Zusammenfassung
Die Volumensubstitution ist ein wesentlicher Bestandteil der Intensivtherapie. Sowohl die Menge des infundierten Volumens, seine Zusammensetzung als auch der Zeitpunkt der Substitution scheinen die Morbidität und Letalität kritisch kranker Patienten zu beeinflussen. Während eine restriktive Volumenstrategie bei kreislaufinstabilen Patienten das Risiko einer Gewebeminderperfusion mit Gewebehypoxie mit sich bringt, begünstigt eine liberale Volumensubstitution bei intakter Gewebeperfusion eine vermeidbare Hypervolämie mit interstitiellen Ödemen und entsprechenden Organfunktionsstörungen. Bislang konnte angesichts fehlender „outcome“-basierter Evidenz keiner der beiden Strategien ein eindeutiger Vorteil zugeordnet werden. Um dem stark variierenden Sauerstoff- (O2)-Bedarf kritisch kranker Patienten gerecht zu werden, wird daher eine bedarfsadaptierte Volumenstrategie empfohlen, die sich am Nachweis einer gefährdeten Gewebeperfusion und der individuellen Volumenreagibilität orientieren sollte. Aufgrund ihrer zeitabhängigen Effektivität zur Korrektur einer Gewebehypoxie sollte die Vorlast möglichst frühzeitig optimiert werden. Ob hierfür kolloidale oder kristalline Lösungen geeigneter sind, ist weiterhin Gegenstand kontroverser Diskussionen. Ein zeitlich limitierter Einsatz von kolloidalen Lösungen in der initialen Phase der Gewebeminderperfusion scheint jedoch dazu beizutragen, deren größeren Volumeneffekt bei Hypovolämie nutzen zu können und mögliche Nebenwirkungen so weit wie möglich zu vermeiden.
Abstract
Volume substitution represents an essential component of intensive care medicine. The amount of fluid administered, the composition and the timing of volume replacement seem to affect the morbidity and mortality of critically ill patients. Although restrictive volume strategies bear the risk of tissue hypoperfusion and tissue hypoxia in hemodynamically unstable patients liberal strategies favour the development of avoidable hypervolemia with edema and resultant organ dysfunction. However, neither strategy has shown a consistent benefit. In order to account for the heavily varying oxygen demand of critically ill patients, a goal-directed, demand-adapted volume strategy is proposed. Using this strategy, volume replacement should be aligned to the need to restore tissue perfusion and the evidence of volume responsiveness. As the efficiency of volume resuscitation for correction of tissue hypoxia is time-dependent, preload optimization should be completed in the very first hours. Whether colloids or crystalloids are more suitable for this purpose is still controversially discussed. Nevertheless, a temporally limited use of colloids during the initial stage of tissue hypoperfusion appears to represent a strategy which uses the greater volume effect during hypovolemia while minimizing the risks for adverse reactions.
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Der korrespondierende Autor weist auf folgende Beziehung hin: B. Nohé hat von der Fa. Fresenius-Kabi Reisekostenerstattung und Unterstützung für wissenschaftliche Projekte erhalten.
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Nohé, B., Ploppa, A., Schmidt, V. et al. Volumentherapie in der Intensivmedizin. Anaesthesist 60, 457–473 (2011). https://doi.org/10.1007/s00101-011-1860-9
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DOI: https://doi.org/10.1007/s00101-011-1860-9