Kardioanästhesie – Was gibt es Neues?

Die unverändert hohe Morbidität und Mortalität von Patienten, die sich komplexen herzchirurgischen Eingriffen unterziehen, stellen hohe Anforderungen an die Kardioanästhesie. Dieser Beitrag gibt einen Überblick über aktuelle Entwicklungen zu den Themen inotrope Therapie, Monitoring, rationaler Einsatz mechanischer Kreislaufunterstützungssysteme, Volumenmanagement, Sedierung, postoperative Schmerztherapie und Point-of-Care-Gerinnungsdiagnostik.

Abstrac

The still unchanged high morbidity and mortality of patients undergoing complex cardiac surgical procedures as well as developments in minimally invasive cardiac surgery are not only an ongoing challenge for all working in cardiac anaesthesia but also a chance for further developing this anaesthetic subdiscipline. Alongside the presentation of a case report, the present article gives an overview about recent developments in inotropic therapy, monitoring, the rational use of mechanical circulatory support, volume therapy, sedation, analgesia, and point-of-care coagulation monitoring in cardiac anaesthesia.

Kernaussagen

• Die unverändert inakzeptabel hohe Sterblichkeit nach komplexen herzchirurgischen Eingriffen erfordert eine adäquate Risikostratifizierung und multimodale Therapiekonzepte, um die kardiale Funktion zu verbessern.

• Eine präemptive, mehrere Stunden präoperativ begonnene Levosimendan-Therapie scheint geeignet, die Morbidität und Mortalität herzchirurgischer Patienten zu reduzieren. Dies gilt insbesondere für Patienten mit reduzierter linksventrikulärer Funktion, die sich einer koronaren Bypassoperation unterziehen.

• Die aktuelle S3-Leitlinie zur hämodynamischen Therapie herzchirurgischer Patienten empfiehlt einen PAK bei Hochrisikopatienten sowie bei Rechtsherzdysfunktion, pulmonalarterieller Hypertonie und zur Differenzierung der Ursachen und Steuerung der Therapie eines Low-cardiac-Output-Syndroms. Diese Empfehlung erscheint vor dem Hintergrund aktueller Registerdaten unverändert gerechtfertigt.

• Aktuelle systematische Reviews legen nahe: Eine Überwachung der ScO₂ mittels NIRS verbunden mit einer zielgerichteten Therapie zur Vermeidung zerebraler Desaturierung könnte geeignet sein, einen postoperativen geistigen Abbau und/oder die Inzidenz eines postoperativen Delirs zu reduzieren.

• Die Implantation einer IABP sollte präoperativ bei kardiochirurgischen Hochrisikopatienten und bei Patienten mit aktiver oder dekompensierter Herzinsuffizienz erwogen werden; ebenso, wenn ein postoperativer Bedarf für eine mechanische Kreislaufunterstützung erwartet wird. Die IABP soll zur Induktion von Pulsatilität während des kardiopulmonalen Bypasses genutzt werden.

• Pathophysiologische Überlegungen und zunehmende Hinweise auf die Toxizität synthetischer Kolloide legen nahe, zum kolloidalen Volumenersatz präferenziell Albumin einzusetzen und perioperativ eine Hypalbuminämie zu vermeiden.

Schlüsselwörter

Inotropika - Monitoring - mechanische Kreislaufunterstützung - Volumentherapie - Sedierung - Schmerztherapie - Point-of-Care-Gerinnungdiagnostik

Keywords

inotropes - monitoring - mechanical circulatory support - volume therapy - sedation - analgesia - point-of-care coagulation monitoring

Publikationsverlauf

Artikel online veröffentlicht:
23. März 2023

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