Severe hyperbilirubinemia secondary to ECMO in a ARDS patient: a case report

History: A 51-year-old male presented with a 9-day history of fever and cough, progressing to severe respiratory failure refractory to conventional management. Diagnostic methods: High-throughput sequencing confirmed influenza A virus. Chest CT revealed bilateral pneumonia and pulmonary edema. Due to a persistently low oxygenation index (PaO₂/FiO₂ 48.9 mmHg), veno-venous extracorporeal membrane oxygenation (VV-ECMO) was initiated. Treatment: The patient was managed with a lung-protective ventilation strategy, prone positioning, and appropriate antimicrobial therapy. During ECMO support, severe mixed hyperbilirubinemia with a significant hemolytic component developed, characterized by a peak total bilirubin of 887 μmol/L. Management of hyperbilirubinemia included liver-protective agents, dual plasma molecular adsorption system (DPMAS), and therapeutic plasma exchange. Immunohematological tests confirmed immune-mediated hemolysis (positive direct and indirect antiglobulin tests). Outcome: Following ECMO decannulation, bilirubin levels normalized. The patient was successfully weaned from mechanical ventilation, transferred to a general ward, and eventually discharged, achieving full social reintegration. Conclusion: This case highlights the diagnostic challenge of differentiating between mechanical and immune-mediated hemolysis in ECMO patients and demonstrates the successful application of a combined therapeutic approach for severe ECMO-associated hyperbilirubinemia.