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Hämodynamisches Monitoring in der perioperativen Phase

Verfügbare Systeme, praktische Anwendung und klinische Daten

Haemodynamic monitoring in the perioperative phase

Available systems, practical application and clinical data

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Zusammenfassung

Ein regulärer Hydratationsstatus und Normovolämie sind Ziele der intra-/perioperativen Flüssigkeits- sowie Volumentherapie und gleichzeitig Voraussetzungen für eine adäquate Hämodynamik zur Sicherstellung einer ausreichenden Gewebeoxygenierung. Die physiologischen und pathophysiologischen Effekte der Flüssigkeits- und Volumentherapie beruhen auf den pharmakologischen Eigenschaften der verwendeten Infusionslösung, dem applizierten Volumen und – nach neueren Erkenntnissen – auch auf dem Zeitpunkt der Flüssigkeitsgabe. In der perioperativen Phase unterliegt der Organismus den hormonellen Bedingungen der metabolischen Stressantwort, die neben den perioperativen Änderungen der Gefäßpermeabilität zu berücksichtigen sind. Das Ziel des hämodynamischen Monitorings im OP ist es, Informationen über die Hämodynamik und das globale Sauerstoffangebot zu gewinnen, die eine Abschätzung des intravasalen Volumenstatus des Patienten erlauben. Dies kann die Volumen- und Flüssigkeitstherapie im Sinne einer Konstanthaltung des Herzzeitvolumens verbessern, das vor allen Dingen für Risikopatienten relevant ist. Eine verbesserte und hypovoläme Zustände vermeidende Volumentherapie kann das postoperative Outcome der Patienten positiv beeinflussen. Ziel dieser Arbeit ist es, dem Leser einen Überblick über die aktuell im klinischen Alltag zur Verfügung stehenden Monitoringverfahren zur Einschätzung des perioperativen Volumenstatus zu geben; hierzu werden jeweils das Messprinzip, die Messparameter sowie die Vor- und Nachteile des jeweiligen Verfahrens dargestellt. Weiter wird diskutiert, welche Monitoringverfahren in klinischen Studien schon zur zielgerichteten perioperativen Flüssigkeits- und Volumentherapie („goal-directed therapy“) untersucht wurden.

Abstract

A regular hydration status and compensated vascular filling are targets of perioperative fluid and volume management and, in parallel, represent precautions for sufficient stroke volume and cardiac output to maintain tissue oxygenation. The physiological and pathophysiological effects of fluid and volume replacement mainly depend on the pharmacological properties of the solutions used, the magnitude of the applied volume as well as the timing of volume replacement during surgery. In the perioperative setting surgical stress induces physiological and hormonal adaptations of the body, which in conjunction with an increased permeability of the vascular endothelial layer influence fluid and volume management. The target of haemodynamic monitoring in the operation room is to collect data on haemodynamics and global oxygen transport, which enable the anaesthetist to estimate the volume status of the vascular system. Particularly in high risk patients this may improve fluid and volume therapy with respect to maintaining cardiac output. A goal-directed volume management aiming at preventing hypovolaemia may improve the outcome after surgery. The objective of this article is to review the monitoring devices that are currently used to assess haemodynamics and filling status in the perioperative setting. Methods and principles for measuring haemodynamic variables, the measured and calculated parameters as well as clinical benefits and shortcomings of each device are described. Furthermore, the results for monitoring devices from clinical studies of goal-directed fluid and volume therapy which have been published will be discussed.

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Interessenkonflikt

Im Rahmen von wissenschaftlichen Untersuchungen haben Prof. Dr. C. Spies von der Firma Edwards Lifesciences und Dr. M. Sander von der Firma Pulsion Medical Systems finanzielle Unterstützung bekommen. Dr. U. Wittkowski, Dr. J. Erb, Dr. A. Feldheiser und Prof. Dr. C. von Heymann erklären keinen Interessenkonflikt zu haben.

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  1. Universitätsklinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Charité Mitte, Charité – Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Deutschland

    U. Wittkowski, C. Spies, M. Sander, J. Erb, A. Feldheiser &  C. von Heymann DEAA

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  1. U. Wittkowski
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  2. C. Spies
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  6. C. von Heymann DEAA
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Correspondence to C. von Heymann DEAA.

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Wittkowski, U., Spies, C., Sander, M. et al. Hämodynamisches Monitoring in der perioperativen Phase. Anaesthesist 58, 764–786 (2009). https://doi.org/10.1007/s00101-009-1590-4

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