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Anästhesiol Intensivmed Notfallmed Schmerzther 2003; 38(3): 143-150
DOI: 10.1055/s-2003-37777
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© Georg Thieme Verlag Stuttgart · New York

Präklinische Anwendungsmöglichkeiten hypertoner Infusionslösungen bei Patienten mit Schädel-Hirn-Trauma

Prehospital Use of Hypertonic Solutions for Traumatic Brain InjuryJ.  Hinkelbein1 , C.  Thome2 , H.  Genzwürker1 , K.  Ellinger3
  • 1Institut für Anästhesiologie und Operative Intensivmedizin (Direktor: Prof. Dr. Dr. K. van Ackern), Universitätsklinikum, Mannheim
  • 2Neurochirurgische Universitätsklinik (Direktor: Prof. Dr. P. Schmiedek), Universitätsklinikum, Mannheim
  • 3Klinik für Anästhesie, Intensiv- und Notfallmedizin (Chefarzt: Priv.-Doz. Dr. med. K. Ellinger), Oberschwaben Klinik gGmbH, Krankenhaus St. Elisabeth, Ravensburg
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Publication History

Publication Date:
12 March 2003 (online)

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Zusammenfassung

Hypertone Infusionslösungen bedingen eine effiziente Senkung eines erhöhten intrakraniellen Drucks und verbessern die zerebrale Hämodynamik insbesondere im Bereich der Mikrozirkulation. Infolgedessen wurden hypertone Infusionslösungen in den letzten Jahren in die stationäre intensivmedizinische Behandlung bei Patienten mit Schädel-Hirn-Trauma eingeführt. Im Hinblick auf die gestörte zerebrale Perfusion und Oxygenierung in der posttraumatischen Akutphase ist ein möglichst frühzeitiger Therapiebeginn wünschenswert, um die Prognose zu verbessern und resultierende Sekundärschäden zu vermindern. Zur präklinischen und stationären Therapie der akuten Hypotension bei Hypovolämie und hämorrhagischem Schock sind in Deutschland zwei hypertone-isoonkotische Infusionslösungen zugelassen. Beide können sinnvolle Therapieoptionen zur Anwendung bei Patienten mit Schädel-Hirn-Trauma und intrakraniellem Druckanstieg bieten. Die Beschränkung der Zulassung auf die Schocktherapie in Deutschland erlaubt den routinemäßigen präklinischen Einsatz beim isolierten Schädel-Hirn-Trauma derzeit nicht. In anderen europäischen Ländern wurde das präklinische Einsatzspektrum hypertoner-isoonkotischer Infusionslösungen inzwischen entsprechend erweitert.

Abstract

Hypertonic solutions efficaciously lower increased intracranial pressure and improve cerebral hemodynamics in particular at the level of microcirculation. Therefore hypertonic solutions have been introduced to the in-hospital intensive care treatment of brain-injured patients. In view of the disturbed cerebral perfusion and oxigenation in the acute phase following traumatic brain injury, early initiation of treatment is desirable to improve long-term outcome and to minimize secondary brain damage. Two different hypertonic isooncotic solutions are licensed in Germany for prehospital and in-hospital treatment of acute hypotension due to hypovolaemia and haemorrhagic shock. Both solutions offer interesting therapeutic options for treatment of patients with increased intracranial pressure. Limitation of license to the treatment of shock in Germany does not allow routine prehospital use in isolated head trauma at the moment. In other European countries, the approval for the prehospital use of hypertonic isooncotic solutions has been modified.

Schlüsselwörter

Schädel-Hirn-Trauma - Intrakranieller Druck - Notarzt - Hypertone Kochsalzlösung - Small-Volume Resuscitation

Key words

Traumatic brain injury - intracranial pressure - emergency physician - hypertonic saline - small-volume resuscitation

Literatur

  • 1 The Brain Trauma Foundation,. The American Association of Neurological Surgeons, The Joint Section on Neurotrauma and Critical Care Use of mannitol. J Neurotrauma 2000 17: 521-525
    Google Scholar
  • 2 The Brain Trauma Foundation,. The American Association of Neurological Surgeons, The Joint Section on Neurotrauma and Critical Care Initial management. J Neurotrauma 2000 17: 463-469
    Google Scholar
  • 3 Kreimeier U, Christ F, Frey L, Habler O, Thiel M, Welte M, Zwissler B. Small-Volume Resuscitation beim hypovolämischen Schock.  Anästhesist. 1997;  46 309-328
    PubMedGoogle Scholar
  • 4 Kreimeier U, Prückner S. Volumentherapie bei Hypovolämie und Schock.  Notfall & Rettungsmedizin. 1998;  1 119-129
    PubMedGoogle Scholar
  • 5 Nakayama S, Sibley L, Gunther R A. et al . Small-volume resuscitation with hypertonic saline (2,400 mOsm/liter) during hemorrhagic shock.  Circ Shock. 1984;  13 149-159
    PubMedGoogle Scholar
  • 6 Kempski O, Obert C, Mainka T, Heimann A, Strecker U. „Small volume resuscitation” as Treatment of Cerebral Blood Flow Disturbances and Increased ICP in Trauma and Ischemia.  Acta Neurochir Suppl. 1996;  66 114-117
    PubMedGoogle Scholar
  • 7 Hinkelbein J, Genzwürker H, Ellinger K. Perspektiven der Small- Volume Resuscitation.  Notfallmedizin. 2001;  27 494-498
    PubMedGoogle Scholar
  • 8 Hinkelbein J, Genzwürker H, Ellinger K. Small-Volume Resuscitation: Primärtherapie des Schocks in der präklinischen Notfallmedizin.  Rettungsdienst. 2002;  25 142-145
    PubMedGoogle Scholar
  • 9 Fresenius Kabi Deutschland GmbH. HyperHAES® Fachinformation. Mai 2000
    Google Scholar
  • 10 Saetzler R K, Jallo J, Lehr H A. et al . Inhibition of leukocyte/endothelium and leukocyte/platelet activation by intravenous administration of hypertonic saline.  Microcirculation. 1996;  3 103
    PubMedGoogle Scholar
  • 11 Vassar M J, Perry C A, Gannaway W L, Holcroft J W. 7.5 % sodium chloride/dextran for resuscitation of trauma patients undergoing helicopter transport.  Arch Surg. 1991;  126 1065-1072
    PubMedGoogle Scholar
  • 12 Vassar M J, Fischer R P, O’Brien P E, Bachulis B L, Chambers J A, Hoyt D B, Holcroft J W. A multicenter trial for resuscitation of injured patients with 7.5 % sodium chloride. The effect of added dextran 70. The Multicenter Group for the Study of Hypertonic Saline in Trauma Patients.  Arch Surg. 1993;  128 1003-1013
    PubMedGoogle Scholar
  • 13 Qureshi A I, Suarez J. Use of hypertonic saline solutions in treatment of cerebral edema and intracranial hypertension.  Crit Care Med. 2000;  28 3301-3313
    CrossrefPubMedGoogle Scholar
  • 14 Weed L H, McKibben P S. Experimental alteration of brain bulk.  Am J Physiol. 1919;  48 531-558
    PubMedGoogle Scholar
  • 15 Wilson B, Jones R F, Coleman S T. et al . The effects of various hypertonic sodium salt solutions on cisternal pressure.  Surgery. 1951;  30 361-366
    PubMedGoogle Scholar
  • 16 De Felippe J, Timoner J, Velasco I T, Lopes O U, Rocha-e-Silva M. Treatment of refractory hypovolaemic shock by 7.5 % sodium chloride injections.  Lancet. 1980;  334 1002-1004
    PubMedGoogle Scholar
  • 17 Holcroft J W, Vassar M J, Turner J E, Derlet R W. et al . 3 % NaCl an 7.5 % NaCl/Dextran 70 in the resuscitation of severely injured patients.  Ann Surg. 1987;  206 279-286
    PubMedGoogle Scholar
  • 18 Berger S, Schürer L, Härtl R, Messmer K, Baethmann A. Reduction of Post-traumatic Intracranial Hypertension by Hypertonic/Hyperoncotic Saline/Dextran and Hypertonic Mannitol.  Neurosurgery. 1995;  37 98-108
    CrossrefPubMedGoogle Scholar
  • 19 Härtl R, Ghajar J, Hochleuthner H, Mauritz W. Hypertonic/Hyperoncotic Saline Reliably Reduces ICP in Severely Head-Injured Patients with Intracranial Hypertension.  Acta Neurochir Suppl. 1997;  70 126-129
    PubMedGoogle Scholar
  • 20 Härtl R, Medary M B, Ruge M, Arfors K E, Ghahremani F, Ghajar J. Hypertonic/Hyperoncotic Saline Attenuates Microcirculatory Disturbances after Traumatic Brain Injury.  J Trauma. 1997;  42 41-47
    PubMedGoogle Scholar
  • 21 Anderson J T, Wisner D H, Sullivan P E, Matteucci M, Freshman S, Hildreth J, Wagner F C. Initial small-volume hypertonic resuscitation of shock and brain injury: short- and long-term effects.  J Trauma. 1997;  42 592-600
    CrossrefPubMedGoogle Scholar
  • 22 Schwarz S, Schwab S, Bertram M, Aschoff A, Hacke W. Effects of Hypertonic Saline Hydroxyethyl Starch Solution and Mannitol in Patients With Increased Intracranial Pressure After Stroke.  Stroke. 1998;  29 1550-1555
    CrossrefPubMedGoogle Scholar
  • 23 Shackford S R. Effect of Small-Volume Resuscitation on Intracranial Pressure and Related Cerebral Variables.  J Trauma. 1997;  42 (Suppl) 48-53
    PubMedGoogle Scholar
  • 24 Walsh J C, Zhuang J, Shackford S R. A comparison of hypertonic to isotonic fluid in the resuscitation of brain injury and hemorrhagic shock.  J Surg Res. 1991;  50 284-292
    CrossrefPubMedGoogle Scholar
  • 25 Wade C E, Grady J J, Kramer G C, Younes R N, Gehlsen K, Holcroft J W. Individual Patient Cohort Analysis of the Efficacy of Hypertonic Saline/Dextran in Patients with Traumatic Brain Injury and Hypotension.  J Trauma. 1997;  42 61-65
    PubMedGoogle Scholar
  • 26 Horn P, Munch E, Vajkoczy P, Herrmann P, Quintel M, Schilling L, Schmiedek P, Schurer L. Hypertonic saline solution for control of elevated intracranial pressure in patients with exhausted response to mannitol and barbiturates.  Neurol Res. 1999;  21 758-764
    PubMedGoogle Scholar
  • 27 Khanna S, Davis D, Peterson B, Fisher B, Tung H, O’Quigley J, Deutsch R. Use of hypertonic saline in the treatment of severe refractory posttraumatic intracranial hypertension in pediatric traumatic brain injury.  Crit Care Med. 2000;  28 1144-1151
    CrossrefPubMedGoogle Scholar
  • 28 Qureshi A I, Suarez J I, Castro A, Bhardwaj A. Use of Hypertonic Saline/Acetate Infusion in Treatment of Cerebral Edema in Patients with Head Trauma: Experience at a Single Center.  J Trauma. 1999;  47 659-665
    PubMedGoogle Scholar
  • 29 Simma B, Burger R, Falk M, Sacher P, Fanconi S. A prospective, randomized, and controlled study of fluid management in children with severe head injury: Lactated Ringer’s solution versus hypertonic saline.  Crit Care Med. 1998;  26 1265-1270
    CrossrefPubMedGoogle Scholar
  • 30 Suarez J I, Qureshi A I, Parekh P D, Razumovsky A, Tamargo R J, Bhardwaj A, Ulatowski J A. Administration of hypertonic (3 %) sodium chloride/acetate in hyponatremic patients with symptomatic vasospasm following subarachnoid hemorrhage.  J Neurosurg Anesthesiol. 1999;  11 178-184
    CrossrefPubMedGoogle Scholar
  • 31 Worthley L IG, Cooper D J, Jones N. Treatment of resistant intracranial hypertension with hypertonic saline.  J Neurosurg. 1988;  68 478-481
    PubMedGoogle Scholar
  • 32 Marmarou A, Abd-Elfattah Foda M A, van den Brink W, Campbell J, Kita H, Demetriadou K. A new model of diffuse brain injury in rats, Part 1: Pathophysiology and biomechanics.  J Neurosurg. 1994;  80 291-300
    CrossrefPubMedGoogle Scholar
  • 33 Tanno H, Nockels R P, Pitts L H, Noble L J. Breakdown of the blood-brain-barrier after fluid percussive brain injury in the rat. Part 1: Distribution and time course of protein extravasation.  J Neurotrauma. 1992;  9 21-32
    PubMedGoogle Scholar
  • 34 Bouma G J, Muizelaar J P. Cerebral blood flow in severe clinical head injury.  New Horizons. 1995;  3 384-394
    PubMedGoogle Scholar
  • 35 Martin N A, Patwardhan R V, Alexander M J, Africk C Z, Lee J H, Shalmon E, Hovda D A, Becker D P. Characterization of cerebral hemodynamic phases following severe head trauma: hypoperfusion, hyperemia, and vasospasm.  J Neurosurg. 1997;  87 9-19
    CrossrefPubMedGoogle Scholar
  • 36 Kelly D F, Martin N A, Kordestani R K, Counelis G, Hovda D A, Bergsneider M, McBride D Q, Shalmon E, Herman D, Becker D P. Cerebral blood flow as a predictor of outcome following traumatic brain injury.  J Neurosurg. 1997;  86 633-641
    CrossrefPubMedGoogle Scholar
  • 37 The Brain Trauma Foundation, The American Association of Neurological Surgeons, The Joint Section on Neurotrauma and Critical Care . Resuscitation of blood pressure and oxygenation.  J Neurotrauma. 2000;  17 471-478
    PubMedGoogle Scholar
  • 38 Procaccio F, Stocchetti N, Citerio G, Berardino M, Beretta L, Della Corte F, D'Avella D, Brambilla G L, Delfini R, Servadei F, Tomei G. Guidelines for the treatment of adults with severe head trauma (part II). Criteria for medical treatment.  J Neurosurg Sci. 2000;  44 11-18
    PubMedGoogle Scholar
  • 39 Graham D I, Ford I, Adams J H, Doyle D, Teasdale G M, Lawrence A E, McLellan D R. Ischaemic brain damage is still common in fatal non-missile head injury.  J Neurol Neurosurg Psychiatry. 1989;  52 346-350
    CrossrefPubMedGoogle Scholar
  • 40 Doyle J A, Davis D P, Hoyt D B. The Use of Hypertonic Saline in the Treatment of Traumatic Brain Injury.  J Trauma. 2001;  50 367-383
    CrossrefPubMedGoogle Scholar
  • 41 Reed R L, Johnston T D, Chen Y. et al . Hypertonic saline alters plasma clotting times and platelet aggregation.  J Trauma. 1991;  31 8-14
    PubMedGoogle Scholar
  • 42 Weinstsabl C, Mayer N, Germann P. et al . Hypertonic, hyperoncotic hydroxyethyl starch decreases intracranial pressure following neurotrauma.  Anesthesiology. 1991;  75 A202
    PubMedGoogle Scholar
  • 43 Finberg L. Dangers to infants caused by changes in osmolar concentrations.  Pediatrics. 1967;  40 1031-1034
    PubMedGoogle Scholar
  • 44 Procaccio F, Stocchetti N, Citerio G, Berardino M, Beretta L, Della Corte F, D'Avella D, Brambilla G L, Delfini R, Servadei F, Tomei G. Guidelines for the treatment of adults with severe head trauma (part I). Initial assessment; evaluation and pre-hospital treatment; current criteria for hospital admission; systemic and cerebral monitoring.  J Neurosurg Sci. 2000;  44 1-10
    PubMedGoogle Scholar
  • 45 Fresenius Kabi Deutschland GmbH.  Kolloide - Wissenschaft gut in Form. Produktinformation Voluven® 2001
    Google Scholar

Dr. med. Jochen Hinkelbein

Institut für Anästhesiologie und Operative Intensivmedizin
Universitätsklinikum Mannheim

Theodor-Kutzer-Ufer 1-3

68167 Mannheim ·

Email: hinkelbein@akutmedizin.de

URL: http://www.akutmedizin.de

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