Hypoperfusionssyndrom und kardiogener Schock

Zusammenfassung

Der kardiogene Schock stellt nach wie vor ein Krankheitsbild mit hoher Mortalität dar. In dieser Situation entwickelt sich nahezu regelhaft eine Laktatazidose durch Gewebsischämie. Diese wiederum unterstützt den klinischen Gesamteindruck eines Schockzustandes. Das erhöhte Laktat bzw. mehr noch die verzögerte oder fehlende Laktatclearance sind harte Prädiktoren der schlechten Prognose. In dieser Situation ist die hämodynamische Stabilisierung neben der Ursachentherapie oberstes Gebot. Eine balancierte Volumen-/Katecholamintherapie stellt die Basis dar. Früh muss aber eine Entscheidung für oder gegen den Einsatz eines mechanischen Unterstützungssystems fallen. Entscheidungshilfen sind klinische, aber auch laborchemische und interventionelle Faktoren. Das fallende Laktat (die Laktatclearance) ist auch unter extrakorporalem System der wichtigste Ausdruck einer funktionierenden Therapie. Randomisierte Studien, die eine Prognoseverbesserung dieser schwer kranken Patienten beweisen, existieren derzeit nicht. Umso wichtiger ist der rationale, aber frühe Einsatz dieser Systeme nach in Positionspapieren definierten Kriterien.

Abstract

Cardiogenic shock continues to be a disease with high mortality. In this situation, lactate acidosis develops almost regularly as a result of tissue ischemia. This in turn supports the overall clinical impression of a state of shock. The increased lactate or even more the delayed or missing lactate clearance are hard predictors of the bad prognosis. In this situation, hemodynamic stabilization is the top priority alongside causal therapy. The basis is a balanced volume/catecholamine therapy. However, a decision for or against the use of a mechanical support system must be made at an early stage. Decision aids are clinical, but also laboratory chemical and interventional factors. The falling lactate (lactate clearance) is also the most important expression of a successful therapy under an extracorporeal system. Currently, randomized studies that show an improvement in the prognosis of these critically ill patients do not exist. This makes the rational but early use of these systems according to criteria defined in position papers all the more important.

Was ist neu/wichtig?

Ein erhöhtes Laktat bzw. eine Laktatazidose stellt ein Kriterium der Diagnosestellung des kardiogenen Schockes dar. Gleichzeitig ist dies neben der verzögerten Laktat-Clearance einer der wichtigsten Prognoseparameter in dieser lebensbedrohlichen Situation. Der Einsatz von extrakorporalen Unterstützungssystemen (Impella, ECLS) führt zu einer zumindest kurzfristigen Stabilisierung solcher Patienten. Die Patientenauswahl und der Umgang mit diesen Systemen sowie den assoziierten Komplikationen stellen wichtige Herausforderungen dar.

Schlüsselwörter

kardiogener Schock - Laktatazidose - extrakorporale Herzunterstützung

Key words

cardiogenic shock - lactate acidosis - extracorporeal cardiac assistance

• Literatur

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