DRUGS, BUGS AND THE ECMO UNPLUGGED: A CASE OF A 61-YEAR-OLD WITH CARDIOGENIC SHOCK AND UTILITY OF PALLIATIVE BEDSIDE ECMO DE-ESCALATION

Introduction Extracorporeal membrane oxygenation (ECMO) is used in the setting of cardiogenic shock for cardio-pulmonary support as a bridge to recovery, advanced therapies, or decision. However, palliation remains when other options have failed. ECMO de-cannulation is often performed in the operating room. We describe the case of a patient with palliative bedside ECMO de-escalation of care. Case Report A 61-year-old male with a history of chronic heart failure with reduced ejection fraction presented to an outside hospital for worsening fatigue and dyspnea. He was diagnosed with cardiogenic shock, started on dobutamine, and transferred to our hospital for consideration of advanced therapies. On arrival, he was hypotensive with multi-organ failure and he underwent urgent bedside VA ECMO, followed by Impella CP placement for venting, as a bridge to advanced therapies. However, post-implant, the pulmonary artery pressures remained elevated and the spouse revealed that he was an active polysubstance user. His family felt that he was unable to stay away from methamphetamines. He was subsequently denied for possible transplant and LVAD. Maximization of medical therapy with hope for recovery was unsuccessful. The patient progressed to renal failure and bacteremia. With an intact neurological status, the patient and his family, assisted by palliative care and the entire medical team, decided to pursue comfort measures. Since decannulation in the OR would require intubation, the decision to wean off ECMO bedside was made. The ECMO was dialed down to 1 LPM of flow and the patient remained alert. Impella support was dialed off and then withdrawn into descending aorta, thus avoiding aortic regurgitation, pulmonary edema, and patient distress. Finally, we clamped the ECMO cannulas and turned off the machine. He spent time with loved ones for a few hours, laughing with family and friends prior to expiration with ongoing comfort drips. Summary The art of palliation for ECMO patients should be further evaluated when advanced treatments are contraindicated, especially in patients with an intact neurological status. Weaning off ECMO at the bedside can be done humanely and allow maximal time with family.