Extracorporeal Membrane Oxygenation for Severe ARDS Due to Immune Diffuse Alveolar Hemorrhage: A Retrospective Observational Study

[An outline of pulmonary hemorrhage - A pulmonologists perspective]

Hemoptysis resembles a clinical emergency and necessitates a fast and well-coordinated diagnostic and therapeutic approach. While up to 50% of the underlying causes remain unidentified, the majority of cases in the western world can be attributed to respiratory infections and pulmonary neoplasm. While 10% of the patients present with massive, life-threatening hemoptysis, which require a timely airway protection in order to secure a sustained pulmonary gas-exchange, the vast majority presents with non-critical pulmonary bleeding events. Most critical pulmonary bleeding events arise from the bronchial circulation. An early chest imaging is key for identifying the bleeding cause and localization. While chest x-rays are widely implemented in the clinical work-flow and rapidly applicable, computed tomography and computed tomography angiography exhibit the highest diagnostic yield. Bronchoscopy can add diagnostic information especially in pathologies of the central airways, while offering multiple therapeutic options to maintain pulmonary gas exchange. The initial therapeutic regimen comprises early supportive care, but treatment of the underlying etiology is of prognostic relevance and avoids recurrent bleeding events. Bronchial arterial embolization usually is the therapy of choice in patients with massive hemoptysis, while definitive surgery is reserved for patients with refractory bleeding and complex pathologies.

Perioperative Management of Antisynthetase Syndrome: A Case Report

Antisynthetase syndrome is a rare idiopathic inflammatory multisystem disorder, which can lead to serious postoperative complications. Due to its low incidence, there is little literature on its anesthetic management. However, patients with this disease can suffer from serious complications secondary to muscle weakness and respiratory complications. Although the intraoperative and the immediate postoperative periods may be uneventful, complications may appear later. The characteristics of the disease can lead to a misdiagnosis in the case of respiratory acute failure. The objective of this clinical report is to discuss the perioperative management of patients suffering from antisynthetase syndrome, assess the usefulness of postoperative monitoring, and evaluate alternatives that could have been carried out to prevent the fatal outcome reported in this narrative.

Heparin-free after 3000 IU heparin loaded in veno-venous ECMO supported acute respiratory failure patients with hemorrhage risk: a novel anti-coagulation strategy

Background

The anti-coagulation protocol of patients with hemorrhage risk primary disease who need extracorporeal membrane oxygenation (ECMO) supported is controversial. This study evaluated the feasibility of a new anti-coagulation strategy, that is heparin-free after 3000 IU heparin loaded in veno-venous ECMO (VV ECMO) supported acute respiratory failure patients with hemorrhage risk.

Methods

A retrospective study was performed in a series of hemorrhage risk patients supported with VV ECMO at the First Affiliated Hospital of Zhengzhou University, between June 2012 to Sept 2020. A total of 70 patients received a low heparin bolus of 3000 units for cannulation but without subsequent, ongoing heparin administration. Patients were divided into survival (n = 25) and non-survival group (n = 45). Data of coagulation, hemolysis and membrane lung function were calculated and analyzed. The complications of patients were recorded. Finally, the binary Logistic regression was conducted.

Results

The longest heparin-free time was 216 h, and the mean heparin-free time was 102 h. Compared with survivors, the non-survivors were showed higher baseline SOFA score and lower platelet counts in 0.5 h, 24 h, 48 h and 96 h after ECMO applied. However, there was no significant differences between survivors and non-survivors in ACT, APTT, INR, D-dimer, fibrinogen, LDH, blood flow rate, Δp and P_post-MLO₂ (all p < 0.05) of all different time point. Moreover, only the baseline SOFA score was significantly associated with mortality (p < 0.001, OR(95%CI): 2.754 (1.486–5.103)) while the baseline levels of ACT, APTT, INR, platelet, D-dimer, fibrinogen and LDH have no association with mortality. The percentage of thrombosis complications was 54.3% (38/70) including 3 oxygenator changed but there was no significant difference of complications in survival and non-survival groups (p > 0.05).

Conclusions

The anticoagulation protocol that no heparin after a 3000 units heparin bolus in VV ECMO supported acute respiratory failure patients with hemorrhage risk is feasible.

Extracorporeal Membrane Oxygenation Support for Antineutrophil Cytoplasmic Antibody-associated Vasculitides: An ELSO Registry Analysis

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides with pulmonary involvement include granulomatosis with polyangiitis, microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis, and can present with life-threatening pulmonary hemorrhage in up to 40% of patients. Mortality in those patients who require intubation and mechanical ventilation can reach 77%. Extracorporeal membrane oxygenation (ECMO) can be used to support these patients through definitive diagnosis and treatment, although minimizing the risk of ventilator-induced lung injury. We aimed to determine factors associated with favorable outcomes in patients with (ANCA)-associated vasculitides supported on ECMO. We performed a retrospective observational study using the Extracorporeal Life Support Organization registry of pediatric and adult patients with ANCA-associated vasculitis supported on ECMO from 2010 to 2020. One hundred thirty-five patients were included for analysis. Many patients had renal involvement (39%) in addition to pulmonary involvement (93%). Survival was 73% in AAV patients supported on ECMO. The presence of pulmonary hemorrhage was not associated with worse outcomes in our cohort. Older age, the use of venoarterial ECMO, ECMO-cardiopulmonary resuscitation, or sustaining a cardiac arrest before ECMO was associated with decreased survival. In conclusion, venovenous ECMO should be considered as a supportive bridge to definitive diagnosis and treatment in (ANCA)-associated vasculitides, regardless if pulmonary hemorrhage is present.

Intracranial Hemorrhages on Extracorporeal Membrane Oxygenation: Differences Between COVID-19 and Other Viral Acute Respiratory Distress Syndrome

OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) is a potentially lifesaving procedure in acute respiratory distress syndrome (ARDS) due to COVID-19. Previous studies have shown a high prevalence of clinically silent cerebral microbleeds in patients with COVID-19. Based on this fact, together with the hemotrauma and the requirement of therapeutic anticoagulation on ECMO support, we hypothesized an increased risk of intracranial hemorrhages (ICHs). We analyzed ICH occurrence rate, circumstances and clinical outcome in patients that received ECMO support due to COVID-19-induced ARDS in comparison to viral non-COVID-19-induced ARDS intracerebral hemorrhage.

DESIGN

Multicenter, retrospective analysis between January 2010 and May 2021.

SETTING

Three tertiary care ECMO centers in Germany and Switzerland.

PATIENTS

Two-hundred ten ARDS patients on ECMO support (COVID-19, n = 142 vs viral non-COVID, n = 68).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Evaluation of ICH occurrence rate, parameters of coagulation and anticoagulation strategies, inflammation, and ICU survival. COVID-19 and non-COVID-19 ARDS patients showed comparable disease severity regarding Sequential Organ Failure Assessment score, while the oxygenation index before ECMO cannulation was higher in the COVID group (82 vs 65 mm Hg). Overall, ICH of any severity occurred in 29 of 142 COVID-19 patients (20%) versus four of 68 patients in the control ECMO group (6%). Fifteen of those 29 ICH events in the COVID-19 group were classified as major (52%) including nine fatal cases (9/29, 31%). In the control group, there was only one major ICH event (1/4, 25%). The adjusted subhazard ratio for the occurrence of an ICH in the COVID-19 group was 5.82 (97.5% CI, 1.9-17.8; p = 0.002). The overall ICU mortality in the presence of ICH of any severity was 88%.

CONCLUSIONS

This retrospective multicenter analysis showed a six-fold increased adjusted risk for ICH and a 3.5-fold increased incidence of ICH in COVID-19 patients on ECMO. Prospective studies are needed to confirm this observation and to determine whether the bleeding risk can be reduced by adjusting anticoagulation strategies.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) for life-threatening isolated pulmonary anti-GBM disease

Anti-glomerular basement membrane disease (anti-GBM disease) associated with renal and lung lesions has a poor prognosis. Diffuse alveolar hemorrhage (DAH) is a complication that worsens anti-GBM disease prognosis. We report a rescue case using veno-venous extracorporeal membrane oxygenation (VV-ECMO) for diffuse alveolar hemorrhage due to isolated pulmonary anti-GBM disease; a rare anti-GBM syndrome. A 30-year-old Japanese female with no past medical history. Presented with acute hypoxemic respiratory failure requiring mechanical ventilation. Progressive deterioration and refractory hypoxemia prompted therapy with VV-ECMO. Serum anti-GBM antibody confirmed the diagnosis of anti-GBM disease. Multi-modal systemic therapy with pulse-dosed methylprednisolone, plasma exchange, and rituximab resulted in significant clinical improvement. VV-ECMO for 10 days was uncomplicated. Renal replacement therapy was not required. The patient was extubated on day 18 and discharged from the hospital after 45 days. VV-ECMO supportive therapy for DAH with refractory respiratory failure was demonstrated to be effective pending definitive diagnostic and therapeutic management in this case of isolated pulmonary anti-GBM disease.

•We report a rescue case using VV-ECMO for diffuse alveolar hemorrhage with isolated pulmonary anti-GBM disease.

•VV-ECMO can provide life-support bridge therapy until a response to disease control with fundamental specific therapy becomes effective.

•

VV-ECMO with associated required anticoagulation was an effective and safe life-support therapy in the setting of DAH.

A novel therapeutic strategy using extracorporeal membrane oxygenation in patients with anti-neutrophil cytoplasmic antibodies-associated vasculitis: a case report and literature review

Diffuse alveolar hemorrhage (DAH) secondary to anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) often results in severe respiratory failure which requires emergent management. In patients who are resistant to traditional mechanical respiratory support, extracorporeal membrane oxygenation (ECMO) can be used to maintain gas exchange, thereby providing time for the administration of immunosuppressive therapy to control the inflammation. Herein, we report the application of ECMO to support an adult patient with AAV complicated by severe respiratory failure due to DAH. Similar cases in the literature were identified and discussed. The patient in our case study was successfully treated with ECMO in the acute phase and relieved by immunosuppressive therapy after withdrawal of ECMO. A search in the PubMed database revealed 32 similar cases with DAH, of which 11 cases were microscopic polyangiitis (MPA), 2 cases were eosinophilic granulomatosis with polyangiitis (EGPA), and 19 cases were granulomatosis with polyangiitis (GPA). These patients were all treated with ECMO. Therefore, to date, we identified 33 patients who were effectively treated with ECMO, including 13 (39.4%) males and 20 (60.6%) females, with a ratio of 1:1.54. The average age was 32.4±17.5 and 36.0±16.1 years for males and females, respectively (t=0.610, P=0.547). Most patients received ECMO on the first day of admission to the intensive care unit (ICU) and it appeared that early initiation of ECMO was associated with a shorter duration of ECMO. In general, complications of ECMO in these patients were mild and were not often seen in the clinical setting. This study suggested that early recognition of respiratory failure and referral for ECMO are vital to achieve a satisfactory outcome in AAV patients with DAH.

Effect of Dihydropyridine Calcium Channel Blocker on Mortality of Hypertension Patients With Moderate-Severe Pulmonary Acute Respiratory Distress Syndrome: A Multicenter Retrospective Observational Cohort Study

The aim was to evaluate the effect of dihydropyridine calcium channel blocker on the prognosis for moderate-severe pulmonary acute respiratory distress syndrome in hypertension patients.

DESIGN

A retrospective, observational, multicenter cohort study.

SETTING

A total of 307 patients without propensity score matching and 186 adult inpatients with propensity score matching diagnosed with hypertension and moderate-severe pulmonary acute respiratory distress syndrome in five teaching hospitals in Jiangsu province, China, from December 2015 to December 2020 were enrolled.

PATIENTS

A total of 307 patients without propensity score matching and 186 patients with propensity score matching diagnosed with hypertension and moderate-severe pulmonary acute respiratory distress syndrome were included in the final analysis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic characteristics and clinical characteristics were recorded. The propensity score matching method was used to eliminate the difference between group with dihydropyridine calcium channel blocker and group without dihydropyridine calcium channel blocker. The primary outcome was in-hospital mortality. We used univariate and multivariate regression analyses for both patients with or without propensity score matching to assess the effect of these variables on mortality. In the subset of 186 patients with propensity score matching, in-hospital mortality was 53.2%. Inpatient mortality was significantly higher in patients treated with dihydropyridine calcium channel blocker than in those not treated with dihydropyridine calcium channel blocker of patients without propensity score matching (65.4% vs 40.4%; p < 0.01). Multivariate analysis for patients without propensity score matching showed that dihydropyridine calcium channel blocker (hazard ratio, 1.954; 95% CI, 1.415-2.699), lactate dehydrogenase greater than or equal to 600 U/L (hazard ratio, 3.809; 95% CI, 2.106-4.531), and lactate greater than or equal to 2 mmol/L (hazard ratio, 1.454; 95% CI, 1.041-2.029) were independently associated with in-hospital mortality. Based on univariate analysis for patients with propensity score matching, dihydropyridine calcium channel blocker (hazard ratio, 2.021; 95% CI, 1.333-3.064), lactate dehydrogenase greater than or equal to 600 U/L (hazard ratio, 4.379; 95% CI, 2.642-7.257), and lactate greater than or equal to 2 mmol/L (hazard ratio, 2.461; 95% CI, 1.534-3.951) were independently associated with in-hospital mortality. In contrast, patients not treated with dihydropyridine calcium channel blocker had a significant survival advantage over those treated with dihydropyridine calcium channel blocker in both patients without or with propensity score matching (p < 0.001; p = 0.001 by Kaplan-Meier analysis).

CONCLUSIONS

Dihydropyridine calcium channel blocker, lactate dehydrogenase greater than or equal to 600 U/L, and lactate greater than or equal to 2 mmol/L at admission were independent risk factors for patients with hypertension and moderate-severe pulmonary acute respiratory distress syndrome.

ECMO Rescues Patients With Acute Respiratory Failure Related to GPA

Granulomatosis with polyangiitis (GPA) is a subtype of anti-neutrophil cytoplasmic antibody-associated vasculitis with a wide range of clinical symptoms related to the systemic involvement of small blood vessels. The respiratory system is one of the most frequently involved, and life-threatening acute respiratory failure could occur due to diffusive alveolar hemorrhage and tracheal stenosis. When maximum mechanical ventilation is unable to maintain oxygenation, extracorporeal membrane oxygenation (ECMO) should be considered as the final respiratory supportive method, if available. Here we present a 32-year-old male patient with acute respiratory failure (ARF) related to GPA, who was rescued by winning time for accurate diagnosis and appropriate treatment. Additionally, we reviewed more than 60 GPA-related ARF cases on multiple online databases, summarized the clinical manifestations of these patients, and concluded that ECMO plays an important role in further respiratory support for ARF patients with GPA and assists in accurate and timely diagnosis and appropriate treatment, thus helping them recuperate.

Comparison of anticoagulation strategies for veno-venous ECMO support in acute respiratory failure

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) support in acute respiratory failure may be lifesaving, but bleeding and thromboembolic complications are common. The optimal anticoagulation strategy balancing these factors remains to be determined. This retrospective study compared two institutional anticoagulation management strategies focussing on oxygenator changes and both bleeding and thromboembolic events.

METHODS

We conducted a retrospective observational cohort study between 04/2015 and 02/2020 in two ECMO referral centres in Germany in patients receiving veno-venous (VV)-ECMO support for acute respiratory failure for > 24 h. One centre routinely applied low-dose heparinization aiming for a partial thromboplastin time (PTT) of 35-40 s and the other routinely used a high-dose therapeutic heparinization strategy aiming for an activated clotting time (ACT) of 140-180 s. We assessed number of and time to ECMO oxygenator changes, 15-day freedom from oxygenator change, major bleeding events, thromboembolic events, 30-day ICU mortality, activated clotting time and partial thromboplastin time and administration of blood products. Primary outcome was the occurrence of oxygenator changes depending on heparinization strategy; main secondary outcomes were the occurrence of severe bleeding events and occurrence of thromboembolic events. The transfusion strategy was more liberal in the low-dose centre.

RESULTS

Of 375 screened patients receiving VV-ECMO support, 218 were included in the analysis (117 high-dose group; 101 low-dose group). Disease severity measured by SAPS II score was 46 (IQR 36-57) versus 47 (IQR 37-55) and ECMO runtime was 8 (IQR 5-12) versus 11 (IQR 7-17) days (P = 0.003). There were 14 oxygenator changes in the high-dose group versus 48 in the low-dose group. Freedom from oxygenator change at 15 days was 73% versus 55% (adjusted HR 3.34 [95% confidence interval 1.2-9.4]; P = 0.023). Severe bleeding events occurred in 23 (19.7%) versus 14 (13.9%) patients (P = 0.256) and thromboembolic events occurred in 8 (6.8%) versus 19 (19%) patients (P = 0.007). Mortality at 30 days was 33.3% versus 30.7% (P = 0.11).

CONCLUSIONS

In this retrospective study, ECMO management with high-dose heparinization was associated with lower rates of oxygenator changes and thromboembolic events when compared to a low-dose heparinization strategy. Prospective, randomized trials are needed to determine the optimal anticoagulation strategy in patients receiving ECMO support.

A Case of Refractory Hypoxemic Respiratory Failure due to Antineutrophil Cytoplasmic Antibodies-associated Diffuse Alveolar Hemorrhage Rescued by Extracorporeal Membrane Oxygenation

Diffuse alveolar hemorrhage (DAH) is a rare but life-threatening disease. Mortality is very high in those patients who require mechanical ventilation. Traditionally, active bleeding has been considered a contraindication for extracorporeal membrane oxygenation (ECMO) support. There is limited evidence for ECMO in DAH as rescue therapy. Herein, we describe a case of antineutrophil cytoplasmic antibodies-associated DAH with intractable hypoxemic respiratory failure. An appropriate ventilator strategy failed to improve her hypoxemia leading to imminent risk to her life. The patient was rescued with veno-venous ECMO targeting lower than usual range of anticoagulation. ECMO proved to be lifesaving in our patient who was initiated on prompt immunosuppressive therapy and plasmapheresis along with continuous veno-venous hemodiafiltration and hemodynamic support. We feel that ECMO could be considered as adjunctive therapy in severe hypoxemic respiratory failure associated with DAH after careful consideration of the risk of bleeding and a restrictive anticoagulation strategy.

How to cite this article: Goel MK, Chauhan M, Kumar A, Wadwa P, Maitra G, Talegaonkkar M, et al. A Case of Refractory Hypoxemic Respiratory Failure due to Antineutrophil Cytoplasmic Antibodies-associated Diffuse Alveolar Hemorrhage Rescued by Extracorporeal Membrane Oxygenation. Indian J Crit Care Med 2020;24(9):879–881.