Abstract
Pneumonia is one of the causes of acute respiratory distress syndrome (ARDS) in pediatrics, which can progress to severe conditions such as pulmonary hypertension, leading to right ventricular failure or cor pulmonale. Pediatric patients requiring veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support are challenging in our country, from the time of initiation to another critical dilemma between managing massive bleeding and preventing clotting in the ECMO circuit. An 18-month-old boy presented in a ward with a 5-day history of fever, cough, and increased work of breathing over the prior 24 hours. He was diagnosed with bronchopneumonia and treated with antibiotic therapy. The patient had a rapid deterioration, requiring endotracheal intubation. Blood gas analysis showed oxygenation and ventilation failure with pulmonary hypertension resulting in cor pulmonale. The patient then underwent cannulation to central VA-ECMO via sternotomy. During the 11-day intensive care unit (ICU) stay, massive bleeding occurred from the cannulation site, with the team attempting to balance between hemorrhage and preventing clot formation in the circuit. The patient died from the failure of the oxygenator, as lung rest could not be achieved due to systemic complications from massive bleeding. For pediatric patients with acute cor pulmonale, it is necessary to be more aggressive in the timing of ECMO initiation, as indicated in the guidelines, and to evaluate the indications for VA-ECMO carefully. This evaluation should consider the benefits and drawbacks from all aspects, including the complications of bleeding that can lead to multiple organ failures in the patient.
Christian Reza Wibowo, Bambang Pujo Semedi
