2024 FSA Podium and Poster Abstracts

P053: ECMO INITIATION FOLLOWING PROLONGED PEA ARREST: EMPHASIS ON ROLE OF ECPR WHEN CONVENTIONAL CPR FAILS
Cayla Y Suthumphong, MD; Harish Ram, MD; University of Miami/Jackson Memorial Hospital

Background: Perioperative cardiogenic and obstructive shock are associated with high morbidity and mortality. Veno-arterial ECMO can be used to support these patients but can lead to multiple complications.

Methods: We present a 59-year-old female with a history of remote hemorrhagic CVA status-post VP shunt and previous Roux-en-Y gastric bypass who was admitted for gastric anastomotic perforation. She remained inpatient and presented to the OR with stable vital signs two weeks after initial admission for VP shunt re-internalization.

Twenty-five minutes after uneventful induction and intubation, the patient became tachycardic and hypoxic with a sudden drop in ETCO2. The ET tube was exchanged and confirmed with bronchoscopy. She then became bradycardic and hypotensive, and atropine, epinephrine and sodium bicarbonate were given. Pulmonary embolism was highly suspected, so the case was aborted, and she was taken for imaging.

During the CTA, she went into PEA arrest and ACLS was initiated with CPR. Bedside ultrasound confirmed lung sliding. With clinical suspicion for PE and no absolute contraindications, tPA 50mg was administered, followed by a second dose. Intra-code TEE demonstrated RA/RV dilation without main pulmonary artery emboli. ROSC was achieved after 50 minutes. She was transported to the Cardiac ICU on multiple vasopressors while the ECMO team was being activated.

Results: After a multidisciplinary discussion, it was decided to proceed with peripheral veno-arterial ECMO cannulation. In the ICU, left femoral central venous and right femoral arterial access was obtained to ease cannulation and she presented to the OR on maximal vasopressor support. Left femoral venous cannulation was unsuccessful using the percutaneous wire exchange technique, requiring right-sided femoral cut down Seldinger method. The venous guidewire position was confirmed using TEE and the venous and arterial cannulas were placed.

Initial TEE examination during the code demonstrated severe RA and RV dilation with severely hypokinetic RV with atrial septal bowing with no notable thrombus in main PA. Further, TEE guided effective chest compressions during CPR.

Final interpretation of the CTA (following tPA) showed no evidence of PE, but an infiltrative process involving right lobes. Bronchoscopy performed showed evidence of bile aspiration.

While initially improving, she began to have seizure-like activity four days later, concerning for hypoxic-ischemic encephalopathy. After family discussion, the patient was transitioned to comfort measures.

Discussion: In this case, the patient experienced acute RV failure of unknown cause, while suspected PE, ischemic cardiomyopathy and aspiration pneumonitis are differentials to be considered. Systemic thrombolysis with tPA for suspected PE during prolonged CPR and ECMO-associated coagulation, thromboembolic, vascular complications, along with associated differential hypoxia (“North-South Syndrome”), will be presented.

While the ECPR practice is several years old, numerous unanswered questions remain. Many management issues following ECPR are handled similarly to patients successfully revived by conventional CPR, despite the advantages and disadvantages of adding ECMO to CPR. This type of management needs modification, but while research data is ongoing, spreading awareness about ECPR is mandatory for wider usage. To conclude, so far data supporting the routine use of ECPR in cardiac arrest patients is not sufficient.