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 3,000 ECLS/ECMO (extracorporeal life support/extracorporeal membrane oxygenation) implantations annually in Germany. Due to the lack of guidelines, there is an urgent need for evidence-based recommendations addressing the central aspects of ECLS/ECMO therapy. 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

Intensivmedizin - ECMO - ECLS - extrakorporale Unterstützung

Keywords

Linksherzversagen - critical care - ECMO - ECLS - extracorporeal support - left ventricular failure

Publication History

Received: 25 July 2022

Accepted: 27 July 2022

Article published online:
27 September 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 DOI: 10.1007/s00134-016-4273-z. (PMID: 26942446)
• 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 DOI: 10.1055/s-0041-1730374. (PMID: 34176107)
• 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 DOI: 10.1055/s-0038-1675597. (PMID: 30458568)
• 4 Balshem H, Helfand M, Schünemann HJ. et al. GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol 2011; 64: 401-406 DOI: 10.1016/j.jclinepi.2010.07.015. (PMID: 21208779)
• 5 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 DOI: 10.1016/j.jclinepi.2012.03.013. (PMID: 23312392)
• 6 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 DOI: 10.1007/s00392-018-1366-4. (PMID: 30361819)
• 7 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 DOI: 10.1007/s00134-016-4536-8. (PMID: 27647331)
• 8 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 DOI: 10.1016/j.jtcvs.2017.02.055.
• 9 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 DOI: 10.7150/ijms.20618. (PMID: 29104480)
• 10 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 DOI: 10.1177/2048872618799745. (PMID: 30406678)
• 11 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 DOI: 10.1155/2018/2428648. (PMID: 29789779)
• 12 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 DOI: 10.1177/2048872615612454. (PMID: 26503919)
• 13 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 DOI: 10.1016/j.resuscitation.2010.03.002. (PMID: 20413202)
• 14 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 DOI: 10.1097/CCM.0b013e3181feb339. (PMID: 21057309)
• 15 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 DOI: 10.1016/j.ijcard.2013.04.183. (PMID: 23664696)
• 16 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 DOI: 10.1016/j.resuscitation.2015.11.013. (PMID: 26683472)
• 17 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 DOI: 10.1097/CCM.0b013e31827ca4c8. (PMID: 23388518)
• 18 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 DOI: 10.1186/s13054-014-0535-8. (PMID: 25255842)
• 19 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 DOI: 10.1016/j.resuscitation.2012.03.028. (PMID: 22469751)
• 20 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 DOI: 10.1161/CIRCULATIONAHA.115.019143. (PMID: 27199466)
• 21 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 DOI: 10.1016/j.athoracsur.2016.10.023. (PMID: 28131429)
• 22 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 DOI: 10.1093/eurheartj/ehv194. (PMID: 26033984)
• 23 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 DOI: 10.1016/j.resuscitation.2016.12.009. (PMID: 27993632)
• 24 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)
• 25 Huesch MD. Volume-Outcome Relationships in Extracorporeal Membrane Oxygenation: Retrospective Analysis of Administrative Data From Pennsylvania, 2007–2015. ASAIO J 2018; 64: 450-457 DOI: 10.1097/MAT.0000000000000675. (PMID: 29076948)
• 26 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 DOI: 10.1007/s00134-018-5064-5. (PMID: 29450594)
• 27 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 DOI: 10.1164/rccm.201404-0630CP. (PMID: 25062496)
• 28 Extracorporeal Life Support Organization (ELSO). ELSO guidelines for ECMO centers 2014. Accessed July 01, 2022 at: https://www.elso.org/Portals/0/IGD/Archive/FileManager/faf3f6a3c7cusersshyerdocumentselsoguidelinesecmocentersv1.8.pdf
• 29 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 DOI: 10.1093/eurheartj/ehs081. (PMID: 22513777)
• 30 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 DOI: 10.1097/MAT.0b013e31828387cd. (PMID: 23438777)
• 31 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 DOI: 10.1097/MAT.0b013e31822e2475.
• 32 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 DOI: 10.1016/j.ejcts.2011.05.011. (PMID: 21683610)
• 33 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 DOI: 10.1007/s00063-015-0052-9. (PMID: 26223445)
• 34 Extracorporeal Life Support Organization (ELSO). ELSO guidelines for adult cardiac failure 2014. Accessed July 01, 2022 at: https://www.elso.org/Portals/0/IGD/Archive/FileManager/e76ef78eabcusersshyerdocumentselsoguidelinesforadultcardiacfailure1.3.pdf
• 35 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 DOI: 10.1097/CCM.0000000000001865. (PMID: 27340754)
• 36 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 DOI: 10.1097/PCC.0b013e3181e28894. (PMID: 20495508)
• 37 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 DOI: 10.1097/PCC.0000000000000317. (PMID: 25647124)
• 38 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 DOI: 10.1007/s00134-013-2985-x. (PMID: 23749154)
• 39 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 DOI: 10.1097/PCC.0000000000000345. (PMID: 25651048)
• 40 Vogel AM, Lew DF, Kao LS. et al. Defining risk for infectious complications on extracorporeal life support. J Pediatr Surg 2011; 46: 2260-2264 DOI: 10.1016/j.jpedsurg.2011.09.013. (PMID: 22152861)
• 41 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 DOI: 10.1016/j.athoracsur.2015.06.020. (PMID: 26298170)
• 42 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 DOI: 10.1097/PCC.0000000000000414. (PMID: 25828782)
• 43 Pappalardo F, Schulte C, Pieri M. et al. Concomitant implantation of Impella® on top of veno-arterial extracorporeal membrane oxygenation may improve survival of patients with cardiogenic shock. Eur J Heart Fail 2017; 19: 404-412 DOI: 10.1002/ejhf.668.
• 44 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 DOI: 10.1097/MAT.0000000000000767. (PMID: 29489461)
• 45 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 DOI: 10.7717/peerj.3813. (PMID: 28975053)
• 46 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 DOI: 10.1186/s13054-017-1633-1. (PMID: 28264702)
• 47 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 DOI: 10.1093/bja/aew151. (PMID: 27317704)
• 48 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 DOI: 10.1097/CCM.0000000000001828. (PMID: 27322361)
• 49 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 DOI: 10.1177/2048872617711169. (PMID: 28574276)
• 50 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 DOI: 10.1186/1471-2253-14-27. (PMID: 24725532)
• 51 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 DOI: 10.1093/ejcts/ezu005. (PMID: 24510911)
• 52 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 DOI: 10.1111/aor.12758. (PMID: 27658844)
• 53 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 DOI: 10.1016/j.jtcvs.2017.10.152. (PMID: 29361299)
• 54 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 DOI: 10.1097/CCM.0000000000002169. (PMID: 27984278)
• 55 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 DOI: 10.1056/NEJMoa1802637. (PMID: 29791247)
• 56 Grundsätze der Bundesärztekammer zur ärztlichen Sterbebegleitung. Dtsch Arztebl [Anonym]. 2011; 108: 346-348
• 57 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 DOI: 10.1038/srep23838. (PMID: 27032984)
• 58 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