Veno-venous and veno-arterial extracorporeal membrane oxygenation (ECMO) therapy is used to support the cardiac and pulmonary systems in the setting of acute failure. Maintaining adequate ECMO flow is crucial for the success of the therapy. Sudden decrease in venous return on ECMO has multiple etiologies, such as intravascular hypovolemia, malposition or kink of the venous cannula, suction occlusion of a cannula, and venous or arterial thrombi. Pathology within the chest, including pneumothorax, tension hemothorax and pericardial tamponade, may also decrease the ECMO flow because of compression of the cannula and decreased atrial volume. Air from a tension pneumothorax may be transmitted from the pleural space to the pericardial and contralateral pleural spaces, as well as the peritoneal cavity if significant pressure is applied to either side of the diaphragm, even without diaphragmatic disruption. The case presented here represents a unique presentation of sudden and sustained decrease of ECMO flow secondary to tension pneumothorax, as well as pneumoperitoneum, following a central venous catheter insertion.
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