High survival in adult patients with acute respiratory distress syndrome treated by extracorporeal membrane oxygenation, minimal sedation, and pressure supported ventilation

Objectives: To evaluate the results of treatment of severe acute respirator y distress syndrome (ARDS) with extracorporeal membrane oxygenation (ECMO), minimal sedation, and pressure supported ventilation. Design and setting: Observational study in a tertiary referral center, Inte nsive Care Unit, Astrid Lindgren Children's Hospital at Karolinska Hospital , Stockholm, Sweden. Subjects and methods: Seventeen adult patients with ARDS were treated with venovenous or venoarterial ECMO after failure of conventional therapy. The Murray score of pulmonary injury averaged 3.5 (3.0-4.0) and the mean PaO2/F IO2 ratio was 46 (31-65). A standard ECMO circuit with nonheparinized surfa ces was used. The patients were minimally sedated and received pressure-sup ported ventilation. High inspiratory pressures were avoided and arterial sa turation as low as 70% was accepted on venovenous bypass. Results: In one patient a stable bypass could not be established. Among the remaining 16 patients 13 survived (total survival rate 76%) after 3-52 day s (mean 15) on bypass. Major surgical procedures were performed in several patients. The cause of death in the three nonsurvivors was intracranial com plications leading to total cerebral infarction. Conclusion: A high survival rate can be obtained in adult patients with sev ere ARDS using ECMO and pressure-supported ventilation with minimal sedatio n. Surgical complications are amenable to surgical treatment during ECMO. B leeding problems can generally be controlled but require immediate and aggr essive approach. It is difficult or impossible to decide when a lung diseas e is irreversible, and prolonged ECMO treatment may be successful even in t he absence of any detectable lung function.