Hämodynamisches Monitoring – Verbessertes Outcome durch erweitertes perioperatives hämodynamisches Monitoring

Zusammenfassung

Ein erweitertes hämodynamisches Monitoring liefert fluss-, volumen- und stoffwechselbezogene Informationen, die in Verbindung mit hierauf basierenden Therapie-Algorithmen zur perioperativen Optimierung des Volumenstatus und des O₂-Angebots genutzt werden können. Es besteht eine zunehmende Evidenz, dass eine solche zielgerichtete Therapie in definierten Patientengruppen die perioperative Morbidität und Mortalität senken kann. Dieser Beitrag gibt eine kurze Übersicht über die verschiedenen verfügbaren Zielparameter und ihren aktuellen Stellenwert im Kontext einer zielgerichteten hämodynamischen Optimierung von Risikopatienten.

Abstract

Advanced haemodynamic monitoring provides information on blood flow, volume status, and oxygen supply to demand ratio. Together with related therapeutic algorithms these variables can be used to optimize cardiac preload and oxygen delivery in the perioperative period. There is increasing evidence that a goal-directed therapy can improve perioperative outcome. In this review we will briefly describe different target variables and their relevance for the haemodynamic optimization of high-risk surgical patients.

Kernaussagen:

• Ein erweitertes Monitoring liefert in Ergänzung zum anästhesiologischen Basismonitoring Informationen über fluss-, volumen- oder stoffwechselbezogene Determinanten der Hämodynamik. Diese umfassen insbesondere das Herzzeitvolumen (HZV), die kardiale Vorlast, die gemischt- oder zentralvenöse O₂-Sättigung sowie Parameter der regionalen Gewebeoxygenierung.

• Ein erweitertes hämodynamisches Monitoring ist nur sinnvoll in Verbindung mit Therapiealgorithmen, die auf die gemessenen Parameter Bezug nehmen.

• Eine zielgerichtete hämodynamische Therapie (”goal-directed therapy“, GDT) ist ein Konzept, das Parameter eines erweiterten Monitorings nutzt, um durch eine individuell angepasste Optimierung des O₂-Angebots (DO₂) die perioperative Morbidität und Mortalität zu senken.

• Das Ziel einer GDT ist es, durch eine angepasste Volumentherapie und ggf. durch die Anwendung von positiv inotropen Substanzen einer globalen oder regionalen O₂-Schuld in der perioperativen Phase vorzubeugen.

• Auswirkungen einer Hypovolämie auf die Herzfrequenz und den Blutdruck spiegeln nicht das Ausmaß eines Volumenverlusts wider und sind bei perioperativer Gabe vasoaktiver Medikamente nur bedingt interpretierbar.

• Durch ein Monitoring der kardialen Vorlast sollen eine perioperative Hypovolämie und ihre negativen Auswirkungen auf das HZV verhindert werden, gleichzeitig jedoch auch einer unangepasst hohen Flüssigkeitszufuhr und den hieraus resultierenden Risiken vorgebeugt werden.

• Aktuelle Metaanalysen zeigen, dass eine GDT in Verbindung mit einem erweiterten Monitoring perioperativ die Komplikationsrate und auch die Mortalität senken kann.

Schlüsselwörter:

erweitertes hämodynamisches Monitoring - zielgerichtete Therapie - Volumenstatus - Sauerstoffangebot - perioperatives Outcome

Keywords:

advanced haemodynamic monitoring - goal-directed therapy - volume status - oxygen delivery - perioperative outcome

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