Skip to main content

ECMO in adult patients with severe trauma: a systematic review and meta-analysis



Severe trauma can result in cardiorespiratory failure, and when conventional treatment is ineffective, extracorporeal membrane oxygenation (ECMO) can serve as an adjunctive therapy. However, the indications for ECMO in trauma cases are uncertain and clinical outcomes are variable. This study sought to describe the prognosis of adult trauma patients requiring ECMO, aiming to inform clinical decision-making and future research.


A comprehensive search was conducted on Pubmed, Embase, Cochrane, and Scopus databases until March 13, 2023, encompassing relevant studies involving over 5 trauma patients (aged ≥ 16 years) requiring ECMO support. The primary outcome measure was survival until discharge, with secondary measures including length of stay in the ICU and hospital, ECMO duration, and complications during ECMO. Random-effects meta-analyses were conducted to analyze these outcomes. The study quality was assessed using the Joanna Briggs Institute checklist, while the certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach.


The meta-analysis comprised 36 observational studies encompassing 1822 patients. The pooled survival rate was 65.9% (95% CI 61.3–70.5%). Specifically, studies focusing on traumatic brain injury (TBI) (16 studies, 383 patients) reported a survival rate of 66.1% (95% CI 55.4–76.2%), while studies non-TBI (15 studies, 262 patients) reported a survival rate of 68.1% (95% CI 56.9–78.5%). No significant difference was observed between these two survival comparisons (p = 0.623). Notably, studies utilizing venoarterial extracorporeal membrane oxygenation (VA ECMO) (15 studies, 39.0%, 95% CI 23.3–55.6%) demonstrated significantly lower survival rates than those using venovenous extracorporeal membrane oxygenation (VV ECMO) (23 studies, 72.3%, 95% CI 63.2–80.7%, p < 0.001). The graded assessment of evidence provided a high degree of certainty regarding the pooled survival.


ECMO is now considered beneficial for severely traumatized patients, improving prognosis and serving as a valuable tool in managing trauma-related severe cardiorespiratory failure, haemorrhagic shock, and cardiac arrest.


Severe trauma is a significant global health issue, particularly for young adults, with high mortality rates [1]. Early post-traumatic deaths are commonly caused by cardiac arrest, haemorrhagic shock, and traumatic brain injury, while multi-organ failure, including cardiopulmonary failure and acute respiratory distress syndrome (ARDS), is often responsible for late deaths [2,3,4]. Extracorporeal membrane oxygenation (ECMO) provides effective support for respiratory and circulatory function by oxygenating venous blood outside the body and returning it through a pump. ECMO assumes the role of an support when conventional therapeutic interventions fall short in addressing circulatory and respiratory failure. Venovenous (VV) ECMO and venoarterial (VA) ECMO are two perfusion methods used, with VV ECMO providing respiratory support and VA ECMO providing both respiratory and circulatory support [5,6,7]. While ECMO use continues to expand in non-trauma scenarios, its application in trauma patients remains controversial in many centers [8]. Factors such as limited resources, anticoagulation during perfusion, haemorrhage, thrombosis, limb ischaemia, traumatic brain injury, and limited technical expertise contribute to the restricted usage of ECMO in trauma patients [9].

In recent years, the use of ECMO in trauma has increased year on year as continuous improvements in ECMO technology [10], such as the implementation of new anticoagulation strategies, have emerged as a proactive approach to reducing complications in ECMO patients [11,12,13]. While there are no formal guidelines, clinical consensus acknowledges the potential benefits of ECMO as a life-saving support for severely traumatized patients. However, there have been limited studies on this topic, mostly retrospective, leading to varying reports on the scope of application and survival rates [14,15,16]. In light of the diverse nature of ECMO’s application, resource implications, and reported outcomes in severe trauma management, we conducted a systematic review of the literature to provide guidance for clinical decisions and future research endeavors.


This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines [17] and was prospectively registered in PROSPERO (CRD 42023406004).

Search strategy

We conducted a thorough search of the Pubmed, Embase, Cochrane, and Scopus databases until 13 March 2023. Our search utilized various medical subject terms, keywords, and their variants, such as 'Extracorporeal Membrane Oxygenation', "Extracorporeal Life Support", "ECMO Treatment", "Injuries and Wounds", and "Trauma" (Additional file 1). Relevant articles were identified through assessing both the included studies and their references.

Selection criteria

Following the PICOS methodology, we established specific inclusion and exclusion criteria for study selection. Eligibility was limited to studies written in English or English translations. Inclusion Criteria: (1) Studies involving 5 or more trauma patients (≥ 16 years old) receiving ECMO support; (2) Both studies with control groups and those without control groups; (3) Outcome metrics including survival to hospital discharge, ICU and hospital length of stay, duration of ECMO, and complications during ECMO; (4) Study designs including both prospective and retrospective studies. Exclusion Criteria: (1) Studies involving animals or children; (2) Studies focusing on ECMO as a bridge to delayed surgery or its application to burns; (3) Case reports to avoid potential publication bias; (4) Letters, expert opinions, and commentaries; (5) Studies lacking relevant data extraction, particularly ECMO implementation details and outcomes. To avoid duplicate patient data, studies using the Extracorporeal Life Support Organisation (ELSO) registry were not included. Larger studies with overlapping patient data were included in the primary meta-analysis. Two independent reviewers (Y.Z. and N.M.) conducted the initial screening, resolving conflicts through consensus or a third-party reviewer (X.J).

Data collection

Two independent reviewers (Y.Z. and P.W) collected data using a predetermined extraction form, resolving conflicts through consensus or a third-party reviewer (X.J). The collected data included study characteristics (design, duration, publication year, country), patient demographics (number, gender ratio, age), pre-ECMO characteristics (injury severity score [ISS], partial pressure of arterial oxygen versus fraction of inspired oxygen [PaO2/FiO2], Sequential Organ Failure Assessment [SOFA] score, mechanism of injury, presence of traumatic brain injury [TBI] and cardiac arrest [CA]), ECMO characteristics (type, initiation time, duration, anticoagulation strategy), survival (hospitalization, time of death), and relevant clinical outcomes (intensive care unit [ICU] and hospital length of stay [LOS], ECMO complications).

Assessment of risk of bias and certainty of evidence

We utilized the Joanna Briggs Institute (JBI) list of case series and cohort studies (Additional file 2) to evaluate the quality of the included studies. Statistical heterogeneity was assessed through I2 statistics, chi-square tests, and visual examination of forest plots. The certainty of the evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology [18], with the assistance of the online GRADEpro app ( [accessed 16 July 2023]).

Outcomes of interest

The primary outcome assessed in this study was survival to hospital discharge, while secondary outcomes included ICU and hospital length of stay, duration of ECMO, and complications during ECMO.

Statistical analysis

Statistical analysis of the pooled data was performed using STATA 14.0, with conversion of median, interquartile range, or extreme values to means and standard deviations [19]. A random-effects meta-analysis was conducted to account for expected heterogeneity due to diverse mechanisms and manifestations of injury, along with the lack of standardized guidelines for ECMO patient selection and management. Confidence intervals (CIs) at 95% were calculated [20, 21]. Survival outcomes were presented as combined proportions, and persistence outcomes as combined means, both with corresponding 95% CIs.

Subgroup analyses involved geographic location (Asia, Europe, and North America), type of injury (traumatic brain injury or other), and type of ECMO initiation (VV or VA), incorporating continuity correction for studies with zero events. Sensitivity analyses explored sources of heterogeneity for the primary outcome of survival to hospital discharge, and publication bias was assessed using funnel plots and Egger’s test.


Eligible studies and study characteristics

A total of 14,699 records were initially identified, of which 4323 duplicate articles were removed prior to screening. An additional 10,208 studies were excluded after screening titles and abstracts. After assessing the full text, 111 more studies were removed. Eventually, a total of 36 eligible publications [3,4,5, 8,9,10, 14,15,16, 22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48] with 1822 patients were included in this meta-analysis. The PRISMA 2020 flow chart for this study is presented in Fig. 1.

Fig. 1
figure 1

PRISMA 2020 flow diagram for the meta-analysis

All included studies were retrospective and observational, consisting of 2 propensity score-matched studies, 12 single-centre retrospective case series, 6 multicentre regression cohort studies, and 18 single-centre retrospective cohort studies. The combined mean age across 34 studies (1757 patients) was 35.5 years (95% CI 33.6–37.4), with a male proportion of 84.2% (95% CI 82.3–86.1%) reported in 31 studies (1428 patients). Cardiac arrest was observed in 14.4% of patients (95% CI 4.7–27.3%) in 20 studies involving 71 patients. The ISS score was reported in 29 studies comprising 1640 patients with a mean value of 34.9 (95% CI 31.7–38.1). Pre-ECMO PaO2/FiO2 was reported in 16 studies involving 333 patients, showing a value of 58.47 (95% CI 55.13–61.80). Furthermore, 10 studies including 244 patients reported a SOFA score of 10.18 (95% CI 6.87–13.49) (Table 1). The included studies presented different recorded times of ECMO onset, encompassing from injury to ECMO, admission to ECMO, emergency to ECMO, and ARDS onset to ECMO. Additional file 3 provides detailed information on these characteristics.

Table 1 Baseline demographics of studies included for systematic review

Primary outcomes

The pooled survival rate before discharge in trauma patients supported with ECMO was 65.9% (95% CI 61.3–70.5%, Fig. 2), based on data from 36 studies comprising 1822 patients. Sensitivity analyses did not find any significant factors that interfered with the results, indicating stable study findings. The funnel plot showed a roughly symmetrical distribution (Additional file 5: Figure S1), and Egger’s test indicated no evidence of publication bias (p = 0.872).

Fig. 2
figure 2

Proportion of survivors among adult patients with trauma requiring extracorporeal membrane oxygenation

Subgroup analysis

The geographic region did not significantly influence outcomes in trauma patients treated with ECMO (p = 0.991). Survival rates were similar across North American studies (17 studies, 1286 patients), European studies (8 studies, 336 patients), and Asian studies (11 studies, 200 patients), with rates of 65.7% (95% CI 59.5–71.9%), 65.1% (95% CI 52.6–77.5%), and 66.1% (95% CI 58.0–74.2%), respectively.

Among the studies focused on traumatic brain injury (TBI) (16 studies, 383 patients), the survival rate was 66.1% (95% CI 55.4–76.2%). Similarly, studies that did not specifically focus on TBI (15 studies, 262 patients) reported a survival rate of 68.1% (95% CI 56.9–78.5%). There was no significant difference in survival rates between the two groups (p = 0.623).

The use of VA ECMO support (15 studies) was associated with significantly lower survival rates (39.0%, 95% CI 23.3–55.6%) compared to the use of VV ECMO support (23 studies, 72.3%, 95% CI 63.2–80.7%, p < 0.001, Fig. 3). Detailed results of the subgroup analyses are summarized in Table 2.

Fig. 3
figure 3

Proportion of survivors among adult patients with trauma requiring extracorporeal membrane oxygenation stratified by VA or VV

Table 2 Result of subgroup analysis

Secondary outcomes

The pooled ICU LOS was 23.49 days (95% CI 19.90–27.08) from 19 studies with 1502 patients, and the pooled hospital LOS was 33.68 days (95% CI 29.90–37.46) from 23 studies with 1548 patients. The pooled ECMO duration was 8.17 days (95% CI 7.15–9.18) from 21 studies with 388 patients. Among the 14 studies (281 patients) reporting ECMO duration, survivors had a longer duration compared to non-survivors (3.872 days, 95% CI 1.487–6.256, p = 0.272). A total of 615 complications were reported in 22 studies (806 patients) treated with ECMO, with renal complications (164/806, 26.7%), infectious complications (131/806, 21.3%), and thrombotic complications (103/806, 16.8%) being the most commonly observed. Patient outcomes of the included studies are summarised in Additional file 3 and Table 3.

Table 3 Patient outcomes of studies included for systematic review

Assessment of study quality

The quality assessment using the JBI checklist for cohort studies and case series indicated a high level of quality for the included studies in this review, with the majority scoring at least an 8 or higher (Additional file 2). Egger’s test showed non-significant publication bias. Additional file 4 provides a summary of the assessment of the level of certainty of evidence. The starting level of evidence for observational studies was high for survival outcomes. The certainty of pooled survival was high, while the certainty of ECMO duration and hospital LOS was downgraded to medium due to gross imprecision. The certainty of ICU LOS was downgraded to low due to gross inconsistency and imprecision.


This systematic review and meta-analysis quantitatively summarizes survival outcomes among adult trauma patients receiving ECMO therapy. Including 1822 patients from 36 studies, with a mean age of 35.5 years and a pooled survival rate of 65.9%. Previous research has shown that trauma patients receiving ECMO are typically younger and have fewer comorbidities compared to non-trauma populations. However, no significant difference in overall survival rates has been observed [20, 21, 23, 49]. Traumatic injuries can cause acute cardiopulmonary failure through direct chest trauma or indirect injuries from non-pulmonary trauma and related treatments like blood transfusions, fluid overload, and ventilator-induced acute lung injury. Managing cardiopulmonary failure in trauma patients poses unique challenges for critical care medical personnel, particularly when considering prone positioning for patients with brain injury and increased intracerebral pressure [9, 50]. Therapeutic anticoagulation during ECMO carries a risk of hemorrhage [50], which can worsen the clinical course and complicate injury patterns [28, 49], posing challenges for treatment. ECMO is not a routine life-saving intervention following trauma, but rather a salvage therapy that effectively replaces conventional treatment for young, healthy patients when conventional methods fail [3, 33, 41]. Its complexity requires a multidisciplinary healthcare team and sufficient resources for optimal implementation [26, 33, 40]. Accordingly, the ability to perform ECMO therapy has become an increasingly important quality indicator for assessing trauma centers [31]. Additionally, the aging population will bring more elderly trauma patients, presenting additional treatment challenges in the future [51].

Subgroup analysis revealed a higher survival rate of 72.3% for VV ECMO supportive therapy compared to 39.0% for VA ECMO supportive therapy. Traumatic lung injury is frequently observed in severe multiple injuries, with 10–20% of severely traumatized patients progressing to respiratory failure or ARDS with a mortality rate of 50–80% [52]. In contrast to traditional protective ventilation and prone position ventilation, VV ECMO effectively maintains gas exchange function, implements a super-protective lung ventilation strategy, prevents and reduces the adverse effects of high positive pressure and hyperventilation on lung injury, promotes lung tissue repair, and improves prognosis [53]. This is particularly beneficial for patients with severe chest trauma or those unable to undergo prone position ventilation [44, 54]. A multicenter retrospective cohort study conducted by Guirand et al. [8] compared VV ECMO and conventional mechanical ventilation (CMV) in trauma patients with acute hypoxic respiratory failure. After propensity score matching, the VV ECMO group demonstrated a significantly higher survival rate at discharge (64.7% vs. 23.5%) compared to the CMV group. However, another retrospective study investigating VV ECMO for adult ARDS treatment found no significant difference in in-hospital mortality between the VV ECMO and CMV groups after propensity score matching for baseline differences [27]. Considering factors such as the inclusion of elderly patients and lower PaO2/FiO2 ratios, among others, the investigators still recommend that critical care physicians consider VV ECMO as a salvage therapy for appropriate trauma patients [27]. The survival rate of VV ECMO in this systematic review was comparable to a previous study in 2017 [55], while the survival rate of VA ECMO was lower. This difference may be due to the inclusion of more patients with traumatic cardiac arrest (TCA). Haemorrhagic shock resulting from cardiac and macrovascular injury is the primary cause of intractable shock and cardiac arrest in trauma patients. The survival rates for TCA caused by blunt and penetrating injuries are 3.3% and 3.7% respectively, with only 1.6% of patients showing a good neurological prognosis [56]. Swol [57] conducted a review of the ELSO Registry from 1989 to 2016, focusing on ECMO support for adult trauma patients. The study found an overall survival rate of 70% and a discharge survival rate of 61%. Specifically, VV ECMO had a survival rate of 63%, VA ECMO had a survival rate of 50%, and extracorporeal cardiopulmonary resuscitation (ECPR) had a survival rate of 25%. These rates are consistent with previous ELSO registry cohorts. Notably, VA ECMO provides comprehensive hemodynamic support in refractory shock cases that do not respond to conventional therapy, effectively managing gas exchange and perfusion while physiologically stabilizing patients without the need for high-dose pressor medications [34, 45]. ECMO is crucial in reducing blood loss and preventing complications related to massive transfusion, such as fatal acidosis, hypothermia, coagulopathy triad, electrolyte abnormalities, citrate toxicity, and transfusion-associated acute lung injury [58]. Moreover, VA ECMO supports the vital signs of trauma patients, allowing for adequate time for definitive haemostatic surgery and further treatment [4]. Additionally, it may aid in preserving neurological function after cardiac arrest [34]. Although the current evidence is insufficient to support routine VA ECMO use in patients with TCA or severe shock, early initiation of VA ECMO is recommended for those with post-traumatic cardiorespiratory insufficiency, particularly younger individuals with less severe injuries (ISS < 35) and reversible tissue perfusion injury. This approach enables damage-control surgery, enhances survival rates, and improves overall prognosis [3, 4, 9, 33, 45, 46, 59]. Despite challenges such as time constraints, resource availability, high costs, and potential complications, VA ECMO presents a valuable and potentially effective emergency intervention for appropriate patients.

TBI was previously contraindicated for ECMO due to the heightened risk of intracranial hemorrhage from systemic anticoagulation [30, 60, 61]. Recently, advancements in procedures have mitigated this bleeding risk, including low-dose anticoagulation [29, 33], delayed anticoagulation (after 48–72 h) [9, 37], heparin-free application [36, 41], and improved heparin-binding circuits [21, 23]. In this study, the survival rate of TBI patients (383, 16 studies) was comparable to non-TBI patients. About 20% to 30% of TBI patients may develop ARDS [55]. Addressing the complex interplay between the brain and lungs is crucial in managing ARDS in TBI patients, given the potential negative impact of hypercapnia, hypoxia, and elevated intrathoracic pressure on the injured brain and increased intracranial pressure. Resuscitative measures for ARDS, including prone positioning, high positive end-expiratory pressure, and permissive hypercapnia, can impact intracranial pressure and lead to secondary neurological damage in TBI [14]. To prevent exacerbation of cerebral edema in trauma patients, early administration of ECMO support may be necessary specifically for severe TBI patients. ECMO offers an appealing option for TBI patients with respiratory failure as it enables the implementation of both neurological and lung-protective ventilation strategies [27]. Positive outcomes have been observed even in TBI patients undergoing craniotomy for intracranial hemorrhage [62]. Although concerns exist about possible worsening of intracranial hemorrhage with systemic anticoagulation during ECMO [60], a study conducted by Parker et al. [14] supported the use of VV ECMO therapy in TBI patients, with 6 out of 13 patients receiving systemic anticoagulation, as no deterioration in intracranial hemorrhage was observed. In a study by Kruit et al. [15], 19 TBI patients were supported on ECMO, with 12 of them receiving anticoagulation. Out of these patients, 3 deaths were unrelated to intracranial hemorrhage in the presence of ECMO anticoagulation. These findings indicate that careful implementation of ECMO supportive therapy can ameliorate secondary brain injury and improve prognosis. The decision to administer early systemic anticoagulation during ECMO in TBI patients should consider individualized factors such as the extent, stability, and location of the injury [14]. TBI alone should not be considered a contraindication for ECMO, as TBI patients receiving ECMO support tend to exhibit higher survival rates and lower rates of neurological complications. Notably, the administration of heparin anticoagulation does not escalate the risk of mortality. Moreover, advancements in ECMO systems and enhancements in circuit anticoagulation management are anticipated to foster greater utilization of ECMO as a life-saving intervention for severe TBI patients [15].

This study has several strengths, including robust inclusion and exclusion criteria, incorporating 36 studies from diverse geographical regions. Subgroup analyses were performed to explore potential sources of heterogeneity and minimize confounding. The study quality was assessed using validated tools, and the certainty of the findings was determined through grading. However, certain limitations should be acknowledged. Firstly, our review only included studies published in English, which may introduce language bias. Additionally, the variability in ECMO initiation and management across centers and regions could contribute to increased result heterogeneity. Most of the included studies were single-center retrospective studies, lacking risk adjustment or propensity score weighting, thus potentially introducing confounding factors. Nonetheless, no publication bias was detected, the majority of articles were considered high-quality based on JBI critical appraisal, and hierarchical assessments indicated a high level of certainty regarding the primary outcome. It is important to address the absence of a trial sequential analysis in our study, which could have offered valuable insights into the reliability and conclusiveness of our meta-analysis findings [63, 64]. Despite this limitation, our study provides a comprehensive analysis based on the available evidence, offering insights into the studied outcomes and their potential implications. We encourage future research to consider incorporating trial sequential analysis to enhance the robustness of findings and guide subsequent investigations.


Our systematic review and meta-analysis provide substantial evidence supporting the viability of ECMO as a therapeutic approach for severely traumatized patients. It is crucial to reassess the contraindication of ECMO in managing severe cardiorespiratory failure, hemorrhagic shock, and TCA, considering its demonstrated ability to improve survival rates and overall patient prognosis, including those with traumatic brain injury TBI.

Availability of data and materials

The dataset generated and analysed during the current study can be found in the included studies and their supplementary information files.



Acute respiratory distress syndrome


Extracorporeal membrane oxygenation






Extracorporeal Life Support Organisation


Injury severity score


Partial pressure of arterial oxygen versus fraction of inspired oxygen


Sequential organ failure assessment


Traumatic brain injury


Cardiac arrest


Intensive care unit


Length of stay


Joanna Briggs Institute


Grading of recommendations, assessment, development, and evaluations


Conventional mechanical ventilation


  1. Disease GBD, Injury I, Prevalence C. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: a systematic analysis for the global burden of disease study 2017. Lancet. 2018;392(10159):1789–858.

    Article  Google Scholar 

  2. 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;15(1):51.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Huh U, Song S, Chung SW, Kim SP, Lee CW, Ahn HY, et al. Is extracorporeal cardiopulmonary resuscitation practical in severe chest trauma? A systematic review in single center of developing country. J Trauma Acute Care Surg. 2017;83(5):903–7.

    Article  PubMed  Google Scholar 

  4. Tseng YH, Wu TI, Liu YC, Lin PJ, Wu MY. Venoarterial extracorporeal life support in post-traumatic shock and cardiac arrest: lessons learned. Scand J Trauma Resusc Emerg Med. 2014;22:12.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Brewer JM, Tran A, Yu J, Ali MI, Poulos CM, Gates J, et al. Application and outcomes of extracorporeal life support in emergency general surgery and trauma. Perfusion. 2022;37(6):575–81.

    Article  PubMed  Google Scholar 

  6. Grant C Jr, Richards JB, Frakes M, Cohen J, Wilcox SR. ECMO and right ventricular failure: review of the literature. J Intensive Care Med. 2021;36(3):352–60.

    Article  PubMed  Google Scholar 

  7. Hamera J, Menne A. Extracorporeal life support for trauma. Emerg Med Clin North Am. 2023;41(1):89–100.

    Article  PubMed  Google Scholar 

  8. Guirand DM, Okoye OT, Schmidt BS, Mansfield NJ, Aden JK, Martin RS, et al. Venovenous extracorporeal life support improves survival in adult trauma patients with acute hypoxemic respiratory failure: a multicenter retrospective cohort study. J Trauma Acute Care Surg. 2014;76(5):1275–81.

    Article  PubMed  Google Scholar 

  9. Al-Thani H, Al-Hassani A, El-Menyar A, Asim M, Fawzy I. Outcome of post-traumatic acute respiratory distress syndrome in young patients requiring extracorporeal membrane oxygenation (ECMO). Sci Rep. 2022;12(1):10609.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  10. Guttman MP, Tillmann BW, Pannell D, Vallelonga M, Nathens AB, Haas B. Extracorporeal membrane oxygenation use in trauma quality improvement program centers: temporal trends and future directions. J Trauma Acute Care Surg. 2020;89(2):351–7.

    Article  PubMed  Google Scholar 

  11. Sanfilippo F, La Via L, Murabito P, Pappalardo F, Astuto M. More evidence available for the use of bivalirudin in patients supported by extracorporeal membrane oxygenation. Thromb Res. 2022;211:148–9.

    Article  PubMed  CAS  Google Scholar 

  12. Li DH, Sun MW, Zhang JC, Zhang C, Deng L, Jiang H. Is bivalirudin an alternative anticoagulant for extracorporeal membrane oxygenation (ECMO) patients? A systematic review and meta-analysis. Thromb Res. 2022;210:53–62.

    Article  PubMed  CAS  Google Scholar 

  13. Sanfilippo F, Currò JM, La Via L, Dezio V, Martucci G, Brancati S, et al. Use of nafamostat mesilate for anticoagulation during extracorporeal membrane oxygenation: a systematic review. Artif Organs. 2022;46(12):2371–81.

    Article  PubMed  Google Scholar 

  14. Parker BM, Menaker J, Berry CD, Tesoreiero RB, O’Connor JV, Stein DM, et al. single center experience with veno-venous extracorporeal membrane oxygenation in patients with traumatic brain injury. Am Surg. 2021;87(6):949–53.

    Article  PubMed  Google Scholar 

  15. Kruit N, Prusak M, Miller M, Barrett N, Richardson C, Vuylsteke A. Assessment of safety and bleeding risk in the use of extracorporeal membrane oxygenation for multitrauma patients: a multicenter review. J Trauma Acute Care Surg. 2019;86(6):967–73.

    Article  PubMed  Google Scholar 

  16. Kim SH, Huh U, Song S, Kim MS, Wang IJ, Tak YJ. Outcomes in trauma patients undergoing veno-venous extracorporeal membrane oxygenation for acute respiratory distress syndrome. Perfusion. 2022.

    Article  PubMed  Google Scholar 

  17. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021;372: n71.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. BMJ. 2008;336(7650):924–6.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Wan X, Wang W, Liu J, Tong T. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol. 2014;14:135.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Ramanathan K, Shekar K, Ling RR, Barbaro RP, Wong SN, Tan CS, et al. Extracorporeal membrane oxygenation for COVID-19: a systematic review and meta-analysis. Crit Care. 2021;25(1):211.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Ling RR, Ramanathan K, Poon WH, Tan CS, Brechot N, Brodie D, et al. Venoarterial extracorporeal membrane oxygenation as mechanical circulatory support in adult septic shock: a systematic review and meta-analysis with individual participant data meta-regression analysis. Crit Care. 2021;25(1):246.

    Article  PubMed  PubMed Central  Google Scholar 

  22. Mader MMD, Lefering R, Westphal M, Maegele M, Czorlich P. Extracorporeal membrane oxygenation in traumatic brain injury—a retrospective, multicenter cohort study. Injury. 2023.

    Article  PubMed  Google Scholar 

  23. Hatfield J, Ohnuma T, Soto AL, Komisarow JM, Vavilala MS, Laskowitz DT, et al. Utilization and outcomes of extracorporeal membrane oxygenation following traumatic brain injury in the United States. J Intensive Care Med. 2022.

    Article  PubMed  Google Scholar 

  24. Weidemann F, Decker S, Epping J, Örgel M, Krettek C, Kühn C, et al. Analysis of extracorporeal membrane oxygenation in trauma patients with acute respiratory distress syndrome: a case series. Int J Artif Organs. 2022;45(1):81–8.

    Article  PubMed  CAS  Google Scholar 

  25. Trivedi JR, Alotaibi A, Sweeney JC, Fox MP, Van Berkel V, Adkins K, et al. Use of extracorporeal membrane oxygenation in blunt traumatic injury patients with acute respiratory distress syndrome. ASAIO J. 2022;68(4):E60–1.

    Article  PubMed  Google Scholar 

  26. Salas De Armas IA, Akkanti B, Doshi PB, Patel M, Kumar S, Akay MH, et al. Traumatic respiratory failure and veno-venous extracorporeal membrane oxygenation support. Perfusion. 2022;37(5):477–83.

    Article  PubMed  Google Scholar 

  27. Lee GJ, Kim MJ, Lee JG, Lee SH. Use of venovenous extracorporeal membrane oxygenation in trauma patients with severe adult respiratory distress syndrome: a retrospective study. Int J Artif Organs. 2022;45(10):833–40.

    Article  PubMed  CAS  Google Scholar 

  28. Eisenga J, Monday K, Blough B, Vandervest K, Lingle K, Espinoza O, et al. Extracorporeal membrane oxygenation support in the setting of penetrating traumatic injuries. J Card Surg. 2022;37(12):4359–61.

    Article  PubMed  Google Scholar 

  29. Henry R, Ghafil C, Piccinini A, Liasidis PK, Matsushima K, Golden A, et al. Extracorporeal support for trauma: a trauma quality improvement project (TQIP) analysis in patients with acute respiratory distress syndrome. Am J Emerg Med. 2021;48:170–6.

    Article  PubMed  PubMed Central  Google Scholar 

  30. Lee HK, Kim HS, Ha SO, Park S, Lee HS, Lee SK, et al. Clinical outcomes of extracorporeal membrane oxygenation in acute traumatic lung injury: a retrospective study. Scand J Trauma Resusc Emerg Med. 2020;28(1):41.

    Article  PubMed  PubMed Central  Google Scholar 

  31. Huang JE, Holland SR, Patrick J, Piper LC, Sams VG. Predictive survival factors of the traumatically injured on venovenous extracorporeal membrane oxygenation: a Bayesian model. J Trauma Acute Care Surg. 2020;88(1):153–9.

    Article  PubMed  Google Scholar 

  32. Akhmerov A, Huang R, Carlson K, Dhillon NK, Ley EJ, Margulies DR, et al. Access to extracorporeal life support as a quality metric: lessons from trauma. J Card Surg. 2020;35(4):826–30.

    Article  PubMed  Google Scholar 

  33. Wu MY, Chou PL, Wu TI, Lin PJ. Predictors of hospital mortality in adult trauma patients receiving extracorporeal membrane oxygenation for advanced life support: a retrospective cohort study. scandinavian journal of trauma. Resusc Emerg Med. 2018.

    Article  Google Scholar 

  34. Strumwasser A, Tobin JM, Henry R, Guidry C, Park C, Inaba K, et al. Extracorporeal membrane oxygenation in trauma: a single institution experience and review of the literature. Int J Artif Organs. 2018;41(12):845–53.

    Article  PubMed  Google Scholar 

  35. Menaker J, Tesoriero RB, Tabatabai A, Rabinowitz RP, Cornachione C, Lonergan T, et al. Veno-venous extracorporeal membrane oxygenation (VV ECMO) for acute respiratory failure following injury: outcomes in a high-volume adult trauma center with a dedicated unit for VV ECMO. World J Surg. 2018;42(8):2398–403.

    Article  PubMed  Google Scholar 

  36. Grant AA, Hart VJ, Lineen EB, Lai C, Ginzburg E, Houghton D, et al. The impact of an advanced ECMO program on traumatically injured patients. Artif Organs. 2018;42(11):1043–51.

    Article  PubMed  Google Scholar 

  37. Ull C, Schildhauer TA, Strauch JT, Swol J. Outcome measures of extracorporeal life support (ECLS) in trauma patients versus patients without trauma: a 7-year single-center retrospective cohort study. J Artif Organs. 2017;20(2):117–24.

    Article  PubMed  Google Scholar 

  38. Kim HS, Ha SO, Han SJ, Kim HS, Lee SH, Jung KS, et al. Extracorporeal membrane oxygenation support in trauma versus nontrauma patients with noninfectious acute respiratory failure. Artif Organs. 2017;41(5):431–9.

    Article  PubMed  CAS  Google Scholar 

  39. Burke CR, Crown A, Chan T, McMullan DM. Extracorporeal life support is safe in trauma patients. Injury. 2017;48(1):121–6.

    Article  PubMed  Google Scholar 

  40. Ahmad SB, Menaker J, Kufera J, Connor JO, Scalea TM, Stein DM. Extracorporeal membrane oxygenation after traumatic injury. J Trauma Acute Care Surg. 2017;82(3):587–91.

    Article  PubMed  Google Scholar 

  41. Chen TH, Shih JY, Shih JJ. Early percutaneous heparin-free veno-venous extra corporeal life support (ECLS) is a safe and effective means of salvaging hypoxemic patients with complicated chest trauma. Acta Cardiol Sin. 2016;32(1):96–102.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Bosarge PL, Raff LA, McGwin G Jr, Carroll SL, Bellot SC, Diaz-Guzman E, et al. Early initiation of extracorporeal membrane oxygenation improves survival in adult trauma patients with severe adult respiratory distress syndrome. J Trauma Acute Care Surg. 2016;81(2):236–41.

    Article  PubMed  CAS  Google Scholar 

  43. Wu SC, Chen WTL, Lin HH, Fu CY, Wang YC, Lo HC, et al. Use of extracorporeal membrane oxygenation in severe traumatic lung injury with respiratory failure. Am J Emerg Med. 2015;33(5):658–62.

    Article  PubMed  Google Scholar 

  44. Ried M, Bein T, Philipp A, Muller T, Graf B, Schmid C, et al. Extracorporeal lung support in trauma patients with severe chest injury and acute lung failure: a 10-year institutional experience. Crit Care. 2013;17(3):R110.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Bonacchi M, Spina R, Torracchi L, Harmelin G, Sani G, Peris A. Extracorporeal life support in patients with severe trauma: an advanced treatment strategy for refractory clinical settings. J Thorac Cardiovasc Surg. 2013;145(6):1617–26.

    Article  PubMed  Google Scholar 

  46. Arlt M, Philipp A, Voelkel S, Rupprecht L, Mueller T, Hilker M, et al. Extracorporeal membrane oxygenation in severe trauma patients with bleeding shock. Resuscitation. 2010;81(7):804–9.

    Article  PubMed  Google Scholar 

  47. Huang YK, Liu KS, Lu MS, Wu MY, Tsai FC, Lin PJ. Extracorporeal life support in post-traumatic respiratory distress patients. Resuscitation. 2009;80(5):535–9.

    Article  PubMed  Google Scholar 

  48. Cordell-Smith JA, Roberts N, Peek GJ, Firmin RK. Traumatic lung injury treated by extracorporeal membrane oxygenation (ECMO). Injury. 2006;37(1):29–32.

    Article  PubMed  CAS  Google Scholar 

  49. Engelhardt LJ, Olbricht C, Niemann M, Graw JA, Hunsicker O, Weiss B, et al. Outcome comparison of acute respiratory distress syndrome (ARDS) in patients with trauma-associated and non-trauma-associated ARDS: a retrospective 11-year period analysis. J Clin Med. 2022.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Prinz V, Manekeller L, Menk M, Hecht N, Weber-Carstens S, Vajkoczy P, et al. Clinical management and outcome of adult patients with extracorporeal life support device-associated intracerebral hemorrhage-a neurocritical perspective and grading. Neurosurg Rev. 2021;44(5):2879–88.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Dixon JR, Lecky F, Bouamra O, Dixon P, Wilson F, Edwards A, et al. Age and the distribution of major injury across a national trauma system. Age Ageing. 2020;49(2):218–26.

    Article  PubMed  Google Scholar 

  52. Birkner DR, Halvachizadeh S, Pape HC, Pfeifer R. Mortality of adult respiratory distress syndrome in trauma patients: a systematic review over a period of four decades. World J Surg. 2020;44(7):2243–54.

    Article  PubMed  Google Scholar 

  53. Rozencwajg S, Guihot A, Franchineau G, Lescroat M, Brechot N, Hekimian G, et al. Ultra-protective ventilation reduces biotrauma in patients on venovenous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome. Crit Care Med. 2019;47(11):1505–12.

    Article  PubMed  Google Scholar 

  54. Roth C, Ferbert A, Deinsberger W, Kleffmann J, Kastner S, Godau J, et al. Does prone positioning increase intracranial pressure? A retrospective analysis of patients with acute brain injury and acute respiratory failure. Neurocrit Care. 2014;21(2):186–91.

    Article  PubMed  Google Scholar 

  55. 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;82(2):400–6.

    Article  PubMed  Google Scholar 

  56. Zwingmann J, Mehlhorn AT, Hammer T, Bayer J, Sudkamp NP, Strohm PC. Survival and neurologic outcome after traumatic out-of-hospital cardiopulmonary arrest in a pediatric and adult population: a systematic review. Crit Care. 2012;16(4):R117.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Swol J, Brodie D, Napolitano L, Park PK, Thiagarajan R, Barbaro RP, et al. Indications and outcomes of extracorporeal life support in trauma patients. J Trauma Acute Care Surg. 2018;84(6):831–7.

    Article  PubMed  Google Scholar 

  58. Sihler KC, Napolitano LM. Complications of massive transfusion. Chest. 2010;137(1):209–20.

    Article  PubMed  Google Scholar 

  59. Larsson M, Talving P, Palmér K, Frenckner B, Riddez L, Broomé M. Experimental extracorporeal membrane oxygenation reduces central venous pressure: an adjunct to control of venous hemorrhage? Perfusion. 2010;25(4):217–23.

    Article  PubMed  Google Scholar 

  60. Muellenbach RM, Redel A, Küstermann J, Brack A, Gorski A, Rösner T, et al. Extracorporeal membrane oxygenation and severe traumatic brain injury: is the ECMO-therapy in traumatic lung failure and severe traumatic brain injury really contraindicated? Anaesthesist. 2011;60(7):647–52.

    Article  PubMed  CAS  Google Scholar 

  61. Arachchillage DRJ, Passariello M, Laffan M, Aw T, Owen L, Banya W, et al. Intracranial hemorrhage and early mortality in patients receiving extracorporeal membrane oxygenation for severe respiratory failure. Semin Thromb Hemost. 2018;44(3):276–86.

    Article  PubMed  Google Scholar 

  62. Biscotti M, Gannon WD, Abrams D, Agerstrand C, Claassen J, Brodie D, et al. Extracorporeal membrane oxygenation use in patients with traumatic brain injury. Perfusion. 2015;30(5):407–9.

    Article  PubMed  CAS  Google Scholar 

  63. Afshari A, Wetterslev J. When may systematic reviews and meta-analyses be considered reliable? Eur J Anaesthesiol. 2015;32(2):85–7.

    Article  PubMed  Google Scholar 

  64. Sanfilippo F, La Via L, Tigano S, Morgana A, La Rosa V, Astuto M. Trial sequential analysis: the evaluation of the robustness of metaanalyses findings and the need for further research. EuroMediterranean Biomed J. 2021;16(25):104–7.

    Article  Google Scholar 

Download references


All authors approved the submission of the final article. The authors have disclosed that they do not have any potential conflicts of interest.


Funding for this research was provided by Jiangsu Province Key Medical Discipline [Suwei Science and Education (2022) No. 17] (grant number: ZDXK202213), 2020 Provincial Financial Support for Clinical Key Specialty Project [Su Finance (2020) No. 155], and 2021 Specialist Capacity Building Project [Su Finance (2021) No. 79].

Author information

Authors and Affiliations



The study was designed by YCZ and XLJ. YCZ and NM screened the articles, assessed the risk of bias and extracted the data under the supervision of XLJ. YCZ and PCW analysed and interpreted the data under the supervision of XLJ and XFC. Tables and figures were produced by YCZ. YZC and XLJ shared the primary responsibility of writing the manuscript, to which all authors contributed to and revised. LZ, XHH, XFC and XLJ critically revised the manuscript for important intellectual content. All authors provided critical conceptual input, interpreted the data analysis, read, and approved the final draft.

Corresponding authors

Correspondence to Xufeng Chen or Xueli Ji.

Ethics declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

All authors have read and approved the submission of the manuscript.

Competing interests

The authors declare no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Additional file 1:

Search strings for respective databases.

Additional file 2:

Joanna Briggs Institute (JBI) checklists for included studies.

Additional file 3:

ECMO characteristics of studies included for systematic review.

Additional file 4:

Grading of Recommendations, Assessments, Developments and Evaluations (GRADE) approach for certainty in evidence.

Additional file 5: Figure S1.

Funnel plot for primary meta-analysis.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Zhang, Y., Zhang, L., Huang, X. et al. ECMO in adult patients with severe trauma: a systematic review and meta-analysis. Eur J Med Res 28, 412 (2023).

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: