A 71-year-old male presented to the Emergency Department with coughing and sputum for one month and dyspnea for 10 days. He had no obvious cause to cough and sputum with white mucus sputum one month ago, no chest tightness, chest pain, dizziness, fatigue and discomfort, no night orthopnea and lower limb edema. He was self-administered take orally "cefoxime plus ambroxol tablets" for 3 days, the illness did not improve. Before 10 days, the patients had difficulty breathing and gradually progressed from climbing the building. The patient went to the emergency department of the local hospital on December 6th, 2020. At that time, the oxygen of the finger vein was 46% (without oxygen), and then he was directly admitted to the intensive care unit for treatment. The partial pressure of arterial blood gas carbon dioxide (PaCO2) was 31mmHg (1mmHg = 0.133kPa) and the partial pressure of oxygen (PaO2) was 50mmHg. He was treated with "non-invasive ventilator ventilation for 3 days and endotracheal intubation ventilator assisted ventilation for 4 days", during which alveolar lavage was performed under fiber bronchoscope, "next-generation" sequencing technology (NGS) indicated positive results of Streptococcus pneumoniae, Streptococcus intermediate, Streptococcus oral, and lepidycovirus, and anti-infective treatment of "piperacillin-tazobactam + imipenem and cilastatin + moxifloxacin" was given, but the effect was not good. Blood and gas analysis was reviewed on December 12th showed pH 7.31, PaCO2 61mmHg, PaO2 61mmHg, lactic acid 2.72mmo1/L; Liver and kidney function: alanine transaminase 174.9U/L, ascorbic transaminase 221.7U/L, creatinine 149.7umol/L, urea nitrogen 15.23mmo1/L; Blood routine: WBC 16.46×10^9/L, hemoglobin 130g/L, platelet 54×10^9/L; C-reactive protein 120.44mg/L; Sputum culture showed Naromonas (no drug sensitivity results). Due to CO2 retention and low PaO2 were difficult to correct, the ECMO team of the intensive care department of our hospital was asked to conduct V-V ECMO support treatment for patient on December 13th, and then he with endotracheal intubation, ECMO tube, gastric tube, and the urinary tube was sent to our hospital at 17:00 on December 13th, 2020, to seek further advanced life support treatment and monitoring. He had Silicosis without systematic treatment for 16 years. He was on treatment for his type II diabetes mellitus and hypertension. Physical examination at admission: Body temperature: 36.8℃, Pulse: 93Times/min, Respiration: 21Times/min, Blood pressure: 115/67mmHg. Psychsanure, Rough breathing sounds in both lungs, lots of dry and wet rales can be heard, no pleural frictions. Heart rhythm, no noise. Abdominal flat soft, intestinal sound active. Urgent blood gas analysis after admission showed pH 7.34, PaCO2 46.1mmHg, PaO2 122mmHg, lactate 2.6mmol/L; Blood routine: WBC 6.84×10^9/L, hemoglobin 95g/L, platelet: 61×10^9/L, neutrophil percentage: 89.7%; C-reactive protein 248.53mg/L; Coagulation function: plasma antithrombin AT-Ⅲ51.1%, fibrinogen degradable substance 166.9ug/mL, fibrinogen concentration 1.15g/L, activated partial thromboplastin time 76.1 SEC; Liver and kidney function: aspartic aminotransferase 60U/L, alanine aminotransferase 59U/L, total bilirubin 20.8µmol/L, direct bilirubin 14.4µmol/L, urea 22.11mmol/L, creatinine 277µmol/L. Beside bed radiograph (Fig. 1A) showed bilateral lung infection with a small amount of pleural effusion on both sides. Admission diagnosis : 1. Severe pneumonia, ARDS 2. Sepsis, septic shock, acute liver damage, acute kidney injury 3. Silicosis stage II with infection 4. Hypertension grade, very high-risk group 5. Type 2 diabetes mellitus.
After admission, V-V ECMO life support treatment was continued (ECMO: Oxygen flow 4L/min, blood flow speed 3015RPM), endotracheal intubation assisted ventilation (CMV mode, peak airway pressure 32cmH2O, ventilation per minute 8.2L/min, exhaled tidal volume 379ml, total respiratory rate was 27Times/min, the respiratory ratio was 1:3:1, blood oxygen saturation was 98%). The symptomatic support treatment of "piperacillin-tazobactam + ciprofloxacin + compound sulfamethoxazole" combined with anti-infection, cough and phlegm relieving, spasmolysis and antiasthmatic, sedation and analgesia, anticoagulation, enteral nutrition, transfusion of blood components. On December 14th, 2020, the patient was changed to VV-V ECMO mode, and the endotracheal intubation was successfully removed. The patient was replaced with high-flow oxygen inhalation, and the blood oxygen saturation of the patient could be maintained above 95%. On December 15th, the patient developed dyspnea and decreased blood oxygen saturation, and an urgent examination of blood gas showed PH 7.38, PaCO2 45mmHg, PaO2 58.2mmHg, lactic acid 1.6mmol/L, and oxygen saturation 88%. The symptoms were not significantly improved after the treatment of more non-invasive ventilator-assisted ventilation. After the treatment of endotracheal intubation and invasive ventilator-assisted ventilation was performed again, the patient's oxygen in the finger vein could rise to 95%, and the blood gas condition was improved compared with the previous review. Two sputum cultures during the period indicated that multidrug-resistant Acinetobacter baumannii was sensitive to polymyxin. After the adjustment of antibiotics to "polymyxin + linezolid + ciprofloxacin", the infection indexes of the patient decreased significantly compared with before. On December 18th, review of calcitonin original, lactic acid from the previous rise, lung infection from the previous progress is shown in Fig. 1 (BC). After the intensive medical general consultation in our hospital, considering the possibility of secondary infection, finally, adjusted the anti-infection plan to "polymyxin + daptomycin + meropenem", review of infection index improved than before, bedside chest radiograph in pulmonary infection improved from the previous Fig. 1 (DE). On December 19th, the patient had a lot of sputum and was not easy to cough, and the effect of oral sputum suction was poor. Therefore, a tracheotomy was performed, and the oxygen saturation could be maintained above 95%. On December 23th, the airway was blocked by blood clots due to repeated oozing of blood in the airway, and the blood clots were cleared by a fiber bronchoscope beside the emergency room. The bronchi-ostomy kit was replaced, and the progressive decline of platelets and hemoglobin was monitored, D-dimer was increased, and APTT was prolonged. The anticoagulant regimen was adjusted and component blood transfusion was performed. Blood gas analysis on December 24th showed pH 7.19, PaCO2 41.5mmHg, PaO2 146mmHg, lactic acid 10.3mmol/L, Actual alkali surplus − 13.2mmol/L, actual hydrogen carbonate 13.9mmol/L. Quantitative detection of procalcitonin was 0.0053mg/L; C-reactive protein determination 151.16mg/L; Blood routine: leukocyte 22.38×10^9/L, hemoglobin 90g/L, platelet 67×10^9/L, Neutrophil percentage 83.2%; Coagulation function: fibrinogen degradable substance 121.8mg/L, D-dimer concentration 39.72mg/L, prothrombin time 14.4 SEC, prothrombin activity 58.2%, activated partial thromboplastin time 57.8 SEC. Beside bed chest radiograph (Fig. 1F) showed bilateral lung infection (the lesion of the right upper lung was slightly less than before, and the lesion of the left middle and lower lung was slightly worse than before), and a small amount of bilateral pleural effusion was slightly worse. Although repeatedly return etiology specimens and adjust the antibiotic solution, however, the patient's infection was further aggravated, and gradually showed less urine, renal impairment, fluid penetration, and drop in blood pressure. Although after full treatment, the patient's blood pressure is still difficult to maintain and the prognosis was extremely poor. We explained the patient's condition to the family in detail and signed for discharge on December 24th, 2020.