40: When a simple procedure becomes a dilemma on Extracorporeal Membrane Oxygenation (ECMO)

Introduction: Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for severe acute respiratory distress syndrome (ARDS). We present a case of venovenous (VV) ECMO in a pediatric patient with ARDS post-drowning, highlighting the challenges of managing hemothorax while balancing anticoagulation. Case Presentation: A healthy 10-month-old boy developed severe ARDS post-drowning. Bilateral large surgical chest tubes (20 Fr) were placed initially for pleural effusions and air leak. VV ECMO was initiated with right internal jugular (14 Fr) drainage and femoral (12 Fr) return cannulas. Initial vital signs: pulse 134, BP 98/65, temperature 36°C, SpO2 90%. Key labs: WBC 16.5, Hb 11.5, PLT 157, PT 17.6, PTT 101, INR 1.3, fibrinogen 2.2, D-dimer 4. Initial heparin doses: 16-20 units/kg/hr (ACT 170-235). On ECMO day 2, significant bleeding from chest tube sites exceeded 5 ml/kg/hr, necessitating massive transfusion and holding heparin. The ECMO circuit was assessed closely for clots. Right chest tube output stopped after 12 hours due to clotted drain. A critical decision to remove this chest drain led to a large right-sided collection on CXR, suspected hemothorax, causing mediastinal shift and worsening lung mechanics. On ECMO day 7, a new 12 Fr chest tube was inserted to drain the collection and allow lung recovery. Anticoagulation management remained challenging, balancing thrombosis risk against bleeding. Heparin was intermittently held and restarted with close monitoring. By ECMO day 8, bleeding was controlled and lung mechanics improved, allowing decannulation on day 9. Conclusions: Pediatric anticoagulation on ECMO is complex, often requiring multiple monitoring tools. Chest tube manipulation during ECMO carries high risks of morbidity and mortality. This case underscores the delicate balance between managing hemothorax and anticoagulation in pediatric ECMO. Careful decision-making and minimizing unnecessary procedures are vital during ECMO support.