A52-01 A Complex ECMO Journey: Refractory Status Asthmaticus Complicated by Cardiac Tamponade, Hemorrhage, and Multisystem Sequelae

Abstract Introduction Extracorporeal membrane oxygenation (ECMO) is increasingly utilized for refractory status asthmaticus and severe hypercapnic respiratory failure. While lifesaving, ECMO initiation and management carry substantial procedural and hemodynamic risks. We present a challenging case of a young woman requiring multiple ECMO conversions and management of severe complications, culminating in full recovery. Case Presentation A 22-year-old female with severe, poorly controlled asthma and obesity presented in respiratory extremis following multiple prior emergency visits for acute exacerbations. She was intubated in the emergency department for hypercapnic respiratory failure (pCO2 139 mmHg) and admitted to the ICU. Despite deep sedation and paralysis, she developed worsening air trapping and dynamic hyperinflation, prompting activation of the ECMO team. Initial veno-venous (VV) ECMO cannulation was complicated by hypotension and pulseless electrical activity arrest with transient ST elevation. The patient was converted to veno-arterial (VA) ECMO for extracorporeal CPR. Transesophageal echocardiography revealed a pericardial effusion; emergent pericardial drainage yielded 200 mL of blood with hemodynamic improvement. Due to differential oxygenation between upper extremities, she was converted to veno-arterial-venous (VAV) ECMO, later reverting to bifemoral VV ECMO after stabilization. Her course was further complicated by right iliac artery occlusion, bilateral groin hematomas, left femoral DVT, and a small left parieto-occipital subdural hematoma managed conservatively. An IVC filter was placed due to a contraindication to anticoagulation. She was successfully decannulated on day 3, extubated to high-flow nasal cannula on day 5, and discharged to rehabilitation with full neurological recovery. Discussion This case underscores the complex hemodynamic and vascular complications of ECMO in patients with obstructive airway disease. Rapid recognition of evolving complications, multidisciplinary coordination, and procedural adaptability are crucial to survival. ECMO can be lifesaving even in catastrophic presentations of status asthmaticus when executed in experienced centers. This abstract is funded by: None