Download PDF
Anästhesiol Intensivmed Notfallmed Schmerzther 2015; 50(5): 350-357
DOI: 10.1055/s-0041-102297
Fachwissen
Anästhesiologie: Topthema
© Georg Thieme Verlag Stuttgart · New York

Perioperative Herzinsuffizienz – Anästhesieführung und Monitoring

Perioperative heart failure – Anesthetic management and monitoring
Matthias Grünewald
Further Information

Publication History

Publication Date:
27 May 2015 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Aufgrund der demografischen und medizinischen Entwicklung wird die Zahl der anästhesiologisch betreuten Patienten mit einer Herzinsuffizienz in den nächsten Jahren weiter ansteigen. Für die optimale Betreuung dieser Patienten ist eine enge Abstimmung zwischen der operativ behandelnden Abteilung, der Kardiologie und der Anästhesie wichtig. Die kardiale Funktion und strukturelle Besonderheiten, wie kardiale Vitien, sollten präoperativ bekannt sein. So können die Anästhesieführung, das intraoperative Monitoring sowie die eventuell notwendigen pharmakologischen Interventionen abgestimmt werden. Gerade bei Hochrisikopatienten ist eine zielgerichtete hämodynamische Therapie sinnvoll. Hierfür stehen neben den etablierten Verfahren, zunehmend weniger invasive Monitoringverfahren zur Verfügung. Während einer akuten hämodynamschen Instabilität gewinnt die transösophageale Echokardiografie aufgrund seiner breiten Diagnostik an Bedeutung.

Due to the demographic and medical development, the number of patients with heart failure needing anaesthesiological care will continue to grow in the upcoming years. For the optimal care of these patients close coordination between the surgically treating, the cardiology and the anesthesiological department is important. Cardiac function and structural characters, such as cardiac valve defects should be known preoperatively. Thus, the anaesthetic management, intraoperative monitoring, as well as necessary pharmacological interventions can be tailored. Especially in high-risk patients goal directed hemodynamic therapy is useful. For this, in addition to the established monitoring procedures, less invasive monitoring devices areincreasingly used. During an acutehaemodynamic instability, thetransoesophageal echocardiography is gaining importance due to its wide diagnostic evaluation.

Kernaussagen Dachzeile

  • Patienten mit Herzinsuffizienz gehören zu den Hochrisikopatienten. Die perioperative Therapie muss eng zwischen Operateur, Kardiologe und Anästhesist abgestimmt werden.

  • Die präoperative Kenntnis der kardialen Strukturen und Funktionen ist für die Anästhesieführung essenziell.

  • Etomidat oder Propofol können zur Einleitung einer Anästhesie bei Patienten mit Herzinsuffizienz verwendet werden, wobei Etomidat bei höhergradiger Herzinsuffizienz bevorzugt werden sollte.

  • Als Inotropika stehen intraoperativ Phosphodiesterase-Inhibitoren und Levosimendan zur Verfügung.

  • Patienten mit Arrhythmien haben ein besonders hohes Risiko und benötigen ein besonderes Management, inklusive der Kenntnis von Besonderheiten im Umgang mit elektrischen Aggregaten.

  • Für Hochrisikopatienten wie Patienten mit relevanter Herzinsuffizienz wird eine zielgerichtete hämodynamische Therapie empfohlen.

  • Bei Patienten mit schwerer Herzinsuffizienz ist ein erweitertes hämodynamisches Monitoring zur Steuerung einer zielgerichteten Therapie sinnvoll.

  • Die transösophagelae Echokardiografie (TEE) sollte bei Patienten mit hohem kardialen Ischämierisiko, bei erwarteten Volumenschwankungen und bei akut instabilen Patienten eingesetzt werden.

Schlüsselwörter:

Herzinsuffizienz - Monitoring - Hochrisikopatienten - hämodynamische Therapie - transösophageale Echokardiografie

Key words:

heart failure - monitoring - haemodynamic therapy - high-risk patients - transoesophageal echocardiography

Ergänzendes Material

 

  • Literaturverzeichnis

  • 1 Sabate S, Mases A, Guilera N et al. Incidence and predictors of major perioperative adverse cardiac and cerebrovascular events in non-cardiac surgery. Br J Anaesth 2011; 107: 879-890
    CrossrefPubMedGoogle Scholar
  • 2 Hammill BG, Curtis LH, Bennett-Guerrero E et al. Impact of heart failure on patients undergoing major noncardiac surgery. Anesthesiology 2008; 108: 559-567
    CrossrefPubMedGoogle Scholar
  • 3 De Hert S, Imberger G, Carlisle J et al. Preoperative evaluation of the adult patient undergoing non-cardiac surgery: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol 2011; 28: 684-722
    CrossrefPubMedGoogle Scholar
  • 4 Troughton R, Michael Felker G, Januzzi Jr. JL. Natriuretic peptide-guided heart failure management. Eur Heart J 2014; 35: 16-24
    CrossrefPubMedGoogle Scholar
  • 5 Kristensen SD, Knuuti J, Saraste A et al. 2014 ESC/ESA Guidelines on non-cardiac surgery: cardiovascular assessment and management: The Joint Task Force on non-cardiac surgery: cardiovascular assessment and management of the European Society of Cardiology (ESC) and the European Society of Anaesthesiology (ESA). Eur Heart J 2014; 35: 2383-2431
    CrossrefPubMedGoogle Scholar
  • 6 Le Manach Y, Ibanez Esteves C, Bertrand M et al. Impact of preoperative statin therapy on adverse postoperative outcomes in patients undergoing vascular surgery. Anesthesiology 2011; 114: 98-104
    CrossrefPubMedGoogle Scholar
  • 7 Devereaux PJ, Sessler DI, Leslie K et al. Clonidine in patients undergoing noncardiac surgery. N Engl J Med 2014; 370: 1504-1513
    CrossrefPubMedGoogle Scholar
  • 8 Magner JJ, Royston D. Heart failure. Br J Anaesth 2004; 93: 74-85
    CrossrefPubMedGoogle Scholar
  • 9 Sessler DI, Sigl JC, Kelley SD et al. Hospital stay and mortality are increased in patients having a "triple low" of low blood pressure, low bispectral index, and low minimum alveolar concentration of volatile anesthesia. Anesthesio logy 2012; 116: 1195-203
    PubMedGoogle Scholar
  • 10 Bijker JB, Persoon S, Peelen LM et al. Intraoperative hypotension and perioperative ischemic stroke after general surgery: a nested case-control study. Anesthesiology 2012; 116: 658-664
    CrossrefPubMedGoogle Scholar
  • 11 Heinrich S, Schmidt J, Ackermann A et al. Comparison of clinical outcome variables in patients with and without etomidate-facilitated anesthesia induction ahead of major cardiac surgery: a retrospective analysis. Crit Care 2014; 18
    PubMedGoogle Scholar
  • 12 Bendel S, Ruokonen E, Polonen P, Uusaro A. Propofol causes more hypotension than etomidate in patients with severe aortic stenosis: a double-blind, randomized study comparing propofol and etomidate. ActaAnaesthesiolScand 2007; 51: 284-289
    PubMedGoogle Scholar
  • 13 Bein B. Clinical application of the cardioprotective effects of volatile anaesthetics: PRO--get an extra benefit from a proven anaesthetic free of charge. Eur J Anaesthesiol 2011; 28: 620-622
    CrossrefPubMedGoogle Scholar
  • 14 Landoni G, Greco T, Biondi-Zoccai G et al. Anaesthetic drugs and survival: a Bayesian network meta-analysis of randomized trials in cardiac surgery. Br J Anaesth 2013; 111: 886-896
    CrossrefPubMedGoogle Scholar
  • 15 Baumert JH, Hein M, Hecker KE et al. Xenon or propofol anaesthesia for patients at cardiovascular risk in non-cardiac surgery. Br J Anaesth 2008; 100: 605-611
    CrossrefPubMedGoogle Scholar
  • 16 Barbosa FT, Juca MJ, Castro AA, Cavalcante JC. Neuraxial anaesthesia for lower-limb revascularization. Cochrane Database Syst Rev CD 007083 2013; 7
    PubMedGoogle Scholar
  • 17 O'Connor CM, Gattis WA, Uretsky BF et al. Continuous intravenous dobutamine is associated with an increased risk of death in patients with advanced heart failure: insights from the Flolan International Randomized Survival Trial (FIRST). Am Heart J 1999; 138: 78-86
    CrossrefPubMedGoogle Scholar
  • 18 Tacon CL, McCaffrey J, Delaney A. Dobutamine for patients with severe heart failure: a systematic review and meta-analysis of randomised controlled trials. Intensiv Care Med 2012; 38: 359-367
    CrossrefPubMedGoogle Scholar
  • 19 Falk SA. Anesthetic considerations for the patient undergoing therapy for advanced heart failure. CurrOpinAnaesthesiol 2011; 24: 314-319
    PubMedGoogle Scholar
  • 20 Landoni G, Biondi-Zoccai G, Greco M et al. Effects of levosimendan on mortality and hospitalization. A meta-analysis of randomized controlled studies. Crit Care Med 2012; 40: 634-646
    CrossrefPubMedGoogle Scholar
  • 21 Katsaragakis S, Kapralou A, Markogiannakis H et al. Preoperative levosimendan in heart failure patients undergoing noncardiac surgery. Neth J Med 2008; 66: 154-159
    PubMedGoogle Scholar
  • 22 Thiele H, Zeymer U, Neumann FJ et al. Intraaortic balloon support for myocardial infarction with cardiogenic shock. N Engl J Med 2012; 367: 1287-1296
    CrossrefPubMedGoogle Scholar
  • 23 Millat MH, Cameron EW. Intra-aortic balloon pump in patients with ischaemic heart disease undergoing oesophagogastrectomy. Irish journal of medical science 2003; 172: 177-179
    PubMedGoogle Scholar
  • 24 Lemaire A, Anderson MB, Lee LY et al. The Impella device for acute mechanical circulatory support in patients in cardiogenic shock. The Annals of thoracic surgery 2014; 97: 133-138
    CrossrefPubMedGoogle Scholar
  • 25 Crossley GH, Poole JE, Rozner MA et al. The Heart Rhythm Society (HRS)/American Society of Anesthesiologists (ASA) Expert Consensus Statement on the perioperative management of patients with implantable defibrillators, pacemakers and arrhythmia monitors: facilities and patient management: executive summary this document was developed as a joint project with the American Society of Anesthesiologists (ASA), and in collaboration with the American Heart Association (AHA), and the Society of Thoracic Surgeons (STS). Heart rhythm : the official journal of the Heart Rhythm Society 2011; 8: 1-18
    CrossrefPubMedGoogle Scholar
  • 26 Stone ME, Salter B, Fischer A. Perioperative management of patients with cardiac implantable electronic devices. Br J Anaesth 2011; 107 (Suppl. 01) 16-26
    CrossrefPubMedGoogle Scholar
  • 27 Barer GR, Shaw JW. Pulmonary vasodilator and vasoconstrictor actions of carbon dioxide. The Journal of physiology 1971; 213: 633-645
    CrossrefPubMedGoogle Scholar
  • 28 Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. The New England journal of medicine 2000; 342: 1301-1308
    CrossrefPubMedGoogle Scholar
  • 29 Wiesen J, Ornstein M, Tonelli AR et al. State of the evidence: mechanical ventilation with PEEP in patients with cardiogenic shock. Heart 2013; 99: 1812-1817
    CrossrefPubMedGoogle Scholar
  • 30 Ausset S, Auroy Y, Verret C et al. Quality of postoperative care after major orthopedic surgery is correlated with both long-term cardiovascular outcome and troponin Ic elevation. Anesthesiology 2010; 113: 529-540
    PubMedGoogle Scholar
  • 31 Feussner M, Mukherjee C, Garbade J, Ender J. Anaesthesia for patients undergoing ventricular assist-device implantation. Best practice & research. Clinical anaesthesiology 2012; 26: 167-177
    PubMedGoogle Scholar
  • 32 Landesberg G, Mosseri M, Wolf Y et al. Perioperative myocardial ischemia and infarction: identification by continuous 12-lead electrocardiogram with online ST-segment monitoring. Anesthesiology 2002; 96: 264-270
    CrossrefPubMedGoogle Scholar
  • 33 Cecconi M, Corredor C, Arulkumaran N et al. Clinical review: Goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups. Critical care 2013; 17: 209-209
    PubMedGoogle Scholar
  • 34 Dalfino L, Giglio MT, Puntillo F et al. Haemodynamic goal-directed therapy and postoperative infections: earlier is better. A systematic review and meta-analysis. Critical care 2011; 15
    PubMedGoogle Scholar
  • 35 Salzwedel C, Puig J, Carstens A et al. Perioperative goal-directed hemodynamic therapy based on radial arterial pulse pressure variation and continuous cardiac index trending reduces postoperative complications after major abdominal surgery: a multi-center, prospective, randomized study. Critical care 2013; 17
    PubMedGoogle Scholar
  • 36 Arulkumaran N, Corredor C, Hamilton MA et al. Cardiac complications associated with goal-directed therapy in high-risk surgical patients: a meta-analysis. Br J Anaesth 2014; 112: 648-659
    CrossrefPubMedGoogle Scholar
  • 37 Shoemaker WC, Appel PL, Kram HB et al. Prospective trial of supranormal values of survivors as therapeutic goals in high-risk surgical patients. Chest 1988; 94: 1176-1186
    CrossrefPubMedGoogle Scholar
  • 38 Connors Jr. AF, Speroff T, Dawson NV et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators. JAMA 1996; 276: 889-897
    CrossrefPubMedGoogle Scholar
  • 39 Polanczyk CA, Rohde LE, Goldman L et al. Right heart catheterization and cardiac complications in patients undergoing noncardiac surgery: an observational study. JAMA 2001; 286: 309-14
    CrossrefPubMedGoogle Scholar
  • 40 Rajaram SS, Desai NK, Kalra A et al. Pulmonary artery catheters for adult patients in intensive care. The Cochrane database of systematic reviews CD 003408 2013; 2
    PubMedGoogle Scholar
  • 41 Mebazaa A, Pitsis AA, Rudiger A et al. Clinical review: practical recommendations on the management of perioperative heart failure in cardiac surgery. Critical care 2010; 14: 201-201
    CrossrefPubMedGoogle Scholar
  • 42 Richard C, Monnet X, Teboul JL. Pulmonary artery catheter monitoring in 2011. Current opinion in critical care 2011; 17: 296-302
    CrossrefPubMedGoogle Scholar
  • 43 Feltracco P, Biancofiore G, Ori C et al. Limits and pitfalls of haemodynamic monitoring systems in liver transplantation surgery. Minerva anestesiologica 2012; 78: 1372-1384
    PubMedGoogle Scholar
  • 44 Broch O, Renner J, Gruenewald M et al. A comparison of the Nexfin(R) and transcardiopulmonarythermodilution to estimate cardiac output during coronary artery surgery. Anaesthesia 2012; 67: 377-383
    CrossrefPubMedGoogle Scholar
  • 45 Broch O, Renner J, Gruenewald M et al. A comparison of third-generation semi-invasive arterial waveform analysis with thermodilution in patients undergoing coronary surgery. TheScientificWorldJournal 2012; 2012: 451081-451081
    PubMedGoogle Scholar
  • 46 Sokolski M, Rydlewska A, Krakowiak B et al. Comparison of invasive and non-invasive measurements of haemodynamic parameters in patients with advanced heart failure. Journal of cardiovascular medicine 2011; 12: 773-778
    CrossrefPubMedGoogle Scholar
  • 47 Slagt C, Malagon I, Groeneveld AB. Systematic review of uncalibrated arterial pressure waveform analysis to determine cardiac output and stroke volume variation. Br J Anaesth 2014; 112: 626-637
    CrossrefPubMedGoogle Scholar
  • 48 Holm JH, Frederiksen CA, Juhl-Olsen P, Sloth E. Perioperative use of focus assessed transthoracic echocardiography (FATE). Anesthesia and analgesia 2012; 115: 1029-1032
    CrossrefPubMedGoogle Scholar