Massive Pulmonary Hemorrhage Research Articles

Management of Massive Pulmonary Hemorrhage Following Pulmonary Endarterectomy

Massive pulmonary hemorrhage is a potentially fatal complication of pulmonary endarterectomy. We describe a successful management in which the patient's right lower lobe bronchus was occluded with a Fogarty balloon catheter while on peripheral venoarterial extracorporeal membrane oxygenation.

Pulmonary hemorrhage in very low‐birthweight infants: Risk factors and management

Beginning 2007, the intratracheal route of epinephrine to end massive pulmonary hemorrhage (MPH) in very low-birthweight (VLBW) infants was modified at Kaohsiung Veterans General Hospital. The aim of the present study was to assess the change in outcomes for these infants, and to evaluate the risk factors of MPH. Using the database of the Premature Baby Foundation of Taiwan, the mortality, risk factors and characteristics of VLBW infants with or without MPH were compared between 2000-2006 and 2007-2010. Between January 2000 and December 2010, 399 VLBW infants were admitted to Kaohsiung Veterans General Hospital. Mean birthweight (BW) was 1099.6 ± 272.7 g, and mean gestational age (GA) was 28.7 ± 2.9 weeks. The overall survival rate was 84.2%. Sixteen (4%) had MPH: 11 in the first group (2000-2006; 18.2% survival rate), and five in the second group (2007-2010; 80% survival rate; P= 0.0000002). Infants with MPH had lower mean BW (864.9 ± 301.4 g, P= 0.0004), smaller mean GA (26.1 ± 2.0 weeks, P= 0.0002), significantly lower Apgar scores at 1 and 5 min, higher severity of respiratory distress syndrome (RDS; grades 3 or 4), and greater use of surfactant than infants without MPH. They also had more intraventricular hemorrhage and higher mortality. Smaller GA, lower BW, lower Apgar scores at 1 and 5 min, severe RDS (grades 3 or 4), and use of surfactant place VLBW infants at greater risk of MPH. Proper prenatal care and preventing premature labor and delivery were the most important preventative factors. A quick, deep thrust of intratracheal epinephrine with a catheter may improve survival.

Cardiopulmonary bypass strategy with low-dose heparin and nafamostat mesilate in cardiac surgery: A safe option for patients with acute stroke

From the Narayana Hrudayalaya Institute of Medical Sciences, Bangalore, India; and theDepartment ofCardiology, St. John’sMedicalCollegeHospital,Bangalore, India. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication Dec 13, 2011; revisions received March 2, 2012; accepted for publication March 16, 2012; available ahead of print April 27, 2012. Address for reprints: Naoto Morimoto, MD, PhD, Department of Cardiovascular Surgery, Himeji Cardiovascular Center, 520, Saishoko, Himeji, Hyogo, 670-0981, Japan (E-mail: naotofrcs@gmail.com). J Thorac Cardiovasc Surg 2012;144:726-8 0022-5223/$36.00 Copyright 2012 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2012.03.030

Venoarterial extracorporeal membrane oxygenation support for two patients after pulmonary thromboendarterectomy

cardiopulmonary bypass (CPB) after PTE secondary to reperfusion injury and massive pulmonary hemorrhage, which are the main causes of in-hospital deaths. Extracorporeal membrane oxygenation (ECMO) may be utilized as a treatment for such critically ill patients, providing basic life support and time for recovery. Recent reports are now suggesting support ECMO using the venoarterial mode (VA ECMO). Here we report two successful cases of VA ECMO in two patients who were also critically ill after PTE. The patients gave their written consent for the publication of this article. In the first case, a 49-yr-old female presented with recurrent syncope and shortness of breath lasting for one month after being immobilized for two months due to a fracture of the left patella. Transthoracic echocardiography (2D TTE) showed an enlarged right ventricle, a normal-sized left ventricle, and right ventricular systolic pressure (RVSP) of 87 mmHg. Cardiac magnetic resonance imaging showed considerable thrombus extending from the main pulmonary artery to the segmental pulmonary arteries. Right-heart catheterization indicated severe pulmonary arterial hypertension with a systolic pulmonary arterial pressure of 86/37 mmHg (mean, 50 mmHg). Thromboendarterectomy was performed under ten minutes of deep hypothermic circulatory arrest (DHCA). The aortic cross-clamping time was 65 min. The pulmonary arterial pressure on weaning from CPB was equal to the pressure of the systemic circulation, while the volume of blood drainage from the tracheal catheter was greater than 400 mL, hence, the patient was continued on CPB. Bleeding was controlled during CPB; however, the patient could not be weaned from it even after an intervening period. Thus, VA ECMO was established through the femoral artery and vein, respectively, in the operating room to wean her from CPB. The VA ECMO flow rate was maintained at *2.5 Lmin -1 , pulmonary arterial

Argon Beam Coagulator: An Effective Adjunct to Stapled Pulmonary Tractotomy to Control Hemorrhage in Penetrating Pulmonary Injuries

Stapled pulmonary tractotomy with selective vascular ligation is a rapid technique used to control hemorrhage in penetrating pulmonary injuries and has assumed an important role in the trauma surgical armamentarium for the management of these injuries. This technique was designed as tissue sparing to avoid complications well known to occur with extensive pulmonary resections. Multiple studies have validated and reported this technique to be both safe and effective. Here we present the use of the argon beam coagulator as a valid adjunct to stapled pulmonary tractotomy for the management of penetrating pulmonary injuries. To our knowledge, the use of this technique has not been reported for control of massive intraparenchymal pulmonary hemorrhage.

Recombinant activated factor VII for diffuse alveolar hemorrhage in microscopic polyangiitis

Diffuse alveolar hemorrhage is a serious complication of the small vessel vasculitis syndromes and carries a high mortality. Recombinant activated factor VII (rFVIIa) is a powerful hemostatic agent developed for treatment of bleeding in patients with hemophilia and antibodies to factors VIII or IX. It has been used increasingly in life-threatening hemorrhage in a variety of other settings in which conventional medical or surgical therapy is unsuccessful. We report the successful use of rFVIIa for massive pulmonary hemorrhage in a patient of microscopic polyangiitis, which was later complicated by thrombotic microangiopathy and posterior reversible encephalopathy syndrome.

Successful liver transplantation following veno‐arterial extracorporeal membrane oxygenation in a child with fulminant Wilson disease and severe pulmonary hemorrhage: A case report

Massive pulmonary hemorrhage and other serious cardiopulmonary diseases in patients with fulminant hepatitis result not only in graft failure but also mortality after LT. ECMO is used to treat children with cardiorespiratory failure refractory to conventional intensive care. We describe a five-yr-old girl with genetically confirmed fulminant Wilson disease and severe pulmonary hemorrhage who underwent successful primary LT following veno-arterial ECMO. To our knowledge, this is the first report of successful primary LT in a patient using veno-arterial ECMO. The present case demonstrates that ECMO, as a bridging modality to LT, may be necessary to manage both massive pulmonary hemorrhage and possible graft loss because of hypoxemia.

Disseminated mucormycosis infection after the first course of dose-modified R-EPOCH for advanced-stage lymphoma

We report the case of a 63-year-old man who presented at our hospital after experiencing fever and dyspnea for more than 1month. Because his general condition was deteriorating, he was referred to our intensive care unit. He needed critical care and was treated with vasopressors, artificial ventilation, and continuous hemodialysis. Considering his systemic condition, hematological malignancy was suspected. Bone marrow and skin biopsies were performed, and the condition was diagnosed as diffuse large B-cell lymphoma. On the 15th day, suspecting infectious lung disease, we performed bronchoscopy, which showed Rhizopus infection. Thus, the patient was administered high-dose liposomal amphotericin B (10mg/kg) therapy. On the 54th day, he died of a massive pulmonary hemorrhage. Autopsy revealed mucormycosis infection in multiple organs, including the lungs and liver. Vigilance regarding possible mucormycosis infection is required, even after initial chemotherapy in patients whose bone marrow is significantly affected by lymphoma cells and leukemic changes.

Perinatal Transmission of Yellow Fever, Brazil

Perinatal Transmission of Yellow Fever, Brazil

Angiosarcoma of the ovary arising in a mucinous cystadenoma

We report the case of a 39-year-old woman who presented with a pelvic mass extending into the upper abdomen. Transabdominal sonography revealed a complex left adnexal mass. Color Doppler imaging and spectral Doppler analysis showed increased vascularity with low impedance blood flow signals, suggestive of neovascularization. The patient underwent a laparotomy and a 56-kg predominantly cystic tumor was removed from the left adnexal region. The patient died 3 months later with pulmonary metastases and massive pulmonary hemorrhage. Postmortem resampling of the ovarian tumor initially diagnosed as mucinous cystadenoma showed nodular areas of malignant pleomorphic cells consistent with angiosarcoma.

Clinical and Imaging Manifestations of Hemorrhagic Pulmonary Leptospirosis: A State-of-the-Art Review

Leptospirosis, a spirochetal zoonosis, is frequently unrecognized due to its manifestation as an undifferentiated fever. It is an emerging infectious disease that has changed from an occupational disease of veterinarians, farmers, butchers, and other animal handlers to a cause of epidemics in poor and decayed urban communities in developing countries. Humans are infected when mucous membranes or abraded skin come into direct contact with the urine of infected animals, especially rats and dogs. Mortality from severe leptospirosis is high, even when optimal treatment is provided. The diagnosis of leptospirosis is based on clinical findings, history of direct or indirect exposure to infected animals in endemic areas, and positive serological tests. It should be considered in the differential diagnosis of patients with febrile illnesses associated with pneumonitis and respiratory failure, especially when hemoptysis is present. Severe pulmonary involvement in leptospirosis consists primarily of hemorrhagic pneumonitis. In advanced cases, adult respiratory distress syndrome and massive pulmonary hemorrhage may occur. Chest radiographs show bilateral alveolar infiltrates and/or resemble viral pneumonia, bronchopneumonia, tuberculosis, adult respiratory distress syndrome, and other causes of pulmonary hemorrhage such as Goodpasture syndrome. High-resolution computed tomography scans may show nodular infiltrates, areas of consolidation, ground-glass attenuation, and crazy-paving patterns. Bronchoalveolar lavage and autopsy studies have suggested that ground-glass opacities and air-space consolidations are secondary to pulmonary hemorrhage. Although not specific, the presence of these computed tomography findings in a febrile patient with an appropriate history should suggest a diagnosis of leptospirosis.

957 Use of Therapeutic Surfactant Lavage in a Preterm Infant with Massive Pulmonary Hemorrhage

Introduction: Pulmonary hemorrhage (PH) is a potentially life-threatening complication occurring in 10-16% of extremely low birth infants (ELBW), leading to chronic lung disease in 60% of cases. Surfactant is mainly used for early management of respiratory distress syndrome in preterm infants. Recently, therapeutic surfactant lavage with diluted surfactant has been proposed for the management of infants suffering from severe meconium aspiration syndrome (MAS). Case presentation: We report a case of a preterm infant (26 weeks GA) presenting with recurrent pulmonary hemorrhage in whom we performed a therapeutic lavage with diluted surfactant after an acute episode of massive bleeding with severe intractable hypoxemia. Repeated small aliquots of diluted surfactant (10 x 2 ml) allowed for marked improvement in oxygenation allowing to reduce mean airway pressures during high frequency oscillatory ventilation rapidly. The infant showed further progressive improvement allowing switching from HFOV back to conventional ventilation and finally extubation within 25 days. Conclusion: Bronchoalveolar lavage with diluted surfactant might be beneficial in massive pulmonary hemorrhage in infants. Further investigations are needed to clarify the potential benefit of such a therapeutic intervention on outcome of infants suffering from life-threatening PH.

Possible role of LECT2 as an intrinsic regulatory factor in SEA-induced toxicity in d-galactosamine-sensitized mice

To elucidate whether leukocyte cell-derived chemotaxin 2 (LECT2) controls the progression of staphylococcal enterotoxin A (SEA)-induced toxicity, we examined the role of LECT2 in a mouse model. Almost all the C57BL/6 J (B6) mice survived for 72 h after the injection of 0.1 μg of SEA and 20 mg of d -galactosamine ( d -GalN). However, the same treatment protocol in LECT2 −/− mice produced a high lethality (~ 90%), severe hepatic apoptosis, and massive hepatic and pulmonary hemorrhage, similar to the situation observed in B6 mice treated with 1.0 μg SEA/ d -GalN. The plasma LECT2 levels in B6 mice treated with 1.0 μg SEA/ d -GalN were inversely correlated with the plasma cytokine levels and were associated with prognosis. LECT2 administration increased the survival of B6 mice and down-regulated TNF-α and IL-6. These results suggest the involvement of LECT2 in the regulation of fatal SEA-induced toxicity in d -GalN-sensitized mice.

The Use of Extracorporeal Membrane Oxygenation, High-Frequency Oscillatory Ventilation, and Surfactant for the Management of Intraoperative Acute Pulmonary Hemorrhage in Tetralogy of Fallot

ACUTE MASSIVE PULMONARY HEMORRHAGE occurring intraoperatively during the repair or palliation of complex congenital cardiac defects is a rare entity and often is fatal. 1 Baden H.P. Li C.M. Hall D. et al. High frequency oscillatory ventilation in the management of infants with pulmonary hemorrhage after cardiac surgery. J Cardiothorac Vasc Anesth. 1995; 9: 578-580 Abstract Full Text PDF PubMed Scopus (6) Google Scholar The authors report their experience in successfully managing acute massive pulmonary hemorrhage that occurred after the creation of a central shunt on cardiopulmonary bypass (CPB) in a 2-month-old former premature infant with tetralogy of Fallot, hypoplastic main and branch pulmonary arteries, and an anomalous coronary artery across the right ventricular outflow tract. The authors used a combination of extracorporeal membrane oxygenation, high-frequency oscillatory ventilation (HFOV), and surfactant to achieve a successful result.

Lacrimal Gland Involvement in Lymphomatoid Granulomatosis and Review of the Literature

Objective. To describe the clinicoradiological and histopathological findings in a case of lacrimal gland enlargement secondary to lymphomatoid granulomatosis (LG) and to review the literature. Design. Case report and systematic literature review. Methods. A 75-year-old woman presented with right ptosis. Computerised tomography showed lacrimal gland enlargement, and biopsy done was inconclusive. She subsequently developed pulmonary symptoms and underwent transbronchial biopsy that was diagnosed as LG. Pub Med and OVID databases were searched using the term “orbit/eye involvement in lymphomatoid granulomatosis”. Articles that predated the databases were gathered from current references. Results. The patient underwent lacrimal gland biopsy which revealed necrotic and inflamed tissue with no further categorisation but transbronchial biopsy helped in establishing the diagnosis of LG. On initiation of prednisolone and cyclophosphamide, her orbital lesion resolved but the patient died following massive pulmonary hemorrhage within a month of diagnosis. Conclusion. Ophthalmic involvement in LG is very rare. Varied presentations are due to central nervous system involvement, vasculitis, or infiltration of ocular or orbital structures. LG is an angiocentric and angiodestructive granulomatous disorder and can involve any tissue, thus accounting for the variable presentations reported in literature.

Perioperative management of plastic bronchitis in children

Purpose The aim of this study was to summarize clinical features and perioperative management of plastic bronchitis in 21 children. Methods We reviewed the clinical data of 21 children diagnosed with plastic bronchitis in our hospital from April 2001 to February 2009 in this retrospective study. Results Bronchoscopy was performed in 19 of the 21 cases. Of these, 13 patients were cured with the first procedure, during which branching bronchial casts were taken out. Six cases required a second procedure; of these, five patients were cured by removing branching bronchial casts; one patient died from massive pulmonary hemorrhage during anesthesia induction. Two patients were critically ill at initial diagnosis and worsened despite airway intubation, these patients died of multiple organ failure. The branching bronchial casts which were composed primarily of gelatinous fibers were sent for pathologic examination. Pathologically, 12 foreign bodies were classified as type I casts (containing inflammatory cells), 9 cases were type II (no inflammatory cells detected). Conclusions Plastic bronchitis in children is a life-threatening disease, the only effective therapeutic modality is bronchoscopic extraction. The early diagnosis of plastic bronchitis is difficult, anesthesia and extraction procedures are demanding, and the postoperative monitoring is challenging. The clinician should try to make an early diagnosis, use enhanced perioperative monitoring, and improve operational technique to provide timely treatment for the children with plastic bronchitis, thereby reducing the associated mortality rate.

Treating severe systemic lupus erythematosus with rituximab. An open study

Systemic lupus erythematosus (SLE) is an autoimmune disease that may be associated to high morbidity and mortality. Disease course is variable and unpredictable and although the prognosis and survival of these patients has dramatically improved, treatment of severe multiorganic organic affection in this condition remains a therapeutic challenge. Since B lymphocytes have an important role in the pathogenesis of SLE, it is expected that the targeting of these cells exerts a significant therapeutic effect in SLE patients with severe multiorganic manifestations. In an open clinical trial, we have explored the therapeutic potential of Rituximab (an anti-CD20 monoclonal antibody) administration in SLE patients with severe nephritis (n=22) or neuropsychiatric manifestations (n=6) or massive pulmonary hemorrhage (n=3). In most cases, we observed significant improvement in both clinical and laboratory parameters, with good tolerance and few side effects. Thus, patients with severe lupus nephritis showed improvement in disease activity (MEX-SLEDAI index) with a significant reduction (p<0.05), as well as proteinuria in most of them (from 3.710g/L to 1.786g/L, p<0.05); patients with serious neurologic involvement had complete remission of their manifestations; but those with pulmonary massive hemorrhage did not have any response. Rituximab could have an important therapeutic potential in severe SLE, and that it is necessary to carry out a controlled blinded clinical trial to further support this point.

Therapeutic Implications of Coexisting Severe Pulmonary Hemorrhage and Pulmonary Emboli in a Case of Wegener Granulomatosis

Wegener granulomatosis classically involves the renal, respiratory, and ear, nose, and throat systems. Pulmonary hemorrhage is recognized as a severe respiratory complication. Untreated, the mortality rate approaches 90% at 2 years. We describe a case of Wegener granulomatosis with coexistent severe lung hemorrhage and pulmonary and deep vein thromboses. A 31-year-old man presented with features of vasculitis, including epistaxis, fever, and acute kidney injury with an increased serum creatinine level (3.27 mg/dL). Kidney biopsy confirmed pauci-immune crescentic glomerulonephritis, and antineutrophil cytoplasmic antibody showing a cytoplasmic staining pattern was strongly positive. Standard immunosuppression therapy (prednisolone and cyclophosphamide) was started. Eleven days later, the patient developed sudden dyspnea. A computed tomographic pulmonary angiogram showed pulmonary emboli, and ultrasound of the limbs showed ileofemoral thrombi bilaterally. Subcutaneous enoxaparin and warfarin therapy was started, but 8 days later, the patient had a massive pulmonary hemorrhage. Anticoagulation therapy was stopped, and plasma exchange was started to prevent further life-threatening hemorrhage. An inferior vena cava filter was inserted to prevent further pulmonary emboli during the period when anticoagulation was withheld. Kidney function improved, and pulmonary hemorrhage resolved after 5 plasma exchanges. Reintroduction of intravenous heparin and subsequently warfarin caused no further bleeding. We discuss the difficult management dilemma this combination of disease manifestations presents and review the current literature.

Recombinant factor VIIa use following massive pulmonary hemorrhage after CPB

Recombinant factor VIIa use following massive pulmonary hemorrhage after CPB

Treating severe systemic lupus erythematosus with rituximab. An open study

Systemic lupus erythematosus (SLE) is an autoimmune disease that may be associated to high morbidity and mortality. Disease course is variable and unpredictable and although the prognosis and survival of these patients has dramatically improved, treatment of severe multiorganic organic affection in this condition remains a therapeutic challenge. Since B lymphocytes have an important role in the pathogenesis of SLE, it is expected that the targeting of these cells exerts a significant therapeutic effect in SLE patients with severe multiorganic manifestations. In an open clinical trial, we have explored the therapeutic potential of rituximab (an anti-CD20 monoclonal antibody) administration in SLE patients with severe nephritis (n=22) or neuropsychiatric manifestations (n=6) or massive pulmonary hemorrhage (n=3). In most cases, we observed significant improvement in both clinical and laboratory parameters, with good tolerance and few side effects. Thus, patients with severe lupus nephritis showed improvement in disease activity (MEX-SLEDAI index) with a significant reduction (P<.05), as well as proteinuria in most of them (from 3710g/L to 1786g/L, P<.05); patients with serious neurologic involvement had complete remission of their manifestations; but those with pulmonary massive hemorrhage did not have any response. Rituximab could have an important therapeutic potential in severe SLE, and that it is necessary to carry out a controlled blinded clinical trial to further support this point