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Open Access

Use of extracorporeal membranous oxygenation in the management of refractory trauma-related severe acute respiratory distress syndrome: a national survey of the Eastern Association for the Surgery of Trauma

Lauren Raff, Jeffrey David Kerby, Donald Reiff, Jan Jansen, Eric Schinnerer, Gerald McGwin, Patrick Bosarge
DOI: 10.1136/tsaco-2019-000341 Published 12 August 2019
Lauren Raff
1Trauma and Acute Care Surgery, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Jeffrey David Kerby
2Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Donald Reiff
2Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Jan Jansen
2Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Eric Schinnerer
3Acute Care Surgery, St. John Trauma Services, Tulsa, Oklahoma, USA
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Gerald McGwin
4Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Patrick Bosarge
5Acute Care Surgery, University of Phoenix, Phoenix, Arizona, USA
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Article Figures & Data

Tables

  • Table 1

    Traumatic conditions respondents think are not amenable for extracorporeal membranous oxygenation in severe acute respiratory distress syndrome

    All respondents (n=196)ECMO director (n=8)Trauma surgeon (n=136)Surgical intensivist (n=44)Critical care fellow (n=8)
    Traumatic condition
    Traumatic brain injury60%38%64%55%25%
    Spinal injury25%13%24%30%13%
    Blunt chest or abdominal trauma6%13%6%7%0%
    Postsurgical condition (splenectomy, colectomy, etc)9%0%9%11%13%
    Postsurgical condition of thorax (pneumonectomy, etc)9%38%7%11%13%
  • Table 2

    Ranking of preference of additional treatments for patients with severe acute respiratory distress syndrome who fail conventional mechanical ventilation

    Rank (all respondents)ModalityRespondents that use modality (%)ECMO directors rankingTrauma surgeons rankingSurgical
    intensivists ranking
    1APRV82.0%APRVAPRVAPRV
    2Bilevel71.4%ProneParalysisBilevel
    3Paralysis83.0%ParalysisBilevelParalysis
    4Prone86.9%NOProneProne
    5NO75.7%BilevelNOEpo
    6Epo59.2%EpoHFOVNO
    7HFOV61.7%HFOVEpoHFOV
    8Steroids60.2%SteroidsSteroidsSteroids
    9Surfactant44.2%SurfactantSurfactantSurfactant
    • APRV, airway pressure release ventilation; Epo, epoprostenol; HFOV, high-frequency oscillatory ventilation; NO, nitric oxide; bilevel, bilevel ventilation; paralysis, pharmacological paralysis; prone, prone positioning; steroids, corticosteroids.

  • Table 3

    Timing of when to initiate extracorporeal membranous oxygenation.

    All respondentsECMO directors (n=8)Trauma surgeons (n=131)Surgical intensivist (n=42)Critical care fellows (n=8)
    Timing of ECMO initiation
    Failure to improve after maximizing conventional ventilation13.1%25.0%12.2%7.1%37.5%
    Failure to improve after APRV/bilevel23.1%0.0%23.7%33.3%0.0%
    Failure to improve after addition of prone, NO, Epo, steroids and/or surfactant16.6%25.0%16.0%16.7%25.0%
    Hypoxic respiratory failure worsening but prior to maximal therapy being reached28.6%50.0%26.7%28.6%12.5%
    I never consider ECMO10.6%0.0%12.2%11.9%0.0%
    I do not know8.0%0.0%9.2%2.4%25.0%
    • APRV, airway pressure release ventilation;ECMO, extracorporeal membranous oxygenation; Epo, epoprostenol; HFOV, high-frequency oscillatory ventilation; NO, inhaled nitric oxide; bilevel, bilevel ventilation; paralysis, pharmacological paralysis; prone, prone positioning; steroids, corticosteroids.

  • Table 4

    Use of VV versus VA extracorporeal membranous oxygenation other than for acute respiratory distress syndrome

    VV ECMO onlyVA ECMO onlyInitiate VV and transition to VA as neededDon’t knowWould not use ECMO
    Condition for ECMO
    Hypoxia from pulmonary embolus19.2%7.9%37.9%26.6%8.5%
    Right heart failure from pulmonary embolus9.7%29.1%25.1%28.0%8.0%
    Right heart failure from traumatic pneumonectomy11.0%24.9%26.6%30.6%6.9%
    Hypoxia from pulmonary contusion37.6%2.3%29.5%24.3%6.4%
    Supportive ‘bridge’ after cardiac arrest from hypoxia/right heart failure6.5%22.6%22.0%33.3%15.5%
    • ECMO, extracorporeal membranous oxygenation; VA, venoarterial; VV, venovenous.

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Use of extracorporeal membranous oxygenation in the management of refractory trauma-related severe acute respiratory distress syndrome: a national survey of the Eastern Association for the Surgery of Trauma
Lauren Raff, Jeffrey David Kerby, Donald Reiff, Jan Jansen, Eric Schinnerer, Gerald McGwin, Patrick Bosarge
Trauma Surg Acute Care Open Aug 2019, 4 (1) e000341; DOI: 10.1136/tsaco-2019-000341

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Use of extracorporeal membranous oxygenation in the management of refractory trauma-related severe acute respiratory distress syndrome: a national survey of the Eastern Association for the Surgery of Trauma
Lauren Raff, Jeffrey David Kerby, Donald Reiff, Jan Jansen, Eric Schinnerer, Gerald McGwin, Patrick Bosarge
Trauma Surg Acute Care Open Aug 2019, 4 (1) e000341; DOI: 10.1136/tsaco-2019-000341
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Use of extracorporeal membranous oxygenation in the management of refractory trauma-related severe acute respiratory distress syndrome: a national survey of the Eastern Association for the Surgery of Trauma
Lauren Raff, Jeffrey David Kerby, Donald Reiff, Jan Jansen, Eric Schinnerer, Gerald McGwin, Patrick Bosarge
Trauma Surgery & Acute Care Open Aug 2019, 4 (1) e000341; DOI: 10.1136/tsaco-2019-000341
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