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Der intensivpflichtige Patient mit Lungenembolie oder arteriellem Gefäßnotfall

The patient with pulmonary embolism or vascular emergency requiring intensive care

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Zusammenfassung

Ein Patient mit akuter Lungenembolie ist nur dann auf der Intensivstation zu versorgen, wenn er kreislaufinstabil oder beatmungspflichtig ist oder wenn er bei erhaltenem Kreislauf Zeichen der schweren rechtsventrikulären Dysfunktion aufweist. Für beide Patientengruppen ist die bettseitige Echokardiographie die entscheidende diagnostische Methode. Therapeutisch ist die wesentliche Entscheidungsfindung die zur Thrombolyse. Sie ist bei Kreislaufinstabilität in der Regel indiziert, bei alleiniger Rechtsherzbelastung nur in Einzelfällen, ohne Rechtsherzbelastung gar nicht.

Ein weiterer Gefäßnotfall ist das komplexe Krankheitsbild der heparininduzierten Thrombozytopenie Typ II, das sowohl arterielle als auch venöse Verschlüsse hervorrufen kann. Die bei Verdacht zu beginnende alternative Antikoagulation muss bei Bestätigung in therapeutischer Dosis fortgesetzt, im viel häufigeren Fall der Nicht-Bestätigung aber zeitgerecht wieder abgesetzt werden. Bezüglich anderer arterieller Verschlüsse (kritische Extremitätenischämie, akrale Läsionen, iatrogene Verletzungen) werden die bei Intensivpflichtigkeit relevanten Vorgehensweisen geschildert.

Abstract

Acute pulmonary embolism requires ICU management only for patients with hemodynamic instability who need artificial ventilation, or for hemodynamically stable patients with significant right ventricular dysfunction. For both patient groups, echocardiography is the most relevant diagnostic method. The main therapeutic consideration is on systemic thrombolysis. It is indicated in almost all patients with hemodynamic instability but only in selected cases of right ventricular dysfunction. All other patients receive standard anticoagulation only.

A second vascular emergency scenario is type 2 heparin-induced thrombocytopeniae (HIT II) which may cause venous as well as arterial complications. Alternative anticoagulation has to be established from the first moment of clinical suspicion. It has to be continued in a therapeutic dosage if HIT II is confirmed, and has to be stopped if the diagnosis is refuted. The latter case is by far more frequent. Regarding arterial occlusions (acute limb ischemia, acral gangrene, iatrogenic vascular trauma) hints are given for the management in the setting of intensive care.

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  1. Medizinische Klinik, Krankenhaus Dresden-Friedrichstadt, Friedrichstraße 41, 01067, Dresden, Deutschland

    S.M. Schellong

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Schellong, S. Der intensivpflichtige Patient mit Lungenembolie oder arteriellem Gefäßnotfall. Internist 51, 995–1002 (2010). https://doi.org/10.1007/s00108-009-2541-5

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