Venoarterial Extracorporeal Membranous Oxygenation: Treatment Option for Sepsis-Induced Cardiogenic Shock? A Systematic Review.

Abstract

Clinicians often encounter adult patients with septic shock who fail to respond to fluid therapy and vasopressors. There is an increasing interest in venoarterial extracorporeal membranous oxygenation in the treatment of patients with septic shock, but its outcomes and safety remain unclear. The aim of this study is to describe in-hospital mortality and complication rate in adult patients with septic shock who underwent venoarterial extracorporeal membranous oxygenation, and to identify patients who may potentially benefit from venoarterial extracorporeal membranous oxygenation. The protocol for this systematic review was registered at International Prospective Register of Systematic Reviews (CRD42018098848). We searched MEDLINE, Embase, and Igaku Chuo Zasshi for studies of any design in which patients with septic shock were treated with venoarterial extracorporeal membranous oxygenation. Our search was updated on October 6, 2019. Two independent reviewers assessed whether titles and abstracts met the eligibility criteria. Studies were included when patients met the following criteria: 1) age 18 years old or older; 2) septic shock; and 3) treated with venoarterial extracorporeal membranous oxygenation as hemodynamic support. When there were disagreements between reviewers, the full text was reviewed, and discussion was continued until a consensus was reached. Two authors independently extracted the selected patient and study characteristics and outcomes. A total of 6,457 studies were screened. Six retrospective studies were included. The in-hospital mortality rate of patients with septic shock who underwent venoarterial extracorporeal membranous oxygenation was 76.7% (188/245). Four studies provided cardiac function with left ventricular ejection fraction and/or cardiac index. In two of these four studies where median left ventricular ejection fraction and cardiac index were 16.0% and 1.3 L/min/m and median left ventricular ejection fraction and mean cardiac index were 30.0% and 2.4 L/min/m, respectively, the in-hospital mortalities were markedly lower (14.8% and 28.6%, respectively) than the other two studies (78.1% and 91.5%, respectively) that included populations with median left ventricular ejection fraction of 25.0% and mean cardiac index of 2.1 L/min/m. Complications were reported in five studies (39 events/174 cases), hemorrhage (22 events/174 cases) being the most common. Venoarterial extracorporeal membranous oxygenation remains a controversial treatment strategy in septic shock. The reported in-hospital mortality rates in patients with sepsis-induced cardiogenic shock who underwent venoarterial extracorporeal membranous oxygenation were quite inconsistent. There is a need for well-designed studies to assess the benefit and safety of venoarterial extracorporeal membranous oxygenation in patients with sepsis-induced cardiogenic shock.