Evolving outcomes of extracorporeal membrane oxygenation during the first 2 years of the COVID-19 pandemic: a systematic review and meta-analysis

Ryan Ruiyang Ling; Kollengode Ramanathan; Jackie Jia Lin Sim; Suei Nee Wong; Ying Chen; Faizan Amin; Shannon M Fernando; Bram Rochwerg; Eddy Fan; Ryan P Barbaro; Graeme MacLaren; Kiran Shekar; Daniel Brodie

doi:10.1186/s13054-022-04011-2

Evolving outcomes of extracorporeal membrane oxygenation during the first 2 years of the COVID-19 pandemic: a systematic review and meta-analysis

Crit Care. 2022 May 23;26(1):147. doi: 10.1186/s13054-022-04011-2.

Authors

Ryan Ruiyang Ling^#¹, Kollengode Ramanathan^#^{2

3}, Jackie Jia Lin Sim¹, Suei Nee Wong⁴, Ying Chen⁵, Faizan Amin⁶, Shannon M Fernando⁷, Bram Rochwerg^{6

8}, Eddy Fan⁹, Ryan P Barbaro^{10

11}, Graeme MacLaren^{1

12}, Kiran Shekar^#^{13

14

15}, Daniel Brodie^#^{16

17}

Affiliations

¹ Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore.
² Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore. surrkr@nus.edu.sg.
³ Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, Singapore, 119228. surrkr@nus.edu.sg.
⁴ Medical Resource Team, National University of Singapore Libraries, Singapore, Singapore.
⁵ Agency for Science, Technology and Research, Singapore, Singapore.
⁶ Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada.
⁷ Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada.
⁸ Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
⁹ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
¹⁰ Division of Paediatrics Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA.
¹¹ Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI, USA.
¹² Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, National University Health System, Level 9, 1E Kent Ridge Road, Singapore, Singapore, 119228.
¹³ Adult Intensive Care Services, Prince Charles Hospital, Brisbane, QLD, Australia.
¹⁴ Queensland University of Technology, Brisbane, Australia.
¹⁵ University of Queensland, Brisbane and Bond University, Gold Coast, QLD, Australia.
¹⁶ Department of Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.
¹⁷ Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA.

^# Contributed equally.

Abstract

Background: Extracorporeal membrane oxygenation (ECMO) has been used extensively for coronavirus disease 2019 (COVID-19)-related acute respiratory distress syndrome (ARDS). Reports early in the pandemic suggested that mortality in patients with COVID-19 receiving ECMO was comparable to non-COVID-19-related ARDS. However, subsequent reports suggested that mortality appeared to be increasing over time. Therefore, we conducted an updated systematic review and meta-analysis, to characterise changes in mortality over time and elucidate risk factors for poor outcomes.

Methods: We conducted a meta-analysis (CRD42021271202), searching MEDLINE, Embase, Cochrane, and Scopus databases, from 1 December 2019 to 26 January 2022, for studies reporting on mortality among adults with COVID-19 receiving ECMO. We also captured hospital and intensive care unit lengths of stay, duration of mechanical ventilation and ECMO, as well as complications of ECMO. We conducted random-effects meta-analyses, assessed risk of bias of included studies using the Joanna Briggs Institute checklist and evaluated certainty of pooled estimates using GRADE methodology.

Results: Of 4522 citations, we included 52 studies comprising 18,211 patients in the meta-analysis. The pooled mortality rate among patients with COVID-19 requiring ECMO was 48.8% (95% confidence interval 44.8-52.9%, high certainty). Mortality was higher among studies which enrolled patients later in the pandemic as opposed to earlier (1st half 2020: 41.2%, 2nd half 2020: 46.4%, 1st half 2021: 62.0%, 2nd half 2021: 46.5%, interaction p value = 0.0014). Predictors of increased mortality included age, the time of final patient enrolment from 1 January 2020, and the proportion of patients receiving corticosteroids, and reduced duration of ECMO run.

Conclusions: The mortality rate for patients receiving ECMO for COVID-19-related ARDS has increased as the pandemic has progressed. The reasons for this are likely multifactorial; however, as outcomes for these patients evolve, the decision to initiate ECMO should include the best contextual estimate of mortality at the time of ECMO initiation.

Keywords: Coronavirus disease 2019; Extracorporeal membrane oxygenation; Meta-analysis; Mortality; Severe acute respiratory syndrome coronavirus 2.

Publication types

Meta-Analysis
Systematic Review

MeSH terms

Adult
COVID-19* / therapy
Extracorporeal Membrane Oxygenation* / methods
Humans
Intensive Care Units
Pandemics
Respiratory Distress Syndrome* / therapy