Scientific Letter
ECMO in severe trauma patient with intracranial bleeding requiring surgery
ECMO en trauma grave con sangrado intracraneal amenazante que requiere cirugía
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"apellidos" => "Chico Carballas" "email" => array:1 [ 0 => "ji_chico@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "S." "apellidos" => "Freita Ramos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "D." "apellidos" => "Mosquera Rodriguez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "E.M." "apellidos" => "Menor Fernandez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "M." "apellidos" => "Piñon Esteban" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "R." "apellidos" => "Casais Pampin" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio Medicina Intensiva, Hospital Alvaro Cunqueiro, Vigo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio Cirugía Cardiaca, Hospital Alvaro Cunqueiro, Vigo, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "ECMO en trauma grave con sangrado intracraneal amenazante que requiere cirugía" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1727 "Ancho" => 2500 "Tamanyo" => 613843 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Thorax CT scan on day 2 showing severe lung infiltrates and atelectasis.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Brain Trauma incidence is about 235/100<span class="elsevierStyleHsp" style=""></span>000 inhabitants/year in Europe, frequently co-existing with thoracic trauma (35%).<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Avoiding hypoxic brain damage is crucial but difficult to achieve in case of respiratory failure, given the potential harmful effect of ventilatory strategies (prone positioning, alveolar recruitment) on intracranial hypertension (ICH).</p><p id="par0010" class="elsevierStylePara elsevierViewall">ECMO is a lifesaving technique, assisting the failing heart or lungs, but circuit anticoagulation is required, which could increase the risk of bleeding. Consequently, trauma bleeding, and especially brain trauma are still formal contra-indications for ECMO.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">We present the case of a severe BTI with intracranial bleeding requiring surgical drainage and VV ECMO for severe respiratory failure.</p><p id="par0020" class="elsevierStylePara elsevierViewall">26 years old male suffered a motorbike crash accident. Initially presenting with GCS 4 on the scene, bilateral nonreactive pupils; BP 110/60<span class="elsevierStyleHsp" style=""></span>mmHg. Injury severity score (ISS) 25. He was intubated and transferred to our hospital; initial CT scan showed temporal bone fracture and hemispheric subdural hematoma with middle line shift (12<span class="elsevierStyleHsp" style=""></span>mm) and signs of uncal herniation (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Multiple rib fractures and right lung consolidation (lung contusion vs. aspiration pneumonitis).</p><p id="par0030" class="elsevierStylePara elsevierViewall">He was immediately transferred to the operating theater; left frontoparietal craniotomy and hematoma drainage was performed. Direct visualization detected loss of pulsatility in frontal and parietal lobes. Parenchymal intracranial pressure (ICP) monitoring (Integra Neurosciences, San Diego) after drainage showed ICP of 25<span class="elsevierStyleHsp" style=""></span>mmHg, needing deep sedation, neuromuscular blocking, and osmotherapy. Postoperative CT scan showed correct drainage with diffuse brain edema.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient develops severe ARDS on day 2. Despite lung protective ventilation, bilateral pneumothorax occurs, requiring chest tube placement.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Open lung strategies such as recruitment maneuvers were not implemented due to the presence of pneumothorax, and prone positioning was tried but unfeasible due to rise in ICP (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">Given the refractory hypoxemia and its impact on secondary brain damage, we decided to put the patient on ECMO (Cardiohelp-Maquet-Getinge group, Rastatt, Germany).</p><p id="par0050" class="elsevierStylePara elsevierViewall">Pre-ECMO respiratory setting: FiO<span class="elsevierStyleInf">2</span> 1; PEEP 10 cmH<span class="elsevierStyleInf">2</span>O; P/F ratio 90; compliance 20<span class="elsevierStyleHsp" style=""></span>ml<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O<span class="elsevierStyleSup">-1</span> Plateau pressure 33<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O; dP 14. Murray score 3.</p><p id="par0055" class="elsevierStylePara elsevierViewall">We utilized 23 Fr femoral drainage and 19 Fr jugular return Maquet HLS cannulae. A bolus of UFH (70<span class="elsevierStyleHsp" style=""></span>IU/kg) was administered during cannulation. We decided no anticoagulation thereafter.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Initial ECMO settings: 4.2<span class="elsevierStyleHsp" style=""></span>lpm, gas flow 5<span class="elsevierStyleHsp" style=""></span>lpm, FiO<span class="elsevierStyleInf">2</span> 1. Ventilator settings after ECMO: VCV FiO<span class="elsevierStyleInf">2</span> 0.4; tidal volume 3<span class="elsevierStyleHsp" style=""></span>cc/kg; RR 10<span class="elsevierStyleHsp" style=""></span>bpm PEEP 10<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Given the still uncontrolled ICH, cannulation was performed under deep sedation, paralysis, and osmotherapy.</p><p id="par0070" class="elsevierStylePara elsevierViewall">Percutaneous tracheostomy was performed on day fifteen, and the last chest tube removed on day twenty.</p><p id="par0075" class="elsevierStylePara elsevierViewall">ECMO system was closely monitored according to our protocol. Oxygenator was replaced on day seven due to an increase in LDH and reticulocyte count and a decrease in haptoglobin levels.</p><p id="par0080" class="elsevierStylePara elsevierViewall">A decision to stop ECMO was made after ECMO time of fifteen days given respiratory improvement, correct weaning parameters, and labs showing incipient coagulopathy (slight increase in PT and aPTT ratio, and slightly decreasing platelets and fibrinogen). Having started decannulation procedure, the patient experience sudden airway bleeding. ECMO was immediately stopped and the patient decannulated, after which bleeding was controlled. 1<span class="elsevierStyleHsp" style=""></span>g fibrinogen and 600<span class="elsevierStyleHsp" style=""></span>IU of Human Prothrombin Complex were administered. Bronchoscopy was performed immediately afterward for airway clearance.</p><p id="par0085" class="elsevierStylePara elsevierViewall">On day thirty the patient is awake, obeying commands, no motor deficit but with severe ICU acquired weakness. He was discharged after 50 days to the neurosurgery ward. Discharged home after four months with full neurological and functional recovery.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Multiple trauma is still a formal contra-indication for ECMO, given the increased risk of bleeding.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">ECMO circuit needs anticoagulation, which could be avoided in particular circumstances. But ECMO also exposes the blood to a foreign surface, triggering inflammation and coagulation, which can lead to a DIC-like consumptive coagulopathy.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Although biocompatible coatings may decrease activation of coagulation, it has not solved the issue. Therefore, running ECMO without anticoagulation does not prevent the occurrence of bleeding diathesis.</p><p id="par0100" class="elsevierStylePara elsevierViewall">These factors, in the context of co-existing severe BTI, could lead to catastrophic intracranial bleeding. Therefore, evidence of ECMO in this scenario is anecdotic.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Biscotti<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> described two patients with severe BTI and intracranial bleeding who needed ECMO for ARDS. The circuit was anticoagulated with UFH with an aPTT target of 40–60<span class="elsevierStyleHsp" style=""></span>s. However, no patient experienced ICH or underwent surgery.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Muellenbach<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">5</span></a> published three trauma patients suffering BTI, none of them requiring surgery. The circuit was not anticoagulated, but ECMO time was short (maximum five days).</p><p id="par0115" class="elsevierStylePara elsevierViewall">Friesenecker<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a> described the first case of severe BTI requiring craniotomy who underwent ECMO for ARF for 17 days. Initially presenting with CT scan showing brain edema, ECMO was started due to severe ARDS under anticoagulation with UFH targeted to ACT of 150<span class="elsevierStyleHsp" style=""></span>s, but CT scan revealed large brain hematoma on day two, potentially influenced by anticoagulation. There are no further similar cases published to our knowledge.</p><p id="par0120" class="elsevierStylePara elsevierViewall">In our case, ECMO was run for 15 days without anticoagulation. It was started shortly after surgery in a patient with severe intracranial bleeding and ICH aggravated by severe ARDS, with a good outcome.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Thorough system monitoring allowed safe management of a non-anticoagulated circuit, and early detection and control of complications. On the other hand, no ICP deterioration during ECMO time was detected.</p><p id="par0130" class="elsevierStylePara elsevierViewall">This case suggests that ECMO can be implemented safely without anticoagulation, and should not be withheld from the therapeutic armamentarium in case of a severe brain trauma bleeding. Appropriate protocol implementation and close monitoring are paramount in this scenario.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1727 "Ancho" => 2500 "Tamanyo" => 215707 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">CT scan showing hemispheric subdural hematoma with middle line shift.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1727 "Ancho" => 2500 "Tamanyo" => 613843 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Thorax CT scan on day 2 showing severe lung infiltrates and atelectasis.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Utilisation d’un ECMO dans un cas d’hypoxemie refractaire associee a un traumatisme cranien grave" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R. 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| 2021 August | 22 | 36 | 58 |
| 2021 July | 22 | 22 | 44 |
| 2021 June | 32 | 12 | 44 |
| 2021 May | 40 | 44 | 84 |
| 2021 April | 98 | 56 | 154 |
| 2021 March | 76 | 29 | 105 |
| 2021 February | 37 | 24 | 61 |
| 2021 January | 24 | 11 | 35 |
| 2020 December | 28 | 13 | 41 |
| 2020 November | 17 | 19 | 36 |
| 2020 October | 18 | 6 | 24 |
| 2020 July | 6 | 12 | 18 |
| 2020 June | 15 | 11 | 26 |
| 2020 May | 18 | 8 | 26 |
| 2020 April | 26 | 18 | 44 |
| 2020 March | 1 | 1 | 2 |
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