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 After 10 days of treatment, the left ventricular EF increased from 8% to 67%, and ECMO support was withdrawn.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.