An 18 year old boy who was studying in a residential school in Bangalore, active in sports including horse-riding, football and cricket started getting joint pain and fever in November 2022. After being treated for a month by a rheumatologist, he developed breathing difficulty and abdominal pain and was then admitted in a tertiary care cardiac specialty hospital in February ‘23.
He was diagnosed to have severe leak of the aortic and mitral valves in his heart, along with congestive heart failure. Despite intensive care management with inotropes and other medication, he developed worsening liver and kidney functions as his heart was inefficient to maintain adequate blood flow to his vital organs. He also started having collection of fluid in his lungs which made it difficult for him to breathe and thus required increasing oxygen support.
As things got worse, he was transferred to MMM and on the day of admission, he had a cardiac arrest and was revived only after 15 minutes of intensive cardiopulmonary resuscitation. He was intubated and initiated on mechanical ventilation to support his lungs and heart. His multi-organ failure further worsened and now involved draining the collection of fluid around his lungs through chest tubes.
After a week of intensive care support, it was clear that correction of his leaking heart valves was the only way to save his failing organs. The risk in open heart surgery is significantly higher in patients with poor liver, kidney and lung function. On 7 March, ’23, a team of doctors headed by Dr Ravi Agarwal, Head of Pediatric Cardiac surgery, replaced the two heart valves in a surgery that lasted 6 hours.
“His damaged lungs and weak heart muscles continued to fail in providing adequate oxygenated blood supply to his body organs. After deliberating with the team, as well as his family, we initiated him on central ECMO (Extra Corporeal Membrane Oxygenation – an advanced treatment that supports the function of the failing heart and lungs). We created a plan to prevent and control infections, optimize nutrition and provide support to the failing kidney and liver function,” said Dr. Ravi Agarwal, Head of Pediatric Cardiac surgery.
“ECMO support involves removing the blood from the patient through large tubes through a series of high-tech equipment such as oxygenators and filters to take over the function of the failing heart, lungs, and kidneys. The blood needs to be maintained in a fluid state without clot formation by carefully regulated blood thinners while monitoring body temperature, oxygenation, organ perfusion, blood pressure and heart rates from minute to minute. This process needed the vigilance of an intensivist, perfusionist, nurse and physiotherapist for 24 hours a day for the two weeks the ECMO support was required,” said Dr. K. Sivakumar, Head of the Department of Paediatric Cardiology.
Senior paediatric intensivists Dr. Uday Charan, Dr. Selvakumar and Dr. Giridhar Gopal stayed with the patient round the clock for the next 14 days till he was weaned off the ECMO support. A team of perfusionists ensured that the prolonged ECMO support progressed without any complications. Aggressive respiratory care including bronchoscopy was performed to improve his lung function. Physiotherapy and nutrition optimization was done by a team of nursing staff, physiotherapists and nutritionists.
“However, the nature of his illness had the patient suffer significant muscle wasting of both skeletal and respiratory muscles that made it difficult for him to breathe and so, a tracheostomy was also done to support his weaning from mechanical ventilation. The combined efforts of the nursing and physiotherapy teams ensured he remained free of serious infections, bedsores, and other complications during his prolonged stay in the ICU and he was successfully weaned from respiratory support. He was finally discharged after having spent 58 days in the hospit al, post-surgery,” added Dr. Ravi Agarwal.