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The CESAR trial evaluated a strategy of referral to a specialised ECMO centre compared with conventional ventilatory support in adults with severe but potentially reversible respiratory failure. Although not every patient assigned to the ECMO arm actually received ECMO, the referral strategy improved the primary outcome of death or severe disability at six months. The trial helped establish the value of centralised expertise and specialised rescue pathways for severe respiratory failure. Its importance extends beyond the technology itself: patients in the ECMO arm were managed within a comprehensive high-expertise system, while referral also enabled the use of sophisticated ventilation and rescue therapies. For clinicians, CESAR supports early discussion with an experienced ECMO centre when conventional management is failing and the underlying disease remains potentially reversible. The study also highlights a recurrent issue in critical care evidence—the effect being tested may be a whole system of care rather than a single machine. This is especially relevant when considering ECMO programmes, which require trained multidisciplinary teams, transport capability, anticoagulation expertise, and robust patient-selection processes. The trial remains a landmark reference for the development of regional ECMO networks and for understanding why outcomes may depend as much on systems and expertise as on extracorporeal technology itself.
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The CESAR trial evaluated a strategy of referral to a specialised ECMO centre compared with conventional ventilatory support in adults with severe but potentially reversible respiratory failure. Although not every patient assigned to the ECMO arm actually received ECMO, the referral strategy improved the primary outcome of death or severe disability at six months. The trial helped establish the value of centralised expertise and specialised rescue pathways for severe respiratory failure. Its importance extends beyond the technology itself: patients in the ECMO arm were managed within a comprehensive high-expertise system, while referral also enabled the use of sophisticated ventilation and rescue therapies. For clinicians, CESAR supports early discussion with an experienced ECMO centre when conventional management is failing and the underlying disease remains potentially reversible. The study also highlights a recurrent issue in critical care evidence—the effect being tested may be a whole system of care rather than a single machine. This is especially relevant when considering ECMO programmes, which require trained multidisciplinary teams, transport capability, anticoagulation expertise, and robust patient-selection processes. The trial remains a landmark reference for the development of regional ECMO networks and for understanding why outcomes may depend as much on systems and expertise as on extracorporeal technology itself.
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