Prolonged extracorporeal life support (ECLS) for varicella pneumonia

Objective: To review the institutional experience of a national tertiary referral center for extracorporeal life support (ECLS) in severe varicella pneumonia. Data Sources: Hospital records and ECLS flow sheets. Study Selection: All pediatric (nonneonatal) and adult patients who were treated for varicella pneumonia with ECLS at the University of Michigan Medical Center between 1986 and 1995. Data Extraction: Diagnosis of varicella pneumonia was made by history of recent exposure to chickenpox, progressive dyspnea, fever, a characteristic diffuse, vesicular rash, and a supporting chest roentgenogram. Indications for ECLS included a shunt fraction of >30% or Pao(2)/FIo(2) ratio of (80 despite maximal conventional therapy, which included aggressive diuresis, blood transfusions to optimize oxygen carrying capacity, pressure-controlled/inverse ratio ventilation, and intermittent prone positioning. Data Synthesis: Between 1986 and 1995, 191 patients were referred for ECLS. Among these patients, there were 51 (27%) cases of viral pneumonia, of which nine cases were due to acute varicella-zoster infection. Intravenous acyclovir was administered to eight of the nine patients. Of the nine patients, two patients improved using conventional ventilator management, and seven patients underwent ECLS. Overall survival on ECLS was 71% (5/7). The mean (+/- SD) alveolar arterial oxygen gradient and Pao(2)/FIo(2) ratio were 533 +/- 101 torr (71.3 +/- 13.5 kPa) and 67 +/- 24, respectively. The median duration of mechanical ventilation before ECLS and the subsequent duration of ECLS were 4 and 12.8 days, respectively. One of the deaths was from progressive right heart failure secondary to pulmonary hypertension and the other death was from overwhelming Pseudomonas sepsis. Conclusions: Early recognition of imminent pulmonary failure and rapid institution of ECLS are critical in the successful management of severe, life-threatening varicella pneumonia.