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Adäquate Volumensubstitution bei septischem Schock unter hohen Katecholamindosen

Adequate fluid resuscitation in septic shock with high catecholamine doses

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Zusammenfassung

Hintergrund

Beim septischen Schock sollten vasokonstriktorische und positiv inotrope Substanzen möglichst erst dann eingesetzt werden, wenn sich Blutdruck und Organperfusion trotz Vorlastoptimierung nicht adäquat verbessern lassen. Der zunehmende Einsatz des hämodynamischen Monitorings hat gezeigt, dass in einigen Fällen bei initial unzureichender Volumensubstitution hoch dosierte Katecholamine Verwendung finden. Ziel der Studie ist zu zeigen, dass es in einigen Fällen möglich ist, durch eine dem Bedarf entsprechende Volumensubstitution verbunden mit einer gezielten Reduktion der Katecholamindosis deren Bedarf zu reduzieren.

Material und Methoden

In einer retrospektiven Beobachtungsstudie wurden 29 Patienten einer chirurgischen Intensivstation (17 männlich, 12 weiblich; mittleres Alter ± Standardfehler: 71 ± 10 Jahre) mit septischem Schock analysiert, die hoch dosiert Katecholamine erhielten (Noradrenalin 0,204; Dobutamin 3,876; Adrenalin 0,025 µg/kgKG/min im Median; bis zu 0,810/22,222/0,407 µg/kgKG/min; 28/20/17 Patienten). Die Extremitäten waren initial bei allen Patienten kühl und marmoriert, während der mittlere arterielle Druck ≥ 65 mmHg war. Der mediane zentrale Venendruck betrug 17 mmHg (5–34 mmHg), der Laktatspiegel 2,78 mmol/l (0,93–10,67 mmol/l). Das Standardtherapiekonzept umfasste eine forcierte, dem Bedarf entsprechende Volumensubstitution, kombiniert mit einer aktiven Reduktion vasokonstriktorischer und positiv inotroper Substanzen, deren Ausmaß mithilfe eines Autotransfusionsmanövers, klinischer Zeichen und in 19 Fällen mithilfe eines hämodynamischen Monitorings gesteuert wurde (Pulmonaliskatheter, Vigilance II™: n = 10; FloTrac, Vigileo™: n = 9, davon PreSpep™: n = 5, Edwards Lifesciences). Der Volumenbelastungstest wurde bei Wiedererwärmung der Extremitäten, ansteigenden Diuresemengen und fehlender Reaktion auf das Autotransfusionsmanöver beendet.

Ergebnisse

Die mittlere Katecholamindosis ließ sich bei allen Patienten signifikant reduzieren: Noradrenalin 0, Dobutamin 1,852, Adrenalin 0 µg/kgKG/min (bis zu 0,133/6,289/0,091 µg/kgKG/min; p < 0,05, Wilcoxon-Vorzeichenrangsummentest). Volumenbelastungstest: + 4.500 ml Ringer-Lösung (0–24.000 ml) und + 1.000 ml Hydroxyethylstärke (0–2.500 ml); mittlere Bilanz + 6.465 ml (2.040–27.255 ml); mittlere Weaning-Zeit von den Katecholaminen 12 h (4–43 h). Alle Patienten hatten anschließend wieder erwärmte Extremitäten. Die Laktatspiegel fielen auf 2,05 mmol/l (0,7–5,4 mmol/l). Die messbaren hämodynamischen Veränderungen differierten interindividuell deutlich, es trat jedoch keine kardiale Dekompensation auf. Der paO2/FiO2 veränderte sich nichtsignifikant von 264 mmHg (75–418 mmHg) auf 250 mmHg (120–467 mmHg; Median, Bereich). 20 Patienten überlebten, 9 verstarben.

Schlussfolgerungen

Bei einem nicht unerheblichen Anteil septischer Schockpatienten, die mit hoch dosierten Katecholaminen behandelt werden, ist es möglich, diese in Kombination mit einem bedarfsadaptierten, forcierten Volumenbelastungstest zu reduzieren. Die Bedeutung einer adäquaten dem Bedarf entsprechenden Volumensubstitution vor dem Einsatz hoch dosierter Katecholamine wird durch unsere Ergebnisse bestätigt. Sie sollte sich an klinischen und wenn möglich hämodynamischen Parametern orientieren und nicht unterschätzt werden.

Abstract

Background

Appropriate fluid resuscitation is a fundamental aspect for the hemodynamic management of septic shock patients and should ideally be achieved before vasopressors and positive inotropic substances are administered. The development of hemodynamic monitoring has revealed that in some cases patients had been improperly treated with high-dose catecholamines for initially insufficient fluid resuscitation. The aim of this study was to show that in some cases it is possible to actively reduce catecholamines by a volume challenge adapted according to the individual patient needs.

Material and methods

In this retrospective observational study 29 patients with septic shock in a surgical intensive care unit (ICU) at a university hospital (17 male, 12 female, mean age 71 ± 10 years) on high-dose catecholamines (median values norepinephrine 0.204 µg/kg body weight/min, dobutamine 3.876 µg/kg/min and epinephrine 0.025 µg/kg/min, ranging up to 0.810 µg/kg/min, 22.222 µg/kg/min and 0.407 µg/kg/min in 28, 20 and 17 patients, respectively) were analyzed. The extremities of the patients were initially cold with a mottled marbled appearance whereas the mean arterial pressure (MAP) was ≥ 65 mmHg. The median central venous pressure (CVP) was 17 mmHg (range 55–34 mmHg) and the mean lactate concentration was 2.78 mmol/l (range 0.93–10.67 mmol/l). The standard therapy concept consisted of a forced volume challenge combined with active reduction of catecholamines to achieve an adequate fluid loading status, guided by the passive leg raising test (PLR), clinical signs and in 19 cases by hemodynamic monitoring (pulmonary artery catheter Vigilance II™ n = 10, FloTrac™, Vigileo™ n = 9 and PreSep™ n = 5; Edwards Life Sciences). The forced volume challenge was stopped after clinical improvement with rewarmed extremities, increasing diuresis volumes and lack of improvement by PLR.

Results

Catecholamine doses could be significantly reduced in all patients: norepinephrine to 0 µg/kg/min, dobutamine to 1.852 µg/kg/min and epinephrine to 0 µg/kg/min (up to 0.133 µg/kg/min, 6.289 µg/kg/min and 0.091 µg/kg/min, respectively, p < 0.05 Wilcoxon signed rank test). Volume challenge test: + 4,500 ml Ringer solution (range 0–24,000 ml) and 1,000 ml hydroxyethyl starch (range 0–2,500 ml) and mean fluid balance + 6,465 ml (range + 2,040 ml to + 27,255 ml). The median weaning time from catecholamines was 12 h (range 4–43 h). After treatment all patients showed rewarmed extremities and a decrease in mean lactate levels from 2.78 mmol/l (range 0.93–10.67 mmol/l) to 2.05 mmol/l (range 0.7–5.4 mmol/l). The measured hemodynamic constellations showed clear interindividual differences but no cardiac deterioration occurred. The median oxygenation index (paO2/FiO2) showed a statistically insignificant change from 264 mmHg (range 75–418 mmHg) to 250 mmHg (range 120–467 mmHg). Of the patients 20 survived and 9 died.

Conclusion

It is possible to wean a substantial proportion of septic shock patients from high-dose catecholamines in combination with a needs-adapted forced volume challenge test. The importance of appropriate fluid loading prior to the use of high catecholamine doses should be a main subject of discussion in patients with severe septic shock and was confirmed in this study. This should be oriented to clinical and if possible, hemodynamic parameters and should not be underestimated.

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  1. Klinik für Chirurgie, Universitätsklinikum Schleswig-Holstein – Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Deutschland

    J.C. Lewejohann, H. Braasch, M. Hansen, C. Zimmermann, E Muhl & T. Keck

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Interessenkonflikt

J.C. Lewejohann hat Vorträge bei Fortbildungsveranstaltungen über hämodynamisches Monitoring gehalten und dafür Honorare von der Fa. Edwards Lifesciences erhalten. H. Braasch, M. Hansen, C. Zimmermann, E. Muhl und T. Keck geben an, dass kein Interessenkonflikt besteht.

Die ethischen Richtlinien für Studien wurden eingehalten. Die Datenverarbeitung und -auswertung erfolgte ausschließlich sekundär anonymisiert. Das Vorhaben wurde bei der Ethikkommission der Universität Lübeck angezeigt (Aktenzeichen 12-035A) und eine Behandlung im normalen Antragsverfahren für nicht notwendig erachtet.

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Lewejohann, J., Braasch, H., Hansen, M. et al. Adäquate Volumensubstitution bei septischem Schock unter hohen Katecholamindosen. Med Klin Intensivmed Notfmed 111, 514–524 (2016). https://doi.org/10.1007/s00063-015-0111-2

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