Abstract Triple cannulation extracorporeal membrane oxygenation (ECMO) is a novel form of cardiopulmonary mechanical support. An additional cannula can be added to an existing Veno-Veno- (VV) or Veno-Arterial- (VA) circuit to form a veno-veno-arterial (VVA) or veno-arterio-venous (VAV) circuit. VAV ECMO is used in patients with concomitant lung and heart failure such as severe left ventricular failure with secondary ARDS or right heart decompensation during ARDS. We present a case of a patient who developed negative pressure pulmonary edema (NPPE) following general anesthesia for a leg debridement and subsequent cardiac arrest requiring VAV ECMO. A 37 year old female with a past medical history of polysubstance abuse, anti-phospholipid syndrome, May-Thurner syndrome, DVT/PE, and chronic lower extremity wounds was admitted for bilateral lower extremity cellulitis. Wound cultures were positive and she was treated with broad spectrum antibiotics. Vascular surgery took the patient for debridement. At the conclusion of the procedure, when the patient was extubated, she developed translucent, pink-tinged, frothy fluid from her mouth and nose. She became cyanotic and was re-intubated. Despite re-intubation and manual bagging, her saturation dropped as low as 30%. Cardiothoracic surgery was called for ECMO. She became pulseless and ACLS was initiated. Return of spontaneous circulation was achieved in 1 minute. She was cannulated for VAV ECMO through the right femoral vein, right femoral artery, and right internal jugular vein. She additionally had insertion of distal perfusion cannula into the right superficial femoral artery. The patient was maintained on VAV ECMO and transported to the ICU in critical condition. On bedside echocardiogram she had reduced ejection fraction. An echocardiogram one day later demonstrated normal biventricular function and she was transitioned to VV ECMO for 2 days. She was decannulated after 4 days and extubated after 8 days. NPPE is a rare potentially life-threatening complication caused by an upper airway obstruction. It occurs in 0.05%-0.1% of patients receiving general anesthesia, either from laryngospasm during intubation or as a postanesthetic laryngospasm. Negative inspiratory pressures as high as -140cmH2O can be generated, which can create hydrostatic movement of fluid into the interstitial and alveolar spaces. This is an extremely rare case in that our patient both developed NPPE and resultant cardiac arrest, with VAV ECMO being used as a rescue therapy to provide both cardiac and respiratory support. This case highlights the utility of VAV ECMO in cardiac arrest patients with simultaneous lung pathology and transient myocardial stunning. This abstract is funded by: none
Arcidiacono et al. (Fri,) studied this question.