CESAR: deliverance or just the beginning?

Extracorporeal membrane oxygenation (ECMO) has been used for over 44 years as a rescue therapy for severe acute respiratory failure that is refractory to mechanical ventilation. The process of establishing the clinical efficacy for this use has a long and fascinating history due to the unique ethical and logistical challenges inherent in this form of support and the patient populations with this disease. In the 1970s and 1980s uncontrolled observational reports suggested clinical benefits with the use of extracorporeal support, but these were not realised in subsequent randomised controlled trials (RCTs). Over the past 40 years, the nature of extracorporeal lung support has evolved and changed. Major developments have included (a) a change in the mode of support from venoarterial to venovenous; (b) variation in the degree of support, from partial to complete; (c) emergence of an appreciation of ventilator-induced lung injury and protective lung ventilation; (d) a substantial reduction in ECMO circuit- and pump-induced complications; (e) a change in staffing and circuit monitoring practices in ECMO care; and (f) a broadening of patient populations considered appropriate for ECMO. These changes have allowed more intensive care units to provide ECMO, and the capacity and preparedness to provide ECMO seem to have increased remarkably in Australia and New Zealand. A recent observational study suggested that, in experienced centres, mortality can be reduced without causing long-term harm