PURPOSE: Bleeding complications occur frequently in ECMO patients due to the necessity for anticoagulation and circuit related factors. Aggressive interventions aimed at controlling bleeding may result in successful outcomes.
METHODS: A retrospective review was conducted in patients treated with veno-arterial or veno-veno ECMO since July 2010 when we instituted new ECMO program. Demographic data, bleeding complications, short and long-term patient outcomes were studied.
RESULTS: Twenty one patients were supported with ECMO during the study period. Five patients (2 females, 3 males) with mean age 37.2 years old (range 17-53) developed bleeding complications. Veno-veno ECMO was employed for 3 patients and veno-arterial ECMO in 2 patients. Indications for ECMO were aspiration pneumonia with ARDS (2), rapidly progressive viral pneumonia (1), empyema with ARDS (1), and profound cardiorespiratory shock (1). The mean length on ECMO was 15 days (9-26), mean length of hospital stay was 47.6 days (29-87), and mean packed red cell usage was 116 units (61-228). Major procedures performed were: 6 thoracotomies, 3 mediastinal explorations for tamponade, 1 exploratory laparotomy, and 3 video assisted thoracoscopies. Minor procedures include 6 or more bronchoscopies, multiple chest tube placements, and 1 push enteroscopy. There were no incidences of wound dehiscence, infection, or systemic sepsis related to the surgical intervention. Anticoagulation was safely discontinued 24 hours before and after major surgical intervention. There were no thrombotic complications due to heparin cessation in the perioperative period. Surgical intervention resulted in dramatic decline in blood product consumption and resolution of the underlying bleeding process. All patients were weaned off ECMO, survived and were discharged to rehabilitation. At last follow-up, all patients are alive and off continuous ventilatory support.
CONCLUSIONS: An aggressive surgical and endoscopic approach to ECMO related bleeding complications using a standardized anticoagulation protocol can result in successful outcomes.
CLINICAL IMPLICATIONS: It appears that an increased level of success can be realized from proper control of bleeding in patients in combination with a standardized anticoagulation protocol in patients on ECMO.
DISCLOSURE: The following authors have nothing to disclose: Kathleen Lamb, Scott Cowan, Nathaniel Evans, Harrison Pitcher, Troy Moritz, Michael Lazar, Hitoshi Hirose, Nicholas Cavarocchi
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