Flüssigkeitsmanagement - Volumentherapie in der Gefäßchirurgie am Beispiel der Bauchaortenchirurgie

Zusammenfassung

„No fluid regimen should be standardized, inflexible, and universal; each patient is unique and has different fluid requirements” (Johnston 2006).

Die Flüssigkeits- und Volumentherapie von Patienten, die sich abdominellen Aorteneingriffen unterziehen müssen, birgt zwei Gefahren. Zum einen droht eine Hyperhydratation, anderer-seits kann eine restriktive Flüssigkeitssubstitution zu ausgeprägten hypotensiven Phasen mit der Folge von Endorganfunktionsstörungen an Herz, Gehirn und Nieren führen. Mit der Gabe kristalloider und kolloidaler Lösungen, ggf. auch der Transfusion von Erythrozytenkonzentraten muss die Sauerstofftranportkapazität des Kreislaufs auf adäquatem Niveau gehalten und (durch gezieltes Eingreifen in die Blutgerinnungskaskade drohende Blutungsstörungen) adäquat therapiert werden. Die Steuerung der Volumentherapie erfolgt in der klinischen Routine meist anhand der Beurteilung von Surrogatparametern wie Herzfrequenz, in-/exspiratorische Schwankungen der arteriellen Druckkurve, Diurese und ZVD bzw. PCWP. Die genannten Parameter sind keine verlässlichen Indikatoren der kardialen Vorlast. Derzeitiger Goldstandard zur Beurteilung der kardialen Füllung und Steuerung der Flüssigkeitstherapie ist die transösophageale Echokardiographie (TEE). Ob die transpulmonale Thermodilution bei abdominellen Aorteneingriffen hierfür gleichermaßen geeignet ist, muss durch weitere Studien geklärt werden.

Abstract

„No fluid regimen should be standardized, inflexible, and universal; each patient is unique and has different fluid requirements” (Johnston 2006).

Fluid and volume therapy for patients who must undergo an operation on the abdominal aorta is accompanied by two risks, Firstly, there is a danger of hyperhydration while, secondly, a restrictive fluid substitution can lead to pronounced hypotensive phases resulting in end organ functional disorders of the heart, brain and kidneys. The oxygen transport capacity of the circulation must be maintained at an adequate level by administration of cystalloid and colloid solutions, if necessary also transfusion of erythrocyte concentrates, together with appropriate therapy (threatening bleeding disorders through specific interventions in the blood coagulation cascade). In clinical routine the control of volume therapy is usually achieved by the evaluation of surrogate parameters such as heart rate, inspiratory/expiratory deviations of the arterial pressure curve, diuresis and central venous pressure (CVP) or pulmocapillary wedge pressure (PCWP). These parameters are not reliable indicators of cardiac performance. The current gold standards for evaluating cardiac filling and the control og fluid therpay is transesophageal echo cardiography (TEE). Whether or not transpulmonal thermodilution is equally suitable in cases of abdominal aorta surgery remains to be determined in further studies.

Schlüsselwörter:

Volumentherapie - Bauchaortenchirugie - Gefäßchirurgie - aortales Clamping - transösophageale Echokardiographie

Keywords:

Volume therapy - abdominal aorta surgery - vascular surgery - aorta clamping - transesophageal echo cardiography

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