key: cord-0808631-t4rxu2hq authors: Ortoleva, J.; Penney, E. title: Intracranial Hemorrhage in COVID-19 Patients on ECMO: Challenges and Future Directions date: 2020-06-09 journal: J Cardiothorac Vasc Anesth DOI: 10.1053/j.jvca.2020.06.010 sha: 4302765ce37af59bf8ac61ed1e30a507ee032d94 doc_id: 808631 cord_uid: t4rxu2hq nan The authors report no conflicts of interest relevant to this work. The COVID-19 crisis has affected nearly every country in the world, with more than four million confirmed cases and over 284,000 deaths. 1 Extracorporeal membrane oxygenation (ECMO) is occasionally being used to support COVID-19 patients refractory to optimal mechanical ventilation, neuromuscular blockade, prone positioning, and inhaled pulmonary vasodilators. [2] [3] [4] The extracorporeal life support organization (ELSO) has been releasing a set of regularly updated statistics for confirmed and possible COVID-19 patients receiving ECMO. 5 Among the most concerning findings in this data set is the rate of intracranial hemorrhage (ICH): reported to be 28 of 457 cases, or 6.1%. 5 Reports of intracranial pathology related to patients with COVID-19 are growing in the literature. [6] [7] [8] [9] Lorusso et al. have reported on the rate of ICH in large cohorts of VA and VV ECMO from ELSO database queries. 10, 11 In these retrospective reviews, the incidence of intracranial hemorrhage was found to be 181 of 4988 ( 10, 11 An explanation for the seemly high rate of ICH in COVID-19 ECMO based on pathophysiology and/or practice patterns must be sought to improve outcomes. The most notable difference in COVID-19 management is the liberal use of anticoagulation due to the disease process inducing a hypercoagulable state from hyper-inflammation (cytokine release resulting in a hyper-inflammatory state) and endothelial cell damage. [12] [13] [14] The micro-vascular thrombosis in COVID-19 is thought to explain the hypoxemia with normal lung compliance, and macrovascular phenomena such as venous thromboembolism seem to be a frequent complication as well. 14 Anticoagulation in COVID-19 patients not receiving ECMO is generally performed with heparin drip or twice daily lovenox, with differing therapeutic targets among institutions; the most frequent parameters used to follow the degree of anticoagulation are partial thromboplastin time and and anti-Xa levels. 15 The Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) in children and adults. Cochrane Database of Systematic Reviews Acute Respiratory Distress Syndrome Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome ECMO in COVID-19: COVID-19 ECMO Statistics, for all cases that have completed their ECMO run COVID-19 -associated Diffuse Leukoencephalopathy and Microhemorrhages Catastrophic Intracranial Hemorrhage in Two Critically Ill Patients with COVID-19 Brain Imaging Use and Findings in COVID-19: A Single Academic Center Experience in the Epicenter of Disease in the United States Veno-venous Extracorporeal Membrane Oxygenation for Respiratory Failure in COVID-19 Patients: Early Experience From a Major Academic Medical Center in North America In-Hospital Neurologic Complications in Adult Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation: Results From the Extracorporeal Life Support Organization Registry Neurologic Injury in Adults Supported With Veno-Venous Extracorporeal Membrane Oxygenation for Respiratory Failure: Findings From the Extracorporeal Life Support Organization Database Association of Treatment Dose Anticoagulation with In-Hospital Survival Among Hospitalized Patients with COVID-19 ECMO for COVID-19 associated severe ARDS and risk of thrombosis Thrombosis and coagulopathy in COVID-19 patients requiring extracorporeal membrane oxygenation COVID-19 and VTE/Anticoagulation: Frequently Asked Questions Extracorporeal Membrane Oxygenation Induces Short-Term Loss of High-Molecular-Weight von Willebrand Factor Multimers Multi-Modal Characterization of the Coagulopathy Associated With Extracorporeal Membrane Oxygenation None