Extrakorporale kardiopulmonale Reanimation (eCPR)

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Empfehlungen zur extrakorporalen kardiopulmonalen Reanimation (eCPR)

Die Anaesthesiologie - Die extrakorporale kardiopulmonale Reanimation („extracorporeal cardiopulmonary resuscitation“, eCPR) kann als Rettungsversuch für hoch selektierte Patienten...     

Extrakorporale Membranoxygenierung

Altough the concept of extracorporeal membrane oxygenation (ECMO) therapy has been established and used for over 30 years, in recent years the number of implanted ECMO systems has increased and it has developed into an integral component of the clinical routine. All forms of ECMO therapy can be summarized under the term extracorporeal life support (ECLS). The latest developments are surface-coated and miniaturized ECMO systems which allow the long-term support of critically ill patients. Severe lung failure with a normal cardiac index is treated by venovenous ECMO (vv-ECMO). The interventional lung assist/pumpless extracorporeal lung assist (iLA/PECLA) systems are mostly indicated for hypercapnic respiratory acidosis as is frequent with acute respiratory distress syndrome (ARDS). The support of ARDS patients with ECMO seems to improve outcome by allowing further protective lung ventilation. Cardiopulmonary failure is treated by venoarterial ECMO (va-ECMO) and is often used in an interdisciplinary setting in emergency rooms where survival of these patients is increased by up to 40%. Although clear indications are defined only a few risk analyses have been carried to show which patients benefit most from va-ECMO. The decision whether to implant a va-ECMO or not is still based on center and physician experience. To guarantee safe and high quality treatment for patients interdisciplinary ECMO therapy has to be regulated in the near future. New concepts for ECMO therapy, e.g. the total artificial lung concept or the long-term treatment of patients with pulmonary hypertension with ECMO need further clinical observation and testing.     

Extrakorporale Herz- und Lungenersatzverfahren

The use of extracorporeal support systems in cardiac and/or pulmonary failure is an established treatment option. Although scientific evidence is limited there is an increasing amount of data from individual studies, e.g. Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial 2010, suggesting that extracorporeal membrane oxygenation (ECMO) as a veno-venous pump-driven system is a life-saving procedure in severe respiratory failure. Initially established as a rescue option for postcardiotomy cardiac failure extracorporeal life support (ECLS) as a pump-driven veno-arterial cardiovascular support system is increasingly being used in cardiogenic shock after myocardial infarction, as bridging to transplantation or as part of extended cardiopulmonary resuscitation. The pumpless extracorporeal lung assist (pECLA) as an arterio-venous pumpless system is technically easier to handle but only ensures sufficient decarboxylation and not oxygenation. Therefore, this method is mainly applied in primarily hypercapnic respiratory failure to allow lung protective ventilation. Enormous technical improvements, e.g. extreme miniaturization of the extracorporeal assist devices must not obscure the fact that this therapeutic option represents an invasive procedure frequently associated with major complications. With this in mind a widespread use of this technology cannot be recommended and the use of extracorporeal systems should be restricted to centers with high levels of expertise and experience.     

Extrakorporale Stoßwellentherapie

Extracorporeal shock wave therapy (ESWT) has been established as a unique treatment option for soft tissue and bone pathologies. Typical indications include plantar fasciitis, tendinosis calcarea, and tennis elbow, as well as bone pathologies such as nonunions. Regarding the efficacy of ESWT in acute fractures, the literature is herein reviewed. Significant and effective acceleration of fracture and osteotomy healing as well as improvement of biomechanical bone properties by ESWT has been demonstrated in most of the relevant published animal studies. Thus, variable and noncomparable treatment parameters have been applied, and an optimized treatment protocol still must be established. Clinical data are limited to one prospective randomized trial, which demonstrated significant stimulation of healing of long bone fractures after ESWT was applied to the fracture site immediately after open reduction and internal fixation. Additional studies are required to corroborate the effectiveness of ESWT in acute fractures. Although the effectiveness of ESWT has been postulated in a myriad of trials investigating nonunions, published data are not sufficient to allow the recommendation of shock wave treatment for acute fractures also.     

181. Extrakorporale Leberassistenz

Zusammenfassung Die extrakorporale Leberassistenz ist ein neues Therapieverfahren, dessen Prinzip darin besteht, beim Coma hepaticum das Blut des Patienten durch eine isolierte Schweineleber zu perfundieren und auf diese Weise von Schlackenstoffen zu reinigen.Es wird über ca. 100 in der Welt mitgeteilte Fälle sowie über 2 in der eigenen Klinik durchgeführte Perfusionen berichtet. Auf die Indikationsstellung, operative Technik und Problematik des Verfahrens wird eingegangen. Bei sorgfältig abgewogener Indikation verspricht die Methode gute Erfolge.

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Summary Extracorporal liver assistance is a new method of treatment. Its principle consists of perfusion of the hepatic coma patient's blood through an isolated pig's liver to cleanse it of slag substances. Ca. 100 cases published throughout the world and 2 perfusions performed in our own clinic are reported. Indications, operative techniques and problems connected with the method are discussed. If the indications are carefully considered the method promises success.

     

117. Extrakorporale Nierenchirurgie

Zusammenfassung Technik und Indikationsbereich anhand 8 eigener Fälle werden diskutiert. Die Indikationen sind begrenzt: Bilaterale Nierentumoren und Tumoren der Einzelniere mit intra-renalem Wachstum sowie intra-renalem Aneuraysmata oder arterielle Stenosen kommen in erster Linie in Frage. Ein Fall mit intra-renalem Carcinom in einer Einzelniere und normaler Nierenfunktion 22 Monate nach der Operation sowie die technischen Möglichkeiten bei multiplen Tumoren in einer Hufeisenniere werden demonstriert.     

Extrakorporale Stoßwellentherapie (ESWT) bei Pseudarthrosen und verzögerter Frakturheilung

Since 1995, a total of 115 patients with pseudarthrosis or delayed bone fracture healing have each undergone a single session of shock wave treatment. After the treatment the fractures were correctly set according to the rules of conservative bone fracture treatment. The mean follow-up ¶period for all patients was 31 months (range 3–50 months. In 87 cases (75.7%) bony consolidation was achieved with simultaneous reduction in the symptoms. Apart from low-grade local reactions (swelling, haematoma, petechiae) no complications were observed. The treatment is noninvasive and requires little investment in terms of personnel or technology. Extracorporeal shock wave therapy should therefore be considered before an elaborate operative procedure is initiated in the treatment of pseudarthrosis and of delayed fracture healing.     

Extrakorporale Membranoxygenierung beim akuten Lungenversagen

Die extrakorporale Membranoxygenierung (ECMO) stellt heute im Rahmen klinischer Algorithmen einen wichtigen Baustein in der Therapie des schweren akuten Lungenversagens (ARDS) dar, nachdem sich in observationellen Studien der Wert dieses Verfahrens für die ARDS-Therapie trotz fehlender positiver kontrollierter Studien gezeigt hat. In spezialisierten Zentren wird bei Patienten mit drohender Hypoxie nach Anwendung verschiedener konservativer Therapieverfahren die ECMO unter Integration von Blutpumpen und künstlichen Membranlungen (Oxygenatoren) als Lungenersatzverfahren angewandt. Die Neuentwicklung von Oberflächenbeschichtungen, optimierten Oxygenatoren und miniaturisierten Blutpumpen sollte in der Zukunft sowohl die Hämokompatibilität steigern als auch die klinische Anwendung vereinfachen und komplikationsärmer machen. Die Entwicklung von Oxygenatoren mit deutlich niedrigeren Strömungswiderständen ermöglicht dabei die klinische Anwendung als pumpenloses, durch die arteriovenöse Druckdifferenz getriebenes Lungenunterstützungsverfahren (ECLA). Diese Neuentwicklungen könnten in der Zukunft zur Anwendung der ECMO nicht mehr nur als ultima ratio, sondern auch bei weniger schwerem ARDS führen, um lungenprotektivere, weniger invasive Beatmungsformen zu ermöglichen.     

Extrakorporale Membranoxygenierung beim akuten Lungenversagen

After various observational studies demonstrated a benefit of extracorporeal membrane oxygenation (ECMO) in the therapy of severe acute respiratory distress syndrome (ARDS), ECMO now represents an important contribution for ARDS therapy using clinical algorithms despite a lack of positive controlled studies. In specialized centers patients with severe ARDS and imminent hypoxia despite intensive conventional therapy, are treated with ECMO using blood pumps and artificial membrane lungs (oxygenators) for extracorporeal lung assist. The development of new surface modifications, optimized oxygenators and miniaturized blood pumps should increase hemocompatibility and lead to simplified treatment as well as less complications. New oxygenators with significantly decreased blood resistance allow the clinical application of pumpless arteriovenous extracorporeal lung assist (ECLA). After these new developments indications for ECMO could be extended from use not only as ultimate ratio but to less severe ARDS to enable lung protective, less invasive mechanical ventilation.     

Extrakorporale Sto?wellentherapie zur Behandlung der Achillessehnentendinopathie

Hintergrund  

Ziel der Studie war die Untersuchung der Effektivität einer extrakorporalen Stoßwellentherapie (ESWT) in der Behandlung erwachsener Patienten mit chronischer Ansatztendinopathie der Achillessehne.     

Extrakorporale Stoßwellentherapie bei Knochenheilungsstörungen

Extracorporeal shock wave therapy (ESWT) is applied increasingly in the treatment of bone and soft tissue pathologies. Animal studies have yielded a broad scientific basis supporting the efficacy of ESWT in bone stimulation and also demonstrated its osteogenic potency. Discussion of molecular mechanisms of action has concentrated mainly on cell membrane hyperpolarization and radical production, followed by stimulation of osteoprogenitor cells and expression of growth factors. Clinical studies also indicate that ESWT is effective in the treatment of non-union and healing rates of 41–89% have been observed, but only on the basis of level IV evidence derived from uncontrolled studies. Among 601 patients prospectively treated for non-union, we achieved a consolidation rate of 83%. However, real evidence of its efficacy is still lacking. Until a randomized controlled study provides this ESWT must be recommended on the basis of the best available evidence – not least because of its low-level risks and side effects and positive cost-benefit ratio. More scientific data is available on ESWT than on most other conservative and operative treatment options for patients with bony non-union.