Extracorporeal life support in pulmonary failure after trauma

Objective: To present a series of 30 adult trauma patients who received ext racorporeal life support (ECLS) for pulmonary failure and to retrospectivel y review variables related to their outcome. Methods: In a Level I trauma center between 1989 and 1997, ECLS with contin uous heparin anticoagulation was instituted in 30 injured patients older th an 15 years, Indication was for an estimated mortality risk greater than 80 %, defined by a Pao(2): FIO2 ratio less than 100 on 100% FIO2, despite pres sure-mode inverse ratio ventilation, optimal positive end-expiratory pressu re, reasonable diuresis. transfusion, and prone positioning. Retrospective analysis included demographic information (age, gender, Injury Severity Sco re, injury mechanism), pulmonary physiologic and gas-exchange values (pre-E CLS ventilator days [VENT days], Pao(2):FIO2 ratio, mixed venous oxygen sat uration [Svo(2)], and blood gas), pre-ECLS cardiopulmonary resuscitation, c omplications of ECLS (bleeding, circuit problems, leukopenia, infection, pn eumothorax, acute renal failure, and pressors on ECLS), and survival. Results: The subjects were 26.3 +/- 2.1 Sears old (range, 15-59 Sears), 50% male, and had blunt injury in 83.3%. Pulmonary recovery sufficient to wean the patient from ECLS occurred in 17 patients (56.7%), and 50% survived to discharge. Fewer VENT days and more normal Svo(2) were associated with sur vival. The presence of acute renal failure and the need for venoarterial su pport (venoarterial bypass) were more common in the patients who died. Blee ding complications (requiring intervention or additional transfusion) occur red in 58.6% of patients and were not associated with mortality. Early use of ECLS (VENT days less than or equal to 5) was associated with all odds ra tio of 7.2 for survival. Fewer VENT days was independently associated with survival in a logistic regression model (p = 0.029). Age, Injury Severity S core, and Pao(2):FIO2 ratio were not related to outcome. Conclusion: ECLS has been safely used in adult trauma patients with multipl e injuries and severe pulmonary failure. In our series, early implementatio n of ECLS was associated with improved survival. Although this may represen t selection bias for less intractable forms of acute respiratory distress s yndrome, it is our experience that early institution of I:CLS may lead to i mproved oxygen delivery, diminished ventilator-induced lung injury, and imp roved survival.