Extracorporeal membrane oxygenation

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Venous-arterial ECMO in the newborn (schematic)
ECMO device

The extracorporeal membrane oxygenation ( ECMO ) and the extracorporeal lung assist ( ECLA ) are intensive care techniques in which a machine or completely takes over partly the respiratory function of the patient. They are used in patients whose lungs are severely damaged ( ARDS ) and no longer allow gas exchange to the extent that ensures the respiratory function. They are often used in newborns who have lung damage ( respiratory distress syndrome , meconium aspiration , persistent pulmonary hypertension ) or certain congenital heart defects.

The ECMO is thus a form of extracorporeal organ replacement procedure and is also referred to as extracorporeal life support (extracorporeal life support, ECLS).

The ECMO can ensure adequate oxygenation for days or weeks, giving the lungs time to heal without aggressive ventilation . Nevertheless, the ECMO because of the high technical and human requirements, cost and risk of complications (eg. As bleeding) as a last treatment option (is a last resort ) is considered.

technology

An ECMO device is a special oxygenator , namely a membrane oxygenator . Technically, it is like a heart-lung machine . To pick up an ECMO, cannulas are inserted into two large blood vessels . A blood clotting to avoid is one anticoagulant agents ( anticoagulants to), usually heparin . The ECMO device pumps blood continuously through a membrane oxygenator, which replaces gas exchange in the lungs: It removes carbon dioxide from the blood and enriches it with oxygen . The blood prepared in this way is then returned to the patient.

The ECMO is currently operated as a manually set therapy in which a doctor or cardio technician specifies the necessary control values. A patient-individually regulated ECMO is being developed as the subject of various research projects.

Variants of the ECMO

VV-ECMO
VA-ECMO

There are different forms of ECMO, the most important being the veno-venous ECMO (VV-ECMO), the veno-arterial ECMO (VA-ECMO) and the pumpless arterio-venous ECLA (pECLA) . In the first two versions, the blood is drawn from large veins (e.g. vena femoralis or vena jugularis interna ). With VV-ECMO, the oxygenated blood is then fed back into a vein; it is indicated in severe lung failure with sufficient pumping function of the heart. With VA-ECMO, on the other hand, the blood is directed past the heart into an artery ( arteria femoralis ), creating a parallel circuit. Since this relieves the heart, this method is used in patients with poor heart pump function ( heart failure ). The pECLA is used in patients with adequate cardiac function who require less support with gas exchange. Since no pump is used, there is generally less blood damage with pECLA.

ECMO in adults

The first use of cardiopulmonary bypass for the treatment of lung failure (ARDS) took place in the early 1970s. With the prospect of an effective therapeutic instrument for the treatment of ARDS, the National Institutes of Health (highest health authority of the USA) started an ARDS multicenter study. The results were sobering: the group with ECMO treatment did not show any better treatment results, and the study was terminated prematurely. Despite methodological deficiencies, the study was a setback for ECMO development. As a result, research concentrated again on improving conventional ventilation methods .

It was not until the 1980s that an Italian research group succeeded in using improved methods to show the benefits of ECMO, albeit in a non-controlled study on carbon dioxide elimination. The result of this and other follow-up examinations is still valid today that ECMO can be useful in ARDS in adults, but without being able to prove a significant advantage over ventilation therapy. In 2006 a randomized multicenter study with 80 centers and 180 patients was completed in Great Britain to determine the value of ECMO in ARDS therapy. Previously published results appear to be beneficial for the use of extracorporeal membrane oxygenation in adult lung failure.

The first successful applications of extracorporeal gas exchange (ECMO, ELA, ECLA, and the extracorporeal CO 2 elimination ECCO2-R) in Germany were made by Rommelsheim for acute lung failure in adults in 1971 and 1983 at the University of Düsseldorf and for burns for the first time in 1975 and Birtel at the Clinic for Anaesthesiology at the University of Bonn .

ECMO in the newborn

Venous-arterial ECMO cannula position in the newborn
ECMO in an infant

Bartlett reported the first successful neonatal ECMO application in California in 1975. This was followed by the first landmark study that showed increased survival from treatment. The significantly better response to ECMO therapy in newborns than in adults led to an increasing number of ECMO treatment cases and ECMO centers, initially in the USA and later worldwide.

In February 1987, the first successful ECMO application was carried out on a newborn in German-speaking countries in the children's clinic at the Mannheim University Hospital . A randomized multicenter study of newborns was carried out in Great Britain from 1994 to 1995. Due to the significantly higher survival rate in the ECMO treatment group, the study was terminated early in November 1995 because continuation was not ethically justifiable. In subsequent follow-up examinations, the study also refuted the fear that the higher survival rate in the ECMO treatment group would be “bought” by psychomotor deficits. Instead, the benefits of ECMO are retained in the follow-up examination of the children.

Extracorporeal Life Support Organization (ELSO)

Extracorporal Life Support Organization (ELSO) ECLS Registry Report
group Number of cases survived percentage
neonatal respiratory 28271 23791 84%
neonatal cardiac 6046 3750 62%
neonatal extracorporeal CPR 1188 766 64%
Pediatric respiratory 9629 4579 66%
Pediatrics cardiac 7668 5084 66%
Pediatrics EHLW 2583 1432 54%
Adults respiratory 7922 5209 66%
Adult cardiac 6522 3661 56%
Adults EHLW 1985 791 40%
Total 69114 49063 71%
Cumulative overview and outcome of the ECMO treatment cases reported to ELSO up to July 2015

In 1989 a central ECMO registry was established in Ann Arbor , Michigan (USA). There, ECLS applications are registered centrally and broken down in detail. This allows a precise overview of the effectiveness and the course of the number of cases of the therapy in certain clinical pictures. This allows therapy-specific improvements or problems in the area of ​​ECLS applications to be identified more quickly and passed on to other ECMO centers. By the end of 2012, more than 53,000 ECLS applications had been reported and statistically evaluated by the Extracorporeal Life Support Organization (ELSO) worldwide. Currently (as of January 2013), ELSO has 200 active ECMO centers worldwide.

Possible complications during therapy

As already mentioned, the ECMO is now only as a result verschiedenster factors Ultima ratio used therapy. One of these factors is the various complications that can occur during ECMO treatment. These include, among other things, the suction of the extraction cannula against the vessel wall , a dislocation of one of the cannulas, a defect in the blood pump used or an air embolism .

The treatment or the early detection of these complications is the subject of current research projects. However, all of this work is still in the preclinical stages.

further reading

  • Invasive ventilation and the use of extracorporeal procedures in acute respiratory insufficiency. In: AWMF online. 2017 ( website (guideline) ).

Web links

Individual evidence

  1. ↑ R. Kopp, D. Henzler, R. Dembinski, R. Kuhlen: Extracorporeal membrane oxygenation in acute lung failure. In: The anesthesiologist. 53, 2004, pp. 168-174, doi: 10.1007 / s00101-003-0643-3 .
  2. ^ P. Feindt, C. Benk, U. Boeken, A. Bauer, U. Mehlhorn, J. Gehron, A. Markewitz, A. Beckmann, F. Beyersdorf: Use of an extracorporeal circulation outside of a cardiac surgery operating room. In: cardio technology. 2010 (19), 3, ISSN  0941-2670 , pp. 58-60, dgfkt.de (PDF; 47 kB).
  3. ↑ M. Hartmann, O. Boehm, A. Koch, St. Loer, K. Zacharowski: The coagulation system during extracorporeal circulation In: Kardiotechnik. 2005 (14), 2, ISSN  0941-2670 , pp. 43-48, dgfkt.de (PDF; 134 kB).
  4. ↑ M. Walter, C. Brendle, A. Stollenwerk, R. Kopp, J. Arens, R. Bensberg, S. Leonhardt: Patient oriented closed loop control of extracorporeal lung assist. In: Journal of Critical Care. 2012, pp. E8 – e9, ISSN  0883-9441 ( PDF file ).
  5. ^ B. Baumgartner, A. Mendoza, S. Eichhorn, U. Schreiber, A. Knoll: A comparative study on extra-corporal circulation control. In: Intl Conf IEEE Engineering in Medicine and Biology Society (EMBC). 2011, pp. 4287–4290 ( PDF file ( Memento of the original from September 6, 2015 in the Internet Archive ) Info: The archive link has been inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. ). @1@ 2Template: Webachiv / IABot / www6.in.tum.de
  6. ↑ N. Madershahian, J. Wippermann, T. Wittwer, J. Strauch, Y.-H. Choi, K. Liebing, M. Kaluza, T. Wahlers: Veno-arterial ECMO for the therapy of refractory ARDS in adult polytrauma In: Kardiotechnik. 16, 4, 2007, pp. 98–101, ISSN  0941-2670 , dgfkt.de (PDF; 126 kB)
  7. ^ A. Liebold, A. Philipp, M. Kaiser, J. Merk, FX Schmid, DE Birnbaum: Pumpless extracorporeal lung assist using an arterio-venous shunt. Applications and limitations. In: Minerva Anestesiol. 68 (5), May 2002, pp. 387-391. PMID 12029251
  8. ^ R. Kopp, R. Bensberg, M. Wardeh, R. Rossaint, R. Kuhlen, D. Henzler: Pumpless arterio-venous extracorporeal lung assist compared with veno-venous extracorporeal membrane oxygenation during experimental lung injury. In: British Journal of Anesthesia. 108, 5, 2012, pp. 745-753, doi: 10.1093 / bja / aes021 , bja.oxfordjournals.org .
  9. ↑ JD Hill, TG O'Brien, JJ Murray, and others. a .: Prolonged extracorporeal oxygenation for acute post-traumatic respiratory failure (shocklung syndrome). In: N Engl J Med . 286, 1972, p. 629. PMID 5060491 .
  10. ↑ WM Zapol, MT Snider, JD Hill and others. a .: Extracorporeal membrane oxygenation in severe acute respiratory failure. A randomized prospective study. In: JAMA . 242, 1979, pp. 2193-2196. PMID 490805 .
  11. ↑ L. Gattinoni, A. Pesenti, D. Mascheroni and a .: Low-frequency positive-pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure. In: JAMA. 256, 1986, pp. 881-886. PMID 3090285 .
  12. ↑ G. Mols et al. a .: Ten years of experience with extra-corporeal membrane oxygenation (ECMO). In: Anästhesiol Intensivmed Emergency Med Schmerzther. 36, 2001, pp. 4-14, doi: 10.1055 / s-2001-10241 # N249-1 .
  13. ↑ GJ Peek, F. Clemens, D. Elbourne, R. Firmin, P. Hardy, C. Hibbert, H. Killer, M. Mugford, M. Thalanany, R. Tiruvoipati, A. Truesdale, A. Wilson: CESAR: Conventional ventilatory support vs extracorporeal membrane oxygenation for severe adult respiratory failure. In: BMC Health Services Research. 6, 2006, p. 163, PMC 1766357 (free full text)
  14. ↑ G. Peek: CESAR: adult ECMO vs conventional ventilation trial . Society of Critical Care Medicine 37th Critical Care Congress; February 2-6, 2008; Honolulu. Summary in: Schuerer 2008.
  15. ↑ DJ Schuerer, NS Kolovos, KV Boyd, CM. Coopersmith: Extracorporeal membrane oxygenation: current clinical practice, coding, and reimbursement .  ( Page no longer available , search in web archives )  Info: The link was automatically marked as defective. Please check the link according to the instructions and then remove this notice. In: Chest. 134 (1), Jul 2008, pp. 179-184.@1@ 2Template: Dead Link / www.chestjournal.org  
  16. ^ HD Schulte, W. Bircks, R. Dudziak: Preliminary results with the Bramson membrane lung. (Also report of a successful, clinical long-term perfusion). In: Thoraxchir Vask Chir. 20, 1972, pp. 54-59. PMID 4537173
  17. ^ WR Thies, M. Breulmann, U. Lenhsen u. a .: Pulmonary function during a 10-day successful extracorporeal CO 2 elimination in acute respiratory failure. Case report. In: The anesthesiologist. 34, Apr 1985, pp. 197-202. PMID 3923858 .
  18. ↑ K. Rommelsheim, FJ Birtel, KH Seidat u. a .: Application of "GE DUALUNG" in the case of pulmonary diffusion disorder after a burn. In: Wissenschaftl. Inform. D. Fresenius Foundation 4, 1975, p. 185.
  19. ↑ K. Rommelsheim, FJ Birtel, KH Seidat u. a .: Prolonged extracorporeal membrane oxygenation due to shock lung with third-degree burn. In: Prakt. Anesthesia. 11, 1976, pp. 8-16. PMID 967804 .
  20. ^ RH Bartlett, AB Gazzaniga, MR Jefferies, et al. a .: Extracorporeal membrane oxygenation (ECMO) cardiopulmonary support in infancy. In: Trans Am Soc Artif Intern Organs. 22, 1976, pp. 80-93. PMID 951895 .
  21. ^ RH Bartlett, AB Gazzaniga, J. Toomasian et al. a .: Extracorporeal membrane oxygenation (ECMO) in neonatal respiratory failure. 100 cases. In: Ann Surg . 204, 1986, pp. 236-245. PMID 3530151 .
  22. ^ W. Kachel, D. Arnold: Extracorporeal membrane oxygenation in the newborn. In: Series of Intensive Care Medicine, Emergency Medicine, Anesthesiology. Volume 73, 1st German-speaking symposium in Mannheim.
  23. ^ UK collaborative randomized trial of neonatal extracorporeal membrane oxygenation. In: Lancet. 348, 1986, pp. 75-82.
  24. ↑ H. McNally, CC Bennett, D. Elbourne et al. a .: United Kingdom Collaborative Randomized Trial of Neonatal Extracorporeal Membrane Oxygenation: Follow-up to Age 7 Years. In: Pediatrics. 117, 2006, pp. E845 – e854.
  25. ↑ ECLS Registry Report. International Summary . ECMO Registry of the Extracorporeal Life Support Organization (ELSO), Ann Arbor MI, January 2013. ( elsonet.org ).
  26. ↑ T. Neitzel, M. Stiller, H. Bushnaq, R.-E. Silber, I. Friedrich: Extracorporeal Live Support (ECLS) for acute cardiogenic shock In: Kardiotechnik. (18), 3, 2009, pp. 77-80, ISSN  0941-2670 , dgfkt.de (PDF; 105 kB).
  27. ↑ A. Stollenwerk, J. Jörgens, M. Walter, J. Arens, R. Kopp, S. Kowalewski: Model-based error diagnosis of a membrane oxygenator. In: Proc. Biomedical engineering (BMT2010). 55, 2010, pp. 174-177 ISSN  1862-278X , ( PDF file ).
  28. ↑ B. Baumgartner, A. Mendoza, U. Schreiber, S. Eichhorn, M. Krane, R. Bauernschmitt, A. Knoll: A 4-layer supervising unit for extra-corporal circulation. In: Proc. 4th International Conference on Bioinformatics and Biomedical Engineering. 2010 ( PDF file ( Memento of the original from September 6, 2015 in the Internet Archive ) Info: The archive link has been inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. ). @1@ 2Template: Webachiv / IABot / www6.in.tum.de
  29. ↑ Andre Stollenwerk: A model-based safety concept for extracorporeal lung support. Dissertation, Shaker, Aachen 2013, AIB-2013-7 ( PDF file ).