Empfehlungen der S3-Leitlinie (AWMF) Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen

Zusammenfassung

In den vergangenen Jahren hat der Einsatz mechanischer Unterstützungssysteme für Patienten mit Herz- und Kreislaufversagen kontinuierlich zugenommen, sodass in Deutschland mittlerweile jährlich etwa 3000 ECLS/ECMO-Systeme implantiert werden. Vor dem Hintergrund bislang fehlender umfassender Leitlinien bestand ein dringlicher Bedarf an der Formulierung evidenzbasierter Empfehlungen zu den zentralen Aspekten der ECLS/ECMO-Therapie.

Im Juli 2015 wurde daher die Erstellung einer S3-Leitlinie durch die Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG) bei der zuständigen Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) angemeldet. In einem strukturierten Konsensusprozess mit Einbindung von Experten aus Deutschland, Österreich und der Schweiz, delegiert aus 11 AWMF-Fachgesellschaften, 5 weiteren Fachgesellschaften sowie der Patientenvertretung, entstand unter Federführung der DGTHG die Leitlinie „Einsatz der extrakorporalen Zirkulation (ECLS/ECMO) bei Herz- und Kreislaufversagen“, die im Februar 2021 publiziert wurde.

Die Leitlinie fokussiert auf klinische Aspekte der Initiierung, Fortführung, Entwöhnung und Nachsorge und adressiert hierbei auch strukturelle und ökonomische Fragestellungen. Dieser Artikel präsentiert eine Übersicht zu der Methodik und den konsentierten Empfehlungen.

Abstract

In recent years, the use of mechanical support for patients with cardiac or circulatory failure has continuously increased, leading to 3000 ECLS/ECMO (extracorporeal life support/extracorporeal membrane oxygenation) implantations annually in Germany. Due to the lack of guidelines, an urgent need for evidence-based recommendations addressing the central aspects of ECLS/ECMO therapy has existed.

In July 2015, the generation of a guideline level S3 according to the standards of the Association of the Scientific Medical Societies in Germany (AWMF) was announced by the German Society for Thoracic and Cardiovascular Surgery (GSTCVS). In a well-structured consensus process, involving experts from Germany, Austria and Switzerland, delegated by 16 scientific societies and the patients’ representation, the guideline “Use of extracorporeal circulation (ECLS/ECMO) for cardiac and circulatory failure” was created under guidance of the GSTCVS, and published in February 2021.

The guideline focuses on clinical aspects of initiation, continuation, weaning and aftercare, herein also addressing structural and economic issues. This article presents an overview on the methodology as well as the final recommendations.

Schlüsselwörter

Leitlinie - Extrakorporale Membranoxygenierung (ECMO) - Extracorporeal Life Support (ECLS) - Herz-Kreislauf-Versagen

Keywords

guideline - extracorporeal membrane oxygenation (ECMO) - extracorporeal life support (ECLS) - cardiac and circulatory failure

Publikationsverlauf

Artikel online veröffentlicht:
08. Juni 2022

• Literatur

• 1 Karagiannidis C, Brodie D, Strassmann S. et al. Extracorporeal membrane oxygenation: evolving epidemiology and mortality. Intensive Care Med 2016; 42: 889-896
• 2 Beckmann A, Meyer R, Lewandowski J. et al. German Heart Surgery Report 2020: The Annual Updated Registry of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 2021; 69: 294-307
• 3 Assmann A, Boeken U, Klotz S. et al. Organization and Application of ECLS Therapy-A Nationwide Survey in German Cardiosurgical Departments. Thorac Cardiovasc Surg 2019; 67: 164-169
• 4 Extrakorporale Zirkulation (ECLS/ECMO), Einsatz bei Herz-und Kreislaufversagen. S3-Leitlinie. AWMF-RN 011–021. 2020 Zugriff am 10. September 2021 unter: https://www.awmf.org/leitlinien/detail/ll/011–021.html
• 5 Balshem H, Helfand M, Schunemann HJ. et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 2011; 64: 401-406
• 6 Andrews J, Guyatt G, Oxman AD. et al. GRADE guidelines: 14. Going from evidence to recommendations: the significance and presentation of recommendations. J Clin Epidemiol 2013; 66: 719-725
• 7 Michels G, Wengenmayer T, Hagl C. et al. Recommendations for extracorporeal cardiopulmonary resuscitation (eCPR): consensus statement of DGIIN, DGK, DGTHG, DGfK, DGNI, DGAI, DIVI and GRC. Clin Res Cardiol 2019; 108: 455-464
• 8 Ouweneel DM, Schotborgh JV, Limpens J. et al. Extracorporeal life support during cardiac arrest and cardiogenic shock: a systematic review and meta-analysis. Intensive Care Med 2016; 42: 1922-1934
• 9 Chen SW, Tsai FC, Lin YS. et al. Long-term outcomes of extracorporeal membrane oxygenation support for postcardiotomy shock. J Thorac Cardiovasc Surg 2017; 154: 469-477.e2
• 10 Chang JJ, Lin MS, Chen TH. et al. Heart Failure and Mortality of Adult Survivors from Acute Myocarditis Requiring Intensive Care Treatment – A Nationwide Cohort Study. Int J Med Sci 2017; 14: 1241-1250
• 11 Schiller P, Hellgren L, Vikholm P. Survival after refractory cardiogenic shock is comparable in patients with Impella and veno-arterial extracorporeal membrane oxygenation when adjusted for SAVE score. Eur Heart J Acute Cardiovasc Care 2019; 8: 329-337
• 12 El Sibai R, Bachir R, El Sayed M. Outcomes in Cardiogenic Shock Patients with Extracorporeal Membrane Oxygenation Use: A Matched Cohort Study in Hospitals across the United States. Biomed Res Int 2018; 2018: 2428648
• 13 Blumenstein J, Leick J, Liebetrau C. et al. Extracorporeal life support in cardiovascular patients with observed refractory in-hospital cardiac arrest is associated with favourable short and long-term outcomes: A propensity-matched analysis. Eur Heart J Acute Cardiovasc Care 2016; 5: 13-22
• 14 Lin JW, Wang MJ, Yu HY. et al. Comparing the survival between extracorporeal rescue and conventional resuscitation in adult in-hospital cardiac arrests: propensity analysis of three-year data. Resuscitation 2010; 81: 796-803
• 15 Shin TG, Choi JH, Jo IJ. et al. Extracorporeal cardiopulmonary resuscitation in patients with inhospital cardiac arrest: A comparison with conventional cardiopulmonary resuscitation. Crit Care Med 2011; 39: 1-7
• 16 Shin TG, Jo IJ, Sim MS. et al. Two-year survival and neurological outcome of in-hospital cardiac arrest patients rescued by extracorporeal cardiopulmonary resuscitation. Int J Cardiol 2013; 168: 3424-3430
• 17 Choi DS, Kim T, Ro YS. et al. Extracorporeal life support and survival after out-of-hospital cardiac arrest in a nationwide registry: A propensity score-matched analysis. Resuscitation 2016; 99: 26-32
• 18 Maekawa K, Tanno K, Hase M. et al. Extracorporeal cardiopulmonary resuscitation for patients with out-of-hospital cardiac arrest of cardiac origin: a propensity-matched study and predictor analysis. Crit Care Med 2013; 41: 1186-1196
• 19 Kim SJ, Jung JS, Park JH. et al. An optimal transition time to extracorporeal cardiopulmonary resuscitation for predicting good neurological outcome in patients with out-of-hospital cardiac arrest: a propensity-matched study. Crit Care 2014; 18: 535
• 20 Masson R, Colas V, Parienti JJ. et al. A comparison of survival with and without extracorporeal life support treatment for severe poisoning due to drug intoxication. Resuscitation 2012; 83: 1413-1417
• 21 Chang CH, Chen HC, Caffrey JL. et al. Survival Analysis After Extracorporeal Membrane Oxygenation in Critically Ill Adults: A Nationwide Cohort Study. Circulation 2016; 133: 2423-2433
• 22 Lorusso R, Gelsomino S, Parise O. et al. Venoarterial Extracorporeal Membrane Oxygenation for Refractory Cardiogenic Shock in Elderly Patients: Trends in Application and Outcome From the Extracorporeal Life Support Organization (ELSO) Registry. Ann Thorac Surg 2017; 104: 62-69
• 23 Schmidt M, Burrell A, Roberts L. et al. Predicting survival after ECMO for refractory cardiogenic shock: the survival after veno-arterial-ECMO (SAVE)-score. Eur Heart J 2015; 36: 2246-2256
• 24 Richardson AS, Schmidt M, Bailey M. et al. ECMO Cardio-Pulmonary Resuscitation (ECPR), trends in survival from an international multicentre cohort study over 12-years. Resuscitation 2017; 112: 34-40
• 25 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
• 26 Huesch MD. Volume-Outcome Relationships in Extracorporeal Membrane Oxygenation: Retrospective Analysis of Administrative Data From Pennsylvania, 2007–2015. ASAIO J 2018; 64: 450-457
• 27 Abrams D, Garan AR, Abdelbary A. et al. Position paper for the organization of ECMO programs for cardiac failure in adults. Intensive Care Med 2018; 44: 717-729
• 28 Combes A, Brodie D, Bartlett R. et al. Position paper for the organization of extracorporeal membrane oxygenation programs for acute respiratory failure in adult patients. Am J Respir Crit Care Med 2014; 190: 488-496
• 29 Extracorporeal Life Support Organization (ELSO) guidelines for ECMO centers 2014. Zugriff am 10. September 2021 unter: https://www.elso.org/Portals/0/IGD/Archive/FileManager/faf3f6a3c7cusersshyerdocumentselsoguidelinesecmocentersv1.8.pdf
• 30 Beurtheret S, Mordant P, Paoletti X. et al. Emergency circulatory support in refractory cardiogenic shock patients in remote institutions: a pilot study (the cardiac-RESCUE program). Eur Heart J 2013; 34: 112-120
• 31 Barrett CS, Jaggers JJ, Cook EF. et al. Pediatric ECMO outcomes: comparison of centrifugal versus roller blood pumps using propensity score matching. ASAIO J 2013; 59: 145-151
• 32 Byrnes J, McKamie W, Swearingen C. et al. Hemolysis during cardiac extracorporeal membrane oxygenation: a case-control comparison of roller pumps and centrifugal pumps in a pediatric population. ASAIO J 2011; 57: 456-461
• 33 Beckmann A, Benk C, Beyersdorf F. et al. Position article for the use of extracorporeal life support in adult patients. Eur J Cardiothorac Surg 2011; 40: 676-680
• 34 Pichler P, Antretter H, Dunser M. et al. Use of ECMO in adult patients with cardiogenic shock: a position paper of the Austrian Society of Cardiology. Med Klin Intensivmed Notfmed 2015; 110: 407-420
• 35 Extracorporeal Life Support Organization (ELSO) guidelines for adult cardiac failure 2014. Zugriff am 10. September 2021 unter: https://www.elso.org/Portals/0/IGD/Archive/FileManager/e76ef78eabcusersshyerdocumentselsoguidelinesforadultcardiacfailure1.3.pdf
• 36 Lorusso R, Barili F, Mauro MD. et al. In-Hospital Neurologic Complications in Adult Patients Undergoing Venoarterial Extracorporeal Membrane Oxygenation: Results From the Extracorporeal Life Support Organization Registry. Crit Care Med 2016; 44: e964-e972
• 37 Bizzarro MJ, Conrad SA, Kaufman DA. et al. Infections acquired during extracorporeal membrane oxygenation in neonates, children, and adults. Pediatr Crit Care Med 2011; 12: 277-281
• 38 Dalton HJ, Garcia-Filion P, Holubkov R. et al. Association of bleeding and thrombosis with outcome in extracorporeal life support. Pediatr Crit Care Med 2015; 16: 167-174
• 39 Polito A, Barrett CS, Wypij D. et al. Neurologic complications in neonates supported with extracorporeal membrane oxygenation. An analysis of ELSO registry data. Intensive Care Med 2013; 39: 1594-1601
• 40 Werho DK, Pasquali SK, Yu S. et al. Hemorrhagic complications in pediatric cardiac patients on extracorporeal membrane oxygenation: an analysis of the Extracorporeal Life Support Organization Registry. Pediatr Crit Care Med 2015; 16: 276-288
• 41 Vogel AM, Lew DF, Kao LS. et al. Defining risk for infectious complications on extracorporeal life support. J Pediatr Surg 2011; 46: 2260-2264
• 42 Werho DK, Pasquali SK, Yu S. et al. Epidemiology of Stroke in Pediatric Cardiac Surgical Patients Supported With Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2015; 100: 1751-1757
• 43 Wightman A, Bradford MC, Symons J. et al. Impact of Kidney Disease on Survival in Neonatal Extracorporeal Life Support. Pediatr Crit Care Med 2015; 16: 576-582
• 44 Pappalardo F, Schulte C, Pieri M. et al. Concomitant implantation of Impella((R)) on top of veno-arterial extracorporeal membrane oxygenation may improve survival of patients with cardiogenic shock. Eur J Heart Fail 2017; 19: 404-412
• 45 Patel SM, Lipinski J, Al-Kindi SG. et al. Simultaneous Venoarterial Extracorporeal Membrane Oxygenation and Percutaneous Left Ventricular Decompression Therapy with Impella Is Associated with Improved Outcomes in Refractory Cardiogenic Shock. ASAIO J 2019; 65: 21-28
• 46 Schmack B, Seppelt P, Weymann A. et al. Extracorporeal life support with left ventricular decompression-improved survival in severe cardiogenic shock: results from a retrospective study. PeerJ 2017; 5: e3813
• 47 Smith M, Vukomanovic A, Brodie D. et al. Duration of veno-arterial extracorporeal life support (VA ECMO) and outcome: an analysis of the Extracorporeal Life Support Organization (ELSO) registry. Crit Care 2017; 21: 45
• 48 Extracorporeal Life Support Organization (ELSO) ultrasound guidance for extra-corporeal membrane oxygenation 2015. Zugriff am 10. September 2021 unter: https://www.elso.org/Portals/0/Files/elso_Ultrasoundguideance_ecmogeneral_guidelines_May2015.pdf
• 49 Distelmaier K, Roth C, Schrutka L. et al. Beneficial effects of levosimendan on survival in patients undergoing extracorporeal membrane oxygenation after cardiovascular surgery. Br J Anaesth 2016; 117: 52-58
• 50 Aso S, Matsui H, Fushimi K. et al. The Effect of Intraaortic Balloon Pumping Under Venoarterial Extracorporeal Membrane Oxygenation on Mortality of Cardiogenic Patients: An Analysis Using a Nationwide Inpatient Database. Crit Care Med 2016; 44: 1974-1979
• 51 Brechot N, Demondion P, Santi F. et al. Intra-aortic balloon pump protects against hydrostatic pulmonary oedema during peripheral venoarterial-extracorporeal membrane oxygenation. Eur Heart J Acute Cardiovasc Care 2018; 7: 62-69
• 52 Lin LY, Liao CW, Wang CH. et al. Effects of Additional Intra-aortic Balloon Counter-Pulsation Therapy to Cardiogenic Shock Patients Supported by Extra-corporeal Membranous Oxygenation. Sci Rep 2016; 6: 23838
• 53 Park TK, Yang JH, Choi SH. et al. Clinical impact of intra-aortic balloon pump during extracorporeal life support in patients with acute myocardial infarction complicated by cardiogenic shock. BMC Anesthesiol 2014; 14: 27
• 54 Ro SK, Kim JB, Jung SH. et al. Extracorporeal life support for cardiogenic shock: influence of concomitant intra-aortic balloon counterpulsation. Eur J Cardiothorac Surg 2014; 46: 186-192
• 55 Cheng R, Ramzy D, Azarbal B. et al. Device Strategies for Patients in INTERMACS Profiles 1 and 2 Cardiogenic Shock: Double Bridge With Extracorporeal Membrane Oxygenation and Initial Implant of More Durable Devices. Artif Organs 2017; 41: 224-232
• 56 Fukuhara S, Takeda K, Kurlansky PA. et al. Extracorporeal membrane oxygenation as a direct bridge to heart transplantation in adults. J Thorac Cardiovasc Surg 2018; 155: 1607-1618.e6
• 57 Davidson JE, Aslakson RA, Long AC. et al. Guidelines for Family-Centered Care in the Neonatal, Pediatric, and Adult ICU. Crit Care Med 2017; 45: 103-128
• 58 White DB, Angus DC, Shields AM. et al. A Randomized Trial of a Family-Support Intervention in Intensive Care Units. N Engl J Med 2018; 378: 2365-2375
• 59 Grundsätze der Bundesärztekammer zur ärztlichen Sterbebegleitung. Dtsch Arztebl Ausg A [Anonym]. 2011; 108: A346-348
• 60 Neitzke G, Burchardi H, Duttge G. et al. Limits of the meaningfulness of intensive care medicine : Position paper of the Ethics Section of DIVI. Med Klin Intensivmed Notfmed 2016; 111: 486-492