Venovenöse extrakorporale Membranoxygenierung

Das ECMO-Verfahren zur Therapie des akuten Lungenversagens hat sich insbesondere seit der H1N1-Pandemie stark verbreitet. Der routinemäßige Einsatz erfordert jedoch eine sorgfältige Indikationsstellung, eine entsprechende Ausstattung und große Erfahrung.

Kernaussagen

• Ziel der venovenösen extrakorporalen Membranoxygenierung (VV-ECMO) ist die Versorgung des Körpers mit ausreichend oxygeniertem Blut.

• Indikationen zur VV-ECMO sind eine schwere Hypoxämie und/oder Hyperkapnie mit hohem Letalitätsrisiko.

• Es gibt jedoch bislang keine gesicherten Vorteile der VV-ECMO gegenüber der konventionellen Therapie des ARDS.

• Die VV-ECMO ermöglicht eine protektive Beatmung. Zur Frage der optimalen Beatmungsform gibt es keine Studiendaten.

• Unter Sedierung ist auch bei ECMO-Patienten eine regelmäßige Beurteilung von Delir, Schmerz und Sedierung obligat. Zur ECMO ist jedoch nicht zwingend eine Sedierung erforderlich.

• Technische Komplikationen sind selten, können aber gravierend sein. Die bei Weitem häufigste Komplikation unter ECMO ist die Blutung, die bei ca. der Hälfte der Patienten auftritt.

• Eine ECMO sollten nur Intensivstationen einsetzen, welche die ELSO-Standards zur technischen und personellen Ausstattung erfüllen und über ein entsprechend geschultes Team verfügen.

• Literatur

• 1 Extracorporeal Life Support Organization. ELSO Adult Respiratory Failure Supplement to the ELSO General Guidelines. Version 1.3 December 2013. Im Internet: http://www.elso.org/Portals/0/IGD/Archive/FileManager/989d4d4d14cusersshyerdocumentselsoguidelinesforadultrespiratoryfailure1.3.pdf Stand: 20.04.2015
• 2 Hill JD, OʼBrien TG, Murray JJ. et al. Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shock-lung syndrome). Use of the Bramson membrane lung. N Engl J Med 1972; 286: 629-634
• 3 Allison PL, Kurusz M, Graves DF. et al. Devices and monitoring during neonatal ECMO: survey results. Perfusion 1990; 5: 193-201
• 4 Peek GJ, Mugford M, Tiruvoipati R. et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial. Lancet 2009; 374: 1351-1363
• 5 Sauer CM, Yuh DD, Bonde P. Extracorporeal membrane oxygenation use has increased by 433 % in adults in the United States from 2006 to 2011. ASAIO J 2015; 61: 31-36
• 6 Brodie D, Bacchetta M. Extracorporeal membrane oxygenation for ARDS in adults. N Engl J Med 2011; 365: 1905-1914
• 7 Guérin C, Reignier J, Richard J. et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med 2013; 368: 2159-2168
• 8 Shekar K, Davies AR, Mullany DV. et al. To ventilate, oscillate, or cannulate?. J Crit Care 2013; 28: 655-662
• 9 Pham T, Combes A, Rozé H. et al. Extracorporeal membrane oxygenation for pandemic influenza A(H1N1)-induced acute respiratory distress syndrome: a cohort study and propensity-matched analysis. Am J Respir Crit Care Med 2013; 187: 276-285
• 10 Kok J, Blyth CC, Foo H. et al. Viral pneumonitis is increased in obese patients during the first wave of pandemic A(H1N1) 2009 virus. PloS One 2013; 8: e55631
• 11 Extracorporeal Life Support Organization. ELSO Patient Specific Supplements to the ELSO General Guidelines Version December 2013. Im Internet: https://www.elso.org/Portals/0/IGD/Archive/FileManager/989d4d4d14cusersshyerdocumentselsoguidelinesforadultrespiratoryfailure1.3.pdf Stand: 02.04.2015
• 12 Murray JF, Matthay MA, Luce JM. et al. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 1988; 138: 720-723
• 13 Esteban A, Fernández-Segoviano P, Frutos-Vivar F. et al. Comparison of clinical criteria for the acute respiratory distress syndrome with autopsy findings. Ann Int Med 2004; 141: 440-445
• 14 Ranieri VM, Rubenfeld GD, Thompson BT. et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA 2012; 307: 2526-2533
• 15 Ferguson ND, Fan E, Camporota L. et al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med 2012; 38: 1573-1582
• 16 Thompson BT, Matthay MA. The Berlin definition of ARDS versus pathological evidence of diffuse alveolar damage. Am J Respir Crit Care Med 2013; 187: 675-677
• 17 Thille AW, Esteban A, Fernández-Segoviano P. et al. Comparison of the Berlin definition for acute respiratory distress syndrome with autopsy. Am J Respir Crit Care Med 2013; 187: 761-767
• 18 Bein T, Weber-Carstens S, Goldmann A. et al. Lower tidal volume strategy (≈ 3 ml/kg) combined with extracorporeal CO₂ removal versus ‘conventional’ protective ventilation (6 ml/kg) in severe ARDS: the prospective randomized Xtravent-study. Intensive Care Med 2013; 39: 847-856
• 19 Cove ME, MacLaren G, Federspiel WJ. et al. Bench to bedside review: Extracorporeal carbon dioxide removal, past present and future. Crit Care 2012; 16: 232
• 20 Terragni P, Maiolo G, Ranieri VM. Role and potentials of low-flow CO(2) removal system in mechanical ventilation. Curr Opin Crit Care 2012; 18: 93-98
• 21 Müller T, Bein T, Philipp A. et al. Extracorporeal pulmonary support in severe pulmonary failure in adults: a treatment rediscovered. Dtsch Arztebl Int 2013; 110: 159-166
• 22 Schmid C, Philipp A, Hilker M. et al. Venovenous extracorporeal membrane oxygenation for acute lung failure in adults. J Heart Lung Transplant 2012; 31: 9-15
• 23 Chalwin RP, Moran JL, Graham PL. The role of extracorporeal membrane oxygenation for treatment of the adult respiratory distress syndrome: review and quantitative analysis. Anaesth Intensive Care 2008; 36: 152-161
• 24 Morris AH, Wallace CJ, Menlove RL. et al. Randomized clinical trial of pressure-controlled inverse ratio ventilation and extracorporeal CO2 removal for adult respiratory distress syndrome. Am J Respir Crit Care Med 1994; 149: 295-305
• 25 Zapol WM, Snider MT, Hill JD. et al. Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. JAMA 1979; 242: 2193-2196
• 26 Davies A, Jones D, Bailey M. et al. Extracorporeal Membrane Oxygenation for 2009 Influenza A(H1N1) Acute Respiratory Distress Syndrome. JAMA 2009; 302: 1888-1895
• 27 Gattinoni L, Carlesso E, Langer T. Clinical review: Extracorporeal membrane oxygenation. Crit Care 2011; 15: 243
• 28 Sidebotham D, McGeorge A, McGuinness S. et al. Extracorporeal membrane oxygenation for treating severe cardiac and respiratory disease in adults: Part 1–overview of extracorporeal membrane oxygenation. J Cardiothorac Vasc Anesth 2009; 23: 886-892
• 29 Zampieri FG, Mendes PV, Ranzani OT. et al. Extracorporeal membrane oxygenation for severe respiratory failure in adult patients: a systematic review and meta-analysis of current evidence. J Crit Care 2013; 28: 998-1005
• 30 Tramm R, Ilic D, Davies AR. et al. Extracorporeal membrane oxygenation for critically ill adults. Cochrane Database Syst Rev 2015; (01) CD010381
• 31 EOLIA Trial. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome (EOLIA). Im Internet: http://clinicaltrials.gov/ct2/show/NCT01470703 Stand: 30.03.2015
• 32 SUPERNOVA-Trial. NCT02282657 Strategy of UltraProtective Lung Ventilation With Extracorporeal CO2 Removal for New-Onset Moderate to seVere ARDS: SUPERNOVA. Im Internet: https://clinicaltrials.gov/ct2/show/NCT02282657 Stand: 30.03.2015
• 33 Lang G, Kim D, Aigner C. et al. Awake extracorporeal membrane oxygenation bridging for pulmonary retransplantation provides comparable results to elective retransplantation. J Heart Lung Transplant 2014; 33: 1264-1272
• 34 Brogan TV, Thiagarajan RR, Rycus PT. et al. Extracorporeal membrane oxygenation in adults with severe respiratory failure: a multi-center database. Intensive Care Med 2009; 35: 2105-2114
• 35 Rosenberg AA, Haft JW, Bartlett R. et al. Prolonged duration ECMO for ARDS: futility, native lung recovery, or transplantation?. ASAIO J 2013; 59: 642-650
• 36 Wiktor AJ, Haft JW, Bartlett RH. et al. Prolonged VV ECMO (265 Days) for ARDS without technical complications. ASAIO J 2015; 61: 205-206
• 37 The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342: 1301-1308
• 38 Bein T, Zimmermann M, Hergeth K. et al. Pumpless extracorporeal removal of carbon dioxide combined with ventilation using low tidal volume and high positive end-expiratory pressure in a patient with severe acute respiratory distress syndrome. Anesthesia 2009; 64: 195-198
• 39 Mauri T, Foti G, Zanella A. et al. Long-term extracorporeal membrane oxygenation with minimal ventilatory support: a new paradigm for severe ARDS?. Minerva Anestesiol 2012; 78: 385-389
• 40 Marhong JD, Telesnicki T, Munshi L. et al. Mechanical ventilation during extracorporeal membrane oxygenation. An international survey. Ann Am Thorac Soc 2014; 11: 956-961
• 41 MacLaren G, Combes A, Bartlett RH. Contemporary extracorporeal membrane oxygenation for adult respiratory failure: life support in the new era. Intensive Care Med 2012; 38: 210-220
• 42 Terragni PP, Rosboch G, Tealdi A. et al. Tidal hyperinflation during low tidal volume ventilation in acute respiratory distress syndrome. Am J Respir Crit Care Med 2007; 175: 160-166
• 43 Caironi P, Cressoni M, Chiumello D. et al. Lung opening and closing during ventilation of acute respiratory distress syndrome. Am J Respir Crit Care Med 2010; 181: 578-586
• 44 Aboab J, Jonson B, Kouatchet A. et al. Effect of inspired oxygen fraction on alveolar derecruitment in acute respiratory distress syndrome. Intensive Care Med 2006; 32: 1979-1986
• 45 Kallet RH, Matthay MA. Hyperoxic acute lung injury. Respir Care 2013; 58: 123-141
• 46 Schmidt M, Pellegrino V, Combes A. et al. Mechanical ventilation during extracorporeal membrane oxygenation. Crit Care 2014; 18: 203
• 47 Dembinski R, Hochhausen N, Terbeck S. et al. Pumpless extracorporeal lung assist for protective mechanical ventilation in experimental lung injury. Crit Care Med 2007; 35: 2359-2366
• 48 Grasso S, Stripoli T, Sacchi M. et al. Inhomogeneity of lung parenchyma during the open lung strategy: a computed tomography scan study. Am J Respir Crit Care Med 2009; 180: 415-423
• 49 Combes A, Bacchetta M, Brodie D. et al. Extracorporeal membrane oxygenation for respiratory failure in adults. Curr Opin Crit Care 2012; 18: 99-104
• 50 Levine S, Nguyen T, Taylor N. et al. Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans. N Engl J Med 2008; 358: 1327-1335
• 51 Jaber S, Jung B, Matecki S. et al. Clinical review: ventilator-induced diaphragmatic dysfunction–human studies confirm animal model findings!. Crit Care 2011; 15: 206
• 52 Mauri T, Bellani G, Grasselli G. et al. Patient-ventilator interaction in ARDS patients with extremely low compliance undergoing ECMO: a novel approach based on diaphragm electrical activity. Intensive Care Med 2013; 39: 282-291
• 53 Karagiannidis C, Lubnow M, Philipp A. et al. Autoregulation of ventilation with neurally adjusted ventilatory assist on extracorporeal lung support. Intensive Care Med 2010; 36: 2038-2044
• 54 Yoshida T, Rinka H, Kaji A. et al. The impact of spontaneous ventilation on distribution of lung aeration in patients with acute respiratory distress syndrome: airway pressure release ventilation versus pressure support ventilation. Anesth Analg 2009; 109: 1892-1900
• 55 Del Sorbo L, Goffi A, Goligher E. et al. Setting mechanical ventilation in ARDS patients during VV-ECMO: where are we?. Minerva Anestesiol 2015; 81: 1369-1376
• 56 Extracorporeal Life Support Organization. Endotracheal extubation in patients with respiratory failure receiving venovenous ECMO. 2015 Im Internet: https://www.elso.org/Portals/0/Files/ELSO_ExtubationGuidelines_May2015.pdf Stand: 20.06.2015
• 57 Lehle K, Philipp A, Müller T. et al. Flow dynamics of different adult ECMO systems: a clinical evaluation. Artif Organs 2014; 38: 391-398
• 58 Wiedemann HP, Wheeler AP, Bernard GR. et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006; 354: 2564-2575
• 59 Schmidt M, Bailey M, Kelly J. et al. Impact of fluid balance on outcome of adult patients treated with extracorporeal membrane oxygenation. Intensive Care Med 2014; 40: 1256-1266
• 60 Kress JP, Pohlman AS, OʼConnor MF. et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342: 1471-1477
• 61 Barr J, Fraser GL, Puntillo K. et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013; 41: 263-306
• 62 Martin J, Heymann A, Bäsell K. et al. Evidence and consensusbased German guidelines for the management of analgesia, sedation and delirium in intensive care–short version. Ger Med Sci 2010; 8: Doc02
• 63 Shekar K, Roberts JA, Welch S. et al. ASAP ECMO: Antibiotic, Sedative and Analgesic Pharmacokinetics during Extracorporeal Membrane Oxygenation: a multi-centre study to optimise drug therapy during ECMO. BMC Anesthesiology 2012; 12: 29
• 64 Shekar K, Fraser JF, Smith MT. et al. Pharmacokinetic changes in patients receiving extracorporeal membrane oxygenation. J Crit Care 2012; 27: 741.e9-18
• 65 Dossow-Hanfstingl V, Deja M, Zwissler B. et al. Postoperative Management – extracorporeal ventilatory Therapy. In: Slinger P. ed. Principles and Practice of Anesthesia for thoracic Surgery. New York, Dordrecht, Heidelberg, London: Springer; 2011
• 66 Sessler CN, Grap MJ, Brophy GM. Multidisciplinary management of sedation and analgesia in critical care. Semin Respir Crit Care Med 2001; 22: 211-226
• 67 Ely EW, Inouye SK, Bernard GR. et al. Delirium in mechanically ventilated patients: validity and reliability of the confusion assessment method for the intensive care unit (CAM-ICU). JAMA 2001; 286: 2703-2710
• 68 Bergeron N, Dubois MJ, Dumont M. et al. Intensive Care Delirium Screening Checklist: evaluation of a new screening tool. Intensive Care Med 2001; 27: 859-864
• 69 Buscher H, Vaidiyanathan S, Al-Soufi S. et al. Sedation practice in veno-venous extracorporeal membrane oxygenation: an international survey. ASAIO J 2013; 59: 636-641
• 70 Myers GJ, Voorhees C, Eke B. et al. The effect of Diprivan (propofol) on phosphorylcholine surfaces during cardiopulmonary bypass – an in vitro investigation. Perfusion 2009; 24: 349-355
• 71 Patil NP, Popov AF, Lees NJ. et al. Novel sequential bridge to lung transplant in an awake patient. J Thorac Cardiovasc Surg 2015; 149: e2-e4
• 72 Mohite PN, Sabashnikov A, Reed A. et al. Extracorporeal Life Support in “Awake” Patients as a Bridge to Lung Transplant. Thorac Cardiovasc Surg 2015; 63: 699-705
• 73 Olsson KM, Simon A, Strueber M. et al. Extracorporeal membrane oxygenation in nonintubated patients as bridge to lung transplantation. Am J Transplant 2010; 10: 2173-2178
• 74 Garcia JP, Iacono A, Kon ZN. et al. Ambulatory extracorporeal membrane oxygenation: a new approach for bridge-to-lung transplantation. J Thorac Cardiovasc Surg 2010; 139: e137-e139
• 75 Hu SL, He HL, Pan C. et al. The effect of prone positioning on mortality in patients with acute respiratory distress syndrome: a meta-analysis of randomized controlled trials. Crit Care 2014; 18: R109
• 76 Culbreth RE, Goodfellow LT. Complications of prone positioning during extracorporeal membrane oxygenation for respiratory failure: a systematic review. Respir Care 2016; 61: 249-254
• 77 Kuhl T, Michels G, Pfister R. et al. Comparison of the Avalon Dual-Lumen Cannula with Conventional Cannulation Technique for Venovenous Extracorporeal Membrane Oxygenation. Thorac Cardiovasc Surg 2015; 63: 653-662
• 78 Bloomfield R, Noble DW, Sudlow A. Prone position for acute respiratory failure in adults. Cochrane Database Syst Rev 2015; (11) CD008095
• 79 Oliver WC. Anticoagulation and coagulation management for ECMO. Semin Cardiothorac Vasc Anesth 2009; 13: 154-175
• 80 Despotis GJ, Avidan MS, Hogue CW. Mechanisms and attenuation of hemostatic activation during extracorporeal circulation. Ann Thorac Surg 2001; 72: 1821-1831
• 81 Skinner SC, Hirschl RB, Bartlett RH. Extracorporeal life support. Semin Pediatr Surg 2006; 15: 242-250
• 82 Le Guennec L, Bertrand A, Laurent C. et al. Diffuse cerebral microbleeds after extracorporeal membrane oxygenation support. Am J Respir Crit Care Med 2015; 191: 594-596
• 83 Esper SA, Levy JH, Waters JH. et al. Extracorporeal membrane oxygenation in the adult: a review of anticoagulation monitoring and transfusion. Anesth Analg 2014; 118: 731-743
• 84 Weingart C, Lubnow M, Philipp A. et al. Comparison of Coagulation Parameters, Anticoagulation, and Need for Transfusion in Patients on Interventional Lung Assist or Veno-Venous Extracorporeal Membrane Oxygenation. Artif Organs 2015; 39: 765-773
• 85 Lequier L, Annich G, Al-Ibrahim O. et al. ELSO anticoagulation guidelines. 2014: 1-17 Im Internet: http://www.elso.org/resources/Guidelines.aspx Stand: 24.04.2015
• 86 Sohn N, Marcoux J, Mycyk T. et al. The impact of different biocompatible coated cardiopulmonary bypass circuits on inflammatory response and oxidative stress. Perfusion 2009; 24: 231-237
• 87 HELP-ECMO pilot study. Heparin low dose protocol versus standard care in critically ill patients undergoing ECMO. Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12613001324707. Im Internet: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365378 Stand: 10.09.2017
• 88 Larsson M, Rayzman V, Nolte MW. et al. A factor XIIa inhibitory antibody provides thromboprotection in extracorporeal circulation without increasing bleeding risk. Sci Transl Med 2014; 6: 222ra17
• 89 Gray BW, Haft JW, Hirsch JC. et al. Extracorporeal life support: experience with 2,000 patients. ASAIO J 2015; 61: 2-7
• 90 Smith A, Hardison D, Bridges B. et al. Red blood cell transfusion volume and mortality among patients receiving extracorporeal membrane oxygenation. Perfusion 2013; 28: 54-60
• 91 Kumar T, Susheel K, Zurakowski D. et al. Extracorporeal membrane oxygenation in postcardiotomy patients: factors influencing outcome. J Thorac Cardiovasc Surg 2010; 140: 330-336.e2
• 92 Repessé X, Au SM, Bréchot N. et al. Recombinant factor VII a for uncontrollable bleeding in patients with extracorporeal membrane oxygenation: report on 15 cases and literature review. Crit Care 2013; 17: R55
• 93 Niebler RA, Punzalan RC, Marchan M. et al. Activated recombinant factor VII for refractory bleeding during extracorporeal membrane oxygenation. Pediatr Crit Care Med 2010; 11: 98-102
• 94 Pieri M, Turla OG, Calabrò MG. et al. A new phosphorylcholine-coated polymethylpentene oxygenator for extracorporeal membrane oxygenation: a preliminary experience. Perfusion 2013; 28: 132-137
• 95 Kalbhenn J, Wittau N, Schmutz A. et al. Identification of acquired coagulation disorders and effects of target-controlled coagulation factor substitution on the incidence and severity of spontaneous intracranial bleeding during venovenous ECMO therapy. Perfusion 2015; 30: 675-682
• 96 Lappa A, Donfrancesco S, Contento C. et al. Weaning from venovenous extracorporeal membrane oxygenation without anticoagulation: is it possible?. Ann Thorac Surg 2012; 94: e1-e3
• 97 Aubron C, Cheng AC, Pilcher D. et al. Factors associated with outcomes of patients on extracorporeal membrane oxygenation support: a 5-year cohort study. Crit Care 2013; 17: R73
• 98 Finney SJ. Extracorporeal support for patients with acute respiratory distress syndrome. Eur Respir Rev 2014; 23: 379-389
• 99 Cooper E, Burns J, Retter A. et al. Prevalence of venous thrombosis following venovenous extracorporeal membrane oxygenation in patients with severe respiratory failure. Crit Care Med 2015; 43: e581-e584
• 100 Hemmila MR, Rowe SA, Boules TN. et al. Extracorporeal life support for severe acute respiratory distress syndrome in adults. Ann Surg 2004; 240: 595-605 discussion 605–607
• 101 Noah MA, Peek GJ, Finney SJ. et al. Referral to an extracorporeal membrane oxygenation center and mortality among patients with severe 2009 influenza A(H1N1). JAMA 2011; 306: 1659-1668
• 102 Mendiratta P, Tang X, Collins RT. et al. Extracorporeal membrane oxygenation for respiratory failure in the elderly: a review of the Extracorporeal Life Support Organization registry. ASAIO J 2014; 60: 385-390
• 103 Schmidt M, Bailey M, Sheldrake J. et al. Predicting survival after extracorporeal membrane oxygenation for severe acute respiratory failure. The Respiratory Extracorporeal Membrane Oxygenation Survival Prediction (RESP) score. Am J Respir Crit Care Med 2014; 189: 1374-1382
• 104 Freeman CL, Bennett TD, Casper TC. et al. Pediatric and neonatal extracorporeal membrane oxygenation: Does center volume impact mortality?. Crit Care Med 2014; 42: 512-519
• 105 Küstermann J, Gehrmann A, Kredel M. et al. Akutes Lungenversagen und septische Kardiomyopathie: Erfolgreicher Einsatz der veno-venoarteriellen extrakorporalen Membranoxygenierung. Der Anaesthesist 2013; 62: 639-643
• 106 Forrest P, Cheong JY, Vallely MP. et al. International retrieval of adults on extracorporeal membrane oxygenation support. Anaesth Intensive Care 2011; 39: 1082-1085
• 107 Extracorporeal Life Support Organization. ELSO Guidelines for Training and Continuing Education of ECMO Specialists. Im Internet: http://www.elso.org/Portals/0/IGD/Archive/FileManager/97000963d6cusersshyerdocumentselsoguidelinesfortrainingandcontinuingeducationofecmospecialists.pdf Stand: 02.04.2015
• 108 Extracorporeal Life Support Organization. ELSO Guidelines for ECMO Centers. Im Internet: https://www.elso.org/Portals/0/IGD/Archive/FileManager/faf3f6a3c7cusersshyerdocumentselsoguidelinesecmocentersv1.8.pdf Stand: 02.04.2015
• 109 Mullany DV, Bull TN, Hunt W. et al. Outcomes of the first 30 cases of an adult extracorporeal membrane oxygenation program: strategies to manage the "learning curve" and implications for intensive care unit risk adjustment models. Crit Care Resusc 2012; 14: 119-129