(901) Go With the Flow: Central ECMO for Group A Streptococcus Refractory Septic Shock

Introduction: Group A streptococcus (GAS) is an emerging cause of refractory septic shock (RSS) in children. We describe a case of successful resuscitation from GAS RSS using central extracorporeal membrane oxygenation (ECMO).

Description: A 4-year-old was admitted to the pediatric intensive care unit (PICU) in uncompensated shock associated with an acute respiratory infection. She progressed to multiorgan failure despite maximal medical therapy and experienced a brief cardiac arrest. Peripheral venoarterial ECMO was initiated 8 hours into admission, achieving flows of 135mL/kg/min. Computed tomography of the chest showed necrotizing pneumonia with pleural effusion. Pleural fluid grew GAS. She developed frank pulmonary hemorrhage with no aortic valve opening on echocardiography and persistent lactic acidosis 25 hours after cannulation; her left hand was noted to be diffusely swollen, erythematous, and pulseless at this time. She was transitioned to central ECMO with left atrial drainage and continuous veno-venous hemofiltration, achieving flows of 200mL/kg/min with lactate clearance and gradual end-organ recovery. Her hand ischemia was managed with warming, nitroglycerin paste, and therapeutic anticoagulation; pulses returned 45 hours into central ECMO, and tissue gradually recovered. She was decannulated after 102 hours of central ECMO and did not require ongoing dialysis. She was extubated hospital day 16 and completed a course of penicillin and clindamycin. Serial echocardiography demonstrated improved left ventricular systolic dysfunction and she was transitioned to an oral heart failure regimen, with a total 37-day PICU stay and 46-day hospital stay, followed by inpatient rehabilitation. 2 months after rehabilitation, she has normal activity tolerance, mild weakness in her left thumb, and takes only enalapril.

Discussion: After reaching a nadir during the COVID-19 pandemic, pediatric GAS infections are rising. Invasive GAS is particularly malignant; population-based studies indicate a case fatality rate of 15%, which rises to 50% when complicated by toxic shock. Presenting features can be nonspecific, making initial recognition challenging. Expedient diagnosis, antibiotic initiation, and transfer to cardiosurgical center, if necessary, can be life and limb-saving for patients with GAS.