Venoarterial extracorporeal life support in post-traumatic shock and cardiac arrest: lessons learned

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.

ECMO (extra corporeal membrane oxygenation) in major trauma: A 10 year single centre experience

Aim To review the indications, complications and outcomes of extracorporeal membrane oxygenation (ECMO) in major trauma patients. Methods Single centre, retrospective, cohort study. Results Over a ten year period, from 13,420 major trauma patients, 11 were identified from our institutional trauma registry as having received ECMO. These patients were predominantly younger (mean 39 +/- 17 years), male (91%) and severely traumatised (median ISS 50, IQR 34 - 54). Veno-venous (VV) ECMO was used predominantly (n = 7, 64%), to treat hypoxic respiratory failure (mean PaO2/FiO2 ratio 69.7 +/- 38.6), secondary to traumatic lung injury. Veno-arterial (VA) ECMO was used less frequently, primarily to treat massive pulmonary embolism following trauma. Major bleeding complications occurred in four patients, however only one patient died from haemorrhage. Heparin free (2/11), delayed (3/11) or low dose heparin (2/11) therapy was frequently utilised. The median time from injury to ECMO initiation was 1 day (IQR 0.5 - 5.5) and median ECMO duration 9 days (IQR 6.5 - 10.5). ECMO was initiated <72 hours in 6 patients, with survival to discharge 67%, compared to 20% in those initiated >72 hours. Overall survival to discharge was 45%, and was higher with VV ECMO (64%), than other configurations (25%). Conclusion ECMO was rarely used in major trauma, the most common indication being severe hypoxaemic respiratory failure secondary to lung injury. In this severely injured cohort, overall survival was poor but better in VV compared to VA and better if initiated early (<72 hours), compared to late.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Selective aortic arch perfusion with fresh whole blood or HBOC-201 reverses hemorrhage-induced traumatic cardiac arrest in a lethal model of noncompressible torso hemorrhage

BACKGROUND

Hemorrhage-induced traumatic cardiac arrest (HiTCA) has a dismal survival rate. Previous studies demonstrated selective aortic arch perfusion (SAAP) with fresh whole blood (FWB) improved the rate of return of spontaneous circulation (ROSC) after HiTCA, compared with resuscitative endovascular balloon occlusion of the aorta and cardiopulmonary resuscitation (CPR). Hemoglobin-based oxygen carriers, such as hemoglobin-based oxygen carrier (HBOC)-201, may alleviate the logistical constraints of using FWB in a prehospital setting. It is unknown whether SAAP with HBOC-201 is equivalent in efficacy to FWB, whether conversion from SAAP to extracorporeal life support (ECLS) is feasible, and whether physiologic derangement post-SAAP therapy is reversible.

METHODS

Twenty-six swine (79 ± 4 kg) were anesthetized and underwent HiTCA which was induced via liver injury and controlled hemorrhage. Following arrest, swine were randomly allocated to resuscitation using SAAP with FWB (n = 12) or HBOC-201 (n = 14). After SAAP was initiated, animals were monitored for a 20-minute prehospital period prior to a 40-minute damage control surgery and resuscitation phase, followed by 260 minutes of critical care. Primary outcomes included rate of ROSC, survival, conversion to ECLS, and correction of physiology.

RESULTS

Baseline physiologic measurements were similar between groups. ROSC was achieved in 100% of the FWB animals and 86% of the HBOC-201 animals (p = 0.483). Survival (t = 320 minutes) was 92% (11/12) in the FWB group and 67% (8/12) in the HBOC-201 group (p = 0.120). Conversion to ECLS was successful in 100% of both groups. Lactate peaked at 80 minutes in both groups, and significantly improved by the end of the experiment in the HBOC-201 group (p = 0.001) but not in the FWB group (p = 0.104). There was no significant difference in peak or end lactate between groups.

CONCLUSION

Selective aortic arch perfusion is effective in eliciting ROSC after HiTCA in a swine model, using either FWB or HBOC-201. Transition from SAAP to ECLS after definitive hemorrhage control is feasible, resulting in high overall survival and improvement in lactic acidosis over the study period.

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.

Delayed retroperitoneal hemorrhage during veno-venous extracorporeal membrane oxygenation: a case report

Case

There are several reports of retroperitoneal hemorrhage induced by percutaneous femoral cannulation for extracorporeal membrane oxygenation (ECMO). However, there are no reports of delayed retroperitoneal hemorrhage, which develops a few days after ECMO initiation and is unrelated to the ECMO cannulation. Herein, we report a rare case of delayed retroperitoneal hemorrhage during veno‐venous extracorporeal membrane oxygenation (VV‐ECMO).

Outcome

A 54‐year‐old man was referred to our hospital because of severe acute respiratory distress syndrome. We initiated VV‐ECMO. The patient had severe delirium and was confined to a long‐term supine position to maintain circuit safety. On day 13, computed tomography unexpectedly revealed a large retroperitoneal hemorrhage spreading around the psoas muscle.

Conclusion

Delayed retroperitoneal hemorrhage can develop during VV‐ECMO management a few days after its initiation. Anticoagulant use and forceful muscular strain could be risk factors of delayed retroperitoneal hemorrhage.

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

INTRODUCTION:

Limited options exist for cardiovascular support of the trauma patient in extremis. This patient population offers challenges that are often considered insurmountable. This article identifies a heterogeneous group of trauma patients in extremis who may benefit from extracorporeal membrane oxygenation.

METHODS:

Data were sourced from the medical records of all patients placed on extracorporeal membrane oxygenation following trauma at a Level I Trauma Center between 1 December 2016 and 1 December 2017.

RESULTS:

All patients were male (N = 7), mostly with blunt injuries (n = 5), with an average age of 41 years and with an average Injury Severity Scores of 33 (median = 34). Two out of seven patients survived (28.5%). Survivors tended to have a longer duration on extracorporeal membrane oxygenation (13.5 vs 3.8 days), had extracorporeal membrane oxygenation initiated later (15 vs 7.8 days), and had suffered a blunt injury. Two patients were initiated on veno-arterial extracorporeal membrane oxygenation (both non-survivors) and five were initiated on veno-venous extracorporeal membrane oxygenation (two survivors, three non-survivors). Five patients were heparinized immediately (one survivor, four non-survivors), and two patients were heparinized after clotting was noted in the circuit (one survivor, one non-survivor). Three of the seven (42.8%) patients suffered cardiac arrest either prior to, or during, the initiation of extracorporeal membrane oxygenation (all non-survivors).

DISCUSSION:

Extracorporeal membrane oxygenation use in the trauma patient in extremis is not standard; however, this article demonstrates that extracorporeal membrane oxygenation is feasible in a complex, heterogeneous patient population when treated at designated centers.

Predictors of hospital mortality in adult trauma patients receiving extracorporeal membrane oxygenation for advanced life support: a retrospective cohort study

Background

Using extracorporeal membrane oxygenation (ECMO) to provide advanced life support in adult trauma patients remains a controversial issue now. The study was aimed at identifying the independent predictors of hospital mortality in adult trauma patients receiving ECMO for advanced cardiopulmonary dysfunctions.

Methods

This retrospective study enrolled 36 adult trauma patients receiving ECMO due to advanced shock or respiratory failure in a level I trauma center between August 2006 and October 2014. Variables collected for analysis were demographics, serum biomarkers, characteristics of trauma, injury severity score (ISS), damage-control interventions, indications of ECMO, and associated complications. The outcomes were hospital mortality and hemorrhage on ECMO. The multivariate logistic regression method was used to identify the independent prognostic predictors for the outcomes.

Results

The medians of age and ISS were 36 (27–49) years and 29 (19–45). Twenty-three patients received damage-control interventions before ECMO. Among the 36 trauma patients, 14 received ECMO due to shock and 22 for respiratory failure. The complications of ECMO are major hemorrhages (n = 12), acute renal failure requiring hemodialysis (n = 10), and major brain events (n = 7). There were 15 patients died in hospital, and 9 of them were in the shock group.

Conclusions

The severity of trauma and the type of cardiopulmonary dysfunction significantly affected the outcomes of ECMO used for sustaining patients with post-traumatic cardiopulmonary dysfunction. Hemorrhage on ECMO remained a concern while the device was required soon after trauma, although a heparin-minimized protocol was adopted.

Trial registration

This study reported a health care intervention on human participants and was retrospectively registered. The Chang Gung Medical Foundation Institutional Review Board approved the study (no. 201601610B0) on December 12, 2016. All of the data were extracted from December 14, 2016, to March 31, 2017.

Blunt and Penetrating Cardiac Trauma

Patients with traumatic cardiac injuries can present with wide variability in their severity of illness. The most severe will present in cardiac arrest, whereas the most benign may be altogether asymptomatic; most will fall somewhere in between. Management of cardiac injuries largely depends on mechanism of injury and patient physiology. Understanding the spectrum of injuries and their associated manifestations can help providers react more quickly and initiate potentially life-saving therapies more efficiently when time is critical. This article discusses the workup and management of both blunt and penetrating cardiac injuries.

Cardiac Support: Emphasis on Venoarterial ECMO

Major advances have been made in mechanical circulatory support in recent years. Venoarterial (VA) extracorporeal membrane oxygenation (ECMO) provides both pulmonary and circulatory support for critically ill patients with hemodynamic compromise, serving as a bridge to recovery or definitive therapy in the form of transplant or a durable ventricular assist device. In the past, VA ECMO support was used in cases of cardiogenic shock or failure to wean from cardiopulmonary bypass; however, the technology is now being applied to an ever-expanding list of conditions, including massive pulmonary embolism, cardiac arrest, drug overdose, and hypothermia.

Should Extracorporeal Membrane Oxygenation Be Offered? An International Survey

OBJECTIVES

To assess the current attitudes of extracorporeal membrane oxygenation (ECMO) program directors regarding eligibility for ECMO among children with cardiopulmonary failure.

STUDY DESIGN

Electronic cross-sectional survey of ECMO program directors at ECMO centers worldwide within the Extracorporeal Life Support Organization directory (October 2015-December 2015).

RESULTS

Of 733 eligible respondents, 226 (31%) completed the survey, 65% of whom routinely cared for pediatric patients. There was wide variability in whether respondents would offer ECMO to any of the 5 scenario patients, ranging from 31% who would offer ECMO to a child with trisomy 18 to 76% who would offer ECMO to a child with prolonged cardiac arrest and indeterminate neurologic status. Even physicians practicing the same specialty sometimes held widely divergent opinions, with 50% of pediatric intensivists stating they would offer ECMO to a child with severe developmental delay and 50% stating they would not. Factors such as quality of life and neurologic status influenced decision making and were used to support decisions for and against offering ECMO.

CONCLUSIONS

ECMO program directors vary widely in whether they would offer ECMO to various children with cardiopulmonary failure. This heterogeneity in physician decision making underscores the need for more evidence that could eventually inform interinstitutional guidelines regarding patient selection for ECMO.

Outcome measures of extracorporeal life support (ECLS) in trauma patients versus patients without trauma: a 7-year single-center retrospective cohort study

This single-center retrospective study included a total of 99 extracorporeal life support (ECLS) cannulated patients assigned to a traumatic extracorporeal life-support cohort (TECLS) or a non-traumatic extracorporeal life-support cohort (NTECLS). Forty-nine TECLS patients and 50 NTECLS patients were compared. The TECLS patients were significantly younger [49.9 years 16.6-86.2 vs. 57.1 (21.4-78.6); p = 0.007] and had lower body mass indices (BMIs) [27.7 kg/m² (20-37) vs. 32.5 (19-88.5); p = 0.001] than the NTECLS patients. The intensive care unit (ICU) survival rate [n = 34 (69.4%) vs. n = 13 (26%); p ≤ 0.001] and the hospital survival rate [n = 32 (65.3%) vs. n = 13 (26%); p ≤ 0.001] were significantly higher for the TECLS cohort than for the NTECLS cohort. The lengths of stay (LOSs) in the ICU [24 days (4.8-71.1) vs. 11.3 (0-88.6); p = 0.001] and in the hospital [46.6 days (2.9-197.6) vs. 21 (0.1-213.8); p = 0.001] were significantly longer for the TECLS patients than for the NTECLS patients.

Venovenous extracorporeal membrane oxygenation in adult respiratory failure: Scores for mortality prediction

Despite a potentially effective therapy for adult respiratory failure, a general agreement on venovenous extracorporeal membrane oxygenation (VV-ECMO) has not been reached among institutions due to its invasiveness and high resource usage. To establish consensus on the timing of intervention, large ECMO organizations have published the respiratory extracorporeal membrane oxygenation survival prediction (RESP) score and the ECMOnet score, which allow users to predict hospital mortality for candidates with their pre-ECMO presentations. This study was aimed to test the predictive powers of these published scores in a medium-sized cohort enrolling adults treated with VV-ECMO for acute respiratory failure, and develop an institutional prediction model under the framework of the 3 scores if a superior predictive power could be achieved. This retrospective study included 107 adults who received VV-ECMO for severe acute respiratory failure (a PaO2/FiO2 ratio <70 mm Hg) in a tertiary referral center from 2007 to 2015. Essential demographic and clinical data were collected to calculate the RESP score, the ECMOnet score, and the sequential organ failure assessment (SOFA) score before VV-ECMO. The predictive power of hospital mortality of each score was presented as the area under receiver-operating characteristic curve (AUROC). The multivariate logistic regression was used to develop an institutional prediction model. The surviving to discharge rate was 55% (n = 59). All of the 3 published scores had a real but poor predictive power of hospital mortality in this study. The AUROCs of RESP score, ECMOnet score, and SOFA score were 0.662 (P = 0.004), 0.616 (P = 0.04), and 0.667 (P = 0.003), respectively. An institutional prediction model was established from these score parameters and presented as follows: hospital mortality (Y) = -3.173 + 0.208 × (pre-ECMO SOFA score) + 0.148 × (pre-ECMO mechanical ventilation day) + 1.021 × (immunocompromised status). Compared with the 3 scores, the institutional model had a significantly higher AUROC (0.779; P < 0.001). The 3 published scores provide valuable information about the poor prognostic factors for adult respiratory ECMO. Among the score parameters, duration of mechanical ventilation, immunocompromised status, and severity of organ dysfunction may be the most important prognostic factors of VV-ECMO used for adult respiratory failure.

Establishing Benchmarks for Resuscitation of Traumatic Circulatory Arrest: Success-to-Rescue and Survival among 1,708 Patients

BACKGROUND

Attempts are made with emergency department thoracotomy (EDT) to salvage trauma patients who present to the hospital in extremis. The EDT allows for relief of cardiac tamponade, internal cardiac massage, and proximal hemorrhage control. Minimally invasive techniques, such as endovascular hemorrhage control (EHC) are available, but their noninferiority to EDT remains unproven. Before adopting EHC, it is important to evaluate the current outcomes of EDT. We hypothesized that EDT survival has improved during the last 4 decades, and outcomes stratified by pre-hospital CPR and injury patterns will provide benchmarks for success-to-rescue and survival outcomes for patients in extremis.

STUDY DESIGN

Consecutive trauma patients undergoing EDT from 1975 to 2014 were prospectively observed as part of quality improvement. Predicted probabilities of survival were adjusted for pre-hospital CPR, mechanism of injury, injury pattern, patient demographics, and time period of EDT using logistic regression. Success-to-rescue was defined as return of spontaneous circulation with blood pressure permissive for transfer to the operating room.

RESULTS

There were 1,708 EDTs included, with an overall 419 (24%) success-to-rescue patients and 106 survivors (6%), and 1,394 (79%) of these patients had pre-hospital CPR and 900 (54%) had penetrating wounds. The most common injury patterns were chest (29%), multisystem with head (27%), and multisystem without head (21%). Penetrating injury was associated with higher survival than blunt trauma (9% vs 3% p < 0.001). Success-to-rescue increased from 22% in 1975 to 1979 to 35% over the final 5 years (p < 0.001); survival increased from 5% to 14% (p < 0.001).

CONCLUSIONS

Outcomes of EDT have improved over the past 40 years. In the last 5 years, STR was 35% and overall survival was 14%. These prospective observational data provide benchmarks to define the role of EHC as an alternative approach for patients arriving in extremis.

Video-assisted thoracoscopic surgery for retained hemothorax in blunt chest trauma

Purpose of review

In the last decade, video-assisted thoracoscopic surgery (VATS) has become a popular method in diagnosis and treatment of acute chest injuries. Except for patients with unstable vital signs who require larger surgical incisions to check bleeding, this endoscopic surgery could be employed in the majority of thoracic injury patients with stable vital signs.

Recent findings

In the past, VATS was used to evacuate traumatic-retained hemothorax. Recent study has revealed further that lung repair during VATS could decrease complications after trauma. Management of fractured ribs could also be assisted by VATS. Early VATS intervention within 7 days after injury can decrease the rate of posttraumatic infection and length of hospital stay. In studies of the pathophysiology of animal models, N-acetylcysteine and methylene blue were used in animals with blunt chest trauma and found to improve clinical outcomes.

Summary

Retained hemothorax derived from blunt chest trauma should be managed carefully and rapidly. Early VATS intervention is a well tolerated and reliable procedure that can be applied to manage this complication cost effectively.

The feasibility of venovenous extracorporeal life support to treat acute respiratory failure in adult cancer patients

Venovenous extracorporeal life support (VV-ECLS) is a lifesaving but invasive treatment for acute respiratory failure (ARF) that is not improved with conventional therapy. However, using VV-ECLS to treat ARF in adult cancer patients is controversial. This retrospective study included 14 cancer patients (median age: 58 years [interquartile range: 51-66]; solid malignancies in 13 patients and hematological malignancy in 1 patient) who received VV-ECLS for ARF that developed within 3 months after anticancer therapies. VV-ECLS would be considered in selected patients with a P(a)O2/F(i)O2 ratio ≤70 mmHg under advanced mechanical ventilation. Before ECLS, the medians of intubation day, P(a)O2/F(i)O2 ratio, and Sequential Organ Failure Assessment (SOFA) score were 8 (2-12), 62 mmHg (53-76), and 10 (9-14), respectively. The case numbers of bacteremia, thrombocytopenia (platelet count <50000 cells/μL), and neutropenia (actual neutrophil count <1000 cells/μL) detected before ECLS were 3 (21%), 2 (14%), and 1 (7%), respectively. After 24 hours of ECLS, a significant improvement was seen in P(a)O2/F(i)O2 ratio but not in SOFA score. Six patients experienced major hemorrhages during ECLS. The median ECLS day, ECLS weaning rate, and hospital survival were 11 (7-16), 50% (n = 7), and 29% (n = 4). The development of dialysis-dependent nephropathy predicted death on ECLS (odds ratio: 36; 95% confidence interval: 1.8-718.7; P = 0.01). With a median follow-up of 11 (6-43) months, half of the survivors died of cancer recurrence and the others were in partial remission. The most prominent benefit of VV-ECLS is to improve the arterial oxygenation and rest the lungs. This may increase the chance of recovery from ARF in selected cancer patients.

The use of double lumen cannula for veno-venous ECMO in trauma patients with ARDS

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.

Venovenous extracorporeal life support for posttraumatic respiratory distress syndrome in adults: the risk of major hemorrhages

Background

The aim of this retrospective study is to investigate the therapeutic benefits and the bleeding risks of venovenous extracorporeal life support (VV-ECLS) when used for adult posttraumatic respiratory distress syndrome (posttraumatic ARDS).

Materials and methods

Twenty adult trauma patients (median age: 38 years, median injury severity score: 35) treated with VV-ECLS in a level I trauma center between January 2004 and June 2013 were enrolled in this study. The indication of VV-ECLS for posttraumatic ARDS was refractory hypoxemia (P_aO₂/F_iO₂ ratio ≤ 70 mmHg) under advanced mechanical ventilation. To minimize potential complications, a protocol-guided VV-ECLS was adopted.

Results

Sixteen patients were weaned off VV-ECLS, and of these patients fourteen survived. Medians of the trauma-to-ECLS time, the pre-ECLS mechanical ventilation, and the ECLS duration in all patients were 64, 45, and 144 hours respectively. The median P_aO₂/F_iO₂ ratio was improved significantly soon after VV-ECLS, from 56 to 106 mmHg (p < 0.001). However, seven major hemorrhages occurred during VV-ECLS, of which three were lethal. The multivariate analysis revealed that the occurrence of major hemorrhages during VV-ECLS was independently related to the trauma-to-ECLS time < 24 hours (OR: 20; p = 0.02; 95% CI: 2–239; c-index: 0.81).

Conclusions

Despite an effective respiratory support, VV-ECLS should be cautiously administered to patients who develop advanced ARDS soon after major trauma.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-014-0056-0) contains supplementary material, which is available to authorized users.