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 Heparin was withdrawn, and four hours later an emergency EVD placement was performed.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 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lung function had improved to a degree that the sedation was reduced, with the patient subsequently decannulated and withdrawn from ECMO.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.