Invasives Kreislaufmonitoring - Vier Methoden im Vergleich

Zusammenfassung

Der Einfluss der verschiedenen invasiven kardiovaskulären Monitoringverfahren auf Patientensicherheit und -prognose in der perioperativen Medizin ist bis heute nur ungenügend getestet. Daher erscheint es umso wichtiger, diese Verfahren abseits der wenigen gesicherten Indikationen nur nach Abschätzung des individuellen Nutzen-Risiko-Verhältnisses anzuwenden. Die zentralvenöse Sauerstoffsättigung (ScvO₂), deren prognostische Relevanz bei Patienten im septischen Schock gezeigt werden konnte, bietet sich als initialer, wenig invasiver kardiovaskulärer Verlaufsparameter an. Die transpulmonale Thermodilution (z.B. PiCCO-System) ist ein geringinvasives Verfahren, mit dessen Hilfe nicht nur die globale Herzfunktion und der Volumenstatus des Patienten eingeschätzt werden können, sondern das zugleich Informationen über die pulmonalen Auswirkungen der kardiovaskulären Therapie liefert. Die Domäne der geringinvasiven transösophagealen Echokardiographie (TEE) ist neben der Kardioanästhesie die Abklärung der akuten, lebensbedrohlichen hämodynamischen Instabilität. Aufgrund fehlender Wirksamkeit und erhöhter Komplikationsraten wird der invasive Pulmonalarterienkatheter (PAK), abgesehen von Ausnahmeindikationen, zunehmend durch die weniger invasiven Monitoringverfahren ersetzt.

Summary

The impact of invasive hemodynamic monitoring on patient safety and outcome in perioperative medicine remains inadequately tested and unproven. The indications for the use of these tools should, therefore, be evaluated according to an individual risk-benefit analysis. The measurement of central venous oxygen saturation (ScvO₂) is of little invasiveness as most high-risk patients are instrumented with central venous catheters, and ScvO₂ has been shown to improve outcome in patients with septic shock. Transpulmonary thermodilution (e.g. PiCCO-system) delivers information not only on global cardiac function and intravascular volume status but also helps to define the pulmonary consequences of cardiovascular therapy. Transesophageal echocardiography (TEE) is a valuable tool in patients undergoing cardiac surgery and represents the beside-method of choice for rapid assessment of acute life-threatening cardiovascular instability. Apart from special indications, these tools tend to replace the pulmonary artery catheter (PAC) which has been shown to be of little value in various patient populations.

Zentralvenöse Sauerstoffsättigung - transpulmonale Thermodilution - Echokardiographie - Pulmonalarterienkatheter - Perioperatives hämodynamisches Monitoring

Central venous oxygen saturation - transpulmonary thermodilution - echocardiography - pulmonary artery catheter - perioperative hemodynamic monitoring

Literaturverzeichnis

• 1 Kumar A, Anel R, Bunnell E. et al. . Pulmonary artery occlusion pressure and central venous pressure fail to predict ventricular filling volume, cardiac performance, or the response to volume infusion in normal subjects.  Crit Care Med. 2004;  32 691-699
• 2 Artucio H, Hurtado J, Zimet L. et al. . PEEP-induced tricuspid regurgitation.  Intensive Care Med. 1997;  23 836-840
• 3 Rivers E, Nguyen B, Havstad S. et al. . Early goal-directed therapy in the treatment of severe sepsis and septic shock.  N Engl J Med. 2001;  345 1368-1377
• 4 Reinhart K, Kuhn HJ, Hartog C. et al. . Continuous central venous and pulmonary artery oxygen saturation monitoring in the critically ill.  Intensive Care Med. 2004;  30 1572-1578
• 5 Edwards JD, Mayall RM. Importance of the sampling site for measurement of mixed venous oxygen saturation in shock.  Crit Care Med. 1998;  26 1356-1360
• 6 Richard C, Warszawski J, Anguel N. et al. . Early use of the pulmonary artery catheter and outcomes in patients with shock and acute respiratory distress syndrome: a randomized controlled trial.  JAMA. 2003;  290 2713-2720
• 7 Sandham JD, Hull RD, Brant RF. et al. . A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients.  N Engl J Med. 2003;  348 5-14
• 8 Connors AF, Jr., Speroff T, Dawson NV. et al. . The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators.  JAMA. 1996;  276 889-897
• 9 Iberti TJ, Fischer EP, Leibowitz AB. et al. . A multicenter study of physicians' knowledge of the pulmonary artery catheter. Pulmonary Artery Catheter Study Group.  JAMA. 1990;  264 2928-2932
• 10 Pulmonary Artery Catheter Consensus conference: consensus statement.  Crit Care Med. 1997;  25 910-925
• 11 Wheeler AP, Bernard GR, Thompson BT. et al. . Pulmonary-artery versus central venous catheter to guide treatment of acute lung injury.  N Engl J Med. 2006;  354 2213-2224
• 12 Hinder F, Poelaert JI, Schmidt C. et al. . Assessment of cardiovascular volume status by transoesophageal echocardiography and dye dilution during cardiac surgery.  Eur J Anaesthesiol. 1998;  15 633-640
• 13 Michard F, Alaya S, Zarka V. et al. . Global end-diastolic volume as an indicator of cardiac preload in patients with septic shock.  Chest. 2003;  124 1900-1908
• 14 Rex S, Brose S, Metzelder S. et al. . Prediction of fluid responsiveness in patients during cardiac surgery.  Br J Anaesth. 2004;  93 782-788
• 15 Reuter DA, Kirchner A, Felbinger TW. et al. . Usefulness of left ventricular stroke volume variation to assess fluid responsiveness in patients with reduced cardiac function.  Crit Care Med. 2003;  31 1399-1404
• 16 Tavernier B, Makhotine O, Lebuffe G. et al. . Systolic pressure variation as a guide to fluid therapy in patients with sepsis-induced hypotension.  Anesthesiology. 1998;  89 1313-1321
• 17 Goedje O, Hoeke K, Lichtwarck-Aschoff M. et al. . Continuous cardiac output by femoral arterial thermodilution calibrated pulse contour analysis: comparison with pulmonary arterial thermodilution.  Crit Care Med. 1999;  27 2407-2412
• 18 Wiesenack C, Fiegl C, Keyser A. et al. . Assessment of fluid responsiveness in mechanically ventilated cardiac surgical patients.  Eur J Anaesthesiol. 2005;  22 658-665
• 19 Szakmany T, Heigl P, Molnar Z. Correlation between extravascular lung water and oxygenation in ALI/ARDS patients in septic shock: possible role in the development of atelectasis?.  Anaesth Intensive Care. 2004;  32 196-201
• 20 Mitchell JP, Schuller D, Calandrino FS. et al. . Improved outcome based on fluid management in critically ill patients requiring pulmonary artery catheterization (see comments).  Am Rev Respir Dis. 1992;  145 990-998
• 21 Vignon P, Mentec H, Terre S. et al. . Diagnostic accuracy and therapeutic impact of transthoracic and transesophageal echocardiography in mechanically ventilated patients in the ICU.  Chest. 1994;  106 1829-1834
• 22 Shanewise JS, Cheung AT, Aronson S. et al. . ASE/SCA guidelines for performing a comprehensive intraoperative multiplane transesophageal echocardiography examination: recommendations of the American Society of Echocardiography Council for Intraoperative Echocardiography and the Society of Cardiovascular Anesthesiologists Task Force for Certification in Perioperative Transesophageal Echocardiography.  Anesth Analg. 1999;  89 870-884
• 23 Practice guidelines for perioperative transesophageal echocardiography. A report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography.  Anesthesiology. 1996;  84 986-1006
• 24 Cheitlin MD, Armstrong WF, Aurigemma GP. et al. . ACC/AHA/ASE 2003 guideline update for the clinical application of echocardiography: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASE Committee to Update the 1997 Guidelines for the Clinical Application of Echocardiography).  Circulation. 2003;  108 1146-1162