Utilization and Outcomes of Extracorporeal Membrane Oxygenation Following Traumatic Brain Injury in the United States

Abstract

Objectives: Describe contemporary ECMO utilization patterns among patients with traumatic brain injury (TBI) and examine clinical outcomes among TBI patients requiring ECMO. Design: Retrospective cohort study. Setting: Premier Healthcare Database (PHD) between January 2016 to June 2020. Subjects: Adult patients with TBI who were mechanically ventilated and stratified by exposure to ECMO. Results: Among patients exposed to ECMO, we examined the following clinical outcomes: hospital LOS, ICU LOS, duration of mechanical ventilation, and hospital mortality. Of our initial cohort (n = 59,612), 118 patients (0.2%) were placed on ECMO during hospitalization. Most patients were placed on ECMO within the first 2 days of admission (54.3%). Factors associated with ECMO utilization included younger age (OR 0.96, 95% CI (0.95–0.97)), higher injury severity score (ISS) (OR 1.03, 95% CI (1.01–1.04)), vasopressor utilization (2.92, 95% CI (1.90–4.48)), tranexamic acid utilization (OR 1.84, 95% CI (1.12–3.04)), baseline comorbidities (OR 1.06, 95% CI (1.03–1.09)), and care in a teaching hospital (OR 3.04, 95% CI 1.31–7.05). A moderate degree (ICC = 19.5%) of variation in ECMO use was explained at the individual hospital level. Patients exposed to ECMO had longer median (IQR) hospital and ICU length of stay (LOS) [26 days (11–36) versus 9 days (4–8) and 19.5 days (8–32) versus 5 days (2–11), respectively] and a longer median (IQR) duration of mechanical ventilation [18 days (8–31) versus 3 days (2–8)]. Patients exposed to ECMO experienced a hospital mortality rate of 33.9%, compared to 21.2% of TBI patients unexposed to ECMO. Conclusions: ECMO utilization in mechanically ventilated patients with TBI is rare, with significant variation across hospitals. The impact of ECMO on healthcare utilization and hospital mortality following TBI is comparable to non-TBI conditions requiring ECMO. Further research is necessary to better understand the role of ECMO following TBI and identify patients who may benefit from this therapy.

Health Disparities in Extracorporeal Membrane Oxygenation Utilization and Outcomes: A Scoping Review and Methodologic Critique of the Literature*

“…Race and/or ethnicity was the primary study aim in five citations (13%). No statistical difference or mixed results were observed in 25 (64%) of studies (51, 52, 135–147). Studies with cardiac disease, arrest, transplant, or shock observed patients from diverse backgrounds having lower ECMO use in seven (28, 31, 129, 148–151) versus higher ECMO use in three (26, 89, 152).…”

“…Of 17 studies examining insurance status, one from South Korea showed higher ECMO use in patients with NHI versus “medical aid” (164). Of 16 U.S. studies, four found no difference (31, 139, 159, 165), 10 showed greater use in patients with private insurance (vs government insurance) (28, 89, 129, 132, 137, 148, 154, 160, 166) or any insurance (vs uninsured) (167). One obstetric study observed higher ECMO use with government insurance (155), and another showed lower ECMO use in insured patients with COVID-19 (138).…”

ECMO in adult patients with severe trauma: a systematic review and meta-analysis

“…Previous research has shown that trauma patients receiving ECMO are typically younger and have fewer comorbidities compared to non-trauma populations. However, no significant difference in overall survival rates has been observed [ 20 , 21 , 23 , 49 ]. Traumatic injuries can cause acute cardiopulmonary failure through direct chest trauma or indirect injuries from non-pulmonary trauma and related treatments like blood transfusions, fluid overload, and ventilator-induced acute lung injury.…”

“…TBI was previously contraindicated for ECMO due to the heightened risk of intracranial hemorrhage from systemic anticoagulation [ 30 , 60 , 61 ]. Recently, advancements in procedures have mitigated this bleeding risk, including low-dose anticoagulation [ 29 , 33 ], delayed anticoagulation (after 48–72 h) [ 9 , 37 ], heparin-free application [ 36 , 41 ], and improved heparin-binding circuits [ 21 , 23 ]. In this study, the survival rate of TBI patients (383, 16 studies) was comparable to non-TBI patients.…”