Outcome-relevante Anästhesiologie: intraoperatives hämodynamisches Monitoring und Management

Zusammenfassung

Hämodynamisches Monitoring und Management ist ein wichtiger Bestandteil einer jeden Narkose und damit von großer Bedeutung für die tägliche anästhesiologische Praxis. In diesem Beitrag werden die Grundlagen des hämodynamischen Monitorings dargelegt und die Relevanz eines intraoperativen hämodynamischen Managements aufgezeigt.

Abstract

Postoperative deaths are a consequence of postoperative complications – including acute kidney injury and myocardial injury. Postoperative complications are associated with non-modifiable patient-specific risk factors (i.e., age, medical history), but also with potentially modifiable risk factors – including intraoperative hypotension and compromised intraoperative blood flow. Based on patient- and surgery-specific risk factors, the intraoperative hemodynamic monitoring strategy needs to be selected. Intraoperative hypotension is associated with postoperative organ failure and should thus be avoided. To optimize intraoperative hemodynamics, cardiac output-guided hemodynamic management has been proposed. Cardiac output-guided hemodynamic management aims at optimizing oxygen delivery using fluids, vasopressors, and inotropes. Cardiac output-guided hemodynamic management has been shown to reduce postoperative complications compared to routine hemodynamic management in high-risk patients having major surgery.

Kernaussagen

• Die Auswahl des intraoperativen hämodynamischen Monitorings sollte an das individuelle operations- und patientenspezifische Risiko angepasst werden.

• Die invasive Blutdruckmessung mittels eines arteriellen Katheters ist das Referenzverfahren der arteriellen Blutdruckmessung.

• Intraoperative Hypotonie ist mit postoperativen Komplikationen assoziiert.

• Ein zielgerichtetes Herzzeitvolumen-gesteuertes Management soll einen adäquaten Blutfluss sowie ein ausreichendes Sauerstoffangebot gewährleisten.

• Therapiealgorithmen können bei der klinischen Umsetzung eines intraoperativen Herzzeitvolumen-gesteuerten Managements hilfreich sein.

Schlüsselwörter

Blutdruck - Blutfluss - Herzzeitvolumen - intraoperative zielgerichtete Therapie

Key words

blood pressure - blood flow - cardiac output - intraoperative goal-directed therapy

Publikationsverlauf

Artikel online veröffentlicht:
16. Februar 2022

• Literatur

• 1 Li G, Warner M, Lang BH. et al. Epidemiology of anesthesia-related mortality in the United States, 1999–2005. Anesthesiology 2009; 110: 759-765 DOI: 10.1097/aln.0b013e31819b5bdc.
• 2 Spence J, LeManach Y, Chan MTV. et al. Association between complications and death within 30 days after noncardiac surgery. CMAJ 2019; 191: E830-E837 DOI: 10.1503/cmaj.190221.
• 3 Sessler DI, Bloomstone JA, Aronson S. et al. Perioperative Quality Initiative consensus statement on intraoperative blood pressure, risk and outcomes for elective surgery. Br J Anaesth 2019; 122: 563-574 DOI: 10.1016/j.bja.2019.01.013.
• 4 Gregory A, Stapelfeldt WH, Khanna AK. et al. Intraoperative hypotension is associated with adverse clinical outcomes after noncardiac surgery. Anesth Analg 2021; 132: 1654-1665 DOI: 10.1213/ANE.0000000000005250.
• 5 Parker T, Brealey D, Dyson A. et al. Optimising organ perfusion in the high-risk surgical and critical care patient: a narrative review. Br J Anaesth 2019; 123: 170-176 DOI: 10.1016/j.bja.2019.03.027.
• 6 Saugel B, Vincent JL, Wagner JY. Personalized hemodynamic management. Curr Opin Crit Care 2017; 23: 334-341 DOI: 10.1097/MCC.0000000000000422.
• 7 Meng L, Wang Y, Zhang L. et al. Heterogeneity and variability in pressure autoregulation of organ blood flow: Lessons learned over 100+ years. Crit Care Med 2019; 47: 436-448 DOI: 10.1097/CCM.0000000000003569.
• 8 Bijker JB, van Klei WA, Kappen TH. et al. Incidence of intraoperative hypotension as a function of the chosen definition: literature definitions applied to a retrospective cohort using automated data collection. Anesthesiology 2007; 107: 213-220 DOI: 10.1097/01.anes.0000270724.40897.8e.
• 9 Saugel B, Sessler DI. Perioperative blood pressure management. Anesthesiology 2021; 134: 250-261 DOI: 10.1097/ALN.0000000000003610.
• 10 Saugel B, Reese PC, Sessler DI. et al. Automated ambulatory blood pressure measurements and intraoperative hypotension in patients having noncardiac surgery with general anesthesia: A prospective observational study. Anesthesiology 2019; 131: 74-83 DOI: 10.1097/ALN.0000000000002703.
• 11 Ackland GL, Brudney CS, Cecconi M. et al. Perioperative Quality Initiative consensus statement on the physiology of arterial blood pressure control in perioperative medicine. Br J Anaesth 2019; 122: 542-551 DOI: 10.1016/j.bja.2019.01.011.
• 12 Walsh M, Devereaux PJ, Garg AX. et al. Relationship between intraoperative mean arterial pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension. Anesthesiology 2013; 119: 507-515 DOI: 10.1097/ALN.0b013e3182a10e26.
• 13 Salmasi V, Maheshwari K, Yang D. et al. Relationship between intraoperative hypotension, defined by either reduction from baseline or absolute thresholds, and acute kidney and myocardial injury after noncardiac surgery: A retrospective cohort analysis. Anesthesiology 2017; 126: 47-65 DOI: 10.1097/ALN.0000000000001432.
• 14 Sun LY, Wijeysundera DN, Tait GA. et al. Association of intraoperative hypotension with acute kidney injury after elective noncardiac surgery. Anesthesiology 2015; 123: 515-523 DOI: 10.1097/ALN.0000000000000765.
• 15 Mascha EJ, Yang D, Weiss S. et al. Intraoperative mean arterial pressure variability and 30-day mortality in patients having noncardiac surgery. Anesthesiology 2015; 123: 79-91 DOI: 10.1097/ALN.0000000000000686.
• 16 Monk TG, Bronsert MR, Henderson WG. et al. Association between intraoperative hypotension and hypertension and 30-day postoperative mortality in noncardiac surgery. Anesthesiology 2015; 123: 307-319 DOI: 10.1097/ALN.0000000000000756.
• 17 Wesselink EM, Kappen TH, Torn HM. et al. Intraoperative hypotension and the risk of postoperative adverse outcomes: a systematic review. Br J Anaesth 2018; 121: 706-721 DOI: 10.1016/j.bja.2018.04.036.
• 18 Ahuja S, Mascha EJ, Yang D. et al. Associations of intraoperative radial arterial systolic, diastolic, mean, and pulse pressures with myocardial and acute kidney injury after noncardiac surgery: A retrospective cohort analysis. Anesthesiology 2020; 132: 291-306 DOI: 10.1097/ALN.0000000000003048.
• 19 Mathis MR, Naik BI, Freundlich RE. et al. Preoperative risk and the association between hypotension and postoperative acute kidney injury. Anesthesiology 2020; 132: 461-475 DOI: 10.1097/ALN.0000000000003063.
• 20 Shoemaker WC, Appel PL, Kram HB. et al. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 1988; 94: 1176-1186 DOI: 10.1378/chest.94.6.1176.
• 21 Saugel B, Kouz K, Scheeren TWL. The “5 Ts” of perioperative goal-directed haemodynamic therapy. Br J Anaesth 2019; 123: 103-107 DOI: 10.1016/j.bja.2019.04.048.
• 22 Wax DB, Lin HM, Leibowitz AB. Invasive and concomitant noninvasive intraoperative blood pressure monitoring: observed differences in measurements and associated therapeutic interventions. Anesthesiology 2011; 115: 973-978 DOI: 10.1097/ALN.0b013e3182330286.
• 23 Saugel B, Dueck R, Wagner JY. Measurement of blood pressure. Best Pract Res Clin Anaesthesiol 2014; 28: 309-322 DOI: 10.1016/j.bpa.2014.08.001.
• 24 Saugel B, Hoppe P, Nicklas JY. et al. Continuous noninvasive pulse wave analysis using finger cuff technologies for arterial blood pressure and cardiac output monitoring in perioperative and intensive care medicine: a systematic review and meta-analysis. Br J Anaesth 2020; 125: 25-37 DOI: 10.1016/j.bja.2020.03.013.
• 25 Saugel B, Vincent J-L. Cardiac output monitoring: how to choose the optimal method for the individual patient. Curr Opin Crit Care 2018; 24: 165-172
• 26 Reuter DA, Huang C, Edrich T. et al. Cardiac output monitoring using indicator-dilution techniques: basics, limits, and perspectives. Anesth Analg 2010; 110: 799-811 DOI: 10.1213/ANE.0b013e3181cc885a.
• 27 Kouz K, Scheeren TWL, de Backer D. et al. Pulse wave analysis to estimate cardiac output. Anesthesiology 2021; 134: 119-126 DOI: 10.1097/ALN.0000000000003553.
• 28 Saugel B, Kouz K, Scheeren TWL. et al. Cardiac output estimation using pulse wave analysis-physiology, algorithms, and technologies: a narrative review. Br J Anaesth 2021; 126: 67-76 DOI: 10.1016/j.bja.2020.09.049.
• 29 Saugel B, Kouz K, Meidert AS. et al. How to measure blood pressure using an arterial catheter: a systematic 5-step approach. Crit Care 2020; 24: 172 DOI: 10.1186/s13054-020-02859-w.
• 30 Meidert AS, Briegel J, Saugel B. [Principles and pitfalls of arterial blood pressure measurement]. Anaesthesist 2019; 68: 637-650 DOI: 10.1007/s00101-019-0614-y.
• 31 Maheshwari K, Khanna S, Bajracharya GR. et al. A randomized trial of continuous noninvasive blood pressure monitoring during noncardiac surgery. Anesth Analg 2018; 127: 424-431 DOI: 10.1213/ane.0000000000003482.
• 32 Meidert AS, Nold JS, Hornung R. et al. The impact of continuous non-invasive arterial blood pressure monitoring on blood pressure stability during general anaesthesia in orthopaedic patients: A randomised trial. Eur J Anaesthesiol 2017; 34: 716-722 DOI: 10.1097/EJA.0000000000000690.
• 33 Saugel B, Wagner JY, Scheeren TW. Cardiac output monitoring: less invasiveness, less accuracy?. J Clin Monit Comput 2016; 30: 753-755 DOI: 10.1007/s10877-016-9900-2.
• 34 Rajaram SS, Desai NK, Kalra A. et al. Pulmonary artery catheters for adult patients in intensive care. Cochrane Database Syst Rev 2013; (02) CD003408 DOI: 10.1002/14651858.CD003408.pub3.
• 35 Kristensen SD, Knuuti J, Saraste A. et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35: 2383-2431 DOI: 10.1093/eurheartj/ehu282.
• 36 Futier E, Lefrant JY, Guinot PG. et al. Effect of individualized vs. standard blood pressure management strategies on postoperative organ dysfunction among high-risk patients undergoing major surgery: A randomized clinical trial. JAMA 2017; 318: 1346-1357 DOI: 10.1001/jama.2017.14172.
• 37 Chong MA, Wang Y, Berbenetz NM. et al. Does goal-directed haemodynamic and fluid therapy improve peri-operative outcomes?: A systematic review and meta-analysis. Eur J Anaesthesiol 2018; 35: 469-483 DOI: 10.1097/EJA.0000000000000778.
• 38 Pearse RM, Harrison DA, MacDonald N. et al. Effect of a perioperative, cardiac output-guided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA 2014; 311: 2181-2190 DOI: 10.1001/jama.2014.5305.
• 39 Edwards MR, Forbes G, MacDonald N. et al. Optimisation of Perioperative Cardiovascular Management to Improve Surgical Outcome II (OPTIMISE II) trial: study protocol for a multicentre international trial of cardiac output-guided fluid therapy with low-dose inotrope infusion compared with usual care in patients undergoing major elective gastrointestinal surgery. BMJ Open 2019; 9: e023455 DOI: 10.1136/bmjopen-2018-023455.
• 40 Nicklas JY, Diener O, Leistenschneider M. et al. Personalised haemodynamic management targeting baseline cardiac index in high-risk patients undergoing major abdominal surgery: a randomised single-centre clinical trial. Br J Anaesth 2020; 125: 122-132 DOI: 10.1016/j.bja.2020.04.094.
• 41 Ahmad T, Beilstein CM, Aldecoa C. et al. Variation in haemodynamic monitoring for major surgery in European nations: secondary analysis of the EuSOS dataset. Perioper Med (Lond) 2015; 4: 8 DOI: 10.1186/s13741-015-0018-8.
• 42 Maheshwari K, Malhotra G, Bao X. et al. Assisted fluid management software guidance for intraoperative fluid administration. Anesthesiology 2021; 135: 273-283 DOI: 10.1097/ALN.0000000000003790.
• 43 Joosten A, Alexander B, Duranteau J. et al. Feasibility of closed-loop titration of norepinephrine infusion in patients undergoing moderate- and high-risk surgery. Br J Anaesth 2019; 123: 430-438 DOI: 10.1016/j.bja.2019.04.064.
• 44 Joosten A, Rinehart J, Van der Linden P. et al. Computer-assisted individualized hemodynamic management reduces intraoperative hypotension in intermediate- and high-risk surgery: A randomized controlled trial. Anesthesiology 2021; 135: 258-272 DOI: 10.1097/ALN.0000000000003807.