What is the management of a retroperitoneal bleed during Extracorporeal Membrane Oxygenation (ECMO)?

Management of Retroperitoneal Bleeding During ECMO

For retroperitoneal bleeding during ECMO, immediately hold anticoagulation, provide blood product replacement as needed, and consider interventional radiology with selective arterial embolization as the preferred treatment approach for persistent bleeding. 1

Initial Assessment and Diagnosis

• Clinical presentation:

  • Abdominal pain, flank pain, or back pain
  • Suprainguinal tenderness and fullness
  • Decreases in ECMO circuit flow rate
  • Unexplained drops in hemoglobin levels
  • Hemodynamic instability in severe cases 2

• Diagnostic imaging:

  • CT scan with IV contrast is the gold standard for hemodynamically stable patients
  • CT angiography (CTA) is preferred for detecting active bleeding (can identify bleeding rates as low as 0.3 mL/min) 1
  • First follow-up scan within 24-72 hours if there are concerns about hematoma expansion

Management Algorithm

1. Immediate Measures

• Anticoagulation management:

  • For VV-ECMO: Prolonged cessation of systemic anticoagulation (>2 days) is recommended 3
  • For VA-ECMO: Balance the risk of anticoagulation cessation against thromboembolism risk (VA-ECMO has higher thrombotic risk than VV-ECMO) 3

• Hemodynamic stabilization:

  • Fluid resuscitation
  • Blood product replacement based on clinical needs
  • Vasopressors if needed for hemodynamic support

2. Blood Product Management

• Maintain hemoglobin >10 mg/dL
• Keep platelet count >100,000 per mm³
• Maintain fibrinogen >200 mg/dL
• Target AT III >1 U/mL 3
• Consider VWF concentrates if acquired von Willebrand syndrome is suspected 3

3. Treatment Approach Based on Hemodynamic Status

For Hemodynamically Stable Patients:

• Conservative management with:
  • Fluid resuscitation
  • Blood transfusion as needed
  • Correction of coagulopathy
  • Close monitoring with serial hemoglobin measurements 1

For Hemodynamically Unstable Patients or Ongoing Bleeding:

• Interventional radiology approach:

  • Selective intra-arterial embolization (success rates approximately 89%)
  • Stent-graft deployment for identified bleeding vessels 1, 4

• Surgical intervention (reserved for specific scenarios):

  • Failure of conservative and endovascular measures
  • Unavailability of endovascular facilities/expertise
  • Persistent hypotension unresponsive to volume resuscitation
  • Progressive fall in hematocrit despite conservative measures
  • Abdominal compartment syndrome requiring decompression 1, 5

Special Considerations for ECMO Patients

Anticoagulation Resumption

• Early cessation and judicious resumption of anticoagulation with repeated neuroimaging is recommended 3
• When resuming anticoagulation:
  • Consider lower intensity anticoagulation targets
  • Monitor with anti-FXa levels, PT, PTT, fibrinogen, platelet count, and AT III levels
  • Target PTT 1.5-2.5 times control value and anti-FXa level of 0.3-0.7 U/mL 3

ECMO Circuit Management

• Visual inspection of the ECMO circuit for clots regularly
• Consider higher flow rates to reduce stasis if anticoagulation is held
• Monitor for signs of circuit thrombosis if anticoagulation is withheld 3

Monitoring for Complications

• Watch for abdominal compartment syndrome
• Monitor for signs of infection
• Assess for compression syndromes (e.g., femoral neuropathy) 1, 5

Risk Factors to Consider

• Patients on ECMO have increased bleeding risk due to:
  • Systemic anticoagulation
  • Acquired von Willebrand syndrome (AVWS) from high shear stress 3
  • Thrombocytopenia and platelet dysfunction
  • Local mechanical injury from cannulation 2

Common Pitfalls and Caveats

• Delayed diagnosis is common as symptoms may be nonspecific or attributed to other causes
• Retroperitoneal bleeding should be suspected in any ECMO patient with unexplained hemoglobin drops or abdominal/flank pain
• Transporting ECMO patients for imaging can be performed safely with proper planning and equipment 6
• Avoid over-anticoagulation, which significantly increases bleeding risk
• Low-dose heparin protocols may reduce bleeding complications without increasing thrombotic events 3

By following this systematic approach to retroperitoneal bleeding during ECMO, clinicians can promptly diagnose and effectively manage this potentially life-threatening complication.