A 20-year-old woman, with a history of IgG deficiency, presented at her local outpatient clinic with shortness of breath and was prescribed antibiotics. One week later the patient was admitted to her local hospital with signs indicative of septic shock, and shortly thereafter she went into cardiac arrest and cardiopulmonary resuscitation (CPR) was initiated. Extracorporeal cardiopulmonary resuscitation (ECPR) was commenced using VA ECMO. Shortly after cannulation the patient developed bilateral mydriasis but the cranial CT scan did not show any apparent ischemia or intracranial mass lesions. To prevent development of cerebral edema, the patient was managed with hyperosmolar therapy, hyperventilation, hypothermia and heavy sedation (Pentobarbital coma monitored with burst suppression on continuous electroencephalography (EEG)). Despite this, a CT scan performed on ECMO day (ED) 6 revealed increased cerebral edema, and the patient underwent ICP catheter (Codman®) placement. No significant bleeding events occurred during the procedure, however, post-operatively her right-sided mydriasis increased. A cranial CT scan revealed a frontal IPH (6.75 ml, largest diameter 27 mm) and a SDH with 14 mm midline shift (). The ongoing heparin infusion was withdrawn, and 30 minutes later an emergency SDH hematoma evacuation was performed. The pre-operative coagulation parameters were: platelet count 69 x109/mL, APTT 55 seconds, ACT 204 seconds and INR 1.0. Intra-operatively, no significant bleeding events occurred. However, the post-operative cranial CT scan revealed a subgaleal hemorrhage and an SDH recurrence with 14 mm midline-shift (). A new hematoma evacuation was performed without any significant intra-operative bleeding. A post-operative CT scan showed a decrease in the midline shift without any signs of hematoma recurrence (). However, the following morning her ICP increased drastically, and a new CT scan revealed a SDH and 20 mm midline shift, as well as epidural and subgaleal bleeding with impending uncal herniation (). Again, emergency hematoma evacuation was performed. Following this, the pupils regained their normal size and the CT scan showed a decreased midline shift without any signs of hematoma recurrence (). The ECMO treatment continued without heparin while prophylactic Levetirecetam was administered to prevent epileptic seizures. On ED 11 rewarming was successfully initiated, and the patient was decannulated from ECMO. At this stage, the patients had been without the heparin infusion for five days without any sign of complications. The patient was transferred to the neurosurgical ICU department, where extubation was successfully performed. After this the patient was transferred to a neurological care unit for rehabilitation. Within a year the patient had made a full recovery, with no neurological sequelae or physiological deficits, and had returned to work.
A 41-year-old male of Indian ethnicity with no comorbidities presented with an 8 day history of fever and dyspnoea. His COVID-19 RT PCR test was positive. He did not have any significant past medical or surgical history. He had no known drug allergies. He was not on any medication at the time of presentation. His family history was not significant for any inheritable conditions. There was no history of alcohol consumption or smoking. He initially received treatment at a local hospital where his oxygen requirement at admission was 15 lit O2/min via a non-rebreathing mask. HRCT chest scan done on day 8 of illness showed CT severity score of 14/25. A repeat HRCT chest scan done on day 15 of illness showed a CT severity score of 20/25. Due to worsening hypoxia and tachycardia, CT pulmonary angiogram was done on day 20 of illness which was negative for pulmonary thromboembolism. His oxygen support was extended to intermittent non-invasive ventilation (NIV). On day 26 of illness, he developed severe respiratory distress and was placed on mechanical ventilator support.\nAt this stage, he was shifted to our hospital for extra corporeal life support. At the time of referral, he was on ventilator support with 90% FiO2 and a PEEP of 10. P/F ratio was 60 and driving pressures were 30 cms H2O. Acute Physiology and Chronic Health Evaluation (APACHE II) score was 14. He was maintained on prone ventilation for 16 hours. After the first cycle of proning, he continued to have persistent hypoxemia and carbon dioxide retention despite lung-protective ventilation. His Respiratory Extracorporeal Membrane Oxygenation Survival Prediction Score (RESP) was 3, with a predicted survival chance of 76%. A decision was made to initiate V–V ECMO (Maquet Rotaflow) on day 3 of mechanical ventilation. Cannulation was done with a double-lumen single 27F jugular venous cannula (paraglide) under transesophageal echocardiography guidance. Heparin infusion was started for anticoagulation. Monitoring of anticoagulation was done using activated clotting time (ACT) and activated partial thromboplastin time (aPTT) levels with a target range of 180–220 seconds for ACT and 60–80 seconds for aPTT. Mechanical ventilation settings were changed to ultra lung-protective ventilation. Driving pressures were adjusted to 15 cm H2O.\nOn day 3 of ECMO, his GCS was E1VTM1, and anisocoria was noted. A non-contrast CT brain scan revealed a large intraparenchymal hemorrhage (). The ECMO run continued hereafter without heparin and prophylactic levetiracetam was added to prevent seizures. ACT levels were noted to be in the range of 140–170 sec. A decision to proceed with decompressive craniectomy was taken by the neurosurgery team. After taking consent surgery was performed by the chief of neurosurgery under general anaesthesia at our hospital, which is a multi-specialty tertiary care center. Pre-operatively coagulation parameters included a platelet count of 1.5 lakh cells/mm3, ACT of 150 seconds, aPTT of 30 seconds, an INR of 1.2. Within 3 hours of diagnosis of the ICH, right frontotemporoparietal decompressive craniectomy was done with lax duroplasty.\nOn postoperative day 4 (day 8 of V–V ECMO), the patient showed spontaneous eye-opening and non-purposeful movements of the right upper limb (with a power of 3/5) and lower limb (with a power of 1/5). However, on day 9 of V–V ECMO, the patient developed septic shock. Blood cultures were positive for E.coli and multi-drug resistant Klebsiella pneumoniae. Antibiotic therapy was escalated as per culture and sensitivity reports and inotrope support was initiated. Despite aggressive invasive organ-supportive care the patient progressively deteriorated and eventually succumbed due to refractory septic shock with multi-organ dysfunction syndrome on day 12 of V–V ECMO.