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Wenn maschinelle Beatmung nicht mehr ausreicht – venovenöse extrakorporale Membranoxygenierung

When mechanical ventilation fails—Venovenous extracorporeal membrane oxygenation

  • Schwerpunkt: Neue Entwicklungen in der internistischen Intensivmedizin
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Zusammenfassung

Die venovenöse extrakorporale Membranoxygenierung (vv-ECMO) wird bisher vorwiegend als Rescue-Maßnahme bei Patienten im akuten Lungenversagen mit schwerer Oxygenierungs- und/oder Decarboxylierungsstörung angewendet. Venös eingebrachte Kanülen führen Blut durch einen Membranoxygenator, in dem es über Spülgas („sweep gas“) mit Sauerstoff oxygeniert (pO2 bis zu 600 mm Hg) und CO2 eliminiert wird. Die zwei wesentlichen Indikationen für eine vv-ECMO sind nach der bisher größten randomisierten Studie das hypoxische Atemversagen (paO2 < 80 mm Hg für mehr als 6 h) und die refraktäre Hyperkapnie (pH < 7,25 und pCO2 > 60 mm Hg unter einer Beatmungsfrequenz von über 30/min), jeweils unter einer protektive Beatmung beim „acute respiratory distress syndrome“ (ARDS; Δp < 14 mbar, Plateaudruck < 30 mbar, Tidalvolumen VT < 6 ml/kg idealisiertes Körpergewicht). Relative Kontraindikationen sind eine lebenslimitierende Komorbidität oder terminale Lungenerkrankungen, die nicht mittels Lungentransplantation behandelt werden können. Das Alter stellt keine absolute Kontraindikation dar, verschlechtert aber die Prognose, insbesondere bei Coronavirus-disease-2019(COVID-19)-Pneumonien. Zu den häufigsten Komplikationen der vv-ECMO zählen Blutungen, Thrombenbildung und seltener kanülenassoziierte Infektionen. Ein Einsatz bei nichtintubierten Patienten („Wach-ECMO“) ist in seltenen Fällen möglich und insbesondere als „bridge to transplant“ sinnvoll. Einige ECMO-Zentren bieten eine Kanülierung im peripheren Krankenhaus mit anschließendem Transport zum Zentrum („ECMO-Transport“) an. Die COVID-19-Pandemie hat nicht nur zu einer weiteren Verbreitung der vv-ECMO geführt, sondern dieses extrakorporale Verfahren auch in den Blickpunkt der Öffentlichkeit gerückt. Die nahe Zukunft bringt hoffentlich eine deutlich strengere Qualitätskontrolle und eine daraus resultierende Verbesserung im Rahmen der Krankenhausreform, zumal die Technik mit einem erheblichen Ressourcenverbrauch und in den Händen Ungeübter mit einer hohen Mortalität einhergeht.

Abstract

Venovenous extracorporeal membrane oxygenation (VV-ECMO) is predominantly being used as a rescue strategy in patients with acute lung failure, suffering from severe oxygenation and/or decarboxylation impairment. Cannulas introduced into the central veins lead blood through a membrane oxygenator in which it is oxygenated via sweep gas (pO2 up to 600 mm Hg) flow, eliminating CO2. According to the largest randomized studies carried out so far, the two most important indications for VV-ECMO are hypoxic respiratory failure (paO2 < 80 mm Hg for more than 6 h) and refractory hypercapnia (pH < 7.25 und pCO2 > 60 mm Hg with a breathing frequency of >30/min) despite optimal protective mechanical ventilation settings (ARDS, Δp < 14 mbar, plateau pressure < 30 mbar, tidal volume VT < 6 ml/kg idealized body weight). Relative contraindications are life-limiting comorbidities and terminal pulmonary diseases that cannot be treated by lung transplantation. Advanced patient age is not regarded as an absolute contraindication, though it highly impacts ARDS survival rates, especially for pneumonia associated with coronavirus disease 2019 (COVID-19). The most frequent complications of VV-ECMO include bleeding, thrombus formation and rare cases of cannula-associated infections. Its use in nonintubated patients (awake ECMO) is possible in specific cases and has proven valuable as a bridge to lung transplant approach. Some ECMO centers offer cannulation of a patient at primary care hospitals, facilitating subsequent transport to the center (ECMO transport). The COVID-19 pandemic not only caused the number of VV-ECMO runs to skyrocket but has also drawn public attention to this extracorporeal procedure. Strict quality control to improve vvECMO outcomes according to the German hospital reform is urgently needed, especially so since the technique has a high demand in resources and bears significant risks when performed by untrained personnel.

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Abb. 1

Abbreviations

ACT:

„Activated clotting time“

aPTT:

Aktivierte partielle Thromboplastinzeit

ARDS:

„Acute respiratory distress syndrome“

BGA:

Blutgasanalyse

COVID-19:

„Coronavirus disease 2019“

CRI:

„Cannula-related infection“

CTCAE:

Common Terminology Criteria for Adverse Events

ECCO2R:

„Extracorporeal CO2 removal“ (extrakorporale CO2-Entfernung)

ECLS:

„Extracorporeal life support“

ECMO:

Extrakorporale Membranoxygenierung

ELSO:

Extracorporeal Life Support Organization

FIO2 :

Inspiratorische Sauerstofffraktion

IBW:

„Ideal body weight“ (idealisiertes Körpergewicht)

ICB:

Intrakranielle Blutung

ILA:

„Interventional lung assist“

IMV:

„Intermittent mandatory ventilation“

LDH:

Laktatdehydrogenase

MSSA:

Methicillinsensibler Staphylococcus aureus

NCI:

US National Cancer Institute

paCO2 :

Arterieller Kohlendioxidpartialdruck

paO2 :

Arterieller Sauerstoffpartialdruck

PEEP:

Positiver endexspiratorischer Druck

OR:

Odds Ratio

PEEP:

Positiver endexspiratorischer Druck

PMP:

Polymethylpenten

PP:

Polypropylen

PRESERVE:

Predicting Death for Severe ARDS on vv-ECMO

PRESET:

Prediction of Survival on ECMO Therapy

RCT:

Randomisierte, kontrollierte Studie

SIRS:

„Systemic inflammatory response syndrome“

VT :

Tidalvolumen

va:

Venoarteriell

VILI:

„Ventilator-induced lung injury“

vv:

Venovenös

WHO:

World Health Organization

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Authors and Affiliations

  1. Klinik für Innere Medizin V – Pneumologie, Allergologie, Intensivmedizin, Notfallmedizin, ECLS-Center Saar, Universitätsklinik des Saarlandes, Kirrberger Str. 100, 66421, Homburg/Saar, Deutschland

    Sebastian Mang &  Philipp M. Lepper

  2. Lungenklinik Köln-Merheim, Kliniken der Stadt Köln gGmbH, Köln, Deutschland

    Christian Karagiannidis

  3. Universität Witten/Herdecke, Witten/Herdecke, Deutschland

    Christian Karagiannidis

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Correspondence to Philipp M. Lepper.

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S. Mang, C. Karagiannidis und P.M. Lepper geben an, dass kein Interessenkonflikt besteht.

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Mang, S., Karagiannidis, C. & Lepper, P.M. Wenn maschinelle Beatmung nicht mehr ausreicht – venovenöse extrakorporale Membranoxygenierung. Innere Medizin 64, 922–931 (2023). https://doi.org/10.1007/s00108-023-01586-y

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