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The Rabbit ECMO-Trauma model. The animal sustained laparotomy and bilateral femur fractures and were exsanguinated to class IV Shock. The venoarterial ECMO circuit: Venous draining cannulae in the right atrium (blue), roller pump, heparinized membrane oxygenator for saturation and carbondioxide removal, water heat exchanger (38.5 °C). Blood is reinfused in the descending aorta (red). Bilateral femurfractures are indicated
Source publication
Purpose:
Hemorrhage is the most common cause of preventable death after trauma. Coagulopathy plays a central role in uncontrolled bleeding and is caused by multiple factors. Extracorporeal Membrane Oxygenation (ECMO) is an established treatment for patients with respiratory failure and has in recent years also been used in severely injured trauma...
Citations
... These injury patterns are highly lethal and often require technically skilled and lengthy surgical repair. Animal studies suggest that ECMO-based resuscitative strategies for trauma can help decrease inflammation and mitigate the "lethal triad of death," which consists of acidosis, coagulopathy, and hypothermia [5,71,72]. This is largely due to the ECMO circuit's innate ability to provide sufficient blood flow, oxygenation, and rapid blood warming. ...
... Larsson et al. explored these concepts within a traumabased hemorrhagic shock rabbit model and demonstrated significantly improved blood pressures, temperature, acidosis, lactate, coagulopathy parameters, and survival within subjects allocated to the ECMO-based treatment strategy compared to standard measures. Moreover, when compared to traditional warmed blood product transfusions and external heating techniques, hypothermia mitigation via the blood warmer within the ECMO circuit proved to be superior [71]. ...
Purpose of Review
Extracorporeal membrane oxygenation (ECMO) represents an increasingly utilized rescue therapy for critically ill patients. Despite increasing literature supporting its use for cardiac, pulmonary, and combined cardiopulmonary failure, its role in acute trauma remains ill-defined.
Recent Findings
Venovenous and venoarterial ECMO have demonstrated utility following acute respiratory distress syndrome (ARDS) and cardiac arrest and as a temporary bridge to transplantation. Venovenous ECMO for trauma patients with ARDS appears safe and may offer mortality benefits when performed early, although more robust data is needed. The data surrounding venoarterial ECMO following traumatic arrest or for devastating cardiopulmonary injuries is limited to small case series and low-quality evidence.
Summary
ECMO cannulation for cardiac and hemodynamic support in trauma patients is limited to low-quality data. Early cannulation in select cases, however, may provide an opportunity to help correct physiologic parameters, maintain perfusion, and temporize various injury patterns prior to surgical repair. Following traumatic arrest, venoarterial ECMO may help improve hemodynamics and augment hemorrhage control; however, more robust data is needed.
... Patients with shock are often treated with fluid resuscitation, and changes in blood pressure fluctuations, heart rate, and urine output should be observed in real time. Coagulopathy, hypothermia, and acidosis are the "posttraumatic lethal triad," which can be induced by massive fluid resuscitation [15]. INR and APTT are effective indicators for monitoring coagulation function and the occurrence of DIC [16], and LAC can reflect the severity of shock and hypoperfusion, as well as the level of oxygenation, and serve as indicators for judging metabolic disorders and prognosis [17]. ...
Objective:
To explore the construction of standard fast medical procedures for traumatic shock and its application effects.
Methods:
84 patients with traumatic shock were admitted to emergency department of the hospital between January 2018 and January 2020. Using random number table method, the patients were divided into the control group (was given emergency treatment by routine emergency rescue procedures) and the study group (was given emergency treatment by standard fast medical procedures) with 42 patients in each group. The treatment time (rescue time, consultation time in each department, and examination time), shock index (SI), blood pressure fluctuation range, urine output, serum lactate (LAC) level, activated partial thromboplastin time (APTT), and international normalized ratio (INR) were recorded. The incidences of complications in the two groups within 3 days were counted.
Results:
The rescue time, consultation time, and examination time of the study group were shorter than those of the control group (P < 0.05). After 18 h of treatment, the SI, blood pressure fluctuation range, LAC, and APTT in the study group were lower or shorter than those in the control group (P < 0.05), while urine volume and INR were higher than those in the control group (P < 0.05). Within 3 days of treatment, the incidence of complications in the study group was 5.41% lower than that in the control group which was 24.14% (P < 0.05).
Conclusion:
Standard fast medical procedures can effectively shorten the time of each stage of emergency treatment for traumatic shock, which allows patients to receive effective treatment in the shortest time while improving shock symptoms and reducing related complications.
... Larsson et al. 4 muestran que cuando está completamente desarrollada, la coagulopatía es muy difícil de revertir. En este estudio muestra que la ECMO puede mejorar la acidosis y la temperatura en un modelo hemorrágico experimental traumático 4 , Renaudier et al demostraron que la isquemia mesenterica aguda es relativamente frecuente (OR)4.5, (IC) 95%, (p=0.02) 5 . ...
... Another study using a rabbit hemorrhagic shock model comparing VA-ECMO to standard transfusion protocol showed improvements in clot formation time (111 vs . 1,770 s), and reduction in acidosis (pH 7.08 vs. 6.90), and serum lactate (7.8 mmol/L vs. 14.3 mmol/L) (104). ...
The emerging concept of endovascular resuscitation applies catheter-based techniques in the management of patients in shock to manipulate physiology, optimize hemodynamics and bridge to definitive care. These interventions hope to address an unmet need in the care of severely injured patients, or those with refractory non-traumatic cardiac arrest, who were previously deemed non-survivable. These evolving techniques include Resuscitative Endovascular Balloon Occlusion of Aorta (REBOA), Selective Aortic Arch Perfusion (SAAP) and Extracorporeal Membrane Oxygenation (ECMO) and there is growing literature base behind them. This review presents the up to date techniques and interventions, along with their application, evidence base and controversy within the new era of resuscitation.
... As we all known, major trauma is an important contributing factor of death worldwide. Hemorrhage is the most common preventable cause of death after trauma, accounting for up to 30-40% of trauma-related deaths [1]. Hemorrhagic shock is a common complication of trauma and is the main cause of death of the wounded [2]. ...
Background
Our previous study found a novel fluid combination with better resuscitation effects under hypotensive condition at the early stage of uncontrolled hemorrhagic shock (UHS). However, the optimal recovery concentration of hypertonic saline in this fluid combination remains unknown. This experiment aimed to explore the optimal concentration.
Material/Methods
New Zealand white rabbits (n=40) were randomly divided into 5 groups, including a sham-operated group (SO), a shock non-treated group (SNT), a normal saline group (NS), and hypertonic saline groups (4.5% and 7.5%). We established an UHS model and administered various fluid combinations (dose-related sodium chloride solution+crystal-colloidal solution) to the groups followed by monitoring indexes of hemodynamic and renal function, measuring infusion volume and blood loss, and analyzing pathological morphology by hematoxylin and eosin staining.
Results
The hypertonic saline groups showed more stable hemodynamic indexes, reduced blood loss, fewer required infusions, and milder decreases in renal function than those of control groups (SNT and NS groups), and exhibited fewer pathological changes in the heart, lung, kidney, and liver. All indexes in the 4.5% and 7.5% groups were better than those of the NS group, and the hemodynamic indexes in the 7.5% group were more stable than those of the 4.5% group (P<0.05), with reduced blood loss and infusion volume and a milder decrease in renal function.
Conclusions
The novel fluid combination with 7.5% hypertonic saline group had a better recovery effect at the early stage of UHS before hemostasis compared to that of the 4.5% hypertonic saline group. This result may provide guidance for clinical fluid resuscitation.
... The clinical relevance of some of these models has been discussed. The experimental rabbit model has previously been proven to be useful to simulate trauma hemorrhage [16]. The pathophysiology of platelet dysfunction in severe traumatic hemorrhage and coagulopathy needs to be further studied. ...
Introduction Platelets are critical for hemostasis, and a low platelet count predicts mortality in trauma. The role of platelet dysfunction in severe traumatic hemorrhage and coagulopathy needs to be further defined. The aim of this study was to evaluate the platelet function in a new model of experimental traumatic hemorrhage.
Material and methods New Zealand white rabbits (n = 10) were subjected to tracheostomy and trauma laparotomy, and then bilateral femur fractures with 40% hemorrhage of their estimated blood volume. Arterial blood gases, standard coagulation tests, mean platelet volume, platelet aggregation using impedance aggregometry with agonist collagen, arachidonic acid (ASPI), and adenosine diphosphate (ADP), rotational thromboelastometry, and fibrinogen binding of platelets were analyzed using flow cytometry.
Results After traumatic hemorrhage, there was a significant physiological response with a rise in lactate (P < .001) and a decrease in base excess (P < .001) and temperature (P < .001). Platelet count decreased from a mean of 244x10⁹/L to 94 x10⁹/L (P = .004) and the mean platelet volume increased from 5.1fL to 6.1fL (P = .002). Impedance aggregometry with the agonist collagen, ASPI, and ADP was all significantly decreased after hemorrhage (P = .007). However, there was an increased fibrinogen binding of ADP-activated platelets after traumatic hemorrhage analyzed by flow cytometry (P < .05).
Conclusions This traumatic hemorrhage model presents two parallel pathophysiological responses of platelets; platelet consumption as evidenced by a significant decrease in platelet count and aggregation, and platelet hyperreactivity as shown by a higher mean platelet volume and enhanced platelet fibrinogen binding. Further studies are needed to characterize these different aspects of platelet function in severe traumatic hemorrhage.
... Our study found no example of a contemporary small animal model combining features of ARDS and ECMO. This may reflect the inherent difficulties of replicating a clinically relevant extracorporeal circulation in a small animal species, although such models have been described in the absence of lung injury in rodents [33] and rabbits [34,35]. While small animal models are limited by the inability to use clinical ECMO devices, differences in lung morphology [36], and variations in innate immunity [37], they offer several advantages. ...
Objectives
Extracorporeal membrane oxygenation (ECMO) is an increasingly accepted means of supporting those with severe acute respiratory distress syndrome (ARDS). Given the high mortality associated with ARDS, numerous animal models have been developed to support translational research. Where ARDS is combined with ECMO, models are less well characterized. Therefore, we conducted a systematic literature review of animal models combining features of experimental ARDS with ECMO to better understand this situation.
Data sources
MEDLINE and Embase were searched between January 1996 and December 2018.
Study selection
Inclusion criteria: animal models combining features of experimental ARDS with ECMO. Exclusion criteria: clinical studies, abstracts, studies in which the model of ARDS and ECMO has been reported previously, and studies not employing veno-venous, veno-arterial, or central ECMO.
Data extraction
Data were extracted to fully characterize models. Variables related to four key features: (1) study design, (2) animals and their peri-experimental care, (3) models of ARDS and mechanical ventilation, and (4) ECMO and its intra-experimental management.
Data synthesis
Seventeen models of ARDS and ECMO were identified. Twelve were published after 2009. All were performed in large animals, the majority (n = 10) in pigs. The median number of animals included in each study was 17 (12–24), with a median study duration of 8 h (5–24). Oleic acid infusion was the commonest means of inducing ARDS. Most models employed peripheral veno-venous ECMO (n = 12). The reporting of supportive measures and the practice of mechanical ventilation were highly variable. Descriptions of ECMO equipment and its management were more complete.
Conclusion
A limited number of models combine the features of experimental ARDS with ECMO. Among those that do, there is significant heterogeneity in both design and reporting. There is a need to standardize the reporting of pre-clinical studies in this area and to develop best practice in their design.
Electronic supplementary material
The online version of this article (10.1186/s40635-019-0232-7) contains supplementary material, which is available to authorized users.
... Furthermore, there was a report suggesting that ECMO improved coagulopathy in a trauma patient [15]. Secondly, disruption of ECMO flow in patients with ACS due to compression of the IVC has been reported [1,2]. ...
... Animal models suggest that ECMO may actually prevent traumatic coagulopathy after hemorrhage. 21 Coagulopathy is intrinsically linked to the presence of hypothermia, which can also be corrected, in part, by ECMO. 22 It may be that the temperature control offered by ECMO helps to abort the "lethal triad" of coagulopathy, acidosis, and hypothermia. ...
Introduction:
Limited options exist for cardiovascular support of the trauma patient in extremis. This patient population offers challenges that are often considered insurmountable. This article identifies a heterogeneous group of trauma patients in extremis who may benefit from extracorporeal membrane oxygenation.
Methods:
Data were sourced from the medical records of all patients placed on extracorporeal membrane oxygenation following trauma at a Level I Trauma Center between 1 December 2016 and 1 December 2017.
Results:
All patients were male (N = 7), mostly with blunt injuries (n = 5), with an average age of 41 years and with an average Injury Severity Scores of 33 (median = 34). Two out of seven patients survived (28.5%). Survivors tended to have a longer duration on extracorporeal membrane oxygenation (13.5 vs 3.8 days), had extracorporeal membrane oxygenation initiated later (15 vs 7.8 days), and had suffered a blunt injury. Two patients were initiated on veno-arterial extracorporeal membrane oxygenation (both non-survivors) and five were initiated on veno-venous extracorporeal membrane oxygenation (two survivors, three non-survivors). Five patients were heparinized immediately (one survivor, four non-survivors), and two patients were heparinized after clotting was noted in the circuit (one survivor, one non-survivor). Three of the seven (42.8%) patients suffered cardiac arrest either prior to, or during, the initiation of extracorporeal membrane oxygenation (all non-survivors).
Discussion:
Extracorporeal membrane oxygenation use in the trauma patient in extremis is not standard; however, this article demonstrates that extracorporeal membrane oxygenation is feasible in a complex, heterogeneous patient population when treated at designated centers.
Background:
Clarity about indications and techniques in extracorporeal life support (ECLS) in trauma is essential for timely and effective deployment, and to ensure good stewardship of an important resource. ECLS deployments in a tertiary trauma centre were reviewed to understand the indications, strategies, and tactics of ECLS in trauma.
Methods:
The provincial trauma registry was used to identify patients who received ECLS at a level 1 trauma centre and Extracorporeal Life Support Organization accredited site between January 2014 to February 2021. Charts were reviewed for indications, technical factors, and outcomes following ECLS deployment. Based on this data, consensus around indications and techniques for ECLS in trauma was reached and refined by a multidisciplinary team discussion.
Results:
A total of 25 patients underwent ECLS as part of a comprehensive trauma resuscitation strategy. Eighteen patients underwent venovenous ECLS and 7 received venoarterial ECLS. Nineteen patients survived the ECLS run, of which 15 survived to discharge. Four patients developed vascular injuries secondary to cannula insertion while four patients developed circuit clots. On multidisciplinary consensus, three broad indications for ECLS and their respective techniques were described: gas exchange for lung injury (GE), extended damage control for severe injuries associated with the lethal triad (EDC), and circulatory support for cardiogenic shock or hypothermia (CS).
Conclusions:
The three broad indications for ECLS in trauma (GE, EDC, and CS) require specific advanced planning and standardization of corresponding techniques (cannulation, circuit configuration, anticoagulation, and duration). When appropriately and effectively integrated into the trauma response, ECLS can extend the damage control paradigm to enable the management of complex multisystem injuries.
Level of evidence:
IV, Therapeutic/Care Management.
