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 June 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%). 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 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 …”

A case of sepsis‐induced cardiomyopathy successfully treated with venoarterial extracorporeal membrane oxygenation

“… 10 Despite the emerging use of VA ECMO for the treatment of SIC, 10 its use in adults with SIC is not as effective as in children with SIC. 11 The hemodynamic pattern of septic shock differs markedly across age groups: newborn infants typically present with pulmonary hypertension and right heart failure, young children with left heart failure, and adolescents and adults with distributive shock. 12 Recently, Ling et al .…”

“…The survival rates among patients with LVEF >35%, LVEF between 20% and 35%, and LVEF <20% were 32.1%, 42.3%, and 62.0%, respectively. 11 This means that a higher pre‐ECMO LVEF results in lower survival. In septic patients with preserved cardiac function, VA ECMO may be contraindicated due to decreasing cardiac output.…”

“…In septic patients with preserved cardiac function, VA ECMO may be contraindicated due to decreasing cardiac output. 11 , 13 According to the Extracorporeal Life Support Organization interim guidelines for adult cardiac patients, VA ECMO should be initiated within 6 h in patients with cardiogenic shock refractory to conventional pharmacological and fluid therapy and in patients with reversible cardiocirculatory assistance. 10 As Bréchot et al .…”

A Rescue Use of ECPELLA for Sepsis-Induced Cardiogenic Shock Followed by Mitral Valve Replacement

“…A retrospective cohort study confirmed the survival improvement by using extracorporeal membrane oxygenation (ECMO) in the cohort with sepsis-induced cardiogenic shock [3], whereas a recent meta-analysis clarified that ECMO had rather worse outcomes in patients with septic shock without severely decreased cardiac function [4]. ECMO is considered a suitable treatment option in selected patients with severe sepsis-induced cardiogenic shock [2], although the optimal patient selection procedure requires further investigation.…”