P033: RECOGNIZE, ESCALATE, CANNULATE: VV-ECMO RESCUE AFTER PERI-INDUCTION ASPIRATION
Shaunak Mishra; Yiliam F Rodriguez-Blaco, MD; Jake Rachiele, MD; Jadelis Giquel, MD
University of Miami Miller School of Medicine
Background: Aspiration during GA induction can precipitate acute respiratory distress syndrome (ARDS) and significant hypoxemic respiratory failure. When refractory to lung-protective ventilation and conventional rescue strategies, extracorporeal membrane oxygenation (ECMO) may be necessary for lifesaving support.
Emergent veno-venous (VV) ECMO initiation in the OR presents unique anesthetic challenges, including hemodynamic instability, anticoagulation management, transport logistics, and ethical considerations if recovery is unsuccessful. This case highlights intraoperative management strategies during emergent VV-ECMO for aspiration-induced ARDS, emphasizing hemodynamic principles, perioperative coordination, and ethical considerations.
Methods: A retrospective review was performed of a 49 y.o. F (ASA II) undergoing surgery for a superinfected 12 cm endometrioma with pelvic abscesses. After standard induction and intubation, bilious material was noted in the endotracheal tube, consistent with witnessed aspiration. Despite aggressive suctioning, bronchoscopy, lung-protective ventilation, paralysis, recruitment maneuvers, and FiO2 of 1.0, the patient developed persistent hypoxemia (PaO2 74 mmHg), hypercapnia (PaCO2 52 mmHg), respiratory acidosis (pH 7.24), worsening compliance, and bilateral infiltrates on chest radiography, meeting criteria for refractory isolated respiratory failure.
Hemodynamic Principles and Monitoring: Key physiologic priorities included preserving cardiac output to maintain O2 delivery, recognizing that VV-ECMO provides respiratory but not circulatory support, and preventing right ventricular (RV) strain from hypoxemia and elevated pulmonary vascular resistance. Monitoring included invasive arterial pressure, serial ABGs, end-tidal CO2, and transesophageal echocardiography (TEE) to assess biventricular function and guide cannulation.
The ECMO team was activated early. Under TEE guidance, VV-ECMO cannulation was performed via right internal jugular drainage and right femoral venous return following systemic heparinization.
Intraoperative Management: Maintaining preload for adequate ECMO flow, avoiding excessive positive pressure ventilation, transitioning to a lung-rest ventilation strategy post-cannulation, and titrating vasopressors to a MAP >65 mmHg were anesthetic priorities. Anticoagulation was managed with ACT monitoring, balancing bleeding risk from recent laparotomy against circuit thrombosis. Once flows were established, oxygenation improved immediately. The planned hysterectomy was aborted in favor of drainage and partial adnexal resection due to the patient’s physiologic instability and infection risk. Transport to the thoracic ICU required securing cannulas, verifying portable equipment, and a multidisciplinary handoff covering cannulation configuration, flow parameters, anticoagulation targets, and vasopressor requirements.
Results: Following VV-ECMO initiation, oxygenation normalized, gas exchange stabilized, and RV function remained preserved. Vasopressors and broad-spectrum antibiotics were administered postoperatively for suspected septic shock. The patient was successfully decannulated on postoperative day three, extubated two days later, and discharged home on postoperative day 13.
Discussion: This case demonstrates the anesthesiologist's critical role in early recognition of refractory respiratory failure, physiology-based decision-making, and safe ECMO initiation in the OR. Understanding oxygen delivery, preload dependence, RV physiology, and ECMO flow dynamics are crucial to administration.
Emergent mechanical life support also raises important ethical considerations. When pulmonary recovery does not occur and no bridge strategy exists, early discussions with families regarding prognosis and goals of care are essential. As ECMO use increases, anesthesiologists must be prepared in crisis management, anticoagulation, safe transport, and compassionate ethical leadership.