EXTRACORPOREAL MEMBRANE OXYGENATION IN TRAUMA

• Ahmet Melih Savaş
• 20 April, 2022
• 3896 Person Viewed

The use of ECMO in trauma is increasing as it saves time for life-saving interventions such as early stabilization and damage control surgery, organ/vascular structure repair.  We have evaluated the article (1) on the use of ECMO in trauma written by Swol et al.

 

Over the past decades, extracorporeal membrane oxygenation (ECMO) has been utilized increasingly in severe trauma patients, and its advantages are becoming widely accepted (2,3). The use of ECMO in the trauma population has been reported to have a survival benefit in patients with severe refractory hypoxic respiratory failure (2,4-9). Trivedi et al. highlighted the role of ECMO in supporting gas exchange while allowing for lung-protective ventilation although the details of both pre-ECMO gas exchange and ventilator management while on ECMO are not provided. (4). Thus, in principle, ECMO can provide a temporary measure of support while awaiting pulmonary recovery in the setting of trauma, especially in pulmonary contusion, hemopneumothorax, or aspiration. The weight of the current evidence suggests that an acute hemorrhagic condition should not be considered an absolute contraindication to either V-V or V-A ECMO (10). An anticoagulant-free period might be useful in these cases, especially considering the coagulopathy already existing in a bleeding patient or in special conditions like brain injury. The use of ECMO in patients with traumatic brain injuries (TBIs) remains controversial due to the risk of lethal intracerebral bleeding. Additionally, because jugular venous cannulation may obstruct brain venous outflow, femoral-femoral cannulation for V-V ECMO should be considered in patients with TBI.

ECMO may be a bridging strategy to buy time to stabilize the patient. Examples include an adjunct to damage control resuscitation, facilitating stabilization for damage control surgery, and a temporizing measure for radiological interventions directed at hemorrhage control. Early cannulation for ECMO preserves systemic organ perfusion in cases of hemorrhagic shock, and tailored anticoagulation protocols may outweigh the risk of associated bleeding. (8,10). Endovascular repair (EVAR) of thoracic aortic injuries and resuscitative endovascular balloon occlusion of the aorta (REBOA) might also play a role in damage control resuscitation in trauma, but the present

The article by Trivedi et al. illustrates a recent contribution to the field of extracorporeal respiratory support in blunt injuries. A total of seven male patients, aged 32.1 ± 8.7 years, experienced pulmonary contusions after blunt trauma, causing acute respiratory distress syndrome (ARDS) and receiving ECMO for respiratory support. Of the seven patients, five (71%) received venovenous (V-V) ECMO and two (29%) received venoarterial (V-A) ECMO. The mean ECMO support duration was 13.2 ± 6.5 days (median, 17 days), and six patients were successfully weaned off ECMO. Overall, two (29%) patients died before discharge or transfer (one before and one after weaning off ECMO), both of whom had required V-A ECMO (4).

Given varying survival rates between 35% and 90%, future studies should use multi-institutional registry data or multiinstitutional prospective analysis to avoid positive outcome bias and to determine actual survival rates associated with ECMO in trauma (2,11). Reviews of national trauma databanks and registries have shown that survival in trauma patients may be similar to nontrauma ECMO patients in both adults and children (2,12-14).

To this end, a separate notification for “trauma” patients in the ELSO Registry has been created. Further, a new registry addendum for trauma patients is being developed. The Trauma Addendum will serve to collect specific relevant details about trauma patients supported with ECMO, especially regarding the severity of injuries and decisions surrounding anticoagulation. Several publications report acceptable outcomes in trauma patients supported with ECMO, upward of 70% for respiratory support. Yet, we need more evidence to support this preliminary observation, and the Trauma Addendum should provide it. To this end, we advocate for an active participation in the ELSO registry for all institutions that provide this lifesaving critical care support in trauma patients.

 

In particular, recording national and international trauma is important to guide new multi-centric studies in this area.  The national database must be created in our country.

 

For further reading and full text of the article, visit ASAIO Journal article page 

 

References:

1. Swol J, Cannon JW, Barbaro RP, Fanning JJ, Zonies D. Extracorporeal Membrane Oxygenation in Trauma. ASAIO J. 2022 Apr 1;68(4):e62-e63. doi: 10.1097/MAT.0000000000001724. PMID: 35349527.

2. Swol J, Brodie D, Napolitano L, et al; Extracorporeal Life Support Organization (ELSO): Indications and outcomes of extracorporeal life support in trauma patients. J Trauma Acute Care Surg 84: 831–837, 2018.

3. Hu PJ, Griswold L, Raff L, et al: National estimates of the use and outcomes of extracorporeal membrane oxygenation after acute trauma. Trauma Surg Acute Care Open 4: e000209, 2019.

4. Trivedi JR, Alotaibi A, Sweeney JC, et al: Use of extracorporeal membrane oxygenation in blunt traumatic injury patients with acute respiratory distress syndrome. ASAIO J 68: e60–e61, 2022.

5. Ull C, Schildhauer TA, Strauch JT, Swol J: Outcome measures of extracorporeal life support (ECLS) in trauma patients versus patients without trauma: A 7-year single-center retrospective cohort study. J Artif Organs 20: 117–124, 2017.

6. Bosarge PL, Raff LA, McGwin G Jr, et al: Early initiation of extracorporeal membrane oxygenation improves survival in adult trauma patients with severe adult respiratory distress syndrome. J Trauma Acute Care Surg 81: 236–243, 2016.

7. Guirand DM, Okoye OT, Schmidt BS, et al: Venovenous extracorporeal life support improves survival in adult trauma patients with acute hypoxemic respiratory failure: A multicenter retrospective cohort study. J Trauma Acute Care Surg 76: 1275–1281, 2014.

8. Arlt M, Philipp A, Voelkel S, et al: Extracorporeal membrane oxygenation in severe trauma patients with bleeding shock. Resuscitation 81: 804–809, 2010.

9. Ried M, Bein T, Philipp A, et al: Extracorporeal lung support in trauma patients with severe chest injury and acute lung failure: A 10-year institutional experience. Crit Care 17: R110, 2013.

10. Willers A, Swol J, Kowalewski M, et al: Extracorporeal life support in hemorrhagic conditions: A systematic review. ASAIO J 67: 476–484, 2021.

11. Wang C, Zhang L, Qin T, et al: Extracorporeal membrane oxygenation in trauma patients: A systematic review. World J Emerg Surg 15: 51, 2020.

12. Behr CA, Strotmeyer SJ, Swol J, Gaines BA: Characteristics and outcomes of extracorporeal life support in pediatric trauma patients. J Trauma Acute Care Surg 89: 631–635, 2020.

13. Burke CR, Crown A, Chan T, McMullan DM: Extracorporeal life support is safe in trauma patients. Injury 48: 121–126, 2017.

14. Watson JA, Englum BR, Kim J, et al: Extracorporeal life support use in pediatric trauma: A review of the National Trauma Data Bank. J Pediatr Surg 52: 136–139, 2017.