A 47-year-old woman, with a history of idiopathic nephrosis, hypertension and diabetes, was admitted to her local hospital after seven days of dyspnea, fever and myalgia. Intravenous antibiotics were administered for a suspected bacterial upper respiratory tract infection, and due to the severe dyspnea the patient was intubated. Despite this, respiratory function continued to decline, and ECMO treatment was advocated. The patient was cannulated for VV ECMO and transported to the ECMO ICU, where H1N1-influensa was diagnosed and appropriate treatment started. On ED 9 the patient developed left-sided mydriasis and level of consciousness decreased. A CT scan revealed a SAH (Fisher grade 4) with IVH (Le Roux grade 2) as well as hydrocephalus and absent basal cisterns. A cerebral angiography could not detect any bleeding source. Heparin was withdrawn, and seven hours later an EVD placement was performed. The pre-operative coagulation parameters were: platelet count 39, APTT 26, ACT 134 and INR 1.1. Intra-operatively, no significant bleeding events occurred. Post-operatively, the ECMO system continued to run without heparin. ICP was further managed through hyperosmolar therapy, hyperventilation and heavy sedation (Pentobarbital coma monitored with burst suppression on continuous electroencephalography (EEG)). In addition, Nimodipine was administered to prevent cerebral vasospasm, as well as prophylactic Levetirecetam to prevent potential epileptic seizures. On ED 10, the EVD clotted and a new EVD was placed without any complications. The following day RVF developed and the patient was converted to VA ECMO. On ED 13, her pupils were of normal size and sedation was reduced, revealing signs of consciousness and movement of the left hand. Due to clotting, a week later the ECMO circuit was replaced, and the heparin infusion was restarted. On ED 30 a CT scan showed no rebleeding, ischemia, edema or hydrocephalus and the EVD was removed. Nevertheless, the patient was still GCS 3 and respiratory function continued to decline, which resulted in increased hypercapnia. Further ECMO treatment was deemed futile and, consequently, treatment was withdrawn and the patient passed away.
A 67-year old man, with a history of alcohol addiction and rheumatoid arthritis, was admitted to his local hospital with a respiratory tract infection. Despite treatment with antibiotics, the patient developed septic shock with refractory respiratory failure. ECMO was indicated and cannulation for VV ECMO initiated. However, during cannulation the patient suffered multiple transient cardiac arrests and VA ECMO was commenced instead. On ED 3 a routine cranial CT scan showed no abnormalities. By ED 6, the patient’s native lung function had improved to a degree that the sedation was reduced, with the patient subsequently decannulated and withdrawn from ECMO. However, the patient did not wake up and a CT scan showed a cerebellar IPH (10 mL, largest diameter 25 mm), several minimal parietal IPHs as well as hydrocephalus and imminent cerebral herniation. Two hours later the patient underwent emergency EVD placement and evacuation of the cerebellar hematoma. Because enough time had passed since decannulation (24 hours), pre-operative hemostatic intervention was deemed unnecessary. The pre-operative coagulation parameters were: platelet count 77, APTT 30, ACT N/A, INR 1.2. Intra-operatively no significant bleeding occurred. Post-operatively, the patient was taken back to the ICU where ICP was further managed through hyperosmolar therapy and hyperventilation. After three days the EVD was removed. However, while the cranial CT scan showed resorption of IPHs, his GCS was still 3. An EEG showed slow wave activity indicative of an unspecific cerebral pathology, but a magnetic resonance imaging scan and lumbar puncture revealed no signs of encephalopathy. After transfer to the neurological ward the patient began to show signs of minor neurological improvement, but a few weeks later the patient suffered a massive pulmonary embolism. Showing no signs of further neurological improvement, life-sustaining treatment was withdrawn and the patient passed away.\nsummarizes the clinical course of these five patients.