Kathleen is a 70yo female with a history of ovarian cancer, (S/P surgery and chemotherapy 12 years ago), GERD, hypothyroidism, and hyperlipidemia who presented to the ED with 5-month history of post-prandial nausea and vomiting which has become more severe recently and associated with general and malaise. She denied abdominal pain or weight loss. She was found to have a fever of 103 C. An abdominal CT showed evidence of mesenteric lymphadenitis and she was cultured and started on IVF and antibiotics. Further evaluation revealed a chronic perforated esophagus with paraesophageal and superior mediastinal fluid collections which were drained through the right neck. A week later she underwent a laparoscopic cholecystectomy, lysis of adhesions, and placement of a feeding jejunostomy tube. Post operatively she continued to deteriorate and developed ARDS, requiring intubation and escalating ventilatory support. Initial blood cultures returned positive for an unidentified gram-negative rod and she was 5L positive for 24 hrs with a significant capillary leak and early anasarca. Evaluation of a significant drop in her platelet count led to a positive ELISA and SRA tests and a diagnosis of Heparin Induced Thrombocytopenia. Her poor urine output did not respond to diuretics and she was started on CVVHD. Because of previous chemotherapy access, a venous duplex was performed which revealed a chronically occluded right internal jugular vein, with a patent superior vena cava. With continued deterioration in her oxygenation, you are consulted for possible ECMO support.