Extracorporeal membrane oxygenation in Trauma: A single-center review

Extracorporeal membrane oxygenation in Trauma: A single-center review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Extracorporeal membrane oxygenation in Trauma: A single-center review Mathias Ahlqvist, Pär Forsman, Pål Morberg, Magnus Larsson, Lars Mikael Broman, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4473247/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Jan, 2025 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted 11 You are reading this latest preprint version Abstract Purpose Globally, trauma is a leading cause of death in young adults. The use of extracorporeal membrane oxygenation (ECMO) in the trauma population remains controversial due to the limited published research. This study aimed to analyze 30-day survival of all the trauma ECMO patients at our center, with respect to injury severity score (ISS), new injury severity score (NISS). Methods We performed a retrospective analysis of all trauma patients receiving ECMO support at a Level 1 trauma center in Sweden between 1997 and 2019. Results A total of 53 trauma patients received ECMO support. Eighty-five percent were male; the median age was 24, with interquartile range (IQR) 17–44 years. More than 70% were multi-trauma patients. The mean NISS and ISS were 50 (IQR:34–57) and 42 (IQR:33–57), respectively. Sixty-two percent were supported on veno-arterial ECMO with a survival benefit for veno-venous ECMO (75% vs. 36%, respectively (p = 0.01)). There was no association between severity in terms of trauma-score and survival. Sixteen patients (30%) were cannulated at referring hospitals and transported to our unit on ECMO with a survival of 69%, similar to those cannulated in-house. Sixty percent of patients survived ECMO, and 51% survived to hospital discharge. Conclusions This study indicates that trauma patients benefit from ECMO, independent of severity. Furthermore, our results support ECMO transport as feasible in trauma patients. We recommend larger multi-center studies to determine which trauma patients would have the greatest benefit of ECMO. ECMO Extracorporeal Membrane Oxygenation VA ECMO veno-arterial ECMO VV ECMO veno-venous ECMO ISS Injury severity score NISS New injury severity score Figures Figure 1 Figure 2 Figure 3 Figure 4 INTRODUCTION Globally, trauma is a leading cause of death in young adults [1]. The common causes of immediate death are traumatic brain injury, high spinal lesions, and massive bleeding with refractory hemorrhagic shock. Death within the first few hours is often related to hemorrhage and coagulopathies [2]. In the treatment of trauma, time is thus critical. Overall, the time-to-trauma center is paramount to good survival outcomes [3]. The majority of trauma is blunt (90%), while penetrating injuries account for the remaining 10%. Most cases of severe multi-trauma, as defined by the American College of Surgeons Committee of Trauma Triage Criteria, present at major trauma centers [4]. Of these cases, traumatic thoracic injuries are reported in up to 50% of cases, and consists of primary injuries, such as major hemorrhage, contusions, acute lung injury (ALI), as well as secondary complications such as pneumonia, or acute respiratory distress syndrome (ARDS) [5–8]. To quantify the severity of trauma it is common practice to use the injury severity score (ISS) and its later adaptation, the new injury severity score (NISS), which shows a good correlation with survival in trauma patients (9). The correlation between ISS and mortality is not strictly linear, as Copes et al. demonstrated, and hence the scores are usually divided into intervals [10]. Generally, an ISS of 1–8 is considered minor trauma, 9–15 moderate, 16–24 severe, and ≥ 25 very severe trauma, with a corresponding increase in risk of mortality [11]. Modern intensive care has improved in recent decades, and overall survival of patients has increased [12,13]. However, a small percentage of trauma patients do not respond to resuscitative care and may die both from acute and chronic complications, such as shock, hypoxia, hypercapnia, and acidosis. These patients may benefit from extracorporeal life support, i.e., extracorporeal membrane oxygenation (ECMO) [14–16]. The use of ECMO in the trauma population has been described since the 1970s [17]. Yet there is no consensus, and treatment remains controversial. This is mainly because of the limited published research on ECMO in trauma, with mostly small cohort studies and a handful of reviews, as well as the limited availability of ECMO [18]. ECMO indications also vary, from acute hemorrhagic shock and severe pulmonary contusions to secondary ALI or ARDS. Recent ECMO advances, such as development of circuits, coating materials, and a broader understanding of the physiology in the trauma patient, have increased its use as an advanced critical care treatment modality [19]. The primary aim of this study was to describe ECMO in trauma patients regarding 30-day survival at our center. Secondary aims were to describe indications, patient demographics, time to ECMO support, complications during treatment, and to compare outcome in terms of survival to the trauma severity score models. METHODS We performed a single center retrospective cohort analysis of both pediatric and adult trauma patients receiving ECMO at our center between 1997 and 2019. Ethical approval was obtained from the Swedish Ethical Review Authority (EPM DNR 2019–03808). The data was collected from a Level 1 trauma center with a high volume of both trauma and ECMO patients. The center has more than 25 years of experience treating patients with pulmonary and/or cardiac pathologies across all age groups. Furthermore, the clinic has a mobile ECMO team that usually cannulates the patient at a referring hospital and then transports them back to the ECMO center. Inclusion criteria were patients who were admitted to the hospital under the trauma team activation (TTA) and who were offered ECMO, as well as trauma patients who were accepted from other hospitals. Patients who were deemed dead-on-arrival or did not survive in the trauma room were excluded. Data was collected from the hospital’s trauma registry and the department’s ECMO intensive care unit (ICU) quality database. Data was cross-checked and verified against the department's patient medical charts, which are linked to the National Population Register, allowing for long-term follow-up of mortality. After the completion of the dataset, data was anonymized. Analysis was performed on aggregates. Patients were subdivided into three groups: early cannulation ( 24 h). Patient demographics, diagnoses, ECMO mode (veno-arterial (VA) and veno-venous (VV) ECMO), type of trauma, and trauma scores (ISS and NISS) were also included in the data [20–21]. Acute lung injury and ARDS were defined according to Bernard et al. as “acute onset of diffuse bilateral pulmonary infiltrates by chest radiograph; a PaO2/FiO2 ≤ 300 for ALI and ≤ 200 for ARDS; and a pulmonary artery wedge pressure ≤ 18 or no clinical evidence of left atrial hypertension” [22]. Additionally, baseline characteristics, before (pre) and after (post) cannulation, physiologic data, complications, and outcomes were recorded. Survival was categorized by decannulation alive from ECMO and survival to hospital discharge. Survival in the Swedish National Trauma Registry was based on a 30-day survival. Injury coding in the national registry was performed manually according to the Abbreviated Injury Scale (AIS) code manual based on injuries at the time of presentation to hospital. Using the AIS, the ISS and NISS were calculated [23]. The scores were calculated after patient demise or hospital discharge. Furthermore, from the ISS and NISS, patients were divided into 5 groups of trauma-severity according to Copes et. al. [10]. Statistics. Data is presented as numbers (n) and percentages (%). Normality was tested by Shapiro-Wilk’s test. Normally distributed data is presented as mean (± SD). Non-parametric data is presented as median (IQR 25%-75%). Statistical analysis was performed using Mann Whitney U test. For categorical variables Fisher’s exact test was used. A p-value < 0.05 was considered statistically significant. All statistical analyses were performed using RStudio 2021.09.0. RESULTS Pre-ECMO: demographics During the study period 53 trauma patients received ECMO support. Majority of the patients were males (n = 45, 85%). The most common cause of trauma was traffic accidents, followed by falls, and burns (Table 1, Fig. 1). Over half of the patients (72%, n = 38), were classified as multi-trauma., followed by severe burns (9%, i.e. burn severity > 18%), and penetrating trauma (7.5%, n = 4) (Table 1). In three cases head injuries were the only presenting trauma; however, these patients also suffered from cardiac arrest (n = 2), or sepsis (n = 1) and were placed on ECMO due to ARDS, cardiac failure, and cardiopulmonary failure, respectively (Table 2). In total 26 patients had either an isolated head injury or a head injury in combination with multi-trauma. The overall ISS was 42 (IQR: 33–57, range: 19–75), and NISS 50 (IQR: 34–57, range: 21–75). Using the Copes et al. intervals of ISS, most patients had a score either between 25–40 or 50–65 (Table 3); there was a similar pattern for the NISS interval-scores, however, more patients were classified as being in the two upper intervals, i.e. 50–65 and 66–75 (Table 4). At time of cannulation The most common indication for ECMO was combined cardiopulmonary failure. Other indications for ECMO and their respective frequencies are listed in Table 5. Fifty-one percent of the patients were cannulated within 24 hours of the trauma, and of these 67% (n = 18) were cannulated between 0–12 hours post trauma (Table 1). Sixteen patients (30%) were cannulated at a referring hospital, 15 (28%) were cannulated in hospital in the emergency room (ER), and 22 (42%) in the ICU. Most patients (n = 33) were initially treated with VA ECMO, however, of the 20 patients started on VV two were converted to VA ECMO (Table 1). The median time from ER arrival to ECMO start was 36.4 h (5.1-101.5). Time to commencement of VA ECMO was 17.3 h (3.2–65.8), and time to VV ECMO was 60.0 h (34.6-204.4). Treatment outcomes General Sixty percent (n = 32) of the patients survived ECMO, and 51% (n = 27) survived to hospital discharge. One patient reportedly died after 13 days due to cerebral infarction suspected to be secondary to ECMO-related coagulopathy. All twenty-seven patients that survived to hospital discharge were still alive 30 days post discharge, and 22 patients are still alive today with the shortest follow-up time of 2 years (median long-term follow-up 13.2 years). Twenty-two patients were cannulated in the ICU, 15 in the ER, and 16 at a referring hospital, with a survival rate of 50%, 27%, and 69%, respectively. There was no difference in 30-day survival over the study period (Fig. 1). Injury type Thirty-day survival was 48% for traffic accidents, 56% for falls, and 80% for burns (Fig. 2). For those patients where burn severity was quantified (n = 2), both were classified as severe burns (> 40% of body surface area) [24]. The patients were also stratified based on type of injury, as shown in Table 1, where 30-day survival was 47% in multi-trauma (n = 38), 25% penetrating injuries (n = 4), and 33% in isolated head injuries (n = 3). However, 58% (n = 22) of the multi-trauma patients had a concomitant head injury. Hence, for all patients with a head injury, 30-day survival was 54% (n = 14/26). Lastly, there were five confirmed suicide attempts of which three (60%) survived 30 days post discharge. Survival outcomes based on ECMO indication The patients who were treated with ECMO due to ALI had the highest 30-day survival rate (80%), followed by ARDS (73%). There was a significant difference between patients initiated on ECMO due to ARDS or ALI compared to patients who received ECMO due to circulatory failure or combined circulatory and pulmonary failure (p < 0.001). Patients with combined circulatory and pulmonary failure had the lowest survival outcome, in all six patients representing a survival rate of 27% (Table 5). Cardiac arrest In total, 17 patients experienced cardiac arrest (CA) before or at the time of cannulation. Nine patients arrested outside of the hospital. Of these, eight (47%) had a return of spontaneous circulation (ROSC). Fourteen (82%) patients had ongoing cardiopulmonary resuscitation (CPR) during the cannulation procedure, of which six had CA outside of the hospital. Fifteen of 17 patients were placed on VA ECMO and two on VV ECMO. One VA and one VV patient survived. Extracorporeal cardiopulmonary resuscitation (ECPR) was used in five cases with only one surviving 30 days post discharge. Complications to trauma: Overall, 77% (n = 41) of the patients suffered some form of complication, and 60% experienced two or more complications in addition to the trauma per se . The most common complication was severe neurological disability, followed by sepsis and hemorrhagic shock. The highest morbidity was associated with severe neurological disabilities, whereas sepsis showed the highest 30-day survival (55%). Complications and associated survival rates are listed in Table 6. Survival outcomes and trauma scoring A scatter plot of NISS and ISS vs. mortality within the first 30 days showed a correlation of higher mortality in patients with higher NISS (Fig. 3). The ISS score in survivors after 30 days was similar to the deceased (36 IQR:25–51 vs. 50 IQR:34–64, p = 0.052) (Table 1). This relationship was repeated for NISS. Likewise, no difference was observed concerning age or time from trauma to start of ECMO. Patients supported with VA ECMO had a 30-day survival of 34% compared to 76% in the VV group (p < 0.005). The seventeen patients cannulated at a referring hospital and then transported to our unit on ECMO showed a survival rate of 69% compared to 57% in those cannulated in-house (p = 0.14) (Table 1). Concerning complications, massive hemorrhage as a presenting symptom was associated with poor outcome (p < 0.01). Five out of 20 patients with reported bleeding survived. Overall, 26 patients died before or within 30 days of discharge (causes of death, see Fig. 4). DISCUSSION In this retrospective analysis we present data on 30-day survival in 53 patients treated with ECMO at a Level 1 trauma center. Our data shows significantly higher survival patients treated with VV than with VA ECMO. There was also a significant difference in survival based on the indication for ECMO support, and no difference was observed among patients cannulated at a referring hospital and then transferred to our hospital compared to those cannulated in-house. Furthermore, we found no difference in survival outcomes throughout the study period. According to the ELSO Registry, overall survival for adult ECMO patients in North America and Europe over the last 5 years is 53% [25]. This is comparable to our results of 51%, and results previously reported by others [26–27]. Hence, our results provide further evidence that ECMO can be used successfully to support patients with very severe trauma. Major trauma is the primary cause of death among young adults. The use of ECMO in trauma, while still controversial, has become more prevalent over the past decades. However, most reports are case studies or retrospective analyses with a limited number of patients, usually less than 20 subjects [26]. With the increased interest in ECMO for trauma there is a need for clearer indications to identify the patients most likely to benefit from this support. To quantify the severity of trauma in this patient population we chose the widely used ISS and NISS for easy comparison to previous studies. The mean NISS and ISS assessed in this study were 46 and 44, respectively, thus representing a very high risk of mortality as shown by Copes et al., and Ghorbani [10,28]. Overall, 41% of the patients had an ISS greater than 50, which otherwise is associated with close to 100% mortality rate [10]. Even though ECMO is not a typical supportive modality in the trauma patient, the results showed more than half of the patients were still alive at follow-up. Furthermore, we divided both the ISS and NISS into intervals according to Copes et al. showing that there was similar distribution with a slight tendency towards the higher bins within the VA group, but with a higher proportion 30-day survival for the patients on VV ECMO (Table 3–4). The cause of higher mortality in the VA group might be partially explained by the fact that most patients with cardiac arrest and ongoing CPR, a subgroup with a very high mortality rate, were placed on VA ECMO. Almost two thirds of the patients were placed on VA ECMO in contrast to earlier studies where pure respiratory support was more common due to ALI/ARDS [26,27]. The ELSO Registry reported an overall survival rate of 43% for all VA ECMO patients, and 30% for patients treated with extracorporeal cardiopulmonary resuscitation [25]. Previous studies on the use of VV ECMO in the trauma population show a survival range of to 56–89% compared to 42–63% for VA ECMO [26]. This was similar to our findings of 75% 30-day survival in the VV ECMO group, and 36% for VA ECMO. This difference may be explained by patient selection, center preference, and experience. Although the center in this study is primarily a “respiratory” ECMO center, 55–60% of normal cases are placed on VA ECMO and approximately 20% of VV ECMO patients are converted to VA ECMO [29]. Part of the difference in mortality may be explained by the fact that patients who experienced CA were offered VA ECMO. However, after the exclusion of the patients with CA, survival from VA was 61%, i.e. patients on VV ECMO generally had a higher survival (75%). Taken together, this may reflect that trauma patients who present with lung problems, and who are then placed on VV ECMO are more likely to benefit from ECMO support than the VA patients experiencing circulatory or combined circulatory and pulmonary problems. ECMO support increases the risk of bleeding complications and subsequently the risk of cerebral hemorrhage [30]. Hence, most clinicians may feel apprehensive to offer ECMO to trauma patients with head injuries. In this study, most of the patients were multi-trauma, and nearly half presented head injuries. Three patients were categorized as isolated head injuries, which by default , is a relative contraindication for ECMO. Despite this, one of these patients survived. Of the 26 patients with head trauma, 54% survived 30 days after discharge, a survival rate, similar to the average survival rate for the study population at large (51%). Previous studies have shown benefits in patients with traumatic brain injury (TBI), both from VV and VA ECMO [31,32]. Considering the patients with TBI in both this study and previous studies had an outcome comparable to the typical trauma patient supported on ECMO, the risk-benefit of ECMO use in patients with TBI should be re-evaluated. Another area of limited knowledge is the outcome of trauma patients transported on ECMO. We observed no difference in mortality between those patients cannulated and then transported on ECMO compared to those who were cannulated in house. The mobile ECMO team in this study has ample experience including both in-hospital cannulations and > 1300 ECMO transports and has only recorded three deaths during transport (n = 1373), of which one was a trauma patient [33–35]. The analysis showed that cannulations at referring hospitals were generally performed at a later stage (> 12 hours post trauma), and the patients still alive had been stabilized by local intensive care for several hours and thus more stable than the patients brought directly to our university hospital from the trauma site. This finding may be subject to selection bias influenced by more strict selection criteria where the time factor and prognosis would strongly impact a decision to dispatch the mobile ECMO team. Nonetheless, the high survival rate (69%) suggests that with strict selection criteria a mobile ECMO team that transports patients to a larger ECMO center may be a life-saving strategy for patients suffering from severe trauma. Limitations Limitations of this work include the sample size, which was relatively low from a general perspective but rather high given the targeted ECMO population from a single center. The applicability of findings from a high-volume center may not extend to institutions with less experience, potentially limiting their generalizability. Other limitations may be patient heterogeneity, with respect to age, where we had patients from one to 72 years of age. Further limitations include changes in practice at our center during the study period, and patients recovered from other hospitals may have been subjects of selection bias. The key strengths of this study were the Swedish Civic registration number, which allowed for long-term follow-up of patients, and the local databases for trauma and ECMO support. CONCLUSIONS This single-center retrospective study indicated that ECMO support in patients with severe to very severe trauma may benefit from ECMO in terms of survival. We also find support favoring out-reach services by a mobile ECMO team to cannulate and transport the patient to a high-volume ECMO/trauma center. Furthermore, we review the evidence of whether traumatic brain injuries should constitute a relative contraindication for ECMO and suggest further studies to assess whether this patient group may, in fact, benefit from ECMO. Further multicenter studies for larger patient numbers are needed to assess the benefits of ECMO in the trauma setting. Declarations Conflicts of interest No conflicts of interest reported for any of the authors Disclosures LMB is a member of the Medical Advisory Boards of Eurosets Srl., Medolla, Italy; Xenios Ag., Heilbronn, Germany; and HemoCue AB, Ängelholm, Sweden. Ethical approval was obtained from the Swedish Ethical Review Authority (EPM DNR 2019–03808). Competing Interests LMB is a member of the Medical Advisory Boards of Eurosets Srl., Medolla, Italy; Xenios Ag., Heilbronn, Germany; and HemoCue AB, Ängelholm, Sweden. Funding No funding was received for conducting this study. Author Contribution Author contributionSA, ML, PM and LMB designed the concept. SA, ML, PM and PF collected the data. MA and SA analyzed the data. MA drafted the manuscript. PF, LMB and SA revised the manuscript for important intellectual content. Approval for submission: all authors. Acknowledgement This retrospective study was preregistered in the Database for Clinical Research at Karolinska University Hospital, Stockholm, Sweden, DNR K 2021–8410 References The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013 [Internet]. Institute for Health Metrics and Evaluation. 2015 [cited 2021 Oct 7]. Available from: http://www.healthdata.org/research-article/global-burden-injury-incidence-mortality-disability-adjusted-life-years-and-time Probst C, Zelle BA, Sittaro NA, Lohse R, Krettek C, Pape HC. Late death after multiple severe trauma: when does it occur and what are the causes? J Trauma. 2009 Apr;66(4):1212–7. American College of Surgeons Committe on Trauma. Advanced Trauma Life Support. 10th ed. American College of Surgeons; 2018. Eriksson L, Östlund A. Trauma Manual Karolinska [Internet]. Karolinska Universitetssjukhuset Solna; 2013 [cited 2022 Apr 13]. Available from: https://www.karolinska.se/4967e2/globalassets/global/4-gamla-kataloger/traumacentrum/traumamanual_karolinska_20130626.pdf?id=12984 Stahel PF, Schneider P, Buhr HJ, Kruschewski M. [Emergency management of thoracic trauma]. Orthopade. 2005 Sep 1;34(9):865–79. Havlícek K, Motycka V, Siller J, Cervinka V. Systemic Inflammatory Response Syndrome (SIRS) in Serious Chest Injuries: Is a Pharmacological Blockade Effective? 2005;11(4):6. Waydhas C, Nast-Kolb D. [Chest injury. Part I: Significance--symptoms--diagnostic procedures]. Unfallchirurg. 2006 Sep 1;109(9):777–84; quiz 785. Lewandowski K. Extracorporeal membrane oxygenation for severe acute respiratory failure. Crit Care. 2000 Apr 12;4(3):156. Baker SP, Long WB, Haddon W, Jr, O’Neill B. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma Vol 14 No 3 March 1974 P 187-196. 1974; COPES WS, CHAMPION HR, SACCO WJ, LAWNICK MM, KEAST SL, BAIN LW. The Injury Severity Score Revisited. J Trauma. 1988;28(1):69–77. VanDerHeyden N, Cox TB. CHAPTER 6 - TRAUMA SCORING. In: Asensio JA, Trunkey DD, editors. Current Therapy of Trauma and Surgical Critical Care [Internet]. Philadelphia: Mosby; 2008 [cited 2021 Nov 7]. p. 26–32. Available from: https://www.sciencedirect.com/science/article/pii/B9780323044189500102 Zimmerman JE, Kramer AA, Knaus WA. Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012. Crit Care. 2013;17(2):R81. Herlitz J, Magnusson C, Hagiwara MA, Lundgren P, Larsson G, Rawshani A, et al. Den prehospitala akutsjukvården i Sverige har stora utmaningar [Internet]. Läkartidningen. 2021 [cited 2022 Jun 13]. Available from: https://lakartidningen.se/klinik-och-vetenskap-1/artiklar-1/klinisk-oversikt/2021/11/den-prehospitala-akutsjukvarden-i-sverige-har-stora-utmaningar/ Lewandowski K, Metz J, Deutschmann C, Preiss H, Kuhlen R, Artigas A, et al. Incidence, severity, and mortality of acute respiratory failure in Berlin, Germany. Am J Respir Crit Care Med. 1995 Apr 1;151(4):1121–5. Luce JM. Acute lung injury and the acute respiratory distress syndrome. Crit Care Med. 1998 Feb;26(2):369–76. Suchyta MR, Clemmer TP, Orme JF, Morris AH, Elliott CG. Increased Survival of ARDS Patients with Severe Hypoxemia (ECMO Criteria). Chest. 1991 Apr 1;99(4):951–5. Hill JD, O’Brien TG, Murray JJ, Dontigny L, Bramson ML, Osborn JJ, et al. Prolonged Extracorporeal Oxygenation for Acute Post-Traumatic Respiratory Failure (Shock-Lung Syndrome). N Engl J Med. 1972 Mar 23;286(12):629–34. Chen CY, Hsu TY, Chen WK, Muo CH, Chen HC, Shih HM. The use of extracorporeal membrane oxygenation in trauma patients. Medicine (Baltimore). 2018 Sep 7;97(36):e12223. Fina D, Matteucci M, Jiritano F, Meani P, Kowalewski M, Ballotta A, et al. Extracorporeal membrane oxygenation without systemic anticoagulation: a case-series in challenging conditions. J Thorac Dis. 2020 May;12(5):2113–9. Lavoie A, Moore L, LeSage N, Liberman M, Sampalis JS. The New Injury Severity Score: A More Accurate Predictor of In-Hospital Mortality than the Injury Severity Score. J Trauma Acute Care Surg. 2004 Jun;56(6):1312–20. Kuo SCH, Kuo PJ, Chen YC, Chien PC, Hsieh HY, Hsieh CH. Comparison of the new Exponential Injury Severity Score with the Injury Severity Score and the New Injury Severity Score in trauma patients: A cross-sectional study. PLOS ONE. 2017 Nov 9;12(11):e0187871. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, et al: Acute respiratory distress syndrome: The Berlin definition. Journal of the American Medical Association 307:2526–2533, 2012. doi: 10.1001/jama.2012.5669 Palmer CS, Gabbe BJ, Cameron PA. Defining major trauma using the 2008 Abbreviated Injury Scale. Injury. 2016 Jan;47(1):109–15. Burn Triage and Treatment - Thermal Injuries - CHEMM [Internet]. [cited 2022 Feb 24]. Available from: https://chemm.hhs.gov/burns.htm Registry Dashboard | ECMO | Extracorporeal Membrane Oxygenation [Internet]. [cited 2024 May 23]. Available from: https://www.elso.org/Registry/ELSOLiveRegistryDashboard.aspx Wang C, Zhang L, Qin T, Xi Z, Sun L, Wu H, et al. Extracorporeal membrane oxygenation in trauma patients: a systematic review. World J Emerg Surg. 2020 Sep 11;15(1):51. Bedeir K, Seethala R, Kelly E. Extracorporeal life support in trauma: Worth the risks? A systematic review of published series. J Trauma Acute Care Surg. 2017 Feb;82(2):400–6. Ghorbani P. Review and prediction of trauma mortality [Internet]. Inst för klinisk vetenskap, intervention och teknik / Dept of Clinical Science, Intervention and Technology; 2018 [cited 2022 May 26]. Available from: http://openarchive.ki.se/xmlui/handle/10616/46450 Falk L, Fletcher-Sandersjöö A, Hultman J, Broman LM. Conversion from Venovenous to Venoarterial Extracorporeal Membrane Oxygenation in Adults. Membranes. 2021 Mar;11(3):188. Fletcher Sandersjöö A, Bartek J, Thelin EP, Eriksson A, Elmi-Terander A, Broman M, et al. Predictors of intracranial hemorrhage in adult patients on extracorporeal membrane oxygenation: an observational cohort study. J Intensive Care. 2017 Dec;5(1):27. Biderman P, Einav S, Fainblut M, Stein M, Singer P, Medalion B. Extracorporeal life support in patients with multiple injuries and severe respiratory failure: a single-center experience? J Trauma Acute Care Surg. 2013 Nov;75(5):907–12. Muellenbach RM, Kredel M, Kunze E, Kranke P, Kuestermann J, Brack A, et al. Prolonged heparin-free extracorporeal membrane oxygenation in multiple injured acute respiratory distress syndrome patients with traumatic brain injury. J Trauma Acute Care Surg. 2012 May;72(5):1444–7. Broman LM, Holzgraefe B, Palmér K, Frenckner B. The Stockholm experience: interhospital transports on extracorporeal membrane oxygenation. Crit Care Lond Engl. 2015 Jul 9;19:278. Ericsson A, Frenckner B, Broman LM. Adverse Events during Inter-Hospital Transports on Extracorporeal Membrane Oxygenation. Prehospital Emerg Care Off J Natl Assoc EMS Physicians Natl Assoc State EMS Dir. 2017 Aug;21(4):448–55. Fletcher-Sandersjöö A, Frenckner B, Broman M. A Single-Center Experience of 900 Interhospital Transports on Extracorporeal Membrane Oxygenation. Ann Thorac Surg. 2019 Jan 1;107(1):119–27. Tables Tables 1-6 are available in the Supplementary Files section. Additional Declarations Competing interest reported. LMB is a member of the Medical Advisory Boards of Eurosets Srl., Medolla, Italy; Xenios Ag., Heilbronn, Germany; and HemoCue AB, Ängelholm, Sweden. Supplementary Files FiguresandTablesTable1.pdf FiguresandTablesTable2.pdf FiguresandTablesTable3.pdf FiguresandTablesTable4.pdf FiguresandTablesTable5.pdf FiguresandTablesTable6.pdf Cite Share Download PDF Status: Published Journal Publication published 27 Jan, 2025 Read the published version in European Journal of Trauma and Emergency Surgery → Version 1 posted Editorial decision: Revision requested 27 Jun, 2024 Reviews received at journal 24 Jun, 2024 Reviews received at journal 22 Jun, 2024 Reviews received at journal 30 May, 2024 Reviewers agreed at journal 28 May, 2024 Reviewers agreed at journal 28 May, 2024 Reviewers agreed at journal 26 May, 2024 Reviewers invited by journal 26 May, 2024 Editor assigned by journal 26 May, 2024 Submission checks completed at journal 25 May, 2024 First submitted to journal 24 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Ahlqvist","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA60lEQVRIie3RsarCMBTG8SOBdCm4ni76BBciQhF8mYSCTsJ9AAkVoU7qKvgUvkGlUBfBNaBDoSCOncRBLjfWxSnETTD//ccXcgBcrs+MAgdoAZIYgFkJUpMuYKMmaEd0Iq4JWJCf2SEvirEcLteTydH/lRK8eXkxkXAfeYzn2Wh12k77PssQ/F3YM5I0oshpOoqVSIIVSxFwQI2/EB5KTf7ksP0k0oIovSISwpkmWDHyIKQwkzJEscg6GyWmvYplQeLn1CT0w8Q5uF1lu6WireJ32Wx6CamM5rX6JnqC2tzzhejeWHG5XK5v6B/pzUgzVo2QrwAAAABJRU5ErkJggg==","orcid":"","institution":"Karolinska University Hospital","correspondingAuthor":true,"prefix":"","firstName":"Mathias","middleName":"","lastName":"Ahlqvist","suffix":""},{"id":311082082,"identity":"98ab7d1b-92f7-4fdf-8d37-178df98e432d","order_by":1,"name":"Pär Forsman","email":"","orcid":"","institution":"Karolinska University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Pär","middleName":"","lastName":"Forsman","suffix":""},{"id":311082083,"identity":"2ba58555-af66-41a6-aaf2-b1ef359b8a0b","order_by":2,"name":"Pål Morberg","email":"","orcid":"","institution":"Sykehuset i Vestfold","correspondingAuthor":false,"prefix":"","firstName":"Pål","middleName":"","lastName":"Morberg","suffix":""},{"id":311082084,"identity":"fc8dc2fd-44f1-4758-937a-91f36af56c65","order_by":3,"name":"Magnus Larsson","email":"","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"Magnus","middleName":"","lastName":"Larsson","suffix":""},{"id":311082085,"identity":"a22d8717-fdd7-459c-a210-a0333b61bcfe","order_by":4,"name":"Lars Mikael Broman","email":"","orcid":"","institution":"Karolinska 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LMB is a member of the Medical Advisory Boards of Eurosets Srl., Medolla, Italy; Xenios Ag., Heilbronn, Germany; and HemoCue AB, Ängelholm, Sweden.","formattedTitle":"Extracorporeal membrane oxygenation in Trauma: A single-center review","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eGlobally, trauma is a leading cause of death in young adults [1]. The common causes of immediate death are traumatic brain injury, high spinal lesions, and massive bleeding with refractory hemorrhagic shock. Death within the first few hours is often related to hemorrhage and coagulopathies [2]. In the treatment of trauma, time is thus critical. Overall, the \u003cem\u003etime-to-trauma center\u003c/em\u003e is paramount to good survival outcomes [3]. The majority of trauma is blunt (90%), while penetrating injuries account for the remaining 10%. Most cases of severe multi-trauma, as defined by the American College of Surgeons Committee of Trauma Triage Criteria, present at major trauma centers [4]. Of these cases, traumatic thoracic injuries are reported in up to 50% of cases, and consists of primary injuries, such as major hemorrhage, contusions, acute lung injury (ALI), as well as secondary complications such as pneumonia, or acute respiratory distress syndrome (ARDS) [5\u0026ndash;8]. To quantify the severity of trauma it is common practice to use the injury severity score (ISS) and its later adaptation, the new injury severity score (NISS), which shows a good correlation with survival in trauma patients (9). The correlation between ISS and mortality is not strictly linear, as Copes et al. demonstrated, and hence the scores are usually divided into intervals [10]. Generally, an ISS of 1\u0026ndash;8 is considered minor trauma, 9\u0026ndash;15 moderate, 16\u0026ndash;24 severe, and \u0026ge;\u0026thinsp;25 very severe trauma, with a corresponding increase in risk of mortality [11].\u003c/p\u003e \u003cp\u003eModern intensive care has improved in recent decades, and overall survival of patients has increased [12,13]. However, a small percentage of trauma patients do not respond to resuscitative care and may die both from acute and chronic complications, such as shock, hypoxia, hypercapnia, and acidosis. These patients may benefit from extracorporeal life support, i.e., extracorporeal membrane oxygenation (ECMO) [14\u0026ndash;16]. The use of ECMO in the trauma population has been described since the 1970s [17]. Yet there is no consensus, and treatment remains controversial. This is mainly because of the limited published research on ECMO in trauma, with mostly small cohort studies and a handful of reviews, as well as the limited availability of ECMO [18]. ECMO indications also vary, from acute hemorrhagic shock and severe pulmonary contusions to secondary ALI or ARDS. Recent ECMO advances, such as development of circuits, coating materials, and a broader understanding of the physiology in the trauma patient, have increased its use as an advanced critical care treatment modality [19].\u003c/p\u003e \u003cp\u003eThe primary aim of this study was to describe ECMO in trauma patients regarding 30-day survival at our center. Secondary aims were to describe indications, patient demographics, time to ECMO support, complications during treatment, and to compare outcome in terms of survival to the trauma severity score models.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eWe performed a single center retrospective cohort analysis of both pediatric and adult trauma patients receiving ECMO at our center between 1997 and 2019. Ethical approval was obtained from the Swedish Ethical Review Authority (EPM DNR 2019\u0026ndash;03808).\u003c/p\u003e \u003cp\u003eThe data was collected from a Level 1 trauma center with a high volume of both trauma and ECMO patients. The center has more than 25 years of experience treating patients with pulmonary and/or cardiac pathologies across all age groups. Furthermore, the clinic has a mobile ECMO team that usually cannulates the patient at a referring hospital and then transports them back to the ECMO center.\u003c/p\u003e \u003cp\u003eInclusion criteria were patients who were admitted to the hospital under the trauma team activation (TTA) and who were offered ECMO, as well as trauma patients who were accepted from other hospitals. Patients who were deemed dead-on-arrival or did not survive in the trauma room were excluded. Data was collected from the hospital\u0026rsquo;s trauma registry and the department\u0026rsquo;s ECMO intensive care unit (ICU) quality database. Data was cross-checked and verified against the department's patient medical charts, which are linked to the National Population Register, allowing for long-term follow-up of mortality. After the completion of the dataset, data was anonymized. Analysis was performed on aggregates. Patients were subdivided into three groups: early cannulation (\u0026lt;\u0026thinsp;12 h from the time of trauma), intermediate cannulation (12\u0026ndash;24 h), and late cannulation (\u0026gt;\u0026thinsp;24 h). Patient demographics, diagnoses, ECMO mode (veno-arterial (VA) and veno-venous (VV) ECMO), type of trauma, and trauma scores (ISS and NISS) were also included in the data [20\u0026ndash;21]. Acute lung injury and ARDS were defined according to Bernard et al. as \u0026ldquo;acute onset of diffuse bilateral pulmonary infiltrates by chest radiograph; a PaO2/FiO2\u0026thinsp;\u0026le;\u0026thinsp;300 for ALI and \u0026le;\u0026thinsp;200 for ARDS; and a pulmonary artery wedge pressure\u0026thinsp;\u0026le;\u0026thinsp;18 or no clinical evidence of left atrial hypertension\u0026rdquo; [22]. Additionally, baseline characteristics, before (pre) and after (post) cannulation, physiologic data, complications, and outcomes were recorded. Survival was categorized by decannulation alive from ECMO and survival to hospital discharge. Survival in the Swedish National Trauma Registry was based on a 30-day survival. Injury coding in the national registry was performed manually according to the Abbreviated Injury Scale (AIS) code manual based on injuries at the time of presentation to hospital. Using the AIS, the ISS and NISS were calculated [23]. The scores were calculated after patient demise or hospital discharge. Furthermore, from the ISS and NISS, patients were divided into 5 groups of trauma-severity according to Copes et. al. [10].\u003c/p\u003e \u003cp\u003e \u003cem\u003eStatistics.\u003c/em\u003e Data is presented as numbers (n) and percentages (%). Normality was tested by Shapiro-Wilk\u0026rsquo;s test. Normally distributed data is presented as mean (\u0026plusmn;\u0026thinsp;SD). Non-parametric data is presented as median (IQR 25%-75%). Statistical analysis was performed using Mann Whitney U test. For categorical variables Fisher\u0026rsquo;s exact test was used. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. All statistical analyses were performed using RStudio 2021.09.0.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003ePre-ECMO: demographics\u003c/h2\u003e \u003cp\u003eDuring the study period 53 trauma patients received ECMO support. Majority of the patients were males (n\u0026thinsp;=\u0026thinsp;45, 85%). The most common cause of trauma was traffic accidents, followed by falls, and burns (Table\u0026nbsp;1, Fig.\u0026nbsp;1). Over half of the patients (72%, n\u0026thinsp;=\u0026thinsp;38), were classified as multi-trauma., followed by severe burns (9%, i.e. burn severity\u0026thinsp;\u0026gt;\u0026thinsp;18%), and penetrating trauma (7.5%, n\u0026thinsp;=\u0026thinsp;4) (Table\u0026nbsp;1). In three cases head injuries were the only presenting trauma; however, these patients also suffered from cardiac arrest (n\u0026thinsp;=\u0026thinsp;2), or sepsis (n\u0026thinsp;=\u0026thinsp;1) and were placed on ECMO due to ARDS, cardiac failure, and cardiopulmonary failure, respectively (Table\u0026nbsp;2). In total 26 patients had either an isolated head injury or a head injury in combination with multi-trauma. The overall ISS was 42 (IQR: 33\u0026ndash;57, range: 19\u0026ndash;75), and NISS 50 (IQR: 34\u0026ndash;57, range: 21\u0026ndash;75). Using the Copes et al. intervals of ISS, most patients had a score either between 25\u0026ndash;40 or 50\u0026ndash;65 (Table\u0026nbsp;3); there was a similar pattern for the NISS interval-scores, however, more patients were classified as being in the two upper intervals, i.e. 50\u0026ndash;65 and 66\u0026ndash;75 (Table\u0026nbsp;4).\u003c/p\u003e \u003c/div\u003e \u003ch2\u003eAt time of cannulation\u003c/h2\u003e \u003cp\u003eThe most common indication for ECMO was combined cardiopulmonary failure. Other indications for ECMO and their respective frequencies are listed in Table\u0026nbsp;5. Fifty-one percent of the patients were cannulated within 24 hours of the trauma, and of these 67% (n\u0026thinsp;=\u0026thinsp;18) were cannulated between 0\u0026ndash;12 hours post trauma (Table\u0026nbsp;1). Sixteen patients (30%) were cannulated at a referring hospital, 15 (28%) were cannulated in hospital in the emergency room (ER), and 22 (42%) in the ICU. Most patients (n\u0026thinsp;=\u0026thinsp;33) were initially treated with VA ECMO, however, of the 20 patients started on VV two were converted to VA ECMO (Table\u0026nbsp;1). The median time from ER arrival to ECMO start was 36.4 h (5.1-101.5). Time to commencement of VA ECMO was 17.3 h (3.2\u0026ndash;65.8), and time to VV ECMO was 60.0 h (34.6-204.4).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eTreatment outcomes\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eGeneral\u003c/h2\u003e \u003cp\u003eSixty percent (n\u0026thinsp;=\u0026thinsp;32) of the patients survived ECMO, and 51% (n\u0026thinsp;=\u0026thinsp;27) survived to hospital discharge. One patient reportedly died after 13 days due to cerebral infarction suspected to be secondary to ECMO-related coagulopathy. All twenty-seven patients that survived to hospital discharge were still alive 30 days post discharge, and 22 patients are still alive today with the shortest follow-up time of 2 years (median long-term follow-up 13.2 years). Twenty-two patients were cannulated in the ICU, 15 in the ER, and 16 at a referring hospital, with a survival rate of 50%, 27%, and 69%, respectively. There was no difference in 30-day survival over the study period (Fig.\u0026nbsp;1).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eInjury type\u003c/h3\u003e\n\u003cp\u003eThirty-day survival was 48% for traffic accidents, 56% for falls, and 80% for burns (Fig.\u0026nbsp;2). For those patients where burn severity was quantified (n\u0026thinsp;=\u0026thinsp;2), both were classified as severe burns (\u0026gt;\u0026thinsp;40% of body surface area) [24]. The patients were also stratified based on type of injury, as shown in Table\u0026nbsp;1, where 30-day survival was 47% in multi-trauma (n\u0026thinsp;=\u0026thinsp;38), 25% penetrating injuries (n\u0026thinsp;=\u0026thinsp;4), and 33% in isolated head injuries (n\u0026thinsp;=\u0026thinsp;3). However, 58% (n\u0026thinsp;=\u0026thinsp;22) of the multi-trauma patients had a concomitant head injury. Hence, for all patients with a head injury, 30-day survival was 54% (n\u0026thinsp;=\u0026thinsp;14/26). Lastly, there were five confirmed suicide attempts of which three (60%) survived 30 days post discharge.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSurvival outcomes based on ECMO indication\u003c/h2\u003e \u003cp\u003eThe patients who were treated with ECMO due to ALI had the highest 30-day survival rate (80%), followed by ARDS (73%). There was a significant difference between patients initiated on ECMO due to ARDS or ALI compared to patients who received ECMO due to circulatory failure or combined circulatory and pulmonary failure (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patients with combined circulatory and pulmonary failure had the lowest survival outcome, in all six patients representing a survival rate of 27% (Table\u0026nbsp;5).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eCardiac arrest\u003c/h2\u003e \u003cp\u003eIn total, 17 patients experienced cardiac arrest (CA) before or at the time of cannulation. Nine patients arrested outside of the hospital. Of these, eight (47%) had a return of spontaneous circulation (ROSC). Fourteen (82%) patients had ongoing cardiopulmonary resuscitation (CPR) during the cannulation procedure, of which six had CA outside of the hospital. Fifteen of 17 patients were placed on VA ECMO and two on VV ECMO. One VA and one VV patient survived. Extracorporeal cardiopulmonary resuscitation (ECPR) was used in five cases with only one surviving 30 days post discharge.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eComplications to trauma:\u003c/h2\u003e \u003cp\u003eOverall, 77% (n\u0026thinsp;=\u0026thinsp;41) of the patients suffered some form of complication, and 60% experienced two or more complications in addition to the trauma \u003cem\u003eper se\u003c/em\u003e. The most common complication was severe neurological disability, followed by sepsis and hemorrhagic shock. The highest morbidity was associated with severe neurological disabilities, whereas sepsis showed the highest 30-day survival (55%). Complications and associated survival rates are listed in Table\u0026nbsp;6.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSurvival outcomes and trauma scoring\u003c/h2\u003e \u003cp\u003eA scatter plot of NISS and ISS vs. mortality within the first 30 days showed a correlation of higher mortality in patients with higher NISS (Fig.\u0026nbsp;3). The ISS score in survivors after 30 days was similar to the deceased (36 IQR:25\u0026ndash;51 vs. 50 IQR:34\u0026ndash;64, p\u0026thinsp;=\u0026thinsp;0.052) (Table\u0026nbsp;1). This relationship was repeated for NISS. Likewise, no difference was observed concerning age or time from trauma to start of ECMO. Patients supported with VA ECMO had a 30-day survival of 34% compared to 76% in the VV group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.005). The seventeen patients cannulated at a referring hospital and then transported to our unit on ECMO showed a survival rate of 69% compared to 57% in those cannulated in-house (p\u0026thinsp;=\u0026thinsp;0.14) (Table\u0026nbsp;1). Concerning complications, massive hemorrhage as a presenting symptom was associated with poor outcome (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Five out of 20 patients with reported bleeding survived. Overall, 26 patients died before or within 30 days of discharge (causes of death, see Fig.\u0026nbsp;4).\u003c/p\u003e \u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this retrospective analysis we present data on 30-day survival in 53 patients treated with ECMO at a Level 1 trauma center. Our data shows significantly higher survival patients treated with VV than with VA ECMO. There was also a significant difference in survival based on the indication for ECMO support, and no difference was observed among patients cannulated at a referring hospital and then transferred to our hospital compared to those cannulated in-house. Furthermore, we found no difference in survival outcomes throughout the study period. According to the ELSO Registry, overall survival for adult ECMO patients in North America and Europe over the last 5 years is 53% [25]. This is comparable to our results of 51%, and results previously reported by others [26\u0026ndash;27]. Hence, our results provide further evidence that ECMO can be used successfully to support patients with very severe trauma.\u003c/p\u003e \u003cp\u003eMajor trauma is the primary cause of death among young adults. The use of ECMO in trauma, while still controversial, has become more prevalent over the past decades. However, most reports are case studies or retrospective analyses with a limited number of patients, usually less than 20 subjects [26]. With the increased interest in ECMO for trauma there is a need for clearer indications to identify the patients most likely to benefit from this support.\u003c/p\u003e \u003cp\u003eTo quantify the severity of trauma in this patient population we chose the widely used ISS and NISS for easy comparison to previous studies. The mean NISS and ISS assessed in this study were 46 and 44, respectively, thus representing a very high risk of mortality as shown by Copes et al., and Ghorbani [10,28]. Overall, 41% of the patients had an ISS greater than 50, which otherwise is associated with close to 100% mortality rate [10]. Even though ECMO is not a typical supportive modality in the trauma patient, the results showed more than half of the patients were still alive at follow-up. Furthermore, we divided both the ISS and NISS into intervals according to Copes et al. showing that there was similar distribution with a slight tendency towards the higher bins within the VA group, but with a higher proportion 30-day survival for the patients on VV ECMO (Table\u0026nbsp;3\u0026ndash;4). The cause of higher mortality in the VA group might be partially explained by the fact that most patients with cardiac arrest and ongoing CPR, a subgroup with a very high mortality rate, were placed on VA ECMO.\u003c/p\u003e \u003cp\u003eAlmost two thirds of the patients were placed on VA ECMO in contrast to earlier studies where pure respiratory support was more common due to ALI/ARDS [26,27]. The ELSO Registry reported an overall survival rate of 43% for all VA ECMO patients, and 30% for patients treated with extracorporeal cardiopulmonary resuscitation [25]. Previous studies on the use of VV ECMO in the trauma population show a survival range of to 56\u0026ndash;89% compared to 42\u0026ndash;63% for VA ECMO [26]. This was similar to our findings of 75% 30-day survival in the VV ECMO group, and 36% for VA ECMO. This difference may be explained by patient selection, center preference, and experience. Although the center in this study is primarily a \u0026ldquo;respiratory\u0026rdquo; ECMO center, 55\u0026ndash;60% of normal cases are placed on VA ECMO and approximately 20% of VV ECMO patients are converted to VA ECMO [29]. Part of the difference in mortality may be explained by the fact that patients who experienced CA were offered VA ECMO. However, after the exclusion of the patients with CA, survival from VA was 61%, i.e. patients on VV ECMO generally had a higher survival (75%). Taken together, this may reflect that trauma patients who present with lung problems, and who are then placed on VV ECMO are more likely to benefit from ECMO support than the VA patients experiencing circulatory or combined circulatory and pulmonary problems.\u003c/p\u003e \u003cp\u003eECMO support increases the risk of bleeding complications and subsequently the risk of cerebral hemorrhage [30]. Hence, most clinicians may feel apprehensive to offer ECMO to trauma patients with head injuries. In this study, most of the patients were multi-trauma, and nearly half presented head injuries. Three patients were categorized as isolated head injuries, which \u003cem\u003eby default\u003c/em\u003e, is a relative contraindication for ECMO. Despite this, one of these patients survived. Of the 26 patients with head trauma, 54% survived 30 days after discharge, a survival rate, similar to the average survival rate for the study population at large (51%). Previous studies have shown benefits in patients with traumatic brain injury (TBI), both from VV and VA ECMO [31,32]. Considering the patients with TBI in both this study and previous studies had an outcome comparable to the typical trauma patient supported on ECMO, the risk-benefit of ECMO use in patients with TBI should be re-evaluated.\u003c/p\u003e \u003cp\u003eAnother area of limited knowledge is the outcome of trauma patients transported on ECMO. We observed no difference in mortality between those patients cannulated and then transported on ECMO compared to those who were cannulated in house. The mobile ECMO team in this study has ample experience including both in-hospital cannulations and \u0026gt;\u0026thinsp;1300 ECMO transports and has only recorded three deaths during transport (n\u0026thinsp;=\u0026thinsp;1373), of which one was a trauma patient [33\u0026ndash;35]. The analysis showed that cannulations at referring hospitals were generally performed at a later stage (\u0026gt;\u0026thinsp;12 hours post trauma), and the patients still alive had been stabilized by local intensive care for several hours and thus more stable than the patients brought directly to our university hospital from the trauma site. This finding may be subject to selection bias influenced by more strict selection criteria where the time factor and prognosis would strongly impact a decision to dispatch the mobile ECMO team. Nonetheless, the high survival rate (69%) suggests that with strict selection criteria a mobile ECMO team that transports patients to a larger ECMO center may be a life-saving strategy for patients suffering from severe trauma.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eLimitations of this work include the sample size, which was relatively low from a general perspective but rather high given the targeted ECMO population from a single center. The applicability of findings from a high-volume center may not extend to institutions with less experience, potentially limiting their generalizability. Other limitations may be patient heterogeneity, with respect to age, where we had patients from one to 72 years of age. Further limitations include changes in practice at our center during the study period, and patients recovered from other hospitals may have been subjects of selection bias. The key strengths of this study were the Swedish Civic registration number, which allowed for long-term follow-up of patients, and the local databases for trauma and ECMO support.\u003c/p\u003e \u003c/div\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThis single-center retrospective study indicated that ECMO support in patients with severe to very severe trauma may benefit from ECMO in terms of survival. We also find support favoring out-reach services by a mobile ECMO team to cannulate and transport the patient to a high-volume ECMO/trauma center. Furthermore, we review the evidence of whether traumatic brain injuries should constitute a relative contraindication for ECMO and suggest further studies to assess whether this patient group may, in fact, benefit from ECMO. Further multicenter studies for larger patient numbers are needed to assess the benefits of ECMO in the trauma setting.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eConflicts of interest\u003c/h2\u003e \u003cp\u003eNo conflicts of interest reported for any of the authors\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eDisclosures\u003c/strong\u003e \u003cp\u003e LMB is a member of the Medical Advisory Boards of Eurosets Srl., Medolla, Italy; Xenios Ag., Heilbronn, Germany; and HemoCue AB, \u0026Auml;ngelholm, Sweden.\u003c/p\u003e \u003ch2\u003eEthical approval\u003c/h2\u003e \u003cp\u003ewas obtained from the Swedish Ethical Review Authority (EPM DNR 2019\u0026ndash;03808).\u003c/p\u003e \u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cp\u003eLMB is a member of the Medical Advisory Boards of Eurosets Srl., Medolla, Italy; Xenios Ag., Heilbronn, Germany; and HemoCue AB, \u0026Auml;ngelholm, Sweden.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funding was received for conducting this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthor contributionSA, ML, PM and LMB designed the concept. SA, ML, PM and PF collected the data. MA and SA analyzed the data. MA drafted the manuscript. PF, LMB and SA revised the manuscript for important intellectual content. Approval for submission: all authors.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e \u003cp\u003eThis retrospective study was preregistered in the Database for Clinical Research at Karolinska University Hospital, Stockholm, Sweden, DNR K 2021\u0026ndash;8410\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eThe global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013 [Internet]. Institute for Health Metrics and Evaluation. 2015 [cited 2021 Oct 7]. Available from: http://www.healthdata.org/research-article/global-burden-injury-incidence-mortality-disability-adjusted-life-years-and-time\u003c/li\u003e\n\u003cli\u003eProbst C, Zelle BA, Sittaro NA, Lohse R, Krettek C, Pape HC. Late death after multiple severe trauma: when does it occur and what are the causes? J Trauma. 2009 Apr;66(4):1212\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eAmerican College of Surgeons Committe on Trauma. Advanced Trauma Life Support. 10th ed. American College of Surgeons; 2018.\u003c/li\u003e\n\u003cli\u003eEriksson L, \u0026Ouml;stlund A. Trauma Manual Karolinska [Internet]. Karolinska Universitetssjukhuset Solna; 2013 [cited 2022 Apr 13]. Available from: https://www.karolinska.se/4967e2/globalassets/global/4-gamla-kataloger/traumacentrum/traumamanual_karolinska_20130626.pdf?id=12984\u003c/li\u003e\n\u003cli\u003eStahel PF, Schneider P, Buhr HJ, Kruschewski M. [Emergency management of thoracic trauma]. Orthopade. 2005 Sep 1;34(9):865\u0026ndash;79.\u003c/li\u003e\n\u003cli\u003eHavl\u0026iacute;cek K, Motycka V, Siller J, Cervinka V. Systemic Inflammatory Response Syndrome (SIRS) in Serious Chest Injuries: Is a Pharmacological Blockade Effective? 2005;11(4):6.\u003c/li\u003e\n\u003cli\u003eWaydhas C, Nast-Kolb D. [Chest injury. Part I: Significance--symptoms--diagnostic procedures]. Unfallchirurg. 2006 Sep 1;109(9):777\u0026ndash;84; quiz 785.\u003c/li\u003e\n\u003cli\u003eLewandowski K. Extracorporeal membrane oxygenation for severe acute respiratory failure. Crit Care. 2000 Apr 12;4(3):156.\u003c/li\u003e\n\u003cli\u003eBaker SP, Long WB, Haddon W, Jr, O\u0026rsquo;Neill B. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma Vol 14 No 3 March 1974 P 187-196. 1974;\u003c/li\u003e\n\u003cli\u003eCOPES WS, CHAMPION HR, SACCO WJ, LAWNICK MM, KEAST SL, BAIN LW. The Injury Severity Score Revisited. J Trauma. 1988;28(1):69\u0026ndash;77.\u003c/li\u003e\n\u003cli\u003eVanDerHeyden N, Cox TB. CHAPTER 6 - TRAUMA SCORING. In: Asensio JA, Trunkey DD, editors. Current Therapy of Trauma and Surgical Critical Care [Internet]. Philadelphia: Mosby; 2008 [cited 2021 Nov 7]. p. 26\u0026ndash;32. Available from: https://www.sciencedirect.com/science/article/pii/B9780323044189500102\u003c/li\u003e\n\u003cli\u003eZimmerman JE, Kramer AA, Knaus WA. Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012. Crit Care. 2013;17(2):R81.\u003c/li\u003e\n\u003cli\u003eHerlitz J, Magnusson C, Hagiwara MA, Lundgren P, Larsson G, Rawshani A, et al. Den prehospitala akutsjukv\u0026aring;rden i Sverige har stora utmaningar [Internet]. L\u0026auml;kartidningen. 2021 [cited 2022 Jun 13]. Available from: https://lakartidningen.se/klinik-och-vetenskap-1/artiklar-1/klinisk-oversikt/2021/11/den-prehospitala-akutsjukvarden-i-sverige-har-stora-utmaningar/\u003c/li\u003e\n\u003cli\u003eLewandowski K, Metz J, Deutschmann C, Preiss H, Kuhlen R, Artigas A, et al. Incidence, severity, and mortality of acute respiratory failure in Berlin, Germany. Am J Respir Crit Care Med. 1995 Apr 1;151(4):1121\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eLuce JM. Acute lung injury and the acute respiratory distress syndrome. Crit Care Med. 1998 Feb;26(2):369\u0026ndash;76.\u003c/li\u003e\n\u003cli\u003eSuchyta MR, Clemmer TP, Orme JF, Morris AH, Elliott CG. Increased Survival of ARDS Patients with Severe Hypoxemia (ECMO Criteria). Chest. 1991 Apr 1;99(4):951\u0026ndash;5.\u003c/li\u003e\n\u003cli\u003eHill JD, O\u0026rsquo;Brien TG, Murray JJ, Dontigny L, Bramson ML, Osborn JJ, et al. Prolonged Extracorporeal Oxygenation for Acute Post-Traumatic Respiratory Failure (Shock-Lung Syndrome). N Engl J Med. 1972 Mar 23;286(12):629\u0026ndash;34.\u003c/li\u003e\n\u003cli\u003eChen CY, Hsu TY, Chen WK, Muo CH, Chen HC, Shih HM. The use of extracorporeal membrane oxygenation in trauma patients. Medicine (Baltimore). 2018 Sep 7;97(36):e12223.\u003c/li\u003e\n\u003cli\u003eFina D, Matteucci M, Jiritano F, Meani P, Kowalewski M, Ballotta A, et al. Extracorporeal membrane oxygenation without systemic anticoagulation: a case-series in challenging conditions. J Thorac Dis. 2020 May;12(5):2113\u0026ndash;9.\u003c/li\u003e\n\u003cli\u003eLavoie A, Moore L, LeSage N, Liberman M, Sampalis JS. The New Injury Severity Score: A More Accurate Predictor of In-Hospital Mortality than the Injury Severity Score. J Trauma Acute Care Surg. 2004 Jun;56(6):1312\u0026ndash;20.\u003c/li\u003e\n\u003cli\u003eKuo SCH, Kuo PJ, Chen YC, Chien PC, Hsieh HY, Hsieh CH. Comparison of the new Exponential Injury Severity Score with the Injury Severity Score and the New Injury Severity Score in trauma patients: A cross-sectional study. PLOS ONE. 2017 Nov 9;12(11):e0187871.\u003c/li\u003e\n\u003cli\u003eARDS Definition Task Force, Ranieri VM, Rubenfeld GD, et al: Acute respiratory distress syndrome: The Berlin definition. Journal of the American Medical Association 307:2526\u0026ndash;2533, 2012. doi: 10.1001/jama.2012.5669\u003c/li\u003e\n\u003cli\u003ePalmer CS, Gabbe BJ, Cameron PA. Defining major trauma using the 2008 Abbreviated Injury Scale. Injury. 2016 Jan;47(1):109\u0026ndash;15.\u003c/li\u003e\n\u003cli\u003eBurn Triage and Treatment - Thermal Injuries - CHEMM [Internet]. [cited 2022 Feb 24]. Available from: https://chemm.hhs.gov/burns.htm\u003c/li\u003e\n\u003cli\u003eRegistry Dashboard | ECMO | Extracorporeal Membrane Oxygenation [Internet]. [cited 2024 May 23]. Available from: https://www.elso.org/Registry/ELSOLiveRegistryDashboard.aspx\u003c/li\u003e\n\u003cli\u003eWang C, Zhang L, Qin T, Xi Z, Sun L, Wu H, et al. Extracorporeal membrane oxygenation in trauma patients: a systematic review. World J Emerg Surg. 2020 Sep 11;15(1):51.\u003c/li\u003e\n\u003cli\u003eBedeir K, Seethala R, Kelly E. Extracorporeal life support in trauma: Worth the risks? A systematic review of published series. J Trauma Acute Care Surg. 2017 Feb;82(2):400\u0026ndash;6.\u003c/li\u003e\n\u003cli\u003eGhorbani P. Review and prediction of trauma mortality [Internet]. Inst f\u0026ouml;r klinisk vetenskap, intervention och teknik / Dept of Clinical Science, Intervention and Technology; 2018 [cited 2022 May 26]. Available from: http://openarchive.ki.se/xmlui/handle/10616/46450\u003c/li\u003e\n\u003cli\u003eFalk L, Fletcher-Sandersj\u0026ouml;\u0026ouml; A, Hultman J, Broman LM. Conversion from Venovenous to Venoarterial Extracorporeal Membrane Oxygenation in Adults. Membranes. 2021 Mar;11(3):188.\u003c/li\u003e\n\u003cli\u003eFletcher Sandersj\u0026ouml;\u0026ouml; A, Bartek J, Thelin EP, Eriksson A, Elmi-Terander A, Broman M, et al. Predictors of intracranial hemorrhage in adult patients on extracorporeal membrane oxygenation: an observational cohort study. J Intensive Care. 2017 Dec;5(1):27.\u003c/li\u003e\n\u003cli\u003eBiderman P, Einav S, Fainblut M, Stein M, Singer P, Medalion B. Extracorporeal life support in patients with multiple injuries and severe respiratory failure: a single-center experience? J Trauma Acute Care Surg. 2013 Nov;75(5):907\u0026ndash;12.\u003c/li\u003e\n\u003cli\u003eMuellenbach RM, Kredel M, Kunze E, Kranke P, Kuestermann J, Brack A, et al. Prolonged heparin-free extracorporeal membrane oxygenation in multiple injured acute respiratory distress syndrome patients with traumatic brain injury. J Trauma Acute Care Surg. 2012 May;72(5):1444\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eBroman LM, Holzgraefe B, Palm\u0026eacute;r K, Frenckner B. The Stockholm experience: interhospital transports on extracorporeal membrane oxygenation. Crit Care Lond Engl. 2015 Jul 9;19:278.\u003c/li\u003e\n\u003cli\u003eEricsson A, Frenckner B, Broman LM. Adverse Events during Inter-Hospital Transports on Extracorporeal Membrane Oxygenation. Prehospital Emerg Care Off J Natl Assoc EMS Physicians Natl Assoc State EMS Dir. 2017 Aug;21(4):448\u0026ndash;55.\u003c/li\u003e\n\u003cli\u003eFletcher-Sandersj\u0026ouml;\u0026ouml; A, Frenckner B, Broman M. A Single-Center Experience of 900 Interhospital Transports on Extracorporeal Membrane Oxygenation. Ann Thorac Surg. 2019 Jan 1;107(1):119\u0026ndash;27.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1-6 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"ECMO, Extracorporeal Membrane Oxygenation; VA ECMO, veno-arterial ECMO; VV ECMO, veno-venous ECMO; ISS, Injury severity score; NISS, New injury severity score","lastPublishedDoi":"10.21203/rs.3.rs-4473247/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4473247/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eGlobally, trauma is a leading cause of death in young adults. The use of extracorporeal membrane oxygenation (ECMO) in the trauma population remains controversial due to the limited published research. This study aimed to analyze 30-day survival of all the trauma ECMO patients at our center, with respect to injury severity score (ISS), new injury severity score (NISS).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe performed a retrospective analysis of all trauma patients receiving ECMO support at a Level 1 trauma center in Sweden between 1997 and 2019.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 53 trauma patients received ECMO support. Eighty-five percent were male; the median age was 24, with interquartile range (IQR) 17\u0026ndash;44 years. More than 70% were multi-trauma patients. The mean NISS and ISS were 50 (IQR:34\u0026ndash;57) and 42 (IQR:33\u0026ndash;57), respectively. Sixty-two percent were supported on veno-arterial ECMO with a survival benefit for veno-venous ECMO (75% vs. 36%, respectively (p\u0026thinsp;=\u0026thinsp;0.01)). There was no association between severity in terms of trauma-score and survival. Sixteen patients (30%) were cannulated at referring hospitals and transported to our unit on ECMO with a survival of 69%, similar to those cannulated in-house. Sixty percent of patients survived ECMO, and 51% survived to hospital discharge.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThis study indicates that trauma patients benefit from ECMO, independent of severity. Furthermore, our results support ECMO transport as feasible in trauma patients. We recommend larger multi-center studies to determine which trauma patients would have the greatest benefit of ECMO.\u003c/p\u003e","manuscriptTitle":"Extracorporeal membrane oxygenation in Trauma: A single-center review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-11 18:24:34","doi":"10.21203/rs.3.rs-4473247/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-06-27T13:22:16+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-24T20:30:06+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-22T16:47:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-05-30T16:14:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233892821629478621721979794352050216677","date":"2024-05-28T14:07:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"224646523556010613710540730495735396533","date":"2024-05-28T10:18:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"109360048494122298603131308637279493921","date":"2024-05-26T10:27:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-26T09:56:29+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-26T07:02:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-25T12:32:27+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Trauma and Emergency Surgery","date":"2024-05-24T15:03:34+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-trauma-and-emergency-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejot","sideBox":"Learn more about [European Journal of Trauma and Emergency Surgery](http://link.springer.com/journal/68)","snPcode":"68","submissionUrl":"https://submission.nature.com/new-submission/68/3","title":"European Journal of Trauma and Emergency Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"cdef25b8-1494-47d3-a86b-68efe570a932","owner":[],"postedDate":"June 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-03T16:00:24+00:00","versionOfRecord":{"articleIdentity":"rs-4473247","link":"https://doi.org/10.1007/s00068-024-02734-1","journal":{"identity":"european-journal-of-trauma-and-emergency-surgery","isVorOnly":false,"title":"European Journal of Trauma and Emergency Surgery"},"publishedOn":"2025-01-27 15:57:10","publishedOnDateReadable":"January 27th, 2025"},"versionCreatedAt":"2024-06-11 18:24:34","video":"","vorDoi":"10.1007/s00068-024-02734-1","vorDoiUrl":"https://doi.org/10.1007/s00068-024-02734-1","workflowStages":[]},"version":"v1","identity":"rs-4473247","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4473247","identity":"rs-4473247","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}