Kardioanästhesie: Monitoring und aktuelle hämodynamische Konzepte

Zusammenfassung

Die Krankheitsschwere herzchirurgischer Patienten und die Komplexität der Eingriffe haben in den letzten Jahren deutlich zugenommen. Dies stellt nicht nur erhöhte Anforderungen an die neurologische und hämodynamische Überwachung, sondern macht es auch erforderlich, die hämodynamische Therapie – unter Berücksichtigung aktueller pharmakologischer Entwicklungen – individuell dem höheren Risikoprofil der Patienten anzupassen.

Abstract

Patients undergoing cardiac surgery are growing older, present with more comorbidities, and are frequently scheduled for more complex and prolonged surgical procedures. Routine application of neurological as well as extended hemodynamic monitoring combined with goal-directed perioperative hemodynamic optimization, targeting optimization of systemic and cerebral oxygen balance, show promise to reduce postoperative complications and to improve mortality in this high risk population. Expert recommendations suggest to avoid synthetic colloids for fluid optimization. Additionally, pathophysiological reasoning and results from recent trials suggest to start inotropic and vasoactive therapy primarily with non-adrenergic drugs like levosimendan and vasopressin and to add classical catecholamines like dobutamine and noradrenalin only if necessary to accomplish hemodynamic goals.

Kernaussagen

• Da herzchirurgische Patienten ein Risikokollektiv für intraoperative Awareness darstellen, sollte die Narkosetiefe kontinuierlich mittels prozessiertem EEG überwacht werden.

• Herzchirurgische Patienten haben ein deutlich erhöhtes Risiko für neurologische Komplikationen. Die Vermeidung eines Abfalls der regionalen zerebralen Sauerstoffsättigung unter den präoperativen Ausgangswert kann die Rate an Delir oder POCD reduzieren.

• Die transösophageale Echokardiografie ist bei herzchirurgischen Patienten zur Evaluation der kardialen Funktion und des operativen Ergebnisses nach Klappenersatz/-rekonstruktion ein Standardverfahren.

• Zur Einschätzung der z. T. komplexen hämodynamischen Bilder herzchirurgischer Patienten ist nicht selten ein erweitertes Monitoring mittels Pulmonalarterienkatheter erforderlich. Eine kontinuierliche Überwachung der arteriellen und zentralvenösen Druckkurve ist obligat.

• Eine Hypalbuminämie bei herzchirurgischen Patienten ist prognostisch ungünstig und mit einer erhöhten Rate an Nierenfunktionsstörungen assoziiert.

• Die Gabe klassischer Betamimetika wie Adrenalin oder Dobutamin ist mit einer erhöhten Morbidität und Letalität assoziiert. Der Kalziumsensitizer Levosimendan hat inotrope und vasodilatatorische Eigenschaften und kann Morbidität und Letalität bei herzchirurgischen Patienten reduzieren.

• Rechtsventrikuläre Funktionsstörungen sind bei herzchirurgischen Patienten häufig und prognostisch ungünstig. Therapeutisch stehen dabei neben einer Steigerung des systemischen Perfusionsdrucks eine Reduktion der rechtsventrikulären Nachlast durch Gabe inhalativer pulmonal-arterieller Vasodilatatoren, ggf. supportiert mit Inodilatatoren, im Vordergrund.

Schlüsselwörter

Kardioanästhesie - hämodynamisches Monitoring - Bispektralindex - zerebrale Oxymetrie - Inotropika - Vasopressoren

Key words

cardiac anesthesia - hemodynamic monitoring - bispectral index - cerebral oximetry - inotropes - vasopressors

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