Management of Acquired von Willebrand Syndrome During Prolonged VV-ECMO

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.

Common online early childhood education Patterns during the Corona Pandemic

This research aims to identify the most common online early education patterns and the reasons why parents choose such patterns. It also aims to identify the most significant statistical differences to be applied to parents according academic qualification, number of children they have, and their occupation, following the descriptive methodology. This has been applied to a sample consisting of 252 parents of the children in early years of education. A questionnaire of three dimensions has been used, and it has been consistent with the subject of the research. This research concluded that the most common online early education patterns are exemplified in etting education through electronic devices such as the educational tablet and mobile phones. This pattern received the first place with a percentage of 75.4%., and an arithmetic mean of 2. 26.. The least common education pattern is exemplified in education through audio platforms (The radio and the Broadcasting), receiving the 13th place with a percentage of 43.65% and an arithmetic mean of 1.31. This is because electronic devices make available the opportunity for direct interaction and communication with the learner. This research concludes that there are no significant differences between the individuals of the sample regarding being applicable owing to the research variables. This research recommends that it is necessary to get parents, and their children trained and qualified to employ and use technology in education. © 2021, CA and C Press AB. All rights reserved.