Indications of extracorporeal life support in poly-trauma

Extracorporeal Membrane Oxygenation During Adult Noncardiac Surgery and Perioperative Emergencies: A Narrative Review

Over the last decade, the use of extracorporeal membrane oxygenation (ECMO) has increased significantly. In some centers, ECMO has been deployed to manage perioperative emergencies and plays a role in facilitating high-risk thoracic, airway, and trauma surgery, which may not be feasible without ECMO support. General anesthesiologists who usually manage these cases may not be familiar with the initiation and management of patients on ECMO. This review discusses the use of ECMO in the operating room for thoracic, airway, and trauma surgery, as well as obstetric and perioperative emergencies.

AAST Critical Care Committee clinical consensus: ECMO, nutrition

The American Association for the Surgery of Trauma Critical Care Committee has developed clinical consensus guides to help with practical answers based on the best evidence available. These are focused in areas in which the levels of evidence may not be that strong and are based on a combination of expert consensus and research. Overall, quality of the research is mixed, with many studies suffering from small numbers and issues with bias. The first two of these focus on the use of extracorporeal membrane oxygenation in trauma patients and nutrition for the critically ill surgical/trauma patient.

Extracorporeal life support in the emergency department: A narrative review for the emergency physician

BACKGROUND

Extracorporeal life support (ECLS) describes the use of blood perfusion devices to provide advanced cardiac or respiratory support. Advances in percutaneous vascular cannula insertion, centrifugal pump technologies, and the miniaturization of extracorporeal devices have simplified ECLS. The intention of this discussion is to review the role of ECLS as a potential rescue method for emergency department (ED) clinicians in critical clinical scenarios and to focus on the prerequisites for managing an ECLS program in an ED setting.

DISCUSSION

Possible indications for ECLS cannulation in the ED include ongoing circulatory arrest, shock or refractory hypoxemia and pulmonary embolism with refractory shock. Severe trauma, foreign body obstruction, hypothermia and near drowning are situations in which patients may potentially benefit from ECLS. Early stabilization in the ED can provide a time window for a diagnostic workup and/or urgent procedures, including percutaneous coronary intervention, rewarming or damage control surgery in trauma. The use of ECLS is resource intensive and can be associated with a high risk of complications, especially when performed without previous training. Therefore, ECLS should only be used when the underlying problem is potentially reversible, and the resources are available to address the etiology of organ dysfunction.

CONCLUSION

Emergent ECLS has a role in the ED for selected indications in the face of life-threatening conditions. ECLS provides a bridge to recovery, definitive therapy, intervention or surgery. ECLS program requires an appropriately trained staff (physicians, nurses and ECLS specialists), equipment resources and logistical planning.

Extracorporeal life support in polytraumatized patients

Major trauma is a leading cause of death, particularly amongst young patients. Conventional therapies for post-traumatic cardiovascular shock and acute pulmonary failure may sometimes be insufficient and even dangerous. New approaches to trauma care and novel salvage techniques are necessary to improve outcomes. Extracorporeal life support (ECLS) has proven to be effective in acute cardiopulmonary failure from different etiologies, particularly when conventional therapies fail. Since 2008 we have used ECLS as a rescue therapy in severe poly-trauma patients with refractory clinical setting (cardiogenic shock, cardiac arrest, and/or pulmonary failure). The rationale for using ECLS in trauma patients is to support cardiopulmonary function, providing adequate systemic perfusion and, therefore, avoiding consequent multi-organ failure and permitting organ recovery. From our data ECLS, utilizing heparin-coated support to avoid systemic anticoagulation, is a valuable option to support severely injured patients when conventional therapies are insufficient. It is safe, feasible, and effective in providing hemodynamic support and blood-gas exchange. Moreover, we have identified several pre-ECLS patient characteristics useful in predicting ECLS treatment appropriateness in severe poly-traumatized patients. These might be helpful in deciding whether the ECLS should be initiated in patients who are severely complex and compromised. Future improvements in materials and techniques are expected to make ECLS even easier and safer to manage, leading to a further extension of its use in severely injured patients.