Early extracorporeal membranous oxygenation and burn excision in severe burn and inhalation injury.

Abstract

Introduction: Extracorporeal membranous oxygenation (ECMO) as a salvage therapy for patients with severe acute respiratory distress syndrome (ARDS) has been described but experience is limited in burn cases. Few case reports detail the use of ECMO the setting of burn excision.

Case: Here, we describe a 40-year-old female found down in a house fire who presented with 30% total body surface area burns and severe inhalation injury resulting in ARDS. Veno-venous ECMO was initiated 12 h after injury, with a total ECMO run of 523 h. In that time, she underwent three tangential excisions with significant intraoperative and postoperative bleeding complications requiring in total 37 units of packed red blood cells, 8 pools of platelets, 24 units of fresh frozen plasma, and 1 unit of cryoprecipitate. The patient was successfully weaned from veno-venous ECMO. She required six subsequent excisions after her ECMO decannulation for both infection control and complete excision of her full-thickness burns. She was ultimately discharged to an inpatient rehabilitation facility.

Discussion: This report serves as the first detailed description of perioperative resuscitation on ECMO during burn excision and adds to the body of literature regarding ECMO support in the burned patient. This case specifically highlights the multidisciplinary care and resource demands of performing burn excision during ECMO as well as the associated bleeding complications of doing so. Further study is needed to define optimal timing, patient selection, and strategy for coagulopathy management and surgical care of the burn patient with ARDS treated with ECMO.

Lay summary: Patients with severe burn injuries can have associated injuries to their lungs from both smoke and as a response to the stress a severe burn puts on the body. The injuries can be so severe that supportive machines can be needed that do the work of the lungs by adding oxygen to the blood, called extracorporeal membranous oxygenation (ECMO). These extreme measures are critical to supporting severe respiratory problems and have been incorporated into caring for burn patients with severely injured lungs. ECMO requires significant resources and has risks, including bleeding and clotting issues. Severely burned patients also need surgery to remove burned skin and decrease the stress placed on the body. Only a handful of cases have been described where burn surgery has been performed while a patient was on ECMO support. In our experience caring for a severely burned patient and performing multiple surgeries on ECMO, we encountered multiple bleeding complications secondary to the use of ECMO, resulting in large amounts of transfusion products needed. After one month, the patient's lungs recovered and ECMO was not needed. The patient survived to discharge from the hospital after completion of additional necessary burn surgeries. This report is the first to explain in detail the experience of performing burn excision on a patient on ECMO. We describe the resources and team members needed for success and believe further research must be done to best manage burn injuries while on ECMO.