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Anästhesiol Intensivmed Notfallmed Schmerzther 2012; 47(07/08): 490-498
DOI: 10.1055/s-0032-1323569
Fachwissen
Anästhesiologie & Intensivmedizin Topthema: Perioperatives Flüssigkeitsmanagement
© Georg Thieme Verlag Stuttgart · New York

Perioperatives Flüssigkeitsmanagement – Zielgerichtete Therapie

Fluid Management: Goal-Directed Therapy
Matthias Gruenewald
,
Ole Broch
,
Berthold Bein
Further Information

Publication History

Publication Date:
23 August 2012 (online)

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Zusammenfassung

Eine zielgerichtete perioperative Flüssigkeitstherapie kann durch Optimierung des Sauerstoffangebots als ein entscheidender Therapiebaustein die Komplikationsrate in der perioperativen Phase senken. Gerade bei Hochrisikopatienten und rechtzeitigem Therapiebeginn, vor Eintritt eines Organschadens, kann die Mortalität gesenkt werden. Die modernen Algorithmen nutzen ein erweitertes hämodynamisches Monitoring und basieren auf dem Konzept der Volumenreagibilität und Optimierung der globalen Perfusion. Zukünftig wird sich zeigen, welchen Stellenwert die neuen nicht invasiven hämodynamischen Monitore und automatisierte Closed-Loop-Systeme für die zielgerichtete Flüssigkeitstherapie erreichen werden.

Abstract

Goal-directed fluid therapy (GDT) is one important step in perioperative therapy as it improves complication rate and mortality by optimisation of oxygen delivery. There is a convincing evidence for GDT when used early, before organ failure occurs, and in high-risk patients. Moderne algorithms use goals derived from advanced haemodynamic monitoring and are based on the concept of fluid responsiveness and optimisation of global perfusion. Future investigations will have to prove the advantage of using the new less or non-invasive haemodynamic monitoring devices or automatic closed-loop fluid administration systems for GDT.

Kernaussagen

  • Das Flüssigkeitsmanagement ist fester Bestandteil der anästhesiologischen Versorgung. Die Verantwortung geht über den direkten operativen Zeitraum hinaus, da resultierende Komplikationen erst Tage später relevant werden können.

  • Im Vordergrund der zielgerichteten Therapie steht die Sicherstellung des globalen Sauerstoffangebots durch Optimierung der kardialen Funktion mithilfe von Flüssigkeits- und Katecholamintherapie.

  • Das Konzept der Volumenreagibilität dient der Optimierung des Schlagvolumens durch Flüssigkeitsgabe bis zur bestmöglichen Vordehnung der Herzmuskelfasern.

  • Ein Abfall der zentral- oder gemischtvenösen Sättigung und / oder ein Anstieg des Stoffwechselprodukts Laktat können auf eine Sauerstoffschuld hinweisen.

  • Es gibt eine überzeugende Evidenz für eine zielgerichtete perioperative Therapie wenn sie rechtzeitig (vor Eintritt des Organschadens) und bei Hochrisikopatienten angewandt wird.

  • Eine perioperativ durchgeführte zielgerichtete Therapie führt zu weniger Komplikationen (Wundinfektionen, Pneumonien und gastrointestinalen Komplikationen), verkürzter Krankenhausverweildauer und Reduktion der Mortalität.

  • Ein erweitertes hämodynamisches Monitoring macht ausschließlich einen Sinn, wenn die erhobenen Parameter in einem Therapieprotokoll verknüpft angewandt werden.

  • Zurzeit werden neue minimal oder nicht invasive hämodynamische Monitore entwickelt und eingeführt. Die zwingend notwendige klinische Evaluation steht überwiegend noch aus.

Schlüsselwörter:

zielgerichtete Therapie - perioperative Optimierung - Flüssigkeitsbalance/-therapie - hämodynamisches Monitoring - Patientenoutcome

Keywords:

goal-directed therapy - perioperative optimisation - fluid balance/therapy - haemodynamic monitoring - patient outcomes

Ergänzendes Material

 

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