Thoracic trauma is the most common injury in polytrauma patients. Often associated with the development of an acute respiratory distress syndrome (ARDS), conservative treatment options are very restricted and reach their limits quickly.
Objective:
Extracorporeal membrane oxygenation (ECMO) is a wellestablished therapy in cardio-thoracic surgery and internal medicine intensive care units. The purpose of this study is to analyse the potential benefit of ECMO therapy in ARDS treatment in polytrauma patients.
Design:
Retrospective case series.
Setting:
Level 1 trauma centre, Germany, 04/2011-04/2019.
Patients:
Nineteen patients with ARDS treated with a veno-venous ECMO system.
Main outcome measures:
This study focused on the time leading to therapy initiation, the severity of thoracic and overall injury. The Sequential Organ Failure Assessment (SOFA) Score, the Murray Score, the Abbreviated Injury Scale (AIS) 2005 level and the Injury Severity Score (ISS) were analysed. The results were analysed regarding survival and death.
Results:
The survival rate was 53%. The ISS was the same for survivors and deceased patients (p = 0.604). Early initiation of ECMO therapy showed a significant trend for survivors (p = 0.071). The SOFA Score level before ECMO therapy was significantly lower in the survivors than in those who died (p = 0.035). The AISThorax level for survivors showed a significantly higher score level than the one for deceased patients (p = 0.05).
Conclusion:
ECMO therapy in polytrauma patients is a safe and effective option, in particular when used early in ARDS treatment. The overall severity of organ failure determined the likelihood of survival rather than the thoracic trauma itself.
BayerJLeferingRReinhardtS, et al. Severity-dependent differences in early management of thoracic trauma in severely injured patients - analysis based on the TraumaRegister DGU®. Scand J Trauma Resusc Emerg Med2017; 25: 10.
2.
HansenMHachenbergT. Der Patient mit Thoraxtrauma: präklinische Versorgung. AINS - Anästhesiologie Intensivmedizin Notfallmedizin Schmerztherapie2017; 52(6): 408–421.
3.
PernaVMoreraR. Prognostic factors in chest traumas: a prospective study of 500 patients. Cir Esp2010; 87: 165–170.
4.
JarrarDKueblerJFRueLW, et al. Alveolar macrophage activation after trauma-hemorrhage and sepsis is dependent on NF-kappaB and MAPK/ERK mechanisms. Am J Physiol Lung Cell Mol Physiol2002; 283: 799.
5.
HildebrandFStuhrmannMvan GriensvenM, et al. Association of IL-8-251A/T polymorphism with incidence of acute respiratory distress syndrome (ARDS) and IL-8 synthesis after multiple trauma. Cytokine2007; 37: 192–199.
6.
ParkPKCannonJWYeW, et al. Transfusion strategies and development of acute respiratory distress syndrome in combat casualty care. J Trauma Acute Care Surg2013; 75: 238.
7.
TsaiHChangCTsaiF, et al. Acute respiratory distress syndrome with and without extracorporeal membrane oxygenation: a score matched study. Ann Thorac Surg2015; 100: 458–464.
8.
KingCMayCWWilliamsJ, et al. Management of right heart failure in the critically ill. Crit Care Clin2014; 30: 475–498.
9.
BernardGRArtigasABrighamKL, et al. Report of the american-european consensus conference on acute respiratory distress syndrome: definitions, mechanisms, relevant outcomes, and clinical trial coordination. consensus committee. J Crit Care1994; 9: 72–81.
10.
RanieriVMRubenfeldGDThompsonBT, et al. Acute respiratory distress syndrome: the berlin definition. JAMA2012; 307: 2526–2533.
11.
FergusonNDFanECamporotaL, et al. The berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med2012; 38: 1573–1582.
12.
ArltMPhilippAVoelkelS, et al. Extracorporeal membrane oxygenation in severe trauma patients with bleeding shock. Resuscitation2010; 81: 804–809.
13.
StriebelHW. Die Anästhesie. Stuttgart: Georg Thieme Verlag, 2019; 4: 612. doi:10.1055/b-006-163370
14.
ColeEGillespieSVulliamyP, et al. Multiple organ dysfunction after trauma. Br J Surg2020; 107(4): 402.
15.
VincentJLMorenoRTakalaJ, et al. The SOFA (sepsis-related organ failure assessment) score to describe organ dysfunction/failure. on behalf of the working group on sepsis-related problems of the European Society of Intensive Care Medicine. Intensive Care Med1996; 22(7): 707–710.
16.
MurrayJFMatthayMALuceJM, et al. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis1988; 138: 720–723.
17.
PeekGJMugfordMTiruvoipatiR, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet2009; 374(9698): 1351–1363.
18.
PalmerCSGabbeBJCameronPA. Defining major trauma using the 2008 abbreviated injury scale. Injury2016; 47: 109–115.
19.
RuchholtzSWirtzDC. 3.1.4 klassifikation/scoring. Orthopädie und Unfallchirurgie essentials. Stuttgart: Georg Thieme Verlag, 2013.
StrumwasserATobinJMHenryR, et al. Extracorporeal membrane oxygenation in trauma: a single institution experience and review of the literature. Int J Artif Organs2018; 41: 845–853.
22.
GothnerMBuchwaldDStrauchJT, et al. The use of double lumen cannula for veno-venous ECMO in trauma patients with ARDS. Scand J Trauma Resusc Emerg Med2015; 23: 30.
23.
GrantAAHartVJLineenEB, et al. The impact of an advanced ECMO program on traumatically injured patients. Artif Organs2018; 42: 1043–1051.
24.
RiedMBeinTPhilippA, et al. Extracorporeal lung support in trauma patients with severe chest injury and acute lung failure: a 10-year institutional experience. Crit Care 2013; 17: R110.
25.
SwolJBrodieDNapolitanoL, et al. Indications and outcomes of extracorporeal life support in trauma patients. J Trauma Acute Care Surg2018; 84: 831–837.
26.
FuchsLFengMNovackV, et al. The effect of ARDS on survival: do patients die from ARDS or with ARDS?J Intensive Care Med2019; 34: 374–382.
MadershahianNWittwerTStrauchJ, et al. Application of ECMO in multitrauma patients with ARDS as rescue therapy. J Card Surg2007; 22: 180–184.
29.
DadrasMWagnerJMWallnerC, et al. Extracorporeal membrane oxygenation for acute respiratory distress syndrome in burn patients: a case series and literature update. Burns Trauma2019; 7: 28.
30.
BosargePLRaffLAMcGwinG, et al. Early initiation of extracorporeal membrane oxygenation improves survival in adult trauma patients with severe adult respiratory distress syndrome. J Trauma Acute Care Surg2016; 81: 236–243.
31.
BelenkiySMBatchinskyAIParkTS, et al. Automated inhaled nitric oxide alerts for adult extracorporeal membrane oxygenation patient identification. J Trauma Acute Care Surg2014; 77: 184.
32.
LohbrunnerHDejaMBuschT, et al. Stellenwert von inhaliertem Stickstoffmonoxid bei der Behandlung des schweren akuten Lungenversagens. Anaesthesist2004; 53: 771–784.
33.
GebistorfFKaramOWetterslevJ, et al; Group, Cochrane Emergency and Critical Care. Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) in children and adults. Cochrane Database Syst Rev2016; (6): CD002787.
34.
MunshiLDel SorboLAdhikariNKJ, et al. Prone position for acute respiratory distress syndrome. A systematic review and meta-analysis. Ann Am Thorac Soc2017; 14: S280–S288.
35.
LucchiniADe FelippisCPelucchiG, et al. Application of prone position in hypoxaemic patients supported by veno-venous ECMO. Intensive Crit Care Nurs2018; 48: 61–68.
36.
ScholtenELBeitlerJRPriskGK, et al. Treatment of ARDS with prone positioning. Chest2017; 151: 215–224.
37.
Della TorreVRobbaCPelosiP, et al. Extra corporeal membrane oxygenation in the critical trauma patient. Curr Opin Anaesthesiol2019; 32(2): 234–241.
38.
ChenCHsuTChenW, et al. The use of extracorporeal membrane oxygenation in trauma patients: a national case-control study. Medicine (Baltimore)2018; 97: e12223.
