• Yu-Hsuan Lien, You-Cian Lin, and Robert Jeenchen Chen.
• Division of Cardiovascular Surgery, Department of Surgery, China Medical University Hospital, Taichung, Taiwan.
• Medicine (Baltimore). 2021 Apr 16; 100 (15): e25522e25522.

RationaleSevere methemoglobinemia (Met-Hb) is rare. The delayed diagnosis and treatment often cause further damage. The management of cellular hypoxemia is challenging and the use of extra-corporeal membrane oxygenation (ECMO) has never been reported.Patient ConcernsThe young patient, healthy with unremarkable past medical history, was sent to emergency room with out-of-hospital circulatory arrest (OHCA) and severe generalized cyanosis. His family reported he ingested sodium nitrite accidentally.DiagnosesAfter successful resuscitation and return of spontaneous circulation (ROSC), the paradoxically normal arterial blood gas (ABG) with the unusual brownish blood led to the suspicion of Met-Hb. The lab test confirmed it and showed a very high level of 80%.InterventionsBecause of recovered and normal cardiac function, we placed veno-venous extracorporeal membrane oxygenation (VV-ECMO) for tissue hypoxemia in addition to exchange transfusion, vitamin C, and methylene blue.OutcomesMet-Hb blood level dropped rapidly. After vigorous rehabilitation for weeks, the patient was able to be discharged home without major neurological sequela.LessonsVV-ECMO can hyper-oxygenate the hypoxemic tissue regardless the etiology and minimize hypoxemia-reperfusion injury while awaiting the definite diagnosis and therapy.Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.

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