Saying no until the moment is right: initiating ECMO in the EOLIA era
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LETTER
Saying no until the moment is right: initiating ECMO in the EOLIA era Graeme MacLaren1,2* , Alain Combes3,4 and Daniel Brodie5,6 © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
The use of extracorporeal membrane oxygenation (ECMO) for refractory acute respiratory distress syndrome (ARDS) has increased considerably over the last decade [1]. The main reasons for this were the apparent benefits of ECMO during the influenza A(H1N1) pandemic of 2009 and the publication of a randomized trial (‘Conventional ventilation or ECMO for severe adult respiratory failure’ or CESAR) in the same year showing reduced mortality in patients treated in an ECMO-capable centre [2, 3]. The methodology of the CESAR trial, however, was criticized because of the lack of standardized management in the control arm and because 25% of patients in the treatment arm did not actually receive ECMO. This led to a new trial, ‘ECMO to Rescue Lung Injury in Severe ARDS’ (EOLIA) [4]. EOLIA had a number of strengths including its international, multicentre design and strict inclusion criteria. The primary outcome was 60-day mortality. Thirty-five percent of the treatment group had died by day 60 vs 46% of the control group (95% CI 0.55–1.04, p = 0.087). There was substantial cross-over (28%) from the control to the treatment arm. This was only permitted in patients with no irreversible multiorgan failure and arterial oxygen saturations (SaO2) 6 h despite mandatory prone positioning, recruitment manoeuvres and pulmonary vasodilators. The secondary endpoint—death or crossover to ECMO—occurred in 57% of the control group (95% CI 0.47–0.82, p 12 h/day [11]. Nonetheless, prone positioning does not appear to be commonly used, with only 16% of patients with severe ARDS being proned in two recent studies [12, 13]. It is noteworthy that 90% of the control group in EOLIA was proned vs 66% of the treatment group and some advocate that even patients on ECMO may have better outcomes when proned [14]. While prone positioning is contraindicated in some ARDS patients, such as those with multitrauma or pregnancy, it is not contraindicated in the majority. It seems misguided to utilize ECMO in ARDS without a trial of prone positioning and it is much simpler and cheaper to try the latter first. The relative investments in building a respiratory ECMO program are not comparable in scope, evidence, or expense to prone positioning.
Other strategies for managing patients with severe ARDS have been more controversial, such as the use of neuromuscular blockade. A randomized trial demonstrated reduced mortality with 48 h of early neuromuscular blockade [15] but a larger, more recent trial did not replicate these findings [13]. Routine neuromuscular blockade is no longer advocated but should still be used on a case-by-case basis. One lesson from EOLIA was that ECMO should be used in severe ARDS only after the current best, evidence-based practices have been attempted [16]. It is important to establish as early as possible when these interventions fail, h
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