J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website https://jmc.elmerpub.com

Case Report

Volume 17, Number 9, September 2026, pages 482-492

Combined Red Cell Exchange and Plasma Exchange for Post-Arrest Refractory Cardiorespiratory Failure in Sickle Cell Disease Sparing Extracorporeal Membrane Oxygenation

↓ Figure 1. Vasopressor requirements and Vasoactive Inotropic Score (VIS) during recovery from refractory multiorgan failure. PLEX: plasma exchange.

↓ Figure 2. Temporal evolution of hemodynamic (a), inflammatory (b), and respiratory (c) parameters during combined RCE and plasma exchange therapy. ARDS: acute respiratory distress syndrome; CRP: C-reactive protein; CVP: central venous pressure; LDH: lactate dehydrogenase; MAP: mean arterial pressure; P/F ratio: PaO₂/FiO₂ ratio; PEA: pulseless electrical activity; PEEP: positive end-expiratory pressure; RCE: red cell exchange; VT: ventricular tachycardia.

↓ Figure 3. Serial laboratory parameters and clinical response to combined apheresis therapy (a–d). INR: international normalized ratio; RCE: red cell exchange.

↓ **Table 1.** Timeline of Clinical Events
Date/day	Event
AF: atrial fibrillation; ARDS: acute respiratory distress syndrome; BiPAP: bilevel positive airway pressure; CPR: cardiopulmonary resuscitation; FiO₂: fraction of inspired oxygen; GCS: Glasgow Coma Scale; HbS: hemoglobin S (sickle hemoglobin); ICU: intensive care unit; LVEF: left ventricular ejection fraction; PaO₂: partial pressure of oxygen in arterial blood; PEA: pulseless electrical activity; PLEX: plasma exchange; RCE: red cell exchange; ROSC: return of spontaneous circulation; RVR: rapid ventricular response; RV: right ventricular; SVT: supraventricular tachycardia; VT: ventricular tachycardia.
Day 0	Admission to ward for vaso-occlusive crisis; supportive care initiated
Day 1 (morning)	Progressive dyspnea and hypoxemia; BiPAP initiated
Day 1 (afternoon)	ICU transfer; hypotension requiring norepinephrine; PEA arrest with ROSC after 6 min CPR
Day 1 (evening)	SVT to AF with RVR; two synchronized cardioversions; recurrent VT; three defibrillations + 6 min CPR; second ROSC
Day 1 (post-arrest)	Shock with four vasopressors; severe ARDS (PaO₂/FiO₂ 56); biventricular failure on echo; GCS 12; multidisciplinary decision to initiate combined RCE and PLEX; ECMO circuit prepared but not initiated
Day 2	First PLEX session; first RCE session; vasopressor requirements begin to decrease
Days 2–8	Daily PLEX (seven total sessions); intermittent RCE every 48 h
Day 3	HbS 35%; inflammatory markers declining
Day 8	Complete vasopressor independence
Day 10	Repeat echocardiography showing normalized LVEF and improved RV function; platelet count normalized; extubation to pressure support ventilation (PaO₂/FiO₂ 491)
Day 14	ICU discharge; full neurologic recovery
Day 16	Hospital discharge to home

↓ Table 1. Timeline of Clinical Events

Date/day

Event

AF: atrial fibrillation; ARDS: acute respiratory distress syndrome; BiPAP: bilevel positive airway pressure; CPR: cardiopulmonary resuscitation; FiO₂: fraction of inspired oxygen; GCS: Glasgow Coma Scale; HbS: hemoglobin S (sickle hemoglobin); ICU: intensive care unit; LVEF: left ventricular ejection fraction; PaO₂: partial pressure of oxygen in arterial blood; PEA: pulseless electrical activity; PLEX: plasma exchange; RCE: red cell exchange; ROSC: return of spontaneous circulation; RVR: rapid ventricular response; RV: right ventricular; SVT: supraventricular tachycardia; VT: ventricular tachycardia.

Day 0

Admission to ward for vaso-occlusive crisis; supportive care initiated

Day 1 (morning)

Progressive dyspnea and hypoxemia; BiPAP initiated

Day 1 (afternoon)

ICU transfer; hypotension requiring norepinephrine; PEA arrest with ROSC after 6 min CPR

Day 1 (evening)

SVT to AF with RVR; two synchronized cardioversions; recurrent VT; three defibrillations + 6 min CPR; second ROSC

Day 1 (post-arrest)

Shock with four vasopressors; severe ARDS (PaO₂/FiO₂ 56); biventricular failure on echo; GCS 12; multidisciplinary decision to initiate combined RCE and PLEX; ECMO circuit prepared but not initiated

Day 2

First PLEX session; first RCE session; vasopressor requirements begin to decrease

Days 2–8

Daily PLEX (seven total sessions); intermittent RCE every 48 h

Day 3

HbS 35%; inflammatory markers declining

Day 8

Complete vasopressor independence

Day 10

Repeat echocardiography showing normalized LVEF and improved RV function; platelet count normalized; extubation to pressure support ventilation (PaO₂/FiO₂ 491)

Day 14

ICU discharge; full neurologic recovery

Day 16

Hospital discharge to home

↓ **Table 2.** Vital Signs and Hemodynamic Parameters
Time point	Temperature (°C)	HR (/min)	BP (mm Hg)	MAP (mm Hg)	CVP (mm Hg)
HR: heart rate; BP: blood pressure; MAP: mean arterial pressure; CVP: central venous pressure; AF: atrial fibrillation; VT: ventricular tachycardia; SR: sinus rhythm; PLEX: plasma exchange; ICU: intensive care unit.
Admission	37.2	95	128/78	95	8
Pre-arrest	38.5	118	85/52	68	14
Post-arrest 1	36.8	145 (AF)	68/42	52	18
Post-arrest 2	35.5	165 (VT)	62/38	48	22
PLEX day 1	37.0	95 (SR)	75/48	58	16
PLEX day 2	37.2	88 (SR)	82/55	65	14
PLEX day 3	37.1	82 (SR)	95/62	72	12
PLEX day 5	36.9	78 (SR)	105/68	78	10
PLEX day 7	36.8	76 (SR)	115/72	85	8
Pre-extubation	36.8	72 (SR)	118/75	88	8
ICU discharge	36.7	68 (SR)	125/78	92	6

↓ Table 2. Vital Signs and Hemodynamic Parameters

Time point

Temperature (°C)

HR (/min)

BP (mm Hg)

MAP (mm Hg)

CVP (mm Hg)

HR: heart rate; BP: blood pressure; MAP: mean arterial pressure; CVP: central venous pressure; AF: atrial fibrillation; VT: ventricular tachycardia; SR: sinus rhythm; PLEX: plasma exchange; ICU: intensive care unit.

Admission

37.2

128/78

Pre-arrest

38.5

118

85/52

Post-arrest 1

36.8

145 (AF)

68/42

Post-arrest 2

35.5

165 (VT)

62/38

PLEX day 1

37.0

95 (SR)

75/48

PLEX day 2

37.2

88 (SR)

82/55

PLEX day 3

37.1

82 (SR)

95/62

PLEX day 5

36.9

78 (SR)

105/68

PLEX day 7

36.8

76 (SR)

115/72

Pre-extubation

36.8

72 (SR)

118/75

ICU discharge

36.7

68 (SR)

125/78

↓ **Table 3.** Detailed Vasopressor Administration and Titration
Time point	Norepinephrine (µg/kg/min)	Epinephrine (µg/kg/min)	Vasopressin (units/min)	Dobutamine (µg/kg/min)	Total VIS
Vasoactive Inotropic Score (VIS) was calculated as: norepinephrine (µg/kg/min × 100) + epinephrine (µg/kg/min × 100) + dobutamine (µg/kg/min × 1) + vasopressin (units/min × 10,000). PLEX: plasma exchange; ICU: intensive care unit.
Pre-arrest (day 1, 8:00 am)	0.15	0	0	0	15
Post-arrest 1 (day 1, 2:00 pm)	0.45	0.15	0.04	5.0	75
Post-arrest 2 (day 2, 2:00 am)	0.65	0.25	0.04	8.0	108
PLEX day 1 (day 2, 8:00 am)	0.35	0.12	0.04	5.0	62
PLEX day 2 (day 3, 8:00 pm)	0.28	0.08	0.04	3.0	49
PLEX day 3 (day 4, 8:00 am)	0.18	0.06	0.03	2.0	33.5
PLEX day 4 (day 5, 8:00 pm)	0.12	0.03	0.02	1.0	21
PLEX day 5 (day 6, 8:00 am)	0.08	0	0.02	0	13
PLEX day 6 (day 7, 8:00 pm)	0.05	0	0	0	5
PLEX day 7 (day 8, 8:00 am)	0.04	0	0	0	4
Day 9 (8:00 am)	0	0	0	0	0
Pre-extubation (day 10)	0	0	0	0	0
ICU discharge (day 14)	0	0	0	0	0

↓ Table 3. Detailed Vasopressor Administration and Titration

Time point

Norepinephrine (µg/kg/min)

Epinephrine (µg/kg/min)

Vasopressin (units/min)

Dobutamine (µg/kg/min)

Total VIS

Vasoactive Inotropic Score (VIS) was calculated as: norepinephrine (µg/kg/min × 100) + epinephrine (µg/kg/min × 100) + dobutamine (µg/kg/min × 1) + vasopressin (units/min × 10,000). PLEX: plasma exchange; ICU: intensive care unit.

Pre-arrest (day 1, 8:00 am)

0.15

Post-arrest 1 (day 1, 2:00 pm)

0.45

0.15

0.04

5.0

Post-arrest 2 (day 2, 2:00 am)

0.65

0.25

0.04

8.0

108

PLEX day 1 (day 2, 8:00 am)

0.35

0.12

0.04

5.0

PLEX day 2 (day 3, 8:00 pm)

0.28

0.08

0.04

3.0

PLEX day 3 (day 4, 8:00 am)

0.18

0.06

0.03

2.0

33.5

PLEX day 4 (day 5, 8:00 pm)

0.12

0.03

0.02

1.0

PLEX day 5 (day 6, 8:00 am)

0.08

0.02

PLEX day 6 (day 7, 8:00 pm)

0.05

PLEX day 7 (day 8, 8:00 am)

0.04

Day 9 (8:00 am)

Pre-extubation (day 10)

ICU discharge (day 14)

↓ **Table 4.** Selected Laboratory and Physiologic Parameters
Parameter	Admission/day 0	Pre-arrest/day 1	Post-PLEX/day 1	Post-PLEX/day 3	Pre-extubation/day 10	ICU discharge/day 14
Reference ranges: hemoglobin 13.5–17.5 g/dL (male); platelets 150–400 × 10³/µL; WBC 4.5–11.0 × 10³/µL; LDH 140–280 U/L; total bilirubin 0.1–1.2 mg/dL; direct bilirubin 0.0–0.3 mg/dL; troponin I < 0.04 ng/mL; procalcitonin < 0.05 ng/mL; CRP < 5 mg/L; INR 0.9–1.1; PT 11–13.5 s; aPTT 25–35 s; fibrinogen 2.0–4.0 g/L; creatinine 0.7–1.3 mg/dL; BUN 7–20 mg/dL; lactate 0.5–2.2 mmol/L; pH 7.35–7.45; pO₂ 80–100 mm Hg; pCO₂ 35–45 mm Hg; HCO₃^– 22–28 mmol/L; base excess −2 to +2 mmol/L; PaO₂/FiO₂ > 300 mm Hg. aPTT: activated partial thromboplastin time; BUN: blood urea nitrogen; CRP: C-reactive protein; FiO2: fraction of inspired oxygen; HCO3–: bicarbonate; INR: international normalized ratio; LDH: lactate dehydrogenase; PaO2: partial pressure of oxygen in arterial blood; PT: prothrombin time; WBC: white blood cell.
Hemoglobin (g/dL)	7.8	7.7	11.4	9.6	9.9	10.0
Hemoglobin S (%)	73	73	35	18.7	20	18
Platelets (× 10³/µL)	145	84	37	51	76	145
WBC (× 10³/µL)	12.3	12.7	7.6	8.1	6.4	6.6
LDH (U/L)	2,150	3,855	7,169	4,583	1,747	827
Total bilirubin (mg/dL)	4.2	6.5	6.8	2.8	2.3	1.3
Direct bilirubin (mg/dL)	0.9	0.95	1.1	0.64	0.53	0.47
Troponin I (ng/mL)	0.04	1.240	0.9	0.45	0.12	0.05
Procalcitonin (ng/mL)	2.1	13.72	26	16.4	5.8	0.8
CRP (mg/L)	16	48	45.8	12.44	4.59	2.4
INR	1.2	2.0	2.19	1.76	1.31	1.4
PT (s)	12	24	26	15.8	13.5	12.8
aPTT (s)	32	58	52	45	35	32
Fibrinogen (g/L)	3.2	1.8	2.1	2.4	3.8	4.1
Creatinine (mg/dL)	0.67	0.96	1.18	0.82	0.62	0.54
BUN (mg/dL)	28	43	45	37	21	21
Lactate (mmol/L)	1.2	8.23	5.2	2.4	1.6	1.6
pH	7.38	7.17	7.45	7.52	7.52	7.44
pO₂ (mm Hg)	78	55	66	88	209	88
pCO₂ (mm Hg)	42	38	52	42	41	40
HCO₃^– (mmol/L)	24	14	26	33	30	28
Base excess (mmol/L)	+1	−14	+1	+5	+4	+2
PaO₂/FiO₂ ratio	280	56	86	195	491	303

↓ Table 4. Selected Laboratory and Physiologic Parameters

Parameter

Admission/day 0

Pre-arrest/day 1

Post-PLEX/day 1

Post-PLEX/day 3

Pre-extubation/day 10

ICU discharge/day 14

Reference ranges: hemoglobin 13.5–17.5 g/dL (male); platelets 150–400 × 10³/µL; WBC 4.5–11.0 × 10³/µL; LDH 140–280 U/L; total bilirubin 0.1–1.2 mg/dL; direct bilirubin 0.0–0.3 mg/dL; troponin I < 0.04 ng/mL; procalcitonin < 0.05 ng/mL; CRP < 5 mg/L; INR 0.9–1.1; PT 11–13.5 s; aPTT 25–35 s; fibrinogen 2.0–4.0 g/L; creatinine 0.7–1.3 mg/dL; BUN 7–20 mg/dL; lactate 0.5–2.2 mmol/L; pH 7.35–7.45; pO₂ 80–100 mm Hg; pCO₂ 35–45 mm Hg; HCO₃^– 22–28 mmol/L; base excess −2 to +2 mmol/L; PaO₂/FiO₂ > 300 mm Hg. aPTT: activated partial thromboplastin time; BUN: blood urea nitrogen; CRP: C-reactive protein; FiO2: fraction of inspired oxygen; HCO3–: bicarbonate; INR: international normalized ratio; LDH: lactate dehydrogenase; PaO2: partial pressure of oxygen in arterial blood; PT: prothrombin time; WBC: white blood cell.

Hemoglobin (g/dL)

7.8

7.7

11.4

9.6

9.9

10.0

Hemoglobin S (%)

18.7

Platelets (× 10³/µL)

145

WBC (× 10³/µL)

12.3

12.7

7.6

8.1

6.4

6.6

LDH (U/L)

2,150

3,855

7,169

4,583

1,747

827

Total bilirubin (mg/dL)

4.2

6.5

6.8

2.8

2.3

1.3

Direct bilirubin (mg/dL)

0.9

0.95

1.1

0.64

0.53

0.47

Troponin I (ng/mL)

0.04

1.240

0.9

0.45

0.12

0.05

Procalcitonin (ng/mL)

2.1

13.72

16.4

5.8

0.8

CRP (mg/L)

45.8

12.44

4.59

2.4

INR

1.2

2.0

2.19

1.76

1.31

1.4

PT (s)

15.8

13.5

12.8

aPTT (s)

Fibrinogen (g/L)

3.2

1.8

2.1

2.4

3.8

4.1

Creatinine (mg/dL)

0.67

0.96

1.18

0.82

0.62

0.54

BUN (mg/dL)

Lactate (mmol/L)

1.2

8.23

5.2

2.4

1.6

7.38

7.17

7.45

7.52

7.44

pO₂ (mm Hg)

209

pCO₂ (mm Hg)

HCO₃^– (mmol/L)

Base excess (mmol/L)

−14

PaO₂/FiO₂ ratio

280

195

491

303

↓ **Table 5.** Respiratory and Ventilatory Parameters
Phase	Mode	FiO₂	PEEP (cm H₂O)	pH	PaO₂ (mm Hg)	PaCO₂ (mm Hg)	P/F ratio
BiPAP: bilevel positive airway pressure; PC-CMV: pressure-controlled continuous mandatory ventilation; PCV: pressure control ventilation; PRVC: pressure regulated volume control; PSV: pressure support ventilation; NC: nasal cannula; RA: room air; PEEP: positive end-expiratory pressure; FiO₂: fraction of inspired oxygen; ICU: intensive care unit; P/F ratio: PaO₂/FiO₂ ratio; PaCO₂: partial pressure of carbon dioxide in arterial blood; PaO₂: partial pressure of oxygen in arterial blood; PLEX: plasma exchange.
Pre-ICU (BiPAP)	BiPAP	0.60	12/8	7.35	65	48	108
Post-arrest	PC-CMV	1.00	12	7.16	33	57	33
PLEX day 1	PC-CMV	0.80	10	7.28	52	48	65
PLEX day 2	PRVC	0.60	10	7.35	72	45	120
PLEX day 3	PCV	0.45	8	7.42	88	42	195
PLEX day 5	PCV	0.40	6	7.47	95	38	237
Pre-extubation	PSV	0.35	5	7.52	172	42	491
Post-extubation	NC	0.28	—	7.48	85	40	303
Hospital discharge	RA	0.21	—	7.44	88	40	419

↓ Table 5. Respiratory and Ventilatory Parameters

Phase

Mode

FiO₂

PEEP (cm H₂O)

PaO₂ (mm Hg)

PaCO₂ (mm Hg)

P/F ratio

BiPAP: bilevel positive airway pressure; PC-CMV: pressure-controlled continuous mandatory ventilation; PCV: pressure control ventilation; PRVC: pressure regulated volume control; PSV: pressure support ventilation; NC: nasal cannula; RA: room air; PEEP: positive end-expiratory pressure; FiO₂: fraction of inspired oxygen; ICU: intensive care unit; P/F ratio: PaO₂/FiO₂ ratio; PaCO₂: partial pressure of carbon dioxide in arterial blood; PaO₂: partial pressure of oxygen in arterial blood; PLEX: plasma exchange.

Pre-ICU (BiPAP)

BiPAP

0.60

12/8

7.35

108

Post-arrest

PC-CMV

1.00

7.16

PLEX day 1

PC-CMV

0.80

7.28

PLEX day 2

PRVC

0.60

7.35

120

PLEX day 3

PCV

0.45

7.42

195

PLEX day 5

PCV

0.40

7.47

237

Pre-extubation

PSV

0.35

7.52

172

491

Post-extubation

0.28

—

7.48

303

Hospital discharge

0.21

—

7.44

419