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ECMO – Extracorporeal membrane oxygenation

ECMO – Extracorporeal membrane oxygenation. SILVA ARIANA | MORAIS CATARINA | PEREIRA DIOGO | SILVA EUNICE | ROCHA HENRIQUE | SILVA JOÃO | JARDIM MÓNICA | SANTOS PEDRO | MARTINS RITA | LOPES RUI | CLASS9. Support in critically ill adult patients – is its use evidence driven?

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ECMO – Extracorporeal membrane oxygenation

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  1. ECMO – Extracorporealmembraneoxygenation SILVAARIANA | MORAISCATARINA | PEREIRADIOGO | SILVAEUNICE | ROCHAHENRIQUE | SILVAJOÃO |JARDIMMÓNICA | SANTOSPEDRO | MARTINSRITA | LOPESRUI | CLASS9 Support in critically ill adult patients – is its use evidence driven? A META-ANALYSIS Adviser: Prof. Sandra Filipa Canário Almeida Introdução à Medicina II 2010/2011

  2. In what circumstances can ECMO be used ? Introduction Aims • Heartfailure • Heterogenousconditioninwhichtheheartisunable to pumpoutsufficientblood to meetthemetabolicneedsofthe body1. • Criticalillpatients • Individualswhosestateofdiseasemaylead to eminent death3. • Respiratoryinsufficiency • Inadequatesupplyofoxygen to thecellsofthebody, andremovalofcarbon dioxide2. • Respiratoryinsufficiency • Heartfailure Methods • Heartfailure • Heterogenousconditioninwhichtheheartisunable to pumpoutsufficientblood to meetthemetabolicneedsofthe body1. • Respiratoryinsufficiency • Inadequatesupplyofoxygen to thecellsofthebody, andremovalofcarbon dioxide2. • Criticalillpatients • Individualswhosestateofdiseasemaylead to eminent death3. Results Conclusions • Critically ill patient Acknowledgements • Inexistanceofotherformsoftreatmentwhich are likely to besuccessful References • ECMO 1 MeSH Browser [Internet].  MeSH Unique ID: D006333. 2MeSH Browser [Internet].  MeSH Unique ID: D012131. 3 MeSH Browser [Internet].  MeSH Unique ID: D016638. Diagram 1 ECMO’s application.

  3. ECMO and its importance Introduction • Technique used to provide life support to the critically ill; • Temporary support for patients with pulmonary or cardiac failure (or both), when no other form of treatment is likely to be successful [1]; • Expensive therapy, requiring the weighing of its application, instead of other forms of treatment[1]. Aims Methods Results Conclusions Acknowledgements Fig. 1: ECMO system. References Are thereany positive outcomesofthistreatmentincriticalilladultpatients? [1] Marasco SF. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ. 2008;

  4. Past records Introduction • Mechanical circulatory support has evolved markedly since the first successful application of the heart–lung machine in 1953 [2]; • First successful implantation of ECMO , by Robert Bartlett , dates from 1972 [3]; • Used commonly at several specialized hospitals for the treatment of infants and, less frequently, for adults with respiratory or cardiac failure [3]; • Its use in adults remained controversial for some time, due to lower survival rates [4]. Aims Methods Results Conclusions Acknowledgements References • Studies stating satisfactory results in critically ill adults have been published recently. [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 CardiothoracVascAnesth. 2009;

  5. Modalities of ECMO Venoarterial ECMO Introduction • Blood is drawn from the venous system, oxygenated and pumped into the arterialcirculation; • Provides partial or complete support of heart, and allows the oxygenation of blood [3]. Aims Methods Results Conclusions Acknowledgements Extra corporeal References Intra corporeal Fig. 2 Venoarterial ECMO system. Diagram 2 Venoarterial ECMO system. [3] Schmid C. Extracorporeal life support - systems, indications, and limitations. ThoracCardiovasc Surg. 2009.

  6. Modalities of ECMO Venovenous ECMO Introduction • Blood is drained and returned to venous system, providing complete or partial support of the lungs, as long as the cardiac output is sufficient; • Diseased lungs may heal while the potential additional injury of aggressive mechanical ventilation is avoided [3]. Aims Methods Results Conclusions Acknowledgements Extra corporeal References Intra corporeal Fig. 3 Venovenous ECMO system. Diagram 3 Venovenous ECMO system. [3] Schmid C. Extracorporeal life support - systems, indications, and limitations. ThoracCardiovasc Surg. 2009.

  7. Indications for the use of ECMO Introduction More Recommended* More Recommended* More Recommended* More Recommended* Aims Methods Results Less Recommended* Less Recommended* Less Recommended* Conclusions Acknowledgements References * Inpublished 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

  8. Indications for the use of ECMO Introduction More Recommended* More Recommended* More Recommended* More Recommended* Aims Methods Results Less Recommended* Less Recommended* Less Recommended* Less Recommended* Conclusions Acknowledgements References * Inpublished literature [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 CardiothoracVascAnesth. 2009

  9. ECMO support Introduction Aims Methods Results Conclusions Acknowledgements References [7] Peek GJ. CESAR: a multicentrerandomisedcontrolledtrial. Lancet. 2009;

  10. ECMO support Introduction Aims Methods Results Conclusions Acknowledgements References [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.

  11. Aims Introduction MAIN OBJECTIVE Aims • 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). Methods Results Conclusions Acknowledgements OTHER OBJECTIVES References • Evaluate the support of ECMO in the treatment of the least recommended indications in the literature.

  12. Study design Introduction • SYSTEMATIC REVIEW + META-ANALYSIS • Analysis of previously published articles(observational studies and clinical trials). Aims Methods Results Conclusions • 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. Acknowledgements References • A query was created and criteria for selection was defined.

  13. Methods Introduction Aims Methods Results Conclusions Acknowledgements References

  14. Collecting articles Introduction Aims Methods Results Conclusions Acknowledgements References

  15. Collecting articles Introduction • The literature research was conducted using the following Online databases:PubMed/MEDLINE, [http://www.ncbi.nlm.nih.gov/pubmed/];ISI Web of Knowledge [http:// www.isiknowledge.com];SciVerse/SCOPUS[http://www.scopus.com/home.url ]. In order to conduct the literature research it was imperative to develop specific query’s to apply on the chosen databases. The development of the query’s were based in the analysis of the main objective of this article. Aims Methods Results Conclusions Acknowledgements References 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).

  16. Buildingquery • ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction • To include ECMO related articles referring only to adult patients, the following descriptors were applied: Aims Methods Results Conclusions Acknowledgements References

  17. Buildingquery • ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction • To include patients whose state of disease may lead to eminent death, the following descriptors were applied: Aims Methods Results Conclusions Acknowledgements References

  18. Buildingquery • ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction • To include patients whose state of disease may lead to eminent death, the following descriptors were applied: Aims Methods Results Conclusions Acknowledgements References

  19. Buildingquery • ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction Aims Methods Results Conclusions Acknowledgements References PortugueseandSpanishtermswerenotincorporated. Anaditionalresearchrevealedthatsuchterms are noteffective, as theiromittancegavethesameresults. Thepresentedqueryreturned 7 articleswritteninPortugueseand/orSpanish.

  20. Buildingquery • ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction Aims Methods Results Conclusions Acknowledgements References

  21. Buildingquery • ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction Aims Methods Results Conclusions Acknowledgements References PortugueseandSpanishtermswerenotincorporated. Anaditionalresearchrevealedthatsuchterms are noteffective, as theiromittancegavethesameresults. Thepresentedqueryreturned 3 articleswritteninPortugueseand/orSpanish.

  22. Buildingquery • ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction Aims Methods Results Conclusions Acknowledgements References

  23. Buildingquery • ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction Aims Methods Results Conclusions Acknowledgements References PortugueseandSpanishtermswerenotincorporated. Anaditionalresearchrevealedthatsuchterms are noteffective, as theiromittancegavethesameresults. Thepresentedqueryreturned 6 articleswritteninPortugueseand/orSpanish.

  24. Collecting articles Introduction • The research returned: Aims 381 Methods Results 813 Conclusions 970 Acknowledgements • After elimination of duplicates, there was a total of1444: References 2164 Total articles Uniquearticles 1444

  25. Methods Introduction Aims Methods Results Conclusions Acknowledgements References

  26. Firstselectionphase Introduction Aims Methods Results Conclusions Acknowledgements References

  27. Inclusion and exclusion criteria Introduction Aims Methods Results Conclusions Acknowledgements References

  28. First selection phase • Thetitlesandabstractsofthearticleswerereviewedbytworevisors. Introduction Aims Methods 1358 Excluded Results 78 Language1 Conclusions Notavailable2 53 Acknowledgements Articletype3 450 References 398 Notrelevant4 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 Population5 377 Included 86

  29. Methods Introduction Aims Methods Results Conclusions Acknowledgements References

  30. Secondselectionphase Introduction Aims Methods Results Conclusions Acknowledgements References

  31. Second selection phase Introduction • Thearticlewasfullyreviewedbytworevisors. Aims Methods 76 Excluded Results 3 Articletype1 Conclusions Notrelevant2 23 Acknowledgements Controlgroup3 33 References 3 Population4 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 14 Not available5 10 Included

  32. Second selection phase Introduction • In the process of reading full articles, revisors decide if they fulfill the criteria to beincluded. In order to help assess the quality of the article, revisors use the CONSORT [11] (for reporting randomized trials) and STROBE [12] (for reporting observational studies) checklists. Aims Methods Results Conclusions Acknowledgements References [11] von Elm E.The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies]. Rev EspSaludPublica. 2008. [12] Moher D. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. JAMA. 2001.

  33. Second selectionphase Quality evaluation of included publications. Introduction Aims Methods Results Conclusions Acknowledgements References [11] von Elm E.The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies]. Rev EspSaludPublica. 2008. [12] Moher D. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomized trials. JAMA. 2001.

  34. Methods Introduction Aims Methods Results Conclusions Acknowledgements References

  35. Data extraction Introduction Aims Methods Results Conclusions Acknowledgements References

  36. Data extraction Introduction • Google Docswastheplataformusedto buildforms, whichwereused for theextractionof data. Itwasthencompiledusingspss. Aims Methods Results Conclusions Acknowledgements References Fig.3 Image of form used to extract data

  37. Data extraction Table 3 Synthesis table with data from each study. Introduction Aims Methods Results Conclusions Acknowledgements References

  38. Data extraction Introduction • Thevariablesselected for extraction are listedbelow: Aims Methods Results Conclusions Acknowledgements References

  39. Data extraction Introduction • Thefollowcategorieswerecreated to codethe data: Aims Methods Results Conclusions Acknowledgements References

  40. Data extraction • Whenever data wasavailable, subgroupanalysiswouldbeperformedconsidering: Introduction Aims Methods • The primary outcome - Mortality • Subgroup Analysis: Results • Type of intervention; • ECMO vs Control; • Modality of ECMO; • Indication; • Intervention duration Conclusions Acknowledgements References • The primary outcome - Complications • Subgroup Analysis: • Typeofintervention • ECMO vs Control • Modalityof ECMO; • Indication;

  41. Statisticalanalysis Introduction Aims • After data extraction, itwascompiledin a single document in order to simplify its posterior analysis, inReviewManager 5. Methods Results Conclusions Acknowledgements References

  42. Data extraction • STUDY TYPE Introduction Aims • The quality of reviews is influenced by the type of studies found in the articles selected. Clinical trial (1) Methods Results Conclusions Acknowledgements • Consequences: • Less control of the intervention; • Lower valid results. Observational study (9) References

  43. Data extraction • THERAPY Introduction Aims Methods Results • Most control groups used conventional mechanical treatments. Conclusions Mechanical (8) Pharmacological (2) Acknowledgements References

  44. Data extraction • ECMO MODALITY Introduction Aims • It was verified that VV ECMO was more requested, although the frequencies of the use of each modality were similar. Methods Results Conclusions Acknowledgements References

  45. Data extraction • ECMO INDICATIONS Introduction Aims • The main indications observed for the use of ECMO were respiratory. • There were some difficulties categorizing the diagnosis. Methods Results Conclusions Acknowledgements References

  46. Data extraction • ECMO COMPLICATIONS Introduction Aims • ComplicationsweremainlyobservedinECMO’sgroup. • Therewasalmost no reference to theamountofindividualswhosufferedfromeachcomplication. Methods Results Conclusions Acknowledgements References

  47. Mortality rates ANZ ECMO Introduction Beiderlinden M Aims Cianchi G Methods Klotz S Results Lin JW Conclusions Pee GJ Acknowledgements Roch A ECMO group References Controlgroup Schellongowski P Shin TG Taghavi S 0% 25% 50% 75% 100%

  48. Results • RESPIRATORY + CARDIAC INDICATIONS Introduction Aims Methods Results Conclusions Acknowledgements References

  49. Results • RESPIRATORY + CARDIAC INDICATIONS Introduction Aims • There was no statistical difference between ECMO and Control groups. • Studies with a higher N and more control over the intervention would be needed to achieve better conclusions. Methods Results Conclusions Acknowledgements References Does it worth to continue using ECMO over other conventional therapies?

  50. Results • RESPIRATORY INDICATIONS Introduction Aims Methods Results Conclusions Acknowledgements References

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