AggiornAmenti in riAnimAzione e terApiA intensivA - Pacini Editore

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42 extracorporeal membrane oxygenation in severe trauma patients with bleeding shock M. Arlt A. Philipp S. Voelkel L. Rupprecht T. Mueller M. Hilker B.M. Graf C. Schmid Department of Anesthesiology, University Hospital Regensburg, Germany AIM Of ThE STUdy: Death to trauma is caused by disastrous injuries on scene, bleeding shock or acute respiratory failure (ARDS) induced by trauma and massive blood transfusion. Extracorporeal membrane oxygenation (ECMO) can be effective in severe cardiopulmonary failure, but preexisting bleeding is still a contraindication for its use. We report our first experiences in application of initially heparin-free ECMO in severe trauma patients with resistant cardiopulmonary failure and coexisting bleeding shock retrospectively and describe blood coagulation management on ECMO. METhOdS: From June 2006 to June 2009 we treated adult trauma patients (n = 10, mean age: 32 ± 14 years, mean ISS score 73 ± 4) with percutaneous veno-venous (v-v) ECMO for pulmonary failure (n = 7) and with venoarterial (v-a) ECMO in cardiopulmonary failure (n = 3). Diagnosis included polytrauma (n = 9) and open chest trauma (n = 1). We used a new miniaturised ECMO device (PLS-Set, MAQUET Cardiopulmonary AG, Hechingen, Germany) and performed initially heparin-free ECMO. RESULTS: Prior to ECMO median oxygenation ratio (OR) was 47 (36-90) mmHg, median paCO was 67 (36-89) mmHg and median norepinephrine 2 demand was 3.0 (1.0-13.5) mg/h. Cardiopulmonary failure was treated effectively with ECMO and systemic gas exchange and blood flow improved rapidly within 2 h on ECMO in all patients (median OR 69 (52-263) mmHg, median paCO 41 (22-85) mmHg. 60% of our patients had recovered com- 2 pletely. COnCLUSIOnS: Initially heparin-free ECMO support can improve therapy and outcome even in disastrous trauma patients with coexisting bleeding shock. Resuscitation 2010;81(7):804-9
ons formation under restrictive reperfusion does not affect organ dysfunction early after hemorrhage and trauma C. Zifko A.V. Kozlov A. Postl H. Redl S. Bahrami Ludwig Boltzmann Institute for Experimental and Clinical Traumatology in AUVA Research Center, Vienna, Austria Reactive oxygen species have been implicated in the pathophysiology of early reperfusion. We aimed to determine 1) reactive oxygen and nitrogen species (RONS) formation in organs of rats and 2) its pathophysiological relevance during a phase of restrictive reperfusion after hemorrhagic/ traumatic shock (HTS). Fifty-seven male Sprague-Dawley rats were subjected to a clinically relevant HTS model, featuring laparotomy, bleeding, and a phase of restrictive reperfusion. The RONS scavenger 1-hydroxy-3carboxy-2,2,5,5-tetramethyl-pyrrolidine hydrochloride (continuous i.v. infusion) and electron paramagnetic resonance spectroscopy were applied for RONS (primarily superoxide and peroxynitrite) detection. Compared with sham-operated animals, the organ-specific distribution of RONS changed during restrictive reperfusion after HTS. Reactive oxygen and nitrogen species formation increased during restrictive reperfusion in red blood cells and ileum only but decreased in the kidney and remained unchanged in other organs. Hemorrhagic traumatic shock followed by restrictive reperfusion resulted in metabolic acidosis, dysfunction of liver and kidney, and increased oxidative burst capacity in circulating cells. Plasma RONS correlated with shock severity and organ dysfunction. However, RONS scavenging neither affected organ dysfunction nor oxidative burst capacity nor myeloperoxidase activity in lung when compared with the shock controls. In summary, a phase of restrictive reperfusion does not increase RONS formation in most organs except in intestine and red blood cells. Moreover, scavenging of RONS does not affect the early organ dysfunction manifested at the end of a phase of restrictive reperfusion. Shock 2010;34(4):384-9 43
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