massive bleed from oral cavity & tracheostmy tube in a patient on ecmo for 22 days with H1N1

[Dr.Pranay Oza]

30 yrs/M, premorbidly healthy, H1N1, on ecmo for 22 days. Initially in mof but now only the lung remains issue. Since last 10 days, he developed some torrential bleed coming from oral cavity, nostrils, tracheostomy tube. Bleeding to the extent, his lungs are completely whiteout, air passages are blocked & we are just able to deliver tidal volume of 30 to 50 ml since last 10 days. He is just ecmo dependent He needs almost 4 - 6 units of packed cell daily, around 6 to 10 of FFP, cryo & platelets. Repeated bronchoscopy &. Ent opinion with direct laryngoscopy taken but unable to locate bleed. Possibilities are diffuse alveolar bleed, bleeding from posterior larynx. Or trachea tracking down worsened due to coagulopathy.
We are maintaining his act around 140 to 150,(need to change one oxygenator), platelets are around 50 to 70000.
Patient conscious, good urine output, hemodynamically stable, normal lft & rft.
I personally feel to get CT angio of neck & lungs but primary physician reluctant due to risk involved in transport & we don't know the benefit from that.
Any suggestions from anyone?
Pranay

[SAMIR gami]

if it is diffuse alveloar bleed , CT angio neck or lung will not help in my view

is Hb is still dropping ?

posterior laryngeal bleed may stop going lung if u little over inflate ET / Tracheostomy Cuff

if Hb is not dropping , is it advisable to wait an watch as blood present in lung will take time to clot and dissolve and get clear 

regards 

samir 

Dr Samir Gami

Chest Physician & Intensivist

+91 9925276708

Pranay

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[drpran...@gmail.com]

We need to transfuse. At least 3 to 4 units to maintain Hb at 9.

We don't know the site

Pranay

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From: SAMIR gami Sent: Tuesday 4 April 2017 5:29 PM To: ecmosocie...@googlegroups.com Reply To: ecmosocie...@googlegroups.com Subject: Re: {ESOI} massive bleed from oral cavity & tracheostmy tube in a patient on ecmo for 22 days with H1N1

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[Manish Dangi]

CT angio with embolisation of bleesing vessel if any found. 

[Trishala Singhvi]

Resp Sir,

We need to differentiate between pulmonary hemorrhage and tracheal bleed. 

Pulmonary hemorrhage can be diagnosed with sequential BAL which will be all hemorrhagic.

For tracheal bleed, you must rule out tracheo- innominate fistula by CT angio or interventional radiology, because it's a potentially​lethal condition. 

Also rule out co- incident rheumatic disorders in which diffuse alveolar hemorrhage is common and responds well to plasmapheresis and/ or IVIG.

Better to take help from Rotem for diagnosing exact deficiency of coagulation.

Regards

On Apr 4, 2017 3:06 PM, "Manish Dangi" <drmanis...@gmail.com> wrote:

CT angio with embolisation of bleesing vessel if any found. 

On 4 Apr 2017 16:17, "Dr.Pranay Oza" <drpran...@gmail.com> wrote:

30 yrs/M, premorbidly healthy, H1N1, on ecmo for 22 days. Initially in mof but now only the lung remains issue. Since last 10 days, he developed some torrential bleed coming from oral cavity, nostrils, tracheostomy tube. Bleeding to the extent, his lungs are completely whiteout, air passages are blocked & we are just able to deliver tidal volume of 30 to 50 ml since last 10 days. He is just ecmo dependent He needs almost 4 - 6 units of packed cell daily, around 6 to 10 of FFP, cryo & platelets. Repeated bronchoscopy &. Ent opinion with direct laryngoscopy taken but unable to locate bleed. Possibilities are diffuse alveolar bleed, bleeding from posterior larynx. Or trachea tracking down worsened due to coagulopathy.
We are maintaining his act around 140 to 150,(need to change one oxygenator), platelets are around 50 to 70000.
Patient conscious, good urine output, hemodynamically stable, normal lft & rft.
I personally feel to get CT angio of neck & lungs but primary physician reluctant due to risk involved in transport & we don't know the benefit from that.
Any suggestions from anyone?
Pranay

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[drpran...@gmail.com]

We are using TEG & correcting coagulopathy

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From: Trishala Singhvi Sent: Tuesday 4 April 2017 9:34 PM

To: ecmosocie...@googlegroups.com Reply To: ecmosocie...@googlegroups.com Subject: Re: {ESOI} massive bleed from oral cavity & tracheostmy tube in a patient on ecmo for 22 days with H1N1

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[Shuba S]

dear Sir,
Angio and embolization would be helpful if it is a single point bleed. angio would give an answer optimization of coag products with TEG. If it is diffuse bleedactivated factor 7 may help.
Dr Shuba
--------------------------------------------
On Tue, 4/4/17, Dr.Pranay Oza <drpran...@gmail.com> wrote:

Subject: {ESOI} massive bleed from oral cavity & tracheostmy tube in a patient on ecmo for 22 days with H1N1
To: "ECMO SOCIETY OF INDIA(ESOI)" <ecmosocie...@googlegroups.com>
Date: Tuesday, 4 April, 2017, 4:17 PM

[paulr...@gmail.com]

High on the differential is a tracheal innominate fistula
Will need to be addressed surgically
Early venous phase image of CT at first pass may help -but may also not give a clear picture
Will require proximal and distal control - Run ACT as low as possible ( may need to change oxygenator ) then control fistula - may need strap/ pericardial interposition if not amenable to direct repair
Regards

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