Präklinische Anwendungsmöglichkeiten hypertoner Infusionslösungen bei Patienten mit Schädel-Hirn-Trauma

Zusammenfassung

Hypertone Infusionslösungen bedingen eine effiziente Senkung eines erhöhten intrakraniellen Drucks und verbessern die zerebrale Hämodynamik insbesondere im Bereich der Mikrozirkulation. Infolgedessen wurden hypertone Infusionslösungen in den letzten Jahren in die stationäre intensivmedizinische Behandlung bei Patienten mit Schädel-Hirn-Trauma eingeführt. Im Hinblick auf die gestörte zerebrale Perfusion und Oxygenierung in der posttraumatischen Akutphase ist ein möglichst frühzeitiger Therapiebeginn wünschenswert, um die Prognose zu verbessern und resultierende Sekundärschäden zu vermindern. Zur präklinischen und stationären Therapie der akuten Hypotension bei Hypovolämie und hämorrhagischem Schock sind in Deutschland zwei hypertone-isoonkotische Infusionslösungen zugelassen. Beide können sinnvolle Therapieoptionen zur Anwendung bei Patienten mit Schädel-Hirn-Trauma und intrakraniellem Druckanstieg bieten. Die Beschränkung der Zulassung auf die Schocktherapie in Deutschland erlaubt den routinemäßigen präklinischen Einsatz beim isolierten Schädel-Hirn-Trauma derzeit nicht. In anderen europäischen Ländern wurde das präklinische Einsatzspektrum hypertoner-isoonkotischer Infusionslösungen inzwischen entsprechend erweitert.

Abstract

Hypertonic solutions efficaciously lower increased intracranial pressure and improve cerebral hemodynamics in particular at the level of microcirculation. Therefore hypertonic solutions have been introduced to the in-hospital intensive care treatment of brain-injured patients. In view of the disturbed cerebral perfusion and oxigenation in the acute phase following traumatic brain injury, early initiation of treatment is desirable to improve long-term outcome and to minimize secondary brain damage. Two different hypertonic isooncotic solutions are licensed in Germany for prehospital and in-hospital treatment of acute hypotension due to hypovolaemia and haemorrhagic shock. Both solutions offer interesting therapeutic options for treatment of patients with increased intracranial pressure. Limitation of license to the treatment of shock in Germany does not allow routine prehospital use in isolated head trauma at the moment. In other European countries, the approval for the prehospital use of hypertonic isooncotic solutions has been modified.

Schädel-Hirn-Trauma - Intrakranieller Druck - Notarzt - Hypertone Kochsalzlösung - Small-Volume Resuscitation

Traumatic brain injury - intracranial pressure - emergency physician - hypertonic saline - small-volume resuscitation

Literatur

• 1 The Brain Trauma Foundation,. The American Association of Neurological Surgeons, The Joint Section on Neurotrauma and Critical Care Use of mannitol. J Neurotrauma 2000 17: 521-525
• 2 The Brain Trauma Foundation,. The American Association of Neurological Surgeons, The Joint Section on Neurotrauma and Critical Care Initial management. J Neurotrauma 2000 17: 463-469
• 3 Kreimeier U, Christ F, Frey L, Habler O, Thiel M, Welte M, Zwissler B. Small-Volume Resuscitation beim hypovolämischen Schock.  Anästhesist. 1997;  46 309-328
• 4 Kreimeier U, Prückner S. Volumentherapie bei Hypovolämie und Schock.  Notfall & Rettungsmedizin. 1998;  1 119-129
• 5 Nakayama S, Sibley L, Gunther R A. et al . Small-volume resuscitation with hypertonic saline (2,400 mOsm/liter) during hemorrhagic shock.  Circ Shock. 1984;  13 149-159
• 6 Kempski O, Obert C, Mainka T, Heimann A, Strecker U. „Small volume resuscitation” as Treatment of Cerebral Blood Flow Disturbances and Increased ICP in Trauma and Ischemia.  Acta Neurochir Suppl. 1996;  66 114-117
• 7 Hinkelbein J, Genzwürker H, Ellinger K. Perspektiven der Small- Volume Resuscitation.  Notfallmedizin. 2001;  27 494-498
• 8 Hinkelbein J, Genzwürker H, Ellinger K. Small-Volume Resuscitation: Primärtherapie des Schocks in der präklinischen Notfallmedizin.  Rettungsdienst. 2002;  25 142-145
• 9 Fresenius Kabi Deutschland GmbH. HyperHAES® Fachinformation. Mai 2000
• 10 Saetzler R K, Jallo J, Lehr H A. et al . Inhibition of leukocyte/endothelium and leukocyte/platelet activation by intravenous administration of hypertonic saline.  Microcirculation. 1996;  3 103
• 11 Vassar M J, Perry C A, Gannaway W L, Holcroft J W. 7.5 % sodium chloride/dextran for resuscitation of trauma patients undergoing helicopter transport.  Arch Surg. 1991;  126 1065-1072
• 12 Vassar M J, Fischer R P, O’Brien P E, Bachulis B L, Chambers J A, Hoyt D B, Holcroft J W. A multicenter trial for resuscitation of injured patients with 7.5 % sodium chloride. The effect of added dextran 70. The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients.  Arch Surg. 1993;  128 1003-1013
• 13 Qureshi A I, Suarez J. Use of hypertonic saline solutions in treatment of cerebral edema and intracranial hypertension.  Crit Care Med. 2000;  28 3301-3313
• 14 Weed L H, McKibben P S. Experimental alteration of brain bulk.  Am J Physiol. 1919;  48 531-558
• 15 Wilson B, Jones R F, Coleman S T. et al . The effects of various hypertonic sodium salt solutions on cisternal pressure.  Surgery. 1951;  30 361-366
• 16 De Felippe J, Timoner J, Velasco I T, Lopes O U, Rocha-e-Silva M. Treatment of refractory hypovolaemic shock by 7.5 % sodium chloride injections.  Lancet. 1980;  334 1002-1004
• 17 Holcroft J W, Vassar M J, Turner J E, Derlet R W. et al . 3 % NaCl an 7.5 % NaCl/Dextran 70 in the resuscitation of severely injured patients.  Ann Surg. 1987;  206 279-286
• 18 Berger S, Schürer L, Härtl R, Messmer K, Baethmann A. Reduction of Post-traumatic Intracranial Hypertension by Hypertonic/Hyperoncotic Saline/Dextran and Hypertonic Mannitol.  Neurosurgery. 1995;  37 98-108
• 19 Härtl R, Ghajar J, Hochleuthner H, Mauritz W. Hypertonic/Hyperoncotic Saline Reliably Reduces ICP in Severely Head-Injured Patients with Intracranial Hypertension.  Acta Neurochir Suppl. 1997;  70 126-129
• 20 Härtl R, Medary M B, Ruge M, Arfors K E, Ghahremani F, Ghajar J. Hypertonic/Hyperoncotic Saline Attenuates Microcirculatory Disturbances after Traumatic Brain Injury.  J Trauma. 1997;  42 41-47
• 21 Anderson J T, Wisner D H, Sullivan P E, Matteucci M, Freshman S, Hildreth J, Wagner F C. Initial small-volume hypertonic resuscitation of shock and brain injury: short- and long-term effects.  J Trauma. 1997;  42 592-600
• 22 Schwarz S, Schwab S, Bertram M, Aschoff A, Hacke W. Effects of Hypertonic Saline Hydroxyethyl Starch Solution and Mannitol in Patients With Increased Intracranial Pressure After Stroke.  Stroke. 1998;  29 1550-1555
• 23 Shackford S R. Effect of Small-Volume Resuscitation on Intracranial Pressure and Related Cerebral Variables.  J Trauma. 1997;  42 (Suppl) 48-53
• 24 Walsh J C, Zhuang J, Shackford S R. A comparison of hypertonic to isotonic fluid in the resuscitation of brain injury and hemorrhagic shock.  J Surg Res. 1991;  50 284-292
• 25 Wade C E, Grady J J, Kramer G C, Younes R N, Gehlsen K, Holcroft J W. Individual Patient Cohort Analysis of the Efficacy of Hypertonic Saline/Dextran in Patients with Traumatic Brain Injury and Hypotension.  J Trauma. 1997;  42 61-65
• 26 Horn P, Munch E, Vajkoczy P, Herrmann P, Quintel M, Schilling L, Schmiedek P, Schurer L. Hypertonic saline solution for control of elevated intracranial pressure in patients with exhausted response to mannitol and barbiturates.  Neurol Res. 1999;  21 758-764
• 27 Khanna S, Davis D, Peterson B, Fisher B, Tung H, O’Quigley J, Deutsch R. Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury.  Crit Care Med. 2000;  28 1144-1151
• 28 Qureshi A I, Suarez J I, Castro A, Bhardwaj A. Use of Hypertonic Saline/Acetate Infusion in Treatment of Cerebral Edema in Patients with Head Trauma: Experience at a Single Center.  J Trauma. 1999;  47 659-665
• 29 Simma B, Burger R, Falk M, Sacher P, Fanconi S. A prospective, randomized, and controlled study of fluid management in children with severe head injury: Lactated Ringer’s solution versus hypertonic saline.  Crit Care Med. 1998;  26 1265-1270
• 30 Suarez J I, Qureshi A I, Parekh P D, Razumovsky A, Tamargo R J, Bhardwaj A, Ulatowski J A. Administration of hypertonic (3 %) sodium chloride/acetate in hyponatremic patients with symptomatic vasospasm following subarachnoid hemorrhage.  J Neurosurg Anesthesiol. 1999;  11 178-184
• 31 Worthley L IG, Cooper D J, Jones N. Treatment of resistant intracranial hypertension with hypertonic saline.  J Neurosurg. 1988;  68 478-481
• 32 Marmarou A, Abd-Elfattah Foda M A, van den Brink W, Campbell J, Kita H, Demetriadou K. A new model of diffuse brain injury in rats, Part 1: Pathophysiology and biomechanics.  J Neurosurg. 1994;  80 291-300
• 33 Tanno H, Nockels R P, Pitts L H, Noble L J. Breakdown of the blood-brain-barrier after fluid percussive brain injury in the rat. Part 1: Distribution and time course of protein extravasation.  J Neurotrauma. 1992;  9 21-32
• 34 Bouma G J, Muizelaar J P. Cerebral blood flow in severe clinical head injury.  New Horizons. 1995;  3 384-394
• 35 Martin N A, Patwardhan R V, Alexander M J, Africk C Z, Lee J H, Shalmon E, Hovda D A, Becker D P. Characterization of cerebral hemodynamic phases following severe head trauma: hypoperfusion, hyperemia, and vasospasm.  J Neurosurg. 1997;  87 9-19
• 36 Kelly D F, Martin N A, Kordestani R K, Counelis G, Hovda D A, Bergsneider M, McBride D Q, Shalmon E, Herman D, Becker D P. Cerebral blood flow as a predictor of outcome following traumatic brain injury.  J Neurosurg. 1997;  86 633-641
• 37 The Brain Trauma Foundation, The American Association of Neurological Surgeons, The Joint Section on Neurotrauma and Critical Care . Resuscitation of blood pressure and oxygenation.  J Neurotrauma. 2000;  17 471-478
• 38 Procaccio F, Stocchetti N, Citerio G, Berardino M, Beretta L, Della Corte F, D'Avella D, Brambilla G L, Delfini R, Servadei F, Tomei G. Guidelines for the treatment of adults with severe head trauma (part II). Criteria for medical treatment.  J Neurosurg Sci. 2000;  44 11-18
• 39 Graham D I, Ford I, Adams J H, Doyle D, Teasdale G M, Lawrence A E, McLellan D R. Ischaemic brain damage is still common in fatal non-missile head injury.  J Neurol Neurosurg Psychiatry. 1989;  52 346-350
• 40 Doyle J A, Davis D P, Hoyt D B. The Use of Hypertonic Saline in the Treatment of Traumatic Brain Injury.  J Trauma. 2001;  50 367-383
• 41 Reed R L, Johnston T D, Chen Y. et al . Hypertonic saline alters plasma clotting times and platelet aggregation.  J Trauma. 1991;  31 8-14
• 42 Weinstsabl C, Mayer N, Germann P. et al . Hypertonic, hyperoncotic hydroxyethyl starch decreases intracranial pressure following neurotrauma.  Anesthesiology. 1991;  75 A202
• 43 Finberg L. Dangers to infants caused by changes in osmolar concentrations.  Pediatrics. 1967;  40 1031-1034
• 44 Procaccio F, Stocchetti N, Citerio G, Berardino M, Beretta L, Della Corte F, D'Avella D, Brambilla G L, Delfini R, Servadei F, Tomei G. Guidelines for the treatment of adults with severe head trauma (part I). Initial assessment; evaluation and pre-hospital treatment; current criteria for hospital admission; systemic and cerebral monitoring.  J Neurosurg Sci. 2000;  44 1-10
• 45 Fresenius Kabi Deutschland GmbH.  Kolloide - Wissenschaft gut in Form. Produktinformation Voluven® 2001