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Venoarterielle extrakorporale Membranoxygenierung beim präklinischen Herz-Kreislauf-Stillstand

Fallserie prä- und innerklinischer Behandlungen

Venoarterial extracorporeal membrane oxygenation for out-of-hospital cardiac arrest

Case series of prehospital and in-hospital therapys

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Zusammenfassung

Trotz neuer Konzepte und verbesserter Reanimationsmaßnahmen bei Patienten mit präklinischem Herz-Kreislauf-Stillstand ist das Outcome nach konventioneller kardiopulmonaler Reanimation (CPR) weiterhin sehr eingeschränkt. Einen der Hauptgründe stellt eine prolongierte „Low-flow“-Phase während CPR mit insuffizienter Organperfusion dar. In retrospektiven Untersuchungen konnte gezeigt werden, dass bei ausgewählten Patienten durch den frühzeitigen Einsatz einer venoarteriellen extrakorporalen Membranoxygenierung (va-ECMO) unter Reanimation, der sog. extrakorporalen kardiopulmonalen Reanimation (ECPR), eine Verbesserung der Überlebensrate erreicht werden kann. In dieser Fallserie wird das Management von 3 Patienten mit präklinischem Herz-Kreislauf-Stillstand vorgestellt und anhand der gegenwärtigen Literatur kritisch diskutiert. Alle Patienten erlitten einen präklinisch beobachteten Herz-Kreislauf-Stillstand mit umgehender CPR. Bei prolongierter CPR mit Ausbleiben eines „return of spontaneous circulation“ (ROSC) wurde eine vaECMO entweder präklinisch oder nach dem Transport des sich in Reanimation befindlichen Patienten in die Klinik etabliert. Zwei der Patienten verstarben im weiteren Verlauf; eine Patientin wurde nach vollständiger Genesung in die häusliche Umgebung entlassen. Durch den Einsatz einer ECPR bei prolongiertem Herz-Kreislauf-Stillstand ohne ROSC kann das Outcome eines ausgewählten Patientenkollektivs verbessert werden. Die Indikationsstellung erfolgt individuell und sollte vom erfahrenen ECPR-Team anhand definierter Ein- und Ausschlusskriterien gestellt werden. Das Outcome ist hauptsächlich von der Länge und der Qualität der CPR vor ECMO-Anschluss abhängig, sodass die Entscheidungsfindung frühzeitig, z. B. nach Etablierung der Maßnahmen des Advanced Life Support (ca. 10–15 min), erfolgen sollte.

Abstract

Despite new concepts and strategies of basic and advanced life support, the outcome of patients with out-of-hospital cardiac arrest (OHCA) remains poor. The main reason accounting for these poor results is a low-flow phase during conventional cardiopulmonary resuscitation (CPR) with insufficient end organ perfusion. The early use of venoarterial extracorporeal membrane oxygenation (vaECMO) during CPR, i.e. extracorporeal resuscitation (ECPR) might improve OHCA survival rates as well as the neurological outcome in resuscitated patients. This article on a case series discusses the management of ECPR in three patients with OHCA. All patients suffered from a witnessed OHCA and received effective bystander CPR. After subsequent advanced cardiac life support could not achieve a return of spontaneous circulation (ROSC), vaECMO support was established as a bridge to therapy on site or after transportation to a primary or tertiary hospital. During the course of therapy two patients died and one patient was discharged after a full recovery. Early ECPR might improve the outcome in patients with prolonged cardiac arrest without ROSC. The use of ECPR should be based on the individual decision of an experienced ECPR team considering defined inclusion and exclusion criteria. As the outcome mainly depends on the duration and quality of conventional CPR, ECPR support should be requested immediately after establishing advanced life support (approximately 10–15 min).

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Notes

  1. Die Abkürzung 24/7 (gesprochen „twentyfourseven“) bezeichnet die ständige Bereitschaft bzw. Verfügbarkeit einer Dienstleistung oder seltener die Fähigkeit zum Dauerbetrieb eines Gerätes oder einer Maschine.

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Authors and Affiliations

  1. ARDS/ECMO-Zentrum, Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland

    M. Kippnich, C. Lotz M.D., M. Kredel M.D., C. Schimmer M.D., D. Weismann M.D., C. Sommer M.D., P. Kranke M.D., N. Roewer M.D. &  R.M. Muellenbach M.D., MHBA

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  1. M. Kippnich
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  2. C. Lotz M.D.
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  3. M. Kredel M.D.
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  4. C. Schimmer M.D.
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  5. D. Weismann M.D.
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  6. C. Sommer M.D.
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  7. P. Kranke M.D.
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  8. N. Roewer M.D.
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  9. R.M. Muellenbach M.D., MHBA
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Correspondence to R.M. Muellenbach M.D., MHBA.

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M. Kippnich, C. Lotz, M. Kredel, C. Schimmer, D. Weismann, C. Sommer, P. Kranke, N. Roewer und R. M. Muellenbach geben an, dass kein Interessenkonflikt besteht.

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M. Kippnich und C. Lotz teilen sich die Erstautorschaft.

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Kippnich, M., Lotz, C., Kredel, M. et al. Venoarterielle extrakorporale Membranoxygenierung beim präklinischen Herz-Kreislauf-Stillstand. Anaesthesist 64, 580–585 (2015). https://doi.org/10.1007/s00101-015-0058-y

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  • DOI: https://doi.org/10.1007/s00101-015-0058-y

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