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Anästhesiol Intensivmed Notfallmed Schmerzther 2008; 43(7/08): 500-512
DOI: 10.1055/s-0028-1083092
Fachwissen
Intensivmedizin
© Georg Thieme Verlag Stuttgart · New York

Transösophageale Echokardiografie in der Intensivmedizin – Technik, Indikationen, Möglichkeiten

Transesophageal echocardiography in critically ill patientsEgbert Hüttemann, Clemens-Alexander Greim
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Publication History

Publication Date:
31 July 2008 (online)

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Zusammenfassung

Die transösophageale Echokardiographie (TEE) ist aufgrund der Einsatzmöglichkeit am Krankenbett, der hohen Bildqualität, der raschen Verfügbarkeit der diagnostischen Information sowie einer niedrigen Komplikationsrate (2,6 %) ein äußerst vielseitigen Verfahren zur Überwachung, Diagnostik sowie Therapiesteuerung von kritisch kranken Patienten entwickelt. Eine Vielzahl von Studien haben einen hohen diagnostischen (67 %) und therapeutischen (36 %) Stellenwert der TEE aufgezeigt, insbesondere bei einem kardiologischen und kardiochirurgischen Patientengut.

Abstract:

TEE is one of the most versatile modalities for diagnosing and guiding treatment of critically ill patients due to its ease of use at patient bedside, the high quality imaging, the rapid availability of diagnostic information and its low complication rate (2,6 %). Numerous studies habe shown a significant diagnostic (67 %) and therapeutic (36 %) impact on patient management in critically ill patients, particularly in cardiological and cardiosurgical populations.

Schlüsselwörter:

Transösophageale - Echokardiographie - Intensivmedizin

Key words:

Transesophageal - echocardiography - critical care - intensive care unit

Kernaussagen

  • Die Echokardiografie ist aufgrund der Einsatzmöglichkeit am Krankenbett, der hohen Bildqualität, der raschen Verfügbarkeit der diagnostischen Information sowie einer niedrigen Komplikationsrate ein äußerst vielseitiges Verfahren zur Überwachung, Diagnostik und Therapiesteuerung bei kritisch kranken Patienten.

  • Grundsätzlich ist die TTE wegen fehlender Invasivität das Verfahren der Wahl ist.

  • Doch die TEE bietet bei beatmeten Intensivpatienten technische Vorteile: bessere Darstellung der Herzstrukturen, keine Interferenzen im Schallfeld durch Lungengewebe, Verbände, Drainagen, Ödeme usw. sowie die Möglichkeit zum längeren Verweilen der Sonde in unveränderter Position.

  • Eine Zunahme des Körpergewichtes >10 %, ein PEEP≥15cmH2O, Thoraxdrainagen, Inotropika und Vasopressoren lassen auf inadäquate transthorakale Beschallungsbedingungen schließen.

  • Die Echokardiografie und die Verfahren eines erweiterten hämodynamischen Monitorings (Pulmonaliskatheter, transpulmonale Indikatordilution) sind als komplementär und nicht als kompetitiv anzusehen.

  • Die Mehrzahl der vorliegenden Studien belegt den hohen diagnostischen Stellenwert der TEE in 44–99 % der untersuchten Fälle (Mittelwert 67 %) und die besondere Bedeutung der TEE für die Therapie (Gabe von Antibiotika, Inotropika, Vasopressoren oder Infusionen) bei 10–69 % der echokardiografierten Patienten (Mittelwert 36 %). Hiervon profitieren in der Intensivmedizin v.a. kardiologische und kardiochirurgische, aber auch gemischt operative Patientengruppen.

  • Für die Beurteilung der kardialen Funktion, und insbesondere zur Differenzialdiagnose

  • bei einer hämodynamischen Instabilität, ist die (transösophageale) Echokardiografie gerade auch beim kritisch Kranken die Methode der Wahl.

  • In der Intensivmedizin ist die TEE der TTE bei folgenden Konstellationen bzw. Fragestellungen überlegen:

    • Eingeschränkte Lagerungsgmöglichkeiten, Bauchlagerung, Verbände, Drainagen etc.

    • Abklärung einer hämodynamischen Instabilität insbesondere nach kardiochirurgischen Eingriffen an den Herzklappen

    • Ausschlussdiagnostik

      • Perikardtamponade nach kardiochirurgischen Eingriffen

      • Endokarditis

      • kardiale Emboliequelle

      • Aortendissektion

      • Lungenembolie

    • Thoraxtrauma

    • Myokardkontusion

    • Verletzung der Herzklappen

    • Aortenruptur

  • Derzeit fehlen für die TEE bei kritisch Kranken prospektive randomisierte kontrollierte Studien mit Endpunkten wie Kosteneffizienz, Morbidität oder Letalität.

  • Bisherige Daten und klinische Erfahrung weisen jedoch auf einen hohen Nutzen durch den intensivmedizinischen Einsatz der Echokardiografie hin.

  • Die TEE wird daher von den maßgeblichen intensivmedizinischen Fachgesellschaften (European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM)) als ein unverzichtbarer Bestandteil eines modernen intensivmedizinischen Instrumentariums bewertet. Daher sollte auch der Erwerb echokardiografischer Kenntnisse Teil der intensivmedizinischen Ausbildungscurricula werden.

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PD Dr. med. Egbert Hüttemann
Prof. Dr. med. Clemens–Alexander Greim

Email: egbert.huettemann@klinikum-worms.de

Email: sek.anaesth@klinikum-fulda.de

    Literaturverzeichnis