Central venoarterial ECMO for a child with Clostridium sepsis and an open abdomen: A case report

Structured Abstract: Introduction Severe septic shock secondary to Clostridium sordellii carries a historically high case-fatality rate and is exceedingly rare in the pediatric population. Furthermore, the application of central venoarterial extracorporeal membrane oxygenation (VA ECMO) in a pediatric patient with clostridial sepsis and an open abdomen presents unique clinical considerations. Case Presentation A previously healthy 22-month-old male presented with small bowel obstruction secondary to segmental volvulus. He underwent emergent exploratory laparotomy, small bowel resection, and temporary abdominal closure with the gastrointestinal tract left in discontinuity. Postoperatively, he developed refractory septic shock, profound leukocytosis, acute renal failure, and massive capillary leak. Plasma cell-free DNA metagenomic sequencing rapidly identified polymicrobial bacteremia, including Clostridium sordellii and Clostridium perfringens . Due to escalating hemodynamic instability despite aggressive conventional resuscitation, he was cannulated by a cardiothoracic surgeon via sternotomy to central VA ECMO with high flows up to 140 cc/kg/min while maintaining an open abdomen. He was successfully decannulated on ECMO day 8 without secondary bowel ischemia or hemorrhagic complications. An end ileostomy was created on hospital day 11, and the abdomen was closed on hospital day 13. The patient was extubated on hospital day 18, had fully recovered to baseline renal function, and was discharged home after six weeks with intact neurologic function, later undergoing an uneventful ileostomy takedown. Conclusion High-flow central VA ECMO may serve as an effective rescue strategy in children with refractory clostridial pediatric septic shock. An open abdomen should not be viewed as an absolute contraindication to central cannulation.