ABSTRACT
Acquired von Willebrand syndrome (AVWS) contributes to bleeding during extracorporeal membrane oxygenation (ECMO) support. Although it is recognized that AVWS rapidly resolves after ECMO decannulation, this approach may often be clinically unsuitable. In such cases, optimal AVWS management during ECMO support is not well established. We report our approach to managing AVWS in a patient on veno-venous (VV) ECMO for 59 days. A 19-year-old male developed hypoxemic respiratory failure from SARS-CoV-2 pneumonia. Following intubation, he progressed to VV-ECMO support for refractory hypoxemia and was started on bivalirudin for systemic anticoagulation. Two days later, he developed refractory gastrointestinal and oro-nasopharyngeal bleeding despite blood product transfusions and discontinuing bivalirudin. He was started on pantoprazole along with infusions of octreotide and aminocaproic acid. Upper endoscopy on ECMO day 5 revealed an ulcerative bleeding vessel in the duodenum that was clipped. Recurrent mucosal bleeding precluded resumption of systemic anticoagulation. On ECMO day 23, AVWS was diagnosed based on elevated von Willebrand factor (VWF) activity (207%, normal 55-189%) and antigen (234%, normal 50-210%) levels with abnormally low VWF high-molecular-weight multimers. Factor VIII complex was administered twice over the following week. Between doses, the ECMO circuit was exchanged to empirically mitigate suspected shear-related VWF consumption from the fibrin burden, and a repeat endoscopy controlled additional intestinal bleeding with local hemostatic agents. He received 36 units of red blood cells, 2 units of platelets, 2 units of plasma, and 7 pooled units of cryoprecipitate over 31 days leading into these combined interventions. In the 28 days afterwards, he received 3 units of red blood cells, 3.5 pooled units of cryoprecipitate, and no additional platelets or plasma. Our patient was maintained off systemic anticoagulation for 54 of 59 days of VV-ECMO support without any thrombotic complications occurring. With no subsequent clinical evidence of bleeding, repeat VWF testing was done two months post-decannulation and showed near-normal VWF activity (54%) and normal multimer distribution. Our patient rehabilitated well without any neurologic deficits and on discharge was requiring supplemental oxygen with sleep and strenuous activity. Avoiding systemic anticoagulation, repleting VWF, maintaining circuit integrity, and providing local hemostasis, when possible, may be a safe and effective management strategy of AVWS on ECMO support when decannulation is not a viable option.
ABSTRACT
The COVID-19 pandemic has affected emergency department (ED) usage. This study examines changes in the number of ED visits for gastrointestinal (GI) bleeding and nonemergency GI conditions, such as acute gastroenteritis (AGE) and constipation, before the pandemic and at the peak and slack periods of the pandemic in Taiwan. This retrospective observational study was conducted at a referral medical center in northern Taiwan. We recorded the number of weekly ED visits for GI bleeding, AGE, and constipation from 2019 to 2021. We then compared the baseline period (calendar weeks 4-18 and 21-31, 2019) with two peak pandemic periods (period 1, calendar weeks 4-18, 2020; period 2, calendar weeks 21-31, 2021) and their corresponding slack periods. The decline in the number of ED visits during the two peak pandemic periods for GI bleeding (-18.4% and -30.2%) were not as substantial as for AGE (-64.1% and -76.7%) or for constipation (-44.4% and -63.6%), but GI bleeding cases were still significantly lower in number relative to the baseline. During the slack period, the number of ED visits for all three diagnoses rebounded but did not exceed the baseline. Our study revealed that there was a significant decline of GI complaint during the pandemic. This phenomenon was more prominent in nonemergency complaints (AGE and constipation) and less prominent in serious complaints (GI bleeding).