Extracorporeal Life Support for Posttraumatic Acute Respiratory Distress Syndrome at a Children’s Medical Center By James D. Fortenberry, Andreas H. Meier, Robert Pettignano, Michael Heard, C. Robert Chambliss, and Mark Wulkan Atlanta, Georgia and Orlando, Florida Background: Primary traumatic injury was considered previ- ously a contraindication for institution of extracorporeal life support because of high risk for persistent or new bleeding. Published experience in adults suggests that extracorporeal membrane oxygenation (ECMO) can successfully support trauma victims with pulmonary failure. The authors re- viewed their experience with the use of ECMO in pediatric and adult trauma patients with acute respiratory distress syndrome (ARDS) at a children’s medical center. Methods: ECMO Center records from 1991 through 2001 (76 children, 8 adults) were reviewed to identify all patients with a primary or secondary ICD-9 diagnostic code of posttrau- matic ARDS in addition to documented trauma. Results: Five children and 3 adults with traumatic injury and ARDS received ECMO support. Seven patients were injured in motor vehicle collisions; one patient suffered a gunshot wound to the chest. Patient ages ranged from 21 months to 29 years (pediatric median, 4 years; range, 21 months to 18 years). Four patients had pre-ECMO laparotomies, including 3 who required splenectomy. Four patients had liver lacera- tions, 3 had pulmonary contusions, and 1 had a renal contu- sion. Median ventilation before ECMO was 6 days (range, 2 to 10). Seven of 8 patients were placed on venovenous (VV) ECMO. Seven patients had significant bleeding on ECMO. Patients were treated with blood product replacement, epsi- lon-aminocaproic acid (EACA), and aprotinin infusions. Sur- gical intervention was not required for bleeding. Six patients received hemofiltration. Median time on ECMO was 653 hours (range, 190 to 921 hours). Six of 8 patients overall survived (75%). Four of 5 pediatric patients survived. Conclusions: Children and adults with severe posttraumatic ARDS can be treated successfully on VV extracorporeal sup- port. Hemorrhage occurs frequently but is manageable. J Pediatr Surg 38:1221-1226. © 2003 Elsevier Inc. All rights reserved. INDEX WORDS: Extracorporeal life support, extracorporeal membrane oxygenation, trauma, respiratory failure, acute respiratory distress syndrome. P ATIENTS WITH MULTIPLE traumatic injuries are at significant risk for acute lung injury, either from direct injury or from secondary acute respiratory distress syndrome. 1,2 Extracorporeal life support (ELS) is a ther- apeutic modality that can provide cardiorespiratory sup- port while allowing lung rest for patients with acute respiratory failure. 3 Traumatic injury was once consid- ered a contraindication for institution of ELS, primarily because of the high risk for severe bleeding in the presence of systemic heparinization required for extra- corporeal circuits. 4 However, increasing experience in adults suggests that ELS provided by extracorporeal membrane oxygenation (ECMO) can be performed suc- cessfully in adult trauma victims with pulmonary failure. 4,5 Based on adult (and limited pediatric) experience, we have utilized ECMO in children with posttraumatic acute respiratory distress syndrome (ARDS) and in adult trauma patients referred to our institution for ECMO. This report reviews our experience with ECMO in these patients. MATERIALS AND METHODS Children’s Healthcare of Atlanta Institutional Review Board ap- proval was obtained for review of ECMO patient medical records. Medical records of all patients treated with ECMO at Children’s Healthcare of Atlanta at Egleston (formerly Egleston Children’s Hos- pital) from 1991 through 2001 were reviewed to identify all patients with a diagnosis of postsurgical or traumatic ARDS (ICD-9 code 518.5 as a primary or secondary diagnosis). The study group then was limited to include only patients who had blunt or penetrating trauma as the primary etiology associated with respiratory failure. Four burn patients with secondary ARDS were identified and excluded from this review. Patients receiving ECMO after near-drowning events, toxic ingestions, hydrocarbon and foreign body aspirations, or after elective surgical procedures also were excluded. Demographic information, indications for ECMO, duration of ECMO, and complications during ECMO were recorded. Pediatric patients were defined as 18 years of age. Significant bleeding was From the Center for ECMO and Advanced Technologies and Crit- ical Care Division, Children’s Healthcare of Atlanta at Egleston, Atlanta, GA; Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA; and Division of Pediatric Critical Care, Arnold Palmer Children’s Hospital, Orlando, FL. Address reprint requests to James D. Fortenberry, MD, FAAP, FCCM, Critical Care Division, Children’s Healthcare of Atlanta at Egleston; 1405 Clifton Road, NE; Atlanta, GA 30322. © 2003 Elsevier Inc. All rights reserved. 0022-3468/03/3808-0018$30.00/0 doi:10.1016/S0022-3468(03)00272-0 1221 Journal of Pediatric Surgery, Vol 38, No 8 (August), 2003: pp 1221-1226