Hämodynamisches Monitoring auf der Intensivstation: Je invasiver, desto besser?

Die jüngsten Entwicklungen im Bereich minimalinvasiver und nichtinvasiver hämodynamischer Monitoringverfahren mögen deren Einsatz im operativen wie im intensivmedizinischen Bereich fördern. Diese Übersicht beurteilt den Stellenwert invasiver und weniger invasiver Monitoringverfahren und deren spezifische hämodynamische Variablen in der Anwendung bei kritisch kranken Patienten im intensivmedizinischen Bereich.

Abstract

Less invasive or even completely non-invasive haemodynamic monitoring technologies have evolved during the last decades. However, the invasive devices such as the pulmonary artery catheter and transpulmonary thermodilution technologies are still the clinical gold standard in terms of advanced haemodynamic monitoring, especially in the treatment of critically ill patients. The current data situation regarding the early use of continuous haemodynamic monitoring in this patient population, specifically flow-based variables such as stroke volume to prevent occult hypoperfusion, is overwhelming. However, the effective implementation of these technologies in daily clinical routine is remarkably low. Given the fact that perioperative morbidity and mortality are higher than anticipated, anaesthesiologists and intensivists are in charge to deal with this problem. The recent advances in minimally invasive and non-invasive haemodynamic monitoring technologies may facilitate a more widespread use in the operating theatre and in critical care patients. This review evaluates the significance of invasive, minimally- and non-invasive monitoring devices and their specific haemodynamic variables in this particular field of perioperative medicine.

Schlüsselwörter

hämodynamisches Monitoring - invasiv - nicht-invasiv - Thermodilution - Pulskonturanalyse - Schlagvolumen - Volumenreagibilität - Echokardiografie

Keywords

haemodynamic monitoring - invasive - non-invasive - thermodilution - pulse contour analysis - stroke volume - volume responsiveness - echocardiography

• Literatur

• 1 Cecconi M, De Backer D, Antonelli M. et al. Task force of the European Society of Intensive Care Medicine. Intensive Care Med 2014; 40: 1795-1815
• 2 Meregalli A, Oliveira RP, Friedman G. Occult hypoperfusion is associated with increased mortality in hemodynamically stable, high-risk, surgical patients. Crit Care 2004; 8: R60-R65
• 3 Funcke S, Sander M, Goepfert MS. et al. Practice of hemodynamic monitoring and management in German, Austrian, and Swiss intensive care units: the multicenter cross-sectional ICU-CardioMan Study. Ann Intensive Care 2016; 6: 49
• 4 Linton RA, Linton NW, Kelly F. Is clinical assessment of the circulation reliable in postoperative cardiac surgical patients?. J Cardiothorac Vasc Anesth 2002; 16: 4-7
• 5 Gnaegi A, Feihl F, Perret C. Intensive care physicians’ insufficient knowledge of right-heart catheterization at the bedside: time to act?. Crit Care Med 1997; 25: 213-220
• 6 Lima A, van Genderen ME. et al. Nitroglycerin reverts clinical manifestations of poor peripheral perfusion in patients with circulatory shock. Crit Care 2014; 18: R126
• 7 Hernandez G, Cavalcanti AB, Ospina-Tascón G. ANDROMEDA-SHOCK Study Investigators. et al. Early goal-directed therapy using a physiological holistic view: the ANDROMEDA-SHOCK-a randomized controlled trial. Ann Intensive Care 2018; 8: 52
• 8 Rhodes A, Evans LE, Alhazzani W. et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med 2017; 43: 304-377
• 9 Crippa IA, Subira C, Vincent JL. et al. Impaired cerebral autoregulation is associated with brain dysfunction in patients with sepsis. Crit Care 2018; 22: 327
• 10 Penaz J. Current photoelectric recording of blood flow through the finger. Cesk Fysiol 1975; 24: 349-352
• 11 Truijen J, van Lieshout JJ, Wesselink WA. et al. Noninvasive continuous hemodynamic monitoring. J Clin Monit Comput 2012; 26: 267-278
• 12 Vincent JL, De Backer D. Circulatory shock. N Engl J Med 2014; 370: 583
• 13 Cecconi M, Parsons AK, Rhodes A. What is a fluid challenge?. Curr Opin Crit Care 2011; 17: 290-295
• 14 Michard F, Giglio MT, Brienza N. Perioperative goal-directed therapy with uncalibrated pulse contour methods: impact on fluid management and postoperative outcome. Brit J Anaesth 2017; 119: 22-30
• 15 Chong MA, Wang Y, Berbenetz NM. et al. Does goal-directed haemodynamic and fluid therapy improve peri-operative outcomes? A systematic review and meta-analysis. Eur J Anaesthesiol 2018; 35: 469-483
• 16 Saugel B, Thiele RH, Hapfelmeier A. et al. Technological assessment and objective evaluation of minimally invasive and noninvasive cardiac output monitoring systems. Anesthesiology 2020; 133: 921-928
• 17 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
• 18 Schloglhofer T, Gilly H, Schima H. Semi-invasive measurement of cardiac output based on pulse contour: a review and analysis. Can J Anaesth 2014; 61: 452-479
• 19 Kouz K, Scheeren TWL, de Backer D. et al. Pulse wave analysis to estimate cardiac output. Anesthesiology 2021; 134: 119-126
• 20 Balzer F, Sander M, Simon M. et al. High central venous saturation after cardiac surgery is associated with increased organ failure and long-term mortality: an observational cross-sectional study. Crit Care 2015; 19: 168
• 21 Lat I, Coopersmith CM, De Backer D. et al. The surviving sepsis campaign: fluid resuscitation and vasopressor therapy research priorities in adult patients. Crit Care Med 2021; 49: 623-635
• 22 Hartog C, Bloos F. Venous oxygen saturation. Best Pract Res Clin Anaesthesiol 2014; 28: 419-428
• 23 Marik PE. Obituary: pulmonary artery catheter 1970 to 2013. Ann Intensive Care 2013; 3: 38
• 24 Charron C, Caille V, Jardin F. et al. Echocardiographic measurement of fluid responsiveness. Curr Opin Crit Care 2006; 12: 249-254
• 25 Endo T, Kushimoto S, Yamanouchi S. et al. Limitations of global end-diastolic volume index as a parameter of cardiac preload in the early phase of severe sepsis: a subgroup analysis of a multicenter, prospective observational study. J Intensive Care 2013; 1: 11
• 26 Damman K, van Deursen VM, Navis G. et al. Increased central venous pressure is associated with impaired renal function and mortality in a broad spectrum of patients with cardiovascular disease. J Am Coll Cardiol 2009; 53: 582-588
• 27 Biais M, Ehrmann S, Mari A. et al. Clinical relevance of pulse pressure variations for predicting fluid responsiveness in mechanically ventilated intensive care unit patients: the grey zone approach. Crit Care 2014; 18: 587
• 28 Magder S. Clinical usefulness of respiratory variations in arterial pressure. Am J Respir Crit Care Med 2004; 169: 151-155
• 29 Perel A. Using Dynamic Variables to guide perioperative fluid management. Anesthesiology 2020; 133: 929-935
• 30 De Backer D, Vincent JL. Noninvasive monitoring in the intensive care unit. Semin Respir Crit Care Med 2021; 42: 40-46
• 31 Cavallaro F, Sandroni C, Marano C. et al. Diagnostic accuracy of passive leg raising for prediction of fluid responsiveness in adults: systematic review and meta-analysis of clinical studies. Intensive Care Med 2010; 36: 1475-1483
• 32 Minini A, Abraham P, Malbrain M. Predicting fluid responsiveness with the passive leg raising test: don’t be fooled by intra-abdominal hypertension!. Ann Transl Med 2020; 8: 799
• 33 Monnet X, Teboul JL. Transpulmonary thermodilution: advantages and limits. Crit Care 2017; 21: 147
• 34 Rajaram SS, Desai NK, Kalra A. et al. Pulmonary artery catheters for adult patients in intensive care. Cochrane Database Syst Rev 2013; (02) CD003408
• 35 Habicher M, Zajonz T, Heringlake M. et al. S3-Leitlinie zur intensivmedizinischen Versorgung herzchirurgischer Patienten: Hämodynamisches Monitoring und Herz-Kreislauf – ein Update. Anaesthesist 2018; 67: 375-379
• 36 Pilarczyk K, Werdan K, Russ M. et al. The German-Austrian S3 guideline “cardiogenic shock due to myocardial infarction: diagnosis, monitoring, and treatment”. Thorac Cardiovasc Surg 2021; 69: 684-692
• 37 Pourmand A, Pyle M, Yamane D. et al. The utility of point-of-care ultrasound in the assessment of volume status in acute and critically ill patients. World J Emerg Med 2019; 10: 232-238
• 38 Mercado P, Maizel J, Beyls C. et al. Transthoracic echocardiography: an accurate and precise method for estimating cardiac output in the critically ill patient. Crit Care 2017; 21: 136
• 39 Feng M, McSparron JI, Kien DT. et al. Transthoracic echocardiography and mortality in sepsis: analysis of the MIMIC-III database. Intensive Care Med 2018; 44: 884-892
• 40 Heringlake M, Sander M, Treskatsch S. et al. Hämodynamische Zielvariablen auf der Intensivstation. Anaesthesist 2018; 67: 797-808