- Journal club critique
- Open Access
Ave, CESAR, morituri te salutant! (Hail, CESAR, those who are about to die salute you!)
© BioMed Central Ltd 2010
- Published: 26 April 2010
Evidence-Based Medicine Journal Club
Edited by: Eric B Milbrandt. University of Pittsburgh Department of Critical Care Medicine
Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM, Hibbert CL, Truesdale A, Clemens F, Cooper N, Firmin RK, Elbourne D: Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009, 374:1351-1363 .
Severe acute respiratory failure in adults causes high mortality despite improvements in ventilation techniques and other treatments (e.g., steroids, prone positioning, bronchoscopy, and inhaled nitric oxide).
We aimed to delineate the safety, clinical efficacy, and cost-effectiveness of extracorporeal membrane oxygenation (ECMO) compared with conventional ventilation support.
Randomized controlled trial.
UK-based multicenter trial from July 2001 to August 2006.
180 adults aged 18-65 years with severe (Murray score >3.0 or pH <7.20) but potentially reversible respiratory failure. Exclusion criteria were: high pressure (>30 cm H2O of peak inspiratory pressure) or high FiO2 (>0.8) ventilation for more than 7 days; intracranial bleeding; any other contraindication to limited heparinization; or any contraindication to continuation of active treatment.
Subjects were randomly assigned in a 1:1 ratio to receive continued conventional management or referral to consideration for treatment by ECMO.
The primary outcome was death or severe disability at 6 months after randomization or before discharge from hospital. Primary analysis was by intention to treat. Only researchers who did the 6-month follow-up were masked to treatment assignment. Data about resource use and economic outcomes (quality-adjusted life-years) were collected. Studies of the key cost generating events were undertaken, and we did analyses of cost-utility at 6 months after randomization and modeled lifetime cost-utility.
766 patients were screened; 180 were enrolled and randomly allocated to consideration for treatment by ECMO (n = 90 patients) or to receive conventional management (n = 90). 68 (75%) patients actually received ECMO; 63% (57/90) of patients allocated to consideration for treatment by ECMO survived to 6 months without disability compared with 47% (41/87) of those allocated to conventional management (relative risk 0.69; 95% CI 0.05-0.97, p = 0.03). Referral to consideration for treatment by ECMO led to a gain of 0.03 quality-adjusted life-years (QALYs) at 6-month follow-up. A lifetime model predicted the cost per QALY of ECMO to be £19 252 (95% CI 7622-59 200) at a discount rate of 3.5%.
We recommend transferring of adult patients with severe but potentially reversible respiratory failure, whose Murray score exceeds 3.0 or who have a pH of less than 7.20 on optimum conventional management, to a centre with an ECMO-based management protocol to significantly improve survival without severe disability. This strategy is also likely to be cost-effective in settings with similar services to those in the UK.
Referral of adult patients with severe respiratory failure to an ECMO-capable facility results in improved 6-month survival without disability and is cost-effective from the standpoint of the UK National Health Service. Replication of the CESAR findings will establish whether the trial describes a limited institutional experience or offers a preferred management strategy for patients with severe respiratory failure.
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