration to find the optimal level
• FiO₂ up to 100%
• Prone positioning (in our Falcon 900EX, our large stretchers allow us to safely prone our patients, and our medical ECMO/ICU teams are well trained for the prone positioning of our patients).

  The medical team was ready to perform a jugulo-femoral cannulation for a venovenous ECMO at any point of the journey

The medical team was ready to perform a jugulo-femoral cannulation for a venovenous (VV) ECMO at any point of the journey; the veins had been checked by ultrasound to make sure of their anatomical location and permeability.

During the flight the patient improved and, on arrival, the FiO₂ was 70% and the noradrenaline had been weaned. He was safely handed over to the receiving French ICU.

In this case, the evolution of the severe pancreatitis with severe ARDS was difficult to prognosticate. As the local medical team, in charge of the patient, required a transfer to an ECMO center, the decision to transport with our ECMO team was taken.

The expertise of the medical team, with regular practice and training, allowed us to take all parameters into account in the risk–benefit balance, and to avoid iatrogenics due to a non-necessary cannulation and ECMO support.

Recap

In a complex medical operation, Airlec, renowned for its medical transport expertise, was called upon to transfer a critically ill 43-year-old patient back to France. The patient, who was vacationing on an island lacking specialized medical facilities, found himself in a dire situation with severe abdominal pain and vomiting.

Upon admission, medical tests revealed pancreatitis with a concerning lipase level, but no gallstones were found. His condition rapidly deteriorated, leading to acute respiratory failure and hemodynamic instability, requiring intubation, sedation, and vasopressors.

Recognizing the need for specialized care, the local medical team sought a transfer to a facility equipped with ECMO capabilities. With the patient’s condition worsening, Airlec was tasked with safely transporting him to an ECMO center in France.

At the time of activation, the patient faced severe ARDS, abdominal compartment syndrome, acute kidney injury, and hemodynamic shock. Despite the complexity of the situation, Airlec assembled a fully trained ICU/ECMO team, including a cardiothoracic surgeon, ICU physician, ICU nurse, and ECMO nurse, to accompany the patient.

Before departure, the medical team assessed the patient’s condition, noting improvements in respiratory and kidney function, albeit with ongoing hemodynamic support. After careful deliberation and consultation with the treating medical team, it was decided to transport the patient without ECMO, considering his stable condition.

The decision-making process, guided by the expertise of the medical team, prioritized the patient’s wellbeing while mitigating the unnecessary risks associated with ECMO support

Return to France

During the flight, the patient’s condition continued to improve, with decreased reliance on respiratory support and vasopressors. The medical team remained vigilant, ready to perform a jugulo-femoral cannulation for VV ECMO if necessary, showcasing their preparedness and expertise.

Upon arrival in France, the patient was safely transferred to the receiving ICU, where he could receive further specialized care. This successful operation highlights the importance of timely and expert medical transport in critical situations.

The decision-making process, guided by the expertise of the medical team, prioritized the patient’s wellbeing while mitigating the unnecessary risks associated with ECMO support. Through careful consideration of the risk–benefit balance, Airlec ensured the best possible outcome for the patient, underscoring the importance of specialized medical transport services in saving lives.