Less is More: not (always) simple—the case of extracorporeal devices in critical care

Fan, Eddy; Karagiannidis, Christian

doi:10.1007/s00134-019-05726-7

Cited by 5 publications

(5 citation statements)

References 17 publications

(23 reference statements)

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“…The benefit of ECMO in severe ARDS patients has long been debated [24][25][26][27]. Because of highly challenging design and conduct issues, only four randomised trials of extracorporeal life support for adult patients with acute respiratory failure have been performed in the last 5 decades [15,17,28,29].…”

Section: Discussionmentioning

confidence: 99%

ECMO for severe ARDS: systematic review and individual patient data meta-analysis

et al. 2020

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To assess the effect of venovenous extracorporeal membrane oxygenation (ECMO) compared to conventional management in patients with severe acute respiratory distress syndrome (ARDS). Methods: We conducted a systematic review and individual patient data meta-analysis of randomised controlled trials (RCTs) performed after Jan 1, 2000 comparing ECMO to conventional management in patients with severe ARDS. The primary outcome was 90-day mortality. Primary analysis was by intent-to-treat. Results: We identified two RCTs (CESAR and EOLIA) and combined data from 429 patients. On day 90, 77 of the 214 (36%) ECMO-group and 103 of the 215 (48%) control group patients had died (relative risk (RR), 0.75, 95% confidence interval (CI) 0.6-0.94; P = 0.013; I 2 = 0%). In the per-protocol and as-treated analyses the RRs were 0.75 (95% CI 0.6-0.94) and 0.86 (95% CI 0.68-1.09), respectively. Rescue ECMO was used for 36 (17%) of the 215 control patients (35 in EOLIA and 1 in CESAR). The RR of 90-day treatment failure, defined as death for the ECMO-group and death or crossover to ECMO for the control group was 0.65 (95% CI 0.52-0.8; I 2 = 0%). Patients randomised to ECMO had more days alive out of the ICU and without respiratory, cardiovascular, renal and neurological failure. The only significant treatment-covariate interaction in subgroups was lower mortality with ECMO in patients with two or less organs failing at randomization. Conclusions: In this meta-analysis of individual patient data in severe ARDS, 90-day mortality was significantly lowered by ECMO compared with conventional management.

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Section: Discussionmentioning

confidence: 99%

ECMO for severe ARDS: systematic review and individual patient data meta-analysis

et al. 2020

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“…With the ultimate goal of protecting the injured lung, and improving oxygenation, there has been increasing adoption of extracorporeal life support (ECLS) in adult patients with very severe ARDS. Advances in supportive care, innovations in technologies and insights from recent clinical trials have contributed to improved outcomes and a renewed interest in the scope and use of ECLS [ 3 – 5 ].…”

Section: Introductionmentioning

confidence: 99%

Extracorporeal life support for adults with acute respiratory distress syndrome

et al. 2020

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Extracorporeal life support (ECLS) can support gas exchange in patients with the acute respiratory distress syndrome (ARDS). During ECLS, venous blood is drained from a central vein via a cannula, pumped through a semipermeable membrane that permits diffusion of oxygen and carbon dioxide, and returned via a cannula to a central vein. Two related forms of ECLS are used. Venovenous extracorporeal membrane oxygenation (ECMO), which uses high blood flow rates to both oxygenate the blood and remove carbon dioxide, may be considered in patients with severe ARDS whose oxygenation or ventilation cannot be maintained adequately with best practice conventional mechanical ventilation and adjunctive therapies, including prone positioning. Extracorporeal carbon dioxide removal (ECCO 2 R) uses lower blood flow rates through smaller cannulae and provides substantial CO 2 elimination (~ 20–70% of total CO 2 production), albeit with marginal improvement in oxygenation. The rationale for using ECCO 2 R in ARDS is to facilitate lung-protective ventilation by allowing a reduction of tidal volume, respiratory rate, plateau pressure, driving pressure and mechanical power delivered by the mechanical ventilator. This narrative review summarizes physiological concepts related to ECLS, as well as the rationale and evidence supporting ECMO and ECCO 2 R for the treatment of ARDS. It also reviews complications, limitations, and the ethical dilemmas that can arise in treating patients with ECLS. Finally, it discusses future key research questions and challenges for this technology.

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“…27 Advances in supportive care, innovations in technologies, and insights from recent clinical trials have contributed to improved outcomes and a renewed interest in the scope and use of ECLS. [30][31][32][33][34] Current Evidence for the Use of VV ECMO in Severe ARDS Following the first successful clinical use of ECMO in an adult in 1971, 28 it fell into disuse following the negative outcome of the NIH adult ECMO trial. 32 However, Bartlett and colleagues pioneered the continued use of ECMO for neonatal respiratory failure, where it became an evidence-based intervention.…”

Section: Introduction From Ards To Ecmomentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Mechanical Ventilation during ECMO: Lessons from Clinical Trials and Future Prospects

Fior

Colon

Peek

et al. 2022

Semin Respir Crit Care Med

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Acute Respiratory Distress Syndrome (ARDS) accounts for 10% of ICU admissions and affects 3 million patients each year. Despite decades of research, it is still associated with one of the highest mortality rates in the critically ill. Advances in supportive care, innovations in technologies and insights from recent clinical trials have contributed to improved outcomes and a renewed interest in the scope and use of Extracorporeal life support (ECLS) as a treatment for severe ARDS, including high flow veno-venous Extracorporeal Membrane Oxygenation (VV-ECMO) and low flow Extracorporeal Carbon Dioxide Removal (ECCO2R). The rationale being that extracorporeal gas exchange allows the use of lung protective ventilator settings, thereby minimizing ventilator-induced lung injury (VILI). Ventilation strategies are adapted to the patient's condition during the different stages of ECMO support. Several areas in the management of mechanical ventilation in patients on ECMO, such as the best ventilator mode, extubation-decannulation sequence and tracheostomy timing, are tailored to the patients' recovery. Reduction in sedation allowing mobilization, nutrition and early rehabilitation are subsequent therapeutic goals after lung rest has been achieved.

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Less is More: not (always) simple—the case of extracorporeal devices in critical care

Cited by 5 publications

References 17 publications

ECMO for severe ARDS: systematic review and individual patient data meta-analysis

ECMO for severe ARDS: systematic review and individual patient data meta-analysis

Extracorporeal life support for adults with acute respiratory distress syndrome

Mechanical Ventilation during ECMO: Lessons from Clinical Trials and Future Prospects

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