Extracorporeal membrane oxygenation in trauma patients: a systematic review

Abstract

Background Extracorporeal membrane oxygenation (ECMO) has evolved considerably over the past two decades and has been gradually utilized in severe trauma. However, the indications for the use of ECMO in trauma remain uncertain and the clinical outcomes are different. We performed a systematic review to provide an overall estimate of the current performance of ECMO in the treatment of trauma patients. Materials and methods We searched PubMed and MEDLINE databases up to the end of December 2019 for studies on ECMO in trauma. The PRISMA statement was followed. Data on demographics of the patient, mechanism of injury, injury severity scores (ISS), details of ECMO strategies, and clinical outcome were extracted. Results A total of 58 articles (19 retrospective reports and 39 case reports) were deemed eligible and included. In total, 548 patients received ECMO treatment for severe trauma (adult 517; children 31; mean age of adults 34.9 ± 12.3 years). Blunt trauma (85.4%) was the primary injury mechanism, and 128 patients had traumatic brain injury (TBI). The mean ISS was 38.1 ± 15.0. A total of 71.3% of patients were initially treated with VV ECMO, and 24.5% were placed on VA ECMO. The median time on ECMO was 9.6 days, and the median time to ECMO was 5.7 days. A total of 60% of patients received initially heparin anticoagulation. Bleeding (22.9%) and thrombosis (19%) were the most common complications. Ischemia of the lower extremities occurred in 9 patients. The overall hospital mortality was 30.3%. Conclusions ECMO has been gradually utilized in a lifesaving capacity in severe trauma patients, and the feasibility and advantages of this technique are becoming widely accepted. The safety and effectiveness of ECMO in trauma require further study. Several problems with ECMO in trauma, including the role of VA-ECMO, the time to institute ECMO, and the anticoagulation strategy remain controversial and must be solved in future studies.

Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature

“…Extended advanced monitoring is suggested to detect early deterioration, ideally as a baseline before initiation of ECMO to prevent potentially deleterious bleeding or thromboembolic complications [ 201 , 202 ]. Using extracorporeal lung assist has been reported in various circuit compositions, with all of these reports describing feasibility without an increased risk of bleeding and survival benefits, as well as high survival rates [ 161 , 162 , 203 , 204 , 205 , 206 , 207 , 208 , 209 , 210 , 211 , 212 , 213 , 214 , 215 , 216 , 217 ]. Some authors even reported using it in severe bleeding situations [ 158 , 216 , 217 , 218 ].…”

“…To gain the greatest benefit, a decision to initiate ECMO should not be delayed [ 209 , 213 , 214 , 219 ]. In particular, the injury severity score (ISS) did not show an influence on survival for patients treated with or without ECMO [ 203 , 204 , 206 , 207 , 210 , 211 , 212 ]. Therefore, ECMO should be initiated early in trauma patients if indicated, rather than considered a contraindication ( Table 9 ).…”

Initial Experiences of Extracorporeal Membrane Oxygenation for Trauma Patients at a Single Regional Trauma Center in South Korea

“…There were nine patients in whom heparin was not administered during ECMO application (three survivors [30.0%] and six non-survivors [40.0%]). In patients with multiple traumas, the chances of bleeding are high, mak- ing it challenging to use anti-hemostatic agents [12][13][14].…”

Mechanical Ventilation in the Trauma Patient

“…There is much research needed on the proper initiation time for ECMO in the trauma patient and which patients will have the most benefit from ECMO. The safety and efficacy of ECMO still needs to be studied [20].…”