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Austin SE, Galvagno SM, Podell JE, Teeter WA, Kundi R, Haase DJ, Taylor BS, Betzold R, Stein DM, Scalea TM, Powell EK. Venovenous extracorporeal membrane oxygenation in patients with traumatic brain injuries and severe respiratory failure: A single-center retrospective analysis. J Trauma Acute Care Surg 2024; 96:332-339. [PMID: 37828680 DOI: 10.1097/ta.0000000000004159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
BACKGROUND Venovenous extracorporeal membrane oxygenation (VV ECMO) can support trauma patients with severe respiratory failure. Use in traumatic brain injury (TBI) may raise concerns of worsening complications from intracranial bleeding. However, VV ECMO can rapidly correct hypoxemia and hypercarbia, possibly preventing secondary brain injury. We hypothesize that adult trauma patients with TBI on VV ECMO have comparable survival with trauma patients without TBI. METHODS A single-center, retrospective cohort study involving review of electronic medical records of trauma admissions between July 1, 2014, and August 30, 2022, with discharge diagnosis of TBI who were placed on VV ECMO during their hospital course was performed. RESULTS Seventy-five trauma patients were treated with VV ECMO; 36 (48%) had TBI. Of those with TBI, 19 (53%) had a hemorrhagic component. Survival was similar between patients with and without a TBI (72% vs. 64%, p = 0.45). Traumatic brain injury survivors had a higher admission Glasgow Coma Scale (7 vs. 3, p < 0.001) than nonsurvivors. Evaluation of prognostic scoring systems on initial head computed tomography demonstrated that TBI VV ECMO survivors were more likely to have a Rotterdam score of 2 (62% vs. 20%, p = 0.03) and no survivors had a Marshall score of ≥4. Twenty-nine patients (81%) had a repeat head computed tomography on VV ECMO with one incidence of expanding hematoma and one new focus of bleeding. Neither patient with a new/worsening bleed received anticoagulation. Survivors demonstrated favorable neurologic outcomes at discharge and outpatient follow-up, based on their mean Rancho Los Amigos Scale (6.5; SD, 1.2), median Cerebral Performance Category (2; interquartile range, 1-2), and median Glasgow Outcome Scale-Extended (7.5; interquartile range, 7-8). CONCLUSION In this series, the majority of TBI patients survived and had good neurologic outcomes despite a low admission Glasgow Coma Scale. Venovenous extracorporeal membrane oxygenation may minimize secondary brain injury and may be considered in select patients with TBI. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level IV.
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Affiliation(s)
- Samuel E Austin
- From the Program in Trauma (S.E.A., W.A.T., R.K., D.J.H., D.M.S., T.M.S., E.K.P.), R Adams Cowley Shock Trauma Center, Department of Surgery (S.E.A., R.K., D.J.H., D.M.S., T.M.S.), Department of Anesthesiology (S.M.G.), Neurocritical Care (J.E.P.), Program in Trauma, Department of Neurology, Department of Emergency Medicine (W.A.T., D.J.H., E.K.P.), and Department of Surgery (B.S.T.), Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland; and Department of Trauma and Acute Care Surgery (R.B.), University of Alabama at Birmingham, Birmingham, Alabama
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Saxena A, Curran J, Ahmad D, Nasher N, Miyamoto T, Brailovsky E, Shah MK, Rajapreyar IN, Rame JE, Loforte A, Entwistle JW, Massey HT, Tchantchaleishvili V. Utilization and outcomes of V-AV ECMO: A systematic review and meta-analysis. Artif Organs 2023; 47:1559-1566. [PMID: 37537953 DOI: 10.1111/aor.14610] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/19/2023] [Accepted: 06/30/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Veno-arterial-venous extracorporeal membrane oxygenation (V-AV ECMO) is a less commonly used configuration of ECMO. We sought to understand the indications, utilization patterns, and outcomes of V-AV ECMO by quantitatively pooling the existing evidence from the literature. METHODS Electronic search was performed to identify all relevant studies reporting V-AV ECMO usage. Five studies comprising 77 patients were selected and cohort-level data were extracted for further analysis. RESULTS Mean patient age was 61 (95% CI: 55.2, 66.5) years and 30% (23/77) were female. The majority of cases [91% (70/77)] were transitioned to V-AV ECMO from another pre-existing ECMO configuration: V-A ECMO in 55% (42/77) vs. V-V ECMO in 36% (28/77), p = 0.04. Only 9% (7/77) of cases were directly placed on V-AV ECMO. The mean duration of hospital stay was 42.3 (95% CI: 10.5, 74.2) days, while ICU mortality was 46% (29, 64). Transition to durable left ventricular assist device was performed in 3% (2/64) of patients, while 3% (2/64) underwent heart transplantation. V-AV ECMO was successfully weaned to explantation in 33% (21/64) of patients. CONCLUSION V-AV ECMO is a viable option for optimizing cardiopulmonary support in selected patients. Survival to weaning or bridging therapy appears comparable to more common ECMO configurations.
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Affiliation(s)
- Abhiraj Saxena
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - John Curran
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Danial Ahmad
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nayeem Nasher
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Takuma Miyamoto
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Eugene Brailovsky
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Mahek K Shah
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Indranee N Rajapreyar
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - J Eduardo Rame
- Division of Cardiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Antonio Loforte
- Dipartimento Cardio-Toraco-Vascolare, UOC di Cardiochirurgia, Policlinico di S. Orsola, Università di Bologna, Bologna, Italy
| | - John W Entwistle
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - H Todd Massey
- Division of Cardiac Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Erlebach R, Wild LC, Seeliger B, Rath AK, Andermatt R, Hofmaenner DA, Schewe JC, Ganter CC, Müller M, Putensen C, Natanov R, Kühn C, Bauersachs J, Welte T, Hoeper MM, Wendel-Garcia PD, David S, Bode C, Stahl K. Outcomes of patients with acute respiratory failure on veno-venous extracorporeal membrane oxygenation requiring additional circulatory support by veno-venoarterial extracorporeal membrane oxygenation. Front Med (Lausanne) 2022; 9:1000084. [PMID: 36213640 PMCID: PMC9539450 DOI: 10.3389/fmed.2022.1000084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 09/05/2022] [Indexed: 12/05/2022] Open
Abstract
Objective Veno-venous (V-V) extracorporeal membrane oxygenation (ECMO) is increasingly used to support patients with severe acute respiratory distress syndrome (ARDS). In case of additional cardio-circulatory failure, some experienced centers upgrade the V-V ECMO with an additional arterial return cannula (termed V-VA ECMO). Here we analyzed short- and long-term outcome together with potential predictors of mortality. Design Multicenter, retrospective analysis between January 2008 and September 2021. Setting Three tertiary care ECMO centers in Germany (Hannover, Bonn) and Switzerland (Zurich). Patients Seventy-three V-V ECMO patients with ARDS and additional acute cardio-circulatory deterioration required an upgrade to V-VA ECMO were included in this study. Measurements and main results Fifty-three patients required an upgrade from V-V to V-VA and 20 patients were directly triple cannulated. Median (Interquartile Range) age was 49 (28–57) years and SOFA score was 14 (12–17) at V-VA ECMO upgrade. Vasoactive-inotropic score decreased from 53 (12–123) at V-VA ECMO upgrade to 9 (3–37) after 24 h of V-VA ECMO support. Weaning from V-VA and V-V ECMO was successful in 47 (64%) and 40 (55%) patients, respectively. Duration of ECMO support was 12 (6–22) days and ICU length of stay was 32 (16–46) days. Overall ICU mortality was 48% and hospital mortality 51%. Two additional patients died after hospital discharge while the remaining patients survived up to two years (with six patients being lost to follow-up). The vast majority of patients was free from higher degree persistent organ dysfunction at follow-up. A SOFA score > 14 and higher lactate concentrations at the day of V-VA upgrade were independent predictors of mortality in the multivariate regression analysis. Conclusion In this analysis, the use of V-VA ECMO in patients with ARDS and concomitant cardiocirculatory failure was associated with a hospital survival of about 50%, and most of these patients survived up to 2 years. A SOFA score > 14 and elevated lactate levels at the day of V-VA upgrade predict unfavorable outcome.
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Affiliation(s)
- Rolf Erlebach
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Lennart C. Wild
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Benjamin Seeliger
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hanover, Germany
| | - Ann-Kathrin Rath
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hanover, Germany
| | - Rea Andermatt
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Daniel A. Hofmaenner
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Jens-Christian Schewe
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christoph C. Ganter
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Mattia Müller
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Christian Putensen
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Ruslan Natanov
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hanover, Germany
| | - Christian Kühn
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hanover, Germany
- German Research Foundation (DFG), Clinical Research Group (KFO 311): “(Pre)terminal Heart and Lung Failure: Unloading and Repair”, Germany
| | - Johann Bauersachs
- German Research Foundation (DFG), Clinical Research Group (KFO 311): “(Pre)terminal Heart and Lung Failure: Unloading and Repair”, Germany
- Department of Cardiology and Angiology, Hannover Medical School, Hanover, Germany
| | - Tobias Welte
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hanover, Germany
- German Research Foundation (DFG), Clinical Research Group (KFO 311): “(Pre)terminal Heart and Lung Failure: Unloading and Repair”, Germany
| | - Marius M. Hoeper
- Department of Respiratory Medicine and German Centre of Lung Research (DZL), Hannover Medical School, Hanover, Germany
- German Research Foundation (DFG), Clinical Research Group (KFO 311): “(Pre)terminal Heart and Lung Failure: Unloading and Repair”, Germany
| | | | - Sascha David
- Institute of Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
- *Correspondence: Sascha David,
| | - Christian Bode
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Klaus Stahl
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hanover, Germany
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Lee GJ, Kim MJ, Lee JG, Lee SH. Use of venovenous extracorporeal membrane oxygenation in trauma patients with severe adult respiratory distress syndrome: A retrospective study. Int J Artif Organs 2022; 45:833-840. [PMID: 35918871 DOI: 10.1177/03913988221116649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECMO) has increased, although its survival benefit in trauma patients with severe adult respiratory distress syndrome (ARDS) remains controversial. We investigated the effect of veno-venous (VV)-ECMO on the clinical outcomes of trauma patients with severe ARDS. METHODS This was a retrospective study at a single center comprising trauma patients admitted between January 2013 and December 2017, diagnosed with severe ARDS using the Berlin definition (PaO2/FiO2 ratio ⩽100), in the 7 days following trauma. Patients were managed with VV-ECMO or conventional mechanical ventilation (CMV). The primary outcome was in-hospital mortality (mortality at 60 days); secondary outcomes comprised 28-day mortality, hospital length of stay (LOS), intensive care unit (ICU) LOS, ICU-free days, duration of mechanical ventilation (MV), and MV-free days. Propensity score matching was performed to adjust for the baseline differences. RESULTS Sixteen patients (22.5%) were managed with VV-ECMO and 55 were managed with CMV. After matching, the in-hospital mortality rate (43.8% vs 53.1%; p = 0.760), 28-day mortality rate (37.5% vs 31.3%; p = 0.750), median hospital LOS (39.5 vs 36.5 days; p = 0.533), ICU-free days (0 vs 0 days; p = 0.241), and MV-free days (0 vs 0 days; p = 0.272) did not significantly differ between the VV-ECMO and CMV groups. CONCLUSION In-hospital mortality (mortality at 60 days) did not differ significantly between the VV-ECMO and CMV groups. Although the safety of ECMO in trauma patients requires further investigation, VV-ECMO may be considered as a rescue therapy.
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Affiliation(s)
- Gil Jae Lee
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Republic of Korea.,Department of Traumatology, Gachon University College of Medicine, Incheon, Republic of Korea
| | - Myung Jun Kim
- Department of Surgery, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Jae Gil Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Hwan Lee
- Department of Trauma Surgery, Gachon University Gil Medical Center, Incheon, Republic of Korea
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Kim SH, Huh U, Song S, Kim MS, Wang IJ, Tak YJ. Outcomes in trauma patients undergoing veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome. Perfusion 2022:2676591221093880. [PMID: 35678471 DOI: 10.1177/02676591221093880] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The use of veno-venous extracorporeal membrane oxygenation (VV ECMO) remains controversial in trauma patients with acute respiratory distress syndrome (ARDS). Here, we aimed to investigate the therapeutic benefits of VV ECMO and the factors affecting patient outcomes. METHODS From 2017 to 2019, 21/1938 trauma patients (median age: 47 years; 18 men) at a level I trauma center received VV ECMO for post-traumatic ARDS. Demographic, injury-specific, ECMO, and outcome data were prospectively collected and retrospectively reviewed to analyze the factors affecting hospital mortality and ECMO results. RESULTS 19 patients (90.5%) were successfully weaned off ECMO; 16 patients (76.2%) survived to discharge. In univariate analysis, there was a significant difference in survival between the groups with a Trauma and Injury Severity Score (TRISS) ⩾0.5 and TRISS <0.5 (p = 0.05). The area under the receiver operating characteristic curve (AUC) for both TRISS and Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) scores for death was 0.78. In those who failed ECMO weaning, the AUCs of the TRISS and RESP scores were 0.90 and 0.80, respectively. CONCLUSIONS In patients with ARDS caused by severe trauma and supported by VV ECMO, survival is associated with TRISS; TRISS and RESP scores may be predictive of mortality and failure in ECMO weaning.
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Affiliation(s)
- Seon Hee Kim
- Departments of Trauma Surgery, Pusan National University School of Medicine, Biomedical Research Institute, Pusan National University Hospital Trauma Center, Republic of Korea
| | - Up Huh
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Biomedical Research Institute, Pusan National University Hospital, Republic of Korea
| | - Seunghwan Song
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Biomedical Research Institute, Pusan National University Hospital, Republic of Korea
| | - Min Su Kim
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine, Biomedical Research Institute, Pusan National University Hospital, Republic of Korea
| | - Il Jae Wang
- Department of Emergency Medicine, Pusan National University School of Medicine, Biomedical Research Institute, Pusan National University Hospital, Republic of Korea
| | - Young Jin Tak
- Department of Family Medicine, Pusan National University School of Medicine, Biomedical Research Institute, Pusan National University Hospital, Republic of Korea
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Willers A, Swol J, Kowalewski M, Raffa GM, Meani P, Jiritano F, Matteucci M, Fina D, Heuts S, Bidar E, Natour E, Sels JW, Delnoij T, Lorusso R. Extracorporeal Life Support in Hemorrhagic Conditions: A Systematic Review. ASAIO J 2021; 67:476-484. [PMID: 32657828 DOI: 10.1097/mat.0000000000001216] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Extracorporeal life support (ECLS) is indicated in refractory acute respiratory or cardiac failure. According to the need for anticoagulation, bleeding conditions (e.g., in trauma, pulmonary bleeding) have been considered a contraindication for the use of ECLS. However, there is increasing evidence for improved outcomes after ECLS support in hemorrhagic patients based on the benefits of hemodynamic support outweighing the increased risk of bleeding. We conducted a systematic literature search according to the PRISMA guidelines and reviewed publications describing ECLS support in hemorrhagic conditions. Seventy-four case reports, four case series, seven retrospective database observational studies, and one preliminary result of an ongoing study were reviewed. In total, 181 patients were identified in total of 86 manuscripts. The reports included patients suffering from bleeding caused by pulmonary hemorrhage (n = 53), trauma (n = 96), postpulmonary endarterectomy (n = 13), tracheal bleeding (n = 1), postpartum or cesarean delivery (n = 11), and intracranial hemorrhage (n = 7). Lower targeted titration of heparin infusion, heparin-free ECLS until coagulation is normalized, clamping of the endotracheal tube, and other ad hoc possibilities represent potential beneficial maneuvers in such conditions. Once the patient is cannulated and circulation restored, bleeding control surgery is performed for stabilization if indicated. The use of ECLS for temporary circulatory or respiratory support in critical patients with refractory hemorrhagic shock appears feasible considering tailored ECMO management strategies. Further investigation is needed to better elucidate the patient selection and ECLS management approaches.
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Affiliation(s)
- Anne Willers
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Justyna Swol
- Department of Pulmonology, Intensive Care Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Mariusz Kowalewski
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapie ad alta specializzazione), Palermo, Italy
| | - Paolo Meani
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Federica Jiritano
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Matteo Matteucci
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Dario Fina
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Samuel Heuts
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Elham Bidar
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Ehsan Natour
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jan Willem Sels
- Cardiology Department, Maastricht University Medical Centre (MUMC), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Intensive Care Department, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Thijs Delnoij
- Cardiology Department, Maastricht University Medical Centre (MUMC), P. Debyelaan 25, 6229 HX, Maastricht, The Netherlands
- Intensive Care Department, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Roberto Lorusso
- From the ECLS Centrum, Cardio-Thoracic Surgery Department, and Cardiology Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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The Effect of Additional Stepwise Venous Inflow on Differential Hypoxia of Veno-Arterial Extracorporeal Membrane Oxygenation. ASAIO J 2021; 66:803-808. [PMID: 31425264 PMCID: PMC7316147 DOI: 10.1097/mat.0000000000001052] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Use of femoral-femoral veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) for cardiopulmonary support during lung transplantation can be inadequate for efficient distribution of oxygenated blood into the coronary circulation. We hypothesized that creating a left-to-right shunt flow using veno-arterio-venous (VAV) ECMO would alleviate the differential hypoxia. Total 10 patients undergoing lung transplantation were enrolled in this study. An additional inflow cannula was inserted into the right internal jugular (RIJ) vein for VAV ECMO. During left one-lung ventilation using a 1.0 inspired oxygen fraction (FiO2), the left-to-right shunt flow was incrementally increased from 0 to 500, 1,000, and 1,500 ml/min. The arterial oxygen partial pressure (PaO2) and oxygen saturation (SaO2) were measured at the proximal ascending aorta and right radial artery. The ascending aorta gas analysis revealed that six patients had a PaO2/FiO2 ratio less than 200 mm Hg at a 0 ml/min shunt flow. The PaO2 (SaO2) values were 48.5 ± 14.8 mm Hg (80.9 ± 11.6%) at the ascending aorta and 77.8 ± 69.7 mm Hg (83.3 ± 13.2%) at the right radial artery. As the left-to-right shunt flow rate increased over 1,000 ml/min, the PaO2 and SaO2 values for the ascending aorta and right radial artery significantly increased. In conclusion, femoral-femoral VA ECMO can produce suboptimal coronary oxygenation in patients unable to tolerate one-lung ventilation. A left-to-right shunt using VAV ECMO can alleviate the differential hypoxia.
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A combined management with vv-ECMO and independent lung ventilation for asymmetric chest trauma. Gen Thorac Cardiovasc Surg 2021; 69:902-905. [PMID: 33439375 DOI: 10.1007/s11748-021-01587-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 01/03/2021] [Indexed: 10/22/2022]
Abstract
Association of independent lung ventilation (ILV) and veno-venous extracorporeal membrane oxygenation (vv-ECMO) may be life-saving therapy in cases of refractory hypoxemia. We report the case of a trauma patient affected by asymmetric hypoxemic lung contusions and massive air leak managed by association of ILV and vv-ECMO. This combined strategy allowed us first to restore physiologic conditions and later to achieve safe thoracic surgery with reduced resection of pulmonary parenchyma. This case highlights the success of a new damage control strategy in extreme cases of persistent air leak with refractory hypoxemia allowing initial vital rescue and a more conservative treatment.
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Weidemann F, Decker S, Epping J, Örgel M, Krettek C, Kühn C, Wilhelmi M. Analysis of extracorporeal membrane oxygenation in trauma patients with acute respiratory distress syndrome: A case series. Int J Artif Organs 2021; 45:81-88. [PMID: 33438507 DOI: 10.1177/0391398820980736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Thoracic trauma is the most common injury in polytrauma patients. Often associated with the development of an acute respiratory distress syndrome (ARDS), conservative treatment options are very restricted and reach their limits quickly. OBJECTIVE Extracorporeal membrane oxygenation (ECMO) is a wellestablished therapy in cardio-thoracic surgery and internal medicine intensive care units. The purpose of this study is to analyse the potential benefit of ECMO therapy in ARDS treatment in polytrauma patients. DESIGN Retrospective case series. SETTING Level 1 trauma centre, Germany, 04/2011-04/2019. PATIENTS Nineteen patients with ARDS treated with a veno-venous ECMO system. MAIN OUTCOME MEASURES This study focused on the time leading to therapy initiation, the severity of thoracic and overall injury. The Sequential Organ Failure Assessment (SOFA) Score, the Murray Score, the Abbreviated Injury Scale (AIS) 2005 level and the Injury Severity Score (ISS) were analysed. The results were analysed regarding survival and death. RESULTS The survival rate was 53%. The ISS was the same for survivors and deceased patients (p = 0.604). Early initiation of ECMO therapy showed a significant trend for survivors (p = 0.071). The SOFA Score level before ECMO therapy was significantly lower in the survivors than in those who died (p = 0.035). The AISThorax level for survivors showed a significantly higher score level than the one for deceased patients (p = 0.05). CONCLUSION ECMO therapy in polytrauma patients is a safe and effective option, in particular when used early in ARDS treatment. The overall severity of organ failure determined the likelihood of survival rather than the thoracic trauma itself.
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Affiliation(s)
| | | | - Jelena Epping
- Medical Sociology Unit, Hannover Medical School, Hannover, Germany
| | - Marcus Örgel
- Trauma Department, Hannover Medical School, Hannover, Germany
| | | | - Christian Kühn
- Department of Cardiothoracic-, Transplant-, and Vascular Surgery, Hannover Medical School, Hannover, Germany
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10
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Ricciardi G, Putman LM, Hazekamp MG. Repair of traumatic avulsion of the right bronchus in children using extracorporeal membrane oxygenation support. Interact Cardiovasc Thorac Surg 2020; 32:834-836. [PMID: 33367800 DOI: 10.1093/icvts/ivaa327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 11/19/2020] [Accepted: 11/28/2020] [Indexed: 11/14/2022] Open
Abstract
Traumatic avulsion of the right main bronchus in children is usually caused by blunt trauma or traffic accidents. Primary repair by suturing is the preferred treatment. Lesions are life threatening and urgent or emergency surgical repair is indicated. We report our experience with 2 cases of traumatic avulsion of right bronchus in children successfully suture repaired with the use of extracorporeal membrane oxygenation.
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Affiliation(s)
- Gabriella Ricciardi
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Léon M Putman
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Mark G Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
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Parker BM, Menaker J, Berry CD, Tesoreiero RB, O'Connor JV, Stein DM, Scalea TM. Single Center Experience With Veno-Venous Extracorporeal Membrane Oxygenation in Patients With Traumatic Brain Injury. Am Surg 2020; 87:949-953. [PMID: 33295187 DOI: 10.1177/0003134820956360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
METHODS We retrospectively reviewed TBI patients ≥ 18 years of age treated with VV-ECMO. The primary outcome was survival to discharge. Secondary outcomes included progression of intracranial hemorrhage, bleeding complications, and episodes of oxygenator thrombosis requiring exchange. Medians and interquartile ranges were reported where appropriate. RESULTS 13 TBI patients received VV-ECMO support during the study period. The median age was 28 years (Interquartile range (IQR) 25-37.5) and 85% were men. Median admission Glasgow coma scale was 5 (IQR 3-13.5). Median injury severity score (ISS) was 48 (IQR 33.5-66). Median pre-ECMO PaO2:FiO2 ratio was 58 (IQR 47-74.5). Five (38.4%) patients survived to discharge. Six patients (46%) received systemic A/C while on ECMO. No patient had worsening of intracranial hemorrhage on computed tomography imaging. There were two bleeding complications in patients on A/C, neither was related to TBI. Four patients required an oxygenator change; 2 in patients on A/C. CONCLUSION VV-ECMO appears safe with TBI. We have demonstrated that A/C can be withheld without increased complications. Traumatic brain injury should not be considered an absolute contraindication to the use of VV-ECMO for severe respiratory failure and should be decided on a case by case basis. Additional research is needed to confirm these preliminary findings.
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Affiliation(s)
- Brandon M Parker
- Department of Surgery, University of Miami, Miller School of Medicine, Miami, FL, USA
| | - Jay Menaker
- Department of Surgery, School of Medicine, University of Maryland Baltimore, MD, USA
| | - Cherisse D Berry
- Department of Surgery, School of Medicine, New York University, New York, NY, USA
| | | | - James V O'Connor
- Department of Surgery, School of Medicine, University of Maryland Baltimore, MD, USA
| | - Deborah M Stein
- Department of Surgery, Univeristy of California, San Francisco, CA, USA
| | - Thomas M Scalea
- Department of Surgery, School of Medicine, University of Maryland Baltimore, MD, USA
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12
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Zhang BY, Chen XC, You Y, Chen M, Yu WK. Massive pulmonary haemorrhage due to severe trauma treated with repeated alveolar lavage combined with extracorporeal membrane oxygenation: A case report. World J Clin Cases 2020; 8:4245-4251. [PMID: 33024785 PMCID: PMC7520764 DOI: 10.12998/wjcc.v8.i18.4245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/31/2020] [Accepted: 08/14/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Massive pulmonary haemorrhage can spoil the entire lung and block the airway in a short period of time due to severe bleeding, which quickly leads to death. Alveolar lavage is an effective method for haemostasis and airway maintenance. However, patients often cannot tolerate alveolar lavage due to severe hypoxia. We used extracorporeal membrane oxygenation (ECMO) to overcome this limitation in a patient with massive pulmonary haemorrhage due to severe trauma and succeeded in saving the life by repeated alveolar lavage.
CASE SUMMARY A 22-year-old man sustained multiple injuries in a motor vehicle accident and was transferred to our emergency department. On admission, he had a slight cough and a small amount of bloody sputum; computed tomography revealed multiple fractures and mild pulmonary contusion. At 37 h after admission, he developed severe chest tightness, chest pain, dizziness and haemoptysis. His oxygen saturation was 68%. Emergency endotracheal intubation was performed, and a large amount of bloody sputum was suctioned. After transfer to the intensive care unit, he developed refractory hypoxemia and heparin-free venovenous ECMO was initiated. Fibreoptic bronchoscopy revealed diffuse and profuse blood in all bronchopulmonary segment. Bleeding was observed in the trachea and right bronchus, and repeated alveolar lavage was performed. On day 3, the patient’s haemoptysis ceased, and ECMO support was terminated 10 d later. Tracheostomy was performed on day 15, and the patient was weaned from the ventilator on day 21.
CONCLUSION Alveolar lavage combined with ECMO can control bleeding in trauma-induced massive pulmonary haemorrhage, is safe and can be performed bedside.
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Affiliation(s)
- Bei-Yuan Zhang
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
| | - Xian-Cheng Chen
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
| | - Yong You
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
| | - Ming Chen
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
| | - Wen-Kui Yu
- Department of Critical Care Medicine, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210008, Jiangsu Province, China
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13
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Wang C, Zhang L, Qin T, Xi Z, Sun L, Wu H, Li D. Extracorporeal membrane oxygenation in trauma patients: a systematic review. World J Emerg Surg 2020; 15:51. [PMID: 32912280 PMCID: PMC7488245 DOI: 10.1186/s13017-020-00331-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 08/23/2020] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Changtian Wang
- Department of Cardiovascular Surgery, School Medicine, Jinling Hospital, Nanjing University, Nanjing, People's Republic of China.
| | - Lei Zhang
- Department of Cardiovascular Surgery, School Medicine, Jinling Hospital, Nanjing University, Nanjing, People's Republic of China
| | - Tao Qin
- Department of Cardiovascular Surgery, School Medicine, Jinling Hospital, Nanjing University, Nanjing, People's Republic of China
| | - Zhilong Xi
- Department of Cardiovascular Surgery, School Medicine, Jinling Hospital, Nanjing University, Nanjing, People's Republic of China
| | - Lei Sun
- Department of Cardiovascular Surgery, School Medicine, Jinling Hospital, Nanjing University, Nanjing, People's Republic of China
| | - Haiwei Wu
- Department of Cardiovascular Surgery, School Medicine, Jinling Hospital, Nanjing University, Nanjing, People's Republic of China
| | - Demin Li
- Department of Cardiovascular Surgery, School Medicine, Jinling Hospital, Nanjing University, Nanjing, People's Republic of China
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14
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Kim SH, Sul YH, Lee JY, Ye JB, Lee JS, Yoon SY, Kim JS. Veno-Veno Extracorporeal Membrane Oxygenation in Post-Traumatic Acute Lung Injury. JOURNAL OF ACUTE CARE SURGERY 2020. [DOI: 10.17479/jacs.2020.10.2.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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15
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Lee HK, Kim HS, Ha SO, Park S, Lee HS, Lee SK, Lee SH. Clinical outcomes of extracorporeal membrane oxygenation in acute traumatic lung injury: a retrospective study. Scand J Trauma Resusc Emerg Med 2020; 28:41. [PMID: 32448260 PMCID: PMC7245644 DOI: 10.1186/s13049-020-00733-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 04/29/2020] [Indexed: 12/21/2022] Open
Abstract
Background Therapeutic extracorporeal membrane oxygenation (ECMO) is a challenging procedure in patients who have experienced severe trauma. Particularly, patients with traumatic lung injury and posttraumatic acute respiratory distress syndrome (ARDS) have a high risk of bleeding during this procedure. This study aimed to determine the safety and feasibility of ECMO in patients with traumatic ARDS. Methods We retrospectively reviewed medical records and investigated the clinical outcomes of ECMO in 42 patients with traumatic ARDS, among whom near-drowning (42.9%) was the most frequent cause of injury. Results Thirty-four of 42 patients (81%) survived and were discharged after a median hospital stay of 23 days. A multivariate analysis identified a lactate level (odds ratio: 1.493, 95% confidence interval: 1.060–2.103, P = 0.022) and veno-venous (VV) ECMO (odds ratio: 0.075, 95% confidence interval: 0.006–0.901, P = 0.041) as favorable independent predictors of survival in patients with traumatic ARDS who underwent ECMO. The optimal cut off value for pre-ECMO lactate level was 10.5 mmol/L (area under the curve = 0.929, P = 0.001). In Kaplan-Meier analysis, the survival rate at hospital discharge was significant higher among the patients with a pre-ECMO lactate level of 10.5 mmol/L or less compared with patients with pre-ECMO lactate level greater than 10.5 mmol/L (93.8% versus 40.0%, respectively; P = 0.01). Conclusions ECMO yielded excellent survival outcomes, particularly in patients with low pre-treatment lactate levels who received VV ECMO. Therefore, ECMO appears safe and highly feasible in a carefully selected population of trauma patients.
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Affiliation(s)
- Hong Kyu Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Gwanpyeong-ro 170 beon-gil 22, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, South Korea
| | - Hyoung Soo Kim
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Gwanpyeong-ro 170 beon-gil 22, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, South Korea.
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, South Korea
| | - Sunghoon Park
- Division of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, South Korea
| | - Hee Sung Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Dongtan Sacred Heart Hospital, Hallym University Medical Center, Hwaseong-si, Gyeonggi-do, South Korea
| | - Soo Kyung Lee
- Department of Anesthesiology and Pain Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang-si, Gyeonggi-do, South Korea
| | - Sun Hee Lee
- Department of Thoracic and Cardiovascular Surgery, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Gwanpyeong-ro 170 beon-gil 22, Dongan-gu, Anyang-si, Gyeonggi-do, 14068, South Korea
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16
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Lee YY, Baik HJ, Lee H, Kim CH, Chung RK, Han JI, Joo H, Woo JH. Heparin-free veno-venous extracorporeal membrane oxygenation in a multiple trauma patient: A case report. Medicine (Baltimore) 2020; 99:e19070. [PMID: 32000456 PMCID: PMC7004685 DOI: 10.1097/md.0000000000019070] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
RATIONALE Extracorporeal membrane oxygenation (ECMO) in multiple trauma patients with post-traumatic respiratory failure can be quite challenging because of the need for systemic anticoagulation, which may lead to excessive bleeding. In the last decade, there is a growing body of evidence that veno-venous ECMO (VV-ECMO) is lifesaving in multiple trauma patients with acute respiratory distress syndrome, thanks to technical improvements in ECMO devices. PATIENT CONCERNS We report a case of a 17-year-old multiple trauma patient who was drunken and had confused mentality. DIAGNOSES She was suffered from critical respiratory failure (life-threatening hypoxemia and severe hypercapnia/acidosis lasting for 70 minutes) accompanied by cardiac arrest and trauma-induced coagulopathy during general anesthesia. INTERVENTIONS We decided to start heparin-free VV-ECMO after cardiac arrest considering risk of hemorrhage. OUTCOMES She survived with no neurologic sequelae after immediate treatment with heparin-free VV-ECMO. LESSONS Heparin-free VV-ECMO can be used as a resuscitative therapy in multiple trauma patients with critical respiratory failure accompanied by coagulopathy. Even in cases in which life-threatening hypoxemia and severe hypercapnia/acidosis last for >1 hours during CPR for cardiac arrest, VV-ECMO could be considered a potential lifesaving treatment.
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Affiliation(s)
- Youn Young Lee
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Hospital
| | - Hee Jung Baik
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Heeseung Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Chi Hyo Kim
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Rack Kyung Chung
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Jong In Han
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
| | - Hyunyoung Joo
- Department of Anesthesiology and Pain Medicine, Ewha Womans University Hospital
| | - Jae Hee Woo
- Department of Anesthesiology and Pain Medicine, College of Medicine, Ewha Womans University, Seoul, South Korea
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17
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Assessment of safety and bleeding risk in the use of extracorporeal membrane oxygenation for multitrauma patients: A multicenter review. J Trauma Acute Care Surg 2019; 86:967-973. [DOI: 10.1097/ta.0000000000002242] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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18
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Ogawa F, Sakai T, Takahashi K, Kato M, Yamaguchi K, Okazaki S, Abe T, Iwashita M, Takeuchi I. A case report: Veno-venous extracorporeal membrane oxygenation for severe blunt thoracic trauma. J Cardiothorac Surg 2019; 14:88. [PMID: 31060587 PMCID: PMC6501329 DOI: 10.1186/s13019-019-0908-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 04/22/2019] [Indexed: 01/25/2023] Open
Abstract
Introduction The use of veno-venous extracorporeal membrane oxygenation (VV-ECMO) in trauma patients has been controversial, but VV-ECMO plays a crucial role when the lungs are extensively damaged and when conventional management has failed. VV-ECMO provides adequate tissue oxygenation and an opportunity for lung recovery. However, VV-ECMO remains contraindicated in patients with a risk of bleeding because of systemic anticoagulation during the treatment. The most important point is controlling the bleeding from severe trauma. Case A 32-year-old male experienced blunt trauma due to a traffic accident. He presented with bilateral hemopneumothorax and bilateral flail chest. We performed emergency thoracotomy for active bleeding and established circulatory stability. After surgery, the oxygenation deteriorated under mechanical ventilation, so we decided to establish VV-ECMO. However, bleeding from the bilateral lung contusions increased after VV-ECMO was established, and the patient was switched to heparin-free ECMO. After conversion, we could control the bronchial bleeding, especially the lung hematomas, and the oxygenation recovered. The patient was discharged without significant complications. VV-ECMO and mechanical ventilation were stopped on days 10 and 11, respectively. He was discharged from the ICU on day 15. Conclusion When we consider the use of ECMO for patients with uncontrollable, severe bleeding caused by blunt trauma, it may be necessary to use a higher flow setting for heparin-free ECMO than typically used for patients without trauma to prevent thrombosis.
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Affiliation(s)
- Fumihiro Ogawa
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan. .,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan.
| | - Takuma Sakai
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan.,Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama, 232-0024, Japan
| | - Ko Takahashi
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan
| | - Makoto Kato
- Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan
| | - Keishi Yamaguchi
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan
| | - Sayo Okazaki
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan
| | - Takeru Abe
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan
| | - Masayuki Iwashita
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan
| | - Ichiro Takeuchi
- Department of Emergency Medicine, Yokohama City University School of Medicine, Yokohama, 232-0024, Japan.,Advanced Critical Care and Emergency Center, Yokohama City University Medical Center, Yokohama, 232-0024, Japan.,Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama, 232-0024, Japan
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19
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Craniectomy and Traumatic Brain Injury in Children on Extracorporeal Membrane Oxygenation Support. Pediatr Emerg Care 2018; 34:e204-e210. [PMID: 27749813 DOI: 10.1097/pec.0000000000000907] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Severe trauma may cause refractory life-threatening respiratory failure requiring extracorporeal membrane oxygenation (ECMO). Concurrent traumatic brain injury, however, complicates the use of ECMO because of the major risk of intracranial bleeding with systemic anticoagulation. Craniotomy and/or craniectomy for hematoma evacuation during ECMO are extremely high-risk procedures secondary to ongoing anticoagulation, and there are only a few such case reports in the literature. We present the case of a child with multiple thoracic injuries and life-threatening respiratory failure supported on ECMO. She developed an intracranial hemorrhage while systemically heparinized that required emergent decannulation and bedside craniectomy for hematoma extraction. She survived with an excellent neurologic outcome. We also review the relevant literature regarding the use of ECMO in patients with polytrauma and the occurrence of craniectomy on extracorporeal support, with a focus on pediatric publications. Patients with polytrauma with brain injury can be supported on ECMO, but extreme precaution must be taken regarding anticoagulation. The intracranial complications of ECMO in this population are not infrequent, but our case report and review of the literature suggest that neurosurgical intervention should be considered in life-threatening conditions when no other alternatives are available.
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20
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Extracorporeal life support in the emergency department: A narrative review for the emergency physician. Resuscitation 2018; 133:108-117. [PMID: 30336233 DOI: 10.1016/j.resuscitation.2018.10.014] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/08/2018] [Accepted: 10/11/2018] [Indexed: 12/31/2022]
Abstract
BACKGROUND Extracorporeal life support (ECLS) describes the use of blood perfusion devices to provide advanced cardiac or respiratory support. Advances in percutaneous vascular cannula insertion, centrifugal pump technologies, and the miniaturization of extracorporeal devices have simplified ECLS. The intention of this discussion is to review the role of ECLS as a potential rescue method for emergency department (ED) clinicians in critical clinical scenarios and to focus on the prerequisites for managing an ECLS program in an ED setting. DISCUSSION Possible indications for ECLS cannulation in the ED include ongoing circulatory arrest, shock or refractory hypoxemia and pulmonary embolism with refractory shock. Severe trauma, foreign body obstruction, hypothermia and near drowning are situations in which patients may potentially benefit from ECLS. Early stabilization in the ED can provide a time window for a diagnostic workup and/or urgent procedures, including percutaneous coronary intervention, rewarming or damage control surgery in trauma. The use of ECLS is resource intensive and can be associated with a high risk of complications, especially when performed without previous training. Therefore, ECLS should only be used when the underlying problem is potentially reversible, and the resources are available to address the etiology of organ dysfunction. CONCLUSION Emergent ECLS has a role in the ED for selected indications in the face of life-threatening conditions. ECLS provides a bridge to recovery, definitive therapy, intervention or surgery. ECLS program requires an appropriately trained staff (physicians, nurses and ECLS specialists), equipment resources and logistical planning.
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21
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Grubmüller M, Kerschbaum M, Diepold E, Angerpointner K, Nerlich M, Ernstberger A. Severe thoracic trauma - still an independent predictor for death in multiple injured patients? Scand J Trauma Resusc Emerg Med 2018; 26:6. [PMID: 29310701 PMCID: PMC5759165 DOI: 10.1186/s13049-017-0469-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 12/22/2017] [Indexed: 01/26/2023] Open
Abstract
Background Over the past, the severe thoracic trauma has had decisive influence on the outcome of multiple injured patients. Today, new therapies (e.g. extracorporeal membrane oxygenation (ECMO), protective ventilation methods and new forms of patient positioning) are available and applied regularly. What impact on the patient’s outcome does the thoracic trauma have today? Methods Prospective data collection of multiple injured patients in a level-I trauma center was performed between 2008 and 2014. Patients with an ISS ≥16 were included and divided into 2 groups: Severe thoracic trauma (STT: AISThorax ≥ 3) and mild thoracic trauma (MTT: AISThorax < 3). In addition to preclinical and trauma room care, detailed information about clinical course and outcome were assessed. Results In total, 529 patients (STT: n = 317; MTT: n = 212) met the in- and exclusion criteria. The mean Injury Severity Score (ISS) was significantly higher in patients of the STT group (STT: 33.5 vs. MTT: 24.7; p < 0.001), while the RISC II Score showed no significant differences (STT: 20.0 vs. MTT: 17.1; p = 0.241). Preclinical data revealed a higher intubation rate, more chest tube insertions and a higher use of catecholamines in the STT group (p < 0.05). Clinically, we found significant differences in the duration of invasive ventilation (STT: 7.3d vs. MTT: 5.4d; p = 0.001) and ICU stay (STT: 12.3d vs. MTT: 9.4d; p < 0.001). While the complication rate was higher for the STT group (sepsis (STT: 11.4% vs. MTT: 5.7%; p = 0.017); lung failure (STT: 23.7% vs. MTT: 12.3%; p = 0,001)), neither the non-adjusted lethality rate (STT: 13.2% vs. MTT: 13.7%; p = 0.493) nor the Standardized Mortality Ratio (SMR) showed significant differences (STT: 0.66 vs. MTT: 0.80; p = 0.397). The multivariate regressive analysis confirmed that severe thoracic trauma is not an independent risk factor for lethality in our patient cohort. Conclusion Despite a higher injury severity, the extended need of emergency measures and a higher rate of complications in injured patients with severe blunt thoracic trauma, no influence on lethality can be proved. The reduction of the complication rate should be a goal for the next decades.
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Affiliation(s)
- Michael Grubmüller
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Maximilian Kerschbaum
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Eva Diepold
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Katharina Angerpointner
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Michael Nerlich
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany
| | - Antonio Ernstberger
- Department of Trauma Surgery, University Medical Center Regensburg, Franz-Josef-Strauss-Allee 11, D-93053, Regensburg, Germany.
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22
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Tu Y, Jin Q, Sun R, Li Q. Extracorporeal membrane oxygenation support for a multitrauma patient with ARDS: A case report and literature review. Exp Ther Med 2017; 15:2062-2065. [PMID: 29434806 DOI: 10.3892/etm.2017.5604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Accepted: 10/06/2017] [Indexed: 11/05/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) provides rescue treatment for patients with severe acute respiratory distress syndrome (ARDS) when conventional management fails. The present study reported ECMO as a life-saving treatment for ARDS due to bilateral pulmonary contusion in a 24-year-old male multiple trauma patient. ECMO therapy lasted 7 days for the patient and was successively stopped without any complications. ECMO modality should be chosen according to the respiratory and circulatory condition of each individual. Venoarteria-ECMO may be chosen for multiple trauma patients with ARDS, and respiratory and circulatory failure. Morphological changes are observed with ARDS progression. The injured lungs may recover completely with effective ECMO therapy.
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Affiliation(s)
- Yuexing Tu
- Department of Critical Care Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang 310014, P.R. China
| | - Qi Jin
- Department of Critical Care Medicine, Zhejiang Provincial Tiantai County People's Hospital, Taizhou, Zhejiang 317200, P.R. China
| | - Renhua Sun
- Department of Critical Care Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang 310014, P.R. China
| | - Qian Li
- Department of Critical Care Medicine, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, Zhejiang 310014, P.R. China
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Della Torre V, Badenes R, Corradi F, Racca F, Lavinio A, Matta B, Bilotta F, Robba C. Acute respiratory distress syndrome in traumatic brain injury: how do we manage it? J Thorac Dis 2017; 9:5368-5381. [PMID: 29312748 PMCID: PMC5756968 DOI: 10.21037/jtd.2017.11.03] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 10/31/2017] [Indexed: 12/24/2022]
Abstract
Traumatic brain injury (TBI) is an important cause of morbidity and mortality worldwide. TBI patients frequently suffer from lung complications and acute respiratory distress syndrome (ARDS), which is associated with poor clinical outcomes. Moreover, the association between TBI and ARDS in trauma patients is well recognized. Mechanical ventilation of patients with a concomitance of acute brain injury and lung injury can present significant challenges. Frequently, guidelines recommending management strategies for patients with traumatic brain injuries come into conflict with what is now considered best ventilator practice. In this review, we will explore the strategies of the best practice in the ventilatory management of patients with ARDS and TBI, concentrating on those areas in which a conflict exists. We will discuss the use of ventilator strategies such as protective ventilation, high positive end expiratory pressure (PEEP), prone position, recruitment maneuvers (RMs), as well as techniques which at present are used for 'rescue' in ARDS (including extracorporeal membrane oxygenation) in patients with TBI. Furthermore, general principles of fluid, haemodynamic and hemoglobin management will be discussed. Currently, there are inadequate data addressing the safety or efficacy of ventilator strategies used in ARDS in adult patients with TBI. At present, choice of ventilator rescue strategies is best decided on a case-by-case basis in conjunction with local expertise.
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Affiliation(s)
- Valentina Della Torre
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Rafael Badenes
- Department of Anesthesiology and Surgical Trauma Intensive Care, Hospital Clinic Universitari Valencia, University of Valencia, Valencia, Spain
| | | | - Fabrizio Racca
- Department of Anesthesiology and Intensive Care Unit, SS Antonio Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Andrea Lavinio
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | - Federico Bilotta
- Department of Anaesthesia and Intensive Care, La Sapienza University, Rome, Italy
| | - Chiara Robba
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
- Department of Neuroscience, University of Genova, Italy
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Abbasi A, Devers C, Muratore CS, Harrington C, Ventetuolo CE. Examining the role of extracorporeal membrane oxygenation in patients following suspected or confirmed suicide attempts: A case series. J Crit Care 2017; 44:445-449. [PMID: 29203213 DOI: 10.1016/j.jcrc.2017.10.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/02/2017] [Accepted: 10/17/2017] [Indexed: 11/28/2022]
Abstract
The decision to offer extracorporeal membrane oxygenation (ECMO) is based on a risk/benefit assessment and the likelihood of a treatable underlying condition or the feasibility of destination therapy (durable mechanical support or thoracic organ transplantation) should heart-lung function fail to improve. Patients who present following suspected suicide attempts who fail medical therapy may pose a dilemma for clinicians. An assessment to determine if a patient has a high likelihood of psychiatric recovery such that bridging with ECMO or ultimately destination therapy could or should be offered is not always feasible in the setting of critical illness. This case series reviews our institution's experience with ECMO in the management of five patients who presented following suspected or confirmed suicide attempts. All five patients survived to hospital discharge. Two had subsequent psychiatric admissions, one following a repeat suicide attempt. A discussion of these cases demonstrates the effectiveness of ECMO in supporting this group of patients in the short-term. The self-limited natural history of many psychiatric episodes, poisonings and traumatic injuries makes the use of ECMO a potentially reasonable support strategy. However, careful consideration must be given to psychiatric history and follow-up given the substantial commitment of resources, potential for complications and for stranding patients on extracorporeal therapy without definitive destination therapy.
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Affiliation(s)
- Adeel Abbasi
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, United States
| | | | - Christopher S Muratore
- Department of Pediatric Surgery, Alpert Medical School of Brown University, Providence, RI, United States
| | - Colin Harrington
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, United States; Department of Psychiatry, Alpert Medical School of Brown University, Providence, RI, United States
| | - Corey E Ventetuolo
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI, United States; Department of Health Services, Policy and Practice, Brown School of Public Health, Providence, RI, United States.
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Abstract
Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) is a form of heart lung bypass that is used to support neonates, pediatrics, and adult patients with cardiorespiratory failure for days or weeks till organ recovery or transplantation. Venoarterial (VA) and venovenous (VV) ECLS are the most common modes of support. ECLS circuit components and monitoring have been evolving over the last 40 years. The technology is safer, simpler, and more durable with fewer complications. The use of neonatal respiratory ECLS use has been declining over the last two decades, while adult respiratory ECLS is growing especially since the H1N1 influenza pandemic in 2009. This review provides an overview of ECLS evolution over the last four decades, its use in neonatal, pediatric and adults, description of basic principles, circuit components, complications, and outcomes as well as a quick look into the future.
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Abdelaty M, Hassan IF, Abdussalam ALM, Ibrahim AS. ECMO for a polytrauma patient without systemic anticoagulation. Qatar Med J 2017. [PMCID: PMC5474638 DOI: 10.5339/qmj.2017.swacelso.70] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Mohamed Abdelaty
- Hamad Medical Corporation, Hamad General Hospital, MICU, PO Box 3050, Doha, Qatar. http://hamad.qa
| | - Ibrahim Fawzy Hassan
- Hamad Medical Corporation, Hamad General Hospital, MICU, PO Box 3050, Doha, Qatar. http://hamad.qa
| | | | - Abdulsalam Saif Ibrahim
- Hamad Medical Corporation, Hamad General Hospital, MICU, PO Box 3050, Doha, Qatar. http://hamad.qa
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Lee OJ, Cho YH, Hwang J, Yoon I, Kim YH, Cho J. Long Term Extracorporeal Membrane Oxygenation after Severe Blunt Traumatic Lung Injury in a Child. Korean J Crit Care Med 2017. [DOI: 10.4266/kjccm.2016.00472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Lee OJ, Cho YH, Hwang J, Yoon I, Kim YH, Cho J. Long-term extracorporeal membrane oxygenation after severe blunt traumatic lung injury in a child. Acute Crit Care 2017; 34:223-227. [PMID: 31723933 PMCID: PMC6849020 DOI: 10.4266/acc.2016.00472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2016] [Revised: 10/08/2016] [Accepted: 10/10/2016] [Indexed: 12/03/2022] Open
Abstract
Managing acute respiratory distress syndrome (ARDS) after severe blunt traumatic lung injury can be challenging. In cases where patients are refractory to conventional therapy, extracorporeal membrane oxygenation (ECMO) should be considered. In addition, the heparin-coated circuit can reduce hemorrhagic complications in patients with multiple traumas. Although prolonged ECMO may be necessary, excellent outcomes are frequently associated. In this study, we report long-term support with venovenous-ECMO applied in a child with severe blunt trauma in Korea. This 10-year-old and 30 kg male with severe blunt thoracic trauma after a car accident developed severe ARDS a few days later, and ECMO was administered for 33 days. Because of pulmonary hemorrhage during ECMO support, heparin was stopped for 3 days and then restarted. He was weaned from ECMO successfully and has been able to run without difficulty for the 2 years since discharge.
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Affiliation(s)
- Ok Jeong Lee
- Department of Pediatrics, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jinwook Hwang
- Department of Thoracic and Cardiovascular Surgery, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Inae Yoon
- Department of Pediatrics, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - Young-Ho Kim
- Department of Pediatrics, Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine, Changwon, Korea
| | - Joongbum Cho
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Extracorporeal life support is safe in trauma patients. Injury 2017; 48:121-126. [PMID: 27866648 DOI: 10.1016/j.injury.2016.11.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 10/30/2016] [Accepted: 11/10/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The role of extracorporeal life support (ECLS) in the critically ill trauma patient is poorly defined, possibly leading to the underutilization of this lifesaving therapy in this population. This study examined survival rates and risk factors for death in trauma patients who received ECLS. METHODS Data from the National Trauma Data Bank was retrospectively reviewed to identify trauma patients who received ECLS from January 2012 to December 2014. Clinical outcomes and risk factors for death were examined in these patients. RESULTS Eighty patients were identified and included in the final analysis. Overall survival to hospital discharge was 64%. Survivors and non-survivors were similar in regard to age, gender, weight, and injury mechanism. Non-survivors had greater median injury severity scores (ISS) (29 non-survivors vs. 24 survivors, p=0.018) and had a shorter median total hospital length of stay (8days non-survivors vs. 32days survivors, p<0.001). Analysis of specific anatomic locations of traumatic injury, including serious head/neck, thoracic, and abdominal injuries, revealed no impact on patient survival. Multivariable logistic regression analysis identified increasing age and ISS as significant risk factors for mortality; whereas treatment at facilities that performed multiple ECLS runs over the study period was associated with improved survival. CONCLUSIONS Extracorporeal life support appears to be an effective treatment option in trauma patients with severe cardiopulmonary failure. Survival in trauma patients receiving ECLS is similar to that observed in the general ECLS population and this may represent an underutilized therapy in this population.
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Extracorporeal membrane oxygenation for adult respiratory distress syndrome in trauma patients. J Trauma Acute Care Surg 2017; 82:165-173. [DOI: 10.1097/ta.0000000000001276] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Napp LC, Kühn C, Hoeper MM, Vogel-Claussen J, Haverich A, Schäfer A, Bauersachs J. Cannulation strategies for percutaneous extracorporeal membrane oxygenation in adults. Clin Res Cardiol 2015; 105:283-96. [PMID: 26608160 PMCID: PMC4805695 DOI: 10.1007/s00392-015-0941-1] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 11/03/2015] [Indexed: 12/28/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has revolutionized treatment of severe isolated or combined failure of lung and heart. Due to remarkable technical development the frequency of use is growing fast, with increasing adoption by interventional cardiologists independent of cardiac surgery. Nevertheless, ECMO support harbors substantial risk such as bleeding, thromboembolic events and infection. Percutaneous ECMO circuits usually comprise cannulation of two large vessels ('dual' cannulation), either veno-venous for respiratory and veno-arterial for circulatory support. Recently experienced centers apply more advanced strategies by cannulation of three large vessels ('triple' cannulation), resulting in veno-veno-arterial or veno-arterio-venous cannulation. While the former intends to improve drainage and unloading, the latter represents a very potent method to provide circulatory and respiratory support at the same time. As such triple cannulation expands the field of application at the expense of increased complexity of ECMO systems. Here, we review percutaneous dual and triple cannulation strategies for different clinical scenarios of the critically ill. As there is no unifying terminology to date, we propose a nomenclature which uses "A" and all following letters for supplying cannulas and all letters before "A" for draining cannulas. This general and unequivocal code covers both dual and triple ECMO cannulation strategies (VV, VA, VVA, VAV). Notwithstanding the technical evolution, current knowledge of ECMO support is mainly based on observational experience and mostly retrospective studies. Prospective controlled trials are urgently needed to generate evidence on safety and efficacy of ECMO support in different clinical settings.
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Affiliation(s)
- L Christian Napp
- Cardiac Arrest Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
| | - Christian Kühn
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Marius M Hoeper
- Department of Respiratory Medicine and German Center of Lung Research (DZL), Hannover Medical School, Hannover, Germany
| | - Jens Vogel-Claussen
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Schäfer
- Cardiac Arrest Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Johann Bauersachs
- Cardiac Arrest Center, Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
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Blum JM, Lynch WR, Coopersmith CM. Clinical and billing review of extracorporeal membrane oxygenation. Chest 2015; 147:1697-1703. [PMID: 25789816 DOI: 10.1378/chest.14-2954] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a temporary technique for providing life support for cardiac dysfunction, pulmonary dysfunction, or both. The two forms of ECMO, veno-arterial (VA) and veno-venous (VV), are used to support cardiopulmonary and pulmonary dysfunction, respectively. Historically, ECMO was predominantly used in the neonatal and pediatric populations, as early adult studies failed to improve outcomes. ECMO has become far more common in the adult population because of positive results in published case series and clinical trials during the 2009 influenza A(H1N1) pandemic in 2009 to 2010. Advances in technology that make the technique much easier to implement likely fueled the renewed interest. Although exact criteria for ECMO are not available, patients who are good candidates are generally considered to be relatively young and suffering from acute illness that is believed to be reversible or organ dysfunction that is otherwise treatable. With the increase in the use in the adult population, a number of different codes have been generated to better identify the method of support with distinctly different relative value units assigned to each code from a very simple prior coding scheme. To effectively be reimbursed for use of the technique, it is imperative that the clinician understands the new coding scheme and works with payers to determine what is incorporated into each specific code.
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Affiliation(s)
- James M Blum
- Department of Anesthesiology, Emory Critical Care Center, Emory University, Atlanta, GA.
| | - William R Lynch
- Section of Thoracic Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Craig M Coopersmith
- Department of Surgery, Emory Critical Care Center, Emory University, Atlanta, GA
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Extracorporeal membranous oxygenation (ECMO) in polytrauma: what the radiologist needs to know. Emerg Radiol 2015; 22:565-76. [PMID: 26047606 DOI: 10.1007/s10140-015-1324-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2015] [Accepted: 05/18/2015] [Indexed: 12/17/2022]
Abstract
The purpose of this article is to review the spectrum of severe traumatic injuries treatable with ECMO and their imaging features, considerations for cannula placement, and complications that may arise in polytraumatized patients on extracorporeal life support. Recent major advances in miniaturization and biocompatibility of ECMO devices have dramatically increased their safety profile and expanded the application of ECMO to patients with severe polytrauma.
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Use of extracorporeal membrane oxygenation in severe traumatic lung injury with respiratory failure. Am J Emerg Med 2015; 33:658-62. [DOI: 10.1016/j.ajem.2015.02.007] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 02/03/2015] [Accepted: 02/04/2015] [Indexed: 11/18/2022] Open
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Gothner M, Buchwald D, Strauch JT, Schildhauer TA, Swol J. The use of double lumen cannula for veno-venous ECMO in trauma patients with ARDS. Scand J Trauma Resusc Emerg Med 2015; 23:30. [PMID: 25886755 PMCID: PMC4377214 DOI: 10.1186/s13049-015-0106-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Accepted: 03/04/2015] [Indexed: 12/19/2022] Open
Abstract
Background The use of a double lumen cannula for veno-venous extracorporeal membrane oxygenation (v.v. ECMO) offers several advantages such as cannulation with only one cannula, patient comfort and the earlier mobilization and physiotherapy. The cannulation should be performed under visual wire and cannula placement into the right atrium, which is associated with risks of malposition and right ventricular perforation. The aim of this patient series is to describe the use of double lumen cannula in trauma patients with posttraumatic ARDS. Material and methods Criteria for the v.v ECMO treatment were defined as hypoxaemia (pO2/FiO2 < 200 mmHg, FiO2 0.8-1,0); tidal volume >4-6 ml/kg ideal body weight; mean inspiratory pressure (Pinsp) >32-34 mmHg; respiratory acidosis pH <7.25; and arterial saturation (SaO2) <90%. The analysis included the Injury Severity Score (ISS), the types of injury, time of treatment, complications and outcomes. Results A total of 24 patients with major trauma were treated for posttraumatic ARDS with v.v. ECMO. The double lumen cannula (Avalon®, Fa. Maquet, Rastatt, Germany) was used in six male patients. The mean ISS was 31 (20–48). The ECMO therapy was started in an average on the third day after trauma. The mean ECMO run time was 7 days ± 5 (6–18), and the hospital stay was in mean of 60 days ± 34 (21–105). Conclusion The use of double lumen cannula for v.v ECMO therapy in trauma patients is a feasible treatment option. No higher risk of bleeding could be found in this case series. A PTT-controlled heparinization is recommended using double lumen cannula. Therefore the use of this cannula type in trauma patients with high risk of bleeding is to discuss controversially.
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Affiliation(s)
- Martin Gothner
- Department of General and Trauma Surgery, University Hospital Bergmannsheil, Ruhr-University Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany.
| | - Dirk Buchwald
- Department of Cardiothoracic Surgery, University Hospital Bergmannsheil, Ruhr-University, Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany.
| | - Justus T Strauch
- Department of Cardiothoracic Surgery, University Hospital Bergmannsheil, Ruhr-University, Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany.
| | - Thomas A Schildhauer
- Department of General and Trauma Surgery, University Hospital Bergmannsheil, Ruhr-University Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany.
| | - Justyna Swol
- Department of General and Trauma Surgery, University Hospital Bergmannsheil, Ruhr-University Bochum, Bürkle-de-la-Camp Platz 1, 44789, Bochum, Germany.
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Wen PH, Chan WH, Chen YC, Chen YL, Chan CP, Lin PY. Non-heparinized ECMO serves a rescue method in a multitrauma patient combining pulmonary contusion and nonoperative internal bleeding: a case report and literature review. World J Emerg Surg 2015; 10:15. [PMID: 25774211 PMCID: PMC4359487 DOI: 10.1186/s13017-015-0006-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 02/09/2015] [Indexed: 11/25/2022] Open
Abstract
Pulmonary contusion and acute respiratory distress syndrome (ARDS) is a common manifestation in polytraumatic patients. Although mechanical ventilation is still the first choice of treatment, a group of patients are still unable to maintain their oxygenation. The role of extracorporeal membrane oxygenation (ECMO) has been more clarified when the lung is extensively damaged and when conventional modality failed. ECMO provides the lung an opportunity to rest by permitting reduced ventilator settings and limiting further barotraumas. However, ECMO is still considered contraindicated in polytramatic patients combining pulmonary contusion and other organ hemorrhage because of systemic anticoagulation during the treatment. We herein report a patient who successfully survive a multitrauma combining pulmonary contusion and grade IV liver laceration using non-heparinized venovenous extracorporeal membrane oxygenation (vv-ECMO). The associated literature were reviewed.
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Affiliation(s)
- Pei-Hung Wen
- General Surgery Division, Surgery Department, Changhua Christian Hospital, Changhua City, Taiwan ; Trauma Division, Surgery Department, Changhua Christian Hospital, 500 No. 135, Nanxiao Street, Changhua City, Taiwan ; Surgery Department, Cishan Hospital, 84247 No. 60, Zhongxue Rd., Cishan District, Kaohsiung City, Taiwan
| | - Wai Hung Chan
- General Surgery Division, Surgery Department, Changhua Christian Hospital, Changhua City, Taiwan ; Trauma Division, Surgery Department, Changhua Christian Hospital, 500 No. 135, Nanxiao Street, Changhua City, Taiwan
| | - Ying-Cheng Chen
- Cardiovascular Division, Surgery Department, Changhua Christian Hospital, Changhua City, Taiwan
| | - Yao-Li Chen
- General Surgery Division, Surgery Department, Changhua Christian Hospital, Changhua City, Taiwan ; Transplant Medicine and Surgery Research Centre, Changhua Christian Hospital, Changhua City, Taiwan
| | - Chien-Pin Chan
- General Surgery Division, Surgery Department, Changhua Christian Hospital, Changhua City, Taiwan ; Trauma Division, Surgery Department, Changhua Christian Hospital, 500 No. 135, Nanxiao Street, Changhua City, Taiwan
| | - Ping-Yi Lin
- Transplant Medicine and Surgery Research Centre, Changhua Christian Hospital, Changhua City, Taiwan
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Chauhan A, Babovic N, Moraca RJ, Altman DT. Use of Extracorporeal Membrane Oxygenation to Stabilize a Polytrauma Patient During Intramedullary Nailing of a Femoral Fracture: A Case Report. JBJS Case Connect 2014; 4:e112. [PMID: 29252780 DOI: 10.2106/jbjs.cc.n.00029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE An eighteen-year-old polytrauma patient sustained multiple nonorthopaedic and orthopaedic injuries, including a closed femoral shaft fracture. She was started on extracorporeal membrane oxygenation (ECMO) for respiratory failure. After added resuscitation and stabilization, she underwent intramedullary nailing of the femoral fracture while on ECMO on the third day after the injury. She remained stable throughout the case and recovered after a prolonged hospital course. At the most recent clinical follow-up, she was walking without assistance and had union of the fracture. CONCLUSIONS ECMO successfully stabilized and mitigated any potential pulmonary complications during intramedullary nailing of a femoral shaft fracture in an unstable patient with polytrauma.
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Affiliation(s)
- Aakash Chauhan
- Departments of Orthopaedic Surgery (A.C., N.B., and D.T.A.) and Thoracic and Cardiovascular Surgery (R.J.M.), Allegheny General Hospital, 320 East North Avenue, Pittsburgh, PA 15212.
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Zhou R, Liu B, Lin K, Wang R, Qin Z, Liao R, Qiu Y. ECMO support for right main bronchial disruption in multiple trauma patient with brain injury--a case report and literature review. Perfusion 2014; 30:403-6. [PMID: 25300436 DOI: 10.1177/0267659114554326] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) may offer life-saving treatment in severe pulmonary contusion or acute respiratory distress syndrome when conventional treatments have failed. However, because of the bleeding risk of systemic anticoagulation, ECMO should be performed only as a last resort in multiple trauma victims. Here, we report ECMO as a bridge for right main bronchus reconstruction and recovery of traumatic wet lung in a 31-year-old male multi-trauma patient with right main bronchial disruption, bilateral pulmonary contusion, cerebral contusion and long bone fracture. The patient was discharged without any obvious complication. ECMO support in a traumatic brain injured patient with severe hypoxemia caused by lung contusion and/or tracheal bronchus disruption is not an absolute contraindication.
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Affiliation(s)
- R Zhou
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - B Liu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - K Lin
- Department of Cardiac Surgery, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - R Wang
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Z Qin
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - R Liao
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
| | - Y Qiu
- Department of Anesthesiology, West China Hospital of Sichuan University, Chengdu, Sichuan 610041, China
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Prolonged Use of Extracorporeal Membrane Oxygenation as a Rescue Modality Following Traumatic Brain Injury. ASAIO J 2014; 60:597-9. [DOI: 10.1097/mat.0000000000000103] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Ventetuolo CE, Muratore CS. Extracorporeal life support in critically ill adults. Am J Respir Crit Care Med 2014; 190:497-508. [PMID: 25046529 PMCID: PMC4214087 DOI: 10.1164/rccm.201404-0736ci] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Accepted: 07/13/2014] [Indexed: 12/18/2022] Open
Abstract
Extracorporeal life support (ECLS) has become increasingly popular as a salvage strategy for critically ill adults. Major advances in technology and the severe acute respiratory distress syndrome that characterized the 2009 influenza A(H1N1) pandemic have stimulated renewed interest in the use of venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal to support the respiratory system. Theoretical advantages of ECLS for respiratory failure include the ability to rest the lungs by avoiding injurious mechanical ventilator settings and the potential to facilitate early mobilization, which may be advantageous for bridging to recovery or to lung transplantation. The use of venoarterial ECMO has been expanded and applied to critically ill adults with hemodynamic compromise from a variety of etiologies, beyond postcardiotomy failure. Although technology and general care of the ECLS patient have evolved, ECLS is not without potentially serious complications and remains unproven as a treatment modality. The therapy is now being tested in clinical trials, although numerous questions remain about the application of ECLS and its impact on outcomes in critically ill adults.
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Affiliation(s)
- Corey E. Ventetuolo
- Division of Pulmonary, Critical Care, and Sleep, Rhode Island Hospital, Departments of Medicine and Health Services, Policy, and Practice, and
| | - Christopher S. Muratore
- Division of Pediatric Surgery, Hasbro Children’s Hospital, Department of Surgery, Alpert Medical School of Brown University, Providence, Rhode Island
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Kalem V, Buchwald D, Strauch J, Sidiropoulos A, Meindl R, Schildhauer TA, Swol J. Surgical extraction after thrombosis around the Avalon dual lumen cannula. Ann R Coll Surg Engl 2014; 96:106E-108E. [PMID: 24417857 PMCID: PMC5137646 DOI: 10.1308/003588414x13824511649814] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The use of a dual lumen cannula (DLC) for venovenous extracorporeal membrane oxygenation (ECMO) has several advantages and reports of complications are rare. We present a case of thrombosis around and inside the Avalon Elite™ bicaval DLC (Avalon Laboratories, Rancho Dominguez, CA, US), for which simple removal by retraction was impossible. A 30-year-old man had experienced an unstable C6/7 fracture with spinal contusion and haematoma in the spinal canal with incomplete neurological paraplegia and thoracic trauma. He developed acute respiratory failure due to posttraumatic systemic inflammatory response syndrome and venovenous extracorporeal membrane oxygenation (ECMO) support was indicated. The cannulation was performed with an Avalon Elite™ cannula (31Fr) in the right jugular vein under fluoroscopy. After 18 days of ECMO therapy, despite the continuous administration of heparin (400iu/h), ECMO was discontinued because of the formation of a massive thrombus in the oxygenator. At that time, the patient's haemodynamic and respiratory parameters were stable, and we were able to induce a rapid weaning from ECMO. The surgical removal of the cannula became necessary and was performed using a small neck incision without complications. We report this case to emphasise that any resistance encountered during an attempt to extract the Avalon Elite™ cannula may cause serious complications. In such cases, surgical removal must be considered.
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Affiliation(s)
- V Kalem
- University Hospital Bergmannsheil, Bochum, Germany.
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Extracorporeal life support in patients with multiple injuries and severe respiratory failure. J Trauma Acute Care Surg 2013; 75:907-12. [DOI: 10.1097/ta.0b013e3182a8334f] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Menut R, Larrieu N, Conil JM, Georges B, Fourcade O, Geeraerts T. Utilisation d’un ECMO (extracorporeal membrane oxygenation) dans un cas d’hypoxémie réfractaire associée à un traumatisme crânien grave. ACTA ACUST UNITED AC 2013; 32:701-3. [DOI: 10.1016/j.annfar.2013.04.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2013] [Accepted: 04/25/2013] [Indexed: 11/24/2022]
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Moravec R, Neitzel T, Stiller M, Hofmann B, Metz D, Bucher M, Silber R, Bushnaq H, Raspé C. First experiences with a combined usage of veno-arterial and veno-venous ECMO in therapy-refractory cardiogenic shock patients with cerebral hypoxemia. Perfusion 2013; 29:200-9. [PMID: 23996694 DOI: 10.1177/0267659113502832] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of extracorporeal membrane oxygenation (ECMO) is becoming a popular tool in the treatment of cardiogenic shock. We present two case reports where classical veno-arterial peripherally cannulated ECMO therapy proved insufficient with profuse cerebral hypoxemia. After augmenting the setting into veno-veno-arterial ECMO, we achieved a remarkable improvement of all oxygenation parameters. The simultaneous use of veno-venous and veno-arterial ECMO might display as a novel strategy to counteract the coronary and cerebral hypoxemia in veno-arterial ECMO therapy in patients with therapy-refractory cardiogenic shock or in combined cardiopulmonary failure. In this manuscript, the veno-veno-arterial ECMO setup is described in full detail and different venous cannulas are discussed.
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Affiliation(s)
- R Moravec
- Department of Anesthesiology and Critical care medicine, Halle-Wittenberg University, Germany
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Ried M, Bein T, Philipp A, Müller T, Graf B, Schmid C, Zonies D, Diez C, Hofmann HS. Extracorporeal lung support in trauma patients with severe chest injury and acute lung failure: a 10-year institutional experience. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R110. [PMID: 23786965 PMCID: PMC4056791 DOI: 10.1186/cc12782] [Citation(s) in RCA: 112] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2012] [Accepted: 06/20/2013] [Indexed: 12/16/2022]
Abstract
Introduction Severe trauma with concomitant chest injury is frequently associated with acute lung failure (ALF). This report summarizes our experience with extracorporeal lung support (ELS) in thoracic trauma patients treated at the University Medical Center Regensburg. Methods A retrospective, observational analysis of prospectively collected data (Regensburg ECMO Registry database) was performed for all consecutive trauma patients with acute pulmonary failure requiring ELS during a 10-year interval. Results Between April 2002 and April 2012, 52 patients (49 male, three female) with severe thoracic trauma and ALF refractory to conventional therapy required ELS. The mean age was 32 ± 14 years (range, 16 to 72 years). Major traffic accident (73%) was the most common trauma, followed by blast injury (17%), deep fall (8%) and blunt trauma (2%). The mean Injury Severity Score was 58.9 ± 10.5, the mean lung injury score was 3.3 ± 0.6 and the Sequential Organ Failure Assessment score was 10.5 ± 3. Twenty-six patients required pumpless extracorporeal lung assist (PECLA) and 26 patients required veno-venous extracorporeal membrane oxygenation (vv-ECMO) for primary post-traumatic respiratory failure. The mean time to ELS support was 5.2 ± 7.7 days (range, <24 hours to 38 days) and the mean ELS duration was 6.9 ± 3.6 days (range, <24 hours to 19 days). In 24 cases (48%) ELS implantation was performed in an external facility, and cannulation was done percutaneously by Seldinger's technique in 98% of patients. Cannula-related complications occurred in 15% of patients (PECLA, 19% (n = 5); vv-ECMO, 12% (n = 3)). Surgery was performed in 44 patients, with 16 patients under ELS prevention. Eight patients (15%) died during ELS support and three patients (6%) died after ELS weaning. The overall survival rate was 79% compared with the proposed Injury Severity Score-related mortality (59%). Conclusion Pumpless and pump-driven ELS systems are an excellent treatment option in severe thoracic trauma patients with ALF and facilitate survival in an experienced trauma center with an interdisciplinary treatment approach. We encourage the use of vv-ECMO due to reduced complication rates, better oxygenation and best short-term outcome.
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Villar J, Kacmarek RM. What is new in refractory hypoxemia? Intensive Care Med 2013; 39:1207-10. [PMID: 23575611 DOI: 10.1007/s00134-013-2905-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 03/16/2013] [Indexed: 01/19/2023]
Affiliation(s)
- Jesús Villar
- CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.
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LINDSKOV C, JENSEN RH, SPROGOE P, KLAABORG KE, KIRKEGAARD H, SEVERINSEN IK, LORENTSEN AG, FOLKERSEN L, ILKJAER S, PEDERSEN CM. Extracorporeal membrane oxygenation in adult patients with severe acute respiratory failure. Acta Anaesthesiol Scand 2013; 57:303-11. [PMID: 23278552 DOI: 10.1111/aas.12050] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2012] [Indexed: 12/16/2022]
Abstract
BACKGROUND A group of patients with severe acute respiratory distress syndrome (ARDS) is resistant to advanced respiratory therapy. In these patients, extracorporeal membrane oxygenation (ECMO) can be used as a rescue therapy. This study presents 14 years of experience from a Scandinavian ECMO centre. The aim of the study is to present outcome results and to investigate whether or not simplified acute physiology score II (SAPS-II), sequential organ failure assessment (SOFA) and/or Murray scores can be used to predict patients' outcome. METHODS In a prospective observational study, we collected data from ECMO patients from January 1997 to March 2011. The treatment was based mainly on venous-venous ECMO and centrifugal pumps. Patients were retrieved from Denmark plus a number from Sweden and Norway. The inclusion criteria were the classical criteria until November 2009 (n = 100), after which the new Extracorporeal Life Support Organisation criteria (n = 24) were used. RESULTS One hundred and twenty-four patients were enrolled with median age 45 (range 16-67) years. The median Murray score was 3.7 (2.5-4.0). One hundred and six (85%) of the patients were retrieved from referring hospitals on ECMO. The median duration of the ECMO runs was 215 (1-578) h. Ninety-seven (78%) of the patients could be weaned from ECMO. A total of 88 (71%) were discharged alive to the referring hospitals. High SAPS-II, SOFA and Murray scores were associated with a high mortality. CONCLUSION Patients with severe ARDS have a favourable outcome when treated with ECMO and when an ECMO retrieval team establishes the ECMO treatment at the referring hospital. SAPS-II, SOFA and Murray scores predicted the outcome.
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Affiliation(s)
- C. LINDSKOV
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus N; Denmark
| | - R. H. JENSEN
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus N; Denmark
| | - P. SPROGOE
- Department of Cardiothoracic and Vascular Surgery; Aarhus University Hospital; Aarhus N; Denmark
| | - K. E. KLAABORG
- Department of Cardiothoracic and Vascular Surgery; Aarhus University Hospital; Aarhus N; Denmark
| | - H. KIRKEGAARD
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus N; Denmark
| | - I. K SEVERINSEN
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus N; Denmark
| | - A. G LORENTSEN
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus N; Denmark
| | - L. FOLKERSEN
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus N; Denmark
| | - S. ILKJAER
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus N; Denmark
| | - C. M. PEDERSEN
- Department of Anaesthesiology and Intensive Care Medicine; Aarhus University Hospital; Aarhus N; Denmark
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Spadoni T, Niermont B, Brun J, Bach V, Bouzat P. [Post-traumatic acute respiratory distress syndrome: Rescue procedure in a trauma network]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2012; 31:930-931. [PMID: 23062228 DOI: 10.1016/j.annfar.2012.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 09/11/2012] [Indexed: 06/01/2023]
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