77: ECMO in Trauma with Justyna Swol

Using ECMO for traumatic patients has had some promising papers through the years, but the data overall is still poor.  Justyna Swol has teamed up with ELSO to improve this deficiency by making a trauma carve out of the ELSO registry.  In this episode, Zack discusses with Justyna the many facets of ECMO in trauma.  A few pearls and references are below:

  • Anticoagulation in ECMO is not mandatory.  A reasonable strategy is heparinized circuit with a titrating dose of systemic heparin as necessary in the trauma patient.  This includes everyone from isolated pulmonary contusions to intracranial hemorrhage.
  • VV-ECMO similar to ARDS in medical causes can be used and likely offers survival benefit to those patients with post traumatic lung injury.  Initiating early (maybe PaO2 of 80 on 100% FiO2) is likely best.
  • ECPR can be done in the traumatic arrest.  Best when done in parallel to the other resuscitative needs of the patient.  Data is promising in case series.  Need for bigger data sets is clear.

 

Reynolds HN, Cottingham C, McCunn M, Habashi NM, Scalea TM. Extracorporeal lung support in a patient with traumatic brain injury: the benefit of heparin-bonded circuitry. Perfusion. 1999 Nov;14(6):489-93. doi: 10.1177/026765919901400612. PMID: 10585157.
Bein T, Scherer MN, Philipp A, Weber F, Woertgen C. Pumpless extracorporeal lung assist (pECLA) in patients with acute respiratory distress syndrome and severe brain injury. J Trauma. 2005 Jun;58(6):1294-7. doi: 10.1097/01.ta.0000173275.06947.5c. PMID: 15995487.
Parker BM, Menaker J, Berry CD, Tesoreiero RB, O’Connor JV, Stein DM, Scalea TM. Single Center Experience With Veno-Venous Extracorporeal Membrane Oxygenation in Patients With Traumatic Brain Injury. Am Surg. 2021 Jun;87(6):949-953. doi: 10.1177/0003134820956360. Epub 2020 Dec 9. PMID: 33295187.
Bosarge PL, Raff LA, McGwin G Jr, Carroll SL, Bellot SC, Diaz-Guzman E, Kerby JD. Early initiation of extracorporeal membrane oxygenation improves survival in adult trauma patients with severe adult respiratory distress syndrome. J Trauma Acute Care Surg. 2016 Aug;81(2):236-43. doi: 10.1097/TA.0000000000001068. PMID: 27032012.
Mazzeffi M, Kon Z, Menaker J, Johnson DM, Parise O, Gelsomino S, Lorusso R, Herr D. Large Dual-Lumen Extracorporeal Membrane Oxygenation Cannulas Are Associated with More Intracranial Hemorrhage. ASAIO J. 2019 Sep/Oct;65(7):674-677. doi: 10.1097/MAT.0000000000000917. PMID: 30398981.
Lorusso R, Belliato M, Mazzeffi M, Di Mauro M, Taccone FS, Parise O, Albanawi A, Nandwani V, McCarthy P, Kon Z, Menaker J, Johnson DM, Gelsomino S, Herr D. Neurological complications during veno-venous extracorporeal membrane oxygenation: Does the configuration matter? A retrospective analysis of the ELSO database. Crit Care. 2021 Mar 17;25(1):107. doi: 10.1186/s13054-021-03533-5. PMID: 33731186; PMCID: PMC7968168.
Willers A, Swol J, Kowalewski M, Raffa GM, Meani P, Jiritano F, Matteucci M, Fina D, Heuts S, Bidar E, Natour E, Sels JW, Delnoij T, Lorusso R. Extracorporeal Life Support in Hemorrhagic Conditions: A Systematic Review. ASAIO J. 2021 May 1;67(5):476-484. doi: 10.1097/MAT.0000000000001216. PMID: 32657828.
Trivedi JR, Alotaibi A, Sweeney JC, Fox MP, van Berkel V, Adkins K, Condley C, Alwair H, Slaughter MS. Use of Extracorporeal Membrane Oxygenation in Blunt Traumatic Injury Patients with Acute Respiratory Distress Syndrome. ASAIO J. 2022 Apr 1;68(4):e60-e61. doi: 10.1097/MAT.0000000000001544. PMID: 34352816.
Swol J, Brodie D, Napolitano L, Park PK, Thiagarajan R, Barbaro RP, Lorusso R, McMullan D, Cavarocchi N, Hssain AA, Rycus P, Zonies D; Extracorporeal Life Support Organization (ELSO). Indications and outcomes of extracorporeal life support in trauma patients. J Trauma Acute Care Surg. 2018 Jun;84(6):831-837. doi: 10.1097/TA.0000000000001895. PMID: 29538235.

72: Should We All Switch To Bivalirudin?

Heparin has been the mainstay of anticoagulation for ECMO patients for years.  In recent years, this has been challenged.  Bivalirudin has become a potential better anticoagulant.  Troy Seelhammer in EDECMO episode 55 gave us some insight into this.  This month Ryan Rivosecchi and his crew at UPitt have released their findings in Critical Care Medicine.  This retrospective study suggests great improvement in major bleeding in patients who received Bivalirudin compare to Heparin (40.7% vs 11.7%, p < 0.001).  Listen to Ryan and Zack discuss anticoagulant use in ECMO patients in this month’s episode.

Rivosecchi RM, Arakelians AR, Ryan J, Murray H, Padmanabhan R, Gomez H, Phillips D, Sciortino C, Arlia P, Freeman D, Sappington PL, Sanchez PG. Comparison of Anticoagulation Strategies in Patients Requiring Venovenous Extracorporeal Membrane Oxygenation: Heparin Versus Bivalirudin. Crit Care Med. 2021 Mar 15. doi: 10.1097/CCM.0000000000004944. Epub ahead of print. PMID: 33711003.

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55 – Anticoagulation of the ECMO Patient with Troy Seelhammer

Do you give heparin to your ECMO patients?  Well, let’s rethink this.  This episode is All Things Anticoagulation!  Zack talks with Troy Seelhammer, an intensivist from Mayo Clinic Rochester.  He manages ECMO patients in his daily practice there.  He has become a master of the subject of anticoagulation and if you’re interested in other medicines you can visit a Canadian Pharmacy online for this.  He will talk about heparin, bilvalirudin, or maybe no anticoagulation.  We talk about how TEG can affect our management.  We talk about PCC and Protamine when bleeding just won’t stop.  He talks about the when to be aggressive and when to cut back.  Below is a wonderful synopsis of Troy’s thoughts on anticoagulation on pump.

 

Goal Heparin levels are far from perfect but some suggestions

APTT 1.5 to 2.5 times normal

ACT level – 180-220 seconds

Antithrombin Levels – next generation

 

Seelhammer doc on BivalirudinBivalirudin & TEG During ECMO