Substanzen zur Flüssigkeitstherapie und Outcome – ein Update

Zusammenfassung

Die Flüssigkeitstherapie zählt zu den häufigsten medizinischen Maßnahmen mit dem Ziel, den Flüssigkeitshaushalt zu normalisieren. Ein entscheidendes Kriterium für die Effizienz des Flüssigkeits- oder Volumenersatzes ist die Funktionsfähigkeit der Glykokalyx, einer dünnen endothelialen Glykoproteinschicht. Sie ist ein wesentlicher Faktor für den Flüssigkeitsaustausch und -transport zwischen Gefäßsystem und Gewebe. Das erst jüngst beschriebene revidierte Starling-Prinzip erweitert das Verständnis erheblich. Aus klinischer Sicht sollte die Flüssigkeitstherapie eine zeitnahe Euvolämie anstreben, ohne relevante Nebenwirkungen zu induzieren. Es stehen hierfür sowohl kristalloide als auch natürliche oder synthetische kolloidale Lösungen zur Verfügung. Bei den kristalloiden Lösungen scheinen die sog. balancierten Vollelektrolytlösungen mit weniger Nebenwirkungen assoziiert zu sein. Kolloide Lösungen haben bei intakter Gefäßbarriere einen höheren Volumeneffekt, besitzen aber teilweise erhebliche Nebenwirkungen. Einige synthetische Kolloide dürfen daher nicht mehr bei kritisch kranken Patienten eingesetzt werden. Im Gegensatz dazu führt die Gabe von Humanalbumin 20% bei kardiovaskulär erkrankten, hypalbuminämen Patienten zu einer Reduktion von Nierenfunktionsstörungen und scheint auch mit weiteren klinischen Vorteilen assoziiert zu sein. Inwieweit zukünftige, individualisierte Therapieansätze das Outcome beeinflussen können, bleibt abzuwarten.

Ziel der Flüssigkeitstherapie ist das zeitnahe Erreichen einer Euvolämie, ohne relevante Nebenwirkungen zu induzieren. Hierfür stehen sowohl kristalloide als auch kolloidale Lösungen zur Verfügung. Der Beitrag veranschaulicht gegenwärtige Aspekte des Flüssigkeitsaustauschs an der Gefäßbarriere, gibt ein Update über die derzeit verfügbaren Optionen in der perioperativen Flüssigkeitstherapie und fasst aktuell publizierte Studien zusammen.

Abstract

Fluid therapy is one of the most frequently used medical interventions with the aim of normalizing the fluid balance. A decisive criterion for the efficiency of fluid or volume replacement is the functionality of the glycocalyx, a thin endothelial glycoprotein layer. Its solidity is an essential factor for fluid exchange and transport from the vascular system to the tissue. The recently described revised Starling principle extends the understanding considerably. From a clinical point of view, fluid treatment should aim for timely euvolemia without inducing relevant side effects. Both crystalloid and natural or synthetic colloidal solutions are available. In the case of crystalloid solutions, the so-called balanced solutions seem to be associated with fewer side effects. If the vascular barrier is intact, colloid solutions have a higher volume effect, but may have significant side effects limiting their use. At least in Europe, some synthetic colloids shall therefore no longer be used in critically ill patients. In contrast, treatment with albumin 20% in hypalbuminemic patients with cardiovascular disease leads to a reduced incidence of acute kidney injury and has also been associated with other clinical benefits. To what extent future, individualized therapeutic approaches employing colloids will influence the outcome is currently speculative.

Kernaussagen

• Die Glykokalyx ist ein wichtiger Bestandteil der Gefäßbarriere, die auf pathophysiologische Veränderungen sensibel reagiert.

• Störungen der Glykokalyx können zu einer vermehrten, lang nachweisbaren Einlagerung von Kolloiden in das Gewebe führen und sind vermutlich ursächlich für deren Funktionsstörungen.

• Balancierte Lösungen (Kristalloide und Kolloide) haben gegenüber unbalancierten Lösungen sehr wahrscheinlich Vorteile hinsichtlich des Säure-Basen- und Elektrolythaushaltes und reduzieren somit konsekutive Komplikationen.

• Synthetische Kolloide können zum Volumenersatz vor allem bei akuten Blutungen eingesetzt werden. Einige Daten weisen auf einen geringeren Volumenbedarf hin. Der Einfluss auf die Anwendungssicherheit und Komplikationsrate wird weiterhin in randomisierten Studien geklärt.

• Mit Humanalbumin steht ein natürliches Kolloid zur Verfügung, das perioperativ z. B. gerade bei der Vermeidung einer Hypalbuminämie Vorteile zeigen konnte. Für einen generellen Einsatz in der Volumentherapie gibt es derzeit keine ausreichende Evidenz und diese ist kritisch unter Verfügbarkeitsaspekten abzuwägen.

Schlüsselwörter

Flüssigkeiten - Glykokalyx - Kristalloide - Kolloide - Humanalbumin

Key words

Fluids - glycocalyx - crystalloids - colloids - human albumin

Publication History

Article published online:
22 April 2021

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