HEPARIN-LESS EXTRACORPOREAL MEMBRANE OXYGENATION IN DIFFUSE ALVEOLAR HEMORRHAGE

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Diffuse alveolar hemorrhage (DAH) is histologic hallmark for acute phase of acute respiratory distress syndrome (ARDS) [1]. Veno-venous extracorporeal membrane oxygenation (VV ECMO) is an effective modality for severe ARDS but requires anticoagulation to prevent life threatening thrombotic events. We present a case of heparin-less ECMO in a patient diagnosed with DAH that was still complicated by worsening pulmonary hemorrhage. CASE PRESENTATION: A 36 yo African American male with past medical history of intellectual disability, obstructive sleep apnea, and hypertension presented with acute hypoxic respiratory failure from what seemed to be DAH. His deteriorating condition demanded increasing ventilator support and was eventually switched to VV ECMO without systemic heparin due to DAH. With worsening kidney failure and metabolic derangement patient required continuous renal replacement therapy (CRRT) leading to a transient improvement in his overall function. Tracheostomy was performed due to prolonged respiratory failure which was complicated by diffuse hemorrhaging in trachea and oropharynx, and occlusion of the trachea with clots. IR angiography did not reveal any extravasation or possible source for the bleeding, so remained to assume vasculitis related DAH, though rheumatological evaluation was negative for underlying vasculitic origin. After failed intrabronchial tPA attempt, bronchoscopy successfully removed the larger clots with some remaining in smaller airways. Patient’s status deteriorated with multiorgan failure despite CVVH, VV ECMO support and immunosuppressant therapy. The patient suffered PEA arrest due to significant hypoxia from ongoing pulmonary hemorrhage, despite being on full VV ECMO. Decision was made by family to withdraw life support and hence the patient expired. The autopsy reported pulmonary hemorrhage with non-occlusive blood clots in the distal trachea and bilateral bronchi and distal branches in bilateral lungs. Histopathology of the lung suggested ongoing hemorrhage but no evidence of inflammation or vasculitis. Histopathology of the kidneys did not show glomerular disease or inflammation. Final Diagnosis was presumed to be DAH related to ARDS. DISCUSSION: Any condition that precludes the use of systemic anticoagulation is considered a strong contraindication for ECMO; however this consideration has changed in the era of increasingly biocompatible circuits [2]. Use of anticoagulation in DAH is controversial as it may exacerbate bleeding, but low level of anticoagulation has been studied in several case series [2], as well as anticoagulation-free ECMO [1-3]. CONCLUSIONS: In our case, our patient continued to deteriorate despite the anticoagulation-free ECMO support, likely due to circuit’s inflammatory effect on platelet function. Hence what makes ECMO support a controversial option in these cases. Reference #1: Galvagno, S. M., Shah, N. G., Cornachione, C. R., Deatrick, K. B., Mazzeffi, M. A., & Menaker, J. (2019). Long term veno-venous extracorporeal life support without intravenous anticoagulation for diffuse alveolar hemorrhage. Perfusion, 026765911982682. https://doi.org/10.1177/0267659119826828 Reference #2: Abrams, D., Agerstrand, C. L., Biscotti, M., Burkart, K. M., Bacchetta, M., & Brodie, D. (2015). Extracorporeal Membrane Oxygenation in the Management of Diffuse Alveolar Hemorrhage. ASAIO Journal, 61(2), 216-218. https://doi.org/10.1097/mat.0000000000000183 Reference #3: Muellenbach RM, Kredel M, Kunze E, et al. Prolonged heparin-free extracorporeal membrane oxygenation in multiple injured acute respiratory distress syndrome patients with traumatic brain injury. J Trauma Acute Care Surg 2012; 72: 1444–1447 DISCLOSURES: No relevant relationships by Riad Akkari, source=Web Response