Extracorporeal membrane oxygenation in trauma: A single institution experience and review of the literature

Veno-arterial extracorporeal membrane oxygenation uses in trauma: a retrospective analysis of the Japanese nationwide trauma registry

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) can provide temporary circulatory support and vital organ oxygenation and is potentially useful as a bridge therapy in some trauma cases. We aimed to demonstrate the characteristics and outcomes of patients with trauma treated with veno-arterial ECMO (V-A ECMO) using data from a Japanese nationwide trauma registry.

METHODS

This retrospective descriptive study analyzed data from the Japan Trauma Data Bank between January 2019 and December 2021. Patients with severe trauma (injury severity score [ISS] ≥ 9) and treated using V-A ECMO were assessed.

RESULTS

Among the 72,439 patients with severe trauma, 51 received V-A ECMO. Sixteen patients (31.3%) survived until hospital discharge. On hospital arrival, six (37.5%) survivors and 15 (42.9%) non-survivors experienced cardiac arrest. The median ISS for the survivor and non-survivor group was 25 (range, 25-39) and 25 (range, 17-33), respectively. Thoracic trauma was the most common type of trauma in both groups. In the non-survivor group, open-chest cardiopulmonary resuscitation, aortic cross-clamping, and resuscitative endovascular balloon occlusion of the aorta were performed in 10 (28.6%), 5 (14.3%), and 4 (11.4%) patients, respectively. However, these procedures were not performed in the survivor group. Peripheral oxygen saturation tended to be lower in the survivor group both before and upon arrival at the hospital.

CONCLUSIONS

The results of this study suggest the potential benefit of V-A ECMO in some challenging trauma cases. Further studies are warranted to assess the indications for V-A ECMO in patients with trauma.

Orthopaedic fracture surgery in polytraumatized patients while on extracorporeal membrane oxygenation (ECMO): A report of two cases

Extracorporeal membrane oxygenation (ECMO) has become a salvage therapy for patients with severe acute respiratory distress syndrome (ARDS). The management of orthopaedic trauma in ECMO-supported patients with ARDS remains an evolving area of interest. Orthopaedic injuries are often temporized with external fixators, skeletal traction, or splints due to hemodynamic instability as well as concerns of exacerbating underlying pulmonary injury. However, patients requiring ECMO support do not rely on their pulmonary system for oxygenation, the need for delayed fixation may not apply. However, patients utilizing ECMO therapy can have external cardiac and pulmonary support depending on their cannulation strategy, bypassing the need for delayed fixation. We present a case series of two polytrauma patients with ARDS who underwent surgical management of pelvic ring and femoral shaft fractures while receiving ECMO support. Both patients underwent surgical management without complication and were able to be weaned from ECMO and ventilator support postoperatively. These cases highlight the potential benefits to orthopaedic fixation and underscore the need for further clinical research.

ECMO in adult patients with severe trauma: a systematic review and meta-analysis

BACKGROUND

Severe trauma can result in cardiorespiratory failure, and when conventional treatment is ineffective, extracorporeal membrane oxygenation (ECMO) can serve as an adjunctive therapy. However, the indications for ECMO in trauma cases are uncertain and clinical outcomes are variable. This study sought to describe the prognosis of adult trauma patients requiring ECMO, aiming to inform clinical decision-making and future research.

METHODS

A comprehensive search was conducted on Pubmed, Embase, Cochrane, and Scopus databases until March 13, 2023, encompassing relevant studies involving over 5 trauma patients (aged ≥ 16 years) requiring ECMO support. The primary outcome measure was survival until discharge, with secondary measures including length of stay in the ICU and hospital, ECMO duration, and complications during ECMO. Random-effects meta-analyses were conducted to analyze these outcomes. The study quality was assessed using the Joanna Briggs Institute checklist, while the certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.

RESULTS

The meta-analysis comprised 36 observational studies encompassing 1822 patients. The pooled survival rate was 65.9% (95% CI 61.3-70.5%). Specifically, studies focusing on traumatic brain injury (TBI) (16 studies, 383 patients) reported a survival rate of 66.1% (95% CI 55.4-76.2%), while studies non-TBI (15 studies, 262 patients) reported a survival rate of 68.1% (95% CI 56.9-78.5%). No significant difference was observed between these two survival comparisons (p = 0.623). Notably, studies utilizing venoarterial extracorporeal membrane oxygenation (VA ECMO) (15 studies, 39.0%, 95% CI 23.3-55.6%) demonstrated significantly lower survival rates than those using venovenous extracorporeal membrane oxygenation (VV ECMO) (23 studies, 72.3%, 95% CI 63.2-80.7%, p < 0.001). The graded assessment of evidence provided a high degree of certainty regarding the pooled survival.

CONCLUSIONS

ECMO is now considered beneficial for severely traumatized patients, improving prognosis and serving as a valuable tool in managing trauma-related severe cardiorespiratory failure, haemorrhagic shock, and cardiac arrest.

Penetrating thoracic injury requiring emergency pneumonectomy supported with two ECMO runs: A testament to multidisciplinary critical care medicine

Post-traumatic pneumonectomies are uncommon and, if necessary, carry significant mortality. The use of extracorporeal membrane oxygenation (ECMO) for lung injury in trauma patient has demonstrated efficacy with minimal bleeding complications. We report a case of a young man with a penetrating thoracic injury that required a pneumonectomy supported with two separate ECMO runs for pulmonary failure postoperatively.

Extracorporeal membrane oxygenation in traumatic brain injury - A retrospective, multicenter cohort study

INTRODUCTION

Patients with traumatic brain injury (TBI) regularly require intensive care with prolonged invasive ventilation. Consequently, these patients are at increased risk of pulmonary failure, potentially requiring extracorporeal membrane oxygenation (ECMO). The aim of this work was to provide an overview of ECMO treatment in TBI patients based upon data captured into the TraumaRegister DGU® (TR-DGU).

METHODS

A retrospective multi-center cohort analysis of patients registered in the TR-DGU was conducted. Adult patients with relevant TBI (AIS_Head ≥3) who had been treated in German, Austrian, or Swiss level I or II trauma centers using ECMO therapy between 2015 and 2019 were included. A multivariable logistic regression analysis was used to identify risk factors for the need for ECMO treatment.

RESULTS

12,247 patients fulfilled the inclusion criteria. The overall rate of ECMO treatment was 1.1% (134 patients). Patients on ECMO had an overall hospital mortality rate of 38% (51/134 patients) while 13% (1523/12,113 patients) of TBI patients without ECMO therapy died. Male gender (p = 0.014), AIS_Chest 3+ (p<0.001), higher Injury Severity Score (p<0.001) and packed red blood cell (pRBC) transfusion (p<0.001) were associated with ECMO treatment.

CONCLUSION

ECMO therapy is a potentially lifesaving modality for the treatment of moderate-to-severe TBI when combined with severe chest trauma and pulmonary failure. The in-hospital mortality is increased in this high-risk population, but the majority of patients is surviving.

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

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

Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature

(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.

Application and outcomes of extracorporeal life support in emergency general surgery and trauma

BACKGROUND

We analyzed the use of Extracorporeal Membranous Oxygenation (ECMO) in acute care surgery patients at our Level-1 trauma center. We hypothesized that this patient population has improved ECMO outcomes.

METHODS

This was a retrospective analysis of emergency general surgery and trauma patients placed on ECMO between the periods of October 2013 and February 2020. There were 10 surgical and 12 trauma patients studied, who eventually required ECMO support. ECMO support and ECMO type/modality were analyzed with injury and survival prognostic scores examined.

MAIN RESULTS

Overall, 16 of the 22 patients survived to hospital discharge, for a survival rate of 73%. Mean age was 34.18 years. Mean hospital length of stay was 23.4 days with mean days on ECMO equal to 7.5. The net negative fluid balance was 5.36 L.

CONCLUSIONS

The survival of our ECMO cohort is notably higher than previously cited studies. Our group demonstrated decreased length of time on ECMO, decreased length of stay in the hospital, and similar rates of complications compared to prior reports. ECMO is a useful modality in acute care surgical patients and should be considered in these patient populations. Our focus on net negative fluid balance for ECMO patients demonstrates improved survival. ECMO should be considered early in surgical patients and early in advanced trauma life support.

VA-ECMO as a salvage strategy for blunt cardiac injury in the context of multisystem trauma

A 47-year-old man sustained multisystem injuries after being struck by a vehicle travelling at high speeds. Shortly after admission to the emergency department he suffered a ventricular tachycardia/ventricular fibrillation cardiac arrest lasting 30 min. Investigations following return of spontaneous circulation raised suspicion for an anterolateral ST-elevation myocardial infarction. Despite his major traumatic injuries the patient was transferred for percutaneous coronary intervention uncovering a complete thrombosis of the ostium of the left anterior descending artery. Immediately following coronary revascularisation, the patient developed cardiogenic shock resulting in a multidisciplinary decision to place the patient on veno-arterial extracorporeal membrane oxygenation (VA-ECMO). The management of cardiogenic shock due to acute myocardial infarction with VA-ECMO and multiple traumatic injuries were often at odds with each other, resulting in a series of challenging decisions on timing of surgery and anticoagulation. The patient was liberated from VA-ECMO after 72 hours and continues rehabilitation in hospital.

Analysis of extracorporeal membrane oxygenation in trauma patients with acute respiratory distress syndrome: A case series

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.

Extracorporeal membrane oxygenation in trauma patients: a systematic review

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical outcomes of extracorporeal membrane oxygenation in acute traumatic lung injury: a retrospective study

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.

Extra corporeal membrane oxygenation in the critical trauma patient

PURPOSE OF REVIEW

The purpose of this review is to describe recent evidence regarding the use of extracorporeal membrane oxygenation (ECMO) as salvage therapy for severe cardiac or respiratory failure in patients with trauma. The characteristics of this cohort of patients, including the risk of bleeding and the need for systemic anticoagulation, are generally considered as relative contraindications to ECMO treatment. However, recent evidence suggests that the use of ECMO should be taken in consideration even in this group of patients.

RECENT FINDINGS

The recent findings suggest that venous-venous ECMO can be feasible in the treatment of refractory respiratory failure and severe acute respiratory distress syndrome trauma-related. The improvement of ECMO techniques including the introduction of centrifugal pumps and heparin-coated circuits are progressively reducing the amount of heparin required; moreover, the application of heparin-free ECMO showed good outcomes and minimal complications. Venous-arterial ECMO has emerged as a salvage intervention in patients with cardiogenic shock and after cardiac arrest. Venous-arterial ECMO provides circulatory support allowing time for other treatments to promote recovery in presence of acute cardiopulmonary failure. Only poor-quality evidence is available, for venous-arterial ECMO in trauma patients.

SUMMARY

ECMO can be considered as a safe rescue therapy even in trauma patients, including neurological injury, chest trauma as well as burns. However, evidence is still poor; further studies are warranted focusing on trauma patients undergoing ECMO, to better clarify the effect on survival, the type and dose of anticoagulation to use, as well as the utility of dedicated multidisciplinary trauma-ECMO units.