A Case Series of Devastating Intracranial Hemorrhage During Venovenous Extracorporeal Membrane Oxygenation for COVID-19
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Published on: October 24, 2018
Asad Ali Usman1, Jason Han2, Andrew Acker2
1Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, University of Pennsylvania, Philadelphia, PA.
Insights
Anticoagulation management for COVID-19 patients on venovenous extracorporeal membrane oxygenation (VV ECMO) is challenging. This study highlights a high rate of intracranial hemorrhage and death in these patients, urging caution and close monitoring.
Area of Science:
- Critical Care Medicine
- Hematology
- Infectious Diseases
Background:
- Anticoagulation in extracorporeal membrane oxygenation (ECMO) for COVID-19 is complex due to endothelial injury and coagulation dysregulation.
- This can lead to increased risks of thrombotic and bleeding complications.
Purpose of the Study:
- To describe the authors' single institutional experience with venovenous ECMO (VV ECMO) in COVID-19 patients.
- To emphasize the high rate of intracranial hemorrhage observed in the initial cohort.
Main Methods:
- Retrospective case series analysis of 10 patients with COVID-19 requiring VV ECMO for ARDS.
- Collection of patient characteristics, mortality, stroke rate, length of stay, D-dimer, C-reactive protein, prothrombin time, and activated partial thromboplastin time.
Main Results:
- Four out of 10 patients experienced hemorrhagic strokes, with 3 deaths.
- Mean VV ECMO duration was 9.4 ± 7 days.
- At 30 days, 7 patients survived, with 6 discharged and 1 remaining in the ICU.
Conclusions:
- Intracranial hemorrhage is a significant complication in COVID-19 patients on VV ECMO, associated with high mortality.
- Caution is advised in anticoagulation management for these patients.
- Close monitoring of hematologic parameters is crucial during VV ECMO support.
Objective:
Anticoagulation may be a challenge in coronavirus disease 2019 (COVID-19) extracorporeal membrane oxygenation due to endothelial injury and dysregulation of coagulation, which may increase the risk of thrombotic and bleeding complications. This report was created to describe the authors' single institutional experience, with emphasis on the high rate of intracranial hemorrhage for the first 10 patients with COVID-19 placed on venovenous extracorporeal membrane oxygenation (VV ECMO).
Design:
Case series, retrospective analysis.
Setting:
Single institution.
Participants:
Ten patients.
Interventions:
None.
Measurements And Main Results:
Patient characteristics, mortality, stroke rate, and length of stay data were collected in all patients. In addition, laboratory values of D-dimer and C-reactive protein and standard measurements of prothrombin and activated partial thromboplastin time were collected on all patients. Ten patients, each confirmed with COVID-19 via reverse transcription-polymerase chain reaction, were supported on VV ECMO for acute respiratory distress syndrome (ARDS) for a mean duration of 9.4 ± 7 days. Four of 10 patients had hemorrhagic strokes, 3 of which resulted in death. At 30 days after initiation of VV ECMO, a total of 7 survivors included 6 patients discharged from the hospital and 1 patient who remained in the intensive care unit.
Conclusions:
In this small study of 10 patients, intracranial hemorrhage was a common complication, resulting in a high rate of death. The authors urge caution in the anticoagulation management of VV ECMO for patients with severe ARDS and COVID-19 patients. Close monitoring of all hematologic parameters is recommended during ECMO support while awaiting larger, multicenter studies to examine the best practice.
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