Introduction: Mortality and morbidity from severe burn injury remains high despite advances in medical care. A common cause of mortality in these patients is ARDS. While the pulmonary function of a majority of burn patients can be supported with conventional mechanical ventilation, the use of ECMO has shown promise for the most severely injured. Recent reviews have shown mixed results, with no strong recommendation in regard to the use of extracorporeal membrane oxygenation (ECMO) for respiratory failure in severely burned patients.

Case Report, Chart Review Results/Findings: We present a case of one severely burned, 39 year old male patient (84% TBSA, total body surface area, 13% 2nd degree, 71% 3rd degree) whose hospital course was complicated by shock, multi-organ failure, and Acute Respiratory Distress Syndrome (ARDS) refractory to conventional therapies. We utilized Venous-Venous ECMO (VV ECMO) with dramatic improvement of shock after initiation of ECMO with a minimal anticoagulation and adjunctive beta blockade strategy. He required a total of nine days on ECMO within a lengthy ICU stay and was ultimately discharged home after multiple burn surgical procedures and a stay in the rehabilitation unit.

Conclusions: VV-ECMO may be a viable adjunctive strategy to severe burn treatment complicated by ARDS.

References and Resources

1. Asmussen S, Maybauer D, Fraser J, Jennings K, George S, Keiralla A, Maybauer M. “Extracorporal membrane oxygenation in burn and smoke inhalation injury.” Burns, May 2013, Vol 39, 429-435
2. 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 Dec 27; Vol 39(1):10-14.
3. 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. Vol 42:1826
4. “Burns.” World Health Organization, World Health Organization, 6 Mar. 2018, www.who.int/news-room/fact sheets/detail/burns.
5. Ahmadabadi A, Khadem-Rezaiyan M, Sedaghat A, Tavousi SH, Khorrampazhouh N, Mohsenpour A, Goudarzi Z, Hassanpour M. “Lethal area 50% (LA5) or standarized mortality ratio (SMR): Which one is more conclusive?” Burns 2018, Vol 44:1468-1474.
6. Steinvall I, Elmasry M, Fredirkson M, Sjoberg F. “Standardized mortality based on the sum of age and percentage total body surface area burned is an adequate quality indicator in burn care: An exploratory review.” Burns 2016, Vol 42: 28-40
7. Strassle PD, Williams FN, Napravnik S, van Duin D, Weber DJ, Charles A, Cairnes BA, Jones SW. “Improved Survival of Patients with Extensive Burns: Trends in Patient Characteristics and Mortality among Burn Patients in a Tertiary Care Burn Facility, 2004-2013.” J Burn Care Res, 2018. Vol 38(3) 187-193.
8. American Burn Association National Burn Repository 2017 Report. Dataset Version 13.0
9. Galvagno SM, Shah NG, Cornachione CR. “Long term veno-venous extracorporeal life support without intravenous anticoagulation for diffuse alveolar hemorrhage.” Perfusion, 2019. Vol 34(6): 523-525
10. Ryu KM, Chang SW, “Heparin-free extracorporeal membrane oxygenation in a patient with severe pulmonary contusions and bronchial disruption.” Clin Exp Emerg Med. 2018. Vol 5(3): 204–207
11. Muellenbach RM, Kredel M, Kunze E “Prolonged heparin-free extracorporeal membrane oxygenation in multiple injured acute respiratory distress syndrome patients with traumatic brain injury.” J Trauma Acute Care Surg. 2012. Vol 72(5):1444-7
12. Seong Ho Moon, Ki Nyun Kim, Jae Jun Jung, Jae Hong Park, Joung Hun Byun. “Heparin-free veno-venous ECMO applied to a patient with severe lung contusion and hypovolemic shock due to trauma.” Ulus Travma Acil Cerrahi Derg. 2018. Vol 24(5): 497-500
13. Herndon D, Hart D, Wolf S, Chinkes D, Wolfe R. “Reversal of Catabolism by Beta Blockade after Severe Burns.” NEJM, October 2001. Vol 345: 1223-1229
14. Ghalayini M, Brun PY, Augustin P, Guivarch E, Dilly MP, Provenchere S, Mordant P, Castier Y, Montravers P, Longrois D. “Esmolol Corrects Severe Hypoxemia in Patients with Femoro-Femoral Venoarterial Extracorporeal Life Support for Lung Transplantation.” J Extra Corpor Technol. 2016. Vol 48(3):113-121.
15. Guarracino F, Zangrillo A, Ruggeri L, Pieri M, Calabrò MG, Landoni G, et al. “β-Blockers to optimize peripheral oxygenation during extracorporeal membrane oxygenation: a case series.” J Cardiothorac Vasc Anesth 2012. Vol 26(1):58–63.
16. Goretsky MJ, Greenhalgh DG, Warden GD, Ryckman FC, Warner BW. “The use of extracorporeal life support in pediatric burn patients with respiratory failure.” J Pediatr Surg, 1995. Vol 30(4): 620-623
17. Ainsworth C, Dellavolpe J, Chung K, Cancio L, Mason P. “Revisiting extracorporeal membrane oxygenation for ARDS in burns: A case series and review of the literature.” Burns 2018, Vol 44: 1433-1438.
18. Burke C, Chan T, McMullan M. “Extracorporal Life Support Use in Adult Burn Patients.” Journal of Burn Care and Research. 2017. Vol 38: 174-178
19. Chiu Y, Ma H, Liao W, Shih Y, Chen M, Shih C, Chen T, Perng C. “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. Vol 44: 118-123.
20. Strassles Pu, Williams F, Napravnik S, van Duin D, Weber D, Charles A, Cairns B, Jones S. “Improved Survival of Patients with Extensive Burns: Trends in Patient Characteristics and Mortality among Burn Patients in a Tertiary Care Burn Facility, 2004-2013.” Journal of Burn Care and Research. 2017. Vol 38, 187-193.
21. Szentgyorgyi L, Shepherd C, Dunn K, Fawcett P, Barker J, Exton P, Maybauer M. “Extracorporeal membrane oxygenation in severe respiratory failure resulting from burns and smoke inahlation injury.” Burns, 2018. Vol 44, 1091-1099