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The Cochrane Database of Systematic... 2002Extracorporeal membrane oxygenation (ECMO) is a complex procedure of life support in severe but potentially reversible respiratory failure, used particularly in mature... (Review)
Review
BACKGROUND
Extracorporeal membrane oxygenation (ECMO) is a complex procedure of life support in severe but potentially reversible respiratory failure, used particularly in mature newborn infants. Although the number of babies requiring ECMO is small, and the ECMO policy invasive and potentially expensive, its benefits may be high.
OBJECTIVES
To determine whether ECMO used for neonatal infants with severe respiratory failure is clinically effective and cost-effective compared to a policy of conventional ventilatory support.
SEARCH STRATEGY
The Cochrane Neonatal Group Specialised Register, the Cochrane Controlled Trials Register, and MEDLINE were searched for 1974 to 2001.
SELECTION CRITERIA
All randomised trials comparing neonatal ECMO to conventional ventilatory support.
DATA COLLECTION AND ANALYSIS
The authors independently evaluated the trials for methodological quality and appropriateness for inclusion in the Review (without consideration of their results), and then independently extracted the data.
MAIN RESULTS
The three trials from the USA and one from the UK recruited clinically similar groups of babies. Two trials excluded infants with congenital diaphragmatic hernias. In two, transfer for ECMO implied transport over a considerable distance. One study included an economic evaluation. Two trials had follow up information. All except the UK trial had very small numbers of patients. Two of the trials used conventional randomisation with low potential for bias. The other two used less usual designs which have led to difficulties in their interpretation. All four trials showed a strong benefit of ECMO on mortality (RR 0.44; 95% CI 0.31 to 0.61), especially for babies without congenital diaphragmatic hernia (RR 0.33, 95% CI 0.21 to 0.53). Only the UK trial provided information about death or disability at one and four years, and showed benefit of ECMO at one year (RR 0.56, 95% CI 0.40 to 0.78), and at four years (RR 0.62, 95% CI 0.45 to 0.86). Overall nearly half of the children had died or were severely disabled at four years of age, reflecting the severity of their underlying conditions. Based on economic analysis from the UK trial, the ECMO policy is as cost-effective as other intensive care technologies in common use.
REVIEWER'S CONCLUSIONS
A policy of using ECMO in mature infants with severe but potentially reversible respiratory failure would result in significantly improved survival without increased risk of severe disability amongst survivors. For babies with diaphragmatic hernia ECMO offers short term benefits but the overall effect of employing ECMO in this group is not clear. Further studies are needed to refine ECMO techniques; to consider the optimal timing for introducing ECMO; to identify which infants are most likely to benefit; and to address the longer term implications of neonatal ECMO during later childhood and adult life.
Topics: Extracorporeal Membrane Oxygenation; Humans; Infant, Newborn; Randomized Controlled Trials as Topic; Respiratory Insufficiency
PubMed: 11869599
DOI: 10.1002/14651858.CD001340 -
The Cochrane Database of Systematic... 2000Congenital diaphragmatic hernia, although rare (1 per 2-4,000 births), is associated with high mortality and cost. Opinion regarding the timing of surgical repair has... (Review)
Review
BACKGROUND
Congenital diaphragmatic hernia, although rare (1 per 2-4,000 births), is associated with high mortality and cost. Opinion regarding the timing of surgical repair has gradually shifted from emergent repair to a policy of stabilization using a variety of ventilatory strategies prior to operation. Whether delayed surgery is beneficial remains controversial.
OBJECTIVES
To summarize the available data regarding whether surgical repair in the first 24 hours after birth rather than later than 24 hours of age improves survival to hospital discharge in infants with congenital diaphragmatic hernia who are symptomatic at or immediately after birth.
SEARCH STRATEGY
Search of Medline (1966-1999), Embase (1978-1999) and the Cochrane databases using the terms "congenital diaphragmatic hernia" and "surg*"; citations search, and contact with experts in the field to locate other published and unpublished studies.
SELECTION CRITERIA
Studies were eligible for inclusion if they were randomized or quasi-randomized trials that addressed infants with CDH who were symptomatic at or shortly after birth, comparing early (<24 hours) vs late (>24 hours) surgical intervention, and evaluated mortality as the primary outcome.
DATA COLLECTION AND ANALYSIS
Data were collected regarding study methods and outcomes including mortality, need for ECMO and duration of ventilation, both from the study reports and from personal communication with investigators. Analysis was performed in accordance with the standards of the Cochrane Neonatal Review Group.
MAIN RESULTS
Two trials met the pre-specified inclusion criteria for this review. Both were small trials (total n<90) and neither showed any significant difference between groups in mortality. Meta-analysis was not performed because of significant clinical heterogeneity between the trials.
REVIEWER'S CONCLUSIONS
There is no clear support for either immediate (within 24 hours of birth) or delayed (until stabilized) repair of congenital diaphragmatic hernia, but a substantial advantage to either one cannot be ruled out. A large, multicenter randomized trial would be needed to answer this question.
Topics: Age Factors; Hernia, Diaphragmatic; Hernias, Diaphragmatic, Congenital; Humans; Infant, Newborn; Length of Stay; Prognosis; Randomized Controlled Trials as Topic; Time Factors
PubMed: 10908506
DOI: 10.1002/14651858.CD001695