Use of an Extracorporeal Membrane Oxygenation Circuit as a Bridge to Salvage a Major Upper-Extremity Replant in a Critically Ill Patient

ABSTRACT

Major replantation of the upper extremity is defined as replantation at or above the level of the wrist. Selection of appropriate candidates is complex and requires consideration of many patient- and injury-associated factors including patient age, associated injuries, patient desire, mechanism of injury, ischemia time, wound condition, and presence of multiple-level injury. With respect to age, younger patients, especially children, are deemed to have a distinct advantage over more elderly patients due to improved nerve regeneration, and many advocate making every effort to replant this population. The risks of major upper-extremity replantation are significant and include bleeding, depletion of coagulation factors, secondary infection, and sepsis. As a result, major systemic illness and significant associated injuries are accepted as contraindications to limb salvage in this patient population. Herein we describe the use of an extracorporeal membrane oxygenation (ECMO) circuit as a potential bridge for short-term preservation of the extremity in a young patient with an acute, concomitant systemic illness. In the authors' opinion, use of ECMO perfusion is a viable means of maintaining extremity perfusion over hours or even days and may lead to broadened replant criteria in patients with associated injuries.

Replantation - ECMO - salvage - limb perfusion

REFERENCES

• 1 Kleinert H E, Jablon M, Tsai T M. An overview of replantation and results of 347 replants in 245 patients.  J Trauma. 1980;  20 390-398
• 2 O'Brien B M. Replantation surgery.  Clin Plast Surg. 1974;  1 405-426
• 3 O'Brien B M, Miller G D. Digital reattachment and revascularization.  J Bone Joint Surg Am. 1973;  55 714-724
• 4 Chew W Y, Tsai T M. Major upper limb replantation.  Hand Clin. 2001;  17 395-410 viii
• 5 Chung K C, Alderman A K. Replantation of the upper extremity: Indications and outcomes.  J Am Soc Surg Hand. 2002;  2 78-94
• 6 Wei F C, Mardini S. Discussion: bilateral high upper limb replantation in a child.  Plast Reconstr Surg. 2004;  113 1739-1741
• 7 Koul A R, Cyriac A, Khaleel V M, Vinodan K. Bilateral high upper limb replantation in a child.  Plast Reconstr Surg. 2004;  113 1734-1738 discussion 1739-1741
• 8 Dagum A B, Slesarenko Y, Winston L, Tottenham V. Long-term outcome of replantation of proximal-third amputated arm: a worthwhile endeavor.  Tech Hand Up Extrem Surg. 2007;  11 231-235
• 9 Brady M S, Brown K, Patel A, Fisher C, Marx W. Isolated limb infusion with melphalan and dactinomycin for regional melanoma and soft-tissue sarcoma of the extremity: final report of a phase II clinical trial.  Melanoma Res. 2009;  19 106-111
• 10 Quiñones-Baldrich W J, Colburn M D, Gelabert H A, Barcliff L T, Moore W S. Isolated limb thrombolysis with extracorporeal pump and urokinase.  J Surg Res. 1994;  57 344-351