key: cord-1029965-e08py6yc authors: LoSavio, Phillip S.; Patel, Tirth; Urban, Matthew J.; Tajudeen, Bobby; Papagiannopoulos, Peter; Revenaugh, Peter C.; Husain, Inna; Batra, Pete S. title: Management of Upper Airway Bleeding in COVID‐19 Patients on Extracorporeal Membrane Oxygenation date: 2020-05-29 journal: Laryngoscope DOI: 10.1002/lary.28846 sha: 1ad84af13c20aca8df91bc3bfeacd8f975bff71b doc_id: 1029965 cord_uid: e08py6yc nan COVID-19, the disease caused by the novel coronavirus (SARS-CoV2) has been declared a global pandemic by the World Health Organization (WHO). Severe acute respiratory distress syndrome (ARDS) may be a consequence of COVID-19 and veno-venous extracorporeal membrane oxygenation (V-V ECMO) may be offered to patients. This strategy is being used at specialized centers for the treatment of severe cases unable to be supported by traditional mechanical ventilation (1) . Typically, the patient's venous system is drained through single femoral vein and an internal jugular vein is then utilized to return oxygenated blood to the system, bypassing the injured lungs. This process requires chronic anticoagulation to avoid thrombosis and circuit failure. There are limited reports of epistaxis and/or upper airway hemorrhage management in ECMO patients in the literature, and none detailing protocols for actively infected patients in the midst of a global pandemic (2) . Among five COVID-19 patients at our institution being supported by V-V ECMO at the time of this writing, three required consultation by the otolaryngology service for management of epistaxis and/or oropharyngeal bleeding and are reported here. All were anticoagulated with bivalirudin, which was briefly held during the course of bleeding in all cases. In all cases, bleeding was successfully controlled after measures taken as detailed. Table 1 This article is protected by copyright. All rights reserved. A 53-year-old intubated male had spontaneous bleeding from the nasal and oral mucosa 7 days after V-V ECMO initiation. Absorbable gelatin sponge (Surgifoam®, Ethicon) and gelatin/thrombin matrix (Surgiflo®, Ethicon) were packed in the bilateral nasal cavities. Gauze oropharyngeal packing was placed and exchanged every two days until removal on the sixth day with resolution of bleeding. A 46-year-old male had epistaxis 14 days after initiation of V-V ECMO. He was extubated and hypertensive (189/105 mm Hg) with a nasogastric tube in the left nasal cavity at time of evaluation. Bilateral nasal cavities were bleeding and were packed with oxidized cellulose absorbable hemostat (Surgicel® Original, Ethicon) and absorbable gelatin sponge. Bleeding resolved and anticoagulation was resumed the day after packing. A 34-year-old male had bilateral epistaxis eight days after initiation of V-V ECMO. He had been extubated prior to evaluation. A nasogastric tube was in the left nasal cavity. Gelatin/thrombin matrix was placed in the bilateral nasal cavities. There was also mild bleeding from the lips and oral cavity mucosa that did not require intervention and had resolved by the following day. The bedside nursing staff was instructed to apply petroleum jelly to the lips twice daily to prevent dryness. All bleeding was controlled and anticoagulation was resumed after being held for three days. The etiology of upper aerodigestive hemorrhage in patients treated with ECMO is multifactorial, and the incidence of hemorrhage has been estimated between 5% and 30% in this While unfractionated heparin (UFH) is commonly utilized for ECMO anticoagulation, early experiences with ECMO in patients with COVID-19 at our institution showed maintaining therapeutic anticoagulation at typical doses was challenging. Recent literature suggests that bivalirudin better maintains ECMO anticoagulation within a therapeutic range than UFH without increasing incidence of bleeding events (5) . Bivalirudin is a direct thrombin inhibitor, as opposed This article is protected by copyright. All rights reserved. to heparin, which indirectly inhibits thrombin by activating antithrombin. As we highlight in this series, there is still a risk of bleeding events requiring intervention with bivalirudin use. Extra precautions are required in the treatment of COVID-19 patients with upper airway bleeding to prevent viral transmission by aerosolization of secretions. Only a single provider was in the patient room during the procedure. The personal protective equipment (PPE) used by the physician included disposable surgical cap, gown, gloves and powered air-purifying respirator (PAPR) with face shield or N-95 mask with eye/face protection (Figure 1 ). Providers were trained in proper donning and doffing protocols for PPE. A handheld light source and overhead lighting were used in all cases. A headlight was not used because a model compatible with the PPE was not immediately available. A headlight may also be less advantageous because adjustments during the procedure increase the risk of contamination. All possible supplies necessary were carried into the room to minimize need for exit and re-entry. Because of the diffuse nature of the bleeding encountered, endoscopy was of little utility and was avoided as it could exacerbate bleeding and cause further aerosolization of secretions. Suctioning was also avoided for the same reasons. Placement of absorbable packing was preferred to limit the number of procedures required to temporize the nasal bleeding. This minimizes the need to remove permanent packing such as petrolatum gauze or polyvinyl alcohol sponge (Merocel®) which could risk rebleeding and requires further instrumentation. Nasal sprays, such as oxymetazoline, were not recommended in these cases to minimize aerosolization. If needed, it should be applied using soaked pledgets rather than spraying. This article is protected by copyright. All rights reserved. As the number of severe COVID-19 cases continue to increase, more patients will likely require ECMO. Otolaryngologists may be required to intervene on these patients who are at risk for bleeding in the upper aerodigestive tract. Bleeding was noted in a high percentage of ECMO cases at our institution. While use of anticoagulation is a major factor, it must be restarted soon after hemorrhage control to avoid thrombus formation near the ECMO cannula sites. Further refinements to our strategy are expected as we continue to encounter additional ECMO cases. This article is protected by copyright. All rights reserved. Planning and Provision of ECMO services for severe ARDS during the COVID-19 pandemic and other outbreaks of emerging infectious diseases Severe epistaxis during adult extracorporeal membrane oxygenation: not your average nosebleed Severe epistaxis in patients on extracorporeal membranous oxygenator support occurrence and management Difference of coagulation features between severe pneumonia induced by SARS-CoV2 and non-SARS-CoV2 Heparin vs bivalirudin anticoagulation for extracorporeal membrane oxygenation Tables Table I