34: Dual ECPR Experience in an ICU: Management of Refractory Cardiac Arrest from Massive PE and Cardiotoxic Overdose

Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) using veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is a critical intervention for refractory cardiac arrest due to potentially reversible causes. We report two ECPR cases from our intensive care unit, highlighting distinct challenges and successful outcomes in obstructive and toxicological shock. Case Presentations: Case 1: Intraoperative Massive Pulmonary Embolism A 64-year-old female experienced intraoperative cardiac arrest secondary to a massive pulmonary embolism, evidenced by acute right ventricular dilation. ECPR with VA-ECMO was initiated at 39 minutes. Management included thrombolysis with tenecteplase (30 mg). Persistent hemodynamic instability and differential hypoxemia necessitated conversion to veno-arterial-venous (V-AV) ECMO. Subsequent imaging identified active bleeding from intercostal and thoracic arteries, which was successfully managed with angiography and embolization. With improving left ventricular function and persistent respiratory failure, support was further transitioned to veno-venous (VV) ECMO on day 14. The patient was successfully weaned and decannulated, achieving a favorable neurological outcome at discharge. Case 2: Propranolol Overdose with Cardiogenic Shock A 42-year-old female presented after ingestion of 2000 mg of propranolol, developing profound bradycardia and cardiac arrest. ECPR with VA-ECMO was initiated for refractory cardiogenic shock (ejection fraction 10%), along with intra-aortic balloon pump support and temporary pacing. Intensive support resulted in rapid cardiac recovery, with improvement in ejection fraction to 35–40%. Transient polyuria due to natriuresis was managed with fluid replacement. The patient remained neurologically intact and was successfully decannulated from VA-ECMO and IABP on day four, with full recovery. Conclusion: These cases demonstrate the effectiveness of a multimodal ECPR strategy in complex scenarios, including obstructive shock requiring definitive intervention and reversible drug-induced cardiogenic shock. Rapid decision-making and dynamic ECMO circuit management are essential for achieving favorable outcomes.