Use of extracorporeal membrane oxygenation in severe traumatic lung injury with respiratory failure
a b s t r a c t
Objectives: The use of extracorporeal membrane oxygenation in managing acute respiratory distress syn- drome had been accepted. Severe lung injury with respiratory failure is often encountered in trauma patients. We report our experience with the use of ECMO in severe traumatic lung injury.
Methods: Patients with severe traumatic lung injury that met the following criteria were candidates for ECMO:
(1) severe hypoxemia, PaO2/fraction of inspired oxygen (1.0) less than 60, and positive end-expiratory pressure greater than 10 cm H2O in spite of vigorous ventilation strategy; (2) irreversible CO2 retention with unstable he- modynamics; and (3) an initial arterial PaO2/fraction of inspired oxygen (1.0) less than 60, where the pulmonary condition and hemodynamics rapidly deteriorated despite vigorous mechanical ventilation strategy.
Results: Over 60 months, a total of 19 patients with severe traumatic lung injury who received ECMO manage- ment were retrospectively reviewed. The median age was 38 years (25-58 years), the median injury severity score was 29 (25-34), the median admission Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 25 (21-36), and the median blood transfusion volume was 5500 mL (3500-13 000). There were 9 venovenous and 10 venoarterial types. The survival rate was 68.4% (13/19). The survivors were younger (30 vs 53 years; 21-39 vs 48-63).
There were 6 mortalities (3 pneumonia, 2 coagulopathy, and 1 Cardiac rupture with cardiac tamponade). There were 5 of 19 patients with pre-ECMO traumatic Brain hemorrhage (3 survived and 2 mortalities). A total of 16 patients received heparinization with 5 mortalities.
Conclusions: The use of ECMO may offer an additional Treatment modality in severe traumatic lung injury with respiratory failure that is unresponsive to optimal conventional ventilator support. Timely ECMO intervention is of value.
(C) 2015
Introduction
Severe trauma is one of the leading causes of death in young adults [1,2], and approximately 50% of cases are associated with chest injury in multiple trauma [3]. Most lung injury patients with mild to moderate
? Conflicts of interest: The authors declare no conflicts of interest related to this study.
?? Author contributions: Wu SC did the study conception and design, initial draft of man-
uscript, interpretation, and manuscript drafting and revision. Chen WT participated in the study design and conception; Lin HH performed the procedure of extracorporeal membrane oxygenation. Fu CY, Wang YC, Lo HC, Cheng HT, and Tzeng CW did the data collection.
? Guarantor of the article: Shih-Chi Wu, MD.
* Corresponding author at: Trauma and Emergency Center, China Medical university hospital, No. 2 Yuh-Der Road, Taichung, Taiwan 404, R.O.C. Tel.: +886 4 22052121×5043; fax: +886 4 22334706.
E-mail addresses: [email protected] (S.-C. Wu), [email protected] (W.T.-L. Chen), [email protected] (H.-H. Lin), [email protected] (C.-Y. Fu), [email protected] (Y.-C. Wang), [email protected] (H.-C. Lo), [email protected] (H.-T. Cheng), [email protected] (C.-W. Tzeng).
respiratory failure respond well to noninvasive respiratory support. How- ever, a small number of lung injury patients may develop severe respirato- ry failure and progress from hypoxia with systemic inflammatory response syndrome to acute lung injury or Acute respiratory distress syndrome . Intubation and mechanical ventilation in these patients may be- come mandatory to correct hypoxia and hypercapnia. Generally, manage- ment with a lower tidal volume and higher Positive end-expiratory pressure is recommended in such respiratory distress [4-6]. How- ever, there were patients who progressed to lung failure even with vigor- ous ventilation support. The hospital survival rates of patients with severe lung dysfunction have ranged from 26% to 58% [7-10]. In cases when most treatment options, including invasive ventilation, have failed, the use of ex- tracorporeal membrane oxygenation (ECMO) may be used as a temporary replacement for the injured lungs; it serves to reduce Ventilator settings and prevent further barotrauma [11,12]; provide adequate ventilation, ox- ygenation, and improvement of hypercapnia; and provide the effect of “lung rest” and buy time for recovery of lungs [13].
http://dx.doi.org/10.1016/j.ajem.2015.02.007
0735-6757/(C) 2015
The use of ECMO in severe neonatal respiratory failure has been pre- viously reported [14]. Recently, there were reports regarding the use of ECMO as a therapeutic option for ARDS in adults [11,12,15].
Massive blood loss and massive transfusion often resulted in “coag- ulopathy” in Multiple trauma patients, which limited the use of ECMO in severe traumatic lung injury because of systemic heparinization. Thus, the use of ECMO in patients with severe traumatic lung injury remains controversial due to the risk of Bleeding complications [16,17]. Howev- er, Arlt et al [18] reported the use of ECMO in 10 patients with severe trauma and hemorrhagic shock with a 60% survival rate, indicating that there might be a role for ECMO in severe traumatic lung injury pa- tients with coagulopathy.
We were interested in the role of ECMO in severe traumatic lung inju- ry and performed this retrospective study. We report our experience with the use of ECMO in severe traumatic lung injury and respiratory failure.
Materials and methods
We retrospectively reviewed the charts of patients who had severe traumatic lung injury that was refractory to conventional therapy and received extracorporeal lung support (ECMO) and were admitted to our intensive care unit (ICU) at the Trauma and Emergency Center from January 2008 to January 2014.
The data abstracted from the chart contained no identifying patient information. Those abstracting data were trained in the use of standard- ized data collection forms and were periodically monitored for accuracy. An assessment of interrater reliability was performed.
Institutional review board approval was not required for this type of retrospective research in our institution.
Inclusion criteria for ECMO in severe traumatic lung injury
Patients with traumatic lung injury who received conventional man- agement initially were considered candidates for ECMO when they met one of the following criteria:
-
Arterial PaO2/fraction of inspired oxygen (1.0) less than 60 and PEEP greater than 10 cm H2O for 2 hours in spite of optimized me- chanical ventilation strategy and conservative treatment.
- Irreversible CO2 retention with unstable hemodynamics.
- The initial arterial blood gas PaO2/fraction of inspired oxygen (1.0) less than 60, where the pulmonary condition and hemody- namics rapidly deteriorated despite vigorous mechanical ventila- tion strategy.
Indications for venovenous and venoarterial ECMO
The indication for venovenous (VV) ECMO was persistent hypoxemia despite vigorous ventilation and PEEP management, blood transfusion, and/or chest tube thoracotomy. Indications for venoarterial (VA) ECMO support were coexistent cardiopulmonary injury as well as profound shock despite vigorous resuscitation and vasopressor support.
Technique and access for ECMO
The VV ECMO was established via bilateral femoral vein or internal jugular vein and femoral vein using the Seldinger technique. The VA ECMO was done via exploring femoral artery and vein or right subclavi- an artery and femoral vein (if the subclavian artery was used, an 8-mm Dacron grafting was done first, then a cannula inserted).
Establishing and operating the ECMO device
Before establishing ECMO, the body surface area was first calculated to choose an appropriate cannula size. For VV ECMO, first, the pump speed was set at 3000/bpm and gas flow/blood flow at 1:1; then, it
was adjusted according to blood gas data. For VA ECMO, the blood flow/body surface area was set at approximately 2, and the gas flow/ blood flow, at 1:3 initially, and this was adjusted according to blood gas data. The speed setting, blood flow rate, and gas flow rate were then tailored to the patient.
The activated clotting time was maintained between 180 and 200 seconds. In patients with coagulopathy and bleeding, a heparin-free strategy may be adopted, and the activated clotting time range is allowed to be within 140 to 160 seconds.
Post-ECMO management in the ICU
Patients received regular intensive care after the establishment of ECMO. Patients who developed an acute kidney injury, according to the risk injury failure loss end-stage kidney disease criteria [19,20], received early continuous renal replacement therapy/continuous VV hemofiltration (CVVH) in circuit. The CVVH machine (DF-080, HF 400;
Informed SA, Geneva, Switzerland) was connected to the ECMO circuit for hemodialysis in the case of renal insufficiency.
Patients who developed sepsis and/or septic shock were managed according to the guidelines from the Surviving Sepsis campaign [21].
The demographics, mechanism of injury, Abbreviated Injury Score , Injury Severity Score (ISS), APACHE II scores, length of stay, amount of blood transfused, and survival rate were collected.
The relation between survivors and nonsurvivors as well as ECMO types (ie, VA and VV) and the use of CVVH during ECMO were evaluated. The bacteremia rate, use of heparin, causes of death, and special charac- teristics of some patients were also collected.
Statistical analyses
SAS software version 9.1 (SAS, Cary, NC) was used for the statistical analyses. Continuous data were reported as medians and interquartile ranges (IQRs) when the data were not normally distributed. Continuous data with a normal distribution were reported as mean and SD. Discrete variables were expressed as counts and percentages. Fisher exact tests were used to compare categorical variables. The Wilcoxon rank sum test and t test were used for continuous variables. Tests for statistical significance were 2 sided with a level of significance of P b .05.
Results
During this 60-month period, there were 19 patients with severe traumatic lung injury who received ECMO management and were en- rolled in this study. There were 17 males and 2 females. The most com- mon mechanism of injury was blunt injury after a motor vehicle crash. The mean age was 40.7 years (SD, 18.7), the median injury severity score was 29 (25-34), the mean admission Acute Physiology and Chronic Health Evaluation II score was 28.7 (SD, 8.10), and the median blood trans- fusion volume was 5500 mL (3500-13 000). There were 9 patients (47.4%) who received VV-type ECMO, and 10 patients (52.6%) received VA-type ECMO. Of 19 patients, 13 survived; the survival rate was 68.4% (Table 1).
There were 6 patients who died, including 3 due to pneumonia, 2 due to coagulopathy, and 1 due to cardiac rupture with cardiac tamponade.
The significant differences between the survivors and nonsurvivors were age and ICU stay; the survivors were much younger than nonsurvivors (55.8 vs 33.8 years), and there was a longer ICU stay in survivors (20.5 days vs 8.97 days) (Table 1). There were no other signif- icant differences between the groups.
There were no significant differences between those who received VV-type ECMO and those who received VA-type ECMO among multiple factors. There was also no difference in the survival rate (Table 2).
Among multiple factors, there were no significant differences be- tween the group who received CVVH during ECMO and those who did not, and there was no significant difference in the survival rate between the 2 groups (Table 3).
Analysis of demographics of patients and comparison between survivors and non survivors
Categorical variable
Overall
Survivors
Nonsurvivors
n = 19 (%)
n = 13 (68.4%)
n = 6 (31.6%)
Sex
.09
Men
17 (10.5)
13 (0)
4 (66.7)
Women
2 (89.5)
0 (100)
2 (33.3)
Mechanism of injury MVC
17 (89.5)
11 (84.6)
1.00
6 (100)
Fall
2 (10.5)
2 (15.4)
0 (0)
ECMO type
.14
VA
10 (52.6)
5 (38.5)
5 (83.3)
VV
9 (47.4)
8 (61.5)
1 (16.7)
Use of heparin
16 (84.2)
11 (84.6)
5 (83.3)
1.00
Use of CVVH
7 (36.8)
4 (30.8)
3 (50.0)
.62
Bacteremia rate
11 (57.9)
9 (69.2)
2 (33.3)
.32
Survival rate
13 (68.4)
Continuous variable
Mean (SD)
Mean (SD)
Mean (SD)
Age
40.7 (18.7)
33.8 (16.4)
55.8 (14.7)
.01
APACHE II score
28.7 (8.10)
26.4 (7.35)
33.7 (7.94)
.07
ICU stay
16.8 (9.37)
20.5 (7.49)
8.67 (8.12)
.006
Continuous variable
Median (IQR)
Median (IQR)
Median (IQR)
AIS of lung
4.0 (4-4)
4.0 (4-4)
4.0 (4-4)
.63
ISS
29.0 (25-34)
29.0 (25-29)
40.5 (25-50)
.19
P/F
60.0 (48-65)
60.0 (48-60)
59.5 (50-86)
.30
PRBC transfused (mL)
5500 (3500-13 000)
5500 (4000-8500)
15 500 (3000-23 000)
.33
ECMO days
7.0 (4-10)
7.0 (6-10)
4.0 (2-9)
.22
Abbreviation: MVC, motor vehicle crash.
a Fisher exact tests.
b t test.
c Wilcoxon rank sum test.
The post-ECMO bacteremia rate was 57.9% (11/19) (Table 1), and the most common infecting organism (6/11 patients) was multiple drug-resistant Acinetobacter baumannii, which caused 2 deaths.
There were 16 patients (84.2%) who received heparinization (Table 1), with 5 mortalities (3 pneumonia, 1 coagulopathy, and 1 cardiac rupture with cardiac tamponade).
Of 19 patients, 5 had pre-ECMO traumatic brain hemorrhage. Among these 5 patients, 2 were noted to have coagulopathy and died; the other 3 patients survived.
There was 1 patient with severe lung contusion and intractable pul- monary hemorrhage that copious blood drained from the endotracheal
The comparison between ECMO types
Categorical variable VA VV Pa
Table 3
The comparison between uses of CVVH
Categorical variable No CVVH CVVH Pa
n = 12 (63.2%) n = 7 (36.8%)
n = 10 (52.6%)
n = 9 (47.4%)
Sex
Men
11 (8.3)
6 (85.7)
1.00
Sex
.47
Women
1 (91.7)
1 (14.3)
Men
8 (80.0)
9 (100)
Mechanism of injury
1.00
Women
2 (20.0)
0 (0)
MVC
11 (91.7)
6 (85.7)
Mechanism of injury
1.00
Fall
1 (8.3)
1 (14.3)
MVC
9 (90.0)
8 (88.9)
ECMO type
.65
Fall
1 (10.0)
1 (11.1)
VA
7 (58.3)
3 (42.9)
Use of heparin
7 (70.0)
9 (100)
.21
VV
5 (41.7)
4 (57.1)
Use of CVVH
3 (30.0)
4 (44.4)
.65
Use of heparin
9 (75.0)
7 (100)
.26
Bacteremia rate
4 (40.0)
7 (77.8)
.17
Bacteremia rate
7 (58.3)
4 (57.1)
1.00
Survival rate
5 (50.0)
8 (88.9)
.14
Survival rate
9 (75.0)
4 (57.1)
.62
Continuous variable Age
Mean (SD)
46.2 (20.4)
Mean (SD)
34.7 (15.5)
.18
Continuous variable Age
Mean (SD)
34.5 (16.7)
Mean (SD)
51.4 (18.1)
.054
APACHE II score
30.7 (7.63)
26.4 (8.46)
.26
APACHE II score
26.7 (7.70)
32.1 (8.13)
.16
ICU stay
13.6 (7.60)
20.3 (10.3)
.12
ICU stay
15.4 (9.28)
19.1 (9.77)
.43
Continuous variable AIS of lung
Median (IQR)
4.0 (4-33)
Median (IQR)
4.0 (4-33)
1.00
Continuous variable AIS of lung
Median (IQR)
4.0 (4-4)
Median (IQR)
4.0 (3-4)
.08
ISS
31.0 (24-48)
29.0 (25-29)
.44
ISS
29.0 (25-33.5)
29.0 (20-48)
.90
P/F
60.0 (54-65)
50.0 (48-60)
.18
P/F
57.5 (48-62.5)
60.0 (48-69)
.68
PRBC transfused (mL)
9750 (4500-20 000)
4000 (3500-8250)
.09
PRBC transfused (mL)
5500 (4000-11 875)
8500 (2000-23 000)
.83
ECMO days
7.0 (6-9)
6.0 (4-12)
.97
ECMO days
6.5 (3.5-9.0)
8.0 (4-17)
.51
Abbreviation: MVC, motor vehicle crash.
c Wilcoxon rank sum test.
Abbreviation: MVC, motor vehicle crash.
a Fisher exact tests.
b t test.
c Wilcoxon rank sum test.
tube; he received ECMO and survived after 8250-mL packed red blood cell transfusion.
Discussion
Trauma is one of the leading causes of death among Young people; severe traumatic acute lung injury was often encountered in patients with multiple trauma and remains a challenge for trauma critical care. Initial management includes airway establishment, decompression of pneumothorax, and Hemorrhage control. Some patients may decline and develop adult respiratory distress syndrome.
The management of severe traumatic lung injury and ARDS includes vigorous ventilation strategies and management. However, the use of ECMO in severe traumatic lung injury can be used in case of failure of optimal ventilation therapy. In comparing ECMO to conventional ARDS management in the trauma patient, the risk for hemorrhage and multiple-organ involvement was of concern with multiple specialty dis- ciplines [22,23].
There are few publications that address the use of ECMO in severe traumatic lung injury as well as a lack of universal indications for its usage. The largest study was done by Ried et al [24] with 52 patients and 79% survival rate. They concluded that the utilization of the extracor- poreal lung support devices was safe and effective in severe lung trauma patients with respiratory failure [24]. Moreover, the reported survival rate is approximately 60% to 77.8% in other series [17,18,23,25]. In the current study, the survival rate is 68.4% (13/19), which is similar to other studies. The indications for the type of ECMO used (ie, VV mode or VA mode) were dependent on the involvement of the cardiac system as well as profound shock or unstable hemodynamics. It has been reported that the use of VA mode in prolonged ventilation time before ECMO may in- fluence the final outcome [26]. A delay in intervening may result in im- paired systemic organ perfusion and make patients susceptible to hypotension that mandates the use of VA mode ECMO [17]. In the cur- rent study, no patient initially received VV mode ECMO and was then shifted to VA or VVA mode, although there were 9 patients with VV mode and 10 patients with VA mode. We found that there were no dif- ferences in the study factors between groups; however, there was a
trend toward more blood transfusions in the VA group.
In the comparison of the survivors and nonsurvivors, those who sur- vived were younger than the nonsurvivors (30 vs 53 years; P = .03; Table 1). This indicates that the decreased physiological reserve and Organ function may play an important role in older severe trauma pa- tients and result in a higher mortality rate.
Acute kidney injury is a common comorbidity for children placed on ECMO. Wolf et al [27] reported that early renal replacement therapy during pediatric cardiac extracorporeal support increases mortality. In addition, there were porcine studies that demonstrated that continuous renal replacement therapy reduces the systemic and pulmonary inflam- mation induced by VV ECMO [28] as well as attenuates myocardial in- flammation and mitochondrial injury [29]. There were few reports that addressed the relationship between CVVH and ECMO in trauma pa- tients. In the current study, 7 of 19 patients received CVVH during ECMO support; however, there were no differences in the study factors be- tween groups (Table 3).
In this study, 16 patients (84.2%) received heparinization during ECMO support with 5 mortalities (Table 1). However, regarding the use of heparin for anticoagulation in those with severe traumatic lung injury receiving ECMO, the possibility of persistent hemorrhage and co- agulopathy was still of concern and deserved attention.
There have been reports of cases in which patients with traumatic in- operable Pulmonary hemorrhage or endobronchial hemorrhage after blunt chest trauma were successfully managed with ECMO support [30,31]. In the current study, a 21-year-old man had blunt chest trauma and persistent pulmonary hemorrhage and received ECMO support with heparinization and survived, indicating that ECMO support was of
value in patients with intractable pulmonary hemorrhage. In addition, a tailored anticoagulation treatment is crucial for an effective outcome.
Another concern is whether previous Traumatic brain injury should be a contraindication for ECMO for patients with severe traumat- ic lung injury. In the well-known CESAR study [12], TBI with hemor- rhage was thought to be a contraindication for ECMO management. In the current study, there were 5 of 19 patients with pre-ECMO TBI and hemorrhage. There were 2 mortalities, and 3 patients survived. It is dif- ficult to draw any meaningful results on this topic from our study. In ad- dition, there were limited cases and experiences of ECMO in patients with TBI among the literature [18,25,32,33]. Therefore, further random- ized studies are warranted.
Limitations of this study
We recognize the limitations of this study, including its retrospective nature, small sample size, and the probable bias in case selection, which may restrict our analytical conclusions. In addition, because there were multifactorial characteristics in patients with severe traumatic lung injury who received ECMO support, it is difficult to collect all of the related data in this study. Therefore, the evaluation of the physiological status and se- verity of these patients was done with physiological scores rather than detailed clinical parameters. Third, the inclusion criteria for the use of ECMO were not fully quantified, which tend to be with subjective bias.
Further multicenter randomized studies are warranted with predefined enrollment criteria for a better understanding of this issue.
Conclusion
The use of ECMO may offer an additional treatment modality in pa- tients with severe traumatic lung injury with respiratory failure that is un- responsive to optimal conventional ventilator support. Timely ECMO intervention is of value.
Acknowledgment
The authors thank Ms Li-Ting Su for her assistance in data analysis. The authors declare that the article and all illustrations used therein are original, have not been previously published or submitted for publi-
cation, and are noninfringing and nonlibelous.
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