Delayed retroperitoneal hemorrhage during extracorporeal membrane oxygenation in COVID-19 patients: A case report and literature review

Iliopsoas haematoma during extracorporeal membrane oxygenation: A registry report from the COVID-19 critical care consortium across 30 countries

INTRODUCTION

Iliopsoas haematoma (IPH) during extracorporeal membrane oxygenation (ECMO) is a rare bleeding complication that can be fatal due to its progression to abdominal compartment syndrome, but its incidence and risk factors are not well known. We have previously reported an IPH incidence rate of 16% in Japan. Among possible reasons for this high incidence, ethnicity has been hypothesised to play a role. Therefore, we used an international multi-centre cohort registry to test this hypothesis by determining the incidence rate of IPH.

METHODS

This study was performed using the COVID-19 Critical Care Consortium database, conducted in 30 countries across five continents between 3 January 2020, and 20 June 2022.

RESULTS

Overall, 1102 patients received ECMO for COVID-19-related acute respiratory distress syndrome. Of them, only seven were reported to have IPH, indicating an incidence rate of 0.64%, with comparable rates between the countries. The IPH group tended to have a higher mortality rate (71.4%) than the non-IPH group (51%).

CONCLUSIONS

Overall incidence of IPH in the studied COVID-19 ECMO cohort was 0.64%. Most cases were reported from Japan, Belgium, and Italy. In our study, this rare complication did not appear to be confined to Asian patients. Due to the high fatality rate, awareness about the occurrence of IPH should be recognised.

Retroperitoneal hematoma in patients with COVID-19 infection during anticoagulant therapy: A case series and literature review

Due to the hypercoagulable status of patients with severe COVID-19 infection, anticoagulants are often used to prevent thrombosis. However, these agents may cause bleeding events such as retroperitoneal hematoma (RPH). We report here on six patients with COVID-19 who developed RPH during treatment. Early evidence of bleeding led to confirmatory diagnosis with imaging. Four patients recovered with supportive treatment (IV fluids and blood transfusions) and two patients recovered by angioembolization. RPH should be considered in COVID patients on anticoagulants as soon as haemoglobin or blood pressure falls. Further studies are required to provide guidance and recommendations on use of anticoagulants in critically ill patients with COVID-19.

Multiple Surgical Treatments for Recurrent Retroperitoneal Hemorrhage in a COVID-19 Patient with Respiratory Failure on Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) may be required in patients with corona virus disease-19 (COVID-19) and respiratory failure. Anticoagulation is the standard treatment to prevent complications of ECMO and COVID-19 coagulopathy, however, there is a risk of bleeding. Some patients with retroperitoneal hemorrhage (RPH) have been treated with angiography-embolization. We report on a patient with COVID-19 on ECMO who underwent multiple operations (×5) for recurrent RPH. A 46-year-old man was admitted with COVID-19 pneumonia. ECMO with anticoagulation therapy was initiated. The patient developed RPH, caused by external compression of the inferior vena cava interrupting the ECMO inflow, and surgical hematoma evacuation was performed, with no obvious bleeding focus during the multiple surgeries. Following the patient’s recovery, a follow-up computed tomography scan showed the hematoma had been resolved, but there was a dilemma regarding anticoagulation. Lowering the threshold for surgical treatment, enabled treatment of a patient with serious RPH.