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DOI: 10.1055/a-1287-9264
Einsatz eines ECLS bei Patienten im kardiogenen und septischen Schock: Untersuchung zur Indikation und zum Outcome
Usage of an ECLS for Patients Whilst Experiencing a Cardiogenic or Septic Shock: Examination of Indication and Outcome![](https://www.thieme-connect.de/media/aktkardio/202101/lookinside/thumbnails/10-1055-a-1287-9264_ka0217-1.jpg)
Zusammenfassung
Einleitung Das Klinikum Weiden ist das größte Klinikum der nördlichen Oberpfalz (Einzugsgebiet 250 000 Einwohnern auf 5300 km2) und Primärversorger für Patienten im Schockgeschehen (WHIN: Weidener Herzinfarktnetz). Es werden 2 Herzkatheterlabore (24/7-Bereitschaft) und 1 Extrakorporales Life-Support System (ECMO Cardiohelp, Maquet) vorgehalten. Das Ziel dieser retrospektiven Studie war es, Indikation und Outcome nach ECLS-Implantation zu analysieren.
Methoden Im Zeitraum vom 01.01.2008 bis zum 31.12.2017 wurde im Klinikum Weiden an 91 Patienten (68 ♂, 23 ♀; 64 ± 13 Jahren) ein ECLS implantiert. 64% des Gesamt-Patientenkollektivs wurden notfallmäßig vorstellig, die restlichen Patienten erhielten eine ECMO supportiv aufgrund einer High-Risk PTCA. 37 Patienten wurden vor Systemimplantation reanimiert, 17 mit einem mechanischen Thoraxkompressionsgerät (LUCAS). Die folgenden Scoring-Systeme wurden verwendet, um die Schwere des Schocks zu bewerten: APACHE II, SOFA und SAPS II.
Ergebnisse Das Überleben (30 d/12 m) nach Systemexplantation betrug bei VA-ECMO 59% bzw. 49% und bei VV-ECMO 70% bzw. 70%. Die Mortalität war abhängig von der Anzahl der applizierten Katecholamine (KA), 45 (49%) Patienten erhielten mehrere KA (1-Jahres-Überleben: ohne KA 89%; 1 KA 55%; 2 KA 31%; 3 KA 30%). Weitere Einflussfaktoren auf die Mortalität waren eine Sepsis und eine Herz-Lungen-Wiederbelebung (CPR) vor Systemimplantation – die Länge der Reanimation, kombiniert externe und interne Reanimation und LUCAS-CPR verschlechterten das Outcome.
Diskussion Bei Patienten im Schockgeschehen, die nach medikamentöser Maximaltherapie weiterhin hämodynamisch und/oder respiratorisch instabil bleiben, kann durch die Implantation eines ECLS das Schockgeschehen durchbrochen werden. Ein primär versorgendes Klinikum kann mit ECMO eine Therapieoption mit vertretbaren Risiken und nachweislichem Nutzen – wenigstens in kleiner Fallzahl belegt – anbieten und Patienten können davon profitieren. So kann es für Landkreise mit größerer Fahrzeit zu einem Klinikum der Maximalversorgung eine in Teilen maximalmedizinische Therapieoption bieten.
Abstract
Background The Hospital Weiden is the largest clinic in the northern Upper Palatinate (catchment area 250 000 inhabitants on 5300 km2) and is a primary care provider for patients in shock (WHIN: Weiden Heart Attack Network). Two cardiac catheterization labs (24/7 stand-by) and an Extracorporeal Life Support System (ECMO Cardiohelp, Maquet) are on hand. The aim of this retrospective study was to analyse the indication and outcome after ECLS implantation.
Methods In the period from January 1st, 2008 to December 31st, 2017, 91 patients (68 ♂, 23 ♀, 64 ± 13 years) were implanted with an ECLS in the Hospital of Weiden. 64% of the total patient population were presented as emergency patients and the remaining patients received an ECMO due to a high-risk PTCA. 37 patients had resuscitation prior to ECLS implantation, 17 using a mechanical resuscitation aid (LUCAS). The following scoring-systems were used to assess the severity of the shock: APACHE II, SOFA and SAPS II.
Results Survival (30 d/12 m) after system explantation was 59% and 49% for VA-ECMO respectively 70% and 70% for VV-ECMO. Mortality was dependent on the number of catecholamines (CA) applied; 45 (49%) patients received several CA (1-year survival: 89% without CA, 1 CA 55%, 2 CA 31%, 3 CA 30%). Other factors influencing mortality were a detected sepsis and cardiopulmonary resuscitation (CPR) before system implantation – the length of resuscitation, combined external and internal resuscitation, and LUCAS-CPR worsened the outcome.
Discussion In shock patients who continue to be hemodynamically and/or respiratory unstable after maximum drug therapy, shock can be broken by implanting an ECLS. With ECMO, a primary care clinic can offer a therapy option with justifiable risks and proven benefits – at least in a small number of cases – and patients can benefit from it. For counties with longer travel times to a maximum care clinic, it can offer a partially maximum medical treatment option.
Publication History
Article published online:
04 November 2020
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