Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database

Brogan, Thomas V.; Thiagarajan, Ravi R.; Rycus, Peter; Bartlett, Robert H.; Bratton, Susan L.

doi:10.1007/s00134-009-1661-7

Cited by 400 publications

(303 citation statements)

References 22 publications

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“…12 The former, a multivariate logistic regression analysis of the Extracorporeal Life Support Organization (ELSO) registry, showed 50% survival to discharge in 1,473 ECMO patients from 1986 to 2006. 11 The latter, which encompassed 135 patients from 11 clinical series and nine case reports, found 40% survived to discharge. 12 The following month, the aforementioned H1N1 case series from Australasia was released, and it reported approximately 70% survival to hospital discharge using ECMO for flu-associated ARDS.…”

Section: Critical Appraisalmentioning

confidence: 99%

“…4,5 There has been renewed interest in adult ECMO due to encouraging results from case series, 6,7 improved ECMO technology, 2 general advances in critical care, 3,8 and, most recently, the use of ECMO in H1N1 patients. 9,10 In fact, CESAR was published electronically in the same month period as a retrospective case review of ECMO in adult respiratory failure 11 and a meta-analysis of ECMO following adult cardiac arrest. 12 The former, a multivariate logistic regression analysis of the Extracorporeal Life Support Organization (ELSO) registry, showed 50% survival to discharge in 1,473 ECMO patients from 1986 to 2006.…”

Section: Critical Appraisalmentioning

confidence: 99%

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Extracorporeal membrane oxygenation (ECMO) in severe adult respiratory distress syndrome

Brindley

Cave

Lequier

2010

Can J Anesth/J Can Anesth

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Article assessedPeek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009; 374: 1351-63. Critical care issueSevere adult respiratory distress syndrome (ARDS) remains associated with high mortality despite improved ventilatory techniques. While extracorporeal membrane oxygenation (ECMO) is not uncommon in neonatal/pediatric critical care, studies had yet to show similar benefits in adults. Therefore, the Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) Trial by Peek et al. 1 was eagerly anticipated. It was the first randomized study of ECMO in adult patients in over 15 yr and the largest ever concerning this condition. 2 Summary and key findingsIn this multicentre randomized control trial from the United Kingdom, 180 patients, aged 18-65 yr, were analyzed. The patients had severe but potentially reversible respiratory failure, a Murray Score of C 3.0 (determined by combining PaO 2 /F I 0 2 ratio, positive end expiratory pressure level, lung compliance, chest radiograph appearance, and F I 0 2 of 1.0), or uncompensated hypercapnea (pH \ 7.2) despite conventional treatment. They were randomized 1:1 to conventional management without transfer vs transfer to one site and consideration of ECMO. A greater proportion of patients randomized to consideration of ECMO were alive at six months compared with patients randomized to conventional management (63% or 57/90 vs 50% or 45/90, respectively). This outcome did not reach statistical significance (relative risk 0.73; 95% confidence interval [CI] [0.52-1.03]; P = 0.07). However, a significantly greater percentage of patients randomized to consideration of ECMO survived to six months without severe disability compared with patients randomized to conventional management (63% [57/90] vs 47% [41/87], respectively; relative risk 0.69; 95% CI [0.05-0.97]; P = 0.03). Referral for ECMO consideration was associated with 0.03 quality-adjusted years (QALYS) at six months. The cost per QALY for ECMO was 19,252 pounds sterling (GBP) (95% CI [7,200]). Despite conventional management, the authors concluded that it was appropriate to transfer adults with severe ARDS to a centre with an ECMO-based management protocol. Critical appraisalCurrent state of the literature and study relevance Extra corporeal membrane oxygenation is accepted as a standard-of-care for neonates and children with progressive respiratory and/or cardiac failure refractory to conventional management. [1][2][3] In contrast, adult ECMO is currently confined to a few specialized centres and reserved for exceptional cases. This is because of increased cost and logistics but also because of disappointing results from the two previous randomized trials. 4,5

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Section: Critical Appraisalmentioning

confidence: 99%

Section: Critical Appraisalmentioning

confidence: 99%

Extracorporeal membrane oxygenation (ECMO) in severe adult respiratory distress syndrome

Brindley

Cave

Lequier

2010

Can J Anesth/J Can Anesth

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“…From 1986-2006 only minor changes in mechanical ventilation settings have been observed, with reported PEEP values around 10 cmH2O, respiratory rate of 10 bpm, and a mean airway pressure around 16 cmH2O [2].…”

Section: Mechanical Ventilation-how?mentioning

confidence: 99%

Ventilation during extracorporeal support

Pesenti

Carlesso

Länger

et al. 2017

Med Klin Intensivmed Notfmed

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“…However, timing of improvement in HPS‐related hypoxemia is highly variable between patients and difficult to predict 9. Given this and the high risk of complications and mortality associated with prolonged ECLS in adults 44, 48, ECLS is suggested as a “last resort” approach, as above.…”

Section: Rationale and Considerations For Included Therapiesmentioning

confidence: 99%

Proposed Management Algorithm for Severe Hypoxemia After Liver Transplantation in the Hepatopulmonary Syndrome

Nayyar

Man

Granton

et al. 2015

American Journal of Transplantation

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The hepatopulmonary syndrome (HPS) is defined as the triad of liver disease, intrapulmonary vascular dilatation, and abnormal gas exchange, and is found in 10–32% of patients with liver disease. Liver transplantation is the only known cure for HPS, but patients can develop severe posttransplant hypoxemia, defined as a need for 100% inspired oxygen to maintain a saturation of ≥85%. This complication is seen in 6–21% of patients and carries a 45% mortality. Its management requires the application of specific strategies targeting the underlying physiologic abnormalities in HPS, but awareness of these strategies and knowledge on their optimal use is limited. We reviewed existing literature to identify strategies that can be used for this complication, and developed a clinical management algorithm based on best evidence and expert opinion. Evidence was limited to case reports and case series, and we determined which treatments to include in the algorithm and their recommended sequence based on their relative likelihood of success, invasiveness, and risk. Recommended therapies include: Trendelenburg positioning, inhaled epoprostenol or nitric oxide, methylene blue, embolization of abnormal pulmonary vessels, and extracorporeal life support. Availability and use of this pragmatic algorithm may improve management of this complication, and will benefit from prospective validation.

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Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database

Cited by 400 publications

References 22 publications

Extracorporeal membrane oxygenation (ECMO) in severe adult respiratory distress syndrome

Extracorporeal membrane oxygenation (ECMO) in severe adult respiratory distress syndrome

Ventilation during extracorporeal support

Proposed Management Algorithm for Severe Hypoxemia After Liver Transplantation in the Hepatopulmonary Syndrome

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