Role of extracorporeal membrane oxygenation in children with sepsis: a systematic review and meta-analysis

Kollengode Ramanathan,Luregn J Schlapbach,Ryan Barbaro,Chuen Seng Tan,Graeme Maclaren,Peta Alexander,Nicholas Yeo,Lakshmi Raman

doi:10.1186/s13054-020-03418-z

Abstract

BackgroundThe benefits of extracorporeal membrane oxygenation (ECMO) in children with sepsis remain controversial. Current guidelines on management of septic shock in children recommend consideration of ECMO as salvage therapy. We sought to review peer-reviewed publications on effectiveness of ECMO in children with sepsis.MethodsStudies reporting on mortality in children with sepsis supported with ECMO, published in PubMed, Scopus and Embase from 1972 till February 2020, were included in the review. This study was done in adherence to Preferred Reporting Items for Systematic Review and Meta-Analysis statement after registering the review protocol with PROSPERO. Study eligibility was independently assessed by two authors and disagreements resolved by a third author. Publications were reviewed for quality using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. Random-effects meta-analyses (DerSimonian and Laird) were conducted, and 95% confidence intervals were computed using the Clopper-Pearson method. Outliers were identified by the Baujat plot and leave-one-out analysis if there was considerable heterogeneity. The primary outcome measure was survival to discharge. Secondary outcome measures included hospital length of stay, subgroup analysis of neonatal and paediatric groups, types and duration of ECMO and complications.ResultsOf the 2054 articles screened, we identified 23 original articles for systematic review and meta-analysis. Cumulative estimate of survival (13 studies, 2559 patients) in the cohort was 59% (95%CI: 51–67%). Patients had a median length of hospital stay of 28.8 days, median intensive care unit stay of 13.5 days, and median ECMO duration of 129 h. Children needing venoarterial ECMO (9 studies, 208 patients) showed overall pooled survival of 65% (95%CI: 50–80%). Neonates (< 4 weeks of age) with sepsis needing ECMO (7 studies, 85 neonates) had pooled survival of 73% (95%CI: 56- 87%). Gram positive organisms were the most common pathogens (47%) in septic children supported with ECMO.ConclusionSurvival rates of children with sepsis needing ECMO was 59%. Neonates had higher survival rates (73%); gram positive organisms accounted for most common infections in children needing ECMO. Despite limitations, pooled survival data from this review indicates consideration of ECMO in refractory septic shock for all pediatric age groups.

Highlights

The benefits of extracorporeal membrane oxygenation (ECMO) in children with sepsis remain controversial
Articles were selected for systematic review if they described neonatal and/or pediatric septic patients undergoing venoarterial and venovenous ECMO and the incidence of mortality was clearly stated
Our meta-analysis of observational studies showed that overall survival rates of children with sepsis treated with ECMO were 59%

Summary

Introduction

The benefits of extracorporeal membrane oxygenation (ECMO) in children with sepsis remain controversial. Current guidelines on management of septic shock in children recommend consideration of ECMO as salvage therapy. Sepsis and septic shock remain an important cause of childhood mortality globally despite advances in early detection and appropriate management in Intensive. While current best practice includes the early delivery of sepsis treatment bundles, therapeutic options for children refractory to initial resuscitation remain very limited [7]. Previous sepsis guidelines, including the American College of Critical Care Medicine, recommended consideration for Extracorporeal Membrane Oxygenation (ECMO) for persistent shock in spite of early fluid- and inotrope-based resuscitation [12, 13]. The 2020 Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children recommended venoarterial ECMO as rescue therapy in children with septic shock only if refractory to all other treatments, with a low level of evidence and a weak recommendation [20]

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