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intensiv 2008; 16(6): 288-294
DOI: 10.1055/s-2008-1027938
Intensivmedizin

© Georg Thieme Verlag KG Stuttgart · New York

Perioperative Flüssigkeitstherapie

Sebastian Rehberg1 , Christian Ertmer1 , Björn Ellger1 , Martin Westphal1
  • 1Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Münster
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Publication History

Publication Date:
26 November 2008 (online)

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Zusammenfassung

Seitdem erste klinische Studien erhebliche Auswirkungen unterschiedlicher Infusionsregime auf die Morbidität und Letalität gezeigt haben, gewinnt die perioperative Flüssigkeitstherapie zunehmend an Bedeutung. Dennoch orientiert sich die tägliche Praxis häufig noch an Gewohnheiten oder „Expertenmeinungen”. Ein adäquates Flüssigkeitsmanagement beinhaltet die Substitution von Verlusten sowie die kausale Therapie von Störungen des Flüssigkeitshaushalts. Dabei müssen die Zielwerte der Verlaufsparameter für den jeweiligen Patienten individuell festgelegt werden. Aktuelle Studien empfehlen perioperativ bei elektiven Eingriffen am Gastrointestinaltrakt eine restriktive Flüssigkeitsgabe zur Verbesserung des Outcomes. Im Falle einer schweren Sepsis oder eines septischen Schocks führt dagegen eine frühzeitige und aggressive Volumentherapie zu einer Senkung der Letalität.

Die große Anzahl von Flüssigkeits- und Volumenersatzmitteln ermöglicht einerseits eine differenzierte Therapie, kann andererseits aber auch zu einem Übersichtsverlust beitragen. Besonders hervorzuheben sind zum einen die neuen, balancierten Infusionslösungen, die aufgrund verminderter Störungen des Säure-Basen-Haushalts wahrscheinlich zu bevorzugen sind. Zum anderen sollte man die aktuelle Diskussion um die Anwendung von Hydroxyethylstärke-Lösungen (HES-Lösungen) vor dem Hintergrund führen, dass für die isoonkotischen HES-Lösungen der dritten Generation (im Gegensatz zu den klassischen hyperonkotischen Präparaten) bis dato keine nephrotoxischen Effekte nachgewiesen worden sind.

Literatur

  • 1 Cannon W. The course of events in secondary wound shock.  JAMA. 1919;  73 174-181
    Google Scholar
  • 2 Coller F A, Campbell K N, Vaughan H H. et al . Postoperative salt intolerance.  Ann Surg. 1944;  154 119 533-542
    Google Scholar
  • 3 Heier H E, Bugge W, Hjelmeland K. et al . Transfusion vs. alternative treatment modalities in acute bleeding: a systematic review.  Acta Anaesthesiol Scand. 2006;  50 (8) 920-931
    Google Scholar
  • 4 Joshi G P. Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery.  Anesth Analg. 2005;  101 (2) 601-605
    Google Scholar
  • 5 Lobo D N, Bostock K A, Neal K R. et al . Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial.  Lancet. 2002;  359 (9320) 1812-1818
    Google Scholar
  • 6 Nisanevich V, Felsenstein I, Almogy G. et al . Effect of intraoperative fluid management on outcome after intraabdominal surgery.  Anesthesiology. 2005;  103 (1) 25-32
    Google Scholar
  • 7 Brandstrup B, Tonnesen H, Beier-Holgersen R. et al . Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial.  Ann Surg. 2003;  238 (5) 641-648
    Google Scholar
  • 8 Lang K, Boldt J, Suttner S. et al . Colloids versus crystalloids and tissue oxygen tension in patients undergoing major abdominal surgery.  Anesth Analg. 2001;  93 (2) 405-409
    Google Scholar
  • 9 Brunkhorst F M, Engel C, Bloos F. et al . Intensive insulin therapy and pentastarch resuscitation in severe sepsis.  N Engl J Med. 2008;  358 (2) 125-139
    Google Scholar
  • 10 Zander R. Base excess and lactate concentration in infusion solutions and blood products.  Anasthesiol Intensivmed Notfallmed Schmerzther. 2002;  37 (6) 359-363
    Google Scholar
  • 11 Holte K, Jensen P, Kehlet H. Physiologic effects of intravenous fluid administration in healthy volunteers. Table of contents.  Anesth Analg. 2003;  96 (5) 1504-1509
    Google Scholar
  • 12 Klein H G, Spahn D R, Carson J L. Red blood cell transfusion in clinical practice.  Lancet. 2007;  370 (9585) 415-426
    Google Scholar
  • 13 Schmidt R F, Lang F, Thews G. Physiologie des Menschen mit Pathophysiologie. Heidelberg; Springer 2005 29th Edition: 705-710
    Google Scholar
  • 14 Zander R, Adams H A, Boldt J. et al . Requirements and expectations for optimal volume replacement.  Anasthesiol Intensivmed Notfallmed Schmerzther. 2005;  40 (12) 701-719
    Google Scholar
  • 15 Zornow M H, Todd M M, Moore S S. The acute cerebral effects of changes in plasma osmolality and oncotic pressure.  Anesthesiology. 1987;  67 (6) 936-941
    Google Scholar
  • 16 White H, Cook D, Venkatesh B. The use of hypertonic saline for treating intracranial hypertension after traumatic brain injury.  Anesth Analg. 2006;  102 (6) 1836-1846
    Google Scholar
  • 17 Adams H. Volume and fluid replacement – Physiology, pathophysiology, pharmacology and clinical use.  Anästh Intensivmed. 2007;  48 518-540
    Google Scholar
  • 18 Brandstrup B. Fluid therapy for the surgical patient.  Best Pract Res Clin Anaesthesiol. 2006;  20 (2) 265-283
    Google Scholar
  • 19 Zausig Y A, Weigand M A, Graf B M. Perioperative fluid management: An analysis of the present situation.  Anaesthesist. 2006;  55 (4) 371-390
    Google Scholar
  • 20 Zander R. Flüssigkeitstherapie..  Melsungen: Bibliomed – Medizinische Verlagsgesellschaft GmbH. 2006; 
    Google Scholar
  • 21 Zander R. Optimal hematocrit 30 %: Farewell from an illusion.  Infusionsther Transfusionsmed. 1999;  26 185-190
    Google Scholar
  • 22 Lowell J A, Schifferdecker C, Driscoll D F. et al . Postoperative fluid overload: not a benign problem.  Crit Care Med. 1990;  18 (7) 728-733
    Google Scholar
  • 23 Moller A M, Pedersen T, Svendsen P E. et al . Perioperative risk factors in elective pneumonectomy: the impact of excess fluid balance.  Eur J Anaesthesiol. 2002;  19 (1) 57-62
    Google Scholar
  • 24 Perko M J, Jarnvig I L, Hojgaard-Rasmussen N. et al . Electric impedance for evaluation of body fluid balance in cardiac surgical patients.  J Cardiothorac Vasc Anesth. 2001;  15 (1) 44-48
    Google Scholar
  • 25 Wilcox C S. Regulation of renal blood flow by plasma chloride.  J Clin Invest. 1983;  71 (3) 726-735
    Google Scholar
  • 26 Wilcox C S, Peart W S. Release of renin and angiotensin II into plasma and lymph during hyperchloremia.  Am J Physiol. 1987;  253 F734-F741
    Google Scholar
  • 27 Drummer C, Gerzer R, Heer M. et al . Effects of an acute saline infusion on fluid and electrolyte metabolism in humans.  Am J Physiol. 1992;  262 F744-F754
    Google Scholar
  • 28 Scheingraber S, Rehm M, Sehmisch C. et al . Rapid saline infusion produces hyperchloremic acidosis in patients undergoing gynecologic surgery.  Anesthesiology. 1999;  90 (5) 1265-1270
    Google Scholar
  • 29 Smith I, Kumar P, Molloy S. et al . Base excess and lactate as prognostic indicators for patients admitted to intensive care.  Intensive Care Med. 2001;  27 (1) 74-83
    Google Scholar
  • 30 Boldt J, Schollhorn T, Munchbach J. et al . A total balanced volume replacement strategy using a new balanced hydoxyethyl starch preparation (6 % HES 130 / 0.42) in patients undergoing major abdominal surgery.  Eur J Anaesthesiol. 2007;  24 (3) 267-275
    Google Scholar
  • 31 Finfer S, Bellomo R, Boyce N. et al . A comparison of albumin and saline for fluid resuscitation in the intensive care unit.  N Engl J Med. 2004;  350 (22) 2247-2256
    Google Scholar
  • 32 Kohler H, Zschiedrich H, Clasen R. et al . The effects of 500 ml 10 % hydroxyethyl starch 200 / 0.5 and 10 % dextran 40 on blood volume, colloid osmotic pressure and renal function in human volunteers (author’s transl).  Anaesthesist. 1982;  31 (2) 61-67
    Google Scholar
  • 33 Mortier E, Ongenae M, De Baerdemaeker L. et al . In vitro evaluation of the effect of profound haemodilution with hydroxyethyl starch 6 %, modified fluid gelatin 4 % and dextran 40 10 % on coagulation profile measured by thromboelastography.  Anaesthesia. 1997;  52 (11) 1061-1064
    Google Scholar
  • 34 Gruber U F, Gerber H, Laubenthal H. et al . Prevention of allergic reactions to dextran by preinjection of 20 ml hapten in 12 000 patients in Switzerland.  Schweiz Rundsch Med Prax. 1983;  72 (29) 990-991
    Google Scholar
  • 35 Haisch G, Boldt J, Krebs C. et al . The influence of intravascular volume therapy with a new hydroxyethyl starch preparation (6 % HES 130 / 0.4) on coagulation in patients undergoing major abdominal surgery.  Anesth Analg. 2001;  92 (3) 565-571
    Google Scholar
  • 36 Laubenthal H. BSE and heparin and gelatin preparations.  Anaesthesist. 1997;  46 (3) 253-254
    Google Scholar
  • 37 Boldt J, Suttner S. Plasma substitutes.  Minerva Anestesiol. 2005;  71 (12) 741-758
    Google Scholar
  • 38 Lorenz W, Duda D, Dick W. et al . Incidence and clinical importance of perioperative histamine release: randomised study of volume loading and antihistamines after induction of anaesthesia. Trial Group Mainz/Marburg.  Lancet. 1994;  343 (8903) 933-940
    Google Scholar
  • 39 Molnar Z, Mikor A, Leiner T. et al . Fluid resuscitation with colloids of different molecular weight in septic shock.  Intensive Care Med. 2004;  30 (7) 1356-1360
    Google Scholar
  • 40 Zander R, Boldt J, Engelmann L. et al . The design of the VISEP trial. Critical appraisal.  Anaesthesist. 2007;  56 (1) 71-77
    Google Scholar
  • 41 Boldt J, Brosch C, Ducke M. et al . Influence of volume therapy with a modern hydroxyethylstarch preparation on kidney function in cardiac surgery patients with compromised renal function: A comparison with human albumin*.  Crit Care Med. 2007;  35 (12) 1740-2746
    Google Scholar
  • 42 Bunn F, Alderson P, Hawkins V. Colloid solutions for fluid resuscitation.  Cochrane Database Syst Rev. 2008;  (1) CD001319
    Google Scholar
  • 43 Feng X, Yan W, Wang Z. et al . Hydroxyethyl starch, but not modified fluid gelatin, affects inflammatory response in a rat model of polymicrobial sepsis with capillary leakage.  Anesth Analg. 2007;  104 (3) 624-630
    Google Scholar
  • 44 Feng X, Yan W, Liu X. et al . Effects of hydroxyethyl starch 130 / 0.4 on pulmonary capillary leakage and cytokines production and NF-kappaB activation in CLP-induced sepsis in rats.  J Surg Res. 2006;  135 (1) 129-136
    Google Scholar
  • 45 Roberts I, Alderson P, Bunn F. et al . Colloids versus crystalloids for fluid resuscitation in critically ill patients.  Cochrane Database Syst Rev. 2004;  4 CD000567
    Google Scholar
  • 46 Kreimeier U, Peter K, Messmer K. Small volume – large benefits.  Anaesthesist. 2001;  50 (6) 442-449
    Google Scholar
  • 47 Amathieu R, Racine S, Triba M. et al . Use of nuclear magnetic resonance spectroscopy to assess renal dysfunction after hypertonic-hyperoncotic resuscitation in rats.  J Trauma. 2007;  63 (2) 379-387
    Google Scholar
  • 48 Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients.  Cochrane Database Syst Rev. 2007;  4 CD000567
    Google Scholar
  • 49 Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: a report by the American Society of Anesthesiologist Task Force on Preoperative Fasting.  Anesthesiology. 1999;  90 (3) 896-905
    Google Scholar
  • 50 Rout C C, Rocke D A, Levin J. et al . A reevaluation of the role of crystalloid preload in the prevention of hypotension associated with spinal anesthesia for elective cesarean section.  Anesthesiology. 1993;  79 (2) 262-269
    Google Scholar
  • 51 Priano L L, Smith J D, Cohen J I. et al . Intravenous fluid administration and urine output during radical neck surgery.  Head Neck. 1993;  15 (3) 208-215
    Google Scholar
  • 52 Lamke L O, Nilsson G E, Reithner H L. Water loss by evaporation from the abdominal cavity during surgery.  Acta Chir Scand. 1977;  143 (5) 279-284
    Google Scholar
  • 53 Holte K, Klarskov B, Christensen D S. et al . Liberal versus restrictive fluid administration to improve recovery after laparoscopic cholecystectomy: a randomized, double-blind study.  Ann Surg. 2004;  240 (5) 892-899
    Google Scholar
  • 54 Adams H A, Baumann G, Cascorbi I. et al .Empfehlungen zur Diagnostik und Therapie der Schockformen der IAG Schock der DIVI. Köln; Deutscher Ärzteverlag 2005
    Google Scholar
  • 55 Cartotto R C, Innes M, Musgrave M A. et al . How well does the Parkland formula estimate actual fluid resuscitation volumes.  Burn Care Rehabil. 2002;  23 (4) 258-265
    Google Scholar
  • 56 Lehnhardt M, Jafari H J, Druecke D. et al . A qualitative and quantitative analysis of protein loss in human burn wounds.  Burns. 2005;  31 (2) 159-167
    Google Scholar
  • 57 Rivers E, Nguyen B, Havstad S. et al . Early goal-directed therapy in the treatment of severe sepsis and septic shock.  N Engl J Med. 2001;  345 (19) 1368-1377
    Google Scholar
  • 58 Reinhart K, Brunkhorst F, Bone H. et al . Diagnosis and therapy of sepsis: guidelines of the German Sepsis Society Inc. and the German Interdisciplinary Society for Intensive and Emergency Medicine.  Anaesthesist. 2006;  55 (Suppl 1) 43-56
    Google Scholar
  • 59 Wiedemann H P, Wheeler A P, Bernard G R. et al . Comparison of two fluid-management strategies in acute lung injury.  N Engl J Med. 2006;  354 (24) 2564-2575
    Google Scholar

Dr. med. Sebastian Rehberg

Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin

Albert-Schweitzer-Straße 33

48149 Münster

Email: Sebastian_Rehberg@web.de

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