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Abstract

Introduction: Case Report: Diffuse alveolar hemorrhage (DAH) can occur secondary to severe sepsis. Intrapulmonary recombinant factor VIIa has been used to treat DAH. Its use has not been described in the setting of extracorporeal membrane oxygenation, nor in concert with cryotherapy. Case discussion: A 45 year old female who presented for aortic dissection repair via left thoracotomy could not be weaned off bypass secondary to pulmonary contusions and concern for pulmonary hemorrhage. She was placed on veno-arterial (VA) ECMO (extra corporeal membrane oxygenation) intraoperatively. She remained on VA ECMO for four days postoperatively. However, after decannulation she developed ARDS and was unable to maintain adequate oxygenation despite efforts with oscillatory ventilation. As a result, veno-venous ECMO was initiated. She subsequently developed DAH that manifested as large blood clots throughout the tracheobronchial tree completely obstructing her airways, necessitating daily bronchoscopy without resolution. Furthermore, the clot could not be removed using suction, or biopsy forceps. Cryotherapy was employed to attempt to remove the clot burden and ameliorate her respiratory failure. Cryotherapy was performed in multiple locations, including the trachea and right and left mainstem bronchi. Extensive clots were removed, and the post procedure lumen sizes were substantially improved. There was, however, diffuse bloody oozing, and as such, intrapulmonary administration of rFVIIa (recombinant factor VIIa) was employed in a further attempt to stop the hemorrhage. rFVIIa was instilled into each segment of the lung in an attempt to achieve pulmonary hemostasis. The dose of rFVIIa was 50 μg/kg prepared in a 50 cc diluent by pharmacy and broken into two, 25 cc aliquots. There were no complications in the ECMO circuit immediately following instillation of rFVIIa. Washings were obtained and sent for factor VIIa and fibrinogen levels. A sample was sent before and after the instillation of rFVIIa. Factor VII serum levels demonstrated 98% activity prior to instillation, and 111% activity post instillation. Fibrinogen levels were not significantly changed after rFVIIa administration (184mg/dL and 198mg/dL respectively). No further hemorrhage was seen on subsequent bronchoscopy. Cryotherapy and intrapulmonary factor VII are effective in resolving life-threatening DAH.