Successful application of extracorporeal membrane oxygenation due to pulmonary hemorrhage secondary to granulomatosis with polyangiitis

Figures & data

Figure 1 Chest computed tomography on admission showing bilateral opacities attributed to alveolar infiltrations as well as a few small cavitary lesions. (A) left lung, (B) right lung.

Figure 2 Sequential dates of radiographic presentation.

Notes: (1) September 9, 2011, (2) September 10, 2011, (3) September 11, 2011, (4) September 13, 2011, (5) September 14, 2011, (6) September 15, 2011, (7) September 16, 2011, (8) September 17, 2011, (9) September 19, 2011, (10) September 23, 2011, (11) September 24, 2011, (12) September 26, 2011, (13) September 30, 2011, (14) October 7, 2011, (15) October 10, 2011.

Table 1 Patient parameters

Date	ECMO			Hb g/dL	Ventilator				Resulting blood gases
	RPM	Flow L/min	Sweep gas FIO2 100%		Mode	FIO2	Pressure in cm H2O	RAMSAY score	PO2 mmHg	pCO2 mmHg	PH
Sept 9	3000	4.2	21	11.2	BIPAP-ASB	100%	35/15; I:E 1:1	5	52	28	7.49–7.40	Just after ECMO-initation
	3000	4.2	21	11.2	BIPAP-ASB	100%	See above; ASB 14	5	84	31	7.6	BIPAP-ASB only
Sept 10	2950	4.03	21	9.8	BIPAP-ASB	90%	25/l2;ASB 14	5	115–70	47–35	7.52–7.44	BIPAP-ASB only
Sept 11	2950	4	21	8.5	BIPAP-ASB	50%	24/13; ASB 17	5	115–77	44–40	7.48–7.44	BIPAP-ASB 2/3 of the day
After 12 pm				8.5	CPAP-ASB	50%	PEEP 13; ASB 17; AF spn 5/min	4	100–70	48–44	7.49–7.44	3 hours attempt during the day
Sept 12	2800	3.8	21	8.9	BIPAP-ASB	50%–35%	24/13; ASB 17	4	117–92	46–40	7.46–7.44	BIPAP-ASB 3/4 of the day
After 12 pm	2800	3.9	21	8.1–6.4	CPAP-ASB	40%	PEEP 13; ASB 17; AF spn 8/min	3	119–100	44–38	7.45–7.39	Start continous weaning during daytime
Sept 13	2800	2.5	21	8	BIPAP-ASB	35%	24/13; ASB 17	3	119–105	44–43	7.45–7.41	Minor CPAP-ASB <2 h
Sept 14	2100	2.7	21	7.1–8.1	BIPAP-ASB	35%	24/13; ASB 17	3	116–99	52–40	7.46–7.37	Minor CPAP-ASB <2 h
Sept 15	2100	2.9	21	6.8	CPAP-ASB*	30%	PEEP 11; ASB l2;AF spn 4	4	102–89	46–41	7.44–7.40
Sept 16	2100	2.5	21	8.2	CPAP-ASB*	30%	PEEP 11;ASB l2;AF spn 11	3	100–71	46–41	7.44–7.40

Notes: Sweep gas is the gas for elimination of CO₂; our standard is a constant flow of 2 L/minute 100% FIO₂, additional flush once per shift with O₂ 10 L/min for 15 seconds to eliminate condensation; ECMO initiation at 9.09 pm; RAMSAY score during the night always 4–5 via sedation protocol with a SOP propofol starting at 10 pm; 50% reduction each day at 5 am, hopeful to introduce the “wake-up call”. Tidal volume was titrated to 500 mL. CPAP-ASB*: Predominant mode: CPAP during the whole day except for 6 hours per night for BIPAP-ASB.*intermittent application of CPAP-ASB until complete weaning.Abbreviations: BIPAP-ASB, bi-level positive airway pressure/assisted spontaneous breathing; CPAP-ASB, continuous positive airway pressure/assisted spontaneous breathing; ECMO, Extracorporeal membrane oxygenation; FIO₂, fractional inspired oxygen; PEEP, positive end expiratory pressure; SOP, standard operating procedure; RAMSAY, RAMSAY sedation scale; pO₂, patrial oxygen pressure; pCO₂, partial carbon dioxide pressure; CO₂, carbon dioxide; pH, measure of the acidity or basicity of an aqueous solution; H₂O, fluid pressure; O₂, oxygen; Hb, hemoglobin; AF spn, spontaneous atrial fibrillation.

Table 2 Citrate hemofiltration was started to reduce the risk of systemic anticoagulation

Day	1	2	3	4	5	6	7	8	→
Plasmaseparation	Citrate	Citrate	Citrate	Citrate	Citrate	Citrate	Citrate	Citrate	→
Hemofiltration	Citrate	Citrate		Heparin	Heparin	Argatroban	Argatroban	Argatroban	→
				↑		↑
				Decrease of hemoptysis		Thrombocytopenia

Notes: Decreasing hemoptysis enabled a change to heparin on day 4. Because of developing thrombocytopenia hemofiltration was continued on argatroban. Plasmapheresis was administered with citrate as standard in our department. ↑, increased; →, ongoing treatment.