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Volumentherapie beim schwerverletzten Traumapatienten

Empfehlungen und aktuelle Leitlinien

Volume therapy in the severely injured patient

Recommendations and current guidelines

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Zusammenfassung

Hintergrund

Die Volumentherapie spielt in der frühen Versorgung von schwerverletzten Traumapatienten eine entscheidende Rolle; jedoch wird die optimale Strategie weiterhin diskutiert. Im Rahmen einer aktuellen Cochrane-Analyse wurde keine Evidenz für vs. gegen einen frühen Volumenersatz sowie große vs. geringe Flüssigkeitsmengen gefunden.

Methode

Aktuelle Empfehlungen und Leitlinien zur Volumentherapie bei Schwerverletzten werden unter Berücksichtigung der Europäischen Traumaleitlinie (The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition) und der S3-Leitlinie Polytrauma zusammengefasst und mit einer selektiven Literaturübersicht kombiniert.

Ergebnisse und Diskussion

Aktuell wird in Leitlinien und aktueller Literatur übereinstimmend der zurückhaltende Volumenersatz mit dem Ziel empfohlen, einen mittleren arteriellen Druck von 65 mm Hg und/oder einen systolischen Druck von 80–90 mm Hg aufrechtzuerhalten. Dadurch soll eine Verstärkung der Blutung verhindert werden, bis eine Kontrolle der Blutungsquelle möglich ist. Die klinische Einschätzung des Blutverlusts entsprechend den Empfehlungen des Advanced Trauma Life Support sowie laborchemische Parameter wie Hämoglobin-, Base-excess- und Laktatwert sind sensitive Tests, um das Ausmaß und die Dynamik einer Blutung bzw. einer Hypotension zu beurteilen. Kristalloide Lösungen sollten an erster Stelle als Volumenersatz beim blutenden, hypotensiven Traumapatienten verwendet werden. Für das Schädel-Hirn-Trauma werden gesonderte Empfehlungen ausgesprochen.

Abstract

Background

Volume therapy is a cornerstone of early resuscitation of severely injured trauma patients, but the optimal strategy remains under debate. A recent Cochrane review could not find evidence for or against early volume replacement or large versus small amounts of fluid.

Method

Current recommendations and guidelines regarding volume therapy in severely injured patients are summarized based upon the updated European Trauma Guideline on the management of major bleeding and coagulopathy following trauma (fourth edition) and the S3-Guideline Polytrauma and combined with a selective review of the literature.

Results and Discussion

Current guidelines and recommendations advocate the initiation of volume replacement at a reduced level in bleeding and hypotensive trauma patients in terms of “permissive hypotension,” with the aim of maintaining mean arterial blood pressure (MAP) at 65 mm Hg and/or target systolic blood pressure at 80–90 mm Hg so as not to exacerbate the bleeding until its source can be controlled. Advanced Trauma Life Support principles, together with independent measurements of hemoglobin, base excess, and/or lactate, are recommended as sensitive tests for assessing the extent of bleeding and shock. Isotonic crystalloid solutions should be used as first-line volume replacement in bleeding, hypotensive trauma patients. Specific recommendations apply for patients with traumatic brain injury.

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Authors and Affiliations

  1. Klinik für Orthopädie, Unfallchirurgie und Sporttraumatologie, Krankenhaus Köln-Merheim, Lehrstuhl für Unfallchirurgie und Orthopädie, Universität Witten/Herdecke (UW/H), Campus Köln Merheim, Ostmerheimerstr.200, 51109, Köln, Deutschland

    Sigune Kaske & Marc Maegele

  2. Institut für Forschung in der operativen Medizin (IFOM), Universität Witten/Herdecke (UW/H), Campus Köln-Merheim, Ostmerheimerstr. 200, 51109, Köln, Deutschland

    Marc Maegele

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  1. Sigune Kaske
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Correspondence to Sigune Kaske.

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S. Kaske und M. Maegele geben an, dass kein Interessenkonflikt besteht.

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F. Gebhard, Ulm

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Kaske, S., Maegele, M. Volumentherapie beim schwerverletzten Traumapatienten. Unfallchirurg 120, 85–90 (2017). https://doi.org/10.1007/s00113-016-0283-0

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  • DOI: https://doi.org/10.1007/s00113-016-0283-0

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