Skip to main content
SpringerLink
Log in

Hämodynamisches Monitoring kritisch Kranker

Bettseitige Integration von Messdaten

Hemodynamic monitoring of critically ill patients

Bedside integration of data

  • Leitthema
  • Published:
Medizinische Klinik - Intensivmedizin und Notfallmedizin Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Das hämodynamische Monitoring kritisch kranker Patienten ist eine der Kernaufgaben der Intensivmedizin. Die Indikationsstellung zum invasiven Monitoring und die Durchführung sind sehr komplex und bedürfen einer gründlichen Ausbildung und Kenntnis.

Material und Methode

Es wurde eine Literaturrecherche durchgeführt.

Ergebnisse

Ein pragmatisches Vorgehen lässt sich in mehrere Schritte unterteilen. Anamnese, körperliche Untersuchung, Bildgebung und Laborwerte sichern die initial gestellte Arbeitsdiagnose ab und erlauben eine Eingrenzung der zugrunde liegenden Pathophysiologie. Ergibt sich die Indikation zur Anlage einer arteriellen Druckmessung und/oder kontinuierlichen Bestimmung des Herzzeitvolumens, erlauben die Komponenten des funktionellen hämodynamischen Monitorings eine weitere Eingrenzung der Volumenreagibilität. Entscheidungen zur Therapie mit Volumen, Diuretika, vasoaktiven bzw. positiv inotropen Substanzen werden somit belegt.

Schlussfolgerung

Alle Informationen der Anamnese, körperlichen Untersuchung, Bildgebung und des hämodynamischen Monitorings sind zu einem Gesamtbild zusammenzuführen und müssen regelmäßig und im Einzelfall bei hämodynamischer Instabilität engmaschig reevaluiert werden. Zielwerte der Therapie sind allenfalls Anhaltspunkte, da jeder Patient sein individuelles pathophysiologisches Profil hat.

Abstract

Background

Hemodynamic monitoring of critically ill patients is a key issue in intensive care medicine. Indication and application of invasive hemodynamic monitoring is a highly complex matter and requires thorough professional education and training.

Materials and methods

A literature review was performed.

Results

A pragmatic approach can be divided into several steps such as medical history, physical examination, imaging, and laboratory results, which support the primary working diagnosis and allow further clarification of the underlying pathophysiology. Invasive arterial blood pressure and cardiac output measurement as well as components of the functional hemodynamic monitoring help to assess fluid responsiveness and to guide volume loading, diuretic therapy as well as administration of vasoactive or positive inotrope substances.

Conclusions

All information gathered through medical history, physical examination, imaging, and hemodynamic monitoring help to form an overall picture and should be reevaluated regularly and in individual cases very closely depending on the hemodynamic instability of the patient. Target values are strictly indicative and are not binding taking into account that each patient has its unique pathophysiological profile.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5

Literatur

  1. Ait-Oufella H, Bige N, Boelle PY et al (2014) Capillary refill time exploration during septic shock. Intensive Care Med 40:958–964

    Article  CAS  PubMed  Google Scholar 

  2. Ait-Oufella H, Lemoinne S, Boelle PY et al (2011) Mottling score predicts survival in septic shock. Intensive Care Med 37:801–807

    Article  CAS  PubMed  Google Scholar 

  3. Antonelli M, Levy M, Andrews PJ et al (2007) Hemodynamic monitoring in shock and implications for management. International Consensus Conference, Paris, France, 27–28 April 2006. Intensive Care Med 33:575–590

    Article  PubMed  Google Scholar 

  4. Asfar P, Meziani F, Hamel JF et al (2014) High versus low blood-pressure target in patients with septic shock. N Engl J Med 370:1583–1593

    Article  CAS  PubMed  Google Scholar 

  5. Barbier C, Loubieres Y, Schmit C et al (2004) Respiratory changes in inferior vena cava diameter are helpful in predicting fluid responsiveness in ventilated septic patients. Intensive Care Med 30:1740–1746

    PubMed  Google Scholar 

  6. Brunauer A, Dünser MW (2011) Zurück zur Basis: Die klinische Beurteilung der Hautperfusion als Fenster zur Mikrozirkulation. Intensiv-News 6(11):1–6

    Google Scholar 

  7. Cecconi M, De BD, Antonelli M, Task force of the European Society of Intensive Care Medicine, - (2014) Consensus on circulatory shock and hemodynamic monitoring. Intensive Care Med 40:1795–1815

    Article  PubMed  PubMed Central  Google Scholar 

  8. Cecconi M, Parsons AK, Rhodes A (2011) What is a fluid challenge? Curr Opin Crit Care 17:290–295

    Article  PubMed  Google Scholar 

  9. Christ M, Siegemund M (2006) Einsatz der Ultraschalluntersuchung in der Intensivmedizin. Anasthesiol Intensivmed Notfallmed Schmerzther 41:269–272

    Article  CAS  PubMed  Google Scholar 

  10. Corl K, Napoli AM, Gardiner F (2012) Bedside sonographic measurement of the inferior vena cava caval index is a poor predictor of fluid responsiveness in emergency department patients. Emerg Med Australas 24:534–539

    Article  PubMed  Google Scholar 

  11. De Backer D, Fagnoul D (2014) Intensive care ultrasound: VI. Fluid responsiveness and shock assessment. Ann Am Thorac Soc 11:129–136

    Article  PubMed  Google Scholar 

  12. Das Ärztliche Zentrum für Qualität in der Medizin (ÄZQ) (2015) http://www.leitlinien.de. Zugegriffen: 19. März 2016

  13. Dellinger RP, Levy MM, Rhodes A et al (2013) Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 39:165–228

    Article  CAS  PubMed  Google Scholar 

  14. Dorrington KL (1981) Skin turgor: do we understand the clinical sign? Lancet 1:264–266

    Article  CAS  PubMed  Google Scholar 

  15. Drexler H, Bonin J von (2002) Kardiogener Schock nach Myokardinfarkt: Therapieansätze. In: Eckart J, Forst H, Burchardi H (Hrsg) Intensivmedizin Kompendium und Repetitorium zur interdisziplinären Fort- und Weiterbildung. Ecomed, Landsberg, S 1–12

    Google Scholar 

  16. Dünser M, Hjortrup PB, Pettila V (2016) Vasopressors in shock: are we meeting our target and do we really understand what we are aiming at? Intensive Care Med. doi:10.1007/s00134-016-4269-8

    Google Scholar 

  17. Dünser MW, Takala J, Brunauer A et al (2013) Re-thinking resuscitation: leaving blood pressure cosmetics behind and moving forward to permissive hypotension and a tissue perfusion-based approach. Crit Care 17:326

    Article  PubMed  PubMed Central  Google Scholar 

  18. Feissel M, Michard F, Faller JP et al (2004) The respiratory variation in inferior vena cava diameter as a guide to fluid therapy. Intensive Care Med 30:1834–1837

    Article  PubMed  Google Scholar 

  19. Feissel M, Michard F, Mangin I et al (2001) Respiratory changes in aortic blood velocity as an indicator of fluid responsiveness in ventilated patients with septic shock. Chest 119:867–873

    Article  CAS  PubMed  Google Scholar 

  20. Fleischmann C, Thomas-Rueddel DO, Hartmann M et al (2016) Fallzahlen und Sterblichkeitsraten von Sepsis-Patienten im Krankenhaus. Dtsch Arztebl Int 113:159–166

    PubMed  PubMed Central  Google Scholar 

  21. Forrester JS, Diamond G, Chatterjee K et al (1976) Medical therapy of acute myocardial infarction by application of hemodynamic subsets (second of two parts). N Engl J Med 295:1404–1413

    Article  CAS  PubMed  Google Scholar 

  22. Goetz AE, Heckel K (2007) Perioperativer Flüssigkeits- und Volumenersatz: Zielgerichtete Therapie ist erforderlich! Anaesthesist 56:745–746

    Article  CAS  PubMed  Google Scholar 

  23. Graf J, Irqsusi M, Janssens U (2008) Perioeratives hämodynamisches Monitoring – ein Überlebensvorteil für anaesthesiologisch betreute Patienten? Anasthesiol Intensivmed Notfallmed Schmerzther 43:364–372

    Article  PubMed  Google Scholar 

  24. Gu WJ, Zhang Z, Bakker J (2015) Early lactate clearance-guided therapy in patients with sepsis: a meta-analysis with trial sequential analysis of randomized controlled trials. Intensive Care Med 41:1862–1863

    Article  PubMed  Google Scholar 

  25. Hayes MA, Timmins AC, Yau EH et al (1994) Elevation of systemic oxygen delivery in the treatment of critically ill patients. N Engl J Med 330:1717–1722

    Article  CAS  PubMed  Google Scholar 

  26. Hudson LD (1985) Monitoring of critically ill patients: conference summary. Respir Care 30:628–636

    Google Scholar 

  27. Janssens U (2000) Hämodynamisches Monitoring. Internist 41:995–1010

    Article  CAS  PubMed  Google Scholar 

  28. Janssens U (2006) Beurteilung des Volumenstatus bei septischen Patienten durch ZVD oder PAOP: Druck ist nicht gleich Volumen! Intensiv-News 6/06:9–12

    Google Scholar 

  29. Janssens U (2009) Die akute Herzinsuffizienz: Diagnostik und Monitoring. Dtsch Med Wochenschr 134:1287–1292

    Article  CAS  PubMed  Google Scholar 

  30. Janssens U (2012) Die akute Herzinsuffizienz. Med Klin Intensivmed Notfmed 107:397–423

    CAS  PubMed  Google Scholar 

  31. Janssens U (2014) Frühe zielorientierte Therapie bei schwerer Sepsis. Med Klin Intensivmed Notfmed 109:568–576

    Article  CAS  PubMed  Google Scholar 

  32. Janssens U (2015) Kreislaufinsuffizienz und Schock – Rationales Monitoring. In: Jorch G, Kluge S, Markewitz A, Putensen C, Quintel M, Sybrecht GW (Hrsg) DIVI Jahrbuch 2014/2015. MWV, Berlin, S 351–358

    Google Scholar 

  33. Janssens U, Graf J (2004) Was ist „Schock“. Internist 45:258–266

    Article  CAS  PubMed  Google Scholar 

  34. Janssens U, Graf J (2005) Systemische Optimierung des O2-Angebotes. Kardiologische Optimierung. Anasthesiol Intensivmed Notfallmed Schmerzther 40:640–652

    Article  CAS  PubMed  Google Scholar 

  35. Janssens U, Hanrath P (1994) Schock. Internist 35:673–689

    CAS  PubMed  Google Scholar 

  36. Janssens U, Hanrath P (2000) Die geschichtliche Entwicklung des Monitorings als Methode der Intensivmedizin. Intensivmed Notfallmed 37:100–112

    Article  Google Scholar 

  37. Janssens U, Jung C, Hennersdorf M et al (2016) Empfehlungen zum hämodynamischen Monitoring in der internistischen Intensivmedizin. Kardiologe (in print)

  38. Janssens U, Kluge S (2015) Indikation und Steuerung der Volumentherapie. Med Klin Intensivmed Notfmed 110:110–117

    Article  CAS  PubMed  Google Scholar 

  39. Janssens U, Werdan K (2006) Erforderliches Monitoring auf der Intensivstation. Herz 31:749–760

    Article  PubMed  Google Scholar 

  40. Jensen MB, Sloth E, Larsen KM et al (2004) Transthoracic echocardiography for cardiopulmonary monitoring in intensive care. Eur J Anaesthesiol 21:700–707

    Article  CAS  PubMed  Google Scholar 

  41. Juneja D, Singh O, Dang R (2011) Admission hyperlactatemia: causes, incidence, and impact on outcome of patients admitted in a general medical intensive care unit. J Crit Care 26:316–320

    Article  CAS  PubMed  Google Scholar 

  42. Kastrati A, Colleran R, Ndrepepa G (2016) Cardiogenic Shock: How Long Does the Storm Last? J Am Coll Cardiol 67:748–750

    Article  PubMed  Google Scholar 

  43. Langlois SP (2007) Focused ultrasound training for clinicians. Crit Care Med 35:S138–S143

    Article  Google Scholar 

  44. Lee CW, Kory PD, Arntfield RT (2016) Development of a fluid resuscitation protocol using inferior vena cava and lung ultrasound. J Crit Care 31:96–100

    Article  PubMed  Google Scholar 

  45. Marik PE, Cavallazzi R (2013) Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 41:1774–1781

    Article  PubMed  Google Scholar 

  46. Marx G, Albers J, Bauer M et al (2014) S3 Leitlinie „Intravasale Volumentherapie beim Erwachsenen“. http://www.awmf.org/leitlinien/detail/ll/001-020.html. Zugegriffen: 11 Jan 2016

    Google Scholar 

  47. McGee S, Abernethy WB III, Simel DL (1999) The rational clinical examination. Is this patient hypovolemic? JAMA 281:1022–1029

    Article  CAS  PubMed  Google Scholar 

  48. Michard F, Boussat S, Chemla D et al (2000) Relation between respiratory changes in arterial pulse pressure and fluid responsiveness in septic patients with acute circulatory failure. Am J Respir Crit Care Med 162:134–138

    Article  CAS  PubMed  Google Scholar 

  49. Monnet X, Marik P, Teboul JL (2016) Passive leg raising for predicting fluid responsiveness: a systematic review and meta-analysis. Intensive Care Med. doi:10.1007/s00134-015-4134-1

    Google Scholar 

  50. Nguyen HB, Rivers EP, Knoblich BP et al (2004) Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med 32:1637–1642

    Article  PubMed  Google Scholar 

  51. Nohria A, Tsang SW, Fang JC et al (2003) Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol 41:1797–1804

    Article  PubMed  Google Scholar 

  52. Prekker ME, Scott NL, Hart D et al (2013) Point-of-care ultrasound to estimate central venous pressure: a comparison of three techniques. Crit Care Med 41:833–841

    Article  PubMed  Google Scholar 

  53. Reuter DA, Kirchner A, Felbinger TW et al (2003) Usefulness of left ventricular stroke volume variation to assess fluid responsiveness in patients with reduced cardiac function. Crit Care Med 31:1399–1404

    Article  PubMed  Google Scholar 

  54. Singer M, Deutschman CS, Seymour CW et al (2016) The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA 315:801–810

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  55. Takala J (2016) Volume responsive, but does the patient need volume? Intensive Care Med. doi:10.1007/s00134-015-4172-8

    PubMed Central  Google Scholar 

  56. Surviving Sepsis Campaign (2015) http://www.survivingsepsis.org/Bundles. Zugriff am 28.3.2016

  57. Taylor AE, Moore TM (1999) Capillary fluid exchange. Am J Physiol 277:S203–S210

    CAS  PubMed  Google Scholar 

  58. Thiele H, Ohman EM, Desch S et al (2015) Management of cardiogenic shock. Eur Heart J. doi:10.1093/eurheartj/ehv051

    Google Scholar 

  59. Werdan K, Ruß M, Buerke M et al (2011) Deutsch-österreichische S3-Leitlinie „Infarktbedingter kardiogener Schock - Diagnose, Monitoring und Therapie“. Intensivmed Notfallmed 48:291–344

    Article  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Klinik für Innere Medizin und Internistische Intensivmedizin, St.-Antonius-Hospital, Dechant-Deckers-Straße 8, 52249, Eschweiler, Deutschland

    U. Janssens

Authors
  1. U. Janssens
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to U. Janssens.

Ethics declarations

Interessenkonflikt

U. Janssens gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Additional information

Redaktion

L. Engelmann, Leipzig

U. Janssens, Eschweiler

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Janssens, U. Hämodynamisches Monitoring kritisch Kranker . Med Klin Intensivmed Notfmed 111, 619–629 (2016). https://doi.org/10.1007/s00063-016-0170-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00063-016-0170-z

Schlüsselwörter

Keywords

Search

Navigation