P-268INSTITUTION OF EXTRACORPOREAL MEMBRANE OXYGENATION SUPPORT IN THE AWAKE PATIENT TO FACILITATE SURGERY FOR HEART LUNG BLOCK TRANSPLANTATION.

Abstract

Objectives: We demonstrate the safe induction of anaesthesia and revision sternotomy in an adult congenital heart case undergoing heart lung transplantation facilitated by the awake institution of extracorporeal membrane oxygenation (ECMO) support in the awake patient prior to general anaesthesia. Case description: We present a congenital heart case who was a candidate for heart lung transplantation. Her background was significant for pulmonary atresia with ventricular septal defect at birth. She had undergone a left Blalock-Taussig (BT) shunt and also a right BT shunt in the past. She had also undergone a corrective pulmonary outflow tract procedure with Hancock valve conduit placement. However her contemporary performance had deteriorated and she was suffering severe cardiovascular failure. She was listed for heart lung block transplantation. She had suprasystemic pulmonary artery pressures (PA 138/65) with an anticipation of cardiovascular collapse on induction of anaesthesia. To facilitate the surgical procedure the patient was placed on ECMO support while awake, prior to anaestheisa for surgery. She subsequently underwent a safe re-sternotomy and completed her heart lung transplant successfully. Regional anaesthesia was achieved with an ilioinguinal and iliohypogastric block performed with ultrasound guidance using lignocaine 1%. This was supplemented with direct local infiltration around her right femoral vessel incision. Once regional anaesthesia was achieved, the right femoral artery and vein were exposed. An 8-mm side arm graft was anastomosed to the artery and the femoral vein cannulated directly. Once ECMO support was instituted, general anaesthesia was achieved safely and the sternum re-opening safely completed. The patient was subsequently switched to full cardiopulmonary bypass with central access and the heart lung transplant completed safely. Conclusion(s): This strategy offers an alternative to high risk anaesthesia and offers a stable platform to perform a sternal re-opening. The awake procedure was well tolerated.