A systematic review to inform institutional decisions about the use of extracorporeal membrane oxygenation during the H1N1 influenza pandemic*

Abstract

Objective To systematically evaluate the effect of extracorporeal membrane oxygenation (ECMO) on survival in adults with acute respiratory failure (ARF), to help inform institutional decisions about implementing an ECMO program or transferring patients to experienced ECMO centers during the H1N1 influenza pandemic. Data Sources National Guideline Clearinghouse, Medline, EMBASE, AHRQ Evidence-based Practice reports, National Institute for Health and Clinical Excellence, Cochrane Library, International Network of Agencies for Health Technology Assessment, citation review. Study Selection Studies of ECMO in adult ARF, reporting mortality rates for at least 10 patients in ECMO and non-ECMO groups. Data Extraction Mortality rates were abstracted for all patients and for influenza patients. Risk ratios were meta-analyzed using random-effects methods and assessed for heterogeneity. Data Synthesis There are no evidence-based clinical guidelines on the use of ECMO in influenza patients. Three randomized controlled trials and three cohort studies evaluated ECMO in ARF patients; none reported specifically on influenza patients. Meta-analysis of the RCTs revealed significant heterogeneity in risk of mortality. The summary risk ratio found by the meta-analysis was 0.93 [95% confidence interval (CI): 0.71 – 1.22]. The most recent trial found a reduction in mortality and severe disability at 6 months among patients in whom ECMO was considered. Observational studies suggest that ECMO for ARF due to viral pneumonia is associated with improved mortality compared with other etiologies of ARF. Conclusions The best evidence to guide decisions regarding the use of ECMO for influenza patients stems from trials of ECMO for ARF of all etiologies, among which significant heterogeneity exists, and from case series describing outcomes of ECMO in patients with influenza. Thus, there is insufficient evidence to provide a recommendation for ECMO use among patients with respiratory failure due to influenza. However, clinicians should consider ECMO within the context of other salvage therapies for ARF.

Extracorporeal Life Support for Acute Respiratory Failure. A Systematic Review and Metaanalysis

“…Five previous systematic reviews have evaluated ECLS in a descriptive fashion (13,(29)(30)(31)(32). A recent review by Zangrillo and colleagues pooled ICU and hospital mortality from eight observational studies of ECLS use during H1N1 and estimated an overall in-hospital mortality of 28% (95% CI, 18-37%; I 2 = 64%) (13) Zangrillo and colleagues more recently performed a review characterizing complications and outcome of all types of extracorporeal membrane oxygenation (with a predominance of venoarterial ECLS) and discovered a high incidence of renal failure, pneumonia, and sepsis (31).…”

Extracorporeal Gas Exchange for Acute Respiratory Failure in Adult Patients: A Systematic Review

“…Randomized controlled trial quality was graded using a nine-point scale combining elements from Jadad's [21] and Chalmers' scales [23,24] whereas the validity of case-controlled studies was appraised with the Newcastle-Ottawa scale [25]; † in the survivors. Pregnant or postpartum, n (%) 18 (15) 10 (17) 10 (16) 4 (8) 7 (19) 1 (7) 1 (7) 3 (23) SOFA 9.5 ± 4.0 9 (7-10) 7 (6-9) 11 (9-14) Pregnant or postpartum 1(10) …”

“…Mortality, n (%) 22 (51) 7 (33) 7 (17) 104 (65) 12 (52) 6 (27) 7 (54) 9 (82) 4 (50) 1 (14) AV: arteriovenous; VV: veno-venous; Multi: multicenter; MV: mechanical ventilation; N: no; RCT: randomized controlled trial; SOFA: Sequential Organ Failure Assessment; Y: yes; * Peak pressure; § RCT quality was graded using a nine-point scale combining elements from Jadad's [21] and Chalmers' scales [23,24] whereas the validity of case-controlled studies was appraised with the Newcastle-Ottawa scale [25]. Data are given as mean ± SD or median (interquartile range).…”

“…Extracorporeal gas exchange devices, i.e., venovenous extracorporeal membrane oxygenation (ECMO) and extracorporeal carbon dioxide removal (ECCO 2 R), were developed more than 40 years ago [4,5] to rescue these dying patients. Whereas venovenous ECMO provides complete extracorporeal blood oxygenation and decarboxylation using high blood flows (4-6 l/min) and large (20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30) cannulas [6][7][8][9], efficient extracorporeal CO 2 removal (with minimal blood oxygenation) can be achieved with ECCO 2 R devices using limited extracorporeal blood flow (0.4-1 l/min) and thin double lumen venous catheters (14)(15)(16)(17)(18) [10,11], because CO 2 clearance is more effective than oxygenation due to the greater solubility and more rapid diffusion of CO 2 [12]. Extracorporeal gas exchange devices also permit 'ultraprotective' mechanical ventilation with further reduction of volume and pressure, which may ultimately enhance lung protection and improve clinical outcomes for patients with acute respiratory distress syndrome (ARDS).…”

Critically Ill Patients With H1N1 Influenza A Undergoing Extracorporeal Membrane Oxygenation

“…4,7,8,13 A full review of clinical and management aspects of H1N1 is beyond the scope of this article. However, Table 1 gives clinical manifestations, 5,8,10,[14][15][16][17] and Table 2 gives medical interventions. 1,2,8,12,15,18,19 For additional information, see the reviews of Kumar et al 8 and the Writing Committee of the WHO Consultation on Clinical Aspects of Pandemic (H1N1) 2009 Influenza.…”