Anticoagulation-free VV-ECMO for a child with intractable pulmonary hemorrhage: A case report

IntroductionSystemic anticoagulation (AC) is standard practice in extracorporeal membrane oxygenation (ECMO). Adults on ECMO have been successfully managed AC-free. However, slower flow rates in pediatric circuits have mostly prevented this strategy. Thus, ECMO is often avoided in children with intractable hemorrhage.Case ReportA 12-year-old female with microscopic polyangiitis was admitted with diffuse alveolar hemorrhage and acute on chronic renal failure requiring venovenous (VV)-ECMO and continuous kidney replacement therapy (CKRT). Systemic AC was withheld entirely, and the CKRT circuit was regionally anticoagulated with citrate. High ECMO flow rates and positioning of the CKRT return line pre-oxygenator enabled an effective AC-free VV-ECMO run of 15 days.DiscussionThis highlights an innovative approach to a rare but successful pediatric VV-ECMO run without systemic AC in conjunction with regional AC for CKRT.ConclusionAlterations to ECMO circuitry including high flow rates and regional anticoagulation may liberalize candidacy for children with hemorrhage.