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Anästhesiol Intensivmed Notfallmed Schmerzther 2012; 47(10): 646-654
DOI: 10.1055/s-0032-1329402
Fachwissen
Intensivmedizin Topthema: Lungenersatzverfahren
© Georg Thieme Verlag Stuttgart · New York

Lungenersatzverfahren – Einsatz und Management extrakorporaler Lungenersatzverfahren

If the extracorporeal lung assist comes to its limit: use and management of extracorporeal membrane oxygenation in severe acute respiratory distress syndrome
Julian Küstermann
,
Jörg Brederlau
,
Peter Kranke
,
Norbert Roewer
,
Ralf Michael Muellenbach
Further Information

Publication History

Publication Date:
24 October 2012 (online)

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Zusammenfassung

Trotz lungenprotektiver Beatmungsstrategien und erweiterter Maßnahmen wie Lagerungstherapie, selektive pulmonale Vasodilatation oder Verfahren zur extrakorporalen CO2-Elimination (extrakorporale Lungenassistenz) kann der Gasaustausch im schweren akuten Lungenversagen (ARDS) therapierefraktär eingeschränkt bleiben. Um sowohl die Oxygenierung als auch die Ventilation in dieser lebensbedrohlichen Situation zu sichern, müssen extrakorporale Lungenersatzverfahren, auch extrakorporale Membranoxygenierung (ECMO) genannt, eingesetzt werden. Technische Verbesserungen sowie die Miniaturisierung der extrakorporalen Systeme haben sowohl die Sicherheit als auch die Bedienbarkeit revolutioniert. So kann beispielsweise aufgrund der Heparinbeschichtung der Systeme auf eine therapeutische Antikoagulation verzichtet und somit das Risiko von Blutungskomplikationen reduziert werden.

Aktuelle Daten zur ECMO-Therapie deuten daraufhin, dass das Outcome bei Patienten mit schwerem ARDS verbessert werden kann. Diese Übersichtsarbeit beschreibt das Funktionsprinzip sowie das Management der ECMO-Therapie bei Patienten mit ARDS.

Abstract

In patients with the most severe forms of acute respiratory distress syndrome (ARDS) refractory to conventional mechanical ventilation and adjunctive or rescue therapies like kinetic therapy, inhaled vasodilators or extracorporeal CO2-elimination (extracorporeal lung assist), the use of the extracorporeal membrane oxygenation (ECMO) can secure gas exchange. Due to technical improvements and miniaturization, the new ECMO system is safer and simpler. Nowadays the ECMO-systems are heparin-coated, so that there is no need of therapeutic systemic anticoagulation, and thus bleeding complications are less frequent. Recent data suggests, that outcome of patients with severe ARDS treated with ECMO may improve. This review describes the function and the management of ECMO-therapy in ARDS-patients.

Kernaussagen

  • Heparinbeschichtete ECMO-Systeme erlauben den Einsatz einer moderaten systemischen Antikoagulation und somit eine Erweiterung des Indikationsspektrums (z. B. polytraumatisierte ARDS-Patienten).

  • Es werden veno-venöse und veno-arterielle extrakorporale Verfahren unterschieden. Im Lungenversagen ohne kardiale Dekompensation sollte stets eine vvECMO zum Einsatz kommen.

  • Hauptindikationen für die vvECMO sind die Hypoxämie, die dekompensierte respiratorische Azidose (pH < 7,2) sowie eine Ventilation mit exzessiv hohen inspiratorischen Beatmungsdrücken.

  • Die Kanülierung erfolgt perkutan in Seldingertechnik und sollte ultraschallgesteuert durchgeführt werden. Eine Lagekontrolle der ECMO-Kanülen mittels transösophagealer Echokardiografie oder mittels Bildwandler ist obligat.

  • Moderne Doppellumenkanülen erleichtern eine Mobilisierung der Patienten während der ECMO-Therapie. Zudem ist auch das Risiko der Rezirkulation des Blutes vermindert.

  • Der extrakorporale Blutfluss determiniert den Oxygenierungseffekt des ECMO-Systems. Die Höhe des anliegenden O2-Frischgasflusses regelt die extrakorporale CO2-Elimination.

  • Während der ECMO-Therapie sollten protektive bis „ultraprotektive“ bzw. assistierte Beatmungsformen zur Anwendung kommen.

  • Eine Lagerungstherapie ist auch unter ECMO möglich.

  • Intrakranielle Blutungen stellen eine seltene, aber häufig letale Komplikation dar.

  • Die Therapie in spezialisierten ARDS / ECMO-Zentren verbessert die Überlebensrate ohne schwere Behinderung.

  • Die Durchführung einer ECMO-Behandlung kann aufgrund der Komplexität der diversen Therapiemaßnahmen sowie der immer noch hohen Komplikationsraten nur in dafür spezialisierten ARDS / ECMO-Zentren empfohlen werden.

Schlüsselwörter:

Akutes Lungenversagen - ARDS - extrakorporale Membranoxygenierung - ECMO - lungenprotektive Beatmung

Keywords:

Acute Respiratory Distress Syndrome - ARDS - extracorporeal membrane oxygenation - ECMO - lung-protective ventilation

Ergänzendes Material

 

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