Conduta em obstrução por coágulo em cânula de duplo lúmen bicaval após diagnóstico guiado por ETE: relato de caso
Bibliographic record
Abstract
A oxigenação por membrana extracorpórea veno‐venosa é terapia estabelecida para pacientes com a síndrome do desconforto respiratório agudo. Uma complicação relacionada ao uso da oxigenação por membrana extracorpórea veno‐venosa é trombose apesar de anti‐coagulação adequada. Relatamos o diagnóstico e conduta em obstrução por coágulo em cânula de acesso único inserida pela veia jugular interna, guiada por ecocardiografia transesofageana. Paciente do sexo masculino de 39 anos desenvolveu síndrome do desconforto respiratório agudo e instabilidade hemodinâmica após episódio de aspiração pulmonar na UTI. Oito horas após a instalação de oxigenação por membrana extracorpórea veno‐venosa de acesso único, o perfusionista notou repentina redução no fluxo. A ETE revelou massa semelhante a um trombo obstruindo o portal de fluxo de entrada na VCS e o fluxo de saída na VCI estava intacto. Após tentativas sem sucesso para reposicionar a cânula, a equipe decidiu inserir cânula de entrada de fluxo adicional pela VCI. O catéter de acesso único foi, então, puxado até que sua ponta se posicionasse no átrio direito e todos os três portais do catéter fossem transferidos para os portais de infusão. A seguir, os fluxos e oxigenação melhoraram significativamente. Infelizmente, apesar dos esforços, o paciente foi a óbito 2 dias depois. O diagnóstico de obstrução de cânula da oxigenação por membrana extracorpórea veno‐venosa se baseia em velocidades reduzidas de entrada de fluxo, instabilidade hemodinâmica e oxigenação pobre do sangue. A ETE permite a avaliação dos fluxos dentro da cânula, e nesse caso foi encontrada obstrução. A técnica apresentada aponta para o fato de que em situação de obstrução de catéter causada por coágulo, existe alternativa factível para garantir interrrupção mínima do suporte hemodinâmico oferecido pela oxigenação por membrana extracorpórea veno‐venosa. Veno‐venous extracorporeal membrane oxygenation is an established therapy for patients with refractory acute respiratory distress syndrome (ARDS). One complication related to the use of veno‐venous extracorporeal membrane oxygenation is thrombosis despite proper anticoagulation. We report the diagnosis and management of a clot‐obstruction in a single site cannula placed through the internal jugular vein, guided by transesophageal echocardiography. A 39 year‐old male developed acute respiratory distress syndrome and hemodynamic instability after an episode of pulmonary aspiration in the ICU. Eight hours after placement of a single site veno‐venous extracorporeal membrane oxygenation, suddenly the perfusionist noticed a reduction in flow. TEE showed a thrombus‐like mass obstructing the inflow port in SVC and inflow at IVC was intact. After unsuccessful attempts to reposition the cannula, the team decided to insert additional femoral inflow cannula through the IVC. The single site catheter was then pulled out until its tip was positioned in the right atrium and all three ports of the catheter were switched to the infusion ports. After this, flows and oxygenation improved significantly. Unfortunately, despite all of the efforts, the patient died 2 days later. The diagnosis of veno‐venous extracorporeal membrane oxygenation cannula obstruction is based on reduced inflow rates, hemodynamic instability and poor oxygenation of blood. TEE allows evaluation of the flows inside the cannula and in this case, an obstruction was found. The management presented points to the fact that in a situation of catheter obstruction caused by a clot, there is a feasible alternative to assure minimal interruption of the hemodynamic support offered by the veno‐venous extracorporeal membrane oxygenation.
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How this classification was reachedexpand
Full frame distilled prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. Learned from the 10,348 direct Codex labels and 10,348 direct Gemma labels. Candidate is the union of thresholded teacher heads; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels or direct frontier model labels.
Codex and Gemma teacher scores by category
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.002 | 0.002 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.002 | 0.001 |
| Bibliometrics | 0.000 | 0.001 |
| Science and technology studies | 0.000 | 0.000 |
| Scholarly communication | 0.000 | 0.000 |
| Open science | 0.002 | 0.000 |
| Research integrity | 0.001 | 0.002 |
| Insufficient payload (model declined to judge) | 0.003 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one teacher head, not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".