Severe hypothermia is a life-threatening condition that often causes hemodynamic instability or cardiac arrest and carries a high risk of mortality. The use of VA-ECMO in this indication has greatly improved the prognosis of patients

1. Chen H, Yuan W, Sun X, Sun Y, Zhang J and Wu H*
Department of Cardiovascular Surgery, The Second Affiliated Hospital of Dalian Medical University, China
*
Corresponding author:
Haibo Wu,
Department of Cardiovascular Surgery, The
Second Affiliated Hospital of Dalian Medical
University, No. 467, Zhongshan Rd, Dalian
116011, China, Tel: +86 17709876970;
E-mail: hbwu9@hotmail.com
Received: 20 Dec 2022
Accepted: 17 Jan 2023
Published: 27 Jan 2023
J Short Name: COS
Copyright:
©2023 Wu H, This is an open access article distributed
under the terms of the Creative Commons Attribution Li-
cense, which permits unrestricted use, distribution, and
build upon your work non-commercially.
Citation:
Wu H. A Case Report of Hypothermia Rescued by
Veno-Arterial Extracorporeal Membrane Oxygenation.
Clin Surg. 2023; 8(8): 1-3
A Case Report of Hypothermia Rescued by Veno-Arterial Extracorporeal Membrane
Oxygenation
Clinics of Surgery
Case Report ISSN: 2638-1451 Volume 8
clinicsofsurgery.com 1
1. Abstract
1.1. Background: Severe hypothermia is a life-threatening con-
dition that often causes hemodynamic instability or cardiac arrest
and carries a high risk of mortality. The use of VA-ECMO in this
indication has greatly improved the prognosis of patients.
1.2. Case Presentation: We describe an incredible case involving
the complete recovery of a 47-year-old man placed on VA-ECMO
for cardiogenic shock and protracted ventricular fibrillation caused
by hypothermia. The patient was discharged home in 20 days with
no neurologic sequelae.
1.3. Conclusions: Extracorporeal Life Support (ECLS) with Car-
diopulmonary Bypass (CPB) or Extracorporeal Membrane Oxy-
genation (ECMO) has been recommended as the gold standard for
the treatment of severe hypothermia due to its rapid availability
and the possibility of prolonged support. Our case demonstrates
the effectiveness of ECMO in treating patients with hypothermic
cardiogenic shock. At the same time, nutritional support and re-
habilitation therapy play an integral role in the whole treatment
process. Therefore, it is recommended that such patients be man-
aged by an experienced cardiac team that can evaluate the patient’s
condition in multiple aspects.
2. Introduction
Accidental hypothermia can be divided into four stages based on
clinical symptoms and core temperature according to the Swiss
clinical staging of hypothermia [1]. Severe hypothermia is a
life-threatening condition that often causes hemodynamic instabil-
ity or cardiac arrest and carries a high risk of mortality, but it can
be successfully treated with appropriate measures. The first reports
on the use of CPB for extracorporeal rewarming in accidental hy-
pothermia date back to 1967 [2]. Nowadays, Extracorporeal Life
Support (ECLS) with Cardiopulmonary Bypass (CPB) or Extra-
corporeal Membrane Oxygenation (ECMO) has been recommend-
ed as the gold standard for the treatment of severe hypothermia
due to its rapid availability and the possibility of prolonged sup-
port [3].
In this article, we will describe an incredible case involving the
complete recovery of a 47-year-old man placed on VA-ECMO for
cardiogenic shock and protracted ventricular fibrillation caused by
hypothermia.
3. Case Presentation
A 47-year-old male was found in the street in a coma at 5:30 am.
The man’s breathing was very weak, the core body temperature
was extremely low, and the major arteries were not palpable. 2mg
of Epinephrine and 100mg of dopamine with 250ml of NS were
immediately administered by the medical staff at the scene, and
a balloon mask was used to assist ventilation. After being trans-
ferred to our hospital, the patient was immediately intubated in the
emergency room, received CPR and other rescue measures, and
was transferred to the intensive care unit for further treatment. The
decision was made to initiate veno-arterial extracorporeal mem-
brane oxygenation because of severe core hypothermia, recurrent
ventricular fibrillation, and tachycardia which did not respond to
amiodarone and Lidocaine, while arterial blood gas analysis sug-
gested acidosis and hypoxia. Percutaneous cannulas were placed
Keywords:
Hypothermia;Ventricular fibrillation; Extracorpore-
al membrane oxygenation; Rewarming

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Volume 8 Issue 8 -2022 Case Report
in the left femoral artery and right vein and VA ECMO was com-
menced. Lung-protective ventilation, paralysis, and sedation were
maintained. Therapeutic hypothermia was carried out through the
ECMO circuit, and the target temperature (32°C) was obtained
within 2 hours after the system was started. No apparent abnor-
malities were shown by coronary angiography and echocardiogra-
phy. At 11:39 a.m., after repeated defibrillation, the sinus rhythm
resumed as shown by the monitor, and blood pressure has risen
to 85/48mmHg. After nearly 10 hours, we observed a decrease in
the oxygen saturation of the patient’s right fingertip on the mon-
itor, while the blood pressure of the left brachial artery remained
normal, and the ECMO flow also decreased, which did not match
the rotational speed. Hence, we consider gradual recovery of car-
diac function. The oxygen saturation of the patient’s right hand
improved after the downregulation of ECMO rotational speed. The
ECMO system and mechanical ventilation were used to maintain
oxygenation to treat respiratory distress, while meropenem, vanco-
mycin, and ornidazole are used to treat lung infections. Therapeu-
tic mild hypothermia was maintained for 7 days with deep sedation
by intravenous administration of midazolam and vecuronium was
used to combat shivering. Rewarming was carried out at a rate
of 0.5°C every 12 hours, and temperature changes were strictly
controlled during resuscitation. BIS monitoring system and intrac-
ranial Doppler were also used to monitor changes in consciousness
and intracranial blood flow. VA-ECMO and Intra-Aortic Balloon
Pump (IABP) was removed on day 2. Continuous Renal Replace-
ment Therapy (CRRT) was also used to treat progressive renal
failure until satisfied urine volume was obtained on day 9. Neuro-
logical complications and the patient’s consciousness were closely
assessed by the Glasgow Coma Scale. The patient awoke on day
10 and gradually transitioned to rehabilitation on day 16. The pa-
tient was discharged from the hospital on day 20.
4. Discussion
Out-of-hospital cardiopulmonary arrest patients who remain un-
conscious after resuscitation still have a poor prognosis [4]. The
poor neurologic outcome is related to the ‘reperfusion injury’ of
brain cells after the return of spontaneous circulation [5]. It has
been reported that Cardiopulmonary Resuscitation (CPR) for pa-
tients with out-of-hospital cardiac arrest using Cardiopulmonary
Bypass (CPB), coronary artery reperfusion therapy, and mild hy-
pothermia has achieved good results [6-8]. In this case, we timely
used various circulatory auxiliary devices such as VA-ECMO, and
Intra-Aortic Balloon Pump (IABP) for effective resuscitation and
combined with CRRT for renal replacement therapy. At the same
time, according to our experience, the protection of the nervous
system in circulatory assistance and later rehabilitation treatment
is extremely vital.
As a protective measure, the lower pacemaker will emit one or
a series of excitations that excite the atria or ventricles when the
higher pacemaker is diseased or inhibited, resulting in arrest or
significantly reduced frequency. Ventricular escape rhythm and
ventricular fibrillation is more common in patients with severe
heart disease, such as acute myocardial infarction [9], myocarditis
[10], electrolyte disturbance [11], and low-temperature anesthesia.
Ventricular escape rhythm without atrial excitement is often an ar-
rhythmia near the end of life, which can lead to rapid death if de-
layed in treatment or not treated. In this case, the hypothermia in-
hibited the function of the sinoatrial node, resulting in ventricular
escape rhythm, repeated ventricular fibrillation, and hemodynamic
collapse. For such patients, our center advocates the establishment
of extracorporeal life support as soon as possible to replace the
cardiopulmonary function, to maintain a relatively stable circula-
tion to ensure the blood supply of organs throughout the body.
Hypothermia can be divided into four stages according to clinical
symptoms and core temperature. Severe hypothermia will lead to
functional failure of cardiovascular, respiratory, nervous, and oth-
er systems, and even lead to death. The treatment strategy is to
restore body temperature and organ functions, and for rewarming,
our center prefers slow rewarming to prevent left ventricular dias-
tolic dysfunction and ischemia-reperfusion injury [12, 13]. In ad-
dition, Extracorporeal Life Support (ECLS) has been recommend-
ed as the gold standard for the treatment of severe hypothermia [3].
Extracorporeal Membrane Oxygenation (ECMO) is a develop-
ment of extracorporeal circulation, which began to be used in the
1970s as temporary cardiopulmonary support for critically ill pa-
tients [14]. The generalized ECMO is often used to describe VV
or VA ECMO. VV ECMO is indicated for patients who require
only respiratory function support, such as severe Acute Respira-
tory Distress Syndrome (ARDS). VA ECMO is suitable for severe
heart disease, refractory ventricular fibrillation, or fulminant myo-
carditis. The establishment of VA ECMO requires the implantation
of two percutaneous vascular catheters, including an arterial cath-
eter and an intravenous catheter with the tip of the venous catheter
located at the inferior vena cava and atrial junction and the tip of
the arterial catheter located at the common iliac artery. The blood
flows into the extracorporeal oxygenator through the venous cath-
eter and into the systemic circulation through the arterial catheter
to supply blood and oxygen to the whole body. When the patient’s
heart resumes beating, IABP is used to reduce the patient’s cardiac
afterload and increase coronary blood flow to improve myocardial
oxygen supply. IABP is the implantation of an inflatable balloon
in the descending aorta. When the aortic valve opens during the
systolic period, the balloon deflates to form negative pressure in
the aorta, thus reducing systolic blood pressure and cardiac after-
load. The balloon is inflated when the aortic valve closes during
the diastolic period, thereby increasing diastolic blood pressure to
increase coronary blood flow [15].
Hypothermia-induced ischemia and hypoxia can cause liver and
kidney insufficiency, hence organ replacement therapy such as
CRRT is particularly important [16]. At the same time, considering

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the protective effects of low temperatures on brain metabolism, for
patients with cardiogenic shock receiving ECMO support, we rou-
tinely use ice caps for head cooling to protect brain function. Strict
temperature control in therapeutic hypothermia is very helpful to
the patient’s nervous system [17]. In addition, nutritional support
and rehabilitation therapy play an integral role in the whole treat-
ment process. Therefore, it is recommended that such patients be
managed by an experienced cardiac team that can evaluate the pa-
tient’s condition in multiple aspects.
References
1. Durrer B, Brugger H, Syme D. The medical on-site treatment of hy-
pothermia: ICAR-MEDCOM recommendation. High Alt Med Biol.
2003; 4(1): 99-103.
2. Davies DM, Millar EJ, Miller IA. Accidental hypothermia treated by
extracorporeal blood warming. Lancet. 1967; 1(7498): 1036-7.
3. Paal P, Pasquier M, Darocha T, Lechner R, Kosinski S, Wallner B, et
al. Accidental Hypothermia: 2021 Update. Int J Environ Res Public
Health. 2022; 19(1).
4. Edgren E, Hedstrand U, Kelsey S, Sutton-Tyrrell K, Safar P. Assess-
ment of neurological prognosis in comatose survivors of cardiac ar-
rest. BRCT I Study Group. Lancet. 1994; 343(8905): 1055-9.
5. Safar P. Cerebral resuscitation after cardiac arrest: research initiatives
and future directions. Ann Emerg Med. 1993; 22(2 Pt 2): 324-49.
6. Peralta R, Ryan DP, Iribrane A, Fitzsimons MG. Extracorpore-
al membrane oxygenation and CO2 removal in an adult after near
drowning. J Extra Corpor Technol. 2005; 37(1): 71-4.
7. Nagao K, Hayashi N, Kanmatsuse K, Arima K, Ohtsuki J, Kikushi-
ma K, et al. Cardiopulmonary cerebral resuscitation using emergen-
cy cardiopulmonary bypass, coronary reperfusion therapy and mild
hypothermia in patients with cardiac arrest outside the hospital. J Am
Coll Cardiol. 2000; 36(3): 776-83.
8. Eich C, Bräuer A, Kettler D. Recovery of a hypothermic drowned
child after resuscitation with cardiopulmonary bypass followed by
prolonged extracorporeal membrane oxygenation. Resuscitation.
2005; 67(1): 145-8.
9. Garcia R, Marijon E, Karam N, Narayanan K, Anselme F, Césari O,
et al. Ventricular fibrillation in acute myocardial infarction: 20-year
trends in the FAST-MI study. Eur Heart J. 2022; 43(47): 4887-4896.
10. Peretto G, Sala S, Rizzo S, Palmisano A, Esposito A, De Cobelli F,
et al. Ventricular Arrhythmias in Myocarditis: Characterization and
Relationships With Myocardial Inflammation. J Am Coll Cardiol.
2020; 75(9): 1046-1057.
11. El-Sherif N, Turitto G. Electrolyte disorders and arrhythmogenesis.
Cardiol J. 2011; 18(3): 233-45.
12. McCullough L, Arora S. Diagnosis and treatment of hypothermia.
Am Fam Physician. 2004; 70(12): 2325-32.
13. Ledoux A, Leger PS. Therapeutic management of severe hypother-
mia with veno-arterial ECMO: where do we stand? Case report and
review of the current literature. Scand J Trauma Resusc Emerg Med.
2020; 28(1): 30.
14. Mattox KL, Beall Jr. AC. Resuscitation of the moribund patient
using portable cardiopulmonary bypass. Ann Thorac Surg. 1976;
22(5): 436-42.
15. Parissis H, Graham V, Lampridis S, Lau M, Hooks G, Mhandu PC.
IABP: history-evolution-pathophysiology-indications: what we
need to know. J Cardiothorac Surg. 2016; 11(1): 122.
16. Karacan H, Valentin A, Carl P. [Mild therapeutic hypothermia after
cardiac arrest through continuous dialysis]. Ugeskr Laeger. 2009;
171(17): 1396-400.
17. Mizobuchi M, Nakamura S, Muranishi H, Utsunomiya M, Funatsu
A, Kobayashi T, et al. Hypothermia with extracorporeal membrane
oxygenation for sudden cardiac death and submersion. Am J Emerg
Med. 2010; 28(1): 115.e1-4.