Conventional ventilatory support versus Extracorporeal membrane oxygenation for Severe Adult Respiratory failure
CESAR trial design and results
Design
UK multicentre randomised controlled trial with central randomisation
Treatment
Referral to a specialist centre for consideration of ECMO
Control
Continued conventional management at the referring hospital
Population
180 adults aged 18 to 65 with severe but potentially reversible respiratory failure, defined by a Murray score above 3.0 or pH below 7.20
Inclusion criteria
Aged 18 to 65 with severe but potentially reversible respiratory failure: Murray score greater than 3.0, or pH less than 7.20 on optimum conventional management.
Exclusion criteria
Peak inspiratory pressure above 30 cm H2O or FiO2 above 0.8 for more than 7 days; intracranial bleeding; any contraindication to limited heparinisation or to continuation of active treatment.
Follow-up
6 months
Primary endpoint
Death or severe disability at 6 months
Result
57 of 90 (63%) allocated to consideration for ECMO survived to 6 months without disability, versus 41 of 87 (47%) allocated to conventional management — relative risk 0.69 (95% CI 0.05 to 0.97, p=0.03). Only 68 of 90 (75%) of those referred actually received ECMO. The modelled lifetime cost per quality-adjusted life-year was £19,252 (95% CI 7,622 to 59,200).
Secondary endpoints
Quality-adjusted life-years, cost-effectiveness, hospital length of stay
We recommend transferring of adult patients with severe but potentially reversible respiratory failure, whose Murray score exceeds 3.0 or who have a pH of less than 7.20 on optimum conventional management, to a centre with an ECMO-based management protocol to significantly improve survival without severe disability.
The trial authors, in the published abstract
How it has aged
Tests referral to a specialist centre, not ECMO itself — a quarter of those referred never received it, and the control arm had no mandated lung-protective strategy. That confounding is why EOLIA was needed, and why the enduring lesson of CESAR is arguably about regionalisation of care rather than about the circuit.
Publications
Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial
Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009 Oct 17;374(9698):1351-63.
6-month survival without severe disability improved from 47% to 63%
Only 75% of those randomised to ECMO referral actually received ECMO
Control arm was not required to use a lung-protective ventilation strategy
Estimated cost per QALY within the usual UK threshold