Venovenous Extracorporeal Membrane Oxygenation After Cardiac Arrest Due to Refractory Anaphylaxis From Nut Ingestion.

BACKGROUND: Severe anaphylaxis can cause vasoplegia, decreased cardiac output, bronchoconstriction, and acute pulmonary edema, leading to cardiopulmonary arrest. In evaluating these patients for extracorporeal membrane oxygenation (ECMO), it is important to determine the principal factor underlying the patient's failure of medical management. In this case, we describe the successful use of venovenous ECMO in a pediatric patient with anaphylactic shock and cardiac arrest.

CASE SUMMARY: A 15-year-old male presented after anaphylaxis leading to a 45-minute cardiac arrest. Although return of spontaneous circulation (ROSC) was achieved while preparing for extracorporeal cardiopulmonary resuscitation, he had profound hypoxic respiratory failure from pulmonary edema with an oxygenation index of 45, and he required vasoactive support with epinephrine and norepinephrine. With signs of adequate perfusion and an improving pulse pressure gradient from 10 to 30, a rapid decision was made to change the cannulation strategy from venoarterial to venovenous ECMO. He was decannulated 3 days later with resolution of his acute respiratory failure, extubated 5 days later, and discharged home neurologically intact 12 days later.

CONCLUSIONS: The periarrest decision to modify the cannulation strategy demonstrates that, even after prolonged cardiac arrest and ROSC, venovenous ECMO can be a safe, potential bridge to the resolution of pulmonary edema, with careful consideration of individual patient characteristics.