|Year : 2022 | Volume
| Issue : 5 | Page : 18-20
Extracorporeal membrane oxygenation in diffuse alveolar hemorrhage: A case report and review of anticoagulation strategies
Mohammed Barghash Alanazi, Abdullah Abudayah, Saud Alajmi
Department of Critical Care, Prince Sultan Medical Military City, Riyadh, Saudi Arabia
|Date of Submission||12-Nov-2023|
|Date of Decision||28-Nov-2023|
|Date of Acceptance||13-Dec-2023|
|Date of Web Publication||04-Feb-2023|
Mohammed Barghash Alanazi
Cardiac Critical Care Department, Prince Sultan Medical Military City, Riyadh
Source of Support: None, Conflict of Interest: None
Anticoagulation in extracorporeal membrane oxygenation (ECMO) can be one of the obstacles in starting and managing patients with refractory hypoxemia, especially with diffuse alveolar hemorrhage (DAH). In this case report, we describe our experience with a 21-year-old male patient who presented with DAH and refractory hypoxemia secondary to systemic lupus erythematosus and was anticoagulated safely during ECMO to maintain circuit integrity, as a bridge to immunosuppressive therapy until he was decannulated successfully. Thromboelastography played a major role in our case management to guide our anticoagulation intensity.
Keywords: Anticoagulation, diffuse alveolar hemorrhage, extracorporeal membrane oxygenation
|How to cite this article:|
Alanazi MB, Abudayah A, Alajmi S. Extracorporeal membrane oxygenation in diffuse alveolar hemorrhage: A case report and review of anticoagulation strategies. Saudi Crit Care J 2022;6, Suppl S1:18-20
|How to cite this URL:|
Alanazi MB, Abudayah A, Alajmi S. Extracorporeal membrane oxygenation in diffuse alveolar hemorrhage: A case report and review of anticoagulation strategies. Saudi Crit Care J [serial online] 2022 [cited 2023 Mar 21];6, Suppl S1:18-20. Available from: https://www.sccj-sa.org/text.asp?2022/6/5/18/369162
| Introduction|| |
Anticoagulation in extracorporeal membrane oxygenation (ECMO) can be one of the obstacles in starting and managing patients with refractory hypoxemia, especially with diffuse alveolar hemorrhage (DAH). In this case report, we describe our experience with a 21-year-old male patient who presented with DAH and refractory hypoxemia secondary to systemic lupus erythematosus and was anticoagulated safely during ECMO maintain circuit integrity as a bridge to immunosuppressive therapy until he was decannulated successfully Thromboelastography played a major role in our case management to guide our anticoagulation intensity.
| Case Report|| |
A 21-year-old male patient, known to have systematic lupus erythematous and lupus nephritis, was diagnosed at the age of 16 in 2016 based on a renal biopsy that previously received induction with mycophenolate mofetil and achieved remission, after which the patient had interrupted follow-up and in compliance with medications, to present on September 11, 2022, to the nephrology day clinic complaining of generalized overload features consistent with lupus nephritis and generalized anasarca. The patient was admitted to the hospital under the care of nephrology, receiving diuretics and colloids in addition to the Euro-Lupus Cyclophosphamide Protocol by rheumatology. The patient spent the following nine days in the hospital for completion of rheumatological management, for which he was on room air with a clear chest X-ray. His stay so far was remarkable only for high blood pressure, for which nifedipine 30 mg was started.
The patient's condition deteriorates nine days post-hospital admission. He developed massive hemoptysis and low oxygen saturation of 80% on a 15L nonrebreather oxygen mask, blood pressure of 180/100, and heart rate of 150 beats/min. The intensive care team was involved, and the patient was intubated with a bloody airway. Postintubation chest X-ray revealed new bilateral opacification. Despite frequent suctioning of persistent bloody secretions, the saturation was barely maintained at 80% with the partial pressure of oxygen of 62 mmHg on continuous bagging. Every attempt to attach the patient to a mechanical ventilator resulted in a severe reduction of oxygen saturation, mandating further bagging, suctioning, and frequent administration of muscle paralysis [Figure 1].
After a few hours of observation without improvement and with a refractory hypoxemia state, the decision was made to initiate rescue veno-venous extracorporeal membrane oxygenation (ECMO). After full disclosure and obtaining consent, the patient's critical condition made the transportation attempt quite hazardous, necessitating the cannulation to be performed at the site of the general medical floor. Cannulation of the left femoral vein with a 23 Fr access cannula and a suitable internal jugular vein 17 Fr return cannula was done successfully, during which the patient received 5000 units of intravenous heparin.
ECMO was initially set with a flow of 4 L/min, FiO2 of 1.0, and sweep gas at 4 L/min. The patient was kept on PEEP of 10, FiO2 of 0.5, and respiratory rate of 10 with 98% SpO2 improvement post initiation of ECMO. Heparin infusion was started targeting activated clotting time (ACT) of 180–200 s. Post cannulation and initiation of ECMO, return cannula site continuous oozing was observed, ACT result of 160 s. Thromboelastography (TEG) was performed due to the questionable validity of the ACT result, which revealed an elevated R time. Accordingly, the heparin infusion was adjusted, and further titration of anticoagulation was made according to TEG results performed on a 12-h basis. No further hemorrhagic complications were observed, and TEG monitoring to guide anticoagulation continued until the successful liberation of ECMO.
Post stabilization of the patient, sequential bronchoalveolar lavage came positive. The patient developed massive hemoptysis with a new drop of hemoglobin from 80 g/l to 69 g/l, and new bilateral infiltrates in the chest X-ray diffuse alveolar hemorrhage (DAH) causing acute respiratory distress syndrome was made. The patient received immunotherapy as a pulse steroid, rituximab, followed by plasma exchange therapy and broad-spectrum antimicrobial agents initiated for the risk of infection.
The patient's course showed a rapid and remarkable recovery. He was successfully weaned from ECMO after four days, extubated on day 6, and discharged home after 2 weeks. Currently, the patient is following up with rheumatology daycare for completion of the Euro-Lupus Cyclophosphamide Protocol.
| Discussion|| |
Anticoagulation in patients with ECMO is essential to maintain circuit and oxygenator integrity. However, anticoagulation decisions might be challenging in cases of DAH due to the risk of worsening alveolar hemorrhage. DAH is a life-threatening condition that may lead to advanced respiratory failure and may require intubation, mechanical ventilation, and even ECMO support to maintain life and buy time to treat the inciting event, mainly autoimmune diseases like systemic lupus erythematosus., Mostly, evidence regarding anticoagulation strategy in ECMO with respiratory failure due to DAH comes from small retrospective studies and case reports suggesting low-intensity anticoagulation (lower than usual target); for example, Abrams et al. described four cases with DAH requiring ECMO; in all cases, anticoagulation was instituted with continuous heparin infusion without major complications with a target-activated partial thromboplastin time of 40–60 s (mean, 47.4 ± 11.6 s), and all patients survived to decannulation. However, in one case, anticoagulation was held after the initial bolus due to worsening hemoptysis, and after 36 h, the oxygenator was replaced due to thrombosis, followed by resumption of heparin infusion.
Another case report published by Rawal et al. described using heparin infusion in a patient with DAH associated with granulomatosis with polyangiitis using target ACT (140–160). The patient had no bleeding complications during ECMO support with low-intensity anticoagulation. As described in our case presentation, our patient had some oozing from cannulas with near-normal activated partial thromboplastin. TEG was done and provided insight to adjust the heparin infusion and manage our patient. The role of TEG was also mentioned in the literature, especially in cases where bleeding and thrombosis might co-exist and may guide the anticoagulation intensity in ECMO if a hypercoagulable state like COVID-19 is present.
| Conclusion|| |
We describe a strategy of low-intensity anticoagulation in patients with DAH being supported with ECMO with careful monitoring of coagulation profile, ACT, and viscoelastic tests like TEG to have a better view and guide anticoagulation strategy. Further studies are needed to support these results
The patient verbally consented according to our research ethical committee protocol.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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