Calm before the storm - austere environments - challenging indications (trauma)

Abstract

Extracorporeal membrane oxygenation (ECMO) is increasingly used as an adjunct in the management of critically injured trauma patients requiring operative intervention. Although trauma represents a small proportion of overall ECMO use, its application has expanded due to advances in circuit technology, cannulation strategies, and anticoagulation practices. This review examines the role of ECMO in stabilizing operative trauma patients across preoperative, intraoperative, and postoperative phases. Preoperatively, ECMO is most commonly indicated for refractory hypoxemia or severe acidosis resulting from thoracic or airway injury, aspiration, transfusion-related acute lung injury, or acute respiratory distress syndrome. Early cannulation can restore gas exchange, improve hemodynamic stability, reduce ventilator-induced lung injury, and facilitate safe transport to the operating room during damage control resuscitation. Emerging evidence also supports selective use of ECMO in patients with traumatic brain injury requiring urgent neurosurgical intervention. Intraoperatively, ECMO has been used during high-risk damage control procedures, including trauma pneumonectomy, retrohepatic inferior vena cava injury, and operations complicated by hemorrhage, hypothermia, and acidosis. Veno-venous ECMO may improve oxygenation and reduce right ventricular strain, while veno-arterial ECMO may be appropriate in select cases of traumatic cardiogenic shock. Postoperatively, ECMO is most often employed for delayed respiratory failure due to acute respiratory distress syndrome, transfusion-related lung injury, or bronchopleural fistula, allowing lung-protective ventilation and recovery. Although evidence supporting ECMO for traumatic respiratory failure continues to grow, data for other perioperative indications remain limited. Prospective multicenter studies are needed to refine patient selection, timing, and outcomes in operative trauma populations.

Keywords

extracorporeal membrane oxygenation trauma surgery damage control resuscitation critical care operative trauma

Background

The first use of extracorporeal membrane oxygenation (ECMO) in the intensive care setting was for a trauma patient. A 24-year-old male with an aortic injury developed Acute Respiratory Distress Syndrome (ARDS) and was successfully supported with veno-arterial (VA) ECMO. He went on to survive with a good outcome.¹ Since that initial case, the use of ECMO in trauma has remained limited compared to medical indications, accounting for fewer than 1% of all cases reported to the Extracorporeal Life Support Organization (ELSO).² However, trauma-related ECMO utilization is also increasing rapidly, at an average annual growth rate of 24%.³ One study found that 62% of trauma ECMO cases from 1993 to 2016 occurred during the last 5 years of that period.⁴ Survival is highest in trauma patients receiving veno-venous (VV) ECMO (63%), followed by VA ECMO (50%), then extracorporeal cardiopulmonary resuscitation (ECPR) during cardiac arrest (25%).²

This paper reviews the use of ECMO for stabilizing the operative trauma patient. It begins with an overview of ECMO cannulation techniques and physiology. Current evidence regarding ECMO use in operative trauma will be summarized, with a focus on preoperative, perioperative, and postoperative indications.

ECMO description and physiology

Veno-venous extracorporeal membrane oxygenation

VV ECMO is the most common configuration of ECMO utilized for trauma patients. VV ECMO drains deoxygenated blood from the venous system then returns oxygenated blood into the right heart. VV ECMO requires adequate cardiac function as there is no direct hemodynamic support provided by the circuit. The ECMO circuit oxygenator provides oxygenation and clearance of carbon dioxide, which can correct hypoxia and acidosis, indirectly improving cardiac dysfunction.⁵ One study in patients initiated on VV ECMO showed rapid decrease in pulmonary artery pressures theorized to be due to improved PaO₂, PaCO₂, and pH. These changes offload the right ventricle and improve function with subsequent improvements in cardiac index.⁶ In addition, VV ECMO allows for weaning ventilator support. Resultant decreased intrathoracic pressures allows for improved cardiac preload and output.^7,8

In addition to correcting hypoxia and hypercarbia, VV ECMO is particularly beneficial in perioperative trauma as it can help correct the “lethal triad” of hemorrhagic shock through several mechanisms. VV ECMO is also a highly effective method to correct hypothermia and has been shown to rapidly warm hypothermic medical patients compared to standard of care.⁹ VV ECMO can also improve acidosis from a respiratory etiology through carbon dioxide clearance. Additionally, correction of severe hypoxia can theoretically allow the body to better utilize aerobic metabolism and decrease metabolic acidosis.

Veno-arterial extracorporeal membrane oxygenation

VA ECMO is primarily indicated for the management of cardiogenic shock. In the trauma setting, this is generally performed via peripheral cannulation for cardiac injury. Deoxygenated blood is drained via a cannula in the common femoral vein and oxygenated blood is returned through a cannula inserted in the common femoral artery. In this configuration, blood bypasses the heart and lungs and is returned retrograde to the aorta to allow for systemic perfusion and provides both hemodynamic support and oxygenation. VA ECMO is uncommon in trauma populations as complication rates are high, and the circuit often requires anticoagulation to prevent clotting in the circuit.

Preoperative ECMO

Indications for early, preoperative ECMO cannulation in the unstable trauma patient include airway injury, severe thoracic trauma, refractory hypoxia or acidosis causing instability that prevents safe transfer to the OR. In fact, impaired gas exchange is the most common indication for ECMO in trauma.^2,10,11 The associated hypoxia and acidosis can cause profound hemodynamic instability, and ventilator settings required to maintain oxygenation can induce severe lung injury. The primary goals of preoperative ECMO cannulation are to rapidly correct hypoxia and acidosis and stabilize hemodynamics and enable safe transfer to the OR, while also mitigating ventilator-induced lung injury. Early preoperative ECMO should be considered as part of a damage control resuscitation strategy.

Correcting hypoxia and acidosis may stabilize hemodynamics to facilitate surgical interventions to control hemorrhage or manage TBI. Warming and acidosis correction also helps manage the lethal triad. For patients with hemodynamic instability or even recent cardiac arrest from hypoxia or acidosis, VV ECMO can successfully restore hemodynamics and is often preferred to VA ECMO in the trauma population because of its lower rate of complications.⁵ Multiple studies have demonstrated that VV ECMO is a reasonable option for patients after cardiac arrest.^2,12,13

In the largest study to look at early ECMO cannulation for trauma patients, patients were cannulated on average 5 h after arrival to the trauma bay. The most common indications for cannulation were pulmonary contusions (60%), aspiration (14%), transfusion related acute lung injury (TRALI) (14%), volume overload (5%), fat embolus (4%), and tracheal injuries (4%). Among this cohort, 35% of patients had suffered a cardiac arrest before cannulation, and all patients in the cohort underwent a surgical intervention. Average precannulation pH was 7.22 and SpO2 was 82%, and these deficits were corrected within 2 h of cannulation in the study. Overall, 70% of patients cannulated for early ECMO survived to hospital discharge.¹⁴

A similar retrospective study evaluated 18 patients cannulated for major trauma in Italy, with an average time to cannulation of 6 h after arrival in the hospital. One third of patients were cannulated in the emergency department, 11% were cannulated in the OR, and 56% were cannulated in the ICU. Blood gas values were normalized within an average of 3.5 h after cannulation for ECMO.¹⁵ Another small retrospective review of trauma patients in Germany also found normalization of blood gas values within 2 h of ECMO cannulation.¹⁶

Preoperative ECMO in patients with traumatic brain injury (TBI)

It is common for a polytrauma patient to require an emergent neurosurgical procedure and to also have acute respiratory failure. TBI patients are at risk of secondary brain injury from hypercarbia and hypoxia, which can be reversed with ECMO.¹⁷ TBI has been historically considered a contraindication to ECMO due to the risk of worsened intracranial hemorrhage with the use of anticoagulation.¹⁸ However, newer ECMO circuits are less thrombogenic and safety of ECMO without anticoagulation has been demonstrated, making preoperative ECMO cannulation a viable strategy for patients with operative TBI and respiratory failure.¹⁹

Even when anticoagulation is used, a significant body of research suggests that ECMO can be safe in appropriately selected TBI patients. One single-center retrospective study of 75 patients with TBI on ECMO showed a low incidence of new findings on repeat head CT including worsening intracranial hemorrhage (14%).²⁰ Another single-center retrospective study found no worsening of intracranial hemorrhage in a smaller cohort of 13 patients all of whom were anticoagulated.²¹ One retrospective multi-center study using TQIP showed that when comparing patients with TBI on ECMO, patients who received anticoagulation had higher unplanned return to OR; however, when comparing patients on ECMO who did or did not receive anticoagulation, there were no differences between these groups in terms of thrombotic complications and stroke.²² However, another study found a higher incidence of hemorrhage on CT in patients on ECMO who received anticoagulation compared to those who did not.¹⁹ While there is a paucity of data regarding outcomes of patients on ECMO requiring neurosurgical intervention before or after cannulation, one small retrospective study of patients on VA or VV ECMO showed that patients had similar survival rates to the general ECMO population at about 63%.²³ Rather than being contraindicated for TBI, ECMO may provide benefits to these patients in preventing secondary brain injury from hypoxia and hypercarbia and allow more safe transition to emergent neurosurgical procedure. Regardless of the oeprative requirements, ECMO can facilitate stabiliationa nd transfer to the OR for definitive intervention.

Intraoperative ECMO

ECMO has been described in the perioperative setting to facilitate damage control surgery. This strategy is most commonly described for trauma pneumonectomy and for hepatic vascular isolation in the setting of retrohepatic IVC injuries but has also been used in select cases with uncontrolled bleeding for rapid correction of the lethal triad.

Pneumonectomy

Uncontrolled pulmonary hemorrhage, tracheobronchial injury, or hilar injury may require pneumonectomy for definitive control. Unfortunately, trauma pneumonectomy carries a high mortality, between 50 and 100%.²⁴ Mortality is commonly caused by acute RV failure when pneumonectomy causes a sudden increase in RV afterload in an already hypoxic, acidotic patient.²⁵ While those patients who receive pneumonecotmy and RV failure may require VA ECMO, VV ECMO has been shown to reduce venous pressures and increase systemic pressures in a swine model in both a hemodynamically normal model and in the setting of right ventricular overload and could be an interoperative “prevention strategy” for RV failure.²⁶ Despite the limited outcomes data in traumatic pneumonectomy, the theoretical benefits of unloading the RV and normalizing oxygen and CO₂ levels has led to VV ECMO being adopted as standard for pneumonectomies at some centers.²⁷

The largest review of the topic compares outcomes among 20 patients at a single center between 2003 and 2023 who underwent trauma pneumonectomy. The patients in the second decade of this study had higher rates of VV ECMO cannulation and had markedly lower late mortality rates (9% vs 50%). However, overall mortality was similarly high in both groups at around 50%.²⁸

Retrohepatic IVC injury

High-grade liver injuries and retrohepatic caval injuries are notoriously hard to manage operatively. Sources of bleeding are difficult to access surgically, and patients often develop hypothermia and profound coagulopathy before bleeding can be controlled. VV ECMO has been described as an adjunct for hepatic vascular isolation while also correcting intraoperative hypothermia and acidosis. Other benefits of ECMO in retrohepatic caval injuries include creating a dry operative field and ensuring adequate venous return despite tight abdominal packing. In these cases, the drainage cannula is usually positioned lower than usual in the infrahepatic vena cava to facilitate hepatic vascular isolation. A concern with cannula placement for this indication is entrapment of air into the circuit from damaged vasculature.²⁹

Correction of lethal triad

Though much improved with modern heparin-bound ECMO cannulae, initiation of ECMO does inherently induce a certain level of coagulopathy. That said, VV ECMO can be used in the damage control setting to correct otherwise uncorrectable hypothermia and acidosis as part of a broader strategy to improve the lethal triad and correct coagulopathy, as described above.³ This is especially useful when prolonged OR time is required to control difficult to access surgical bleeding. ECMO has been shown in multiple studies to correct hypoxia and acidosis rapidly.^15,16,26

Cardiac injury

Relative to VV ECMO, VA ECMO presents more complications related to coagulopathy and bleeding, and to this point has shown worse outcomes in the trauma setting. Because of this, indications are more limited. That said, VA ECMO can provide intraoperative hemodynamic support for patients with cardiac injury and profound cardiogenic shock. One small case series showed better survival in patients with cardiac tamponade and tension hemothorax with presumed cardiac or major vascular injury treated with VA ECMO, but the sample size was too small to support strong conclusions.³⁰

ECMO and perioperative anticoagulation

Intraoperative ECMO has historically been avoided in trauma patients because of high anticoagulation requirements. ECMO circuits carry multiple thrombotic risks including circuit thrombosis, ischemic stroke, deep venous thrombosis, leg ischemia, and pulmonary embolism.^31,32 The 2021 ELSO anticoagulation guidelines still recommend anticoagulation in both VV and VA ECMO due to the lack of robust randomized control trials to demonstrate the safety of ECMO without anticoagulation.¹⁸ However, newer biopassive and bioactive coatings for circuits have been developed that mitigate thrombosis with interaction of blood with the circuit.^33,34 Such circuit coatings include heparin, albumin, and polyethylene glycol among others.^33,34 While these coatings and high flows do not eliminate the risk of circuit thrombosis, the use of ECMO without systemic anticoagulation has been safely performed in patient populations at high risk of bleeding.^35,36

Safe use of ECMO without systemic anticoagulation has been demonstrated in trauma patients. One multi-center retrospective study of trauma patients evaluated outcomes with and without anticoagulation and found no significant difference in thrombosis rate between groups.³⁷ A single-center retrospective study of trauma patients on ECMO showed that systemic anticoagulation was not correlated with higher morbidity, but was associated with survival.³⁸ Still more recent retrospective data has demonstrated that withholding anticoagulation in trauma patients did not result in increased mortality or thrombotic complications.¹⁹ Prospective studies are still needed to support the results of these retrospective studies that holding anticoagulation in patients at high risk of bleeding is safe.

Postoperative ECMO

Common indications for postoperative ECMO include delayed respiratory failure from pulmonary trauma, ARDS, TRALI, and Bronchopleural fistulas (BPFs). VV ECMO for these indications can facilitate lung rest, limit ventilator induced lung injury, and support recovery.

ARDS and TRALI

ARDS is the most common indication for ECMO in trauma. ARDS occurs in 12–25% of trauma patients and accounts for half of all ECMO cannulations in trauma.^2,5,10 The combination of thoracic trauma, systemic inflammatory response to trauma, TRALI, and volume overload predispose the trauma patient to significant pulmonary dysfunction. Management of ARDS and TRALI may require cannulation preoperatively or postoperatively.

VV ECMO has shown benefit in ARDS in the non-trauma population. The CESAR Trial, which did include a small number of trauma patients, demonstrated benefit of referral to ECMO center for patients with ARDS, with 63% of those referred to ECMO surviving compared to 47% of those receiving conventional therapy. Importantly, only 75% of patients randomized to ECMO actually received this therapy.³⁹ The EOLIA Trial showed reduced absolute 60 days mortality (35% vs 46%) in patients with ARDS cannulated for ECMO but was underpowered and did not reach statistical significance.⁴⁰ Average VV ECMO duration is shorter in trauma patients (9.3 days) than medical patients (13 days) with respiratory failure as their indication for cannulation.²

The first retrospective cohort study of VV ECMO for acute respiratory failure in the trauma population evaluated patients cannulated from 2001 to 2009 and found significantly improved survival in the ECMO group (OR 0.038) when matched for age and lung injury severity.¹¹ A subsequent matched cohort study comparing the use of ECMO and conventional therapy in traumatic ARDS found lower mortality in the ECMO group (23% vs 50%) but longer hospital length of stay and ICU length of stay as well as a higher complication rate including acute kidney injury, deep vein thrombosis, pulmonary embolism, ventilator associated pneumonia, and reoperation.¹³ Another propensity matched cohort study found higher survival in trauma patients cannulated for VV ECMO for acute respiratory failure than in those who met criteria for ECMO but were not cannulated (70% vs 41%).¹¹

Conventional ventilator management can be complicated by inability of the trauma or brain injured patient to tolerate even mild hypoxia or hypercarbia. The tidal volumes and pressures required to oxygenate patients with severe thoracic trauma can be injurious to lungs. Cannulation for ECMO can allow lung rest on reduced ventilator settings once there is no longer need for the ventilator to support the patient in gas exchange. In the largest registry study of ECMO in trauma patients, peak inspiratory pressures decreased by 15 cm H₂O after cannulation.² This can greatly reduce ventilator induced lung injury in already fragile patients.

Bronchopleural fistulas

Bronchopleural fistulas (BPFs) are notoriously difficult to manage in trauma patients. The conventional treatment of BPFs involves minimizing airway pressures to reduce flow through the fistula. This can be very challenging in patients with significant thoracic trauma and high ventilator requirements due to the leak from the fistula itself. ECMO has been described as a method of facilitating lung rest settings to minimize airway pressures and promote fistula closure.^41,42 This indication is relatively rare and little data exist to guide treatment.

Complications of ECMO

The primary complications of ECMO are related to bleeding and thrombosis. Beyond bleeding and thrombotic events, high rates of acute kidney injury requiring renal replacement therapy, infectious complications, and neurological injury are also observed, reflecting both the severity of underlying trauma and the physiologic burden of extracorporeal support. In a systematic review of 548 patients undergoing ECMO for trauma, 22.9% of patients suffered bleeding from various sites, most frequently from surgical sites, cannula sites, and diffuse bleeding. It is important to consider devastating bleeding complications such as DIC, intracranial bleeding, and GI bleeding, although most of thesecomplications occur in non-trauma populations who are anticoagulated. Most of the bleeding did not require surgical intervention. Thrombotic complications were also frequent (19%). Deep venous thrombosis is the most common thrombotic event, but other clinically significant complications include oxygenator/circuit clotting, cerebral infarction, pulmonary embolism, and other central venous thrombosis.⁴³ VA ECMO cannulation increases risk of limb ischemia, and placement of a distal perfusion cannula is recommended. Prolonged ICU length of stay and subsequent long-term organ dysfunction are common among survivors, underscoring the substantial resource utilization and the need for careful patient selection in this high-risk population.

Discussion

From our perspective as a high-volume, Level I trauma center with continuous in-house trauma surgery, critical care, and ECMO expertise, extracorporeal support is viewed as an early adjunctive resuscitative strategy rather than a last-resort intervention. The close physical proximity of resuscitation areas to the operating room, combined with 24-h availability of experienced personnel, allows ECMO to be deployed selectively to stabilize physiology and facilitate definitive surgical or critical care interventions in carefully chosen patients through a multi-disciplinary selection process.

Future prospective investigation will require multicenter collaboration among institutions with established trauma and ECMO programs, standardized criteria for patient consideration, and systematic reporting of short- and long-term outcomes, including complications. Ethical considerations remain central, as early evidence suggests potential peri-operative benefit in select patients, but balanced evaluation must also include transparent documentation of morbidity, resource utilization, and cases in which ECMO does not alter outcome, to better define appropriate use in this high-risk population.

Conclusions

ECMO is increasingly used to stabilize operative trauma patients. Research demonstrating safety of ECMO in patients for whom anticoagulation is contraindicated or who have TBI has broadened the population of trauma patients that may benefit from extracorporeal support. Unfortunately, ECMO is a relatively new modality in the trauma population and little data exist to inform its use. No validated physiologic thresholds or standardized algorithms exist to guide ECMO initiation in trauma patients, and current decisions rely on individualized, multidisciplinary assessment rather than specific criteria. In practice, ECMO consideration is best framed around failure of conventional resuscitative strategies, potentially reversible physiology, and alignment with overall damage control and definitive care plans, with early involvement of trauma surgery, critical care, perfusion, and ECMO teams. Integration into trauma systems should emphasize predefined institutional readiness and coordination with established multi-disciplinary workflows, as evidence for specific algorithms or triggers for initiation do not currently exist.

Pre-operative indications for ECMO include acute respiratory failure from direct thoracic or airway trauma, and evidence for this modality largely comes from retrospective case series. Indications for peri-operative ECMO support include trauma pneumonectomy, retrohepatic IVC injury, and correction of hypothermia and acidosis in coagulopathic hemorrhagic shock. Patients requiring ECMO support for these indications are profoundly ill with high expected mortality, and ECMO is often used as a last resort. Evidence to support its use for these indications consists of expert opinion, case reports, and very small case series. Post-operative indications for ECMO include respiratory failure from ARDS and TRALI as well as management of BPFs. The evidence for the use of VV ECMO for ARDS is robust and supported by multiple randomized controlled trials. ECMO use in BPF management is supported by expert opinion only. Finally, intraoperative VA ECMO has been described for traumatic cardiogenic shock. Evidence for VA ECMO use in traumatic cardiac injury is limited.

As most published experience originates from highly resourced trauma centers with established ECMO programs, the broader applicability of these findings beyond similar institutional settings remains uncertain. ECMO for traumatic acute respiratory failure due to ARDS, TRALI, or thoracic trauma is supported by robust literature, but other indications rely on sparce literature and physiologic rationale. Though ECMO is increasingly used in the peri-operative setting, the patient population is small and heterogenous. The current evidence base is weighted toward acute outcomes, leaving important gaps in understanding long-term recovery and functional impact following ECMO in trauma patients. As ECMO use in the operative trauma patient becomes more common, more, preferably multicenter, prospective research is needed to better inform patient selection and to optimize outcomes.

Footnotes

Author note

Any other identifying information related to the authors and/or their institutions, funders, approval committees, etc., that might compromise anonymity.

ORCID iD

Elizabeth K. Powell

Ethical considerations

No human or animal subjects research was performed.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data sharing is not applicable to this article as no new data were created or analyzed in this study.*

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