46: Unmasking the Hidden Threat: The Role of VA ECMO in Managing Masked Obstructive Shock

Introduction: Circulatory shock with it’s different subtypes is a life-threatening condition leading to organ dysfunction, However, these types often overlap or present with similar clinical symptoms, it’s challenging to promptly identify the root cause. This diagnostic uncertainty makes clinical decision-making critical, especially in complex cases where multiple shocks coexist, or one form of shock is “masked”. Case Description: 46-year-old male with a known history of glioblastoma treated with multiple surgical excisions and recent radiotherapy, presented with left leg cellulitis and shock. investigation confirmed left leg cellulitis, extensive DVT and massive bilateral PE. His troponin and BNP were elevated, though his echocardiography showed biventricular hypokinesia and failed to demonstrate the classical signs of PE. This is due the high LV pressure disturbing ventricular interdependence. This combined obstructive shock and sepsis mediated cardiac depression lead to a drastic drop in CO. As The patient continued to deteriorate requiring more inotropes and vasopressors, this mixed pathology dilemma thoughtfully was supported by VA ECMO and IABP. A catheter-directed thrombolysis was initiated with low-dose infusion (1-2mg/hr) and monitored by ROTEM to guide goals of coagulation mechanics. Empirical broad-spectrum antibiotics were started alongside surgical debridement. Despite initial stabilization, echocardiography continued to reveal worsening biventricular function. However, over a course of 5 days both ventricles showed gradual improvement in contractility and preload and after load mechanics suggesting a reduction in the thrombus burden and lessening myocardial depression. Repeated echocardiography showed progressive recovery of both ventricular functions. The patient’s hemodynamics stabilized within 5 days with no bleeding catastrophes. Conclusions: Managing patients with shock demands flexibility, vigilance, and precision. Timely initiation of VA ECMO, continuous monitoring through imaging and hemodynamic assessments, and customized therapies based on the patient’s unique condition can make the difference between survival and adverse outcomes in critical care.