A Severe Traumatic Brain Injury Patient with Refractory Hypoxia Salvaged by VV ECMO: A Case Report

Introduction: Acute respiratory distress syndrome (ARDS) develops in about 20-30% of patients with traumatic brain injury (TBI) and is a predictor of poor outcome.Traumatic brain injury has been considered as a formal contraindication for extracorporeal membrane oxygenation (ECMO) as systemic anticoagulation is necessary.There is limited literature on the feasibility of ECMO for the treatment of severe ARDS in TBI patients.Here, we present a case of a severe TBI with aspiration pneumonia and severe ARDS salvaged by venovenous (VV) ECMO.Clinical presentation: A 51-year-old male suffered a road traffic accident with severe TBI and aspiration pneumonia.He was intubated at an outside hospital due to low a Glasgow Coma Scale (E1V1M4).Though he was planned for craniotomy and intracranial hematoma drainage, it was postponed in view of worsening respiratory status and was referred to our center.At presentation to our intensive care unit (ICU), he was sedated and paralyzed.Pupil: left -4 mm (nonreactive to light), right -2 mm (sluggishly reactive).He was on high ventilatory support.Due to features of raised intracranial pressure, routine ARDS ventilatory management like high positive end-expiratory pressure (PEEP)/PEEP titration, prone ventilation, etc. was not feasible.He continued to have severe hypoxia (PF ratio of 55), respiratory acidosis, and a Murray score of 3.3.Intervention/management: He was placed on VV ECMO using a femorojugular (25F right femoral venous drainage cannula, 19F right internal jugular vein (IJV) return cannula).During cannulation, heparin was not given, and ECMO was run for initial 48 h without heparin anticoagulation.After 48 h of ECMO run, heparin was started with a lower activated clotting time (ACT) target of 140-160.Outcome: His sensorium improved over the days, and became fully conscious by day 8. Gradually his lungs improved, and he was weaned off from ECMO on day 14.He was weaned off from ventilator by day 24, and shifted out of ICU on day 31 in a stable condition.Conclusion: This case suggests that ECMO can be run safely in severe TBI cases though with a modified anticoagulation protocol.With appropriate protocol implementation and close monitoring, VV ECMO can be considered in severe TBI cases with refractory hypoxia for better clinical outcome.