Application of Extracorporeal Membrane Oxygenation in Major Trauma Patients - NTUH Experience

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Application of Extracorporeal Membrane
Oxygenation in Major Trauma Patients- NTUH
Experience
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan

• Chih-Hsien Wang, Shu-Chien Huang, Yih-Sharng
  Chen, Wen-Je Ko, Yung-Chie Lee
• Department of Surgery and Traumatology
• National Taiwan University Hospital
• Taipei City, Taiwan

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Multi-trauma Patients
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan

• gt2 organs injured
• Major trauma
• Increased mortality as Injury Severity Score
  (ISS) gt16

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Catastrophe after major trauma
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan

• Resuscitation (cardiopulmonary failure)
• Hypothermia
• Acidosis
• Coagulopathy
• Post-traumatic acute respiratory distress
  syndrome (ARDS)
• Sepsis

Causes of In-hospital mortality
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Trauma Trimodal Death Distribution
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan

• Immediate deaths
• With seconds to minutes
• Severe brain or high spinal cord injury, heart or
  large vessels ruptures
• Early deaths
• Minutes to several hours
• Organ damages
• Late deaths
• Days to weeks
• Sepsis or multiple organ dysunction

Role of ECMO ?
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Limitation of ECMO in trauma patients
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan

• Bleeding and hemostasis !!!!!!
• Trauma ? hemorrhage
• ECMO ? heparin and prolonged ACT
• Reduced heparin dosage ? clot or thrombosis in
  ECMO

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Dilemma
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan
Bleeding Difficult in hemostasis
Clot in ECMO Thrombosis
ECMO Trauma
Heparin Prolong ACT
Heparin-free
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Backgrounds
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan

• The application of ECMO in trauma patients was
  only executed in limited centers worldwide.
• The experiences of ECMO in major multitrauma
  (Injury Severity Score ?16) patients in National
  Taiwan University Hospital.

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Patients and Methods
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan

• Retrospective review from NTUH ECMO registry
• Aug 1994 December 2008
• 1108 patients underwent ECMO
• 12 patients had primary diagnosis of injuries
  (ICD-9 800-959)
• 11 patients had Injury Severity Score (ISS) gt16

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Trauma Registry
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan
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Pre-ECMO Condition
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan
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ECMO Management
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan
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Outcomes and Complications
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan
GOS Glascow Outecome Score
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Characteristics
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan
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Mechanisms of Injury
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan
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ECMO indication
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan
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Ventilator before ECMO
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan
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Is there any contraindication to ECMO use in
trauma patients ?
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan

• Same features in these 2 patients
• Stab wound with massive bleeding
• Pt No 7 cardiac penetrating injury
• Pt No 11 massive pulmonary hemorrhage
• Resuscitation before damage control surgery
• ECMO under the indication of MCS (ECPR)
• Uncontrolled bleeding
• old news in ECMO

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Complications on ECMO
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan
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Heparin and Oxygenator Lifespan
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan
p0.09
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Heparin-free vs. Heparinized
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan

• Both Heparin-bound Carmeda bioactive surface
  (CBAS, Medtronic Inc. USA)
• Target ACT in heparinized patient 180-220 sec
• Shorter lifespan of the oxygenators in
  Heparin-free patients (41.6 hr vs 81.5 hr)
• Increased costs buy time, buy life

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Conclusion
17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan

• ECMO rescue for major multitrauma patients (ISSgt
  16)
• NTUH experience 81.8 survival, 61.6 in good
  neurologic outcome (GOS5)
• Uncontrolled bleeding is still a contraindication
  to ECMO
• Heparin-free in our series may shorten the
  oxygenator lifespan

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17th ASCVTS Wang CH, et al, NTUH, Taipei, Taiwan
Welcome to Taiwan
Thank you very much