A 34-year-old healthy woman presented with a two-week history of influenza, and was treated with clarithromycin.
A week later, she presented progressive respiratory distress, consulting the Emergency Department in the second region of Chile (1,400 km from Santiago).
The patient is described tachypneic and desaturated with a relapse mask, so she is transferred to the Intensive Care Unit (ICU) with the diagnosis of severe acute respiratory failure.
The blood count showed 17,300 leukocytes with 61% blasts and thrombocytopenia.
A chest X-ray revealed bilateral pulmonary infiltrates.
Chest computed tomography (CT) shows interstitial infiltrates with irregular distribution, areas of ground glass and alveolar filling in patches.
The patient had progressive deterioration of the ̄s position (PaO2/FiO2 = 62.5), so she was referred to our center 24 hours after admission.
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Febrile, hypotensive, tachy, poorly perfused admission, with APACHE II and LIS (lung injury score) of 19 and 3.5 points, respectively.
Hemodynamic resuscitation, antibiotic therapy (ceftriaxone, moxifloxacin, cotrimoxazole and fluconazole) and corticosteroids were initiated.
It was studied with Gram stain and culture of sputum smear positive for Mycobacterium pneumoniae, sputum culture positive for hemocultive agent, viral panel, serology for Mycoplasma pneumoniae, Chla my days and cytomegalovirus, urinary antigen for Streptococcus pneumoniae and
Bronchoalveolar lavage (BAL) was not performed due to blood gas compromise.
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Echocardiography showed a preserved left ventricle with controlled systolic pressure and after 1,000 ml of crystalloids and 0.12 ug/kg/minute of norepinephrine infusion.
Subsequently, ARM7 was performed without response.
Five hours after admission, the patient was placed in prone position, thus totaling 72 hours.
With this technique, it is possible to reduce partially and transiently the rate of consolidation.
A chest CT scan showing worsening of the pulmonary infiltrates is performed when the patient is in a supine position with conventional MV.
Three days after treatment, the patient did not improve and PaCO2, so VAFO (Sensor Medics 3100B, Yorba Linda, CA, USA) was started and the strategy improved.
In parallel, the myelogram confirmed myelomonocytic acute myeloid leukemia (M4FAB).
Considering the lack of response to antibiotic and steroid therapy and in the absence of other causes, pulmonary compromise due to leukemia arises.
Chemotherapy with cytarabine and idarubicin was started seven days after admission.
After 108 hours of HFOV, she developed pneumothorax that was drained and, nevertheless, her gas showed a PaO2 of 45 mmHg with 100% FiO2.
Under these conditions, it was decided to install percutaneous fixation extracorporeal (NovaLung GmbH, Hechingen, Germany) through arterial (15 F) and venous (17 F) cannulas inserted surgically, respectively.
The patient overcomes hypoxemia and hypercapnia allowing ventilatory support with low airway pressures.
To achieve an extracorporeal flow between 1.7 and 2.2 l/minute (estimated as 22% of native cardiac output [CG]), intravenous fluids and milrinone were added.
The CG was monitored with PiCCO8 system.
After seven days, a thorax CAT scan was performed.
Two days later, after progressively reducing gas flow, the system was removed without complications.
One week later, the patient was extubated and later discharged from the ICU.
