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DOI: 10.1055/s-0029-1225277
© Georg Thieme Verlag KG Stuttgart · New York
Die akute Herzinsuffizienz: Diagnostik und Monitoring
Acute Heart Failure: Diagnosis and MonitoringPublikationsverlauf
eingereicht: 9.3.2009
akzeptiert: 2.4.2009
Publikationsdatum:
04. Juni 2009 (online)

Zusammenfassung
Der herzinsuffiziente Patient stellt auf der Intensivstation eine besondere Herausforderung dar. Eine rasche und möglichst genaue und ätiologische Zuordnung der akuten Herzinsuffizienz ist für die nachfolgende Diagnostik aber auch das Monitoring von besonderer Bedeutung, da sich hieraus die erforderliche Therapie ableitet. Neben den Komponenten des obligaten Basismonitorings (EKG, Atemfrequenz, Blutdruck, Urinausscheidung sowie Temperatur) sind das weitere modulare Monitoring bzw. diagnostische Schritte in Abhängigkeit von der Dringlichkeit und der zugrunde liegenden kardiovaskulären Erkrankung zu wählen. Der invasiv gemessene arterielle Blutdruck und das Herzzeitvolumens sind die wesentlichen Eckpunkte eines erweiterten invasiven Monitorings. Das druckbezogene Monitoring mit zentralvenösen Druck oder pulmonalarteriellen Okklusionsdruck als Surrogat der Vorlast muss durch ein volumenbezogenes Monitoring abgelöst werden, welches ateminduzierte dynamische Veränderungen des Schlagvolumens als Schlagvolumenvariation oder systolische Blutdruckvariation abbildet. Diese neuen Messverfahren müssen aber noch in größeren Kollektiven evaluiert werden und anschließend in neue Monitoringkonzepte integriert werden.
Summary
The critically ill patient in acute heart failure continues to present an exceptional challenge concerning diagnostic procedures, monitoring and treatment. The European Society of Cardiology guidelines was the first to classify patients in acute heart failure into distinct clinical entities. Further management and choice of monitoring relies on this classification. Beside the obligatory monitoring (electrocardiography, respiratory rate, blood pressure, urine output, temperature) further components of a modular monitoring, as well as additional diagnostic procedures, must be implemented according to the acuteness and severity of the patient's condition. Measurement of cardiac output and arterial blood pressure are essential elements in an extended invasive monitoring. The pressure-based monitoring, which uses central venous pressure and pulmonary artery occlusion pressure as a surrogate for cardiac preload, should be replaced by a more volume-oriented monitoring. Moreover, new monitoring strategies should incorporate functional hemodynamic monitoring that evaluates the effects of treatment. Changes in volume and passive leg raising can be used to assess volume responsiveness. Changes in left ventricular output during spontaneous breathing or even positive pressure ventilation may be helpful in differentiating the extent of volume dependency. The greater the increase in tidal volume for the same lung compliance, the greater is the transient decrease in venous return and the subsequent decrease in left ventricular output. Variations in systolic pressure or pulse pressure are reliable measures of preload responsiveness. More clinical validation of these measures must be done before they can become standard measures of monitoring patients in acute heart failure.
Schlüsselwörter
Patientenmonitoring - Intensivmedizin - kardiovaskuläre Erkrankungen - Herzinsuffizienz - Pulmonalarterienkatheter - Hämodynamik
Keywords
patient monitoring - intensive care - cardiovascular disease - cardiovascular diagnostic techniques - catheterization - pulmonary artery - hemodynamics
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Prof. Dr. med. Uwe Janssens
Medizinische Klinik, St.-Antonius-Hospital
Dechant-Deckers-Str. 8
52249 Eschweiler
Telefon: 02403/761227
Fax: 02403/761827
eMail: uwe.janssens@sah-eschweiler.de