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Empfehlungen zum hämodynamischen Monitoring in der internistischen Intensivmedizin

Recommendations on hemodynamic monitoring in internal intensive care medicine

  • Empfehlungen und Stellungnahmen
  • Published:
Der Kardiologe Aims and scope

Zusammenfassung

Das hämodynamische Monitoring in der kardiovaskulären Intensivmedizin wird unterteilt in Komponenten des Basismonitorings und des erweiterten Monitorings. Unverzichtbares Basismonitoring ist die Kombination aus EKG, Körpertemperatur, Sauerstoffsättigung, nichtinvasivem Blutdruck, Urinproduktion und dem „klinischen Blick“, bestehend aus gründlicher klinischer Untersuchung und Anamnese. Das Basismonitoring kann mit einer Vielfalt differenzierter erweiterter Monitoringverfahren ergänzt werden, die im Einzelfall für den in der Anwendung Geübten extrem nützlich sein können, aber, wenn undifferenziert eingesetzt, mehr schaden als helfen. Für kritische Phasen der Akuttherapie auf der Intensivstation, insbesondere für das Nichtansprechen auf etablierte Therapieformen müssen differenzierte Optionen erwogen werden. Hierzu werden in dieser Arbeit Empfehlungen abgegeben. Der bettseitige, möglichst zeitnah verfügbare Einsatz der Echokardiographie bzw. Sonographie ist das zentrale Modul in der Diagnostik, Überwachung und Therapiesteuerung kritisch kranker Intensivpatienten und kann Volumenreagibilität und hämodynamischen Unterstützungsbedarf abschätzen. Die Ausbildung und Expertise in diesen Verfahren ist daher unverzichtbar und unterstreicht die zentrale Rolle des internistisch-kardiologisch ausgebildeten Intensivmediziners.

Abstract

Hemodynamic monitoring of critically ill cardiovascular patients consists of basic monitoring and extended monitoring measures. Basic monitoring should be used in all patients and consists of electrocardiography, body temperature, transcutaneous oxygen saturation, non-invasive blood pressure, measurement of urine production and clinical assessment. Multiple modalities of extended monitoring measures are available that can supplement basic monitoring, especially when the patient does not respond to the applied treatment. They are useful for experienced physicians in selected cases but when used in an undifferentiated way most modalities induce harm rather than benefits; therefore, extended monitoring has to be individually tailored to each patient. This article gives recommendations for the use of the various modalities available. The use of bedside echocardiography is a central tool in diagnostics and surveillance of critically ill cardiovascular patients and can be used to guide fluid management and hemodynamic support. Thus, training and expertise in cardiovascular intensive care and echocardiographic imaging are indispensable prerequisites for the treatment of critically ill patients. This underscores the important role of trained personnel in cardiovascular intensive care.

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Abbreviations

BGA:

Blutgasanalyse

CI:

Cardiac Index (HZV bezogen auf Körperoberfläche)

CPO/CPI:

Cardiac Power Output/Index

GEDV:

Globales enddiastolisches Volumen

HZV:

Herzzeitvolumen

ITBV:

Intrathorakales Blutvolumen

LVEDP:

Linksventrikulärer enddiastolischer Druck

LVEDV(i):

Linksventrikuläres enddiastolisches Volumen(-index)

MAD:

Mittlerer arterieller Druck

MPI:

Myocardial Performance Index (Tei-Index)

PAOP:

Pulmonalarterieller Okklusionsdruck

PAP:

Pulmonalarterieller Druck

PLR:

Passiver Beinhebeversuch

PPV:

Pulsdruckvariation

PVR:

Pulmonalvaskulärer Gefäßwiderstand

RAP:

Rechtsatrialer Druck

RVCPI:

Rechtsventrikulärer Cardiac Power Index

ScvO2 :

Zentralvenöse Sauerstoffsättigung

SPV:

Systolische Druckvariation

SV:

Schlagvolumen

SVV:

Schlagvolumenvariation

TAPSE:

Systolische Exkursion der Trikuspidalklappenebene

TASV:

Systolische Geschwindigkeit der Trikuspidalklappenebene

ZVD:

Zentralvenöser Druck

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Authors and Affiliations

  1. Klinik für Innere Medizin und Internistische Intensivmedizin, St. Antonius-Krankenhaus Eschweiler, Eschweiler, Deutschland

    U. Janssens

  2. Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland

    C. Jung & M. Kelm

  3. Klinik für Innere Medizin I, SLK-Kliniken Heilbronn, Heilbronn, Deutschland

    M. Hennersdorf

  4. Klinik für Innere Medizin I, Helios-Dr.-Horst-Schmidt-Kliniken Wiesbaden, Wiesbaden, Deutschland

    M. Ferrari

  5. Klinik für Innere Medizin, DRK-Krankenhaus Sömmerda, Sömmerda, Deutschland

    J. Fuhrmann

  6. Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin, St. Marien-Krankenhaus Siegen, Siegen, Deutschland

    M. Buerke

  7. Klinik für Innere Medizin II, Katholisches Krankenhaus St. Johann Nepomuk Erfurt, Erfurt, Deutschland

    H. Ebelt

  8. Medizinische Klinik II, Universitäres Herzzentrum Lübeck, Universitätsklinikum Schleswig-Holstein, Lübeck, Deutschland

    T. Graf & H. Thiele

  9. Praxisklinik Herz und Gefäße Dresden, Forststr. 3, 01099, Dresden, Deutschland

    G. Simonis

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  1. U. Janssens
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Correspondence to G. Simonis.

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M. Kelm für die Kommission für Klinische Kardiologie der DGK Alle Autoren sind Mitglieder der Arbeitsgruppe 3 – kardiovaskuläre Intensiv- und Notfallmedizin der Deutschen Gesellschaft für Kardiologie. G. Simonis war Sprecher der AG 2014–2016. H. Thiele ist aktueller Sprecher der AG.

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Janssens, U., Jung, C., Hennersdorf, M. et al. Empfehlungen zum hämodynamischen Monitoring in der internistischen Intensivmedizin. Kardiologe 10, 149–169 (2016). https://doi.org/10.1007/s12181-016-0060-x

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