PURPOSE: Trauma patients developing acute hypoxemic respiratory failure (AHRF) have increased morbidity and mortality. Rescue strategies for life-threatening, refractory hypoxemia have demonstrated improved oxygenation, but not a proven survival benefit. Venovenous extracorporeal life support (VV ECLS) provides gas exchange while ventilator settings are decreased to low pressures and non-toxic levels of FiO2. We hypothesize that VV ECLS improves survival in adult trauma patients with AHRF refractory to conventional strategies.
METHODS: Trauma patients 16-55 years old managed at two academic level-1 trauma centers between January 2001 and December 2009 were retrospectively studied. Inclusion criteria were P:F < 80 on > 0.9 FiO2, lung injury score (LIS) > 3.0, and survival > 24 hours post admission. Two cohorts were compared using multivariate logistic regression: Center A used VV ECLS after conventional lung-protective strategies (CONV) failure, Center B offered CONV only. A subset of severe AHRF using LIS ≥ 3.5 was evaluated. Primary outcome was survival to discharge, secondary outcomes were ICU and hospital length of stay (LOS), total ventilator days, and rate of complications requiring intervention.
RESULTS: 26 ECLS and 76 CONV patients were compared. Adjusted survival (58% vs 55%; AOR = 3.34, [95% CI = 1.01, 10.99]; p= 0.047), was greater in the ECLS group. Ventilator days (24.9 vs 20.7; p=0.485), ICU (37.5 vs 25.4; p=0.108) and hospital (38.9 vs 35.4; p=0.713) LOS and complications (46.2% vs. 44.7%; p=1.000) did not differ between groups. ECLS had greatest survival in the severe AHRF subset (58% vs 49%; AOR = 5.52 [95% CI = 1.34, 25.14], p = 0.019).
CONCLUSIONS: Venovenous ECLS demonstrates a survival benefit in adult trauma patients with AHRF, but may utilize more hospital resources. The survival benefit is greatest in severe AHRF. Transfer to an experienced ECLS center should be considered for trauma patients with AHRF refractory to conventional management.
CLINICAL IMPLICATIONS: ECLS demonstrates a survival benefit in acute respiratory failure
DISCLOSURE: The following authors have nothing to disclose: Derek Guirand, Obi Okoye, Shayn Martin, James Aden, Michael Hines, Thomas Pranikoff, Ramon Cestero, Kenji Inaba, Jeremy Cannon
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