Extrakorporaler Life Support in der Intensivmedizin

Der Stellenwert des extrakorporalen Life Supports (ECLS) im refraktären Herz-Kreislauf-Versagen ist durch eine eigene S3-Leitlinie (2021) und ein erweitertes Indikationsspektrum in den europäischen Leitlinien erheblich gestiegen. Mobile ECLS-Teams gewähren zudem einem zunehmend größeren Behandler- und Patientenkollektiv – auch außerhalb von Zentren sowie in der Präklinik – Zugang zu dieser Therapie.

Abstract

Veno-arterial extracorporeal life support (ECLS) may be indicated in patients with refractory heart failure. The list of conditions in which ECLS is successfully used is growing and includes cardiogenic shock following myocardial infarction, refractory cardiac arrest, septic shock with low cardiac output and severe intoxication. Femoral ECLS is the most common and often preferred ECLS-configuration in the emergency setting. Although femoral access is usually quick and easy to establish, it is also associated with specific adverse haemodynamic effects due to the direction of blood flow and access-site complications are inherent. Femoral ECLS provides adequate oxygen delivery and compensates for impaired cardiac output. However, retrograde blood flow into the aorta increases left ventricular afterload and may worsen left ventricular stroke work. Therefore, femoral ECLS is not equivalent to left ventricular unloading. Daily haemodynamic assessments are crucial and should include echocardiography and laboratory tests determining tissue oxygenation. Common complications include the harlequin-phenomenon, lower limb ischaemia or cerebral events and cannula site or intracranial bleeding. Despite a high incidence of complications and high mortality, ECLS is associated with survival benefits and better neurological outcomes in selected patient groups.

Kernaussagen

• ECLS kann die Herz- und Lungenfunktion weitgehend ersetzen und sichert im kardiogenen Schock oder Kreislaufstillstand die Sauerstoffversorgung und die Perfusion der Organe.

• Der periphere ECLS ist im Notfall das favorisierte Verfahren. Die Kanülierung kann sonografisch sowie echokardiografisch gestützt erfolgen.

• Blutfluss und Frischgasfluss sind die Determinanten des Sauerstoffangebots, der Decarboxylierung und Kreislaufunterstützung.

• Im hämodynamischen Monitoring haben die Echokardiografie und laborchemische Marker der Gewebeoxygenierung einen hohen Stellenwert.

• Das empfohlene Monitoring des femoralen ECLS umfasst die NIRS-Messung, Überwachung der Beinperfusion, rechts-radiale Blutgasanalysen sowie Pulsoxymetrie an der rechten oberen Extremität und die Pulsatilität der invasiven Blutdruckkurve.

• Typische Komplikationen sind zerebrale Ereignisse, Harlekin-Phänomen, linksventrikuläre Dilatation und die Extremitätenischämie.

• Das ECLS-Weaning wird bei stabilisierten Organfunktionen begonnen. Ein strukturiertes Vorgehen mit Nutzung festgelegter Protokolle kann die Erfolgswahrscheinlichkeit erhöhen.

Schlüsselwörter

ECLS - femorale Kanülierung - ECLS-Management - Hämodynamik - Überwachung

Keywords

ECLS - femoral access - ECLS-management - haemodynamics - monitoring

Publikationsverlauf

Artikel online veröffentlicht:
16. Mai 2023

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