CASE PRESENTATION
Case data
A previously healthy 32-year-old
woman experienced a sudden choking cough while eating ice cream on May
8, 2021, which caused progressive chest tightness, shortness of breath,
and dyspnea. This patient was diagnosed with severe pneumonia, acute
left heart failure, cardiogenic shock, and giant pheochromocytoma
(Figure 1). Initial treatment in local hospital included tracheal
intubation, VA-ECMO combined with CRRT treatment, α-blockers
(phentolamine), β-blockers (propranolol), and other support care. After
10 days of treatment, the left ventricular EF increased from 8% to
67%, and ECMO support was
withdrawn. Right femoral vein vascular repair was performed(Figure
2),and CRRT was reserved, while the patient developed sepsis. The
patient was then transferred to our hospital on June 3 for further
treatment. Subsequent treatment at our hospital involved anti-infection,
anti-heart failure, volume expansion, CRRT, phentolamine, propranolol,
lyophilized recombinant human brain natriuretic peptide, and morphine,
alongside meticulous wound care. CRRT treatment was suspended on June 9.
On June 15, patient was transferred to the general ward for further
preparation, but experienced another pheochromocytoma crisis during the
bumpy transfer, resulting in multiple organ failure and malignant
arrhythmia. Prompt intervention including nasal high-flux oxygen
therapy, CRRT, and other treatments stabilized patient’s condition. On
June 18, laparoscopic left adrenal giant pheochromocytoma resection was
successfully performed under general anesthesia with CRRT support.
Postoperatively, the patient exhibited favorable wounds healing,
significant reduction in plasma catecholamine metabolites to nearly
normal level, and was subsequently discharged. All treatments described
were administered with the patient’s informed consent. During a
six-months follow-up, the patient remained asymptomatic, with normal
hormone levels.
CRRT treatment strategy
The patient underwent dialysis catheter insertion via the internal
jugular vein. Continuous blood purification was conducted using
Prismaflex (Gambro, Jinbao, Sweden). The supporting hemodialysis filter
and the hemofiltration replacement base fluid was provided by Chengdu
Qingshan Likang Pharmaceutical Co.,Ltd., National Medicine Zhunzi
H20080452. The treatment was set to continuous venous-venous
hemodiafiltration mode (CVVHDF) at a rate of 25-45 ml/kg/h, with a blood
flow rate of 120-150 ml/min. Citric acid anticoagulation for CRRT was
administered during June 4-9 at a dose of 180-220 ml/h, adjusted based
on the serum calcium levels. On June 15, due to impaired liver function
and D-dimer exceeding 20ug/ml, the anticoagulation method was switched
to low molecular weight heparin sodium at a dose of 0.4 ml every 8
hours. Surgical intervention was performed on June 18 without
anticoagulation to reduce bleeding risk. The efficacy of CRRT treatments
were recorded in Table 1-3.