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Volumentherapie bei Hämorrhagie

Fluid resuscitation in hemorrhage

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Zusammenfassung

Wie eine Volumentherapie bei akuter Hämorrhagie durchgeführt werden soll, wird nach wie vor kontrovers diskutiert. Obwohl die forcierte Gabe von Kristalloiden und Kolloiden lange Zeit praktiziert wurde und auch noch praktiziert wird, gibt es heute gute Argumente dafür, dass eine zurückhaltende Infusion von Kristalloiden zunächst ausreichend sein kann. Allerdings sollte 0,9 %ige NaCl-Lösung als Volumenersatz nicht mehr verabreicht werden. Für eine zurückhaltende Volumentherapie spricht, dass keine großen prospektiven und randomisierten Studien existieren, die bewiesen hätten, dass die forcierte Gabe von Volumenersatzmitteln die Überlebensrate verbessert. Dass bislang kein positiver Effekt beobachtet werden konnte, wird damit erklärt, dass die Volumentherapie selbst eine Blutung durch einen Blutdruckanstieg und eine Dilutionskoagulopathie verstärken soll. Gleichwohl empfehlen nationale und internationale Leitlinien, dass ein Volumenersatz spätestens dann verabreicht werden soll, wenn die Hämodynamik unter einer Blutung instabil wird. Es muss auch bedacht werden, dass eine „damage control resuscitation“ per se weder eine bereits reduzierte Gewebeperfusion noch die Hämostase verbessert. Im akuten und ggf. schnell progredienten Volumenmangelschock können Kolloide den Kristalloiden unter dem Aspekt einer hämodynamischen Stabilisierung überlegen sein. Hydroxyethylstärke (HES) der 3. und 4. Generation ist bei gegebener Indikation und unter Beachtung der Höchstdosierung sicher. Werden Volumenersatzmittel unter ständiger Reevaluation der Parameter, die das Sauerstoffangebot beeinflussen, verabreicht, sollte das Ziel sein, so wenig zu infundieren, dass es nicht zu unerwünschten Effekten kommt, aber so viel, dass die Versorgung des Gewebes mit Sauerstoff und das Überleben der Patienten sichergestellt sind.

Abstract

How fluid resuscitation has to be performed for acute hemorrhage situations is still controversially discussed. Although the forced administration of crystalloids and colloids has been and still is practiced, nowadays there are good arguments that a cautious infusion of crystalloids may be initially sufficient. Saline should no longer be used for fluid resuscitation. The main argument for cautious fluid resuscitation is that no large prospective randomized clinical trials exist which have provided evidence of improved survival when fluid resuscitation is applied in an aggressive manner. The explanation that no positive effect has so far been observed is that fluid resuscitation is thought to boost bleeding by increasing blood pressure and dilutional coagulopathy. Nevertheless, national and international guidelines recommend that fluid resuscitation should be applied at the latest when hemorrhage causes hemodynamic instability. Consideration should be given to the fact that damage control resuscitation per se will neither improve already reduced tissue perfusion nor hemostasis. In acute and possibly rapidly progressing hypovolemic shock, colloids can be used. The third and fourth generations of hydroxyethyl starch (HES) are safe and effective if used correctly and within prescribed limits. If fluid resuscitation is applied with ongoing re-evaluation of the parameters which determine oxygen supply, it should be possible to keep fluid resuscitation restricted without causing undesirable side effects and also to administer a sufficient quantity so that survival of patients is ensured.

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Einhaltung ethischer Richtlinien

Interessenskonflikt. M. Roessler, K. Bode und M. Bauer geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag enthält keine Studien an Menschen oder Tieren.

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  1. Zentrum Anästhesiologie, Rettungs- und Intensivmedizin, Georg-August-Universität, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075, Göttingen, Deutschland

    M. Roessler D.E.A.A., EDIC, K. Bode & M. Bauer

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  1. M. Roessler D.E.A.A., EDIC
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  2. K. Bode
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  3. M. Bauer
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Correspondence to M. Roessler D.E.A.A., EDIC.

Addendum

Addendum

Am 04.09.2014, zum Zeitpunkt der Drucklegung des vorliegenden Beitrags „Volumentherapie bei Hämorrhagie“ wurde die „S3-Leitlinie Intravasale Volumentherapie beim Erwachsenen“ (AWMF-Register-Nr.: 001/020) veröffentlicht. Die S3-Leitlinie konnte im vorliegenden Beitrag daher nicht berücksichtigt werden. Gleichwohl entsprechen sich die zur Volumentherapie bei Hämorrhagie gemachten Empfehlungen im Wesentlichen. Die S3-Leitlinie zur intravasalen Volumentherapie geht detailliert auf den Stellenwert invasiver Methoden zur Diagnostik eines Volumenmangels, insbesondere auf den Stellenwert statischer, flussbasierter oder dynamischer Vorlastparameter ein. Der Leitthemenbeitrag „Volumentherapie bei Hämorrhagie“ beschränkt sich diesbezüglich im Wesentlichen auf Parameter, die schnell und fast jederzeit erhoben werden können. Der Stellenwert des ZVD ist – auch in der S3-Leitlinie – weiterhin kontrovers.

Die Autoren hoffen, dass der vorliegende Beitrag – zusammen mit der S3-Leitlinie – den interessierten Lesern eine Hilfestellung sein wird, um bei Patienten mit Hämorrhagie eine rational begründbare, sichere und effektive Volumenersatztherapie durchzuführen.

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Roessler, M., Bode, K. & Bauer, M. Volumentherapie bei Hämorrhagie. Anaesthesist 63, 730–744 (2014). https://doi.org/10.1007/s00101-014-2377-9

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