1148

Abstract

Case Reports: We present the case of a 47-year-old female on VA EMCO while awaiting a bilateral lung/heart transplant with a history of severe pulmonary hypertension with resultant RV failure secondary to CREST syndrome and venoocclusive disease. There are several unusual features to her case while on ECMO. First her cannulation sites were unique. Her left axillary artery was cannulated and her venous cannula was placed through a tunneled approach via a right internal jugular venous cut down. This allowed her to have a closed chest, to participate in physical therapy, be ambulatory while on ECMO, and be extubated after one week.This configuration lead to unanticipated problems. The patient’s axillary artery was smaller than hoped and lead to flow limitations from increased pressure in the circuit. The best flows we could safely obtain were indexes of 1.5-1.8. Her right arm became the sole site for invasive arterial monitoring which became problematic when her right radial arterial line became infected.During her 2nd week on ECMO she began to have brief episodes of severe anxiety. During these “anxiety” attacks her SPO2 would remain relatively normal but her SVO2 would drop from a baseline of high 60’s to the mid 30’s and take several minutes to recover. Because of her history of anxiety, her home antidepressant was restarted, along with some short acting benzodiazepines. These improved her symptoms but they were happening more frequently. During a prolonged anxiety attack a post oxygenator ABG was obtained showing a PaO2 of 39. This indicated oxygenator failure. After an oxygenator change her anxiety attacks resolved, suggesting that her attacks were actually intermittent oxygenator failure rather than anxiety. It was difficult to identify the oxygenator failure for several reasons. First it was intermittent, second her SPO2 remained normal, and third she was extubated and had some degree of compensation.Despite these difficulties she was able to be successfully transplanted and is recovering well.In conclusion this case emphasizes some atypical complications associated with a new ECMO cannulation approach and also an unusual presentation of oxygenator failure.