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Indications and outcomes of extracorporeal life support in trauma patients

Swol, Justyna, MD; Brodie, Daniel, MD; Napolitano, Lena, MD; Park, Pauline, K., MD; Thiagarajan, Ravi, MD; Barbaro, Ryan, P., MD; Lorusso, Roberto, MD, PhD; McMullan, David, MD; Cavarocchi, Nicholas, MD; Hssain, Ali, Ait, MD; Rycus, Peter, MPH; Zonies, David, MD, MPHfor the Extracorporeal Life Support Organization (ELSO)

Journal of Trauma and Acute Care Surgery: June 2018 - Volume 84 - Issue 6 - p 831–837
doi: 10.1097/TA.0000000000001895
AAST 2017 PODIUM PAPER
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BACKGROUND The use of extracorporeal life support (ECLS) in the trauma population remains controversial and has been reported only in small cohort studies. Recent ECLS technical advances have increased its use as an advanced critical care option in trauma. Given the degree of resource utilization, costs, and expertise required to provide ECLS support in trauma patients, we sought to perform a multi-institutional study to assess the indications and outcomes of ECLS in trauma.

METHODS A retrospective review of adult (≥16 years) trauma patients receiving ECLS support in the Extracorporeal Life Support Organization (ELSO) registry (1989–2016) was performed. Standardized data from the contributing ELSO centers includes patient demographics, diagnoses, and ECLS technique and procedures. Additionally, baseline characteristics, precannulation and postcannulation physiologic data, complications, and outcomes were recorded. Survival was categorized both by transition off ECLS support and survival to hospital discharge.

RESULTS Two hundred seventy-nine trauma patients were identified (0.92% of 30,273 adult ECLS patients). Extracorporeal life support increased significantly in the last 5 years (173 in 2011–2016, 62%) compared with 106 in the prior 18 years. Trauma patients were predominantly male (78%), with a mean age of 34.8 ± 15.4 years (range, 16–88 years). Thoracic injury was the most common diagnosis; acute respiratory distress syndrome was the most common indication. Extracorporeal life support was venovenous for respiratory failure (89%), VA for cardiac failure (7%), and VA for ECLS-assisted cardiopulmonary resuscitation (CPR) (E-CPR) (4%). Extracorporeal life support duration was 8.8 ± 9.5 days (longest 83 days), and was longer for respiratory support (9.3 ± 9.3 days) vs. cardiac support (4.1 ± 4.5 days) and E-CPR (6.5 ± 16.8 days). Overall survival from ECLS was 70% and survival to hospital discharge was 61% in the total cohort (63% respiratory, 50% cardiac, 25% E-CPR), similar to survival rates in other ELSO registry cohorts. More than 80% of patients had a reported complication during ECLS support. The most common complication was cardiovascular (51%) followed by a bleeding complication (29%). Multiple organ failure was the most common cause of death (15.4%).

CONCLUSION Data from the largest registry of critically ill trauma patients receiving ECLS support demonstrates reasonable survival. With growing experience and improved safety profile, trauma should not be considered a contraindication for ECLS. Further analysis of the ELSO registry regarding trauma-specific risk factors and ECLS-specific practices may identify best candidates and improve trauma ECLS outcomes.

LEVEL OF EVIDENCE Therapeutic study, level III.

From the Department of General, Visceral, Vascular, and Pediatric Surgery (J.S.), University Hospital Würzburg, Germany; Department of Medicine, Columbia College of Physicians & Surgeons (D.B.), New York-Presbyterian Hospital, New York, New York; Department of Surgery, University of Michigan Health System (L.N., P.K.P.), University Hospital, Ann Arbor, Michigan; Department of Surgery, Harvard Medical School (R.T.), Boston, Massachusetts; Department of Pediatrics (R.P.B.), C.S. Mott Children’s Hospital, Ann Arbor, Michigan; Cardio-Thoracic Surgery Department (R.L.), Heart and Vascular Centre, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands; Department of Surgery, Seattle Children's Hospital (D.M.), Seattle, Washington; Department of Surgery, Thomas Jefferson University (N.C.), Philadelphia, Pennsylvania; Medical Intensive Care Unit (A.A.H.), Hamad General Hospital, Doha, Qatar; Extracorporeal Life Support Organization (P.R.), Ann Arbor, Michigan; and Division of Trauma, Critical Care & Acute Care Surgery, Department of Surgery, Oregon Health and Science University (D.Z.), Portland,.

Submitted: August 30, 2017, Revised: February 26, 2018, Accepted: March 1, 2018, Published online: March 14, 2018.

Presented at the 76th Annual Meeting of the AAST & Clinical Congress of Acute Care Surgery. September 13–16, 2017, Baltimore, Maryland.

Address for reprints: David Zonies, MD, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Rd, L611 Portland, OR 97239; email: zonies@ohsu.edu.

© 2018 Lippincott Williams & Wilkins, Inc.