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Venoarterielle extrakorporale Membranoxygenierung

Indikationen, Limitationen und praktische Anwendung

Veno-arterial extracorporeal membrane oxygenation

Indications, limitations and practical implementation

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Zusammenfassung

Dank des technischen Fortschritts, insbesondere bei der Weiterentwicklung der Antriebssysteme, Oxygenatoren und Kanülen, ist die venoarterielle extrakorporale Membranoxygenierung (va-ECMO, angloamerikanischer Oberbegriff für extrakorporale Membranoxygenierung: „extracorporeal life support“, ECLS) in den letzten Jahren zunehmend in der Notfall- und Intensivmedizin breiter eingesetzt und intensiver angewendet worden. Neben anerkannten Einsatzgebieten wie periinterventionellem kardialem Versagen in der Herzchirurgie („postcardiotomy low cardiac output syndrome“) wird die va-ECMO auch in anderen Bereichen, z. B. bei Sepsis mit septischer Kardiomyopathie oder im Rahmen der kardiopulmonalen Reanimation eingesetzt. Die grundsätzliche Indikation ist das therapierefraktäre kardiozirkulatorische und kardiopulmonale Versagen. Die va-ECMO überbrückt die eingeschränkte kardiopulmonale Organfunktion („bridging“). Diese Maßnahme stellt somit keine kausale Therapie dar, sondern hilft nur beim zeitlichen Überwinden eines Krankheitsbilds mit dem Ziel der Erholung des betroffenen Organs („bridge to recovery“) oder bei der Entscheidung, die Organfunktion beispielsweise durch ein ventrikuläres „Assist“-System oder durch eine Transplantation zu ersetzen („bridge to decision“). Die ersten Ergebnisse eines erweiterten va-ECMO-Einsatzes sind vielversprechend, dürfen jedoch nicht darüber hinwegtäuschen, dass es sich hierbei um ein invasives Verfahren mit potenziell lebensbedrohlichen Komplikationen handelt. Dementsprechend muss der Einsatz unter Abwägung von Nutzen und Risiken individuell entschieden werden. Die entsprechenden Ressourcen sowie ein kompetentes und erfahrenes (interdisziplinäres) Team sind Voraussetzungen.

Abstract

Due to the technical advances in pumps, oxygenators and cannulas, veno-arterial extracorporeal membrane oxygenation (va-ECMO) or extracorporeal life support (ECLS) has been widely used in emergency medicine and intensive care medicine for several years. An accepted indication is peri-interventional cardiac failure in cardiac surgery (postcardiotomy low cardiac output syndrome). Furthermore, especially the use of va-ECMO for other indications in critical care medicine, such as in patients with severe sepsis with septic cardiomyopathy or in cardiopulmonary resuscitation has tremendously increased. The basic indications for va-ECMO are therapy refractory cardiac or cardiopulmonary failure. The fundamental purpose of va-ECMO is bridging the function of the lungs and/or the heart. Consequently, this support system does not represent a causal therapy by itself; however, it provides enough time for the affected organ to recover (bridge to recovery) or for the decision for a long-lasting organ substitution by a ventricular assist device or by transplantation (bridge to decision). Although the outcome for bridged patients seems to be favorable, it should not be forgotten that the support system represents an invasive procedure with potentially far-reaching complications. Therefore, the initiation of these systems needs a professional and experienced (interdisciplinary) team, sufficient resources and an individual approach balancing the risks and benefits. This review gives an overview of the indications, complications and contraindications for va-ECMO. It discusses its advantages in organ transplantation and transport of critically ill patients. The reader will learn the differences between peripheral and central cannulation and how to monitor and manage va-ECMO.

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Abbreviations

ARDS:

„acute respiratory distress syndrome“

CPR:

„cardiopulmonary resuscitation“

ECLS:

„extracorporeal life support“

ECMO:

extrakorporale Membranoxygenierung

E-CPR:

„extracorporeal cardiopulmonary resuscitation“

ELSO:

Extracorporeal Life Support Organization

HLM:

Herz-Lungen-Maschine

IHCA:

„in-hospital cardiac arrest“

MAP:

„mean arterial pressure“

NIRS:

„near-infrared spectroscopy“

OHCA:

„out-of-hospital cardiac arrest“

PTT:

„partial thromboplastin time“

VA:

venoarteriell

VV:

venovenös

ZVD:

zentraler Venendruck

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Einhaltung ethischer Richtlinien

Interessenkonflikt. M. Dolch und Y.A. Zausig geben an, dass kein Interessenkonflikt besteht. F. Born hat ein Honorar für Vortragstätigkeit der Fa. Sorin® erhalten. D. Lunz und A. Philipp haben Honorare für Vortragstätigkeiten der Fa. Maquet® erhalten und eine Unterstützung für Forschungstätigkeiten von der Fa. Sorin®. Der Beitrag enthält keine Studien an Menschen oder Tieren.

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  1. Klinik für Anaesthesiologie, Universitätsklinik Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland

    D. Lunz &  Y.A. Zausig

  2. Herz-, Thorax- und herznahe Gefäßchirurgie, Universitätsklinik Regensburg, Regensburg, Deutschland

    A. Philipp

  3. Klinik für Anaesthesiologie, Klinikum der Universität München – Campus Großhadern, München, Deutschland

    M. Dolch

  4. Herzchirurgische Klinik und Poliklinik, Klinikum der Universität München – Campus Großhadern, München, Deutschland

    F. Born

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Lunz, D., Philipp, A., Dolch, M. et al. Venoarterielle extrakorporale Membranoxygenierung. Anaesthesist 63, 625–635 (2014). https://doi.org/10.1007/s00101-014-2362-3

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