North Pacific Surgical Association
Adult refractory hypoxemic acute respiratory distress syndrome treated with extracorporeal membrane oxygenation: the role of a regional referral center

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Abstract

Background

The investigators present a series of adults with severe acute respiratory distress syndrome (ARDS) who were treated with extracorporeal membrane oxygenation (ECMO) at a regional referral center.

Methods

Patients with refractory hypoxic ARDS received ECMO until they recovered lung function or demonstrated futility. ECMO was initiated at the referring facility if necessary, and aggressive critical care was maintained throughout.

Results

ARDS due to multiple etiologies was managed with ECMO in 36 adults. The pre-ECMO ratio of partial pressure of oxygen to fraction of inspired oxygen was 48.3 ± 2.2. Regional facilities referred 89% of these patients, and 69% required ECMO for transport. The mean duration of ECMO was 7.1 ± .9 days for survivors, and the mean post-ECMO ratio of partial pressure of oxygen to fraction of inspired oxygen was 281.2 ± 11. ECMO was successfully weaned in 67% of patients, and 60% survived to discharge.

Conclusions

ECMO provides support that prevents ventilator-induced lung injury while the lungs heal. The investigators present a series of 36 adults with refractory hypoxemic ARDS (ratio of partial pressure of oxygen to fraction of inspired oxygen <50) from 17 different facilities who, treated with ECMO at a single referral center, had a 60% survival rate.

Section snippets

Methods

Our approach to ARDS is protocolized and, as much as possible, evidence based. Our goals are to use the lowest level of support to provide adequate oxygen delivery14 (Fig. 1). We use a full spectrum of ventilator modes, including ARDS Network lung-protective strategies, airway pressure release ventilation, and high-frequency percussive ventilation (HFPV) with the Volume Diffusive Respirator (VDR-4 critical care ventilator; Percussionaire Corporation, Sandpoint, ID). We also use numerous

Results

Between January 2009 and September 2012, 36 adults (aged >17 years) were treated with ECMO for ARDS at the Legacy Emanuel Medical Center. All patients were cared for by the ECMO service primarily, a surgically directed multidisciplinary team of cardiac and critical care surgeons, intensivists and specialists, perfusionists, and therapists. Thirty-two of these patients (89%) were referred from regional hospitals. Twenty-five patients (69% of the total cohort or 78% of referrals) required ECMO

Comments

The use of ECMO for adults with profound and refractory hypoxemic ARDS remains controversial despite significant advances in technology, practice, and evidence. First reported for posttraumatic ARDS30 in 1972, the early randomized trials of Zapol et al11 in 1979 and Morris et al12 in 1994 failed to show improved survival in the ECMO groups. These studies were conducted using equipment, techniques, patient selection and critical care methods that are not comparable with today's standards. In

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    The authors declare no conflicts of interest.

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