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In welcher Weise sollte ein Anästhesist sonographieren können?

Diagnostischer Einsatz des Ultraschalls in der Akut- und Intensivmedizin

How should anesthesiologists perform ultrasound examinations?

Diagnostic use of ultrasound in emergency and intensive care and medicine

  • Leitthema
  • Published:
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Zusammenfassung

Die Sonographie als Diagnostikum hat in der Akut- und Intensivmedizin einen hohen Stellenwert erlangt. Große Vorteile dieser Untersuchungsmethode liegen in der schnellen bettseitigen Verfügbarkeit und der Wiederholbarkeit der Untersuchung. Erst die technische Entwicklung hin zu kleinen portablen Geräten mit Schnellstartfunktion und einer hohen Leistungsfähigkeit in der Bildgebung hat den breiten Einsatz in dieser Indikation freigegeben. Die akut- und intensivmedizinische Sonographie findet entsprechend der durch die Erkrankung vorgegebenen zeitlichen Dringlichkeit statt. Zur Anwendung kommen alle etablierten Basismethoden wie Echokardiographie, Gefäßsonographie, abdomineller und thorakaler Ultraschall. Die Untersuchung wird entsprechend der klinischen Situation gestaltet und variiert von der nur Sekunden dauernden Sonographie unter Reanimation bis hin zur Lösung zeitaufwendigerer Fragen. Die Übergänge zum fachspezifischen Ultraschall sind fließend und müssen entsprechend den lokalen Gegebenheiten geordnet werden. Die akut- und intensivmedizinische Untersuchung wird im Sinne einer Ganzkörpersonographie durchgeführt. Es geht um die Einordnung der vorliegenden Krankheitssituation mit dem Ziel der Festlegung konkreter therapeutischer Entscheidungen. Der Charakter dieser Sonographie ist wie das Fach selbst interdisziplinär. Dieses findet in der Sonographieausbildung bisher noch zu wenig Berücksichtigung.

Abstract

Ultrasound imaging has attained great significance as a tool for diagnostics in emergency and intensive care medicine. The major advantages of this technique are its instantaneous bedside availability and the possibility to perform repeatable examinations. These advantages are based on recent developments, such as portable ultrasound devices offering excellent imaging quality as well as a quick-start-function. Ultrasound imaging in critically ill patients is frequently performed under pressure of time depending on the current acute physical state. All standard examinations in echocardiography, vascular, abdominal and thoracic ultrasound scanning can be applied in these patients. Based on the clinical scenario the duration of examinations may vary from seconds during cardiopulmonary resuscitations to time-consuming repeated scanning. The transition from basic to subject-specific detailed examinations is flowing and has to be adjusted to local conditions. In the field of emergency and intensive care medicine the technique used is whole-body sonography. The goal is to classify the patient’s present physical state and to define a targeted therapeutic approach. The characteristics of whole-body sonography are similar to the field of anesthesiology which is an interdisciplinary one. Currently, these characteristics deserve more attention in training in sonography.

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Interessenkonflikt

Die Firmen General Electrics® (Solingen, Deutschland), Esaote® (Köln, Deutschland), BK Medical® (Pinneberg, Deutschland) und SonoSite® (Erlangen, Deutschland) haben die Klinik für Anaesthesiologie des Berufsgenossenschaftlichen Universitätsklinikums Bergmannsheil bei der Umsetzung von wissenschaftlichen Projekten unterstützt. Die Autoren erhielten für Vorlesungen und Workshops finanzielle Entschädigungen.

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  1. Klinik für Anaesthesiologie, Intensiv-, Palliativ- und Schmerzmedizin, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum, Deutschland

    T. Maecken & M. Zenz

  2. Medizinische Klinik – Intensivstation, Hanse-Klinikum-Stralsund, Stralsund, Deutschland

    H. Zinke

  3. Klinik für Anästhesiologie, Intensiv-, Notfall- und Schmerzmedizin, Klinikum Gütersloh, Reckenberger Str. 19, 33332, Gütersloh, Deutschland

    T. Grau MA (HCM)

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  1. T. Maecken
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  2. H. Zinke
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  3. M. Zenz
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  4. T. Grau MA (HCM)
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Zusatzmaterial online

Video 1 - Aortendissektion (QuickTime Video 1,7 MB)

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Video 2 - Kompressionssonografie: Die Venen in der Axilla lassen sich komprimieren – die A. axillaris sowie ihre drei begleitenden Nerven nicht (QuickTime Video 3,9 MB)

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Video 3 - Kompressionssonografie: Die V. jugularis externa mit liegender Verweilkanüle ist aufgrund einer Thrombose nicht komprimierbar (QuickTime Video 4,4 MB)

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Video 4 - Sichtbare gleitende Pleura im normalen thorakalen Bild, Schnittrichtung längs der Rippen (QuickTime Video 7,4 MB)

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Video 5 - Pneumothorax mit fehlender Darstellung der Pleura visceralis, Schnittrichtung quer zu den Rippen (QuickTime Video 6,8 MB)

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Video 6 - Bronchoaerogramm. Längsschnitt der rechten Lunge mit Erguß und ausgeprägter Lungenkonsolidierung. Die Bronchien zeigen sich als helle Linien mit unbeweglichen Kometenschweifartefakten – statisches Bronchoaerogramm (QuickTime Video 3,7 MB)

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Video 7 - Die anliegende bewegliche Pleura visceralis ist sichtbar. Übergang zum Pneumothorax (Lungenpunkt) (QuickTime Video 3,2 MB)

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Video 8 - Subcostale Anlotung: primär wird der Lebervenenstern eingestellt; von hier aus lässt sich in der Schallebene über das Herz schwenken (QuickTime Video 4,0 MB)

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Video 10 - Abschätzen der Pumpfunktion durch "Eye-Balling". Beispiel einer schlechten Pumpfunktion. Auch für den ungeübten Betrachter ist der Kontraktilitätsunterschied zwischen beiden Herzen wahrnehmbar (QuickTime Video 1,6 MB)

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Video 11 - Aufnahme eines Herzens mit Rechtsherzbelastung. Der rechte Ventrikel ist massiv vergrößert, der linke Ventrikel ist klein und D-förmig zur Seite gedrängt. Sichtbar ist eine paradoxe Septumbewegung (QuickTime Video 0,8 MB)

Video 12 - Echokardiographische Darstellung eines gesunden Herzens bei Hypovolämie (QuickTime Video 1,7 MB)

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Maecken, T., Zinke, H., Zenz, M. et al. In welcher Weise sollte ein Anästhesist sonographieren können?. Anaesthesist 60, 203–213 (2011). https://doi.org/10.1007/s00101-011-1869-0

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