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. 2023 Sep 26;9(9):CD010381.
doi: 10.1002/14651858.CD010381.pub3.

Extracorporeal membrane oxygenation for critically ill adults

Aidan Burrell  1   2 , Jiwon Kim  1 , Patricia Alliegro  1 , Lorena Romero  3 , Ary Serpa Neto  1   4 , Frederick Mariajoseph  1 , Carol Hodgson  1   5
Affiliations

Extracorporeal membrane oxygenation for critically ill adults

Aidan Burrell et al. Cochrane Database Syst Rev. .

Abstract

Background: Extracorporeal membrane oxygenation (ECMO) may provide benefit in certain populations of adults, including those with severe cardiac failure, severe respiratory failure, and cardiac arrest. However, it is also associated with serious short- and long-term complications, and there remains a lack of high-quality evidence to guide practice. Recently several large randomized controlled trials (RCTs) have been published, therefore, we undertook an update of our previous systematic review published in 2014.

Objectives: To evaluate whether venovenous (VV), venoarterial (VA), or ECMO cardiopulmonary resuscitation (ECPR) improve mortality compared to conventional cardiopulmonary support in critically ill adults.

Search methods: We used standard, extensive Cochrane search methods. The latest search date was March 2022. The search was limited to English language only.

Selection criteria: We included RCTs, quasi-RCTs, and cluster-RCTs that compared VV ECMO, VA ECMO or ECPR to conventional support in critically ill adults.

Data collection and analysis: We used standard Cochrane methods. Our primary outcome was 1. all-cause mortality at day 90 to one year. Our secondary outcomes were 2. length of hospital stay, 3. survival to discharge, 4. disability, 5. adverse outcomes/safety events, 6. health-related quality of life, 7. longer-term health status, and 8. cost-effectiveness. We used GRADE to assess certainty of evidence.

Main results: Five RCTs met our inclusion criteria, with four new studies being added to the original review (total 757 participants). Two studies were of VV ECMO (429 participants), one VA ECMO (41 participants), and two ECPR (285 participants). Four RCTs had a low risk of bias and one was unclear, and the overall certainty of the results (GRADE score) was moderate, reduced primarily due to indirectness of the study populations and interventions. ECMO was associated with a reduction in 90-day to one-year mortality compared to conventional treatment (risk ratio [RR] 0.80, 95% confidence interval [CI] 0.70 to 0.92; P = 0.002, I2 = 11%). This finding remained stable after performing a sensitivity analysis by removing the single trial with an uncertain risk of bias. Subgroup analyses did not reveal a significant subgroup effect across VV, VA, or ECPR modes (P = 0.73). Four studies reported an increased risk of major hemorrhage with ECMO (RR 3.32, 95% CI 1.90 to 5.82; P < 0.001), while two studies reported no difference in favorable neurologic outcome (RR 2.83, 95% CI 0.36 to 22.42; P = 0.32). Other secondary outcomes were not consistently reported across the studies.

Authors' conclusions: In this updated systematic review, which included four additional RCTs, we found that ECMO was associated with a reduction in day-90 to one-year all-cause mortality, as well as three times increased risk of bleeding. However, the certainty of this result was only low to moderate, limited by a low number of small trials, clinical heterogeneity, and indirectness across studies.

PubMed Disclaimer

Conflict of interest statement

AB is supported by a National Health and Medical Research Council (NHMRC) emerging leader scholarship, and is a chief investigator on the BLENDER RCT (high versus low dose oxygen in patients on VA ECMO) funded by the Medical Research Future Fund (MRFF), and the REDEEM RCT (VV ECMO in moderate to severe acute respiratory failure) funded by the MRFF.

JK: none.

PA: none.

LR: none.

ASN: none.

FM: none.

CH leads the binational ECMO registry in Australia and New Zealand, funded by the NHMRC and the Heart Foundation. She also leads the ECMO‐Rehab RCT, funded by the MRFF, and is a chief investigator on the BLENDER RCT (high versus low dose oxygen in patients on VA‐ECMO) also funded by the MRFF.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1: All‐cause mortality: day 90 to 1 year, Outcome 1: All‐cause mortality: day 90 to 1 year
2.1
2.1. Analysis
Comparison 2: Major hemorrhage, Outcome 1: Major hemorrhage
3.1
3.1. Analysis
Comparison 3: Neurologic outcome, Outcome 1: Neurologic outcome (Cerebral Performance Category at 6 months)
See this image and copyright information in PMC

Update of

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