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Zentralbl Chir 2019; 144(01): 86-92
DOI: 10.1055/a-0774-8151
Übersicht – Thoraxchirurgie
Georg Thieme Verlag KG Stuttgart · New York

Extrakorporale Membranoxygenierung in der Thoraxchirurgie: die Sicht des Anästhesisten

Extracorporeal Membrane Oxygenation in Thoracic Surgery: the Anesthesiologistʼs Perspective
Stephanie Rehers
1   Anästhesie, operative Intensivmedizin, Schmerztherapie und Notfallmedizin, Klinikum Ibbenbüren, Deutschland
,
Martin Beiderlinden
2   Anästhesiologie, Marienhospital Osnabrück, Deutschland
,
Stephan Ziegeler
1   Anästhesie, operative Intensivmedizin, Schmerztherapie und Notfallmedizin, Klinikum Ibbenbüren, Deutschland
› Author Affiliations
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Publication History

Publication Date:
08 January 2019 (online)

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Zusammenfassung

Auch in der Thoraxchirurgie sind in den letzten Jahren Behandlungspfade im Rahmen von „Enhanced-Recovery-after-Surgery“-Programmen entwickelt worden. Neben minimalinvasiven Operationstechniken sind dabei eine Vielzahl von anästhesiologischen Aspekten wie die Wahl kurz wirksamer Narkoseregime, der Einsatz von Regionalanalgesie, eine ausgeglichene intraoperative Flüssigkeitstherapie, die Vermeidung von postoperativer Übelkeit und Erbrechen und vor allem eine protektive Beatmung zu berücksichtigen. Bei einem Patientenkollektiv, das zunehmend auch bei vorbestehenden, teils schweren Lungenfunktionsstörungen operiert werden muss, führt eine protektive Beatmung unter den Bedingungen einer Ein-Lungen-Ventilation häufig zu schweren Gasaustauschstörungen. In dieser Situation stellt der Einsatz einer venovenösen extrakorporalen Membranoxygenierung (vvECMO) eine suffiziente und sichere Methode dar, die perioperative Behandlung dieser Patienten zu ermöglichen. Auch postoperativ kann die Genesung der Patienten durch eine Weiterführung des Verfahrens im Wachzustand sowohl notwendige Maßnahmen, wie Physio- und Atemtherapie und die Frühmobilisation, als auch die Ausheilung von Luftfistelung der operierten Lunge begünstigen. Zur Vermeidung von Blutungskomplikationen kann die ECMO aufgrund der Heparinbeschichtung der Schlauchsysteme intraoperativ zunächst ohne Antikoagulation betrieben werden. Postoperative Optionen der Antikoagulation stellen Heparin, Argatroban oder Bivalirudin dar. Auch neue Techniken, wie die minimalinvasive Thoraxchirurgie unter Regionalanästhesie mit Sedierung, können in der Zukunft möglicherweise durch den Einsatz einer vvECMO weiterentwickelt werden.

Abstract

“Enhanced Recovery after Surgery” programs have been developed for thoracic surgery over the last couple of years. Besides minimally invasive surgical techniques, there are a number of anaesthesiological aspects like the choice of short acting anaesthetics, the use of regional analgesia, a balanced intraoperative fluid therapy, the avoidance of postoperative nausea and vomiting and, most importantly, protective ventilation, that need to be considered. In patients undergoing thoracic surgery procedures with preexisting severe limitations in pulmonary function, protective ventilation under the conditions of one lung ventilation often leads to severe dysfunction of pulmonary gas exchange. In this situation, establishing veno-venous membrane oxygenation (vvECMO) is a sufficient and safe method to facilitate perioperative treatment of these patients. Postoperatively, patients benefit from the continuation of the conscious vvECMO by augmentation of necessary therapeutic procedures such as physical and respiratory therapy or early mobilisation as well as healing of air leakage of the operated lung. To avoid bleeding complications, ECMO can be operated without anticoagulation intraoperatively with heparin-coating of the tube system. Postoperatively, heparin, argatroban or bivalirudin are options for anticoagulation. New techniques like minimally-invasive thoracic surgery under regional anaesthesia and sedation can potentially be developed further using vvECMO support in the future.

Schlüsselwörter

Thoraxanästhesie - Enhanced Recovery - extrakorporale Membranoxygenierung

Key words

thoracic anesthesia - enhanced recovery - extracorporeal membrane oxygenation
 

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