Severe respiratory failure in multiple trauma patients: extracorporeal support as a salvage therapy - a single-center experience

Abstract

Introduction Use of extracorporeal life support (ECLS) in trauma casualties is limited by concerns regarding hemorrhage, particularly in the presence of traumatic brain injury (TBI). We report usage of ECMO/ interventional lung assist (iLA) as salvage therapy in 13 trauma patients. A high-flow technique without anticoagulation was used in cases with coagulopathy or severe TBI. Methods Data were collected from all adult trauma cases referred to one center for ECMO/iLA treatment due to severe hypoxemic respiratory failure. Thirteen consecutives cases are reported. The type of assistance was chosen based on a flowchart. Type of Study: therapeutic, level of evidence IV. We analyzed patient data, injury data, blood gases before connection, methods of assistance, coagulation study, complications, survival and neurological outcome. Results Thirteen casualties had an average Injury Severity Score of 50.3 +/- 10.5 (age 27.7 +/- 8.6 years, 69.2% male) and were supported 9.9 +/- 4.8 days on ECMO (n = 7) and 7.16 +/- 5.9 days on iLA (n = 6). All suffered severe chest injuries, including one cardiac perforation. Most were coagulopathic prior to initiation of ECMO/iLA support. Among the seven patients with TBI, four had active intracranial hemorrhage. Only 30% of the patients received continuous anticoagulation during the first 24 hours of support without clotting of the system or diagnosis of a thromboembolic event. 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 due to septic (n = 3) and cardiogenic shock (n = 1). Survival rates were 57 and 83% on ECMO and iLA, respectively. Follow-up of survivors detected no neurological deterioration. Conclusion ECMO/iLA therapy can be used as rescue therapy in adult trauma cases with severe hypoxemic respiratory failure, even in the presence of coagulopathy, bleeding and/or brain injury. The benefits of oxygenation and circulatory support must be weighed individually against the risk of hemorrhage. Further research should determine whether ECMO therapy also confers survival benefit.