The Need for Thoracic Surgery in Adult Patients Receiving Extracorporeal Membrane Oxygenation: A 16-year Experience

Objectives:Patients on extracorporeal membrane
oxygenation (ECMO) are at risk from thoracic complications such as
bleeding or pneumothorax, which may subsequently necessitate thoracic
surgical intervention. We aimed to: 1) analyse the indication and nature
of thoracic surgical intervention in these patients and 2) analyse the
effect of a change in the ECMO circuit from roller pump to centrifugal
pump on transfusion requirements pre and post thoracotomy.

METHODS:

We
retrospectively reviewed a prospectively collected database of 569
adults put on ECMO between 1995 and 2011. Patients undergoing
thoracotomy were identified and outcomes were statistically analysed.

RESULTS:

Forty
thoracotomies were performed in 18 patients [61% male, median age 31
(14-56) years, one bilateral procedure]. The indications for ECMO
included: pneumonia 14/18 (78%), trauma 2/18 (11%) and other 2/18 (11%).
Median duration on ECMO was 13 (1-257) days and the time to initial
thoracotomy was 10 (1-183) days. The indications for thoracotomy were:
excessive bleeding post chest drain insertion (11/19, 58%), uncontrolled
air leak (9/19, 47%) and pleural effusion (4/19, 21%). The primary
operations were 12/19 (63%) evacuation of haemothorax, 3/19 (16%) lung
repair, 2/19 (11%) diagnostic lung biopsy and 2/19 (11%) other. Ten
patients needed a further 21 thoracotomies (3 lobectomies); average 2
(1-5) per patient. In total, 30/40 (75%) thoracotomies were performed
for bleeding complication. The change from roller to centrifugal pump
trended towards a reduction in mean transfusion requirements in these
patients following thoracotomy (11.5 versus 4 units, p=0.14). The
in-hospital mortality was 7/18 (39%) patients. There were no
statistically significant predictors of poor outcome.

CONCLUSIONS:

The
need for thoracotomy whilst on ECMO is 3.2% in this large series.
Intervention may be complicated, thus, either ECMO specialists should
have thoracic training or thoracic surgeons should be on-site. Potential
mortality is high and, although not statistically significant, a
difference in transfusion requirements was observed following the change
of circuit.