Extrakorporale Membranoxygenierung bei COVID-19

COVID-19-Patienten, die nicht durch mechanische Beatmung und maximale medikamentöse Therapie stabilisiert werden können, kommen für eine ECMO infrage. An der Medizinischen Universität Wien haben wir am Beginn der Pandemie (März 2020) Leitlinien für die Behandlung solcher kritischen Patienten erstellt. Dieser Artikel stellt ein Follow-up zu diesen Leitlinien dar und soll insbesondere auf die bisherigen „lessons learned“ eingehen.

Kernaussagen

• Die Pandemie hat ECMO-Zentren weltweit vor bislang unbekannte Herausforderungen gestellt und zu einem sprunghaften Zuwachs an Erfahrung und Evidenz geführt.

• Fragen der Ressourcenallokation je nach verfügbarer Kapazität und eine strikte Balance zwischen Indikationen/Kontraindikationen haben sich als Voraussetzung für eine erfolgreiche Behandlung der schwerstkranken Patienten herausgestellt.

• Die aufwendige Versorgung von ECMO-Patienten unter Pandemiebedingungen (Personal protective Equipment!) ist Schwerstarbeit und hat sich dennoch mit der Zeit zu einer professionellen Routine entwickelt.

• Sowohl Patienten mit schwersten Lungenversagen als auch solche mit kardialem Pumpversagen aufgrund von COVID-19 benötigen meist einen hohen Level an ECMO-Support.

• Von langen ECMO-Laufzeiten muss ausgegangen werden.

• Das prinzipielle Management der extrakorporalen Therapie sollte nach Standardprotokollen und -kriterien erfolgen.

• Bei entsprechender Patientenauswahl kann an erfahrenen Zentren mit einer durchaus guten Prognose gerechnet werden.

Schlüsselwörter

Covid-19 - ECMO - veno-venös - veno-arteriell - Patientenmanagement - Intensivstation

Publication History

Article published online:
06 December 2022

• Literatur

• 1 Lang C, Jaksch P, Hoda MA. et al. Lung transplantation for COVID-19-associated acute respiratory distress syndrome in a PCR-positive patient. Lancet Respir Med 2020; 8: 1057-1060 DOI: 10.1016/S2213-2600(20)30361-1. (PMID: 32857987)
• 2 Schmidt M, Hajage D, Lebreton G. et al. Extracorporeal membrane oxygenation for severe acute respiratory distress syndrome associated with COVID-19: a retrospective cohort study. Lancet Respir Med 2020; 8: 1121-1131 DOI: 10.1016/S2213-2600(20)30328-3. (PMID: 32798468)
• 3 Barbaro RP, MacLaren G, Boonstra PS. et al. Extracorporeal membrane oxygenation support in COVID-19: an international cohort study of the Extracorporeal Life Support Organization registry. Lancet 2020; 396: 1071-1078 DOI: 10.1016/S0140-6736(20)32008-0. (PMID: 32987008)
• 4 Shaefi S, Brenner SK, Gupta S. et al. Extracorporeal membrane oxygenation in patients with severe respiratory failure from COVID-19. Intensive Care Med 2021; 47: 208-221 DOI: 10.1007/s00134-020-06331-9. (PMID: 33528595)
• 5 Lebreton G, Schmidt M, Ponnaiah M. et al. Extracorporeal membrane oxygenation network organisation and clinical outcomes during the COVID-19 pandemic in Greater Paris, France: a multicentre cohort study. Lancet Respir Med 2021; 9: 851-862 DOI: 10.1016/S2213-2600(21)00096-5. (PMID: 33887246)
• 6 Karagiannidis C, Strassmann S, Merten M. et al. High In-Hospital Mortality Rate in Patients with COVID-19 Receiving Extracorporeal Membrane Oxygenation in Germany: A Critical Analysis. Am J Respir Crit Care Med 2021; 204: 991-994 DOI: 10.1164/rccm.202105-1145LE. (PMID: 34283685)
• 7 Barbaro RP, MacLaren G, Boonstra PS. et al. Extracorporeal membrane oxygenation for COVID-19: evolving outcomes from the international Extracorporeal Life Support Organization Registry. Lancet 2021; 398: 1230-1238 DOI: 10.1016/S0140-6736(21)01960-7. (PMID: 34599878)
• 8 Hermann M, Laxar D, Krall C. et al. Duration of invasive mechanical ventilation prior to extracorporeal membrane oxygenation is not associated with survival in acute respiratory distress syndrome caused by coronavirus disease 2019. Ann Intensive Care 2022; 12: 6 DOI: 10.1186/s13613-022-00980-3. (PMID: 35024972)
• 9 Friedrichson B, Kloka JA, Neef V. et al. Extracorporeal membrane oxygenation in coronavirus disease 2019: A nationwide cohort analysis of 4279 runs from Germany. Eur J Anaesthesiol 2022; 39: 445-451 DOI: 10.1097/EJA.0000000000001670. (PMID: 35180152)
• 10 Combes A, Peek GJ, Hajage D. et al. ECMO for severe ARDS: systematic review and individual patient data meta-analysis. Intensive Care Med 2020; 46: 2048-2057 DOI: 10.1007/s00134-020-06248-3. (PMID: 33021684)
• 11 Whebell S, Zhang J, Lewis R. et al. Survival benefit of extracorporeal membrane oxygenation in severe COVID-19: a multi-centre-matched cohort study. Intensive Care Med 2022; 48: 467-478 DOI: 10.1007/s00134-022-06645-w. (PMID: 35238946)
• 12 Barbaro RP, Odetola FO, Kidwell KM. et al. Association of hospital-level volume of extracorporeal membrane oxygenation cases and mortality. Analysis of the extracorporeal life support organization registry. Am J Respir Crit Care Med 2015; 191: 894-901 DOI: 10.1164/rccm.201409-1634OC. (PMID: 25695688)
• 13 Combes A, Hajage D, Capellier G. et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med 2018; 378: 1965-1975 DOI: 10.1056/NEJMoa1800385. (PMID: 29791822)
• 14 Badulak J, Antonini MV, Stead CM. et al. Extracorporeal Membrane Oxygenation for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization. ASAIO J 2021; 67: 485-495 DOI: 10.1097/MAT.0000000000001422. (PMID: 33657573)
• 15 Levy JH, Staudinger T, Steiner ME. How to manage anticoagulation during extracorporeal membrane oxygenation. Intensive Care Med 2022; 48: 1076-1079 DOI: 10.1007/s00134-022-06723-z. (PMID: 35689697)
• 16 Robak O, Grafeneder-Weissteiner T, Schellongowski P. et al. In Vivo Suction Pressures of Venous Cannulas During Veno-venous Extracorporeal Membrane Oxygenation. ASAIO J 2022; DOI: 10.1097/MAT.0000000000001668.
• 17 Mulholland JW, Massey W, Shelton JC. Investigation and quantification of the blood trauma caused by the combined dynamic forces experienced during cardiopulmonary bypass. Perfusion 2000; 15: 485-494 DOI: 10.1177/026765910001500603. (PMID: 11131211)
• 18 Feldman C, Anderson R. The role of co-infections and secondary infections in patients with COVID-19. Pneumonia (Nathan) 2021; 13: 5 DOI: 10.1186/s41479-021-00083-w. (PMID: 33894790)
• 19 Cheng V, Abdul-Aziz MH, Roberts JA. et al. Optimising drug dosing in patients receiving extracorporeal membrane oxygenation. J Thorac Dis 2018; 10: S629-S641 DOI: 10.21037/jtd.2017.09.154. (PMID: 29732181)
• 20 Guerin C, Reignier J, Richard JC. Prone positioning in the acute respiratory distress syndrome. N Engl J Med 2013; 369: 980-981 DOI: 10.1056/NEJMc1308895. (PMID: 24004127)
• 21 Papazian L, Schmidt M, Hajage D. et al. Effect of prone positioning on survival in adult patients receiving venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis. Intensive Care Med 2022; 48: 270-280 DOI: 10.1007/s00134-021-06604-x. (PMID: 35037993)
• 22 Lorusso R, Shekar K, MacLaren G. et al. ELSO Interim Guidelines for Venoarterial Extracorporeal Membrane Oxygenation in Adult Cardiac Patients. ASAIO J 2021; 67: 827-844 DOI: 10.1097/MAT.0000000000001510. (PMID: 34339398)
• 23 Basir MB, Schreiber TL, Grines CL. et al. Effect of Early Initiation of Mechanical Circulatory Support on Survival in Cardiogenic Shock. Am J Cardiol 2017; 119: 845-851 DOI: 10.1016/j.amjcard.2016.11.037. (PMID: 28040188)
• 24 Siripanthong B, Nazarian S, Muser D. et al. Recognizing COVID-19-related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management. Heart Rhythm 2020; 17: 1463-1471 DOI: 10.1016/j.hrthm.2020.05.001. (PMID: 32387246)
• 25 Kang Y, Chen T, Mui D. et al. Cardiovascular manifestations and treatment considerations in COVID-19. Heart 2020; 106: 1132-1141 DOI: 10.1136/heartjnl-2020-317056. (PMID: 32354800)
• 26 Zou X, Chen K, Zou J. et al. Single-cell RNA-seq data analysis on the receptor ACE2 expression reveals the potential risk of different human organs vulnerable to 2019-nCoV infection. Front Med 2020; 14: 185-192 DOI: 10.1007/s11684-020-0754-0. (PMID: 32170560)
• 27 Bhatia M, Kumar PA. Pro: Venoarterial ECMO Should Be Considered in Patients With COVID-19. J Cardiothorac Vasc Anesth 2021; 35: 703-706 DOI: 10.1053/j.jvca.2020.11.027. (PMID: 33288430)
• 28 Yao XH, Li TY, He ZC. et al. A pathological report of three COVID-19 cases by minimal invasive autopsies. Zhonghua Bing Li Xue Za Zhi 2020; 49: 411-417 DOI: 10.3760/cma.j.cn112151-20200312-00193. (PMID: 32172546)
• 29 Chow J, Alhussaini A, Calvillo-Arguelles O. et al. Cardiovascular Collapse in COVID-19 Infection: The Role of Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO). CJC Open 2020; 2: 273-277 DOI: 10.1016/j.cjco.2020.04.003. (PMID: 32363334)
• 30 Wiedemann D, Bernardi MH, Distelmaier K. et al. Recommendations for extracorporeal membrane oxygenation (ECMO) in COVID-19 patients : Consensus paper of the Medical University of Vienna. Wien Klin Wochenschr 2020; 132: 671-676 DOI: 10.1007/s00508-020-01708-8. (PMID: 32621065)
• 31 Schaefer AK, Distelmaier K, Riebandt J. et al. Access site complications of postcardiotomy extracorporeal life support. J Thorac Cardiovasc Surg 2021; DOI: 10.1016/j.jtcvs.2021.09.074. (PMID: 34949456)
• 32 Riebandt J, Haberl T, Distelmaier K. et al. Awake Implementation of Extracorporeal Life Support in Refractory Cardiogenic Shock. Medicina (Kaunas) 2021; 58: 43 DOI: 10.3390/medicina58010043. (PMID: 35056351)
• 33 Poppe M, Schriefl C, Steinacher A. et al. Extracorporeal cardiopulmonary resuscitation at the emergency department: A retrospective patient selection evaluation. Eur J Anaesthesiol 2020; 37: 280-285 DOI: 10.1097/EJA.0000000000001142. (PMID: 31860604)