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.

Abstract

Background: While recommended by international societal guidelines in the paediatric population, the use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) as mechanical circulatory support for refractory septic shock in adults is controversial. We aimed to characterise the outcomes of adults with septic shock requiring VA-ECMO, and identify factors associated with survival.Methods: We searched Pubmed, Embase, Scopus and Cochrane databases from inception until 1st April 2021, and included all relevant publications reporting on >5 adult patients requiring VA-ECMO for septic shock. Study quality and certainty in evidence were assessed using the appropriate Joanna Briggs Institute checklist, and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach respectively. The primary outcome was survival to hospital discharge, and secondary outcomes included intensive care unit length of stay, duration of ECMO support, complications while on ECMO, and sources of sepsis. Random-effects meta-analysis (DerSimonian and Laird) were conducted. Data synthesis: We included 14 observational studies with 468 patients in the meta-analysis. Pooled survival was 36.4% (95% confidence interval [CI] :23.6%-50.1%). Survival among patients with left ventricular ejection fraction (LVEF) <20% (62.0%, 95%CI: 51.6%-72.0%) was significantly higher than those with LVEF>35% (32.1%, 95%CI: 8.69%-60.7%, p=0.05). Survival reported in studies from Asia (19.5%, 95%CI: 13.0%-26.8%) was notably lower than those from Europe (61.0%, 95%CI: 48.4%-73.0%) and North America (45.5%, 95%CI: 16.7%-75.8%). Extracorporeal cardiopulmonary resuscitation was associated with reduced chances of survival (Risk ratio: 0.403, 95%CI: 0.197-0.826, p=0.01). GRADE assessment indicated high certainty of evidence for pooled survival.Conclusions: When treated with VA-ECMO, the majority of patients with septic shock and severe sepsis-induced myocardial depression survive. However, VA ECMO has poor outcomes in adults with septic shock but without severe left ventricular depression. VA-ECMO may be a viable treatment option in carefully selected adult patients with refractory septic shock.

Emergency colectomy during mechanical circulatory support for septic cardiomyopathy

“…Survival rates among patients with severely reduced left ventricular ejection fraction (<20%) were 62% in a recent meta-analysis. 3 We described the course of transaminases (Figure 1) that helped to identify acute heart failure at an early stage, and eventually indicated recovery of the patient as a marker of successful right ventricular unloading and adequate systemic perfusion. Slattery and colleagues 4 also reported that abnormal liver function tests were among the first abnormalities in a comparable case.…”

Extracorporeal membrane oxygenation in children: A brief review

“…Outcomes vary with age and clinical presentation, with neonates faring better on ECMO, 14 and those with septic cardiomyopathy responding more favourably than those without. 15 VA ECMO with higher flow is associated with improved survival in paediatric sepsis. 16 As indications for ECMO have expanded, there is also a reciprocal decline in absolute and relative contraindications (Table 2).…”

Similarities in extracorporeal membrane oxygenation management across intensive care unit types in the United States: An analysis of the Extracorporeal Life Support Organization Registry

“…As such, there is robust literature specific to its role in cardiac surgery and the cardiothoracic ICU (CTICU) 17,18 . Recent descriptions show a wide array of use beyond the paradigm of postcardiotomy shock in the CTICU as demonstrated by the advent of specialized respiratory ECMO units, mobile ECMO teams, and multidisciplinary shock teams 1–13,19–22 . It is unknown how expanding indications and novel/non‐CTICU locations may affect the delivery of ECMO given this historical context.…”

“…As indications for extracorporeal membrane oxygenation (ECMO) have expanded, its use among different ICU settings has grown. [1][2][3][4][5][6][7][8][9][10][11][12][13] From its origins in cardiopulmonary bypass and the early respiratory support trials of the 1970s to the recent CESAR and EOLIA era, ECMO has typically been dichotomized into either cardiac or respiratory support. [14][15][16] As such, there is robust literature specific to its role in cardiac surgery and the cardiothoracic ICU (CTICU).…”

“…17,18 Recent descriptions show a wide array of use beyond the paradigm of postcardiotomy shock in the CTICU as demonstrated by the advent of specialized respiratory ECMO units, mobile ECMO teams, and multidisciplinary shock teams. [1][2][3][4][5][6][7][8][9][10][11][12][13][19][20][21][22] It is unknown how expanding indications and novel/non-CTICU locations may affect the delivery of ECMO given this historical context. Importantly, the hospital units where ECMO initiation and maintenance occur have increasingly included non-CTICU locations (i.e.…”