Extracorporeal membrane oxygenation (ECMO) in patients with H1N1 influenza infection: a systematic review and meta-analysis including 8 studies and 266 patients receiving ECMO

Abstract

IntroductionH1N1 influenza can cause severe acute lung injury (ALI). Extracorporeal membrane oxygenation (ECMO) can support gas exchange in patients failing conventional mechanical ventilation, but its role is still controversial. We conducted a systematic review and meta-analysis on ECMO for H1N1-associated ALI.MethodsCENTRAL, Google Scholar, MEDLINE/PubMed and Scopus (updated 2 January 2012) were systematically searched. Studies reporting on 10 or more patients with H1N1 infection treated with ECMO were included. Baseline, procedural, outcome and validity data were systematically appraised and pooled, when appropriate, with random-effect methods.ResultsFrom 1,196 initial citations, 8 studies were selected, including 1,357 patients with confirmed/suspected H1N1 infection requiring intensive care unit admission, 266 (20%) of whom were treated with ECMO. Patients had a median Sequential Organ Failure Assessment (SOFA) score of 9, and had received mechanical ventilation before ECMO implementation for a median of two days. ECMO was implanted before inter-hospital patient transfer in 72% of cases and in most patients (94%) the veno-venous configuration was used. ECMO was maintained for a median of 10 days. Outcomes were highly variable among the included studies, with in-hospital or short-term mortality ranging between 8% and 65%, mainly depending on baseline patient features. Random-effect pooled estimates suggested an overall in-hospital mortality of 28% (95% confidence interval 18% to 37%; I2 = 64%).ConclusionsECMO is feasible and effective in patients with ALI due to H1N1 infection. Despite this, prolonged support (more than one week) is required in most cases, and subjects with severe comorbidities or multiorgan failure remain at high risk of in-hospital death.

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).…”

“…During the H1N1 pandemic, a surge in ECLS use in highly selected patients yielded promising results, leading to a resurgence of interest in its use for severe ARDS. The recently completed Conventional ventilatory support versus Extracorporeal membrane oxygenation for Severe Adult Respiratory failure (CESAR) trial and a systematic review of ECLS for the H1N1 cohort further strengthened its potential role as rescue therapy in ARDS (12,13). However, poor outcomes from historical trials and conflicting results from recent reports have tempered the recent enthusiasm for its use and have reestablished clinical equipoise for ECLS in patients with ARDS (14,15).…”

Severe Influenza Treatment Guideline

“…Most of the studies are case studies most of which are about the pandemic H1N1 in 2009. Reports have shown different mortality rates of severe influenza in which ECMO was applied between 8% and 75%, but the average mortality rate was 32%, indicating a relatively good effect [32][33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49]. Therefore, it is recommended to apply ECMO to an influenza patient presenting continued hypoxia which does not respond to a conventional treatment (BIII).…”

High rate of respiratory MDR gram-negative bacteria in H1N1-ARDS treated with ECMO

“…Infectious complications of ECMO are ranked second after haemorragic complications, and are mainly represented by bloodstream infections (BSI) with Gram-positive cocci (3,4). We report the main clinical and microbiological findings of 16 patients (Table 1) with H1N1-ARDS treated with or without ECMO, according to the Italian guidelines (2,5).…”

“…Dear Editor, During the H1N1 viral respiratory epidemic some patients required admission to the Intensive care unit (ICU) and ECMO was sometimes used after failure of mechanical ventilation (1,2). Infectious complications of ECMO are ranked second after haemorragic complications, and are mainly represented by bloodstream infections (BSI) with Gram-positive cocci (3,4).…”