(862) Anticoagulation-Free VV ECMO for a Child With Intractable Pulmonary Hemorrhage

Introduction: The use of systemic anticoagulation (AC) is standard practice in extracorporeal membrane oxygenation (ECMO) to prevent both circuit and patient-related thrombotic events. While there have been reports of adult venovenous (VV)-ECMO use without systemic AC, there is only one reported pediatric case where AC was avoided for most of a VV-ECMO course and no cases where systemic AC was fully avoided. Because of the use of systemic AC, ECMO is often avoided in children with intractable hemorrhage. Little guidance exists around the AC strategy for these high-risk children.

Description: A 12-year-old female with recently diagnosed Microscopic Polyangiitis, P-ANCA-Associated Vasculitis, and stage 4 chronic kidney disease was admitted with recurrent hemoptysis and a one-week 23kg weight gain. Chest computed tomography showed diffuse alveolar hemorrhage. During hospital day 1, she had exacerbations of her pulmonary hemorrhage with the use of first low-dose heparin and then epoprostenol for local AC of her continuous kidney replacement (CKRT) circuit. Despite pulse steroids, inhaled tranexamic acid, and plasma exchange, she deteriorated and was cannulated to VV-ECMO via her right common femoral vein (23fr, drainage) and right internal jugular vein (21fr, return). She received a heparin bolus during cannulation. Systemic AC was withheld after cannulation given her intractable pulmonary hemorrhage. ECMO ran with high flows (5-5.75 LPM with the bridge open), achieving a venous return of 2.2-2.6 L/min/m2. Regional AC with citrate was administered to the CKRT circuit by infusing citrate directly to the CKRT circuit. Blood was pulled from the ECMO circuit to the CKRT circuit before the ECMO pump and returned before the oxygenator. Calcium was infused post-oxygenator to neutralize citrate’s anticoagulant effect. Neutralizing citrate post-oxygenator may have extended the oxygenator lifespan, enabling an effective AC-free VV-ECMO run of 15 days.

Discussion: This highlights the first reported successful pediatric VV-ECMO run entirely without systemic AC in conjunction with regional AC for CKRT without any major bleeding or clotting events. For children at high risk of severe bleeding in whom high ECMO flow rates can be achieved, ECMO may be feasible without systemic AC.