Extracorporeal membrane oxygenation is associated with decreased mortality in non-acute respiratory distress syndrome patients following severe blunt thoracic trauma.
Bardiya Zangbar, Aryan Rafieezadeh, Kartik Prabhakaran, Anna Jose, Ilya Shnaydman, Matthew Bronstein, Joshua Klein, Gabriel Froula, Jordan Kirsch
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Abstract
Background: Extracorporeal membrane oxygenation (ECMO) has emerged as a critical intervention in the management of patients with trauma-induced cardiorespiratory failure. This study aims to compare outcomes in patients with severe thoracic injuries with and without venovenous extracorporeal membrane oxygenation (VV-ECMO).
Methods: We performed a retrospective cohort study on Trauma Quality Improvement Program (2017-2021) and included all patients with isolated blunt thoracic injuries with Abbreviated Injury Scale score of ≥4 who required intubation. Patients were divided into two groups based on VV-ECMO and were compared using propensity score matching with the primary outcome of mortality.
Results: A total of 14,106 patients with severe thoracic injuries were identified. Propensity score matching resulted in two groups of 812 VV-ECMO and 812 non-VV-ECMO groups. Venovenous ECMO group had significantly lower in-hospital mortality rates (22.3% vs. 37.3%, p < 0.001). However, VV-ECMO group had significantly higher rates of complications including cardiac arrest (27.7% vs. 10.6%), pulmonary embolism (7.6% vs. 2.1%), ventilator-associated pneumonia (16.7% vs. 4.2%), unplanned intubation (11.9% vs. 8.5%), unplanned intensive care unit (ICU) admission (8.4% vs. 4.9%), and unplanned return to operation room (10.1% vs. 2.6%) (p < 0.001, for all). Patients in VV-ECMO group had significantly higher hospital (29.46 ± 26.37 vs. 13.59 ± 13.3 days) and ICU (22.96 ± 19.38 vs. 9.38 ± 9.05 days) length of stay (p < 0.001, for both). In VV-ECMO group, the mean ± SD time to perform VV-ECMO was 5.54 ± 5.91 days. Each day earlier initiation of VV-ECMO resulted in decreased hospital and ICU length of stay by 67.1% and 59.9%, respectively (p < 0.001 for both). Among patients without acute respiratory distress syndrome (n = 435 in each group after repeated PS matching), we observed significantly lower mortality rates in VV-ECMO group (26.9% vs. 40%, p < 0.001).
Conclusion: While VV-ECMO in isolated blunt thoracic trauma patients is associated with higher survival rates even in non-acute respiratory distress syndrome cases, it is associated with higher incidence of complications. These findings emphasize earlier consideration of VV-ECMO in severe blunt thoracic trauma.
Level of evidence: Retrospective Study; Level III.
背景：体外膜氧合（ECMO）已成为创伤性心肺衰竭患者管理的关键干预措施。本研究的目的是比较重症胸外伤患者采用和不采用静脉-静脉体外膜氧合（VV-ECMO）治疗的结果。方法：我们进行了一项创伤质量改善计划（2017-2021）的回顾性队列研究，纳入了所有需要插管的单纯钝性胸部损伤患者，其简略损伤量表评分≥4分。根据VV-ECMO将患者分为两组，并使用倾向评分与死亡率的主要结局相匹配进行比较。结果：共鉴定出14106例重型胸外伤患者。倾向评分匹配结果为812例VV-ECMO组和812例非VV-ECMO组。静脉-静脉ECMO组住院死亡率显著降低（22.3% vs. 37.3%, p < 0.001）。然而，VV-ECMO组的并发症发生率明显更高，包括心脏骤停（27.7%比10.6%）、肺栓塞（7.6%比2.1%）、呼吸机相关性肺炎（16.7%比4.2%）、计划外插管（11.9%比8.5%）、计划外重症监护病房（ICU）入院（8.4%比4.9%）和计划外返回手术室（10.1%比2.6%）（均p < 0.001）。VV-ECMO组患者住院时间（29.46±26.37天比13.59±13.3天）和ICU住院时间（22.96±19.38天比9.38±9.05天）均显著高于对照组（p < 0.001）。VV-ECMO组VV-ECMO的平均±SD时间为5.54±5.91天。每提前一天开始VV-ECMO，住院时间和ICU住院时间分别减少67.1%和59.9% （p < 0.001）。在无急性呼吸窘迫综合征的患者中（重复PS匹配后每组n = 435例），我们观察到VV-ECMO组的死亡率显著降低（26.9% vs. 40%, p < 0.001）。结论：孤立性钝性胸外伤患者的VV-ECMO即使在非急性呼吸窘迫综合征病例中也具有较高的生存率，但其并发症发生率较高。这些发现强调了在严重钝性胸外伤中早期考虑VV-ECMO。证据水平：回顾性研究；第三层次。
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The Journal of Trauma and Acute Care Surgery® is designed to provide the scientific basis to optimize care of the severely injured and critically ill surgical patient. Thus, the Journal has a high priority for basic and translation research to fulfill this objectives. Additionally, the Journal is enthusiastic to publish randomized prospective clinical studies to establish care predicated on a mechanistic foundation. Finally, the Journal is seeking systematic reviews, guidelines and algorithms that incorporate the best evidence available.
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