Recurrent diffuse alveolar hemorrhage and extracorporeal membrane oxygenation utilization in a hematopoietic stem cell transplant patient with Hunter's syndrome

We describe the natural history of a three-month-old patient with Hunter Syndrome with hematopoietic stem cell transplant (HSCT) who developed recurrent diffuse alveolar hemorrhage (DAH) requiring extracorporeal membrane oxygenation (ECMO). The patient underwent HSCT with several complications, including veno-occlusive disease and DAH. He was managed with ECMO. Unfortunately, despite initial success he developed recurrent DAH and ultimately died. This is a novel report of this severe adverse event requiring ECMO following the use of HSCT in this rare patient population. We share the clinical strategies employed to address the complications associated with HSCT and the progression of his disease over his hospitalization.

Management of massive airway hemorrhage associated with extracorporeal membrane oxygenation: A retrospective case series study

Background and Aims

Extracorporeal membrane oxygenation (ECMO) is an important means of treating patients with respiratory failure. Massive airway hemorrhage is a rare complication of ECMO, with high mortality. The aim of this study was to provide a reference for improving the success rate of treatment of this complication by analyzing and summarizing patient clinical data.

Methods

We searched PubMed, Medline, and EMBASE databases for case reports of massive airway bleeding associated with ECMO from January 2000 to January 2022 and included one case treated at our facility. All patients were disconnected from the ventilator, and the endotracheal tube was clamped during treatment, resulting in complete airway packing for hemostasis. The clinical data of these patients were analyzed.

Results

Through searching and further screening, two works of literature reported four cases that met our inclusion criteria. Including our patient's case, five patients were included in this study (four adults and one neonate). The longest ECMO treatment time before bleeding was 14 days, and the shortest was 20 min. In all patients, conservative treatment was ineffective after a major airway hemorrhage. They were disconnected from the ventilator and the tracheal tube was clamped for 13-72 h. The four adult patients underwent bronchial artery embolization in the interventional radiology suite. All patients' bleeding stopped after treatment; they were successfully weaned off ECMO and discharged.

Conclusions

Treatment measures to disconnect the ventilator and clamp the endotracheal tube with full support from ECMO are feasible for massive airway bleeding associated with ECMO. Early bronchial arteriography and embolization can prevent rebleeding.

Severe Pulmonary Hemorrhage in a Neonate With Hypoxic Ischemic Encephalopathy and Sepsis Managed on Extracorporeal Membrane Oxygenation

Pulmonary hemorrhage (PH) is an infrequent and potentially fatal event in term neonates. Reports of successful management of PH on extracorporeal membrane oxygenation (ECMO) are limited, given the accentuated risk of mortality imposed by the use of heparin to prevent thrombosis on ECMO. We present a case of a term neonate with hypoxic ischemic encephalopathy undergoing controlled hypothermia who developed hypoxic respiratory failure, hemodynamic instability, Enterobacter cloacae pneumonia and sepsis complicated by severe PH who required support with veno-arterial ECMO. We describe the therapeutic strategies used on veno-arterial ECMO to successfully manage this infant, including clamping the endotracheal tube, aggressive correction of coagulopathy, and use of dornase alfa, as well as elaborate on the subtle changes in ECMO parameters during the run that preceded worsening pneumonia with sepsis.

Extracorporeal Life Support in Hemorrhagic Conditions: A Systematic Review

Extracorporeal life support (ECLS) is indicated in refractory acute respiratory or cardiac failure. According to the need for anticoagulation, bleeding conditions (e.g., in trauma, pulmonary bleeding) have been considered a contraindication for the use of ECLS. However, there is increasing evidence for improved outcomes after ECLS support in hemorrhagic patients based on the benefits of hemodynamic support outweighing the increased risk of bleeding. We conducted a systematic literature search according to the PRISMA guidelines and reviewed publications describing ECLS support in hemorrhagic conditions. Seventy-four case reports, four case series, seven retrospective database observational studies, and one preliminary result of an ongoing study were reviewed. In total, 181 patients were identified in total of 86 manuscripts. The reports included patients suffering from bleeding caused by pulmonary hemorrhage (n = 53), trauma (n = 96), postpulmonary endarterectomy (n = 13), tracheal bleeding (n = 1), postpartum or cesarean delivery (n = 11), and intracranial hemorrhage (n = 7). Lower targeted titration of heparin infusion, heparin-free ECLS until coagulation is normalized, clamping of the endotracheal tube, and other ad hoc possibilities represent potential beneficial maneuvers in such conditions. Once the patient is cannulated and circulation restored, bleeding control surgery is performed for stabilization if indicated. The use of ECLS for temporary circulatory or respiratory support in critical patients with refractory hemorrhagic shock appears feasible considering tailored ECMO management strategies. Further investigation is needed to better elucidate the patient selection and ECLS management approaches.

Endotracheal tube clamping and extracorporeal membrane oxygenation to resuscitate massive pulmonary haemorrhage

Massive pulmonary haemorrhage is a life‐threatening and difficult‐to‐manage condition. In certain circumstances, traditional approaches for haemoptysis may not be effective. Here, we report a 64‐year‐old man presenting with dyspnoea and leg oedema. He was diagnosed with microscopic polyangiitis due to positive perinuclear anti‐neutrophil cytoplasmic antibody and other supportive evidence. His hospital course was complicated with massive pulmonary haemorrhage, which led to hypoxic respiratory failure, shock, and pulseless electrical activity. Extracorporeal membrane oxygenation (ECMO) was employed during cardiopulmonary resuscitation. To control blood loss from his lungs, we clamped the endotracheal tube for tamponade therapy. The tube was clamped for 15 h till the haemorrhage subsided. ECMO and ventilator support were successfully weaned off after 5 and 10 days, respectively. Our favourable experience suggests that endotracheal tube clamping with ECMO support is a viable management option for life‐threatening pulmonary haemorrhage.