Online ISSN: 2187-2988 Print ISSN: 0911-1794
特定非営利活動法人日本小児循環器学会 Japanese Society of Pediatric Cardiology and Cardiac Surgery
Pediatric Cardiology and Cardiac Surgery 33(1): 50-57 (2017)

症例報告Case Report

緑膿菌市中肺炎に敗血症性ショックを合併しVA ECMOで救命したFontan術後の1例Successful Treatment of Pseudomonas aeruginosa Community-acquired Pneumonia and Septic Shock using Venoarterial Extracorporeal Membrane Oxygenation after the Fontan Procedure

山形大学医学部小児科学講座Department of Pediatrics, Yamagata University Faculty of Medicine ◇ Yamagata, Japan

受付日:2016年5月23日Received: May 23, 2016
受理日:2016年11月30日Accepted: November 30, 2016
発行日:2017年1月1日Published: January 1, 2017

症例は33歳女性.肺動脈閉鎖症,両大血管右室起始症で12歳時にFontan手術を受けた.経過良好でクリニック看護師として就労していた.入院2日前から易疲労感があり,呼吸困難感が増悪したため,入院当日の夜間に山形大学医学部附属病院へ救急搬送された.来院時の意識は概ね清明で,著明な湿性咳嗽を認めた.大葉性肺炎の診断でICUに入室し,循環維持目的にドブタミン,カルペリチドで治療を開始した.数時間でショックになったため容量負荷,ノルアドレナリンで治療を行ったが,不整脈から意識障害をきたし,気管挿管を要した.昇圧剤,容量負荷,ステロイド静注,一酸化窒素吸入に反応しない低血圧が遷延し循環不全に陥ったため,入院3日目にVA ECMOを導入した.ECMO導入後に入院時血液培養,喀痰培養の結果が判明し,緑膿菌市中肺炎,敗血症と診断した.心機能障害は徐々に改善し,敗血症性心筋症と診断した.入院14日目にECMOを離脱し,入院54日目に退院した.退院前頭部CTでは,低酸素や虚血の影響を示唆する所見を認めなかった.本報告は,緑膿菌市中肺炎,敗血症性ショックをきたしたFontan術後症例を救命し得た,初めての報告である.

The patient was a 33-year-old female who had undergone the Fontan procedure at 12 years for pulmonary atresia with a double-outlet right ventricle. She was working as a nurse at a medical office. She noticed general fatigue and dyspnea 2 days prior to admission. Although she took cefcapene pivoxil, she developed dyspnea and was admitted to Yamagata university hospital after a visit to the emergency unit at night. She was alert, and had a severe, productive cough. She was subsequently diagnosed with lobar pneumonia that required intensive care. She progressed to septic shock a few hours after admission. Although treatment for septic shock was initiated, her condition deteriorated because of arrhythmia, and she required mechanical ventilation. Three days after admission, venoarterial extracorporeal membrane oxygenation (VA ECMO) was initiated for circulatory failure, which had been refractory to the escalation of inotropic support, fluid resuscitation, corticosteroids and inhaled nitric oxide. Both blood and sputum cultures revealed the presence of Pseudomonas aeruginosa, and she was diagnosed with P. aeruginosa community-acquired pneumonia and sepsis. With intensive treatment, her cardiac function gradually stabilized, and she was diagnosed with septic cardiomyopathy. She was decannulated from ECMO on day 14 after admission, and was discharged on day 54. Brain CT before discharge revealed no findings of hypoxia or hypoperfusion. This is the first report of the successful treatment of P. aeruginosa community-acquired pneumonia and septic shock using VA ECMO after previous Fontan procedure.

Key words: Fontan; ECMO; septic shock; Pseudomonas aeruginosa; community-acquired pneumonia

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