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mitral plasty&#44; and mechanical aortic prosthesis 5 years previously&#46; He was admitted to our hospital for acute pulmonary edema&#44; with normally functioning prostheses&#44; LVEF 52&#37;&#44; pulmonary hypertension&#44; and restrictive filling&#46; He developed cardiogenic shock requiring orotracheal intubation&#44; intra-aortic balloon counterpulsation &#40;IABC&#41;&#44; norepinephrine 0&#46;5&#8239;&#181;g&#47;kg&#47;min&#44; and dobutamine 8&#8239;&#181;g&#47;kg&#47;min&#46; In the following hours&#44; the patient&#8217;s progress was favorable&#44; and IABC and vasoactive drugs could be withdrawn&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">However&#44; his subsequent course was marked by respiratory worsening with alveolar opacities on the right lung base&#44; fever&#44; and raised acute phase reactants despite favorable hemodynamic&#44; echocardiographic and NTproBNP values&#46; Although microbiological results were not yet available&#44; these data&#44; together with a favorable response to wide spectrum empirical antibiotics&#44; supported the suspicion of right lower lobe pneumonia associated with mechanical ventilation&#46; The infectious disease was beginning to resolve&#44; but then&#44; on day 7 of admission&#44; the patient developed a sudden desaturation of up to 85&#37; despite increasing FiO<span class="elsevierStyleInf">2</span> to 100&#37;&#46; Auscultation revealed disseminated rhonchi with marked hypoventilation of the right hemithorax&#44; and blood clots were aspirated through the orotracheal tube&#46; An urgent bedside chest X-ray showed atelectasis of the right lower lobe with bilateral alveolar opacities in the rest of the parenchyma&#46; The patient presented rapidly progressing hypoxemia within the next few minutes &#40;minimum PaO<span class="elsevierStyleInf">2</span> 32&#8239;mmHg&#41; that did not improve with right lateral decubitus Ambu ventilation&#44; along with hypotension and hyperlactacidemia &#40;lactate 5&#46;1&#8239;mmol&#47;L&#41; refractory to the administration of increasing doses of volume expanders and vasopressors&#46; Given the immediate risk to life&#44; we decided not to perform fiberoptic bronchoscopy and ruled out the option of selective orotracheal intubation&#46; We therefore prioritized respiratory and circulatory stabilization&#44; using ultrasound guided cannulation to establish venovenous ECMO at the bedside within a few minutes&#44; without sodium heparin&#44; by placing a 23&#8239;F afferent cannula via the right femoral vein and a 17&#8239;F efferent cannula via the right jugular artery&#46; This procedure left us with the option of subsequently adding an arterial cannula for hemodynamic support in the form of venoarterial ECMO if necessary&#46; Oxygenation was immediately normalized after implantation&#44; and hemodynamics improved gradually&#46; We could then proceed with diagnostic fiberoptic bronchoscopy that showed the presence of fresh blood in the left bronchial tree and hyperemic mucosa with no underlying injury after aspiration&#44; and a cast of thrombotic material in the right pulmonary tree that was impossible to extract completely&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the chest X-ray after ECMO cannulation confirming an sufficient distance between the cannulas to prevent recirculation phenomena&#44; the disappearance of left hemitorax condensations&#44; and persistent right pulmonary atelectasis where the presence of a clot in the bronchial lumen within a few centimeters of the carina is observed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Support was maintained with ECMO at a flow of 4&#8239;L&#47;min and FiO<span class="elsevierStyleInf">2</span> for PaO<span class="elsevierStyleInf">2</span> &#62; 60&#8239;mmHg&#44; under protective ventilation&#44; without anticoagulation&#46; Daily bronchoscopies were performed until the thrombotic material was extracted in its entirety&#46; After 4 days on ECMO&#44; reexpansion of the right lung was achieved with no new bronchial bleeds&#46; Tests to disconnect venovenous ECMO were then undertaken and the patient was subsequently decannulated&#46; This was followed by a computed tomography scan with contrast in the arterial and venous phases that detected an image of right basal condensation with no evidence of bleed foci in the bronchial circulation&#44; fistulas&#44; cavitations or other lesions &#40;fig&#46; 2&#41;&#46; Hemoptysis was eventually attributed to bleeding associated with pneumonia in a patient with pulmonary hypertension receiving anticoagulation&#46; Progress in the following weeks was gradual&#44; and the patient was discharged 69 days after admission&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The number of indications for ECMO are increasing steadily&#46; This treatment can be coupled with cardiorespiratory support in severe situations&#44; permitting subsequent investigation and treatment of the cause&#46; The main indication for venovenous ECMO is respiratory distress&#59; however&#44; it can also be beneficial in other settings&#44; such as status asthmaticus&#44; airway obstruction&#44; or massive pulmonary hemorrhage&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Rescue with venovenous ECMO has only been mentioned briefly in recent reviews of massive hemoptysis&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> yet ECMO is a useful tool for stabilizing the situation prior to the usual sequence of tests and therapies&#46; Other hospitals have published successful results in similar contexts&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a> The largest series is that of Kim et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> who report 15 ECMO implants for airway obstruction&#44; 5 of which were due to massive hemoptysis from different origins&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This case also illustrates the balance between hemorrhagic and thrombotic risk&#44; since a patient with life-threatening hemoptysis could be managed for 4 days without anticoagulation using venovenous ECMO support at flows greater than 4&#8239;l&#47;min&#44; with close monitoring of prosthesis function&#46; Venovenous ECMO support without anticoagulation may increase the incidence of thrombotic phenomena&#44; mainly deep vein thrombosis&#44; pulmonary thromboembolism and oxygenation membrane thrombosis&#44; although this appears to be compensated by the use of high flows&#44; which help reduce blood stasis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Evidence supporting the safety of venovenous ECMO without anticoagulation in selected patients appears to be growing&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> This strategy has already been described in patients with trauma or active bleeding&#44; and both venovenous ECMO<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and venoarterial ECMO<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> have even been used in patients with no particular hemorrhagic risk&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">No funding has been received for this manuscript&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mart&#237;nez-Solano J&#44; Sousa-Casasnovas I&#44; Fern&#225;ndez MJ&#44; Devesa-Cordero C&#44; Fern&#225;ndez-Avil&#233;s F&#44; Mart&#237;nez-Sell&#233;s M&#46; Canulaci&#243;n urgente a pie de cama y sin anticoagulaci&#243;n de membrana de oxigenaci&#243;n extracorp&#243;rea venovenosa en un paciente con hemoptisis masiva y <span class="elsevierStyleItalic">shock</span> refractario&#46; Arch Bronconeumol&#46; 2020&#59;57&#58;73&#8211;74&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">1A&#41; Chest X-ray&#46; Subtotal atelectasis of the right lung&#44; ECMO ejection cannula in the right jugular and suction cannula in the inferior vena cava&#46; Contrast computed tomography &#40;arterial phase&#44; lung window&#41;&#46; 1B&#41; Predominantly central ground glass infiltrates &#40;yellow arrows&#41; observed in both lung fields&#46; Consolidation in right lower lobe &#40;red arrow&#41;&#46; 1C&#41; Permeability of the bronchial tree observed in the center of the consolidation focus &#40;For interpretation of the references to colour in this figure legend&#44; the reader is referred to the web version of this article&#41;&#46;</p>"
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Case Report
Emergency bedside venovenous extracorporeal oxygenation membrane cannulation without anticoagulation in a patient with massive hemoptysis and unresponsive shock
Canulación urgente a pie de cama y sin anticoagulación de membrana de oxigenación extracorpórea venovenosa en un paciente con hemoptisis masiva y shock refractario
Jorge Martínez-Solanoa,b, Iago Sousa-Casasnovasa,b, Miriam Juárez Fernándeza,b, Carolina Devesa-Corderoa,b, Francisco Fernández-Avilésa,b,c, y Manuel Martínez-Sellésa,b,c,d,
Corresponding author
mmselles@secardiologia.es

Corresponding author at: Servicio de Cardiología, Instituto de Investigación, Hospital General Universitario Gregorio Marañón, Madrid, España.
a Servicio de Cardiología, Instituto de Investigación, Hospital General Universitario Gregorio Marañón, Madrid, España
b CIBERCV, Instituto de Salud Carlos III, Madrid, España
c Universidad Complutense, Madrid, España
d Universidad Europea, Madrid, España
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mitral plasty&#44; and mechanical aortic prosthesis 5 years previously&#46; He was admitted to our hospital for acute pulmonary edema&#44; with normally functioning prostheses&#44; LVEF 52&#37;&#44; pulmonary hypertension&#44; and restrictive filling&#46; He developed cardiogenic shock requiring orotracheal intubation&#44; intra-aortic balloon counterpulsation &#40;IABC&#41;&#44; norepinephrine 0&#46;5&#8239;&#181;g&#47;kg&#47;min&#44; and dobutamine 8&#8239;&#181;g&#47;kg&#47;min&#46; In the following hours&#44; the patient&#8217;s progress was favorable&#44; and IABC and vasoactive drugs could be withdrawn&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">However&#44; his subsequent course was marked by respiratory worsening with alveolar opacities on the right lung base&#44; fever&#44; and raised acute phase reactants despite favorable hemodynamic&#44; echocardiographic and NTproBNP values&#46; Although microbiological results were not yet available&#44; these data&#44; together with a favorable response to wide spectrum empirical antibiotics&#44; supported the suspicion of right lower lobe pneumonia associated with mechanical ventilation&#46; The infectious disease was beginning to resolve&#44; but then&#44; on day 7 of admission&#44; the patient developed a sudden desaturation of up to 85&#37; despite increasing FiO<span class="elsevierStyleInf">2</span> to 100&#37;&#46; Auscultation revealed disseminated rhonchi with marked hypoventilation of the right hemithorax&#44; and blood clots were aspirated through the orotracheal tube&#46; An urgent bedside chest X-ray showed atelectasis of the right lower lobe with bilateral alveolar opacities in the rest of the parenchyma&#46; The patient presented rapidly progressing hypoxemia within the next few minutes &#40;minimum PaO<span class="elsevierStyleInf">2</span> 32&#8239;mmHg&#41; that did not improve with right lateral decubitus Ambu ventilation&#44; along with hypotension and hyperlactacidemia &#40;lactate 5&#46;1&#8239;mmol&#47;L&#41; refractory to the administration of increasing doses of volume expanders and vasopressors&#46; Given the immediate risk to life&#44; we decided not to perform fiberoptic bronchoscopy and ruled out the option of selective orotracheal intubation&#46; We therefore prioritized respiratory and circulatory stabilization&#44; using ultrasound guided cannulation to establish venovenous ECMO at the bedside within a few minutes&#44; without sodium heparin&#44; by placing a 23&#8239;F afferent cannula via the right femoral vein and a 17&#8239;F efferent cannula via the right jugular artery&#46; This procedure left us with the option of subsequently adding an arterial cannula for hemodynamic support in the form of venoarterial ECMO if necessary&#46; Oxygenation was immediately normalized after implantation&#44; and hemodynamics improved gradually&#46; We could then proceed with diagnostic fiberoptic bronchoscopy that showed the presence of fresh blood in the left bronchial tree and hyperemic mucosa with no underlying injury after aspiration&#44; and a cast of thrombotic material in the right pulmonary tree that was impossible to extract completely&#46; <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the chest X-ray after ECMO cannulation confirming an sufficient distance between the cannulas to prevent recirculation phenomena&#44; the disappearance of left hemitorax condensations&#44; and persistent right pulmonary atelectasis where the presence of a clot in the bronchial lumen within a few centimeters of the carina is observed&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Support was maintained with ECMO at a flow of 4&#8239;L&#47;min and FiO<span class="elsevierStyleInf">2</span> for PaO<span class="elsevierStyleInf">2</span> &#62; 60&#8239;mmHg&#44; under protective ventilation&#44; without anticoagulation&#46; Daily bronchoscopies were performed until the thrombotic material was extracted in its entirety&#46; After 4 days on ECMO&#44; reexpansion of the right lung was achieved with no new bronchial bleeds&#46; Tests to disconnect venovenous ECMO were then undertaken and the patient was subsequently decannulated&#46; This was followed by a computed tomography scan with contrast in the arterial and venous phases that detected an image of right basal condensation with no evidence of bleed foci in the bronchial circulation&#44; fistulas&#44; cavitations or other lesions &#40;fig&#46; 2&#41;&#46; Hemoptysis was eventually attributed to bleeding associated with pneumonia in a patient with pulmonary hypertension receiving anticoagulation&#46; Progress in the following weeks was gradual&#44; and the patient was discharged 69 days after admission&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The number of indications for ECMO are increasing steadily&#46; This treatment can be coupled with cardiorespiratory support in severe situations&#44; permitting subsequent investigation and treatment of the cause&#46; The main indication for venovenous ECMO is respiratory distress&#59; however&#44; it can also be beneficial in other settings&#44; such as status asthmaticus&#44; airway obstruction&#44; or massive pulmonary hemorrhage&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Rescue with venovenous ECMO has only been mentioned briefly in recent reviews of massive hemoptysis&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> yet ECMO is a useful tool for stabilizing the situation prior to the usual sequence of tests and therapies&#46; Other hospitals have published successful results in similar contexts&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a> The largest series is that of Kim et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> who report 15 ECMO implants for airway obstruction&#44; 5 of which were due to massive hemoptysis from different origins&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">This case also illustrates the balance between hemorrhagic and thrombotic risk&#44; since a patient with life-threatening hemoptysis could be managed for 4 days without anticoagulation using venovenous ECMO support at flows greater than 4&#8239;l&#47;min&#44; with close monitoring of prosthesis function&#46; Venovenous ECMO support without anticoagulation may increase the incidence of thrombotic phenomena&#44; mainly deep vein thrombosis&#44; pulmonary thromboembolism and oxygenation membrane thrombosis&#44; although this appears to be compensated by the use of high flows&#44; which help reduce blood stasis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Evidence supporting the safety of venovenous ECMO without anticoagulation in selected patients appears to be growing&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> This strategy has already been described in patients with trauma or active bleeding&#44; and both venovenous ECMO<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> and venoarterial ECMO<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> have even been used in patients with no particular hemorrhagic risk&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">No funding has been received for this manuscript&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Mart&#237;nez-Solano J&#44; Sousa-Casasnovas I&#44; Fern&#225;ndez MJ&#44; Devesa-Cordero C&#44; Fern&#225;ndez-Avil&#233;s F&#44; Mart&#237;nez-Sell&#233;s M&#46; Canulaci&#243;n urgente a pie de cama y sin anticoagulaci&#243;n de membrana de oxigenaci&#243;n extracorp&#243;rea venovenosa en un paciente con hemoptisis masiva y <span class="elsevierStyleItalic">shock</span> refractario&#46; Arch Bronconeumol&#46; 2020&#59;57&#58;73&#8211;74&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">1A&#41; Chest X-ray&#46; Subtotal atelectasis of the right lung&#44; ECMO ejection cannula in the right jugular and suction cannula in the inferior vena cava&#46; Contrast computed tomography &#40;arterial phase&#44; lung window&#41;&#46; 1B&#41; Predominantly central ground glass infiltrates &#40;yellow arrows&#41; observed in both lung fields&#46; Consolidation in right lower lobe &#40;red arrow&#41;&#46; 1C&#41; Permeability of the bronchial tree observed in the center of the consolidation focus &#40;For interpretation of the references to colour in this figure legend&#44; the reader is referred to the web version of this article&#41;&#46;</p>"
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Article information
ISSN: 15792129
Original language: English
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