ECMO in major burn patients: feasibility and considerations when multiple modes of mechanical ventilation fail

Abstract

BackgroundWe report two cases of acute respiratory distress syndrome in burn patients who were successfully managed with good outcomes with extra corporeal membrane oxygenation (ECMO) after failing multiple conventional modes of ventilation, and review the relevant literature.Case presentationThe two patients were a 39-year-old male and 53-year-old male with modified Baux Scores of 79 and 78, respectively, with no known inhalation injury. After the initial modified Parkland-based fluid resuscitation and partial escharotomy, both patients developed worsening hypoxemia and acute respiratory distress syndrome.The hypoxemia continued to worsen on multiple modes of ventilation including volume control, pressure regulated volume control, pressure control, airway pressure release ventilation and volumetric diffusive ventilation. In both cases, the PaO2 ≤ 50 mm Hg on a FiO2 100% during the trial of mechanical ventilation. The deterioration was rapid (<12 h since onset of worsening oxygenation) in both cases.A decision was made to trial the patients on ECMO. Veno-Venous ECMO (V-V ECMO) was successfully initiated following cannulation-under transesophgeal echo guidance—with the dual lumen Avalon® (Maquet, NJ, USA) cannula. ECMO support was maintained for 4 and 24 days, respectively. Both patients were successfully weaned off ECMO and were discharged to rehabilitation following their complex hospital course.ConclusionEarly ECMO for isolated respiratory failure in the setting on maintained hemodynamics resulted in a positive outcome in our two burn patients suffered from acute respiratory distress syndrome.

Extracorporeal Membrane Oxygenation in Patients with Burns, Hero or Futile Medical Care? A Systematic Review and Meta-Analysis

“…In recent decades, ECMO has become an essential tool in the care of patients with severe cardiac and pulmonary dysfunctions that are refractory to conventional management [10,11,50]. [23,[25][26][27][28][29][30][31]. In this study, our meta-analysis revealed a pooled SMR of 2.07, suggesting a two-fold higher mortality rate compared to the predicted mortality in patients receiving ECMO therapy.…”

“…Soussi et al in 2016 reported 91% in-hospital mortality rate in 11 burn patients receiving ECMO therapy, suggesting that ECMO treatment for burn patients is not advisable [3]. However, in the last few years, several observational studies have revealed favourable outcomes from the use of ECMO [23,[25][26][27][28][29][30][31]. In this study, our meta-analysis revealed a pooled SMR of 2.07, suggesting a two-fold higher mortality rate compared to the predicted mortality in patients receiving ECMO therapy.…”

“…Due to the insu cient patient numbers from the available literature, along with limited evidence, the role of ECMO in patients with burn and inhalation injuries is unclear [2]. In recent years, several case series and retrospective studies have been performed, but the ndings still vary [3,[22][23][24][25][26][27][28][29][30][31][32]. Randomised controlled trials of ECMO compared to conventional therapy might be the solution.…”

A Review of Burn Patients Requiring Extracorporeal Membrane Oxygenation at a Burns Facility

“…Kennedy et al described two burn patients requiring ECMO for ARDS. Both patients survived [23]. Thompson et al also described two similar patients surviving [24].…”

Extracorporeal membrane oxygenation combined with continuous renal replacement therapy for the treatment of severe burns: current status and challenges

“…A few studies have investigated the effects of ECMO for burns with inhalation injury and it has been demonstrated that early implementation of ECMO is of benefit in the treatment of severe refractory ARDS [ 47 , 48 ]. CRRT can be used to treat AKI to alleviate fluid overload, improve renal recovery and reduce inflammation and it has been widely used in clinical practice for severe burns [ 49 , 50 ].…”