Transplantologiya 2014

Keywords: veno-venous and veno-arterial ECMO, acute respiratory failure, the organization of ECMO in the hospital.
The treatment of an acute respiratory failure has still remained one of the most challenging tasks that makes us search for new methods to cope with it. In the latest decades, the mechanical ventilation in various modes, including "aggressive" ones, has been the only management technique in acute respiratory failure [1]. Current advances in medicine give us the opportunity to use new technologies related to the development and implementation of extracorporeal membrane oxygenation (ECMO) for the treatment of terminally ill patients with severe cardiopulmonary failure. The use of this technique allows an efficient and safe maintenance of gas exchange in a patient for several weeks [2-4].

The purpose of the article was to show the potential of using ECMO for the treatment of acute respiratory failure in a multidisciplinary hospital basing on the experience of Regensburg University Hospital (Bavaria, Germany).

The multidisciplinary Regensburg University Hospital was chosen to study a foreign clinical experience with ECMO as the facility taking a leading place in Europe in the implementation and use of this technique to treat various clinical conditions. The Hospital located about 100 km from Munich is a tertiary health care center providing a specialized care for the population of about 2 million inhabitants in the North East Bavaria region. The Hospital counts 20 clinical departments including Cardiac Surgery, Transplantation, Neurosurgery, Trauma Departments. The Hospital has 804 beds specialized in major fields of medicine, including 84 beds (10%) in the Intensive Care Units (ICUs). Annually, about 30,000 in-patients and approximately 100,000 out-patients receive treatment in the Hospital. Regensburg University Hospital has the largest Accident and Emergency (A&E) Centre in the region. Besides modern ambulances and emergency doctors’ cars, the Hospital has two intensive care helicopters well-equipped to provide a critical care during the transportation of severely injuried in traffic accidents, during interhospital transfers, and, when necessary, to use ECMO in the patients with an out-of-hospital cardiac arrest (Fig. 1). There is a constant communication and coordination with the rescue service and other medical institutions.

Figure 1. A&E Department of Regensburg University Hospital

All ICUs are located on one and the same floor of the Hospital. There are also the Operating Theatre, diagnostic departments with the capacities of radiology, angiography, extracorporeal treatment, and perfusion services. Such arrangement has its undisputed advantages allowing a time reduction in intra-hospital transports, an earlier initiation of care at admission, an easy use of additional implements attached to the medical equipment in a critically ill patient, and also an easier inter-ICU transport of patients and medical equipment.

The University Hospital has gained a many-year experience in the treatment of cardiovascular and respiratory failure by using extracorporeal techniques. For example, in the period from 2006 to 2014, 391 veno-arterial ECMOs and 393 veno-venous ECMOs were performed (Fig. 2). A routine use of this efficient innovative technique for the treatment of critical care patients with severe multisystem trauma, those waiting for transplantation, and the patients after cardiopulmonary resuscitation, etc. is impressive.

Figure 2. ECMO use in patients with cardiovascular and respiratory failure.

 

ECMO technology is aimed at a life support of critical care patients whose cardiovascular and/or respiratory systemic impairments are still being potentially reversible, but who are failing to respond to a standard therapy.

Critical conditions that may bear potential indications to the ECMO use are listed in Table 1.