Extracorporeal life support in patients with multiple injuries and severe respiratory failure: a single-center experience?

BACKGROUND: The use of extracorporeal life support in trauma casualties is limited by concerns regarding hemorrhage, particularly in the presence of traumatic brain injury (TBI). We report the use of extracorporeal membrane oxygenation (ECMO)/interventional lung assist (iLA) as salvage therapy in trauma patients. High-flow technique without anticoagulation was used in patients with coagulopathy or TBI.

METHODS: Data were collected from all adult trauma patients referred to one center for ECMO/iLA treatment owing to severe hypoxemic respiratory failure.

RESULTS: Ten casualties had a mean (SD) Injury Severity Score (ISS) of 50.3 (10.5) (mean [SD] age, 29.8 [7.7] years; 60% male) and were supported 9.5 (4.5) days on ECMO (n = 5) and 7.6 (6.5) days on iLA (n = 5). All experienced blunt injury with severe chest injuries, including one cardiac perforation. Most were coagulopathic before initiation of ECMO/iLA support. Among the seven patients with TBI, four had active intracranial hemorrhage. Complications directly related to support therapy were not lethal; these included hemorrhage from a cannulation site (n = 1), accidental removal of a cannula (n = 1), and pressure sores (n = 3). Deaths occurred owing to septic (n = 2) and cardiogenic shock (n = 1). Survival rates were 60% and 80% on ECMO and iLA, respectively. Follow-up of survivors detected no neurologic deterioration.

CONCLUSION: ECMO/iLA therapy can be used as a rescue therapy in adult trauma patients with severe hypoxemic respiratory failure, even in the presence of coagulopathy and/or brain injury. The benefits of rewarming, acid-base correction, oxygenation, and circulatory support must be weighed individually against the risk of hemorrhage. Further research should determine whether ECMO therapy also confers survival benefit.

LEVEL OF EVIDENCE: Therapeutic study, level V.