Articel Content
Sarah's alive.
Text: Eva Mell
A little girl falls into a bitterly cold pond. When her father finds her, she has no pulse. Her chances of survival are poor. But at the University Children's Hospital Basel, the improbable is about to take place.
It's Easter Monday. In the resuscitation room of the University Hospital Basel, around 20 people are fighting to save the life of a two-year-old girl. She's in a deep coma. The child – we’ll call her Sarah – was brought here via helicopter by Swiss Air Rescue. Her body temperature is 25 degrees Celsius. It was just 23 degrees when she was first found. Sarah had fallen into a pond in her apartment complex near Delémont. It’s April 5, 2021, the coldest April in decades.
Difficult decisions.
Sarah's parents had been looking for her for 15 minutes before her father pulled her out of the water and performed CPR until emergency services arrived on the scene to take over. She was in cardiac arrest for almost an hour before her heart began beating again.
When she arrives in Basel, her pupils still aren't responding to light. Senior physicians from multiple departments are discussing her case in the resuscitation room. They discuss options for how to proceed. At the center of the huddle is a pediatric intensivist with a colorful vest over her white coat. The vibrant article of clothing signals that she is the team's leader.
Two years later, on a summer afternoon in 2023, senior pediatric physician and intensivist Maya André sits in her office at the University Children's Hospital Basel discussing the situation back in 2021 in the resuscitation room. She and her team had some difficult decisions to make. A colleague from the University Hospital recommended ECMO therapy for Sarah, she recalls. ECMO, or extracorporeal membrane oxygenation, involves using a large tube to pump the patient's entire blood supply out of the body, carefully heat it to the correct temperature and pump it back into the body together with blood thinners. But this complex technique is risky: Children experience thrombosis, circulatory issues and aneurysms more often than adults do.
“In Basel, we don't perform this treatment on children younger than ten,” says Maya André. She could have called in colleagues from Bern or Zürich, but: “In the meantime, I would have had to continue attempting resuscitation and raising her temperature anyway.” As there was no official recommendation for the use of ECMO therapy in cases like Sarah's, the physician decided not to undertake the procedure.
Procedure with hurdles.
Instead, Maya André asks the pediatric surgeon on duty to open up the two-year-old's abdominal cavity just enough to allow her to insert a catheter. This is a routine procedure for the surgeon and far less risky for the child than ECMO. Maya André injects a warm saline solution, extracts it again, injects more warm fluid and repeats the procedure again and again – for three hours. “Every time we pumped the saline out, intestinal coils would block the catheter,” she recalls. But the method is successful.
Once the tiny body has reached 33 degrees, the team brings Sarah to the intensive care unit of the University Children's Hospital.“There was still a lot of fluid in the abdomen, so I had a very difficult time with the artificial respiration when we moved her to the intensive care unit. The water was pressing up against the lungs, so they couldn't expand properly.” On the way to the pediatric intensive care unit, Maya André administers artificial respiration manually using a breathing bag.
When they arrive at the unit, she medicates Sarah to suppress her body's muscular activity. “That way we had full control over the respiration,” she says. Two hours later, a miracle occurs: The two-year-old's pupils finally respond to light.
A stroke of luck.
The next morning, the team removes the breathing tube, and Sarah begins to breathe on her own. Maya André heads home after many hours on duty. A little while later, she receives a video that she will never forget: It shows Sarah insisting that she doesn’t need any help brushing her teeth. Five days later, the healthy little girl is discharged from hospital.
Long after the child has been returned to her family, the physicians at the University Children's Hospital continue to discuss her case. Would ECMO therapy have been the right choice after all? To find out, Maya André searches the literature for similar cases. She finds 57 case reports from different countries. On each occasion, the children were under six years of age and had suffered accidental drowning that left their body temperature at a maximum of 28 degrees Celsius. Forty-four of the patients received ECMO therapy, while only 13 were treated without the highly invasive procedure.
Her analysis reveals that many children in the ECMO group died or suffered severe complications. Maya André is skeptical as to whether all possible technical measures should be employed to rewarm the bodies of very young drowning victims who may have severe oxygen deprivation in the brain. “Children aren't adults. We can't simply assume that a treatment will work for them just because it's being used more frequently in adult medicine,” she points out.
Yet, she realizes that her analysis has its weak points: Even within each of the two groups, the accidents and treatments are hard to compare. And it doesn't account for reporting error, as very few cases of drowning are ever published. The data she has collected offer clues, but what Maya André really wants is an international registry that contains information on all cases, procedures and results. That would give her a solid basis for deciding how best to treat children like Sarah.
In Sarah's case, it turned out that the team made the right decision. “But anything could have happened, really,” says Maya André. “She might have died, survived with disabilities or – most improbable of all – fully recovered.” The fact the most improbable of all outcomes happened in this case might simply have been a stroke of luck in the midst of misfortune. “We believe that Sarah's body temperature dropped before she went into circulatory arrest.” The cold protected her brain from the fatal consequences of oxygen deprivation. A follow-up exam confirmed these results – Sarah had fully recovered from her accident. “It couldn't have turned out better,” says Maya André with a smile.
Original publication
Maya Caroline Andre et al.
Rewarming Young Children After Drowning-Associated Hypothermia and Out-of-Hospital Cardiac Arrest: Analysis Using the CAse REport Guideline.
Pediatric Critical Care Medicine (2023), doi: 10.1097/PCC.0000000000003254
More articles in this issue of UNI NOVA (November 2023).