Acquired factor XIII deficiency in two patients with bleeding events during veno-venous extracorporeal membrane oxygenat
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CASE REPORT Artificial Lung / ECMO
Acquired factor XIII deficiency in two patients with bleeding events during veno‑venous extracorporeal membrane oxygenation treatment Asami Ito1 · Yoshiaki Iwashita2 · Ryo Esumi1 · Ken Sasaki1 · Masahiro Yukimitsu1 · Takafumi Kato1 · Eiji Kawamoto1 · Kei Suzuki1 · Hiroshi Imai1 Received: 27 June 2019 / Accepted: 3 December 2019 © The Author(s) 2019
Abstract We report two cases of acquired factor XIII deficiency with bleeding events during veno-venous extracorporeal membrane oxygenation (ECMO). Case 1: A 76-year-old man diagnosed with aspiration pneumonia after near-drowning was started on ECMO. Later, the patient presented with hemoptysis and anemia. Blood tests showed a decreased factor XIII activity of 29%. Although the patient recovered after receiving 1200 International Units of factor XIII concentrate, the patient had another episode of decreased factor XIII activity and bloody stool and was treated again with factor XIII concentrate. Case 2: A 48-year-old female diagnosed with pneumonia was started on ECMO. Soon after, she presented with hemoptysis and anemia. Blood tests showed a decreased factor XIII activity of 39%. The patient was treated with 720 IU of factor XIII concentrate with good recovery. Acquired factor XIII deficiency cannot be detected by routine coagulation tests, therefore it may be under-diagnosed in the ICU. Detection of acquired factor XIII deficiency is essential when treating a bleeding ECMO patient. Keywords Factor XIII · VV-ECMO · Factor XIII deficiency
Introduction
Case 1
Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) can be a successful treatment for certain patients. While use of ECMO is becoming more widely used among institutions, bleeding events are not uncommon in the ICU. Furthermore, bleeding events lead to a low survival rate due to hemodynamic instability, massive transfusion and prolonged ECMO treatment [1, 2]. We herein report two VV-ECMO patients with uncontrollable bleeding events and acquired factor XIII deficiency, who were successfully treated with factor XIII concentrate.
A 76-year-old man was transported to the emergency room for respiratory failure due to near drowning. CT scan showed widely distributed bilateral infiltration (Fig. 1a). The patient had severe respiratory failure despite mechanical ventilation settings of PEEP 12 cmH2O and FiO2 1.0, with a PaO2/ FiO2 (P/F) ratio of 82. VV-ECMO was initiated shortly after arrival. An access cannula was placed in the right femoral vein, and a return cannula was placed in the right internal jugular vein. Initial ECMO circuit flow was set at 2000–2500 rpm, 3.5–4.5 L/min. ECMO circuit FiO2 was set at 1.0 during the entirety of support. The patient improved and was weaned off of ECMO on the 5th day. However, his respiratory failure relapsed due to volume overload and infection (Fig. 1b) leading to a second run of ECMO on the 15th day. On the 40th day, we observed bleeding from the cannulation site and hemoptysis, along with anemia. Bronchoscopy revealed hemorrha
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