Einfluss der Kardioanästhesie auf das Patientenoutcome

Zusammenfasssung

Die Kardioanästhesie ist ein hoch technisierter, subspezialisierter Bereich der Anästhesiologie. Die Verbesserung des Patientenoutcomes wurde untersucht für hämodynamisches Management durch zielgerichtete Therapie, Nierenprotektion durch ischämische Fernpräkonditionierung, Myokardprotektion durch pharmakologische Präkonditionierung mittels volatiler Anästhetika, Neuroprotektion durch Nahinfrarotspektrometrie und perioperative Echokardiografie.

Die Kardioanästhesie ist ein hoch technisierter, subspezialisierter Bereich der Anästhesiologie. Die Verbesserung des Patientenoutcomes wurde untersucht für hämodynamisches Management durch zielgerichtete Therapie, Nierenprotektion durch ischämische Fernpräkonditionierung, Myokardprotektion durch pharmakologische Präkonditionierung mittels volatiler Anästhetika, Neuroprotektion durch Nahinfrarotspektrometrie und perioperative Echokardiografie.

Abstract

The perioperative management of complex patients in a highly technical and subspecialized environment is the domain of the cardiac anesthesiologist. Evidence suggests that hemodynamic management using goal directed hemodynamic therapy (GDHT) improves patient outcome. Organ protection remains a main concern during cardiac surgery using extracorporeal circulation. Mortality can be decreased when remote ischemic preconditioning techniques (RIPC) are being used. Neurological outcomes can be improved with near-infrared-spectometry (NIRS), volatile anesthetics increase myocardial protection through preconditioning and perioperative echocardiography increases overall patient survival.

Kernaussagen

• Die perioperative 30-Tages-Mortalität wird als häufigster Parameter zur Quantifizierung des Patientenoutcomes in der Herzchirurgie herangezogen.

• Die perioperative transthorakale (TTE), transösophageale (TEE) und epikardiale (EU) Echokardiografie liefert wichtige Informationen bezüglich der kardialen Funktion, des operativen Ergebnisses und der Kalzifikation der großen arteriellen Gefäße und kann so das chirurgische Vorgehen und das Patientenoutcome beeinflussen.

• Die zielorientierte hämodynamische Therapie („goal-directed hemodynamic therapy“) verbessert die Gewebeoxygenierung und kann das Auftreten von Komplikationen verringern.

• Der Volumenersatz bei herzchirurgischen Patienten bleibt weiterhin kontrovers. Bei nicht septischen Patienten kann jedoch unter Abwägung der individuellen Vor- und Nachteile sowohl der Einsatz von kristalloiden als auch von neueren kolloiden Lösungen vertreten werden.

• Das neurologische Outcome kann durch den Einsatz der epiaortalen Echokardiografie verbessert werden.

• Das neurokognitive Outcome kann durch den Einsatz der Nahinfrarotspektrometrie (NIRS) verbessert und die Krankenhausverweildauer verkürzt werden.

• Zur pharmakologischen Präkonditionierung und Myokardprotektion sollte eine balancierte Narkoseführung mit inhalativem Sevofluran der TIVA mit Propofol vorgezogen werden.

• Das perioperative Nierenversagen erhöht die Gesamtmortalität und sollte unbedingt vermieden werden.

• Die ischämische Fernpräkonditionierung beruht auf dem Prinzip kurzer Ischämie- und Reperfusionsphasen z. B. an den Extremitäten und kann die Rate des akuten Nierenversagens sowie der Krankenhausverweildauer senken.

Schlüsselwörter

Hämodynamik - Nierenprotektion - Myokardprotektion - Neuroprotektion - Echokardiografie - Herzchirurgie

Key words

hemodynamic management - kidney - myocardial protection - neurological outcome - echocardiography - cardiac surgery

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