Giant Retroperitoneal Hematoma During Extracorporeal Membrane Oxygenation in a Patient With Coronavirus Disease-2019 Pneumonia

Abstract

A 71-YEAR-OLD man was admitted to the intensive care unit because of severe bilateral pneumonia resulting from coronavirus disease-2019. His chief complaints were persistent fever, cough, and shortness of breath. Thoracic computed tomography showed bilateral multiple ground-glass opacities. An arterial blood gas analysis demonstrated a low oxygenation index. The patient received high-flow oxygen therapy via a nasal cannula to maintain his oxygen saturation >90%. After receiving supportive care for 2 days, the patient's respiratory function deteriorated further. Endotracheal intubation was performed, but the patient's oxygen saturation remained approximately 70% despite mechanical ventilation with 100% oxygen. Therefore, percutaneous venovenous extracorporeal membrane oxygenation (ECMO) was initiated. Activated partial thromboplastin time was targeted to 60 seconds using a heparin infusion. Progressive hypotension without apparent cause developed 7 days after ECMO was begun. What is the diagnosis? Acute respiratory distress syndrome and profound hypoxemia are the main causes of death in coronavirus disease-2019 pneumonia.1Ruan Q. Yang K. Wang W. et al.Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan.China. Intensive Care Med. 2020; 46: 846-848Crossref PubMed Scopus (2899) Google Scholar Despite the wide use of mechanical ventilation with low-volume, low-pressure, and prone position ventilation strategies, the mortality is still as high as 60% in severe cases.2Yang X. Yu Y. Xu J. et al.Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: A single-centered, retrospective, observational study.Lancet Respir Med. 2020; 8: 475-481Abstract Full Text Full Text PDF PubMed Scopus (5946) Google Scholar In such situations, ECMO might be a life-saving measure, but it also is associated with hemorrhagic complications.3Henry B.M. COVID-19, ECMO, and lymphopenia: A word of caution.Lancet Respir Med. 2020; 8: e24Abstract Full Text Full Text PDF PubMed Scopus (172) Google Scholar,4Augoustides J.G. Extracorporeal membrane oxygenation – crucial considerations during the coronavirus crisis.J Cardiothorac Vasc Anesth. 2020; 34: 1720-1722Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar In addition, because of a relatively complex management, various complications may occur during ECMO support.5Keller S.P. Contemporary approaches in the use of extracorporeal membrane oxygenation to support patients waiting for lung transplantation.Ann Cardiothorac Surg. 2020; 9: 29-41Crossref PubMed Google Scholar,6Hoyler M.M. Flynn B. Iannacone E.M. et al.Clinical management of venoarterial extracorporeal membrane oxygenation.J Cardiothorac Vasc Anesth. 2020; 34: 2776-2792Abstract Full Text Full Text PDF Scopus (14) Google Scholar Abdominal computed tomography revealed a large cystic retroperitoneal mass, with extravasation of contrast consistent with a retroperitoneal hematoma. The patient remained hypotensive despite volume resuscitation with crystalloid and packed red blood cell transfusion. An intravenous infusion of norepinephrine was required to temporize the hypotension, but the serum lactate concentration continued to increase. The right internal iliac artery was occluded successfully in the angiography suite, and his hemodynamics stabilized. After the procedure, he was returned to the intensive care unit. The patient eventually was weaned from mechanical ventilation and was discharged from hospital 76 days after the procedure. Figure 1 The authors have no conflicts of interest to disclose.