title: Controlling intrathoracic hemorrhage on ECMO: help from Factor VIIa and Virchow.
abstract: OBJECTIVE
  Thoracentesis with chest tube placement is often needed to decompress a clinically significant pneumothorax or pleural effusion. The risks of such a procedure may be considered too great to perform on a systemically anticoagulated patient supported by extracorporeal membrane oxygenation (ECMO).
  
  
  RESULTS
  An 8-year-old child with respiratory failure due to necrotizing pneumonia and autoimmune vasculitis, on veno-venous ECMO, developed a severe tension pneumothorax that required emergent decompression with a chest tube. Post-procedure, the patient developed a hemothorax that was approaching non-sustainability. We developed a strategy based on Virchow's triad to favor homeostasis in the patient while avoiding thrombosis in the ECMO circuit. We employed selective lung ventilation, passive pleural drainage, high flow ECMO, and aggressive coagulation cascade control, including the use of aminocaproic acid and activated factor VIIa. Following this strategy, the hemorrhage was controlled and, later, the patient was able to successfully come off ECMO.
  
  
  CONCLUSIONS
  With careful coagulation cascade manipulation, complete lung rest for the affected lung, control of ECMO blood flow, and prudent hemothorax drainage, we were able to facilitate hemostasis that was required for the successful recovery of our patient while avoiding critical ECMO circuit thrombosis. Even with today's highly advanced medical technologies, centuries-old basic medical principles can still assist in the care of our sickest and most complex patients. Chest tube placement while on ECMO is rare and, although necessary, may be a risky procedure. With precise coagulation control, it can be a successful procedure on ECMO.
authors.affiliation: Section of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children, Indianapolis, IN 46202-5225, USA. mrigby@iupui.edu
authors.forename: M R
authors.initials: MR
authors.lastname: Rigby
authors.forename: P
authors.initials: P
authors.lastname: Kamat
authors.forename: A
authors.initials: A
authors.lastname: Vats
authors.forename: M
authors.initials: M
authors.lastname: Heard
mesh_terms: D000614:Aminocaproates / Q000008:administration & dosage*; D001327:Autoimmune Diseases / Q000150:complications / Q000503:physiopathology / Q000628:therapy; D002648:Child; D019299:Decompression, Surgical; D015199:Extracorporeal Membrane Oxygenation; D015942:Factor VIIa / Q000008:administration & dosage*; D006470:Hemorrhage / Q000150:complications / Q000503:physiopathology / Q000628:therapy; D006801:Humans; D008297:Male; D011014:Pneumonia / Q000150:complications / Q000503:physiopathology / Q000628:therapy; D011030:Pneumothorax / Q000150:complications / Q000503:physiopathology / Q000628:therapy; D012131:Respiratory Insufficiency / Q000150:complications / Q000503:physiopathology / Q000628:therapy; D014657:Vasculitis / Q000150:complications / Q000503:physiopathology / Q000628:therapy
chemical_list: D000614:Aminocaproates; D015942:Factor VIIa