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Volumenmanagement im Schock

Neue Ziele in der ersten Schockphase

Fluid management in shock patients

New targets in the initial phase of shock

Zusammenfassung

Hintergrund

Die rasche Gabe von Volumen ist einer der Eckpfeiler einer initialen Schocktherapie, speziell auch des septischen Schocks. Allerdings gibt es erhebliche Unsicherheiten, wann wie viel Volumen sinnvoll ist und an welchen Zielen oder Messgrößen das Volumenmanagement ausgerichtet werden kann. Dabei ist es wichtig nur die „optimale“ Flüssigkeitsmenge zu geben, da eine Volumenüberladung erhebliche negative Konsequenzen, wie Organversagen und Verschlechterung des Outcomes, nach sich ziehen kann

Ziel

Dieser Review soll die Bedeutung der Volumentherapie, mögliche Strategien des Volumenmanagements sowie mögliche Ziele und Steuerungsparameter darstellen und kritisch diskutieren.

Aktuelle Ergebnisse

Es gibt keinen einzelnen Zielparameter, an dem das Volumenmanagement allein ausgerichtet werden kann. Ein wichtiger Parameter ist die Volumenreagibilität des Patienten, die zusammen mit vielen anderen Parametern zu einer wiederholten Einschätzung des optimalen Volumenmanagements herangezogen werden sollte. Eine Verbesserung des Outcomes ist aber auch für die Messung der Volumenreagibilität nicht gezeigt.

Schlussfolgerungen

Nach einer initialen Volumenreanimation muss die weitere Volumentherapie möglichst individuell anhand multipler Patientenfaktoren und wiederholter Messung der Volumenreagibilität fortgeführt werden. Eine eher restriktive Volumengabe mit auch früherem Einsatz von Vasopressoren scheint zunehmend in den Fokus eines modernen Volumenmanagements zu rücken. Allerdings sind viel Fragen bezüglich eines optimalen Volumenmanagements noch ungelöst.

Abstract

Background

Early i.v. fluid administration is a cornerstone in modern therapy of shock, especially in septic shock. However, there is much uncertainty concerning the amount and rate of fluid and which goals and measures could guide fluid management. Administering the optimal fluid volume is important because fluid overload can lead to severe negative consequences like organ failure and worsening of patient’s outcome.

Aim

This review aims to describe the importance of fluid therapy and discuss possible strategies in fluid management as well as possible measurements and goals to guide such therapy.

Recent findings

There is no single measurement to guide fluid management alone. It is important to assess fluid responsiveness, which together with multiple other parameters can be used to repeatedly assess optimal fluid management. However, it has also not been shown that assessing fluid responsiveness can improve outcome.

Conclusions

After the initial resuscitation, further fluid administration should be determined by individual patient factors and measures of fluid responsiveness. A more restrictive fluid management with early vasopressor administration seems to be increasingly used in modern fluid management. However many questions regarding optimal fluid management remain to be solved.

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Correspondence to Stefan John.

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Interessenkonflikt

S. John gibt an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Stefan Kluge, Hamburg

Carsten Willam, Erlangen

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John, S. Volumenmanagement im Schock. Med Klin Intensivmed Notfmed 116, 636–647 (2021). https://doi.org/10.1007/s00063-021-00878-1

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Schlüsselwörter

  • Volumentherapie
  • Flüssigkeitsverschiebungen
  • Vasopressoren
  • Sepsis
  • Frühe zielgerichtete Behandlung

Keywords

  • Fluid therapy
  • Fluid shifts
  • Vasoconstrictor agents
  • Sepsis
  • Early goal-directed therapy