Extracorporeal membrane oxygenation for post-transplant hypoxaemia following very severe hepatopulmonary syndrome.

Hepatopulmonary syndrome (HPS) associated with end-stage liver disease has a high morbidity when room air PaO 2 is less than 50 mm Hg. Safe levels of oxygenation to facilitate transplantation have not been defined despite advancement in care. Postoperatively, hypoxaemia worsens due to ventilation perfusion mismatch contributed by postoperative pulmonary vasoconstriction and due to decrease in endogenous nitric oxide. A 16-year-old boy with cirrhosis presented with HPS and a PaO 2 of 37 mm Hg on room air and underwent living donor liver transplant. Although stable intraoperatively, he desaturated on the second postoperative day. Despite a number of interventions, oxygenation remained critically low on 100% inspired oxygen. Extracorporeal membrane oxygenator (ECMO) was established with instant improvement in oxygenation (PaO 2 68 mm Hg), and the patient was eventually salvaged. We suggest that ECMO could be a means of managing refractory post-transplant hypoxaemia in patients with HPS.