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Die Überwachung der Leberfunktionen in der Intensivmedizin

Monitoring liver functions in the intensive care unit

  • TECHNIK UND METHODEN
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Intensivmedizin und Notfallmedizin

Abstract

The relevance of liver dysfunction in the management of critically ill patients is increasingly being recognized. It has been found to affect mortality of patients with septic organ failure in several studies. The increasing prevalence of chronic liver disease among intensive care patients adds importance to the issue of monitoring the various aspects of liver function. An array of liver function tests as part of blood biochemistry testing has long been established. In the context of critical care and chronic liver disease, however, they must be interpreted cautiously. In addition, several dynamic tests of liver function have been developed. Relatively best explored are tests based on the hepatic elimination of indocyanine-green (ICG). Commercially available systems analyzing the plasma disappearance rate of ICG (ICG-PDR) are being marketed but these parameters also are difficult to interpret in the intensive care setting and especially in patients with chronic liver disease. ICG-PDR correlates with mortality in patients with septic organ dysfunction but studies investigating the outcome-oriented results of therapeutic interventions directed by these parameters have not been published. The possible relevance to intensive care management of several other dynamic tests of liver function, as well as interventional and ultrasonografic methods to address liver perfusion, are discussed in the article. As yet, there is no single method to monitor the various aspects of liver function and no method whose clinical value has been proved. Clinicians therefore have to mostly rely on clinical judgement aided by a reasonable selection among existing monitoring tools.

Zusammenfassung

Die Bedeutung von akuten Funktionsstörungen der Leber bei schwerstkranken Patienten findet zunehmende Beachtung. Ihr Einfluss auf die Mortalität wurde in mehreren Studien für Patienten mit septischem Organversagen nachgewiesen. Gleichzeitig stellt die zunehmende Prävalenz chronischer Leberschäden bei Intensivpatienten eine Herausforderung für die Überwachung der Leberfunktion dar. Neben den etablierten Parametern des Routinelabors, deren Bedeutung allerdings gerade bei zirrhotischen Patienten umsichtig zu interpretieren ist, sind es vor allem dynamische Funktionstests, denen das Interesse der Intensivmedizin gilt. Am besten etabliert sind Monitoringverfahren, die auf der hepatischen Elimination von Indozyaningrün (ICG) beruhen. Hierauf basieren auch kommerziell angebotene Systeme zur Beurteilung der ICG-Plasmaverschwinderate (ICGPDR). Die Bedeutung der hiermit ermittelten Daten ist jedoch äußerst zurückhaltend zu beurteilen. Während die ICG-PDR beim septischen Multiorganversgen eine Korrelation mit der Mortalität aufzuweisen scheint, liegen ergebnisbezogene Studien hierauf basierter therapeutischer Interventionen bislang nicht vor. Die mögliche Bedeutung weiterer dynamischer Leberfuntionstests und spezieller interventioneller und sonografischer Untersuchungen zur Beurteilung der Leberperfusion für das intensivmedizinische Management wird diskutiert. Da derzeit keine die vielfältigen Leistungen der Leber umfassende und in ihrer klinischen Relevanz gesicherte Methode des Leberfunktionsmonitorings existiert, wird der Kliniker vorerst auf eine umsichtige Anwendung unterschiedlicher Instrumente und deren Interpretation im klinischen Kontext angewiesen bleiben.

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  1. II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Str. 22, 81675, München, Germany

    Andreas Umgelter, Fabian Geisler & Ewert Schulte-Frohlinde

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Correspondence to Andreas Umgelter.

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Wenn’s da kein Problem haben, dann ham’s was übersehen. Ursula Schweigart

Serie:Neue Technologien in der IntensivmedizinHerausgegeben von J. Langgartner (Regensburg) und R.M. Schmid (München)

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Umgelter, A., Geisler, F. & Schulte-Frohlinde, E. Die Überwachung der Leberfunktionen in der Intensivmedizin. Intensivmed 45, 413–423 (2008). https://doi.org/10.1007/s00390-008-0895-x

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