Extracorporeal membrane oxygenation for major burns in adults

Ahmed Labib

doi:10.4103/2543-1854.369160

REVIEW ARTICLE

Year : 2022 | Volume : 6 | Issue : 5 | Page : 11-13

Extracorporeal membrane oxygenation for major burns in adults

Ahmed Labib
Department of Medicine, Weill-Cornell Medicine, Hamad General Hospital, Doha, Qatar

Date of Submission	13-Nov-2023
Date of Decision	24-Nov-2023
Date of Acceptance	09-Dec-2023
Date of Web Publication	04-Feb-2023

Correspondence Address:
Ahmed Labib
Department of Medicine, Hamad General Hospital, Weill Cornell Medicine, Doha
Qatar

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/2543-1854.369160

Abstract

The management of critically ill patients with burns is challenging. Despite recent advances in the management of burns, morbidity and mortality remain high. The indications and applications of extracorporeal life support have expanded in recent years. Here, we discuss the rationale for the use of extracorporeal life support for major burns with emphasis on currently available evidence.

Keywords: Adults, acute respiratory distress syndrome, Baux score, burns, extracorporeal membrane oxygenation

How to cite this article:
Labib A. Extracorporeal membrane oxygenation for major burns in adults. Saudi Crit Care J 2022;6, Suppl S1:11-3

How to cite this URL:
Labib A. Extracorporeal membrane oxygenation for major burns in adults. Saudi Crit Care J [serial online] 2022 [cited 2023 Mar 22];6, Suppl S1:11-3. Available from: https://www.sccj-sa.org/text.asp?2022/6/5/11/369160

Introduction

Burns are a significant cause of morbidity and mortality globally, with more than 100.000 deaths reported in 2019.^[1] Despite advances in burns management, patients with a revised Baux (rBaux) score >70 have a predicted mortality of almost 50%.^[2] rBaux scores are calculated as follows: [Age (years) + % burn + (×17 inhalation injury, 1 = yes, 0 = no)].^[3] The management of critically ill burns with multi-organ failure can be very challenging to the clinical team, particularly from the cardiovascular and respiratory standpoint.^[4]

Veno-venous (VV) and veno-arterial (VA)- Extracorporeal Membrane Oxygenation (ECMO) are lifesaving tools for patients with life-threatening cardiorespiratory failure.^[5]

The Case for Extracorporeal Membrane Oxygenation for Burns

Despite innovations in burns management, the mortality rate of intensive care unit burns patients remains as high as 58%, particularly when the patient develops refractory respiratory or cardiac dysfunction.^[6]

The hemodynamic consequences of major burns are quite complex. The initial state of low cardiac output, severe hypovolemia, and high systemic and pulmonary vascular resistance is followed 24–48 h later by a sepsis-like syndrome where vasodilation, vasoplegia, and high cardiac output are the dominant features.^[7]

Myocardial dysfunction resulting from thermal injury or increased cardiac workload, acute kidney injury, and major fluid shifts complicate the hemodynamic management of major burns.^[4] Both under-and over-resuscitation are significant risk factors for mortality in major burns. Inadequate resuscitation is associated with decreased oxygen delivery and acute kidney injury. Excessive fluid administration can lead to complications such as abdominal hypertension and compartment syndrome and acute kidney injury.^[4],[7],[8] Acute respiratory distress syndrome (ARDS) complicates up to 60% of burn cases and is a major cause of death in this population.^[9] The cause of early ARDS is multifactorial. Direct thermal injury, smoke and particulate inhalation, inflammatory response, capillary leak syndrome, and inadvertently overzealous resuscitative fluids are contributing factors.^[4],[7] In cases of severe refractory hypoxemic respiratory failure, VV-ECMO may be considered, while hemodynamic instability secondary to refractory cardiac dysfunction may be an indication of VA-ECMO. The late course of burns is typically characterized by infections with multi-drug-resistant organisms, and fungal infections, leading to severe septic shock with multi-organ failure and increased mortality where ECMO is questionable. Depending on the extent and severity of burns, vascular access may be restricted and insertion of an ECMO cannula can be challenging.

Nevertheless, ECMO is costly, and invasive and mandates an interprofessional team and appropriate training, resulting in improved ECMO care and outcomes.^[10],[11]

Extracorporeal Membrane Oxygenation for Major Burns: The Evidence

The current literature supporting the use of ECMO in burn patients is relatively poor in quality and limited in quantity. Published literature is comprised case reports, case series, and retrospective analyses.^[12],[13]

A recent meta-analysis of 22 studies demonstrated a high risk of death for burn victims receiving ECMO. Observed mortality of patients receiving ECMO was greater than predicted mortality using the rBaux giving rise to suspicion of the utility of ECMO in patients with severe burns. The authors report a pooled mortality rate of almost 50% among adult burns patients supported with ECMO. Patients with inhalation injury and rBaux score >90 did better on ECMO, implying that the more severe the injury, the more likely ECMO can be beneficial and advantageous. However, the review had studied with overlapping patient data resulting in skewing of results and possible bias. In addition, ECMO was used as a last resort in many instances, which may explain the lack of benefits.^[12] A 2022 survival analysis of 10 studies of rescue ECMO implantation in refractory ARDS demonstrated a survival rate of 54%, which is not dissimilar to general adult ECMO survival. Patients supported with ECMO had severe ARDS with a mean Murray score of 3.44, and a mean arterial partial pressure of oxygen/fraction of the inspired oxygen ratio (PaO₂/FiO₂) of 67.0.^[13] These reports are discordant with a historical meta-analysis of limited studies with methodological shortcomings that suggested poor outcomes of ECMO in burns.^[14] Recent advances in ECMO care, equipment design, training, and timely usage in specialized centers are likely to improve outcomes. This was demonstrated in a retrospective analysis by Huang et al., who reported a survival rate of 43% from a military burns facility. Their cohort suffered extensive life-threatening burns with a median total body surface area of deep dermal or full thickness burns of 94.5% (range: 48%–99%), a median rBaux score of 122, indicating very severe injury, and a very poor prognosis. All patients developed severe ARDS with a median PaO₂/FiO₂ of 61.5 (range: 49–99).^[15] A summary of published reports is presented in [Table 1] in chronological order.

Table 1: A summary of publications on extracorporeal membrane oxygenation for burn cases showing the number of patients included, configuration, and outcome

Click here to view

^[27]

Conclusion

Timely application of ECMO is likely to be advantageous for a select group of burn patients treated in experienced burn and ECMO centers. Major burn victims, particularly those with smoke inhalation, carry a significant risk of morbidity and mortality and ARDS continues to be a common cause of mortality in this cohort. The innovative use of ECMO in critically ill burn patients needs to be carefully considered. Available evidence suggests survival benefits for ECMO in critically ill burn patients with severe ARDS and a high rBaux score. ECMO is an invasive and costly intervention, and to justify its use in major burns, clinicians need scientific evidence for which high-quality research is required.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Yakupu A, Zhang J, Dong W, Song F, Dong J, Lu S. The epidemiological characteristic and trends of burns globally. BMC Public Health 2022;22:1596.
2.	Karimi H, Motevalian SA, Rabbani A, Motabar AR, Vasigh M, Sabzeparvar M, et al. Prediction of mortality in pediatric burn injuries: R-baux score to be applied in children (pediatrics-baux score). Iran J Pediatr 2013;23:165-70.
3.	Osler T, Glance LG, Hosmer DW. Simplified estimates of the probability of death after burn injuries: Extending and updating the baux score. J Trauma 2010;68:690-7.
4.	Soussi S, Dépret F, Benyamina M, Legrand M. Early hemodynamic management of critically Ill burn patients. Anesthesiology 2018;129:583-9.
5.	Combes A, Peek GJ, Hajage D, Hardy P, Abrams D, Schmidt M, et al. ECMO for severe ARDS: Systematic review and individual patient data meta-analysis. Intensive Care Med 2020;46:2048-57.
6.	Toft-Petersen AP, Ferrando-Vivas P, Harrison DA, Dunn K, Rowan KM. The organisation of critical care for burn patients in the UK: Epidemiology and comparison of mortality prediction models. Anaesthesia 2018;73:1131-40.
7.	Soussi S, Gallais P, Kachatryan L, Benyamina M, Ferry A, Cupaciu A, et al. Extracorporeal membrane oxygenation in burn patients with refractory acute respiratory distress syndrome leads to 28% 90-day survival. Intensive Care Med 2016;42:1826-7.
8.	Legrand M, Guttormsen AB, Berger MM. Ten tips for managing critically ill burn patients: Follow the RASTAFARI! Intensive care med 2015;41:1107-9.
9.	Cartotto R, Li Z, Hanna S, Spano S, Wood D, Chung K, et al. The acute respiratory distress syndrome (ARDS) in mechanically ventilated burn patients: An analysis of risk factors, clinical features, and outcomes using the Berlin ARDS definition. Burns 2016;42:1423-32.
10.	Zakhary B, Shekar K, Diaz R, Badulak J, Johnston L, Roeleveld PP, et al. Position paper on global extracorporeal membrane oxygenation education and educational agenda for the future: A statement from the extracorporeal life support organization ECMOed taskforce. Crit Care Med 2020;48:406-14.
11.	Labib A, Alinier G. Can simulation improve ECMO care? Qatar Med J 2017. DOI:10.5339/qmj.2017.swacelso.7.
12.	Chiu YJ, Huang YC, Chen TW, King YA, Ma H. A systematic review and meta-analysis of extracorporeal membrane oxygenation in patients with burns. Plast Reconstr Surg 2022;149:e1181-90.
13.	Ng ES, Ling RR, Mitra S, Tan CS, MacLaren G, Ramanathan K. The use of extracorporeal membrane oxygenation for burns: A systematic review and meta-analysis. ASAIO J 2023;69:e7-13.
14.	Asmussen S, Maybauer DM, Fraser JF, Jennings K, George S, Keiralla A, et al. Extracorporeal membrane oxygenation in burn and smoke inhalation injury. Burns 2013;39:429-35.
15.	Huang CH, Tsai CS, Tsai YT, Lin CY, Ke HY, Chen JL, et al. Extracorporeal Life Support for Severely Burned Patients with Concurrent Inhalation Injury and Acute Respiratory Distress Syndrome: Experience from a Military Medical Burn Center. Injury. 2023;54(1):124-130. doi: 10.1016/j.injury.2022.08.063. Epub 2022 Sep 7. PMID: 36163205; PMCID: PMC9448699.
16.	Chou NK, Chen YS, Ko WJ, Huang SC, Chao A, Jan GJ, et al. Application of extracorporeal membrane oxygenation in adult burn patients. Artif Organs 2001;25:622-6.
17.	Thompson JT, Molnar JA, Hines MH, Chang MC, Pranikoff T. Successful management of adult smoke inhalation with extracorporeal membrane oxygenation. J Burn Care Rehabil 2005;26:62-6.
18.	Hughes W, Guy TS, Shiose A, Hughes L. Lessons learned from the use of ECMO in three adult burn patients with smoke inhalation. Ann Burns Fire Dis 2015;28:223.
19.	Soussi S, Legrand M. Hemodynamic coherence in patients with burns. Best Pract Res Clin Anaesthesiol 2016;30:437-43.
20.	Hsu PS, Tsai YT, Lin CY, Chen SG, Dai NT, Chen CJ, et al. Benefit of extracorporeal membrane oxygenation in major burns after stun grenade explosion: Experience from a single military medical center. Burns 2017;43:674-80.
21.	Nosanov LB, McLawhorn MM, Vigiola Cruz M, Chen JH, Shupp JW. A national perspective on ECMO utilization use in patients with burn injury. J Burn Care Res 2017;39:10-4.
22.	Kennedy JD, Thayer W, Beuno R, Kohorst K, Kumar AB. ECMO in major burn patients: Feasibility and considerations when multiple modes of mechanical ventilation fail. Burns Trauma 2017;5:20.
23.	Ainsworth CR, Dellavolpe J, Chung KK, Cancio LC, Mason P. Revisiting extracorporeal membrane oxygenation for ARDS in burns: A case series and review of the literature. Burns 2018;44:1433-8.
24.	Chiu YJ, Ma H, Liao WC, Shih YC, Chen MC, Shih CC, et al. Extracorporeal membrane oxygenation support may be a lifesaving modality in patients with burn and severe acute respiratory distress syndrome: Experience of Formosa Water park dust explosion disaster in Taiwan. Burns 2018;44:118-23.
25.	Szentgyorgyi L, Shepherd C, Dunn KW, Fawcett P, Barker JM, Exton P, et al. Extracorporeal membrane oxygenation in severe respiratory failure resulting from burns and smoke inhalation injury. Burns 2018;44:1091-9.
26.	Dadras M, Wagner JM, Wallner C, Huber J, Buchwald D, Strauch J, et al. Extracorporeal membrane oxygenation for acute respiratory distress syndrome in burn patients: A case series and literature update. Burns Trauma 2019;7:28.
27.	Marcus JE, Piper LC, Ainsworth CR, Sams VG, Batchinsky A, Okulicz JF, et al. Infections in patients with burn injuries receiving extracorporeal membrane oxygenation. Burns 2019;45:1880-7.