Survival rate and Outcome of extracorporeal life support (ECLS) for treatment of acute cardiorespiratory failure in trauma patients

Veno-arterial-venous extracorporal membrane oxygenation (V-AV ECMO) in a patient in ARDS and cardiac instability after severe polytrauma

The role of extracorporeal life support (ECLS) in critically ill trauma patients is underutilized, mainly due to concerns of anticoagulation. However, short-term ECLS in these patients can be safely performed with no or minimal systemic anticoagulation. Case series show favorable outcomes in trauma patients with veno-venous (V-V) and veno-arterial (V-A) ECMO, respectively, but there are only a few case reports of successful veno-arterio-venous (V-AV) ECMO in polytrauma patients. We report on a 63-year-old female admitted to our emergency department following a severe car accident who was successfully treated in a multidisciplinary approach, including bridging to damage control surgery and recovery with a V-AV ECMO.

Plasma biomarkers for brain injury in extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) is a life-saving intervention for patients with refractory cardiorespiratory failure. Despite its benefits, ECMO carries a significant risk of neurological complications, including acute brain injury (ABI). Although standardized neuromonitoring and neurological care have been shown to improve early detection of ABI, the inability to perform neuroimaging in a timely manner is a major limitation in the accurate diagnosis of neurological complications. Therefore, blood-based biomarkers capable of detecting ongoing brain injury at the bedside are of great clinical significance. This review aims to provide a concise review of the current literature on plasma biomarkers for ABI in patients on ECMO support.

Extracorporeal life support use in limited lung function: a narrative review

Background and Objective

In thoracic surgery, different modalities of extracorporeal life support (ECLS) can be used for cardiorespiratory support in complex scenarios. Decades of learning in clinical practice and physiology associated with technological development led to a great variety of ECLS technologies available. Thoracic surgery procedures with difficult or impossible single lung ventilation may still be performed using different ECLS modalities. The aim of this review is to describe the use of ECLS, with its different modalities, as a solution to perform complex surgeries in a patient with difficult or impossible single lung ventilation.

Methods

A literature review was conducted using the terms "extracorporeal life support pulmonary resection" and "extracorporeal life support thoracic surgery", and articles were selected according to defined criteria.

Key Content and Findings

To support lung function during thoracic surgery, the most efficient and popular variety of ECLS is venovenous extracorporeal membrane oxygenation. Lung resection on a single lung after pneumonectomy, surgery in a patient with severe hypercapnia and/or low respiratory reserve, carinal and airway surgery, and severe thoracic trauma are the main examples of situations where ECLS may be the solution to provide a safe surgical environment in patients who cannot tolerate single lung ventilation. Multidisciplinarity, selection of patients and careful surgical planning are cornerstones in defining the situations that may benefit from ECLS support.

Conclusions

Knowledge on techniques of ECLS are essential for every thoracic surgeon. Although rarely used, these techniques of cardiorespiratory support should be considered when planning complex cases with difficulties in ventilation and emergent situations.

Early Use of Extracorporeal Membrane Oxygenation for Traumatically Injured Patients: A National Trauma Database Analysis

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) in acute trauma patients is a poorly characterized event. While ECMO most commonly has been deployed for advanced cardiopulmonary or respiratory failure following initial resuscitation, growing levels of evidence for out of hospital cardiac arrest support early ECMO cannulation as part of resuscitative efforts. We sought to perform a descriptive analysis evaluating traumatically injured patients, who were placed on ECMO, during their initial resuscitation period.

METHODS

We performed a retrospective analysis of the Trauma Quality Improvement Program Database from 2017 to 2019. All traumatically injured patients who received ECMO within the first 24 hours of their hospitalization were assessed. Descriptive statistics were used to define patient characteristics and injury patterns associated with the need for ECMO, while mortality represented the primary outcome evaluated.

RESULTS

A total of 696 trauma patients received ECMO during their hospitalization, of which 221 were placed on ECMO within the first 24 hours. Early ECMO patients were on average 32.5 years old, 86% male, and sustained a penetrating injury 9% of the time. The average ISS was 30.7, and the overall mortality rate was 41.2%. Prehospital cardiac arrest was noted in 18.2% of the patient population resulting in a 46.8% mortality. Of those who underwent resuscitative thoracotomy, a 53.3% mortality rate was present.

CONCLUSION

Early cannulation for ECMO in severely injured patients may provide an opportunity for rescue therapy following severe injury patterns. Further evaluation regarding the safety profile, cannulation strategies, and optimal injury patterns for these techniques should be evaluated.

Outcome of post-traumatic acute respiratory distress syndrome in young patients requiring extracorporeal membrane oxygenation (ECMO)

We aimed to evaluate the outcomes of post-traumatic acute respiratory distress syndrome (ARDS) in young patients with and without Extracorporeal membrane oxygenation (ECMO) support. A retrospective analysis was conducted for trauma patients who developed ARDS at a level I trauma facility between 2014 and 2020. Data were analyzed and compared between ECMO and non-ECMO group. We identified 85 patients with ARDS (22 patients had ECMO support and 63 matched patients managed by the conventional mechanical ventilation; 1:3 matching ratio). The two groups were comparable for age, sex, injury severity score, abbreviated injury score, shock index, SOFA score, and head injury. Kaplan Meier survival analysis showed that the survival in the ECMO group was initially close to that of the non-ECMO, however, during follow-up, the survival rate was better in the ECMO group, but did not reach statistical significance (Log-rank, p = 0.43 and Tarone-Ware, p = 0.37). Multivariable logistic regression analysis showed that acute kidney injury (AKI) (Odds ratio 13.03; 95% CI 3.17–53.54) and brain edema (Odds ratio 4.80; 95% CI 1.10–21.03) were independent predictors of mortality. Sub-analysis showed that in patients with severe Murray Lung Injury (MLI) scores, non-ECMO group had higher mortality than the ECMO group (100% vs 36.8%, p = 0.004). Although ARDS is uncommon in young trauma patients, it has a high mortality. ECMO therapy was used in a quarter of ARDS cases. AKI and brain edema were the predictors of mortality among ARDS patients. ECMO use did not worsen the outcome in trauma patients; however, the survival was better in those who had severe MLI and ECMO support. Further prospective study is needed to define the appropriate selection criteria for the use of ECMO to optimize the outcomes in trauma patients.

Extracorporeal Membrane Oxygenation May Improve Outcomes After Resuscitative Thoracotomy: A National Trauma Data Bank Analysis

BACKGROUND

Albeit low survival rates, resuscitative thoracotomy (RT) is considered standard for selected trauma patients. Because it has potential for rapid cardiopulmonary rescue, extracorporeal membrane oxygenation (ECMO) may augment RT. The aim of this study was to identify the impact of ECMO on trauma patients that recently underwent RT after injury.

STUDY DESIGN

All patients who underwent RT were identified from the National Trauma Data Bank (2007-2017). Patients were excluded if they died within 60 minutes, underwent delayed ECMO, and/or had missing data. Delayed ECMO group was defined as those patients undergoing ECMO after 1 hour following RT.

RESULTS

Out of 8 694 272 injured patients, 10 106 (.1%) underwent RT. Median age was 31 years [23-45], 86% male. Penetrating injury was the dominant mechanism (62%). Of these, .6% (23) underwent immediate ECMO. Extracorporeal membrane oxygenation patients were significantly younger (23[17-33] vs. 31[23-46], p .003) and had significantly higher chest abbreviated injury scale scores (5[4-5] vs. 3[3-4], P < .001). Extracorporeal membrane oxygenation patients achieved significantly higher rate of return of spontaneous circulation (96% vs. 70%, p .007) and had nonsignificant trend of improved mortality (52% vs. 63%, p .260).

CONCLUSION

Immediate ECMO may be a useful therapeutic modality after RT. It achieves higher ROSC rates with opportunity for improved survival. Future prospective study is warranted.

Extracorporeal Life Support (ECLS): A Review and Focus on Considerations for COVID-19

ABSTRACT

Extracorporeal life support (ECLS) is a support modality for patients with severe acute respiratory distress syndrome (ARDS) who have failed conventional treatments including low tidal volume ventilation, prone positioning, and neuromuscular blockade. In addition, ECLS can be used for hemodynamic support for patients with cardiogenic shock or following cardiac arrest. Injured patients may also require ECLS support for ARDS and other indications. We review the use of ECLS for ARDS patients, trauma patients, cardiogenic shock patients, and post-cardiac arrest patients. We then describe how these principles are applied in the management of the novel coronavirus disease 2019 pandemic. Indications, predictors, procedural considerations, and post-cannulation management strategies are discussed.

Extracorporeal Membrane Oxygenation Utilization in Blunt and Penetrating Traumatic Injuries: A Systematic Review

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has become an increasingly used treatment modality for severe respiratory insufficiency in trauma patients. Examining ECMO use specifically in blunt and penetrating traumas can aid in directing future protocols. We aim to evaluate the outcomes of ECMO use in both blunt and penetrating trauma patients through a systematic review of current literature.

METHODS

An online search of 2 databases (PubMed and Google Scholar) was performed to analyze studies, which evaluated the use of ECMO in blunt and penetrating traumas. Preferred Reporting Items for Systematic Reviews and Meta-Analysis and Grading of Recommendations Assessment, Development and Evaluation guidelines were followed. Data extracted included mechanism of injury, injury severity scores (ISSs), complications, and mortality rates.

RESULTS

The search demonstrated 9 studies that met our review inclusion criteria. A total of 207 patients were included, of which 64 (30.9%) were non-survivors and 143 (69.1%) were survivors. There was a total of 201 blunt traumas with 61 (30.3%) deaths, whereas penetrating traumas had 2 deaths (33.3%) out of 6 total patients. Complications reported included acute renal failure, hemorrhage at the cannula site, and transient neurological deficits. Most studies found better survival rates and less complications in younger patients and those with lower ISS.

CONCLUSION

Expanding the use of ECMO to include blunt and penetrating trauma patients provides the trauma surgeons with another crucial potentially lifesaving tool with an overall survival rate of 70%. Anticipating increased future use of ECMO in blunt and penetrating trauma patients, distinct protocols ought to be instilled to better address the care needed for these critically ill trauma patients.

Extracorporeal membrane oxygenation in trauma patients: a systematic review

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has evolved considerably over the past two decades and has been gradually utilized in severe trauma. However, the indications for the use of ECMO in trauma remain uncertain and the clinical outcomes are different. We performed a systematic review to provide an overall estimate of the current performance of ECMO in the treatment of trauma patients.

MATERIALS AND METHODS

We searched PubMed and MEDLINE databases up to the end of December 2019 for studies on ECMO in trauma. The PRISMA statement was followed. Data on demographics of the patient, mechanism of injury, injury severity scores (ISS), details of ECMO strategies, and clinical outcome were extracted.

RESULTS

A total of 58 articles (19 retrospective reports and 39 case reports) were deemed eligible and included. In total, 548 patients received ECMO treatment for severe trauma (adult 517; children 31; mean age of adults 34.9 ± 12.3 years). Blunt trauma (85.4%) was the primary injury mechanism, and 128 patients had traumatic brain injury (TBI). The mean ISS was 38.1 ± 15.0. A total of 71.3% of patients were initially treated with VV ECMO, and 24.5% were placed on VA ECMO. The median time on ECMO was 9.6 days, and the median time to ECMO was 5.7 days. A total of 60% of patients received initially heparin anticoagulation. Bleeding (22.9%) and thrombosis (19%) were the most common complications. Ischemia of the lower extremities occurred in 9 patients. The overall hospital mortality was 30.3%.

CONCLUSIONS

ECMO has been gradually utilized in a lifesaving capacity in severe trauma patients, and the feasibility and advantages of this technique are becoming widely accepted. The safety and effectiveness of ECMO in trauma require further study. Several problems with ECMO in trauma, including the role of VA-ECMO, the time to institute ECMO, and the anticoagulation strategy remain controversial and must be solved in future studies.