title: Extracorporeal membrane oxygenation as a bridge to liver transplantation for acute respiratory distress syndrome-induced life-threatening hypoxaemia aggravated by hepatopulmonary syndrome.
abstract: BACKGROUND
  Combined with massive lung aeration loss resulting from acute respiratory distress syndrome, hepatopulmonary syndrome, a liver-induced vascular lung disorder characterized by diffuse or localized dilated pulmonary capillaries, may induce hypoxaemia and death in patients with end-stage liver disease.
  
  
  METHODS
  The case of such a patient presenting with both disorders and in whom an extracorporeal membrane oxygenation was used is described.
  
  
  RESULTS
  A 51-year-old man with a five-year history of alcoholic cirrhosis was admitted for acute respiratory failure, platypnoea and severe hypoxaemia requiring emergency tracheal intubation. Following mechanical ventilation, hypoxaemia remained refractory to positive end-expiratory pressure, 100% of inspired oxygen and inhaled nitric oxide. Two-dimensional contrast-enhanced (agitated saline) transthoracic echocardiography disclosed a massive right-to-left extracardiac shunt, without patent foramen ovale. Contrast computed tomography (CT) of the thorax using quantitative analysis and colour encoding system established the diagnosis of acute respiratory distress syndrome aggravated by hepatopulmonary syndrome. According to the severity of the respiratory condition, a veno-venous extracorporeal membrane oxygenation was implemented and the patient was listed for emergency liver transplantation. Orthotopic liver transplantation was performed at Day 13. At the end of the surgical procedure, the improvement in oxygenation allowed removal of extracorporeal membrane oxygenation (Day 5). The patient was discharged from hospital at Day 48. Three months after hospital discharge, the patient recovered a correct physical autonomy status without supplemental O2.
  
  
  CONCLUSIONS
  In a cirrhotic patient, acute respiratory distress syndrome was aggravated by hepatopulmonary syndrome causing life-threatening hypoxaemia not controlled by standard supportive measures. The use of extracorporeal membrane oxygenation, by controlling gas exchange, allowed the performing of a successful liver transplantation and final recovery.
authors.affiliation: Multidisciplinary Intensive Care Unit, Department of Anesthesiology and Critical Care, La Pitié-Salpêtrière Hospital, Assistance Publique-Hôpitaux de Paris, UPMC Univ Paris 06, 83 Bd de l'Hôpital, 75013, Paris, France.
authors.forename: Antoine
authors.initials: A
authors.lastname: Monsel
authors.forename: Hervé
authors.initials: H
authors.lastname: Mal
authors.forename: Hélène
authors.initials: H
authors.lastname: Brisson
authors.forename: Rubin
authors.initials: R
authors.lastname: Luo
authors.forename: Daniel
authors.initials: D
authors.lastname: Eyraud
authors.forename: Corinne
authors.initials: C
authors.lastname: Vézinet
authors.forename: Chung Hi
authors.initials: CH
authors.lastname: Do
authors.forename: Qin
authors.initials: Q
authors.lastname: Lu
authors.forename: Jean-Christophe
authors.initials: JC
authors.lastname: Vaillant
authors.forename: Laurent
authors.initials: L
authors.lastname: Hannoun
authors.forename: Pauline
authors.initials: P
authors.lastname: Houssel
authors.forename: François
authors.initials: F
authors.lastname: Durand
authors.forename: Jean-Jacques
authors.initials: JJ
authors.lastname: Rouby
mesh_terms: D015199:Extracorporeal Membrane Oxygenation; D020065:Hepatopulmonary Syndrome / Q000150:complications* / Q000601:surgery; D006801:Humans; D000860:Hypoxia / Q000209:etiology* / Q000628:therapy*; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D012128:Respiratory Distress Syndrome / Q000150:complications* / Q000601:surgery; D014850:Waiting Lists