Aggressive management of massive hemothorax in patients on extracorporeal membrane oxygenation

Objective: Massive hemothorax in patients on extracorporeal membrane oxygenation (ECMO) is potentially life threatening and remains a medical challenge. In this study, we present the clinical results of using aggressive management to treat a consecutive series of patients on ECMO whose conditions were complicated by massive hemothorax. Methods: Between November 2003 and February 2010, 14 adult patients on ECMO developed massive hemothorax that was unrelated to the cannulation problems of the ECMO circuit at National Taiwan University Hospital, Taipei, Taiwan. Information was obtained regarding patient demographics, disease course, and treatment. Aggressive treatment of hemothorax included blood component therapy, chest tube drainage, pleural epinephrine irrigation, and surgical intervention. The criteria for surgical intervention, video-assisted thoracoscopic surgery (VATS), or open-window thoracostomy included one-third or more of the thoracic cavity that had accumulated blood clots resulting in a compromised cardiopulmonary status, continuous blood loss > 300 mL/hour for 4 hours or more, or continued bleeding for 24 hours after persistent blood transfusion. Results: All hemothoraces were unilateral. With coagulopathic correction, control of bleeding was obtained in two patients after decompression of the pleural cavity, four patients after pleural epinephrine irrigation, and eight of 14 patients required surgical intervention for blood clot evacuation. There were no specific findings except blood clot accumulation in each of the patients who underwent thoracotomy or VATS. Three of the eight patients required multiple operations to treat persistent bleeding. The in-hospital mortality rate was 36% (5 of 14 patients); one patient died of intractable bleeding and four deaths were related to multiple organ failure. Blood transfusion (Mann-Whitney U test; p=0.039) and comorbidities such as bacteremia, septic shock, diabetic mellitus, and immunocompromised status (Fisher exact test; p=0.031) were found to be significant and independent predictors of mortality. However, other factors such as age, complicated pneumothorax, and ECMO circuit duration were not statistically correlated with mortality. Conclusion: ECMO-related massive hemothorax usually occurred unilaterally and presented as a life-threatening condition. With intensive treatment, nearly two-thirds of the patients were saved. The most significant risk factor for mortality was the presence of a comorbidity such as sepsis, diabetic mellitus, or immunocompromised status