Robba Chiara, Ortu Andrea, Bilotta Federico, Lombardo Alessandra, Sekhon Mypinder S, Gallo Fabio, Matta Basil F
From the Department of Neurosciences (C.R., A.L., B.F.M.), Department of Anaesthesia (A.O.), Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, United Kingdom; Department of Anaesthesiology, Critical Care and Pain Medicine (F.B.), 'Sapienza' University of Rome, Rome; Neuroscience ICU, Department of Anaesthesia and Critical Care (A.L.), Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy; Division of Critical Care Medicine, Department of Medicine (M.S.S.), Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada; and Section of Biostatistics, Department of Health Science (F.G.), University of Genoa, Genoa, Italy.
J Trauma Acute Care Surg. 2017 Jan;82(1):165-173. doi: 10.1097/TA.0000000000001276.
Venovenous extracorporeal membrane oxygenation (vv-ECMO) is an established salvage therapy for severe respiratory failure, and may provide an alternative form of treatment for trauma-induced adult respiratory distress syndrome (ARDS) when conventional treatments have failed. The need for systemic anticoagulation is a relative contraindication for patients with bleeding risks, especially in multitraumatic injury.
We describe a case series of four trauma patients with ARDS who were managed with ECMO admitted to the neuro critical care unit at Addenbrooke's Hospital, Cambridge (UK), from January 2000 to January 2016. We performed a systematic review of the available literature to investigate the safety and efficacy of vv-ECMO in posttraumatic ARDS, focusing on the use of different anticoagulation strategies and risk of bleeding on patients with multiple injuries.
Thirty-one patients were included. A heparin bolus was given in 16 cases. Eleven patients developed complications during treatment with ECMO with three cases of major bleeding. In all documented cases of bleeding a bolus and infusion of heparin was administered, aiming for an activated clotting time (ACT) target longer than 150 seconds. Two patients treated with heparin-free ECMO developed thromboembolic complications. Four patients died, and death was never directly or indirectly related to use of ECMO.
vv-ECMO can be lifesaving in respiratory failure. Our experience and our literature review suggest that vv-ECMO should be considered as a rescue treatment for the management of severe hypoxemic respiratory failure secondary to ARDS in trauma patients.For patients with a high risk of bleeding, the use of ECMO with no initial anticoagulation could be considered a valid option. For patients with a moderate risk of bleeding, use of a heparin infusion keeping an ACT target shorter than 150 seconds can be appropriate.
Therapeutic study, level V.
静脉-静脉体外膜肺氧合（vv-ECMO）是治疗严重呼吸衰竭的一种既定挽救疗法，当传统治疗失败时，可为创伤性成人呼吸窘迫综合征（ARDS）提供另一种治疗方式。对于有出血风险的患者，尤其是多发伤患者，全身抗凝的需求是一个相对禁忌证。
我们描述了2000年1月至2016年1月期间在英国剑桥阿登布鲁克医院神经重症监护病房接受ECMO治疗的4例创伤性ARDS患者的病例系列。我们对现有文献进行了系统综述，以研究vv-ECMO在创伤后ARDS中的安全性和有效性，重点关注不同抗凝策略的使用以及多发伤患者的出血风险。
纳入31例患者。16例给予肝素推注。11例患者在ECMO治疗期间出现并发症，其中3例发生大出血。在所有记录的出血病例中，均给予肝素推注和输注，目标是使活化凝血时间（ACT）超过150秒。2例接受无肝素ECMO治疗的患者出现血栓栓塞并发症。4例患者死亡，死亡与ECMO的使用从未直接或间接相关。
vv-ECMO可挽救呼吸衰竭患者的生命。我们的经验和文献综述表明，vv-ECMO应被视为创伤患者因ARDS继发的严重低氧性呼吸衰竭管理的挽救治疗方法。对于出血风险高的患者，可考虑使用无初始抗凝的ECMO作为一种有效选择。对于出血风险中等的患者，使用ACT目标短于150秒的肝素输注可能是合适的。
治疗性研究，V级。
