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 Heparin was withdrawn, and seven hours later an EVD placement was performed.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 Further ECMO treatment was deemed futile and, consequently, treatment was withdrawn and the patient passed away.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 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.