Extracorporeal life support in patients with severe trauma: An advanced treatment strategy for refractory clinical settings

Bonacchi, Massimo; Spina, Rosario; Torracchi, Leonardo; Harmelin, Guy; Sani, Guido; Peris, Adriano

doi:10.1016/j.jtcvs.2012.08.046

Cited by 63 publications

(46 citation statements)

References 28 publications

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“…17 Only a few small series have argued that ECMO support could improve outcome in patients with disastrous trauma with coexisting chest injury or bleeding shock. 9,27,28 The preservation of major organ function by ECMO may indeed provide a better chance for survival in these patients. The present study showed a better outcome in this group of patients, especially when they survived the first month.…”

Section: Discussionmentioning

confidence: 99%

Survival Analysis After Extracorporeal Membrane Oxygenation in Critically Ill Adults

et al. 2016

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As a result of many "miraculous" experiences, intensive care facilities everywhere in Taiwan are adopting ECMO technology. 13,14 The Taiwan National Health Insurance (NHI) initiated reimbursement for the high costs of ECMO therapy in 2002, further supporting its rapidly expanding implementation in the years since. The criteria for instituting ECMO in adult patients included cardiogenic shock of various origins, respiratory failure (defined as Pao 2 <60 mm Hg under 100% Fio 2 , CO 2 retention, or a bridge to lung transplantation) resulting from infectious or noninfectious processes, airway injury, and hypothermia (core temperature ≤30°C).15 ECMO is most used as a last resort for patients with severe refractory shock. The Taiwan NHI Background-Extracorporeal membrane oxygenation (ECMO) provides circulatory and respiratory support for patients with severe acute cardiopulmonary failure. The objective of this study was to examine the survival outcomes for patients who received ECMO. Methods and Results-Adult patients who received ECMO from September 1, 2002, to December 31, 2012 from the Taiwan National Health Insurance Database associated with coronary artery bypass graft surgery, myocardial infarction/cardiogenic shock, injury, and infection/septic shock. A Cox regression model was used to determine hazard ratios and to compare 30-day and 1-year survival rates with the myocardial infarction/cardiogenic shock group used as the reference. The mean±SD age of the 4227-patient cohort was 57±17 years, and 72% were male. The overall mortalities were 59.8% and 76.5% at 1 month and 1 year. Survival statistics deteriorated sharply when ECMO was required for >3 days. Acute (30-day) survival was more favorable in the infection/septic shock (n=1076; hazard ratio, 0.61; 95% confidence interval, 0.55-0.67), coronary artery bypass graft surgery (n=1077; hazard ratio, 0.68; 95% confidence interval, 0.61-0.75), and injury (n=369, hazard ratio, 0.82; 95% confidence interval, 0.70-0.95) groups. The extended survival rapidly approached an asymptote near 20% for the infection/septic shock, myocardial infarction/cardiogenic shock (n=1705), and coronary artery bypass graft surgery groups. The pattern of survival for the injury group was somewhat better, exceeding 30% at year-end. Conclusions-Regardless of initial pathology, patients requiring ECMO were critically ill with similar guarded prognoses.Those in the trauma group had somewhat better outcomes. Determining the efficacy and cost-effectiveness of ECMO should be a critical future goal. Continuing medical education (CME) credit is available for this article. Go to http://cme.ahajournals.org to take the quiz.Received August 22, 2015; accepted April 19, 2016. claims database contains extensive clinical data obtained during the roll out of this therapeutic modality and thus allows the study of the outcomes of patients on ECMO. Despite the efficacy of prompt ECMO support as an acute lifesaving strategy in cardiovascular emergencies, the overall mortality associated with cardiogenic shock...

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Section: Discussionmentioning

confidence: 99%

Survival Analysis After Extracorporeal Membrane Oxygenation in Critically Ill Adults

et al. 2016

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“…A secure implantation of VA-ECLS is also necessary to prevent blood loss via the cannulation sites. Cannulation sites hemorrhage related to mal-cannulation is a possible explanation of the high failure rate (29%, 4/14) of VA-ECLS in a practice adopting percutaneous Seldinger technique exclusively [7], as seen in our case 4. The man was found unconscious without obvious injuries in the woods.…”

Section: Discussionmentioning

confidence: 93%

“…VA-ECLS here is a desperate attempt to save patients from irreversibility and the decision to activate it is often made under time pressure [7,8]. Owing to the wide variety of presenting injuries and their corresponding managements, establishing an integrated protocol of VA-ECLS in traumatology can only be learned by exploration.…”

Section: Discussionmentioning

confidence: 99%

“…Theoretically, VA-ECLS is harmful to patients in an uncontrolled bleeding shock because it may augment the hemorrhaging by transiently increasing the arterial pressure and worsen the early-type (fibrinolytic) traumatic coagulopathy [6] with its heparin-bond circuit. Two recent studies of using ECLS to treated patients with traumatic bleeding shock/CA show acceptable survivals, 14% (2/14) [7] and 66% (2/3) [8], in the VA group. However, none of the two studies provides clear information about the timing and strategies to activate this challenging resuscitation.…”

Section: Introductionmentioning

confidence: 99%

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

Tseng

Liu

et al. 2014

Scand J Trauma Resusc Emerg Med

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ObjectivesVenoarterial extracorporeal life support (VA-ECLS) is an effective support of acute hemodynamic collapse caused by miscellaneous diseases. However, using VA-ECLS for post-traumatic shock is controversial and may induce a disastrous hemorrhage. To investigate the feasibility of using VA-ECLS to treat post-traumatic shock or cardiac arrest (CA), a single-center experience of VA-ECLS in traumatology was reported.Materials and methodsThis retrospective study included nine patients [median age: 37 years, interquartile range (IQR): 26.5-46] with post-traumatic shock/CA who were treated with VA-ECLS in a single institution between November 2003 and October 2012. The causes of trauma were high-voltage electrocution (n = 1), penetrating chest trauma (n = 1), and blunt chest or poly-trauma (n = 7). Medians of the injury severity score and the maximal chest abbreviated injury scale were 34 (IQR: 15.5-41) and 4 (IQR: 3-4), respectively. All patients received peripheral VA-ECLS without heparin infusion for at least 24 hours.ResultsThe median time from arrival at our emergency department (ED) to VA-ECLS was 6 h (IQR: 4-47.5). The median duration of VA-ECLS was 91 h (IQR: 43-187) with a duration < 24 h in 2 patients. Among the 9 patients, 5 received VA-ECLS to treat the post-traumatic shock/CA presenting during (n = 2) or following (n = 3) damage-control surgeries for initial trauma, and another 4 patients were supported for non-surgical complications associated with initial trauma. VA-ECLS was terminated in 2 non-survivors owing to uncontrolled hemothorax or retroperitoneal hemorrhage. Three patients survived to hospital discharge. All of them received damage-control surgeries for initial trauma and experienced a complicated hospitalization after weaning off VA-ECLS.ConclusionUsing VA-ECLS to treat post-traumatic shock/CA is challenging and requires multidisciplinary expertise.

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“…Several case reports and small case series describe the use of ECLS in the management of pediatric and adult traumatic respiratory failure including blunt and penetrating parenchymal and tracheobronchial injuries [1][2][3][4][5][6][7][8][9][10], cardiac contusions [11][12][13], traumatic brain injury [14][15][16][17], and shock [18][19][20]. Retrospective cohort studies of trauma patients cared for at tertiary care referral centers report survival after ECLS ranging from 50-79% [21][22][23][24]. These case reports, small case series, and retrospective reviews suggest a potential role for ECLS in the management of traumatically injured patients.…”

Section: Introductionmentioning

confidence: 99%

Outcomes of Extracorporeal Life Support in Trauma

2014

J Surg

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Background: Extracorporeal life support (ECLS) is a lifesaving treatment for critically ill trauma patients with refractory cardiopulmonary failure. The purpose of this analysis is to use a large national trauma database to characterize the use and outcomes of ECLS in trauma. Methods:Patients from centers that performed ECLS were identified from the 2007-2009 National Trauma Data Bank (NTDB). Demographic, clinical, and outcome data were abstracted. Univariate analyses were performed using chi-square, Mann-Whitney U-test, and regression analyses. Propensity score analysis and multiple regression models were developed using backwards stepwise logistic regression to identify risk factors for ECLS and predictors of mortality; p<0.05 was considered significant.Results: Forty-two centers of 682 (6%) performed ECLS on 78 of 245,950 patients (0.03%). ECLS patients were younger, more severely injured, had a longer ICU and hospital length of stay, and a higher mortality. Univariate analysis showed that ECLS patients had a significantly increased risk of death (OR 28; p<0.001). Among patients receiving ECLS, predictors of mortality included injury severity score (ISS) (OR 1.06; 95% CI 1.01-1.11; p=0.03) and cardiac arrest (OR 7.57; 95% CI 1.58-36.2; p=0.01). After propensity score adjusted logistic regression, ECLS was still a significant predictor of mortality (OR 6, 95% CI 2.76-13.1, p<0.01). Patients receiving ECLS at a center that performed 5 or more ECLS runs trended towards a lower mortality rate (27% vs. 73%, p=0.10). Conclusions:ECLS is infrequently used in the trauma setting. When compared to other trauma patients, ECLS patients are more critically ill and are at increased odds of death. Further study is required to determine which patient and hospital characteristics predict improved survival.

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Extracorporeal life support in patients with severe trauma: An advanced treatment strategy for refractory clinical settings

Abstract: From our data, ECLS seems to be a valuable option to resuscitate patients with severe trauma when conventional therapies are insufficient. ECLS is safe, feasible, and effective in providing hemodynamic support and blood gas exchange.

Cited by 63 publications

References 28 publications

Survival Analysis After Extracorporeal Membrane Oxygenation in Critically Ill Adults

Survival Analysis After Extracorporeal Membrane Oxygenation in Critically Ill Adults

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

Outcomes of Extracorporeal Life Support in Trauma

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