RCT

CESAR

Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure

Lancet, 2009 · Multicenter randomized controlled trial across 68 UK hospitals (n=180)

Clinical question

Does referral of severe adult respiratory failure to a specialized ECMO center improve 6-month survival without severe disability compared with conventional ventilation?

Population: Adults with severe but potentially reversible acute respiratory failure (Murray score >= 3.0 or uncompensated hypercapnic acidosis pH < 7.20)
Intervention: Referral to a specialized ECMO center for consideration of VV ECMO and protocolized lung-protective ventilation
Comparator: Continued conventional mechanical ventilation at referring tertiary hospitals
Primary outcome: Death or severe disability at 6 months post-randomization
Result: 63% of patients allocated to the ECMO-referral group survived to 6 months without severe disability compared with 47% allocated to conventional management (relative risk 0.69; 95% CI, 0.50 to 0.97; P=0.03; NNT=6).

What the trial found

Centralized referral to a dedicated ECMO center for severe ARDS significantly improved 6-month survival without severe disability.

Current guideline position

ELSO and ESICM guidelines recommend considering referral to a specialized ECMO center for severe, refractory hypoxemic ARDS.

Clinical interpretation

Established the clinical paradigm of early transfer to high-volume ECMO centers for refractory ARDS.

Clinical Context & Relevant Topics (2)

Disease Reference

ECMO: Physiology, Bedside Management & Troubleshooting

Specialist-level VV/VA ECMO bedside management: selection, cannulation, gas exchange, hemodynamics, anticoagulation, circuit troubleshooting, organ support, ultrasound, ECPR, weaning and decannulation.

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Acute Respiratory Distress Syndrome

Acute, diffuse inflammatory lung injury causing hypoxemia and bilateral infiltrates not fully explained by cardiac failure or fluid overload.

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