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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? - PowerPoint PPT Presentation
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ECMO – Extracorporeal membrane oxygenationSupport in critically ill adult patients – is its use evidence driven?
A META-ANALYSIS
Adviser: Prof. Sandra Filipa Canário Almeida
Introdução à Medicina II2010/2011
SILVAARIANA | MORAISCATARINA | PEREIRADIOGO | SILVAEUNICE | ROCHAHENRIQUE |
SILVAJOÃO |JARDIMMÓNICA | SANTOSPEDRO | MARTINSRITA | LOPESRUI | CLASS9
In what circumstances can ECMO be used ?
2ECMO
Inexistance of other forms of treatment which are likely to be successful
Critically ill patient
Heart failure Respiratory insufficiency
Diagram 1 ECMO’s application.
Heart failure> Heterogenous condition in
which the heart is unable to
pump out sufficient blood to
meet the metabolic needs of
the body1.
1 MeSH Browser [Internet]. MeSH Unique ID: D006333. 2 MeSH Browser [Internet]. MeSH Unique ID: D012131. 3 MeSH Browser [Internet]. MeSH Unique ID: D016638.
Respiratory insufficiency> Inadequate supply of oxygen
to the cells of the body, and
removal of carbon dioxide2.
Critical ill patients> Individuals whose state of
disease may lead to eminent
death3.
Heart failure> Heterogenous condition in which the
heart is unable to pump out sufficient blood to meet the metabolic needs of the body1.
Respiratory insufficiency> Inadequate supply of oxygen to the cells
of the body, and removal of carbon dioxide2.
Critical ill patients> Individuals whose state of disease may
lead to eminent death3.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
ECMO and its importance
3
Are there any positive outcomes of this treatment in critical ill adult patients?
> 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]. Fig. 1: ECMO system.
[1] Marasco SF. Review of ECMO (extra corporeal membrane oxygenation) support in critically ill adult patients. Heart Lung Circ. 2008;
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Past records> 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].
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;
Studies stating satisfactory results in critically ill adults have been published recently.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Modalities of ECMO
> Blood is drawn from the venous
system, oxygenated and pumped into
the arterial circulation;
> Provides partial or complete support
of heart, and allows the oxygenation
of blood [3].
5
Venoarterial ECMO
Diagram 2 Venoarterial ECMO system.
CO2 extracted
from blood
Blood oxygenated
Blood returns to
arterial system
Blood reaches the cells of the
body
Blood is removed
from venous system Extra corporeal
Intra corporeal
Fig. 2 Venoarterial ECMO system.
[3] Schmid C. Extracorporeal life support - systems, indications, and limitations. Thorac Cardiovasc Surg. 2009.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Modalities of ECMO
6
[3] Schmid C. Extracorporeal life support - systems, indications, and limitations. Thorac Cardiovasc Surg. 2009.
> 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].
Venovenous ECMO
Fig. 3 Venovenous ECMO system.
CO2 extracted
from blood
Blood oxygenated
Blood returns to
venous system
Blood reaches the cells of the
body
Blood is removed
from venous system Extra corporeal
Intra corporeal
Diagram 3 Venovenous ECMO system.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Indications for the use of ECMOCa
rdia
c in
dica
tions Bridge for patients with end-stage heart failure to heart transplant [3];
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].
7[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
Less Recom
mended*
More
Recomm
ended*M
ore Recom
mended*
Less Recom
mended*
* In published literature
Less Recom
mended*
More
Recomm
ended*M
ore Recom
mended*
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Indications for the use of ECMO
8
Less Recom
mended*
More
Recomm
ended*M
ore Recom
mended*
Less Recom
mended*
* In published literature
Resp
irato
ry in
dica
tions
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].
Less Recom
mended*
[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
More
Recomm
ended*M
ore Recom
mended*
Less Recom
mended*
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
9
ECMO support
[7] Peek GJ. CESAR: a multicentre randomised controlled trial. Lancet. 2009;
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
ADVANTAGES
Support of the critically ill patients.
Successfully implemented in several situations (stated previously);
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 randomized trials in adults, difficult the evaluation of the benefits of this technique.
10
ECMO supportIntroduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
DISADVANTAGES
Mechanical complications (e.g. oxygenator failure, tubing/circuit disruption, pump or heat exchanger malfunction, problems with cannula placement/removal) [8];
Bleeding, coagulopathy and haemolysis [2], [8], [9];
Hemorrhages associated with anticoagulation requirements [2], [8], [9];
Compartment syndrome and leg ischemia [2], [9];
Air embolism, thromboembolism and neurological sequelae [1], [2], [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
11
> 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).
MAIN OBJECTIVE
OTHER OBJECTIVES
> Evaluate the support of ECMO in the treatment of the least recommended
indications in the literature.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Study design
12
> SYSTEMATIC REVIEW + META-ANALYSIS
× Analysis of previously published articles (observational studies
and clinical trials).
> A query was created and criteria for selection was defined.
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.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Methods
13
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Collecting articles
14
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
> 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 ].
Collecting articles
15
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.
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).
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
> To include ECMO related articles referring only to adult patients, the following descriptors were applied:
Building query
16
ECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE
‘Extracorporeal membrane oxygenation’ [MeSH] ‘Adult’ [MeSH]
ENTRY TERMS BRANCHES
Oxygenation, Extracorporeal Membrane Aged
Extracorporeal Membrane Oxygenations Aged, 80 and over
Membrane Oxygenation, Extracorporeal Fair elderly
Membrane Oxygenations, Extracorporeal Middle aged
Oxygenations, Extracorporeal Membrane Young adult
ECMO
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
> To include patients whose state of disease may lead to eminent death, the following descriptors
were applied:
17
‘Critical care’ [MeSH] ‘Critical illness’ [MeSH]
ENTRY TERMS ENTRY TERMS
Critical care Critical illness(es)
Critical ill
‘Life support care’ [MeSH] ‘Respiratory insufficiency’ [MeSH]
Life support care Respiratory failure / depression
Prolongation of life Ventilatory depression
Extraordinary treatment(s)
Building queryECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
18
‘Heart failure’ [MeSH] ‘Catastrophic illness’ [MeSH]
ENTRY TERMS ENTRY TERMS
Cardiac failure Catastrophic illness(es)
Myocardial failure
Heart failure ‘Acute disease’ [MeSH]
Heart decompensation Acute disease(s)
Congestive heart failure
> To include patients whose state of disease may lead to eminent death, the following descriptors
were applied:
Building queryECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
19Portuguese 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.
Query obtained and applied on PUBMED/MEDLINE
(“Extracorporeal membrane oxygenation"[MeSH] OR "Extracorporeal Life Support") AND ("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])
Building queryECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
20
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)
(adult OR "Young Adult" OR "Middle Age“ OR aged)
Building queryECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
21
Query obtained and applied on SCOPUS
(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 care)) AND TITLE-ABS-KEY(ecmo OR "Extracorporeal Membrane Oxygenation")) AND ALL((adult OR "Young Adult" OR "Middle Age" OR aged))
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 queryECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
22
Definition of the topic
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
REFINED BY
General Categories=( SCIENCE & TECHNOLOGY )
[excluding] Subject Areas=( PEDIATRICS )
Building queryECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
23Portuguese 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.
Query obtained and applied on ISI WEB OF KNOWLEDGE
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))Refined by: General Categories=( SCIENCE & TECHNOLOGY ) AND [excluding] Subject Areas=( PEDIATRICS )Timespan=All Years.
Building queryECMO | CRITICALLY ILL | ADULT PATIENTS | CARDIAC OR RESPIRATORY FAILURE Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Collecting articles
24
> The research returned:
> After elimination of duplicates, there was a total of 1444:
381
813
970
2164
1444Unique articles
Total articles
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Methods
25
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
First selection phase
26
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Inclusion and exclusion criteria
27
Inclusion Criteria All studies with appropriate data relating to the support
of ECMO in the treatment of critically ill adult patients;
Clinical trials and observational studies with control
group.
Exclusion Criteria
Articles not available using UP credentials;
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.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
1358
28
> The titles and abstracts of the articles were reviewed by two revisors.
78
53
398
First selection phase
450
377
Excluded
Language 1
Not available 2
Not relevant 4
Article type 3
Population 5
86Included
1 – Article not written in English, Portuguese or Spanish2 – Article not available for consult3 – Article is not a observational study or clinical trial4 – Study does not contain relevant data5 – Population does not have the desired characteristics
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Methods
29
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Second selection phase
30
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
76
31
> The article was fully reviewed by two revisors.
3
23
3
Second selection phase
33
Excluded
Article type 1
Not relevant 2
Population 4
Control group 3
10Included
1 – Article is not a observational study or clinical trial2 – Study does not contain relevant data3 – No control group was present4 – Population does not have the desired characteristics5 - Article not available for consult
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Not available5 14
> 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
the CONSORT [11] (for reporting randomized trials) and STROBE [12] (for
reporting observational studies) checklists.
Second selection phase
[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.
32
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Second selection phase
[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.
33
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
Quality evaluation of included publications.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Methods
34
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
35
Data extraction
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Data extraction
36
> Google Docs was the plataform used to build forms, which were used for the
extraction of data. It was then compiled using spss.
Fig.3Image of form used to extract data
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Data extraction
37
1st author Publication year Study type Population: Total (ECMO/Control)
Age, median (ECMO/Control) Intervention Comparison Complications Outcomes
Peter Schellongowski 2011 Observational
study 17 (10/7) 45/38Veno-venous
ECMO (8 patients) and Veno-arterial ECMO (2 patients)
Conventional treatment
without ECMOBleeding occurred in 41% of patients
50% of patients died in ECMO
group and 71% in control group
Giovanni Cianchi 2011 Observational study 12 (7/5) 45/42 VV Ecmo Conventional
ventilation
Bleeding (42,9 % ECMO group); no
complications referred on
control group
14,3% died in ECMO group; No deaths in control
group
Antoine Roch 2010 Observational study 18 (9/9) 49/54 VA and VV ECMO Without ECMO
Haemorrhagic complications in
ECMO group (44,4%)
56% died in ECMO group; 56%
died in control group
Jou-Wei Lin 2010 Observational study 118 (55/63) 59/60,6
E-CPR (Extracorporeal
cardiopulmonary resuscitation)
C-CPR (conventional
CPR)No referrences
Survival to discharge: 29,1%
ECPR, 22,2% CCPR; Survival at
1 year: 20,0%, 17,5 %
Stefan Klotz 2007 Observational study
183 (n=150 ECMO; n=20 VAD; n=13 ECMO-VAD)
65,9/41,7 VA ECMO Ventricular Assist Device (VAD)
Right heart failure (25%);
Cerebral bleeding (13%); VAD defect
(6%)
75% died in ECMO group; 50% died in VAD group
Table 3Synthesis table with
data from each study.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Data extraction
38
> The variables selected for extraction are listed below:
Numerical Categorical
CONTINUE NOMINAL
Mortality Indication
Duration of ECMO Complication
Age ECMO modality
Sample size Control type
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Data extraction
39
> The follow categories were created to code the data:
ECMO modality Complications Indications Control
VA EMCO Thromboembolic Respiratory Mechanical
VV ECMO Hemorragic Cardiac Pharmacological
Combined Infectious Other Other
Other Mechanical
Other
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Data extraction
40
> Whenever data was available, subgroup analysis
would be performed considering:
The primary outcome - Mortality
Subgroup Analysis:
× Type of intervention;
× ECMO vs Control;
× Modality of ECMO;
× Indication;
× Intervention duration
× Type of intervention
× ECMO vs Control
× Modality of ECMO;
× Indication;
The primary outcome - Complications
Subgroup Analysis:
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
41
Statistical analysis
ORGANIZED AND ANALYZED
Data
DataData
> After data extraction, it was compiled
in a single document in order to
simplify its posterior analysis, in
Review Manager 5.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Data extraction
42Observational study (9)
Clinical trial (1)
STUDY TYPE
> The quality of reviews is
influenced by the type
of studies found in the
articles selected.
> Consequences:
x Less control of the
intervention;
x Lower valid results.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
43
Data extractionTHERAPY
Mechanical (8)
Pharmacological (2)
> Most control groups used
conventional mechanical
treatments.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
44
Data extractionECMO MODALITY
> It was verified that VV
ECMO was more
requested, although the
frequencies of the use of
each modality were
similar.Other
MISSNG
Both
VV ECMO
VA ECMO
6600tan28a5660 6600tan29a5660 6600tan1a5660 6600tan2a5660
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
45
Data extractionECMO INDICATIONS
> The main indications
observed for the use of
ECMO were respiratory.
> There were some
difficulties categorizing the
diagnosis.
Other
MISSING
Respiratory indication
Cardiac indication
6600tan28a5660 6600tan1a5660 6600tan3a5660 6600tan5a5660
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Other
MISSING
Mechanical
Infectious
Thromboembolic
Neurological
Hemorrhagic
6600tan28a5660 6600tan1a5660 6600tan3a5660 6600tan5a5660
46
Data extractionECMO COMPLICATIONS
> Complications were mainly
observed in ECMO’s group.
> There was almost no
reference to the amount of
individuals who suffered
from each complication.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
47
100%0% 50%
ANZ ECMO
Beiderlinden M
Cianchi G
Klotz S
Lin JW
Pee GJ
Roch A
Schellongowski P
Shin TG
Taghavi S
25% 75%
ECMO group
Control group
Mortality rates
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
48
ResultsRESPIRATORY + CARDIAC INDICATIONS Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
49
ResultsRESPIRATORY + CARDIAC INDICATIONS
> 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.
Does it worth to continue using ECMO over other conventional therapies?
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
50
ResultsRESPIRATORY INDICATIONS Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
51
> There was no statistical difference
between ECMO and Control groups.
> Conventional therapies showed better
results than ECMO’s therapies.
This data contradicts the scientific literature.
ResultsRESPIRATORY INDICATIONS Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
52
ResultsCARDIAC INDICATIONS Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
53
> There was no statistical difference
between ECMO and Control groups.
> ECMO support showed better results than
ECMO’s treatments.
ResultsCARDIAC INDICATIONS
This data is against the scientific literature.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
54
ResultsCARDIAC INDICATIONS
> 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.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Cost assessment
55*Value per patient in a six months period. Data from Peek et al. (2009)[7]
> 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,
practice, and distances from treatment centers might vary.
Mean* Cost difference
ECMO 83 354 €45 670 €
+ 121 %Conventional management 37 684 €
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Conclusion
56
> The use of ECMO in critically ill adults does not offer any improvement;
> There is a tendency for ECMO to have better results (lower mortality) in
cardiac indications;
> Conventional treatments present better results in respiratory indications;
> ECMO has more complications than other therapies;
> More clinical trials are needed to establish a more valid assumption.
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.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Study limitations
57
> 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,
among others;
> Individual outcomes were affected by the period
in which they occurred.
Introduction
Aims
Methods
Results
Conclusions
References
Acknowledgements
Acknowledgements
58
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.
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