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Extra corporeal membrane oxygenation in the critical trauma patient

Della Torre, Valentinaa,*; Robba, Chiarab,*; Pelosi, Paolob,c; Bilotta, Federicod

Current Opinion in Anesthesiology: April 2019 - Volume 32 - Issue 2 - p 234–241
doi: 10.1097/ACO.0000000000000698

Purpose of review The purpose of this review is to describe recent evidence regarding the use of extracorporeal membrane oxygenation (ECMO) as salvage therapy for severe cardiac or respiratory failure in patients with trauma. The characteristics of this cohort of patients, including the risk of bleeding and the need for systemic anticoagulation, are generally considered as relative contraindications to ECMO treatment. However, recent evidence suggests that the use of ECMO should be taken in consideration even in this group of patients.

Recent findings The recent findings suggest that venous–venous ECMO can be feasible in the treatment of refractory respiratory failure and severe acute respiratory distress syndrome trauma-related. The improvement of ECMO techniques including the introduction of centrifugal pumps and heparin-coated circuits are progressively reducing the amount of heparin required; moreover, the application of heparin-free ECMO showed good outcomes and minimal complications. Venous–arterial ECMO has emerged as a salvage intervention in patients with cardiogenic shock and after cardiac arrest. Venous–arterial ECMO provides circulatory support allowing time for other treatments to promote recovery in presence of acute cardiopulmonary failure. Only poor-quality evidence is available, for venous–arterial ECMO in trauma patients.

Summary ECMO can be considered as a safe rescue therapy even in trauma patients, including neurological injury, chest trauma as well as burns. However, evidence is still poor; further studies are warranted focusing on trauma patients undergoing ECMO, to better clarify the effect on survival, the type and dose of anticoagulation to use, as well as the utility of dedicated multidisciplinary trauma-ECMO units.

aDepartment of Anaesthesia and Intensive Care, West Suffolk NHS Trust, Bury St Edmunds, UK

bAnaesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology

cDepartment of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa

dDepartment of Anaeshesia and Intensive Care, University La Sapienza, Rome, Italy

Correspondence to Chiara Robba, Department of Anaesthesia and Intensive Care, San Martino Hospital, Genova, Italy. E-mail:

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Polytrauma is one of the leading causes of death and disability worldwide [1]. Traffic accidents are the predominant cause of death occurring between 15 and 29 years [2]. The definition of major trauma (injury severity score >15) includes physiological and anatomical parameters [3,4], and the management of patients with traumatic injuries presents several challenges. Prognosis depends on different factors, such as the severity and energy of the trauma, the physiological reserve of the patient and a prompt and aggressive medical treatment, the latter being a major modifiable factor [5].

Extracorporeal membrane oxygenation (ECMO) is an extracorporeal technique that provides temporary respiratory (veno-venous, venous–venous configuration) or cardiac (veno-arterial, venous–arterial configuration) support in patients with cardiopulmonary failure [6,7].

A fraction of trauma patients develop posttraumatic acute respiratory distress syndrome (ARDS) [8]. Trauma patients with severe injuries are at risk of developing ARDS from both direct and indirect causes, including lung contusions, aspiration pneumonia, massive blood transfusion and fat embolism syndrome (Fig. 1) [9▪▪]. Venous–arterial ECMO could be considered in patients with cardiogenic shock and in the setting of cardiac arrest, biventricular failure or in patients with acute cardiac injuries, such as myocarditis and myocardial ischaemia, as a bridge to recovery (Fig. 2) [10▪▪].





Patients with concomitant polytrauma, haemodynamic or respiratory failure pose a difficult challenge to clinicians. However, only a limited number of publications have reported the use of ECMO in trauma patients. Recently, survival rates for trauma patients undergoing ECMO have been shown to range from 44% to as high as 74.1% [9▪▪]. On the contrary, most of these studies include patients prior to pandemic H1N1 influenza, which led to rapid advances in ECMO technology. In a study conducted by Grant et al. [11], the survival rate for trauma patients treated with venous–venous ECMO was 33%, while the survival to discharge rate in postvenous–venous ECMO group was 55%.

The use of ECMO in trauma patients is limited by serious concerns regarding the risk of haemorrhage during and after cannulation, in particular in presence of severe coagulopathy, contraindications to the anticoagulant treatment and risk of intracranial haemorrhage following traumatic brain injury (TBI). Although improvements within ECMO devices (i.e. centrifugal pump techniques or the complete heparin-coated circuits) and recent evidence of possible beneficial effects of ECMO within the trauma setting [12,13▪], ECMO is still considered relatively contraindicated in patients with intracranial or active systemic bleeding [12,14,15▪,16,17]. A safer alternative, in case of Type II Respiratory Failure could be Extra Corporeal CO2 Removal [18–20].

The purpose of this review is to discuss the updated literature regarding the use of venous–venous and venous–arterial ECMO in trauma patients.

Box 1

Box 1

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Venous–venous ECMO has the unique potential to support gas exchange enabling protective lung ventilation and preventing lung injury exacerbated by high positive pressure and volumes in adult patients with respiratory failure.

The effect on patients’ outcome of venous–venous ECMO in severe hypoxiemic respiratory failure remains controversial, despite two randomized trials have been published [7,21▪▪]. The first trial was conducted in the United Kingdom and ECMO technology demonstrated a survival benefit in patients transferred to an ECMO centre, when compared with those managed with conventional ventilatory strategies [7]. The more recent EOLIA study demonstrated an 11% reduction in mortality for patients treated with venous–venous ECMO compared with patients undergoing conventional mechanical ventilation, although this was not statistically significant [21▪▪]. In this article, Combes et al. [21▪▪] concluded that among patients with severe ARDS, 60-day mortality was not significantly lower with ECMO than with a strategy of conventional mechanical ventilation that included ECMO as rescue therapy.

Patients with traumatic ARDS present challenging clinical needs. In a multicentre study conducted in Germany [22], ICU survival rate was superior in trauma patients compared with nontrauma population (65 vs. 26%), although hospitalization was prolonged in the traumatic ARDS subgroup. Of note, patients were younger in the trauma group, which may reflect a different physiological status at baseline.

A case series and literature review with a cumulative number of 31 patients was recently reported [23▪], with description of ECMO indications for hypoxemic respiratory failure secondary to ARDS in trauma patients. In this consecutive case series, the authors found a surviving rate of 85%, with none of these patients dying because of ECMO-related complications. A major issue in this group of patients is the administration of heparin. In general, the use of ECMO entails anticoagulation to prevent life-threatening thrombosis in the extracorporeal circuit. On the other hand, inappropriate anticoagulation may result in bleeding due to consumptive coagulopathy [24,25]. Short-term heparin-free venous–venous ECMO in patients with contraindications to therapeutic anticoagulation could be an effective treatment modality with few or no thromboembolic complications [26]. The need for full, half or no loading dose of heparin should be considered case-by-case [23▪,27].

In conclusion, recent growing evidence suggests potential benefits of the use of venous–venous ECMO for the treatment of respiratory failure refractory to conventional therapies [9▪▪], but these effects are still not clear in trauma patients. The selection of patients and timing of starting of the extracorporeal support are crucial to ensure success, and risks and benefits must be weighted up and discussed with an ECMO centre.

Dedicated units for the care of patients undergoing ECMO have been shown to improve outcomes [28▪]. However, there is no description in the literature of the impact of a dedicated trauma-ECMO program.

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Venous–arterial ECMO can provide haemodynamic support in case of refractory shock that does not respond to conventional treatment [29]. The majority of the trauma experience based on the Extracorporeal Life Support Organization (ELSO) registry is reported for venous–venous ECMO for severe posttraumatic ARDS [6]. Venous–arterial ECMO is still a poorly developed technique and it is mostly used to support patients with traumatic cardiac arrest or cardiogenic shock refractory to inotropes and vasopressor. Traumatic cardiac arrest is caused by a variety of cardiac and vascular injuries, where bleeding and haemorrhagic shock are often the main mechanisms involved. Venous–arterial ECMO circuit allows hemodynamic stabilization until transferring the patient to the operating room, where definitive haemostasis is performed [30,31]. Moreover, in trauma, venous–arterial ECMO offers the potential advantage of temporary circulatory rest, and can provide neuroprotection after cardiac arrest [32,33].

Some successful venous–arterial ECMO cases in trauma patients have been published [34]; however, current evidence is still poor, and an outcome benefit has not been demonstrated for a process that involves significant resource expenditure [33].

In patients at risk of bleeding or in those with haemorrhagic shock, the use of heparin-free ECMO has been reported, delaying eventually the administration of heparin for 48–72 h [29]. On the other hand, venous–arterial ECMO and its prothrombotic inflammatory response increase the risk of thrombosis, which may cause pump malfunction, oxygenator failure and thromboembolic events [35]. Major bleeding is reported to occur in roughly one quarter of all venous–arterial ECMO patients and can occur even in patients without anticoagulation therapy [36].

Currently there are not randomized control trials (RCTs) or strong evidence supporting the use of venous–arterial ECMO in patients with traumatic cardiac arrest or refractory cardiogenic shock. Also, there are no clear society endorsed-evidence-based guidelines for the use of venous–arterial ECMO or for the selection of patients most likely to benefit.

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ECMO is not exempt from complications, as it is an invasive technique. Therefore, it should be performed only in dedicated centres, with appropriate experience and equipment [28▪]. The most common complications associated with ECMO can be divided in those directly related to the ECMO circuit, such as oxygenator failure, clots in the circuit and problems related to the cannula and cannula sites, and those not directly related to the ECMO circuit, such as haemorrage, infections and haemolysis. Nosocomial infections occur in the 15% of cases, while haemorrhagic complications (excluding intracranial) account for the 14% of total complications [35]. Ischaemia of the lower limb, due to obstruction of the vascular lumen caused by arterial cannula, is a common complication. To minimize the risk of ischaemia, a second smaller cannula should be placed distally to perfuse the limb [23▪]. In general, a bolus of heparin is administered before insertion of the ECMO cannula to reduce the risk of circuit coagulation, and then heparin infusion is started [23▪]. Over the last 20 years, there have been multiple technological advances in ECMO, which may allow for its more frequent and safer use in trauma patients and reduction of the amount of heparin needed. These advancements include the use of polymethylpentene membrane oxygenators, centrifugal pumps, miniaturization of circuits, and heparin-bonded circuits. Short circuit length and heparin-bonded circuit have proven to decrease the incidence of haemorrhagic complications [37]. Compared with traditional ECMO circuits, heparin-bonded circuits are associated with less blood loss, fewer reinterventions, better platelet function, and decreased leukocyte and complement activation, which result in shorter ventilation time and short hospital stay. Some authors [38] recently proposed the application of heparin-free ECMO, showing good outcome and no complications. Chen et al. [39] used venous–venous ECMO without anticoagulation in seven polytraumatic patients and they didn’t develop any haemorrhagic complications. Other authors proposed the use of half dose of heparin, in particular with the use of heparin-bonded circuits which allow systemic heparin dose to be decreased by half, from 4 to 1.5 mg/kg [40▪]. However, there is lack of consensus among the studies about when to start anticoagulation or in which situations it is better to avoid any anticoagulation, therefore the decision is individualized in each centre [41▪,42]. This ultimately highlights the need for specifically designed RTCs to establish the different anticoagulation strategies, according to the characteristics of the patient.

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The decision on when to initiate ECMO in the trauma population is controversial. In Strumwasser single-centre experience's [9▪▪] the survivors had ECMO initiated later (7 days after trauma). Most data in the literature describe the use of ECMO as a salvage therapy long after the initial resuscitation. A 10-year series from Germany comparing venous–venous ECMO with pump-less extracorporeal support in thoracic trauma demonstrated higher survival when ECMO was initiated 5 days or more after trauma [43]. Other data suggest that a significant delay in the initiation of ECMO may lead to poor outcomes [44]. Early ECMO (<6 h after trauma) may offer advantages; however, in particular venous–arterial-ECMO may also confer an increased risk of traumatic coagulopathy [45]. Overall, based on large epidemiological registry data from the ELSO, shorter duration of ECMO and use of venous–venous ECMO improve survival after blunt thoracic trauma [6].

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Traumatic brain injury

The experience of ECMO in patients with TBI is low and remains controversial [46]. Current guidelines recommending ventilatory strategies for ARDS are often contraindicated in TBI (Fig. 3) [47▪]. When patients with ARDS cannot be oxygenated despite conventional ventilation, venous–venous ECMO can be used as a rescue treatment modality (Fig. 4) [47▪].





The improvement of ECMO technique have reduced the amount of heparin required [23▪]; moreover, some authors recently proposed the application of heparin-free ECMO, showing good results and no cerebral haemorrhage. In this patient group physicians should be consider benefit/risk ratio between conventional ventilatory strategies and ECMO. The use and the amount of heparin administered should be carefully considered case-by-case, after a multidisciplinary discussion. Case series reporting the use of ECMO in TBI patients-reported rare cerebral bleeding complications, but they all occurred in patients who received the full dose of heparin bolus [48]. Moreover, patients who did not receive heparin did not experience any coagulative complications, suggesting that in patients at high risk of bleeding, the use of ECMO with no initial coagulation could be an option. Biderman et al. [49] described the viability of ECMO in patients with TBI and/or coagulopathy before implantation, for patients with traumatic injuries and severe hypoxemic respiratory failure. The authors concluded that ECMO is not contraindicated for the treatment of respiratory diseases in the presence of coagulopathy and/or TBI. The study conducted by Jacobs et al. [50] concluded not to exclude the use of ECMO in TBI, as it could improve overall survival and neurological outcome. On the contrary, there are not currently studies about the use of venous–arterial ECMO in TBI patients.

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Other injuries

In trauma patients with tracheal disruption or endobronchial haemorrhage due to severe pulmonary contusions with intractable hypoxemia and hypercapnia, heparin-free ECMO has been successfully used [27] without any reported thromboembolic complications (Fig. 5). Ryu and Chang [27] published a case report of a patient with tracheobronchial disruption and bilateral pulmonary contusions complicated with alveolar haemorrhage due to chest trauma, where heparin-free venous–venous ECMO was applied. ECMO enabled to successfully wean the patient from mechanical ventilation, without any thromboembolic complications. However, evidence are still very low and mostly based on case-series or case reports.



The most common causes of ARDS in burns patients are inhalation injury and bacterial pneumonia. Recently, Ainsworth et al. [51▪] have demonstrated that the survival rates among burn patients are similar to those published by ELSO (60% survival to hospital discharge) for patients with severe ARDS undergoing venous–venous ECMO. Therefore, ECMO should be considered in burn patients with ARDS.

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Growing evidence suggests the potential use of ECMO for the treatment of refractory respiratory failure in adults, but the clinical benefit in polytraumatic patients is not clear.

The selection of patients and the timing for starting the treatment are crucial for success, and before starting ECMO support, risks and benefits must be considered on a case by case basis. The use of heparin should be carefully considered after a multidisciplinary discussion, involving trauma surgical team, anaesthetists and intensivists. Further studies will be warranted to evaluate the role and effect on outcome of ECMO in this cohort of patients as well as the need for organization of dedicated trauma ECMO units.

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Financial support and sponsorship


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Conflicts of interest

There are no conflicts of interest.

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Papers of particular interest, published within the annual period of review, have been highlighted as:

  • ▪ of special interest
  • ▪▪ of outstanding interest
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This is the first article showing results on outcome of ECMO in trauma, with first indications about timing of extracorporeal initiation in trauma setting.

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This is the latest multicenter RCT trial of venous–venous ECMO, whose results have been published in 2018 and discussed all over the world.

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This is a case series, which includes patients with traumatic brain injury (TBI), describing use of ECMO in trauma patients and a systematic review of the literature. This study shows that no trauma patients died because of complication directly related to ECMO.

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The article shows correlation between success of extra corporeal support and the centre where this is managed and the type of ECMO device.

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The article underlines in a detailed manner indications and outcomes of ECMO in trauma setting.

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This is a current opinion article, such as a detailed and up to date state of the art regarding ECMO in trauma.

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The systematic review explains the challenges in ventilating patients with concomitance of acute respiratory distress syndrome and TBI.

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51▪. Ainsworth CR, Dellavolpe J, Chung KK, et al. Revisiting extracorporeal membrane oxygenation for ARDS in burns: a case series and review of the literature. Burns 2018; 44:1433–1438.

This is one of the very few articles about ECMO in burn patients, showing correlated good outcomes.

* Della Torre and Chiara Robba contributed equally to the article.


acute respiratory distress syndrome; anticoagulation; extra corporeal membrane oxygenation; heparin; respiratory failure; trauma

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