This case is a fairly straightforward and clear indication for VV ECMO. A previously healthy patient with acute ARDS and life threatening hypoxic-hypercarbic respiratory failure. He was taken to the operating room for fluoroscopic guided placement of a 31 Fr DL ECMO Cannula in the RIJ, placing the tip well within the intrahepatic IVC, but keeping the inflow port in the right atrium above the Eustachian valve. His course on ECMO was fairly unremarkable, with improvement in his lung fields on CXR with aggressive diuresis, early tracheostomy, and continued rest settings, although he did have some issues with GI bleeding from gastritis and was on a PPI infusion. His saturations slowly rose into the high 90’s as his lungs began contributing oxygenation. His compliance improved initially, but then stalled despite continued clearly on CXR and improved oxygenation. He was given a bolus of Solumedrol and within 8 hours had significant improvement, and was started on a course (Meduri protocol). He was weaned and decannulated on ECMO Day 11, and transferred to the pulmonary critical care team. After 3 days, he was off the ventilator and on trach collar, and at day 5 was sent back to the referring hospital ICU. Devon is an excellent example of when steroids can be very helpful in recovering ARDS on VV ECMO, namely patients with persistent still lungs from inflammation, despite adequate fluid removal. They can usually oxygenate well, but have trouble with achieving an adequate minute ventilation. Patient’s who will respond positively to steroids will usually show measurable improvement after the first or second daily bolus of 2mg/kg of Solumedrol. A positive response is followed by the full 32 tapering protocol. If patients fail to respond, the steroid is quickly discontinued to avoid the obvious risks in the face of zero benefit. Devon was transferred back with these instructions. He returned to see his ECMO physician in clinic at 2 months and was doing well generally, but was complaining of some persistent SOB. PFT’s were obtained:

This residual scarring and restrictive lung disease is very unusual in VV ECMO patients who do not have any pre-existing lung disease, and who are put on ECMO for acute ARDS and removed from harmful vent settings in a reasonable time. When Devon was asked when he completed his steroids at home, he asked “what steroids?”. Follow-up with the outside hospital discovered that they decided to stop his steroids when he got there because of his gastritis, and despite the request to continue the full course. Devon is a prime example of the importance of completing the full course of steroids in patients who demonstrate a definite improvement in compliance with the first couple doses.