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1/6
Challenging case #PedsICU #PedsCICU
Newborn w/ CHD, with mBTT shunt for pulm BF
low BP
wide PP
bradycardia with ST changes that led to a near arrest
mBTT shunt banded and the infant recovered
Challenging case #PedsICU #PedsCICU
Newborn w/ CHD, with mBTT shunt for pulm BF
low BPwide PP bradycardia with ST changes that led to a near arrestmBTT shunt banded and the infant recovered
2/6
Fairly remote from surgery but still in ICU, had
acute severe desaturation
hypotension
low EtCO2
murmur
shunt occlusion
Progressed to eCPR with neck VA ECMO cannulation
Fairly remote from surgery but still in ICU, had
acute severe desaturationhypotension low EtCO2murmur shunt occlusion Progressed to eCPR with neck VA ECMO cannulation
3/6
Quick recovery with excellent hemodynamics/saturations/pulm mechanics on ECMO. Low flow trial 2/2 oxygenator failure still with excellent hemodynamics. Exchanged circuit.
Went to cath lab to evaluate shuntquite narrowed but not occluded
Question 1:
Quick recovery with excellent hemodynamics/saturations/pulm mechanics on ECMO. Low flow trial 2/2 oxygenator failure still with excellent hemodynamics. Exchanged circuit.
Went to cath lab to evaluate shunt
quite narrowed but not occludedQuestion 1:
4/6
Shunt stented, expected to come off but on return to ICU
hypotensive
labile
bloody ETT secretions
Question 2:
Shunt stented, expected to come off but on return to ICU
hypotensive labilebloody ETT secretions Question 2:
5/6
Increased ECMO flow and vasoactives
more hypotensive
worse bloody ETT frank pulmonary hemorrhage
APRV
inhaled TXA
Turned ECMO flow way down
minimized anticoagulation
pulmonary hemorrhage and hypotension significantly improved
Increased ECMO flow and vasoactives
more hypotensive worse bloody ETT frank pulmonary hemorrhage APRV inhaled TXA Turned ECMO flow way down minimized anticoagulation pulmonary hemorrhage and hypotension significantly improved
6/6
Moral:
When cannulated via the neck, arterial cannula can be directed right toward an mBTT shunt; esp. if less restrictive
torrential pulmonary blood flow pulmonary hemorrhage 
hypotension
ECMO flow is no longer helpful and it is imperative to come off ASAP
Moral:
When cannulated via the neck, arterial cannula can be directed right toward an mBTT shunt; esp. if less restrictive
torrential pulmonary blood flow pulmonary hemorrhage hypotension ECMO flow is no longer helpful and it is imperative to come off ASAP
