Extracorporeal lung support in trauma patients with severe chest injury and acute lung failure: a 10-year institutional experience

Abstract

Introduction: Severe trauma with concomitant chest injury is frequently associated with acute lung failure (ALF). This report summarizes our experience with extracorporeal lung support (ELS) in thoracic trauma patients treated at the University Medical Center Regensburg.

Methods: A retrospective, observational analysis of prospectively collected data (Regensburg ECMO Registry database) was performed for all consecutive trauma patients with acute pulmonary failure requiring ELS during a 10-year interval.

Results: Between April 2002 and April 2012, 52 patients (49 male, three female) with severe thoracic trauma and ALF refractory to conventional therapy required ELS. The mean age was 32±14 years (range, 16 to 72 years). Major traffic accident (73%) was the most common trauma, followed by blast injury (17%), deep fall (8%) and blunt trauma (2%). The mean Injury Severity Score was 58.9±10.5, the mean lung injury score was 3.3±0.6 and the Sequential Organ Failure Assessment score was 10.5±3. Twenty-six patients required pumpless extracorporeal lung assist (PECLA) and 26 patients required veno-venous extracorporeal membrane oxygenation (vv-ECMO) for primary post-traumatic respiratory failure. The mean time to ELS support was 5.2±7.7 days (range, <24 hours to 38 days) and the mean ELS duration was 6.9±3.6 days (range, <24 hours to 19 days). In 24 cases (48%) ELS implantation was performed in an external facility, and cannulation was done percutaneously by Seldinger's technique in 98% of patients. Cannula-related complications occurred in 15% of patients (PECLA, 19% (n=5); vv-ECMO, 12% (n=3)). Surgery was performed in 44 patients, with 16 patients under ELS prevention. Eight patients (15%) died during ELS support and three patients (6%) died after ELS weaning. The overall survival rate was 79% compared with the proposed Injury Severity Score-related mortality (59%).

Conclusion: Pumpless and pump-driven ELS systems are an excellent treatment option in severe thoracic trauma patients with ALF and facilitate survival in an experienced trauma center with an interdisciplinary treatment approach. We encourage the use of vv-ECMO due to reduced complication rates, better oxygenation and best short-term outcome.

Figure 1

Distribution of both extracorporeal lung support systems implanted during the study period. PECLA, pumpless extracorporeal lung assist; vv-ECMO, veno-venous extracorporeal membrane oxygenation.

Figure 2

Time course of the partial oxygen pressure/fraction of inspired oxygen ratio during extracorporeal lung support. Time course of the partial oxygen pressure (PaO₂)/fraction of inspired oxygen (FiO₂) ratio during extracorporeal lung support separated into both systems. Median with 25th to 75th interquartile range. PECLA, pumpless extracorporeal lung assist; vv-ECMO, veno-venous extracorporeal membrane oxygenation.

Figure 3

Changes of relevant gas exchange parameters under extracorporeal lung support. Median with 25th to 75th interquartile range. CO₂, carbon dioxide; O₂, oxygen; PECLA, pumpless extracorporeal lung assist; vv-ECMO, veno-venous extracorporeal membrane oxygenation.

Figure 4

Improvement and normalization of arterial pH immediately after extracorporeal lung support implantation in both groups. Median with 25th to 75th interquartile range. PECLA, pumpless extracorporeal lung assist; vv-ECMO, veno-venous extracorporeal membrane oxygenation.