Perfusion 2015, Vol. 30(4) 291–294 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659114544486 prf.sagepub.com Case Description A 12-year-old, 40 kg, female patient with a known history of asthma and peanut allergy developed severe bronchospasm upon accidental ingestion of a peanut– containing sandwich. After salbutamol inhaler therapy, the school nurse administered two doses of intramuscu- lar epinephrine. On arrival of the paramedical team, the child was semi-conscious, with a pulse and cardiac out- put present. Pulse oximetry was 74% on bag-mask ven- tilation (FiO 2 1.0) and, after four doses of intravenous (iv) 10 μg/kg epinephrine for worsening bronchospasm, there was a loss of cardiac output, therefore, cardiopul- monary resuscitation (CPR) was initiated. The return of spontaneous circulation occurred after 11 minutes, dur- ing which she was intubated and received five further doses of iv 25 μg/kg epinephrine. En route to the nearest tertiary hospital, an epinephrine infusion was started in addition to multiple epinephrine boluses (each 25 μg/kg, totalling 20 mg) for recurrent bradycardia and severe bronchospasm. On arrival at the hospital, the mean arterial pressure was over 60 mmHg on epinephrine 10 Extracorporeal membrane modality conversions ACF Chan-Dominy, 1 M Anders, 1 J Millar, 1 S Horton, 2 D Best, 1 C Brizard, 2 Y D’Udekem, 2 A Hilton 3 and W Butt 1 Abstract We report the case of a patient with cardiovascular and respiratory failure due to severe anaphylaxis requiring multiple extracorporeal membrane oxygenation (ECMO) cannulation strategies to provide adequate oxygen delivery and ventilatory support during a period of rapid physiological change. ECMO provides partial or complete support of oxygenation-ventilation and circulation. The choice of which ECMO modality to use is governed by anatomical (vessel size, cardiovascular anatomy and previous surgeries) and physiologi- cal (respiratory and/or cardiac failure) factors. The urgency with which ECMO needs to be implemented (emergency cardiopulmonary resuscitation (eCPR), urgent, elective) and the institutional experience will also influence the type of ECMO provided. Here we describe a 12-year-old schoolgirl who, having been resuscitated with peripheral veno-venous (VV) ECMO for severe hypoxemia due to status asthmaticus in the setting of acute anaphylaxis, required escalation to peripheral veno-arterial (VA) ECMO for precipitous cardiovascular deterioration. Insufficient oxygen delivery for adequate cellular metabolic function and possible cerebral hypoxia due to significant differential hypoxia necessitated ECMO modification. After six days of central (transthoracic) VA ECMO support and 21 days of intensive care unit (ICU) care, she made a complete recovery with no neurological sequelae. The use of ECMO support warrants careful consideration of the interplay of a patient’s pathophysiology and extracor- poreal circuit dynamics. Particular emphasis should be placed on the potential for mismatch between cardiovascular and respiratory support as well as the need to meet metabolic demands through adequate cerebral, coronary and systemic oxygenation. Cannulation strategies occasionally require alteration to meet and anticipate the patient’s evolving needs. Keywords ECMO; extracorporeal membrane oxygenation; anaphylaxis; status asthmaticus; shock; resuscitation 1 Intensive Care Unit, Royal Children’s Hospital, Melbourne, VIC 3052, Australia 2 Department of Cardiac Surgery, Royal Children’s Hospital, Melbourne, VIC 3052, Australia 3 Department of Intensive Care, Austin Hospital, Melbourne, VIC 3084, Australia Corresponding author: Marc Anders Paediatric Intensive Care Unit Royal Children’s Hospital Melbourne VIC 3052 Australia. Email: marc.anders@rch.org.au 544486PRF 0 0 10.1177/0267659114544486PerfusionChan-Dominy et al. research-article 2014 Original paper