Transcript ECMO – Extra coporeal membrane oxygenation

ECMO – Extracorporeal
membrane oxygenation
Support in critically ill adult patients – is its use evidence driven?
A META-ANALYSIS
SILVAARIANA | MORAISCATARINA | PEREIRADIOGO | SILVAEUNICE | ROCHAHENRIQUE |
SILVAJOÃO |JARDIMMÓNICA | SANTOSPEDRO | MARTINSRITA | LOPESRUI | CLASS9
Adviser: Prof. Sandra Filipa Canário Almeida
Introdução à Medicina II
2010/2011
In what circumstances can
ECMO be used ?
Introduction
Aims
Heart failure
Respiratory
insufficiency
Heart
failure
Heart
failure
Critical
ill patients
Respiratory
insufficiency
Methods
> Heterogenous condition in which the
> Individuals
Heterogenous
condition
ofin
Inadequate
supply
of sufficient
oxygen
heart is unablewhose
to
pump state
out
blood
to the
meet
the
metabolic
needs
which
heart
unable
toof
disease
may
eminent
to
the
cells
oflead
theisto
body,
and
Critically ill patient
the body1.
pump out
blood to
death
.insufficiency
removal
ofsufficient
carbon dioxide
.
Respiratory
3
Inexistance of other forms of treatment
which are likely to be successful
Results
Conclusions
2
> Inadequate
of oxygen
to the of
cells
meet thesupply
metabolic
needs
of the body, and removal of carbon
1.
body
2
Acknowledgements
References
the .
dioxide
Critical ill patients
> Individuals whose state of disease may
ECMO
lead to eminent death3.
1 MeSH
Browser [Internet]. MeSH Unique ID: D006333.
MeSH Browser [Internet]. MeSH Unique ID: D012131.
3 MeSH Browser [Internet]. MeSH Unique ID: D016638.
2
Diagram 1 ECMO’s application.
2
ECMO and its importance
Introduction
> Technique used to provide life support to the critically ill;
Aims
> Temporary support for patients with pulmonary or
Methods
cardiac failure (or both), when no other form of
Results
treatment is likely to be successful [1];
Conclusions
> Expensive therapy, requiring the weighing of its
application, instead of other forms of treatment [1].
Acknowledgements
Fig. 1: ECMO system.
References
Are there any positive outcomes of this treatment
in critical ill adult patients?
[1] Marasco SF. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ. 2008;
3
Past records
Introduction
> Mechanical circulatory support has evolved markedly since the first
successful application of the heart–lung machine in 1953 [2];
Aims
> First successful implantation of ECMO , by Robert Bartlett , dates from 1972
Methods
[3];
Results
> Used commonly at several specialized hospitals for the treatment of infants
Conclusions
and, less frequently, for adults with respiratory or cardiac failure [3];
> Its use in adults remained controversial for some time, due to lower survival
Acknowledgements
rates [4].
References
Studies stating satisfactory results in critically ill adults have been published recently.
4
[2] Lindstrom SJ. Extracorporeal membrane oxygenation. Med J Aust. 2009; [3] Schmid C. Extracorporeal life support - systems, indications, and
limitations. Thorac Cardiovasc Surg. 2009; [4] Sidebotham D. Extracorporeal membrane oxygenation for treating severe cardiac and respiratory
disease in adults: Part 1-overview of extracorporeal membrane oxygenation. J Cardiothorac Vasc Anesth. 2009;
Modalities of ECMO
Venoarterial ECMO
> Blood is drawn from the venous
Blood is
removed
from venous
system
CO2
extracted
from blood
system, oxygenated and pumped into
Introduction
Aims
Methods
the arterial circulation;
Results
> Provides partial or complete support
of heart, and allows the oxygenation
of blood [3].
Fig. 2
Venoarterial
ECMO system.
Blood
reaches the
cells of the
body
Blood
oxygenated
Conclusions
Acknowledgements
Blood
returns to
arterial
system
Diagram 2 Venoarterial ECMO system.
[3] Schmid C. Extracorporeal life support - systems, indications, and limitations. Thorac Cardiovasc Surg. 2009.
References
5
Modalities of ECMO
Venovenous ECMO
> Blood is drained and returned to
Blood is
removed
from venous
system
CO2
extracted
from blood
venous system, providing complete or
> Diseased lungs may heal while the
potential additional injury of aggressive
mechanical ventilation is avoided [3].
Fig. 3
Venovenous
ECMO system.
Aims
Methods
partial support of the lungs, as long as
the cardiac output is sufficient;
Introduction
Results
Blood
reaches the
cells of the
body
Blood
oxygenated
Conclusions
Acknowledgements
Blood
returns to
venous
system
Diagram 3 Venovenous ECMO system.
[3] Schmid C. Extracorporeal life support - systems, indications, and limitations. Thorac Cardiovasc Surg. 2009.
References
6
Coronary artery bypass graft surgery and valve replacement [4];
Post-cardiotomy and primary graft failure after heart transplant [5].
Severe cardiac failure (e.g. myocarditis, decompensated
cardiomyopathy, acute coronary syndrome with cardiogenic shock,
sepsis, drug related) [1], [4];
Severe trauma with coexisting bleeding shock [6].
Introduction
Less Recommended*
Bridge for patients with end-stage heart failure to heart transplant [3];
More Recommended*
Cardiac
indications
Indications for the use of ECMO
Conclusions
Aims
Methods
Results
Acknowledgements
References
* In published
literature
[1] Marasco SF. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ. 2008; [3] Schmid
C. Extracorporeal life support - systems, indications, and limitations. Thorac Cardiovasc Surg. 2009; [4] Sidebotham D. Extracorporeal membrane
oxygenation for treating severe cardiac and respiratory disease in adults: Part 1--overview of extracorporeal membrane oxygenation. J
Cardiothorac Vasc Anesth. 2009; [5] Fiser SM. When to discontinue extracorporeal membrane oxygenation for postcardiotomy support. Ann
Thorac Surg. 2001; [6] Arlt M. Extracorporeal membrane oxygenation in severe trauma patients with bleeding shock. Resuscitation. 2010
7
Adult respiratory distress syndrome (ARDS) [1];
Bridge for lung transplantation and primary graft failure following it [1];
Severe pneumonia and sepsis [1];
Reversable respiratory failure causes (e.g. aspiration pneumonitis,
asthma, near drowning, and Wegener granulomatosis)[4].
More
MoreRecommended*
Recommended* Less Recommended*
Respiratory
indications
Indications for the use of ECMO
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
* In published
literature
8
[1] Marasco SF. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ. 2008;
[4] Sidebotham D. Extracorporeal membrane oxygenation for treating severe cardiac and respiratory disease in adults: Part 1--overview of
extracorporeal membrane oxygenation. J Cardiothorac Vasc Anesth. 2009
ECMO support
Introduction
ADVANTAGES
Aims
Support of the critically ill patients.
Methods
Successfully implemented in several situations (stated previously);
Results
The benefits of ECMO were seen in the CESAR trial regardless of age, duration of
ventilation, diagnosis, and number of organs failing [7].
The heterogenic data, due to the several indications, and the lack of quality
Conclusions
Acknowledgements
References
randomized trials in adults, difficult the evaluation of the benefits of this
technique.
9
[7] Peek GJ. CESAR: a multicentre randomised controlled trial. Lancet. 2009;
ECMO support
Introduction
DISADVANTAGES
Aims
Mechanical complications (e.g. oxygenator failure, tubing/circuit disruption, pump
Methods
or heat exchanger malfunction, problems with cannula placement/removal) [8];
Results
Bleeding, coagulopathy and haemolysis [2], [8], [9];
Hemorrhages associated with anticoagulation requirements [2], [8], [9];
Compartment syndrome and leg ischemia [2], [9];
Conclusions
Acknowledgements
References
Air embolism, thromboembolism and neurological sequelae [1], [2], [10];
10
[1] Marasco SF. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ. 2008; [2]
Lindstrom SJ. Extracorporeal membrane oxygenation. Med J Aust. 2009; [8] Conrad SA. Extracorporeal Life Support Registry Report 2004. ASAIO
J. 2005; [9] Luo XJ. Extracorporeal membrane oxygenation for treatment of cardiac failure in adult patients. Interact Cardiovasc Thorac Surg.
2009; [10] Rossi M. Cardiopulmonary bypass in man. Ann Thorac Surg. 2004.
Aims
Introduction
MAIN OBJECTIVE
> Determine if the application of the ECMO (Extracorporeal membrane
oxygenation) support is better, in detriment of the usual standard care, in
critically ill adult patients who present cardiac or respiratory failure (or both).
Aims
Methods
Results
Conclusions
Acknowledgements
OTHER OBJECTIVES
References
 Evaluate the support of ECMO in the treatment of the least recommended
indications in the literature.
11
Study design
Introduction
> SYSTEMATIC REVIEW + META-ANALYSIS
× Analysis of previously published articles (observational studies
and clinical trials).
In order to compile as many information published as possible, studies were
sought, particularly those which had examined the application of ECMO in
different cases of critically ill patients.
> A query was created and criteria for selection was defined.
Aims
Methods
Results
Conclusions
Acknowledgements
References
12
Methods
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
13
Collecting articles
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
14
Collecting articles
> The literature research was conducted using the following Online databases:
PubMed/MEDLINE, [http://www.ncbi.nlm.nih.gov/pubmed/];
Introduction
Aims
ISI Web of Knowledge [http:// www.isiknowledge.com];
Methods
SciVerse/SCOPUS [http://www.scopus.com/home.url ].
Results
Conclusions
In order to conduct the literature research it was imperative to develop specific query’s to apply on
Acknowledgements
the chosen databases. The development of the query’s were based in the analysis of the main
objective of this article.
Determine if the application of the ECMO (extracorporeal membrane oxygenation)
support is better, in detriment of the usual standard care, in critically ill adult patients
who present cardiac or respiratory failure (or both).
References
15
Building query
ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE
> To include ECMO related articles referring only to adult patients, the following descriptors were applied:
Introduction
Aims
Methods
‘Extracorporeal membrane
oxygenation’ [MeSH]
‘Adult’ [MeSH]
ENTRY TERMS
BRANCHES
Results
Conclusions
Oxygenation, Extracorporeal Membrane
Aged
Acknowledgements
Extracorporeal Membrane Oxygenations
Aged, 80 and over
Membrane Oxygenation, Extracorporeal
Fair elderly
Membrane Oxygenations, Extracorporeal
Middle aged
Oxygenations, Extracorporeal Membrane
Young adult
ECMO
References
16
Building query
ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE
> To include patients whose state of disease may lead to eminent death, the following descriptors
Introduction
Aims
Methods
were applied:
‘Critical care’ [MeSH]
‘Critical illness’ [MeSH]
Results
ENTRY TERMS
ENTRY TERMS
Conclusions
Critical care
Critical illness(es)
Critical ill
‘Life support care’ [MeSH]
References
‘Respiratory insufficiency’ [MeSH]
Life support care
Respiratory failure / depression
Prolongation of life
Ventilatory depression
Extraordinary treatment(s)
Acknowledgements
17
Building query
ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE
> To include patients whose state of disease may lead to eminent death, the following descriptors
Introduction
Aims
Methods
were applied:
‘Heart failure’ [MeSH]
‘Catastrophic illness’ [MeSH]
Results
ENTRY TERMS
ENTRY TERMS
Conclusions
Cardiac failure
Catastrophic illness(es)
Myocardial failure
Heart failure
Heart decompensation
Congestive heart failure
Acknowledgements
References
‘Acute disease’ [MeSH]
Acute disease(s)
18
Building query
ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE
Introduction
Aims
Methods
Query obtained and applied on PUBMED/MEDLINE
Results
(“Extracorporeal membrane oxygenation"[MeSH] OR "Extracorporeal Life Support") AND
Conclusions
("Adult"[MeSH]) AND ("Acute Disease"[Mesh] OR "Critical Illness"[Mesh] OR "Severe Illness" OR "Critical
Care"[Mesh] OR "Life Support Care"[Mesh] OR "Catastrophic Illness"[Mesh] OR "Heart Failure"[MeSH]
OR "Respiratory Insufficiency"[MeSH])
Acknowledgements
References
19
Portuguese and Spanish terms were not incorporated. An aditional research revealed that such terms are not effective, as their omittance gave
the same results. The presented query returned 7 articles written in Portuguese and/or Spanish.
Building query
ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE
Introduction
Aims
Methods
Concepts presented in full article
TOPICS
ECMO OR Extracorporeal Membrane Oxygenation OR Extracorporeal Life Support
(Acute OR Critical OR Severe OR Catastrophic OR Life Support) AND (Disease OR Diseases OR Illness OR
Illnesses OR Care)
Results
Conclusions
Acknowledgements
References
(adult OR "Young Adult" OR "Middle Age“ OR aged)
20
Building query
ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE
Introduction
Aims
Methods
Query obtained and applied on SCOPUS
Results
(ALL(ecmo OR extracorporeal membrane oxygenation OR extracorporeal life support) AND ALL((acute OR
critical OR severe OR catastrophic OR life support) AND (disease OR diseases OR illness OR illnesses OR
Conclusions
Acknowledgements
care)) AND TITLE-ABS-KEY(ecmo OR "Extracorporeal Membrane Oxygenation")) AND ALL((adult OR
"Young Adult" OR "Middle Age" OR aged))
References
21
Portuguese and Spanish terms were not incorporated. An aditional research revealed that such terms are not effective, as their omittance gave
the same results. The presented query returned 3 articles written in Portuguese and/or Spanish.
Building query
ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE
Introduction
Aims
Definition of the topic
Methods
TOPICS
(ecmo OR extracorporeal membrane oxygenation OR extracorporeal life support)
(acute OR critical OR severe OR catastrophic OR life support) AND
(disease OR diseases OR illness OR illnesses OR care)
Definition of the target group and thematic scope
Results
Conclusions
Acknowledgements
References
REFINED BY
General Categories=( SCIENCE & TECHNOLOGY )
[excluding] Subject Areas=( PEDIATRICS )
22
Building query
ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE
Introduction
Aims
Query obtained and applied on ISI WEB OF KNOWLEDGE
Methods
Results
Topic=(ECMO OR Extracorporeal Membrane Oxygenation OR Extracorporeal Life Support) AND
Topic=((Acute OR Critical OR Severe OR Catastrophic OR Life Support) AND (Disease OR Diseases
OR Illness OR Illnesses OR Care))
Conclusions
Acknowledgements
Refined by: General Categories=( SCIENCE & TECHNOLOGY ) AND [excluding] Subject Areas=(
PEDIATRICS )
References
Timespan=All Years.
23
Portuguese and Spanish terms were not incorporated. An aditional research revealed that such terms are not effective, as their omittance gave
the same results. The presented query returned 6 articles written in Portuguese and/or Spanish.
Collecting articles
Introduction
 The research returned:
Aims
381
Methods
Results
813
Conclusions
970
Acknowledgements
 After elimination of duplicates, there was a total of 1444:
2164
Total articles
Unique articles
References
1444
24
Methods
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
25
First selection phase
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
26
Inclusion and exclusion criteria
Introduction
Inclusion
Criteria
All studies with appropriate data relating to the support
Aims
of ECMO in the treatment of critically ill adult patients;
Methods
Results
Clinical trials and observational studies with control
group.
Conclusions
Acknowledgements
Exclusion
Criteria
Articles not available using UP credentials;
References
Articles without original data (review articles, meta-analysis);
Articles not written in English, Portuguese or Spanish;
Studies reporting out-of-hospital ECMO;
Absense of control group.
27
First selection phase
 The titles and abstracts of the articles were reviewed by two revisors.
Introduction
Aims
1358
Excluded
Language 1
Not available 2
Article type 3
Methods
Results
78
Conclusions
53
Acknowledgements
450
References
4
398
Population 5
377
Not relevant
Included
86
1 – Article not written in English, Portuguese or Spanish
2 – Article not available for consult
3 – Article is not a observational study or clinical trial
4 – Study does not contain relevant data
5 – Population does not have the desired characteristics
28
Methods
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
29
Second selection phase
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
30
Second selection phase
Introduction
 The article was fully reviewed by two revisors.
Aims
76
Excluded
Methods
Results
Article type 1
3
Conclusions
Not relevant
2
23
Acknowledgements
Control group 3
Population 4
Not
available5
Included
33
3
14
10
References
1 – Article is not a observational study or clinical trial
2 – Study does not contain relevant data
3 – No control group was present
4 – Population does not have the desired characteristics
5 - Article not available for consult
31
Second selection phase
Introduction
> In the process of reading full articles, revisors decide if they fulfill the criteria
to be included. In order to help assess the quality of the article, revisors use
Aims
the CONSORT [11] (for reporting randomized trials) and STROBE [12] (for
Methods
reporting observational studies) checklists.
Results
Conclusions
Acknowledgements
References
32
[11] von Elm E.The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies].
Rev Esp Salud Publica. 2008. [12] Moher D. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized
trials. JAMA. 2001.
Second selection phase
Quality evaluation of
included publications.
Author
Checklist
Score (0-22)
Beiderlinden M, et al. [13]
STROBE [11]
18
Cianchi G, et al. [14]
STROBE [11]
19
Shin TG, et al. [15]
STROBE [11]
17
Roch A, et al. [16]
STROBE [12]
15
Peek GJ, et al. [7]
STROBE [11]
18
Klotz S, et al. [17]
STROBE [11]
13
ANZ ECMO et al. [18]
STROBE [11]
17
Lin JW, et al. [19]
STROBE [11]
16
Schellonwgowski P, et al. [20]
STROBE [11]
15
Taghavi S, et al. [21]
STROBE [11]
17
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
33
[11] von Elm E.The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies].
Rev Esp Salud Publica. 2008. [12] Moher D. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group
randomized trials. JAMA. 2001.
Methods
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
34
Data extraction
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
35
Data extraction
Introduction
> Google Docs was the plataform used to build forms, which were used for the
Aims
extraction of data. It was then compiled using spss.
Methods
Results
Conclusions
Acknowledgements
References
36
Fig.3
Image of form used
to extract data
Data extraction
Table 3
Synthesis table with
data from each study.
Introduction
st
1 author
Publication year
Study type
Population: Total Age, median
(ECMO/Control) (ECMO/Control)
Intervention
Comparison
Complications
Outcomes
Aims
Peter
Schellongowski
2011
Observational
study
17 (10/7)
45/38
Veno-venous
50% of patients
Conventional
ECMO (8 patients)
Bleeding occurred died in ECMO
treatment
and Veno-arterial
in 41% of patients group and 71% in
without ECMO
ECMO (2 patients)
control group
45/42
Bleeding (42,9 %
14,3% died in
ECMO group); no
ECMO group; No
complications
deaths in control
referred on
group
control group
Methods
Results
Giovanni Cianchi
Antoine Roch
Jou-Wei Lin
Stefan Klotz
2011
Observational
study
2010
Observational
study
12 (7/5)
18 (9/9)
2010
Observational
study
2007
183 (n=150
Observational
ECMO; n=20 VAD;
study
n=13 ECMO-VAD)
118 (55/63)
49/54
59/60,6
65,9/41,7
VV Ecmo
Conventional
ventilation
VA and VV ECMO Without ECMO
E-CPR
(Extracorporeal
cardiopulmonary
resuscitation)
VA ECMO
C-CPR
(conventional
CPR)
Haemorrhagic
56% died in
complications in ECMO group; 56%
ECMO group
died in control
(44,4%)
group
No referrences
Conclusions
Acknowledgements
References
Survival to
discharge: 29,1%
ECPR, 22,2%
CCPR; Survival at
1 year: 20,0%,
17,5 %
Right heart
failure (25%);
75% died in
Ventricular Assist
Cerebral bleeding ECMO group; 50%
Device (VAD)
(13%); VAD defect died in VAD group
(6%)
37
Data extraction
Introduction
> The variables selected for extraction are listed below:
Aims
Methods
Numerical
Categorical
Results
CONTINUE
NOMINAL
Mortality
Indication
Duration of ECMO
Complication
Age
ECMO modality
Sample size
Control type
Conclusions
Acknowledgements
References
38
Data extraction
Introduction
> The follow categories were created to code the data:
Aims
Methods
ECMO modality
Complications
Indications
Control
Results
VA EMCO
Thromboembolic
Respiratory
Mechanical
VV ECMO
Hemorragic
Cardiac
Pharmacological
Combined
Infectious
Other
Other
Other
Mechanical
Conclusions
Acknowledgements
References
Other
39
Data extraction
> Whenever data was available, subgroup analysis
would be performed considering:
The primary outcome - Mortality
Introduction
Aims
Methods
Results
Subgroup Analysis:
×
Type of intervention;
×
Indication;
×
ECMO vs Control;
×
Intervention duration
×
Modality of ECMO;
Conclusions
Acknowledgements
References
The primary outcome - Complications
Subgroup Analysis:
×
Type of intervention
×
Modality of ECMO;
×
ECMO vs Control
×
Indication;
40
Statistical analysis
Introduction
Aims
> After data extraction, it was compiled
in a single document in order to
Data
Data
Results
simplify its posterior analysis, in
Review Manager 5.
Methods
Data
Conclusions
Acknowledgements
References
ORGANIZED AND
ANALYZED
41
Data extraction
Introduction
STUDY TYPE
>
Clinical trial (1)
The quality of reviews is
influenced by the type
of studies found in the
articles selected.
Aims
Methods
Results
Conclusions
Acknowledgements
> Consequences:
References
x
Less control of the
intervention;
Observational study (9)
x
Lower valid results.
42
Data extraction
THERAPY
Introduction
Aims
Pharmacological (2)
Methods
Results
>
Most control groups used
Conclusions
conventional mechanical
Acknowledgements
treatments.
References
Mechanical (8)
43
Data extraction
ECMO MODALITY
Introduction
Aims
VA ECMO
>
VV ECMO
It was verified that VV
Methods
ECMO was more
Results
requested, although the
Both
frequencies of the use of
MISSNG
each modality were
Other
Conclusions
Acknowledgements
References
similar.
0
1
2
3
44
Data extraction
ECMO INDICATIONS
Introduction
Aims
>
Cardiac indication
The main indications
Methods
observed for the use of
Results
ECMO were respiratory.
Respiratory indication
MISSING
>
There were some
difficulties categorizing the
Other
0
1
2
3
4
5
6
Conclusions
Acknowledgements
References
diagnosis.
45
Data extraction
ECMO COMPLICATIONS
Introduction
Aims
Hemorrhagic
>
Neurological
Complications were mainly
observed in ECMO’s group.
Methods
Results
Thromboembolic
Infectious
>
Mechanical
There was almost no
reference to the amount of
MISSING
individuals who suffered
Other
Conclusions
Acknowledgements
References
from each complication.
0
1
2
3
4
5
6
46
Mortality rates
ANZ ECMO
ECMO group
Beiderlinden M
Introduction
Aims
Control group
Cianchi G
Methods
Klotz S
Results
Lin JW
Conclusions
Pee GJ
Acknowledgements
Roch A
References
Schellongowski P
Shin TG
47
Taghavi S
0%
25%
50%
75%
100%
Results
RESPIRATORY + CARDIAC INDICATIONS
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
48
Results
RESPIRATORY + CARDIAC INDICATIONS
>
There was no statistical difference
between ECMO and Control groups.
Introduction
Aims
Methods
Results
>
Studies with a higher N and more
control over the intervention would be
needed to achieve better conclusions.
Conclusions
Acknowledgements
References
Does it worth to continue using
ECMO over other
conventional therapies?
49
Results
RESPIRATORY INDICATIONS
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
50
Results
RESPIRATORY INDICATIONS
>
There was no statistical difference
between ECMO and Control groups.
Introduction
Aims
Methods
Results
>
Conventional therapies showed better
results than ECMO’s therapies.
Conclusions
Acknowledgements
This data contradicts the
scientific literature.
References
51
Results
CARDIAC INDICATIONS
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
52
Results
CARDIAC INDICATIONS
Introduction
Aims
>
There was no statistical difference
between ECMO and Control groups.
Methods
Results
>
ECMO support showed better results than
ECMO’s treatments.
This data is against the
scientific literature.
Conclusions
Acknowledgements
References
53
Results
CARDIAC INDICATIONS
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
>
Control seems to be advantageous over ECMO.
>
ANZ ECMO et al. has a weight that far exceeds other studies (74,4%).
The results are biased, therefore it is not possible to draw conclusions.
References
54
Cost assessment
> Compared to conventional therapies, ECMO is more expensive;
> According to Peek et al. (2009), this values are relevant to other countries where
ECMO is provided or being considered, although local costs, health services,
Introduction
Aims
Methods
practice, and distances from treatment centers might vary.
Results
Conclusions
Mean*
ECMO
83 354 €
Conventional
management
37 684 €
Cost difference
Acknowledgements
References
45 670 €
+ 121 %
55
*Value per patient in a six months period. Data from Peek et al.
(2009)[7]
Conclusion
Introduction
> The use of ECMO in critically ill adults does not offer any improvement;
Aims
> There is a tendency for ECMO to have better results (lower mortality) in
cardiac indications;
Methods
Results
> Conventional treatments present better results in respiratory indications;
> ECMO has more complications than other therapies;
Conclusions
Acknowledgements
> More clinical trials are needed to establish a more valid assumption.
References
Before embarking on the costly task of instituting an ECMO program for
adults, healthcare systems should carefully evaluate the comparative
effectiveness of ECMO compared with conventional treatments.
56
Study limitations
> Low number of clinical trials compared to the
number of observational studies (1/9);
> Bias inherent to original data from observational
studies could not be eliminated;
> Some articles were not accessible using UP
credentials;
> Lack of data related to indication, complications,
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
among others;
> Individual outcomes were affected by the period
in which they occurred.
57
Acknowledgements
Introduction
“
Aims
We gratefully thank our Professor Filipa Canário for her endeavor
throughout the whole year, whose help allowed us to complete the task
we have been assigned. Moreover, we feel our acknowledgements should
also be directed to Professor Altamiro Pereira, PhD, whose reviews
provided our work an undeniable level of quality.
Methods
Results
Conclusions
Acknowledgements
References
58
References
[1] Marasco SF, Lukas G, McDonald M, McMillan J, Ihle B. Review of ECMO (extra corporeal membrane oxygenation)
support in critically ill adult patients. Heart Lung Circ. 2008; 17 Suppl 4:S41-7
[2] Lindstrom SJ, Pellegrino VA, Butt WW. Extracorporeal membrane oxygenation. Med J Aust. 2009 Aug 3; 191(3):17882
[3] Schmid C, Philipp A, Mueller T, Hilker M. Extracorporeal life support - systems, indications, and limitations. Thorac
Cardiovasc Surg. 2009 Dec; 57(8):449-54
[4] Sidebotham D, McGeorge A, McGuinness S, Edwards M, Willcox T, Beca J. Extracorporeal membrane oxygenation for
treating severe cardiac and respiratory disease in adults: Part 1--overview of extracorporeal membrane oxygenation. J
Cardiothorac Vasc Anesth. 2009 Dec ;23(6):886-92
[5] Fiser SM, Tribble CG, Kaza AK, Long SM, Zacour RK, Kern JA, et al. When to discontinue extracorporeal membrane
oxygenation for postcardiotomy support. Ann Thorac Surg. 2001 Jan;71(1):210-4
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
[6] Arlt M, Philipp A, Voelkel S, Rupprecht L, Mueller T, Hilker M, et al. Extracorporeal membrane oxygenation in severe
trauma patients with bleeding shock. Resuscitation. 2010 Jul; 81(7):804-9
[7] Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, 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 Oct 17; 374(9698):1351-63
[8] Conrad SA, Rycus PT, Dalton H. Extracorporeal Life Support Registry Report 2004. ASAIO J. 2005 Jan-Feb; 51(1):4-10
59
References
[9] Luo XJ, Wang W, Hu SS, Sun HS, Gao HW, Long C, et al. Extracorporeal membrane oxygenation for treatment of
cardiac failure in adult patients. Interact Cardiovasc Thorac Surg. 2009 Aug; 9(2):296-300
[10] Rossi M, Sganga G, Mazzone M, Valenza V, Guarneri S, Portale G, et al. Cardiopulmonary bypass in man: role of the
intestine in a self-limiting inflammatory response with demonstrable bacterial translocation. Ann Thorac Surg. 2004 Feb;
77(2):612-8
[11] von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. [The Strengthening the Reporting of
Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies]. Rev Esp
Salud Publica. 2008 May-Jun;82(3):251-9.
[12] Moher D, Schulz KF, Altman D; CONSORT Group (Consolidated Standards of Reporting Trials). The CONSORT
statement: revised recommendations for improving the quality of reports of parallel-group randomized trials.
JAMA. 2001 Apr 18;285(15):1987-91.
[13] Beiderlinden M, et al. Extracorporeal gas exchange. Intensive Care Medicine. 2006 Oct;32(10):1627-31.
Introduction
Aims
Methods
Results
Conclusions
Acknowledgements
References
[14] Cianchi G, et al. Ventilatory and ECMO treatment of H1N1-induced severe respiratory failure: Results of an Italian
referral ECMO center. BMC Pulmonary Medicine. 2011 Jan 11;11:2.
[15] Shin TG, et al. Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison
with conventional cardiopulmonary resuscitation. Critical Care Medicine. 2011 Jan;39(1):1-7.
60
References
[16] Roch A, et al. Extracorporeal membrane oxygenation for severe influenza A (H1N1) acute respiratory distress
syndrome: A prospective observational comparative study. Intensive Care Medicine. 2010 Nov;36(11):1899-905.
[17] Klotz S, et al. Primary extracorporeal membrane oxygenation versus primary ventricular assist device implantation
in low cardiac output syndrome following cardiac operation. Artificial Organs. 2007 May;31(5):390-4.
[18] ANZ ECMO et al.
[19] Lin JW, et al. Comparing the survival between extracorporeal rescue and conventional resuscitation in adult inhospital cardiac arrests: Propensity analysis of three-year data. Resuscitation. 2010 Jul;81(7):796-803.
Introduction
Aims
Methods
Results
Conclusions
[20] Schellonwgowski P, et al. A surge of flu-associated adult respiratory distress syndrome in an Austrian tertiary care
hospital during the 2009/2010 Influenza A H1N1v pandemic. Wien Klin Wochenschr. 2011 Apr;123(7-8):209-214.
Acknowledgements
[21] Taghavi S, et al. Extracorporeal membrane oxygenation is superior to right ventricular assist device for acute right
ventricular failure after heart Transplantation. Annals of Thoracic Surgery. 2004 Nov;78(5):1644-9.
References
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