Hämodynamisches Monitoring – Gibt es Indikationen für den perioperativen Einsatz des pulmonal-arteriellen Katheters?

Zusammenfassung

Der Nutzen des pulmonalarteriellen Katheters (PAK) wird seit mehreren Jahren kritisch hinterfragt. Die Entwicklung alternativer Monitoringtechniken vor allem für Volumenparameter hat zu einem Rückgang in der Anwendung des PAK geführt. Zahlreiche Studien belegen die Vorteile einer Therapie, die frühzeitig die Kreislaufparameter optimiert, unanhängig von der eingesetzten Monitoringtechnik. Patienten mit einem erhöhten perioperativen Risiko, vor allem im Bereich der Kardio- und Gefäßchirurgie, können trotzdem von einem PAK-Monitoring profitieren.

Die Bedenken gegenüber den erhältlichen Monitoringtechniken generieren sich vor allem aus der Invasivität. Bislang erfüllt aber keine Technik alle Anforderungen an ein ideales System.

Abstract

The benefit of the pulmonary-artery catheter (PAC) is a matter of discussion since years. The development of alternative monitoring techniques especially for measurement of volume parameters has decreased routine use of the PAC. Several investigations verified advantages of therapy attempting to optimize circulation parameters regardless of the used technique. Nonetheless, patients with a higher peri-operative risk, especially in cardiovascular surgery, may benefit from PAC monitoring intra- or postoperatively.

The concerns about the available monitoring techniques bear mainly on the fear being too invasive. Up to now, there is no technique complying with all requirements of an ideal monitoring system.

Kernaussagen

• Die Krankenhaus-Letalität ist durch die Anlage eines PAK nicht erhöht.

• Für Patienten mit einem geringen perioperativen Risiko ist die Anlage eines PAK entbehrlich.

• Frühzeitige Stabilisierung und Optimierung der Kreislauftherapie kann das Langzeit-Überleben verbessern.

• Durch verbesserte Therapie und verbessertes Monitoring kann die Letalität reduziert werden.

• Die Auswahl des Monitorings sollte man nach dem kardialen Zustand des Patienten treffen.

• Es gibt deutliche Unterschiede in der Bevorzugung des Monitorings zwischen den USA und Europa.

Schlüsselwörter:

pulmonalarterieller Katheter - Monitoring - Indikation - Kardiochirurgie

Key words:

Pulmonary artery catheter - monitoring - indication - cardiovascular surgery

• Literatur

• 1 Connors AF et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators. Jama 1996; 176: 897-897
• 2 Murdoch SD, Cohen AT, Bellamy MC. Pulmonary artery catheterization and mortality in critically ill patients. British journal of anaesthesia 2000; 85: 611-615
• 3 Harvey S et al. Assessment of the clinical effectiveness of pulmonary artery catheters in management of patients in intensive care (PAC-Man): a randomised controlled trial. Lancet 2005; 366: 472-477
• 4 Mansencal N et al. Comparison of different echocardiographic indexes secondary to right ventricular obstruction in acute pulmonary embolism. The American journal of cardiology 2003; 92: 116-119
• 5 Carl M et al. S3 guidelines for intensive care in cardiac surgery patients: hemodynamic monitoring and cardiocirculary system. Ger Med Sci 2010; 8
• 6 Polonen P et al. A prospective, randomized study of goal-oriented hemodynamic therapy in cardiac surgical patients. Anesth Analg 2000; 90: 1052-1059
• 7 Tuman KJ et al. Effect of pulmonary artery catheterization on outcome in patients undergoing coronary artery surgery. Anesthesiology 1989; 70: 199-206
• 8 Resano FG et al. Clinical outcomes of low-risk patients undergoing beating-heart surgery with or without pulmonary artery catheterization. Journal of cardiothoracic and vascular anesthesia 2006; 20: 300-306
• 9 Pearse R et al. Changes in central venous saturation after major surgery, and association with outcome. Crit Care 2005; 9: 694-699
• 10 Sandham JD et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003; 348: 5-14
• 11 Carl M et al. [Guidelines for intensive care in cardiac surgery patients: haemodynamic monitoring and cardio-circulatory treatment guidelines of the German Society for Thoracic and Cardiovascular Surgery and the German Society of Anaesthesiology and Intensive Care Medicine]. Thorac Cardiovasc Surg 2007; 55: 130-148
• 12 Hamilton MA, Cecconi M, Rhodes A. A systematic review and meta-analysis on the use of preemptive hemodynamic intervention to improve postoperative outcomes in moderate and high-risk surgical patients. Anesth Analg 2011; 112: 1392-1402
• 13 Cannesson M et al. Hemodynamic monitoring and management in patients undergoing high risk surgery: a survey among North American and European anesthesiologists. Critical care 2011; 15
• 14 Rhodes A et al. Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study. Intensive care medicine 2010; 36: 1327-1332
• 15 Kaul TK, Fields BL. Postoperative acute refractory right ventricular failure: incidence, pathogenesis, management and prognosis. Cardiovasc Surg 2000; 8: 1-9
• 16 Kastrup M et al. Current practice of hemodynamic monitoring and vasopressor and inotropic therapy in post-operative cardiac surgery patients in Germany: results from a postal survey. Acta Anaesthesiol Scand 2007; 51: 347-358
• 17 Koo KK et al. Pulmonary artery catheters: evolving rates and reasons for use. Critical care medicine 2011; 39: 1613-1618
• 18 Chittock DR et al. Severity of illness and risk of death associated with pulmonary artery catheter use. Critical care medicine 2004; 32: 911-915
• 19 Friese RS, Shafi S, Gentilello LM. Pulmonary artery catheter use is associated with reduced mortality in severely injured patients: a National Trauma Data Bank analysis of 53,312 patients. Critical care medicine 2006; 34: 1597-1601
• 20 Cowie BS. Does the pulmonary artery catheter still have a role in the perioperative period?. Anaesth Intensive Care 2011; 39: 345-355
• 21 Krowka MJ et al. Pulmonary hemodynamics and perioperative cardiopulmonary-related mortality in patients with portopulmonary hypertension undergoing liver transplantation. Liver Transpl 2000; 6: 443-450
• 22 Fisher MR et al. Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary hypertension. Am J Respir Crit Care Med 2009; 179: 615-621
• 23 Ramsay M. Portopulmonary hypertension and right heart failure in patients with cirrhosis. Curr Opin Anaesthesiol 2010; 23: 145-150
• 24 Costa MG et al. Perioperative intra- and extravascular volume in liver transplant recipients. Transplantation proceedings 2011; 43: 1098-1102
• 25 Cheung AT et al. Echocardiographic and hemodynamic indexes of left ventricular preload in patients with normal and abnormal ventricular function. Anesthesiology 1994; 81: 376-387
• 26 Trof RJ et al. Cardiac filling volumes versus pressures for predicting fluid responsiveness after cardiovascular surgery: the role of systolic cardiac function. Critical care 2011; 15
• 27 Pearse R et al. Early goal-directed therapy after major surgery reduces complications and duration of hospital stay. A randomised, controlled trial [ISRCTN38797445]. Crit Care 2005; 9: 687-693
• 28 Sander M et al. Pulse contour analysis after normothermic cardiopulmonary bypass in cardiac surgery patients. Crit Care 2005; 9: 729-734
• 29 Godje O et al. Reliability of a new algorithm for continuous cardiac output determination by pulse-contour analysis during hemodynamic instability. Crit Care Med 2002; 30: 52-58
• 30 Rodig G et al. Continuous cardiac output measurement: pulse contour analysis vs thermodilution technique in cardiac surgical patients. Br J Anaesth 1999; 82: 525-530
• 31 Schuerholz T et al. Reliability of continuous cardiac output determination by pulse-contour analysis in porcine septic shock. Acta Anaesthesiol Scand 2006; 50: 407-413
• 32 De Backer D et al. Arterial pressure-based cardiac output monitoring: a multicenter validation of the third-generation software in septic patients. Intensive Care Med 2011; 37: 233-240
• 33 Vincent JL et al. Clinical review: Update on hemodynamic monitoring - a consensus of 16. Crit Care 2011; 15: 229-229