INTRODUCTION

Veno-venous (VV) extracorporeal membrane oxygenation (ECMO) is employed as a life-saving therapy in severe thoracic injury [1–4]. Recently, there have been reports of ECMO being used without anticoagulants in patients prone to bleeding. This approach has been considered due to the risk of bleeding in the thorax and abdomen following blunt trauma [5]. However, even in the absence of anticoagulants, intra-abdominal hypertension (IAH) may still develop. This condition can occur due to massive blood transfusions and high-volume support in patients with blunt trauma, potentially impairing venous drainage and diminishing the efficacy of oxygenated blood flow [4,6].

In this report, we describe a case involving an emergency laparotomy for IAH after VV-ECMO in a patient with severe thoracoabdominal injury.

CASE REPORT

Patient information

A 16-year-old boy presented to a trauma center after falling from a height of nine floors. Upon his arrival, the emergency medical services paramedics had already established an intravenous (IV) line and were administering oxygen through a 15-L oxygen non-rebreather mask. His initial vital signs showed a blood pressure of 111/73 mmHg, a heart rate of 147 beats per minute, and severe respiratory distress with an oxygen saturation (SpO₂) of 85%. The initial Glasgow Coma Scale score was 7 (E1, V2, M4). An additional IV line was placed, and 1 L of crystalloid was infused in preparation for endotracheal intubation, which was successfully performed 7 minutes after his arrival. The oral cavity was initially filled with bloody secretions; however, these were cleared with suction, resulting in an SpO₂ recovery to 100%. Initial chest radiography indicated severe bilateral pulmonary infiltration.

Clinical findings and timeline

Initial arterial blood gas analysis indicated acidosis, with a pH of 7.201, a pCO₂ of 47.5 mmHg, a pO₂ of 66.5 mmHg, and a base excess of –8.7 mmol/L. The lactic acid level was measured at 7.5 mmol/L. During the secondary survey, there were no fractures detected in the pelvis or extremities. At 41 minutes post-arrival, a comprehensive body computed tomography (CT) scan was conducted, revealing a right pneumothorax, severe bilateral lung contusions, a grade 3 liver laceration, and a grade 2 spleen laceration. There was no active bleeding noted, and the abdomen was soft (Figs. 1, 2).

Diagnostic assessment

Upon admission to the intensive care unit, a chest tube was inserted on the right side, and sedatives were administered to manage the patient's low blood pressure. Inotropes and transfusions were also given. Although the blood pressure stabilized following treatment, the patient's condition deteriorated after 6 hours. Despite being on 100% fraction of inspired oxygen (FiO₂), the SpO₂ remained at only 73%. Arterial blood gas analysis indicated a pH of 7.245, a pCO₂ of 65.4 mmHg, a pO₂ of 46.5 mmHg, and a base excess of 0.2 mmol/L. Radiography showed increased haziness in both lungs (Fig. 3).

Therapeutic intervention

Due to an inadequate response to additional ventilator support, femoro-femoral VV-ECMO was initiated with a flow rate of 3,500 L/min, oxygen at 9 L/min, and FiO₂ set at 100%. The patient underwent treatment without anticoagulation therapy. After 20 hours of ECMO support, the patient experienced a sudden decrease in flow to 800 L/min and a decrease in blood pressure to 85/46 mmHg. It is presumed that as the amount of hemoperitoneum increased, the abdomen became distended. An emergency laparotomy for decompression was conducted while maintaining ECMO support. This procedure revealed a massive hemoperitoneum containing approximately 4 to 5 L of old hematoma and fresh blood, primarily stemming from oozing at the liver laceration site and the injured hilum of the spleen, which had not been detected on CT. Given the risk of bleeding, a splenectomy was performed. The surgery concluded with packing and temporary abdominal closure. The following day, a second-look operation was carried out. Hepatorrhaphy was performed on the noted laceration at the liver dome, and the patient’s abdomen was subsequently closed (Fig. 4).

Follow-up and outcomes

On the 9th day after admission, we initiated ECMO weaning, and extubation was performed on the 10th day. The patient was transferred to the general ward on the 13th day and discharged from the hospital on the 21st day.

Ethics statement

This study was approved by the Institutional Review Board of Ajou Hospital (No. AJOUIRB-EX-2024-414). Written informed consent for publication of the research details and clinical images was obtained from the patient's parents.

DISCUSSION

VV-ECMO is a critical life-saving therapy for patients with acute respiratory failure when mechanical ventilation cannot maintain adequate oxygenation or carbon dioxide elimination [7–8]. However, the effectiveness of ECMO support in patients with severe pulmonary failure resulting from traumatic life-threatening injuries is still debated, primarily due to the risk of bleeding complications [9]. When solid organ injury is also present, as in the case discussed here, multiple factors must be considered.

First, anticoagulation should be approached with caution when initiating ECMO, as it can lead to bleeding, as demonstrated in the current case. Consequently, strategies that do not involve anticoagulation should be considered. Nevertheless, given the thrombosis risk, it is crucial to maintain a high but not excessive flow rate and to utilize heparin-coated cannulas to reduce this risk [10–12]. When the ECMO flow rate decreases, the extended contact time with the cannula surface heightens the risk of thrombosis, thus necessitating the maintenance of an appropriately high flow [13]. Conversely, excessively high flow rates can damage blood cells mechanically, resulting in hemolysis. They may also cause increased shear stress, enhanced tissue factor expression, accelerated fibrin consumption, and the release of inflammatory cytokines, which collectively exacerbate thrombosis and inflammatory responses while also elevating the risk of bleeding. Therefore, meticulous monitoring is essential [14].

Second, VV-ECMO is generally performed using femoro-jugular cannulation. However, in this instance, we opted for femoro-femoral VV-ECMO cannulation. Known for being easier and quicker to perform than femoro-jugular cannulation, femoro-femoral cannulation does carry a higher risk of recirculation [15]. Given the rapid deterioration of the patient's condition, we proceeded with femoro-femoral VV-ECMO, which necessitates only a single area for skin preparation and allows for a swifter procedure.

To mitigate the risk of recirculation, we employed a drainage catheter equipped with multiple side holes to enhance drainage efficiency, alongside an output catheter devoid of side holes to further minimize recirculation risk.

Another concern is the potential decrease in ECMO flow due to either an insufficient effective volume or increased intra-abdominal pressure. Rebleeding or ongoing bleeding from solid organs can cause increased intra-abdominal pressure or a reduction in effective volume. Even with ECMO support, it is crucial to regularly monitor urine output, conduct periodic blood tests, and perform abdominal physical examinations to detect any potential complications early. Therefore, in the nonoperative management of solid organ damage and severe lung injury, the application of ECMO may lead to failure; thus, vigilance and continuous monitoring are essential. In this case, the early detection of abdominal distension and the timely decision to perform a laparotomy, despite the lack of findings on CT or other modalities, resulted in successful treatment.

In conclusion, ECMO is not a definitive treatment, and continuous monitoring is essential to observe changes in the patient's condition. Therefore, employing ECMO in the nonoperative management of solid organ damage accompanied by severe lung injury may result in treatment failure. Furthermore, continuous monitoring is particularly crucial in cases of IAH.

ARTICLE INFORMATION

Author contributions

Conceptualization: all authors; Investigation: YH, JM; Methodology: all authors; Project administration: all authors; Visualization: HMS, KJ; Writing–original draft: YH, JM; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Additional information

This study was presented as a poster presentation at the 11th Pan-Pacific Trauma Congress (PPTC) 2024 on June 13–14, 2024, in Suwon, Korea.

Fig. 1.

Axial chest computed tomography image.

Fig. 2.

Representative axial abdominal computed tomography image.

Fig. 3.

Follow-up chest x-ray from the intensive care unit before veno-venous extracorporeal membrane oxygenation.

Fig. 4.

Follow-up chest x-ray after the second-look operation.

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Figure & Data

References

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