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Bauchlagerung von Patienten an der venovenösen ECMO ist möglich und sicher

Prone positioning of patients during venovenous extracorporeal membrane oxygenation is safe and feasible

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Zusammenfassung

Hintergrund

Für Patienten mit schwerem akuten Lungenversagen (ARDS) konnte ein signifikanter Überlebensvorteil bei der Durchführung von Bauchlagerungen gezeigt werden. Auch Patienten, die mit einer extrakorporalen Membranoxygenierung (ECMO) behandelt werden, könnten davon profitieren. Die Lagerung ist jedoch mit einem potenziell erhöhten Risiko schwerer lagerungsbedingter Komplikationen vergesellschaftet.

Ziel der Arbeit

In dieser Studie sollen die Machbarkeit und die Sicherheit der intermittierenden Bauchlage für Patienten mit schwerem ARDS unter laufender ECMO-Therapie untersucht werden.

Material und Methoden

Wir untersuchten retrospektiv alle Patienten, die zwischen Januar 2009 und August 2013 auf der Interdisziplinären Operativen Intensivstation des Universitätsklinikums Leipzig mit venovenöser (vv)ECMO und Bauchlage behandelt wurden. Basisdaten, Krankenhausletalität und schwere Zwischenfälle wurden erfasst. Als schwere Zwischenfälle wurden Dislokationen oder Obstruktionen von Atemwegszugängen, ECMO-Kanülen und ein Herz-Kreislauf-Stillstand definiert. Ergebnisse werden als Median (1. Quartile; 3. Quartile) angegeben.

Ergebnisse

Es wurden 26 Patienten mit ECMO-Therapie und Bauchlage behandelt. Ursachen des ARDS waren Pneumonien (n = 20), Aspirationen (n = 2) und in 4 Fällen andere seltenere Gründe. Die 26 Patienten wurden 8 (6;11) Tage mit ECMO behandelt. In dieser Zeit führten wir insgesamt 134 Bauchlagerungen durch. Jeder Patient erfuhr im Mittel 5 (3;7) Lagerungsphasen für jeweils 12 (8;12) h. Wir konnten keine schweren Zwischenfälle feststellen. Die Krankenhausletalität betrug 42 %, die Letalität unter ECMO 35 %.

Schlussfolgerung

Bei Patienten mit ECMO-Therapie bei schwerem ARDS fanden wir bei der Anwendung von Bauchlage keine schwerwiegenden Zwischenfälle.

Abstract

Background

Prone positioning of patients with acute respiratory distress syndrome (ARDS) has been shown to significantly improve survival rates. Prone positioning reduces collapse of dorsal lung segments with subsequent reduction of alveolar overdistension of ventral lung segments, optimizes lung recruitment and enhances drainage. Patients with ARDS treated by extracorporeal membrane oxygenation (ECMO) can also benefit from prone positioning; however, the procedure is associated with a possible higher risk of serious adverse events.

Objective

The aim of this study was to evaluate the safety and feasibility of prone positioning for patients with severe ARDS during ECMO therapy.

Material and methods

This study involved a retrospective analysis of all patients placed in a prone position while being treated by venovenous ECMO (vvECMO) for severe hypoxemia in ARDS as bridge to recovery in the interdisciplinary intensive care unit at the University Hospital Leipzig between January 2009 and August 2013. Baseline data, hospital mortality and serious adverse events were documented. Serious adverse events were defined as dislocation or obstruction of endotracheal tube or tracheal cannula, ECMO cannulas and cardiac arrest. Prone positioning was carried out by at least one doctor and three nurses according to a standardized protocol. Results are given as the median (1st and 3rd quartiles).

Results

A total of 26 patients were treated with vvECMO as bridge to recovery due to severe ARDS. Causes for ARDS were pneumonia (n=20) and aspiration (n=2) and four patients had different rare causes of ARDS. The median time on ECMO was 8 days (6;11) and during this period 134 turning events were documented. Patients were proned for a median of 5 (3;7) periods with a median duration of 12 h (8;12). No serious adverse events were recorded. The hospital mortality was 42 % and mortality during the ECMO procedure was 35 %.

Conclusion

Prone positioning significantly reduces the mortality of patients with severe ARDS. In this series of 26 patients with severe ARDS during ECMO therapy no serious adverse events were found during the use of prone positioning.

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Authors and Affiliations

  1. Klinik und Poliklinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Leipzig, Liebigstr. 20, 04107, Leipzig, Deutschland

    M. T. Voelker, N. Jahn, S. Bercker, D. Becker-Rux, S. Köppen, U. X. Kaisers & S. Laudi

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  1. M. T. Voelker
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  2. N. Jahn
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Correspondence to M. T. Voelker.

Ethics declarations

Interessenkonflikt

M.T. Voelker, N. Jahn, S. Bercker, D. Becker-Rux, S. Köppen, U.X. Kaisers und S. Laudi geben an, dass kein Interessenkonflikt besteht.

Alle im vorliegenden Manuskript beschriebenen Untersuchungen wurden mit Zustimmung der zuständigen Ethikkommission, im Einklang mit nationalem Recht sowie gemäß der Deklaration von Helsinki von 1975 (in der aktuellen, überarbeiteten Fassung) durchgeführt. Auf eine Einverständniserklärung der beteiligten Patienten konnte auf Grund des retrospektiven Charakters der Studie gemäß des vorliegenden Ethikkomissionsvotums verzichtet werden.

Auf dem vorhandenen Bildmaterial ist kein Patient zu identifizieren.

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Voelker, M.T., Jahn, N., Bercker, S. et al. Bauchlagerung von Patienten an der venovenösen ECMO ist möglich und sicher. Anaesthesist 65, 250–257 (2016). https://doi.org/10.1007/s00101-015-0131-6

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