DIFFUSE ALVEOLAR HEMORRHAGE AND EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO): A BLOODY CONUNDRUM

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Diffuse alveolar hemorrhage (DAH) may mimic Acute Respiratory Distress Syndrome (ARDS) and is associated with high mortality. Veno-venous ECMO has proven to be valuable in the treatment of ARDS. Anticoagulation in the setting of DAH is challenging. We present a case of DAH successfully treated with ECMO without anticoagulation. CASE PRESENTATION: A 64-year-old female with minimal past medical history and recent sinusitis was admitted to our facility after being cannulated and placed on ECMO due to worsening ARDS despite paralysis and prone positioning. She was noted to be anemic and urine analysis revealed red blood cell (RBC) casts and dysmorphic RBCs, therefore, bronchoscopy with bronchoalveolar lavage was performed and revealed significant bloody aliquots. Further laboratory investigations revealed positive C-ANCA and PR3 suggestive of Granulomatosis with Polyangiitis (GPA). She was initially placed on bivalirudin, however due to severity of DAH and cannula site bleeding, the decision was made to stop anticoagulation. ECMO was maintained at high flow, 4.2 L/min. and the circuit was switched to a heparin coated system. GPA targeted treatment included Methylprednisolone 1gm/day for 3 days followed by an 8-week taper, IV cyclophosphamide, and 7 sessions of plasmapheresis. She was weaned off ECMO on day 9. With exception of minor oxygenator clots which did not interfere with efficacy of ECMO, there were no complications from absence of systemic anticoagulation. She was liberated from mechanical ventilation on day 27 and discharged to rehabilitation facility. There, she was decannulated and no longer requiring supplemental oxygen. DISCUSSION: Historically, inability to use anticoagulation has been viewed as a relative contraindication to ECMO. There are successful cases of ECMO therapy in DAH attributed to targeting lower activated clotting times. It’s well known that ECMO bleeding complications due to anticoagulation are common and can drastically alter desired outcomes. Advances in the ECMO circuit, now coated with heparin and maintaining high flow allow prolonged ECMO runs without anticoagulation in those with a risk of bleeding. Our patient was able to successfully complete a 9-day ECMO run using the above strategy. CONCLUSIONS: Our case demonstrates the importance of keeping DAH as a differential causing ARDS and ability to provide supportive care with ECMO while curative treatments for DAH are implemented. It also demonstrates relative safety of not using systemic anticoagulation for a prolonged period with the use of high flow through a heparin coated ECMO circuit. Careful monitoring for thrombotic complications is necessary when the above approach is used. Despite the lack of guidelines for this patient population, it’s of great importance that treating clinicians have a low threshold to seek advice and refer to an ECMO center, as its use can dramatically improve the clinical outcome. Reference #1: Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, Hibbert CL. et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicenter randomized controlled trial. Lancet. 2009;374(9698):1351–1363. Reference #2: Combes A, Hajage D, Capellier G, Demoule A, Lavoué S, Guervilly C, et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. N Engl J Med. 2018;378(21):1965-1975. Reference #3: Simpson T, Ling C, Glover G, Barrett N, Ioannou N, Lams B, Langrish C, Meadows C, Agarwal N, D’Cruz D. P278 Extra-corporeal membrane oxygenation and diffuse alveolar haemorrhage – a single centre case series and analysis of the ELSO database. Thorax 2014;69: A195–A196. DISCLOSURES: No relevant relationships by Evan Gajkowski, source=Web Response No relevant relationships by Alejandra Garcia Fernandez, source=Web Response No relevant relationships by Yatin Mehta, source=Web Response No relevant relationships Added 02/27/2019 by Kenneth Snell, source=Web Response, value=Grant/Research Support Removed 03/06/2019 by Kenneth Snell, source=Web Response