Open Access

Non-heparinized ECMO serves a rescue method in a multitrauma patient combining pulmonary contusion and nonoperative internal bleeding: a case report and literature review

World Journal of Emergency Surgery201510:15

https://doi.org/10.1186/s13017-015-0006-9

Received: 19 February 2014

Accepted: 9 February 2015

Published: 12 March 2015

Abstract

Pulmonary contusion and acute respiratory distress syndrome (ARDS) is a common manifestation in polytraumatic patients. Although mechanical ventilation is still the first choice of treatment, a group of patients are still unable to maintain their oxygenation. The role of extracorporeal membrane oxygenation (ECMO) has been more clarified when the lung is extensively damaged and when conventional modality failed. ECMO provides the lung an opportunity to rest by permitting reduced ventilator settings and limiting further barotraumas. However, ECMO is still considered contraindicated in polytramatic patients combining pulmonary contusion and other organ hemorrhage because of systemic anticoagulation during the treatment. We herein report a patient who successfully survive a multitrauma combining pulmonary contusion and grade IV liver laceration using non-heparinized venovenous extracorporeal membrane oxygenation (vv-ECMO). The associated literature were reviewed.

Keywords

ECMOHeparin-freePolytraumaticAcute pulmonary contusionInternal bleeding

Introduction

Acute pulmonary failure is a common manifestation in polytraumatic patients. The mechanism included pulmonary contusion, acute respiratory distress syndrome (ARDS) resulting from any inflammation process such as aspiration pneumonia, or fat embolism because of long bone fracture [1]. The management could be very challenging despite advances in critical care management.

Extracorporeal membrane oxygenation (ECMO) serves as the final method when conventional mechanical ventilation fails to maintain the oxygenation. It helps maintain systemic tissue oxygenation via extracorporeal circuit when the lung function is compromised [2,3]. However, the situation became more complicated when the lung failure combines other vital organ damage and risk of bleeding because of systemic anticoagulation during the treatment.

The introduction of heparin-free ECMO seems to be the possible solution for such dilemma. We report our experience of using heparin-free vv-ECMO to help a patient survive a trauma combining acute pulmonary failure and severe liver subcapsular laceration. The literature regarding the application of ECMO in polytraumatic patients combining acute pulmonary failure and other vital organ damage were reviewed.

Case report

A 19-year-old man suffered from a multi-trauma after a traffic accident when he was riding a motorcycle and collided into a car. Upon arrival at our tertiary trauma center, he initially presented with a Glasgow Coma Score of 8 and severe hypoxia. He was intubated immediately. Large amount of food content was sucked from the endotracheal tube. Primary chest computed tomography (CT) reported right lung consolidation with patchy opacities, which was consistent with a combination of blunt chest contusion and aspiration pneumonia (Figure 1). Abdominal CT showed grade IV laceration over bilateral hemiliver without evident contrast extravasation (Figure 2). The gas exchange did not improve despite of mechanical ventilation, and the patient still presented with severe hypoxemia. The parameter about respiration showed PaO2/FiO2: 70.2 under invasive ventilation (pressure-mode inverse ratio ventilation, I:E 2:1). ECMO was thus recommended for lung contusion, aspiration pneumonia and acute pulmonary failure.
Figure 1

Chest CT showed right lung consolidation with patchy opacities.

Figure 2

The coronal view and saggital view of abdominal CT showed grade IV laceration over bilateral hemiliver without evident contrast extravasation.

With regards of a polytraumatic patient combining liver laceration, ECMO is contraindicated because the need of systemic anticoagulation may induce further internal bleeding. A heparin-free, vv-ECMO was thus suggested. An extracorporeal circuit was constructed via a venous access through internal jugular vein and femoral vein, using Seldinger technique. The blood flow was set at the rate of 2.42 L/min, and the FiO2 was set at 45%. The oxygenation status improved dramatically after the introduction of ECMO (Table 1). The liver laceration was treated conservatively. The patient weaned from ECMO five days later, and was extubated nine days later. The total intensive care unit stay was 10 days, and he discharged after a sixteen-day hospitalization. There was no ECMO related complications during the course.
Table 1

Oxygenation status before and after ECMO introduction

 

Pre-ECMO

Post-ECMO

Pre-weaning

pH

7.231

7.352

7.440

pCO2 (mmHg)

58.4

39.2

30.4

pO2 (mmHg)

70.2

147.2

91.5

O2 Saturation (%)

89.5

98.5

97.9

Literature review

We searched the PubMed (2000–2013) database for case reports about the launch of ECMO regardless of heparin-containing or heparin-free in multi-trauma patients. The abstracts of all articles published in English were screened. The full texts of articles published in other languages but with an abstract in English were analyzed. Articles were selected for review if they included the following patient data: age, sex, clinical presentation, combined injury besides acute pulmonary failure, the details of ECMO treatment, and the outcome.

There were six case reports containing 11 patients described in detail, and one clinical paper containing 10 cases found in the literature, which are listed in Table 2.
Table 2

ECMO in polytraumatic patients combining acute pulmonary failure and other vital organ damage: literature review

References

Case no.

Combined injury besides pulmonary failure

Intervention

ECMO

Heparin

ECMO duration

Outcome

Madershahian et al. [2]

1, 19/F

Spleen, Liver

Laparotomy

v-a5

(+)

138 hours

Survived

Right main bronchus

Thoracotomy

 

2, 48/M

Vertebra and long bone Fracture

Osteosynthesis

v-a

(+)

120 hours

Survived

 

3, 26/M

Spleen

Splenectomy

v-va6

(+)

84 hours

Survived

Brain

Yuan et al. [5]

4, 18/M

Liver, Gr. III

Conservative

v-v

(+)

10 days

Survived

Endobronchial hemorrhage

 

5, 38/M

Brain SDH1

Conservative

v-v

(+)

5 days

Survived

Campione et al. [4]

6, 14/M

Bronchial Disruption

Right bilobectomy of lung

v-v

(+)

3 days

Survived

Yen et al. [7]

7, 21/M

Brain EDH2

Decompressive craniotomy

v-a

(+)

49 hours

Survived

Friesenecker, et al. [8]

8, 34/M

Liver, Spleen

Laparotomy

v-v

(+)

17 days

Survived

Brain ICH3 with edema

Decompressive craniotomy

Muellenbach et al. [9]

9, 53/M

Liver

Laparotomy

v-v

(−)

8 days

Survived

Traumatic brain injury

ICP4 Monitoring

 

10, 16/M

Traumatic brain injury

 

v-v

(−)

3 days

Survived

 

11, 28/M

Spleen

Splenectomy

v-v

(−)

2 days

Survived

Traumatic brain injury

Arlt et al. [6]

10 Cases

Bleeding shock

-

7 v-v

All (−)

Mean 5 days

6/10 Survived

3 v-a

1SDH: Subdural hemorrhage; 2EDH: Epidural hemorrhage; 3ICH: Intracerebral hemorrhage; 4ICP: Intracerebral pressure; 5V-a: Venoarterial ; 6V-va: veno-venoarterial.

Discussion

Despite of the various mechanical ventilation technique and the improved knowledge of the adjustment of ventilation parameters, a group of patients with traumatic pulmonary contusion or ARDS are still unable to benefit from these technique. ECMO has been proved to be an rescue therapy when conventional methods are ineffective. ECMO was also reported to be effective in polytraumatic patients combining pulmonary contusion and other organ damage including bronchial rupture [2,4], endobronchial hemorrhage [5], blunt abdominal trauma (BAT) with internal bleeding necessitating exploratory laparotomy [6], or traumatic brain injury [7-10]. However, the use of ECMO on patients with a preexisting bleeding risk without need of immediate operation is still rarely reported.

The application of heparin-free ECMO has been proposed recently to overcome the dilemma. Muellenbach et al. reported three successful cases of heparin-free vv-ECMO on a patient with traumatic lung failure and severe traumatic brain injury [9]. Matthias et al. reported that six of ten polytraumatic patients with coexisting pulmonary failure or cardiopulmonary failure and bleeding shock survived using a heparin-free ECMO, which is by far the only largest series in the literature [6]. However, ECMO is still a controversy on a multitrauma combining pulmonary failure and blunt abdominal trauma needing only nonoperative management. Of the total 11 cases reported in detail in the literature (Table 2), six patients had concurrent BAT with liver or spleen laceration [2,4,8,9]. Only one received successful nonoperative treatment for grade III liver laceration [4].

The improvement of ECMO technique including centrifugal pumps and heparin-coated circuits reduced the amount of heparin needed. However, with regards to a patient who had spontaneous hemostasis on liver laceration, we still chose the heparin-free method to reduce the risk of rebleeding. Based on the hemodynamic stability and the daily improvement of lung condition, we did not used additional method to prevent clotting of the circuit except the close monitor of ACT. The duration of ECMO was five days, which is comparable to other report.

Conclusion

ECMO can serve as a rescue method to provide the traumatic lung to rest. Although it was previously regarded to be contraindicated in polytraumatic patient with coexisting organ hemorrhage, there are growing successful experiences reported recently. We report a heparin-free, vv-ECMO method for patients combining acute pulmonary failure and nonoperative liver laceration, which may extend the feasibility of ECMO in polytraumatic patients.

Consent

Written informed consent was obtained from the patient for the publication of this report and any accompanying images.

Abbreviations

ECMO: 

Extracorporeal membrane oxygenation

ARDS: 

Acute respiratory distress syndrome

v-v ECMO: 

Venovenous ECMO

CT: 

Computed tomography

FiO2

Fraction of inspired oxygen

BAT: 

Blunt abdominal trauma

SDH: 

Subdural hemorrhage

EDH: 

Epidural hemorrhage

ICH: 

Intracerebral hemorrhage

ICP: 

Intracerebral pressure

V-a ECMO: 

Venoarterial ECMO

V-va ECMO: 

Veno-venoarterial ECMO

Declarations

Authors’ Affiliations

(1)
General Surgery Division, Surgery Department, Changhua Christian Hospital
(2)
Trauma Division, Surgery Department, Changhua Christian Hospital
(3)
Cardiovascular Division, Surgery Department, Changhua Christian Hospital
(4)
Transplant Medicine and Surgery Research Centre, Changhua Christian Hospital
(5)
Surgery Department, Cishan Hospital

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Copyright

© Wen et al.; licensee BioMed Central. 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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