Early veno-venous extracorporeal membrane oxygenation is an effective strategy for traumatically injured patients presenting with refractory respiratory failure

Abstract

Background Veno-venous extracorporeal membrane oxygenation (VV ECMO) is used for respiratory failure when standard therapy fails. Optimal trauma care requires patients be stable enough to undergo procedures. Early VV ECMO (EVV) to stabilize trauma patients with respiratory failure as part of resuscitation could facilitate additional care. As VV ECMO technology is portable and prehospital cannulation possible, it could also be used in austere environments. We hypothesize that EVV facilitates injury care without worsening survival. Methods Our single center, retrospective cohort study included all trauma patients between January 1, 2014, and August 1, 2022, who were placed on VV ECMO. EVV was defined as cannulation ≤48 hours from arrival with subsequent operation for injuries. Data were analyzed with descriptive statistics. Parametric or nonparametric statistics were used based on the nature of the data. After testing for normality, significance was defined as a p < 0.05. Logistic regression diagnostics were performed. Results Seventy-five patients were identified and 57 (76%) underwent EVV. There was no difference in survival between the EVV and non-EVV groups (70% v 61%, p = 0.47). Age, race, and gender did not differ between EVV survivors and non-survivors. Time to cannulation (4.5 h v 8 h, p = 0.39) and injury severity scores (34 v 29, p = 0.74) were similar. EVV survivors had lower lactic acid levels pre-cannulation (3.9 mmol/L v 11.9 mmol/L, p < 0.001). A multivariable logistic regression analysis examining admission and pre-cannulation laboratory and hemodynamic values demonstrated that lower pre-cannulation lactic acid levels predicted survival (OR 1.2, 95% CI 1.02-1.5, p = 0.03) with a significant inflection point of 7.4 mmol/L corresponding to decreased survival at hospital discharge. Conclusions Patients undergoing EVV did not have increased mortality compared to the overall trauma VV ECMO population. EVV resulted in ventilatory stabilization that allowed subsequent procedural treatment of injuries. Level of Evidence Therapeutic Care/Management, IV

Modern mechanical ventilation strategies for the acute care surgeon: What you need to know

“…65 A recent single-center retrospective cohort study of early VV-ECMO to stabilize patients to undergo procedural treatment of injuries reported a 70% survival in 57 patients. 66 Optimal ventilation while on ECMO remains a topic of great interest. Benefits of continuing mechanical ventilation on ECMO versus extubation and complete liberation from the ventilator are unknown.…”