A case report: Extracorporeal membrane oxygenation for multitrauma patient with pneumorrhagia

Abstract Background: Extracorporeal membrane oxygenation (ECMO) can be used as salvage therapy for multitrauma patients with acute respiratory distress syndrome (ARDS) when conventional treatment fails to maintain oxygenation. However, a controversy exists between ECMO application and the risk of bleeding due to systemic anticoagulation during the treatment. Non-heparin introduction seem to be a possible solution for this dilemma, owing to technical improvements in the device and management methods of ECMO. Case presentation: A 58-year-old woman suffered from blunt thoracic, pelvic, and right lower limb fractures due to a falling accident, which resulted in acute respiratory distress syndrome (ARDS). Although the patient received intubation and mechanical ventilation (MV), respiratory failure was not alleviated. Venous-venous (V-V) ECMO was used as a salvage therapy. With the support of V-V ECMO, we safely cleared blood clots in the bronchus and avoided secondary lung injury caused by pressure trauma and oxygen poisoning of the MV. We introduced heparin-free ECMO management as a solution to reduce the risk of bleeding associated with pulmonary contusion and other organ injuries. To prevent thrombosis, we set the blood rate of ECMO to 4.0 L/min, which is much higher than the usual parameter. During ECMO, coagulation factors, such as prothrombin time, activated partial thromboplastin time, and D-dimer, were examined. ECMO was maintained for five days without any complications, MV was stopped on the 13th day, extubated on the 24th day, and discharged from ICU on the 28th day. Conclusion: ECMO with non-heparin could be an optimal treatment for multitrauma patients with ARDS when traditional treatment cannot sustain oxygenation. High blood flow rate could prevent thrombosis through ongoing ECMO therapy without systemic anticoagulation. In addition, monitoring D-dimer value change（Δ D-dimer）may be better than D-dimer value in predicting clot formation in the membrane oxygenator.