897: VV ECMO AFTER COMPLICATED ABDOMINAL SURGERY IN AN OBESE PATIENT: IS EARLIER BETTER?

Abstract

Introduction: Aspiration pneumonia and respiratory failure following abdominal surgery are well-known complications in patients with a body mass index (BMI) over 30 kg/m2. The use of venous-venous extracorporeal membrane oxygenation (VV-ECMO) as rescue therapy has been explored in patients who develop acute respiratory failure postoperatively. This case strives to highlight the importance of early initiation of VV-ECMO to improve outcomes in obese patients. Description: A 59-year-old woman with past medical history of hypertension and morbid obesity status post laparoscopic Roux-en-y gastric bypass presented with new onset nausea, emesis, and abdominal pain. Patient was febrile, tachycardic, hypoxic, and hypotensive upon evaluation. Physical exam was significant for bibasilar coarse breath sounds, abdominal distention, and hypoactive bowel sounds. Abdominal radiography showed evidence of small bowel obstruction and chest radiography revealed massive aspiration with unilateral pleural effusion. Patient ultimately required exploratory laparotomy after failure of conservative management for unresolved bowel obstruction. The post-operative course was complicated by acute respiratory failure, which did not improve despite multiple measures. VV-ECMO was then initiated, which led to significant recovery of hemodynamics and respiratory status in three days. Discussion: Anesthetic-induced decrease in functional residual capacity, disruption of thoracoabdominal musculature during abdominal surgery, and pre-existing lung disease predispose obese patients to respiratory failure. Non-invasive approaches are limited and invasive mechanical ventilation becomes the appropriate next step to achieve improved oxygenation in this sub-set of patients. Studies show that obesity is an independent factor in improving 90-day survival when transitioned to VV-ECMO early in the clinical course. Further clinical studies are required to determine the optimal time between initiation of mechanical ventilation and transition to VV-ECMO, as well as the effect on ICU and hospital length of stay.