Extracorporeal membrane oxygenation in a venovenous configuration (VV-ECMO) is increasingly recognized as an important therapeutic option for patients with severe acute respiratory distress syndrome (ARDS).¹ Accumulating scientific evidence as well as experience garnered during both the 2009 influenza A (H1N1) and coronavirus 2019 (COVID-19) pandemics, have resulted in widespread adoption of VV-ECMO for patients with ARDS.^2–5 In this context, ECMO centers have expanded the application of VV-ECMO to other indications, including severe respiratory failure due to traumatic injury.^6–8

The article by Niles et al.⁹ offers an important contribution to the field of ECMO for respiratory support in traumatically injured patients. In this single-center, retrospective cohort study, 75 patients with trauma-related acute respiratory failure were managed with VV-ECMO over an 8 year period. Pulmonary contusion was the most common etiology of respiratory failure (49% of patients) with aspiration (15%) and transfusion-related acute lung injury (11%) as other leading causes. Thirty-two percent of the patients experienced cardiac arrest before initiation of VV-ECMO and approximately 50% of patients had traumatic brain injury (TBI). Overall survival to hospital discharge was 68%. Thirty-eight (51%) patients received no anticoagulation during ECMO. Of the 37 patients who received systemic anticoagulation, 27 (73%) had anticoagulation infusion held at some point during the ECMO run. In multivariable logistic regression, there was no association between exposure to anticoagulation and survival.