Pulmonary Hemorrhage Treated With Oxidized Regenerated Cellulose

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To the Editor:
Surgicel Fibrillar is an oxidized regenerated cellulose (ORC) material, used to achieve hemostasis. It is loosely woven, having the appearance, consistency, and adherence properties similar to cotton. It can be customized into any size or shape to conform to a wide array of spaces. There are 3 case reports of its use in the tracheobronchial tree for the management of prolonged air leaks.1–3 There are no reports of its use in the tracheobronchial tree for the management of pulmonary hemorrhage. Herein, we report a case of postoperative pulmonary hemorrhage treated with ORC.
A 78-year-old female developed hemoptysis on postoperative day 2 after undergoing a right lower lobe (RLL) superior segment (RB6) wedge resection for an enlarging mass. A chest x-ray revealed worsening infiltrates in the right lung fields. She underwent a flexible bronchoscopy, which showed fresh blood throughout her airways. The bleed was localized to RB6 and a RLL subsuperior segment (sub-RB6). Attempts at instilling cold saline and epinephrine from a wedged position into the affected airways were unsuccessful. She was sent to the intensive care unit with an endotracheal tube in place. Placement of an endobronchial blocker in the bronchus intermedius was not felt to be needed. Bronchial artery embolization and surgical exploration were considered, but it was elected to observe as the volume and rate of bleeding was slow.
Over the next 18 hours, 2 additional bronchoscopic procedures were performed for airway clearance; each confirmed continued slow bleeding. On the basis of thromboelastography results, 2 units of fresh frozen plasma were given but without effect. Interventional pulmonary performed the fourth bronchoscopy at the bedside and again, persistent bleeding was seen. The surgical team favored an endobronchial approach to reoperation and therefore the decision was made to use ORC. The forceps were loaded into the working channel of the bronchoscope with the forceps tip extending just beyond the distal end of the bronchoscope. A small piece of the ORC was grasped with the forceps (Fig. 1A). As a unit, we advanced the bronchoscope to the orifice of both RB6 and sub-RB6 where we placed the ORC (Figs. 1B, C). No further bleeding was evident. She was extubated within 14 hours of ORC placement, transferred out of the intensive care unit within 36 hours, and discharged within 11 days without further hemoptysis.
Pulmonary hemorrhage at a slow rate can be controlled using ORC. There are 3 case reports describing cessation of prolonged air leak with the use of ORC.1–3 Although the indication for the use of ORC differs, the concept remains the same—occlude the airway lumen. We report a case of the successful use of ORC to achieve hemostasis in the tracheobronchial tree.
Bronchoscopic interventions to control airway bleeding include cold saline, topical vasoconstrictive agents, selective mainstem intubation, ablative therapies, balloon tamponade, or placement of an endobronchial spigot.4 If the hemorrhage is refractory to endobronchial measures, options include bronchial artery embolization or surgery.4
Before placement of the ORC, our patient underwent 3 bronchoscopies without evidence of hemostasis. Surgical options were felt to be too invasive for the volume and rate of bleeding. Targeted occlusion of the affected segments using ORC was favored over placement of an endobronchial blocker, which would have unnecessarily occluded unaffected segments and required her to remain intubated.
Placing foreign material in the airway raises the concern for potential complications. The 3 reported cases of the use of ORC in the airways did not result in any complications at 52 and 8 months.1 The third patient was discharged, but died 2 months later due to unrelated causes.3 Our patient was discharged 11 days after ORC placement without apparent complications.
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