Extracorporeal membrane oxygenation for major burns in adults :Ahmed Labib, Saudi Critical Care Journal

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

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

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.

How to cite this article:
Labib A. Extracorporeal membrane oxygenation for major burns in adults.Saudi Crit Care J 2022;6:11-13

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 29 ];6:11-13
Available from: https://www.sccj-sa.org/text.asp?2022/6/5/11/369160

Full Text

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}[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.

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