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      Extracorporeal membrane oxygenation for COVID-19: a systematic review and meta-analysis

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          Abstract

          Background

          There are several reports of extracorporeal membrane oxygenation (ECMO) use in patients with coronavirus disease 2019 (COVID-19) who develop severe acute respiratory distress syndrome (ARDS). We conducted a systematic review and meta-analysis to guide clinical decision-making and future research.

          Methods

          We searched MEDLINE, Embase, Cochrane and Scopus databases from 1 December 2019 to 10 January 2021 for observational studies or randomised clinical trials examining ECMO in adults with COVID-19 ARDS. We performed random-effects meta-analyses and meta-regression, assessed risk of bias using the Joanna Briggs Institute checklist and rated the certainty of evidence using the GRADE approach. Survival outcomes were presented as pooled proportions while continuous outcomes were presented as pooled means, both with corresponding 95% confidence intervals [CIs]. The primary outcome was in-hospital mortality. Secondary outcomes were duration of ECMO therapy and mechanical ventilation, weaning rate from ECMO and complications during ECMO.

          Results

          We included twenty-two observational studies with 1896 patients in the meta-analysis. Venovenous ECMO was the predominant mode used (98.6%). The pooled in-hospital mortality in COVID-19 patients (22 studies, 1896 patients) supported with ECMO was 37.1% (95% CI 32.3–42.0%, high certainty). Pooled mortality in the venovenous ECMO group was 35.7% (95% CI 30.7–40.7%, high certainty). Meta-regression found that age and ECMO duration were associated with increased mortality. Duration of ECMO support (18 studies, 1844 patients) was 15.1 days (95% CI 13.4–18.7). Weaning from ECMO (17 studies, 1412 patients) was accomplished in 67.6% (95% CI 50.5–82.7%) of patients. There were a total of 1583 ECMO complications reported (18 studies, 1721 patients) and renal complications were the most common.

          Conclusion

          The majority of patients received venovenous ECMO support for COVID-19-related ARDS. In-hospital mortality in patients receiving ECMO support for COVID-19 was 37.1% during the first year of the pandemic, similar to those with non-COVID-19-related ARDS. Increasing age was a risk factor for death. Venovenous ECMO appears to be an effective intervention in selected patients with COVID-19-related ARDS.

          PROSPERO CRD42020192627.

          Supplementary Information

          The online version contains supplementary material available at 10.1186/s13054-021-03634-1.

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          Most cited references51

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          Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement

          David Moher and colleagues introduce PRISMA, an update of the QUOROM guidelines for reporting systematic reviews and meta-analyses
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            Meta-analysis in clinical trials

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              Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range

              Background In systematic reviews and meta-analysis, researchers often pool the results of the sample mean and standard deviation from a set of similar clinical trials. A number of the trials, however, reported the study using the median, the minimum and maximum values, and/or the first and third quartiles. Hence, in order to combine results, one may have to estimate the sample mean and standard deviation for such trials. Methods In this paper, we propose to improve the existing literature in several directions. First, we show that the sample standard deviation estimation in Hozo et al.’s method (BMC Med Res Methodol 5:13, 2005) has some serious limitations and is always less satisfactory in practice. Inspired by this, we propose a new estimation method by incorporating the sample size. Second, we systematically study the sample mean and standard deviation estimation problem under several other interesting settings where the interquartile range is also available for the trials. Results We demonstrate the performance of the proposed methods through simulation studies for the three frequently encountered scenarios, respectively. For the first two scenarios, our method greatly improves existing methods and provides a nearly unbiased estimate of the true sample standard deviation for normal data and a slightly biased estimate for skewed data. For the third scenario, our method still performs very well for both normal data and skewed data. Furthermore, we compare the estimators of the sample mean and standard deviation under all three scenarios and present some suggestions on which scenario is preferred in real-world applications. Conclusions In this paper, we discuss different approximation methods in the estimation of the sample mean and standard deviation and propose some new estimation methods to improve the existing literature. We conclude our work with a summary table (an Excel spread sheet including all formulas) that serves as a comprehensive guidance for performing meta-analysis in different situations. Electronic supplementary material The online version of this article (doi:10.1186/1471-2288-14-135) contains supplementary material, which is available to authorized users.
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                Author and article information

                Contributors
                ram_ramanathan@nuhs.edu.sg
                Journal
                Crit Care
                Critical Care
                BioMed Central (London )
                1364-8535
                1466-609X
                14 June 2021
                14 June 2021
                2021
                : 25
                : 211
                Affiliations
                [1 ]GRID grid.4280.e, ISNI 0000 0001 2180 6431, Yong Loo Lin School of Medicine, , National University of Singapore, ; Singapore, Singapore
                [2 ]GRID grid.412106.0, ISNI 0000 0004 0621 9599, Cardiothoracic Intensive Care Unit, , National University Heart Centre, National University Hospital, ; Singapore, 119228 Singapore
                [3 ]GRID grid.415184.d, ISNI 0000 0004 0614 0266, Adult Intensive Care Services, , Prince Charles Hospital, ; Brisbane, QLD Australia
                [4 ]GRID grid.1024.7, ISNI 0000000089150953, Queensland University of Technology, ; Brisbane, Australia
                [5 ]GRID grid.1003.2, ISNI 0000 0000 9320 7537, University of Queensland, ; Brisbane, Australia
                [6 ]GRID grid.1033.1, ISNI 0000 0004 0405 3820, Bond University, ; Gold Coast, QLD Australia
                [7 ]GRID grid.214458.e, ISNI 0000000086837370, Division of Paediatric Critical Care Medicine, , University of Michigan, ; Ann Arbor, USA
                [8 ]GRID grid.214458.e, ISNI 0000000086837370, Child Health Evaluation and Research Center, , University of Michigan, ; Ann Arbor, MI USA
                [9 ]GRID grid.4280.e, ISNI 0000 0001 2180 6431, Saw Swee Hock School of Public Health, , National University of Singapore, ; Singapore, Singapore
                [10 ]GRID grid.25073.33, ISNI 0000 0004 1936 8227, Department of Medicine, Division of Critical Care, , McMaster University, ; Hamilton, ON Canada
                [11 ]GRID grid.25073.33, ISNI 0000 0004 1936 8227, Department of Health Research Methods, Evidence and Impact, , McMaster University, ; Hamilton, ON Canada
                [12 ]GRID grid.28046.38, ISNI 0000 0001 2182 2255, Division of Critical Care, Department of Medicine, , University of Ottawa, ; Ottawa, ON Canada
                [13 ]Japan ECMOnet for COVID-19 & President, Kawaguchi Cardiovascular and Respiratory Hospital, Saitama, Japan
                [14 ]GRID grid.17063.33, ISNI 0000 0001 2157 2938, Interdepartmental Division of Critical Care Medicine, , University of Toronto, ; Toronto, Canada
                [15 ]GRID grid.21729.3f, ISNI 0000000419368729, Department of Medicine, , Columbia University College of Physicians and Surgeons, ; New York, NY USA
                [16 ]GRID grid.413734.6, ISNI 0000 0000 8499 1112, Center for Acute Respiratory Failure, , New York-Presbyterian Hospital, ; New York, NY USA
                Author information
                http://orcid.org/0000-0003-1822-9455
                Article
                3634
                10.1186/s13054-021-03634-1
                8201440
                34127027
                a3388c79-c68c-401d-9f84-1d82bda0e75f
                © The Author(s) 2021

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 29 March 2021
                : 7 June 2021
                Categories
                Research
                Custom metadata
                © The Author(s) 2021

                Emergency medicine & Trauma
                extracorporeal membrane oxygenation,acute respiratory distress syndrome,covid-19,sars-cov-2

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