Original Title: Avis: utilisation de l’oxygénation extracorporelle par membrane (ECMO) chez l’adulte au Québec

Authors' objectives: Extracorporeal membrane oxygenation (ECMO) is a temporary life support technique that provides cardiopulmonary assistance exclusively for the management of patients with refractory and potentially fatal severe cardiac failure or severe respiratory failure. ECMO allows desaturated blood to be pumped into an oxygenator where gas exchange between oxygen and carbon dioxide takes place before blood is returned into the circulation (thus artificially recreating alveolar gas exchange). This technique can temporarily overcome failure of heart or lung functions ensuring adequate oxygenation for a few days, or even weeks or months. There are two main configurations of ECMO depending on the indication: venovenous (VV) ECMO for patients with severe respiratory failure, and venoarterial (VA) ECMO for severe cardiac failure or to provide assistance during cardiopulmonary resuscitation (CPR) following cardiac arrest (know as ECPR). Since the early 2000s, the number patients treated with ECMO has increased, in particular among the adult population, and its application has diversified. However, evidence for clinical benefit compared to conventional therapeutic modalities for the management of severe cardiac or severe respiratory failure remains relatively scarce. Currently in Quebec there is no formal structure or process delineating which centres can or should use ECMO, nor how ECMO services should be organized. It is known, however, that ECMO is currently being used in a number of centres to treat adult patients. The main objective of this work is to develop a set of recommendations to guide the practice and optimal use of ECMO in adult patients (≥ 18 years) in Quebec. This is part of a broader initiative aimed at improving the quality of care and services for critically ill patients, as well as optimizing the use of resources.

Authors' results and conclusions: RESULTS: Based on available evidence, it is at present challenging to make definitive conclusions about the clinical efficacy of ECMO (VA and VV) for patients with severe cardiac or respiratory failure. Current evidence does show that ECPR for in-hospital cardiac arrest could be beneficial, under certain conditions, compared to conventional CPR. For out-of-hospital cardiac arrest, however, the literature does not allow a conclusion to be made about the benefit of ECPR. For all types of ECMO, certain criteria such as age could facilitate the selection of those patients whow would be most likely to benefit from the treatment. In Quebec, ECMO is currently available at 8 adult centres. Consistent with the trend observed worldwide, use of ECMO increased from 21 cases in 2010 to 97 in 2016. The patients being reated or now older (mean age having increased from 40.5 to 54.7 years during the same period), mostly in cardiogenic shock (for 94 of the 178 VA-ECMO patients), having acute respiratory distress syndrome (ARDS) (for 55 of the 68 VV-ECMO patients) or requiring assisted CPR following in-hospital cardiac arrest (for 84 of the 98 ECPR patients). While ECMO services tend to be somewhat organized in recent years, some variations in structure, processes, volumes, indications and outcomes were found. Survival rates have improved over the years, while remaining relatively low, comparable numbers reported in the literature (in 2016, survival was 34.6% for VA-ECMO, 76.5% for VV-ECMO and 35.7% for ECPR). In 2015-2016, the mean cost of hospitalization per patient treated with ECMO was $61,291.78.

Authors' recommendations: The final 18 recommendations are grouped by scope. The first are cross-sectional in scope, relating to topics as service organization (structure), quality assurance and improvement and clinical decision-making (processes). Recommendations regarding the three key indications then follow: first, those relating to the management of severe heart failure; second those for the management of severe respiratory failure; and finally, those that relate to supporting CPR following cardiac arrest. The order of the recommendations presented herein (R1 to R18) does not therefore reflect any order of priority.

Authors' methods: To inform the development of the recommendations, we conducted a systematic literature review and a field evaluation in the “real-world” context of care. The field evaluation among Quebec’s adult ECMO health care centres consisted of: 1) a data collection for all patients treated with ECMO between 2010 and 2016, 2) a survey at the facilities with an ECMO service, 3) interviews with administrators and clinical teams to understand the current organization of services and processes, 4) a group discussion with patients and their family members to obtain their perspective on the shared decision-making process, and 5) an estimate of hospitalization costs for patients treated with ECMO.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/utilisation-de-loxygenation-extracorporelle-par-membrane-ecmo-chez-ladulte-au-quebec.html

Year Published: 2019

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/utilisation-de-loxygenation-extracorporelle-par-membrane-ecmo-chez-ladulte-au-quebec.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec