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Ave, CESAR, morituri te salutant! (Hail, CESAR, those who are about to die salute you!)

2010; BioMed Central; Volume: 14; Issue: 2 Linguagem: Inglês

10.1186/cc8946

1466-609X

David Wallace, Eric B Milbrandt, Arthur J. Boujoukos,

Respiratory Support and Mechanisms

Expanded AbstractCitationPeek 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 [1].BackgroundSevere 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).MethodsObjectiveWe aimed to delineate the safety, clinical efficacy, and cost-effectiveness of extracorporeal membrane oxygenation (ECMO) compared with conventional ventilation support.DesignRandomized controlled trial.SettingUK-based multicenter trial from July 2001 to August 2006.Subjects180 adults aged 18-65 years with severe (Murray score >3.0 or pH 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.InterventionSubjects were randomly assigned in a 1:1 ratio to receive continued conventional management or referral to consideration for treatment by ECMO.OutcomesThe 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.Results766 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%.ConclusionsWe 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.Trial Registration(ISRCTN47279827)