Physiologic considerations, indications and techniques for ECLS in trauma: experience of a level 1 trauma centre

• Published in: Canadian Journal of Surgery Vol. 64; pp. S56 - S57
• Main Authors: Al Khaboori, Sadiq, Hameed, Morad, Garraway, Naisan, Joos, Emilie, Isac, George, Kanji, Hussein, Finlayson, Gordon, Tansley, Gavin, Lee, Alex
• Format: Journal Article
• Language: English
• Published: Ottawa CMA Impact, Inc 01-10-2021
• Subjects: Extracorporeal membrane oxygenation; Injuries; Liver; Trauma
• ISSN: 0008-428X; 1488-2310

Background: Extracorporeal life support (ECLS) is used increasingly in the care of multisystem trauma patients. However, to date, clear indications for ECLS deployment in trauma have not been established. Clarity about indications and techniques is essential for timely deployment in critical trauma situations to improve outcomes and ensure good stewardship of an important resource. We reviewed recent ECLS deployments at our level 1 trauma centre to understand indications, techniques, strategies and logistics of ECLS in trauma. Methods: The BC Trauma Registry was used to identify trauma patients who got ECLS at the Vancouver General Hospital (VGH), a level 1 trauma centre and Extracorporeal Life Support Organization accredited site. The study period was from January 2014 to October 2020. We reviewed charts for indications, technical factors and outcomes. All cases were presented to trauma and intensive care unit staff involved in ECLS management and consensus was achieved. Results: A total of 14 patients underwent ECLS (mean age of 31 yr) within a comprehensive resuscitation strategy. Twelve underwent venovenous (VV) ECLS and 2 got venoarterial (VA) ECLS. Twelve patients sustained blunt injuries and 2 penetrating injuries. The average Injury Severity Score (ISS) was 42 (22-57). The broad indications for ECLS were acute respiratory distress syndrome (ARDS) and pulmonary contusions (PC), cardiac injury, and liver and retrohepatic vena cava (IVC) injury. A variety of cannulation strategies were employed depending on the indication. Systemic anticoagulation for VV ECLS was not used during cannula insertion for 3 of 6 ARDS and PC patients and 5 of 6 liver and IVC patients because of concerns about associated injuries. Of 14 patients, 2 got clots in the circuit causing it to fail; 1 of them received a heparin bolus but no heparin infusion and required complete change of circuit, the other 1 clotted his circuit secondary to ongoing hypovolemia and blood loss in the operating room. The duration of ECLS placement was on average 74 hours (10-185 h) for cardiac and pulmonary indications with mean flow of 4.6 L/min, and on average 2.8 hours for liver and IVC injuries with mean flow of 4.0 L/min. Two patients had major vascular injury secondary to cannula insertion requiring vascular reconstruction and repair. A total of 79% of patients survived the ECLS run. Conclusion: ECLS is a useful strategy in the comprehensive care of severely injured patients but clarity about indications (ARDS and PC; cardiac; and liver and IVC) and advanced standardization of corresponding techniques (cannulation, anticoagulation and duration) may assist decision-making, deployment and team activation. In our experience ECLS can change the damage control paradigm to enable the management of complex injuries and to provide earlier definitive surgery.