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The CESAR study, published in the Lancet is an important paper in the critical care literature. The finding of improved survival without severe disability at 6-months in critically ill patients with severe adult respiratory distress syndrome treated at an ECMO capable centre is arguably proof enough to raise ECMO to standard therapy for severe respiratory failure not responding to conventional therapy. The ANZ ECMO Investigator paper published at the same time in JAMA sets the ideal platform to argue the time has come to build the ECMO capability in 1st world tertiary ICUs. As the southern hemisphere takes stock of the H1N1 surge of severe respiratory failure requiring ventilatory support, it appears that the message is there will be more young adults on ventilators and receiving ECMO in the short-term future. There are a number of points of debate. Of course, the usual questions about CESARs methodology (trial of referral to an ECMO centre, rather than received ECMO, non-standardised conventional ventilation arm etc) exist, and have been addressed in the papers and accompanying editorials. Although the increased length of stay and cost of treatment for ECMO referred patients was discussed by the CESAR investigators, it is arguably the economic and organisational issues around the provision of an ECMO service to a whole population that are most daunting. Of the screened patients 103 were excluded because there was no ECMO bed available, and 5 patients died before they could be put on ECMO. With 180 patients randomised, this suggests there is a long way to go before ECMO is available to all. With 68 from the conventional arm requiring ECMO, and another possible 30 from the 108 It is possible that many of these had other exclusion criteria, with approximately 60% of screened patients excluded for reasons other than lack of bed availability. The other major organisational issue is where should ECMO be administered? The CESAR structure was 1 ECMO capable centre with all the experience and skills. In contrast the ANZ ECMO Investigators reported 15 ECMO centres in 2 countries, of which 4 are heart-lung transplant centres. The 2 models seem to be; 1. The increase in use of ECMO that will occur due to CESAR and H1N1, combined with improved equipment and reduced complications, mean ECMO can be delivered at cardiac surgical centres with adequate case load, multi-site review process to ensure safety. 2. Evidence for efficacy is confined to quarternary centre, and use should be confined to these, with investment in providing service capability that includes referral, retrieval, and the ability to cannulate and commence at the referring site.