A 68-year-old woman, with a history of hypertension, was admitted to her local hospital after three days of dyspnea. She was diagnosed with pneumonia with respiratory failure and was therefore intubated and administered intravenous antibiotics. Despite this, respiratory function continued to decline and ECMO treatment was advocated, and the patient was started on VV ECMO. On ED 1, RVF developed and the patient was converted to VA ECMO. On ED 6, after days of low platelet count despite transfusions, the patient developed right-sided mydriasis and decreased level of consciousness. A CT scan revealed a SAH (Fisher grade 4) with IVH (Le Roux grade 4) as well as hydrocephalus and absent basal cisterns. A cerebral angiography could not detect any bleeding source. Heparin was withdrawn, and four hours later an emergency EVD placement was performed. The pre-operative coagulation parameters were: platelet count 118, APTT 33, ACT 153 and INR 1.1. Intra-operatively, no significant bleeding events occurred. Post-operatively, a decision was made to keep the ECMO system running without heparin and to administer platelets. ICP was managed with hyperosmolar therapy and hyperventilation. Despite these measures, the patient did not regain consciousness. The following day the patient experienced a cardiac arrest and passed away.
A 35-year-old woman, with a history of depression, overdosed on a combination of antidepressants and alcohol, rendering her unconscious and resulting intubation and mechanical ventilation. Unfortunately, a later extubation attempt resulted in aspiration and severe respiratory failure to a degree that ECMO treatment was advocated, and the patient was started on VV ECMO. During the first week of ECMO, the patient developed progressive right ventricular heart failure (RVF), requiring conversion to VA ECMO. During the following weeks, the patient regained native lung function, but also experienced upper gastrointestinal bleeds requiring replacement of fibrinogen and platelets to prevent coagulopathy. On ED 32, the patient developed right-sided mydriasis and hypertension. A CT scan revealed a cerebellar IPH (23 mL, largest diameter 40 mm) with SAH (Fisher grade 4), IVH (Le Roux grade 4) and absent basal cisterns (). No bleeding source was found on a cerebral angiography. The heparin infusion was withdrawn, and protamine sulfate, fibrinogen, platelets and tranexamic acid was administered to reverse anticoagulation. Half an hour later an emergency cerebellar hematoma evacuation was performed. The pre-operative coagulation parameters were: platelet count 87, APTT 50, ACT 200, INR 1.0. Intra-operatively, opening of the dura resulted in uncontrollable hemorrhaging despite extensive use of local hemostatic agents and transfusions of fibrinogen, protamine sulfate, plasma, platelets, eptacog alfa (NovoSeven®, AryoSeven®) and cryoprecipitate. Due to the poor prognosis, an EVD was not placed. The post-operative CT scan showed increased IPH hematoma volume (41 ml) as well as progress of the hydrocephalus, IVH (LeRoux grade 12), SAH (Fisher grade 4) and tonsillar herniation (). Further ECMO treatment was deemed futile and, consequently, treatment was withdrawn and the patient passed away.