PO0002 - Bleeding disorder in a critically ill patient

Wednesday, July 13, 2022

1:00 PM – 2:00 PM

Location: ExCel Center, ICC Capital Suite Room 1

Presenting Author(s)

Rita Pombal, MD

Immunohemotherapy Medical Resident
Centro Hospitalar Vila Nova de Gaia/Espinho EPE, Portugal
Vila Nova de Gaia, Porto, Portugal

Co-Author(s)

LV

Lúcia Vieira

Immunohemotherapy Medical Resident
Centre of Thrombosis and Hemostasis and Department of Transfusion Medicine, Centro Hospitalar Vila Nova de Gaia/Espinho, E.P.E., Portugal
Vila Nova de Gaia, Porto, Portugal
SL

Sara Lopes

Immunohemotherapy Medical Resident
Centre of Thrombosis and Hemostasis and Department of Transfusion Medicine, Centro Hospitalar Vila Nova de Gaia/Espinho, E.P.E., Portugal
Vila Nova de Gaia, Porto, Portugal
RN

Rita Neto

Immunohemotherapy Medical Resident
Centre of Thrombosis and Hemostasis and Department of Transfusion Medicine, Centro Hospitalar Vila Nova de Gaia/Espinho, E.P.E., Portugal
Vila Nova de Gaia, Porto, Portugal
JR

Joana Ribeiro

Immunohemotherapy Medical Resident
Centre of Thrombosis and Hemostasis and Department of Transfusion Medicine, Centro Hospitalar Vila Nova de Gaia/Espinho, E.P.E., Portugal
Vila Nova de Gaia, Porto, Portugal
HG

Helena Gomes

Immunohemotherapy Specialist
Centre of Thrombosis and Hemostasis and Department of Transfusion Medicine, Centro Hospitalar Vila Nova de Gaia/Espinho, E.P.E., Portugal
Vila Nova de Gaia, Porto, Portugal
MF

Manuel Figueiredo

MD
Centre of Thrombosis and Hemostasis and Department of Transfusion Medicine, Centro Hospitalar Vila Nova de Gaia/Espinho, E.P.E., Portugal
Vila Nova de Gaia, Porto, Portugal

Background: Bleeding abnormalities are commonly found in critically ill patients and may have a major impact on the outcome.

Aims: Description of a bleeding disorder in a critically ill patient.

Methods: Collection of clinical data in SClínico® application.

Results: Man, 56-years-old, with chronic coronary disease and multiple cardiovascular risk factors, presented on January 2022 with cardiorespiratory arrest due to acute myocardial infarction. After successful resuscitation and coronary angioplasty, he progressed to cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation (ECMO) and mechanical ventilation. He started unfractionated heparin (UHF) titration to maintain the aPTT in the target range (1.5-2 times normal aPTT). On the fourth day a hepatogastric hematoma (7.6x2.5x1.7cm) was identified and associated with the resuscitation manoeuvres, so UHF was maintained. On the same day sepsis diagnosis arose. On the sixth day, with aPTT in the target range, hemoptysis set in, with hemodynamic repercussion and UHF was stopped even though he was on ECMO. Even without UHF bleeding persisted. Bronchoscopy revealed a large bronchial clot and bronchial mucosa hemorrhage. Analytical findings showed: aPTT 34,8sec; INR 1.2; D-dimer 19,96ug/mL; Fibrinogen 739mg/dL; Hemoglobin 8,8g/dL; Platelets 78000cells/mm3. We do not have access to von Willebrand functional tests at our institution. Despite local hemostatic procedures, platelets transfusion and 1g tranexamic acid nebulization, bleeding persisted. The patient deceased two days later with multiple organ dysfunction.

Conclusion(s): Management of bleeding in critical patients should be directed at the underlying condition, but often presents as a challenging multifactorial clinical setting. Our patient did not respond to the treatment of sepsis and organ dysfunction. Also we could not exclude acquired von Willebrand syndrome ECMO-associated, characterized by loss of von Willebrand factor large multimers. All these aspects contributed to the outcome. With this case we intend to highlight a situation that was difficult to manage and for which we felt powerless.