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Stand der Wissenschaft in der Flüssigkeits- und Volumentherapie

Ein anwenderfreundliches Stufenkonzept

State of the art in fluid and volume therapy

A user-friendly staged concept

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Zusammenfassung

Eine adäquate intraoperative Infusionstherapie ist wesentlich für das perioperative Outcome eines Patienten. Sowohl Hypo- als auch Hypervolämie können zu einer erhöhten Rate perioperativer Komplikationen führen und somit zu einem schlechteren Behandlungsergebnis. Daher sollte die perioperative Flüssigkeitstherapie bedarfsgerecht und zielorientiert durchgeführt werden. Das Hauptziel ist die präoperative Normovolämie durch eine rationale Infusionstherapie aufrechtzuerhalten. Perioperative Flüssigkeitsverluste sollten dabei von Volumenverlusten durch chirurgische Blutungen oder Proteinverlusten ins Interstitium differenziert werden. Flüssigkeitsverluste via Urinexkretion oder Perspiratio insensibilis (0,5–1,0 ml/kg/h) sollten 1:1 mit balancierten, isoonkotischen, kristalloiden Infusionslösungen ausgeglichen werden. Volumentherapie, Stufe 1: Intraoperative Volumenverluste bis zu einem Blutverlust von 20 % des Gesamtblutvolumens werden mit balancierten Kristalloiden im Verhältnis 4–5:1 ausgeglichen. Stufe 2: Darüber hinausgehende Blutverluste sind im Verhältnis 1:1 mit isoonkotischen Kolloiden (bevorzugt balanciert) zu behandeln. In dieser Hinsicht und unter Beachtung der Kontraindikationen wie Sepsis, Verbrennungen, kritische Erkrankung (i. d. R. Patienten auf Intensivstation), eingeschränkte Nierenfunktion oder Nierenersatztherapie, intrakranielle Blutung oder schwere Gerinnungsstörungen können perioperativ auch künstliche Kolloide, wie z. B. HES, zum Volumenersatz verwendet werden. Stufe 3: Wenn die Indikation zur Gabe von Fremdblut besteht, erfolgt ein differenzierter Einsatz von Blut und Blutprodukten.

Abstract

Adequate fluid therapy is highly important for the perioperative outcome of our patients. Both, hypovolemia and hypervolemia can lead to an increase in perioperative complications and can impair the outcome. Therefore, perioperative infusion therapy should be target-oriented. The main target is to maintain the patient’s preoperative normovolemia by using a sophisticated, rational infusion strategy.

Perioperative fluid losses should be discriminated from volume losses (surgical blood loss or interstitial volume losses containing protein). Fluid losses as urine or perspiratio insensibilis (0.5–1.0 ml/kg/h) should be replaced by balanced crystalloids in a ratio of 1:1. Volume therapy step 1: Blood loss up to a maximum value of 20% of the patient’s blood volume should be replaced by balanced crystalloids in a ratio of 4(-5):1. Volume therapy step 2: Higher blood losses should be treated by using iso-oncotic, preferential balanced colloids in a ratio of 1:1. For this purpose hydroxyethyl starch can also be used perioperatively if there is no respective contraindication, such as sepsis, burn injuries, critically ill patients, renal impairment or renal replacement therapy, and severe coagulopathy. Volume therapy step 3: If there is an indication for red cell concentrates or coagulation factors, a differentiated application of blood and blood products should be performed.

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Authors and Affiliations

  1. Klinik für Anaesthesiologie, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland

    M. Rehm, N. Hulde, T. Kammerer, A. S. Meidert & K. Hofmann-Kiefer

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  1. M. Rehm
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  2. N. Hulde
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  3. T. Kammerer
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  4. A. S. Meidert
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Correspondence to M. Rehm.

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Interessenkonflikt

M. Rehm leitet aktuell 2 klinische Studien, eine wird von CSL Behring, eine von Fresenius Kabi unterstützt. Er hat in den letzten 2 Jahren von Pharmafirmen keine Reisekostenerstattungen oder Honorare erhalten. N. Hulde, T. Kammerer, A. S. Meidert und K. Hofmann-Kiefer geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

Additional information

Erweiterte und aktualisierte Version des Beitrags von Hulde N und Rehm M (2016) Grundlagen der Infusionstherapie. In: Refresher Course – Aktuelles Wissen für Anästhesisten, Nr. 42. Aktiv Druck & Verlag, Ebelsbach, S 73–81

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Rehm, M., Hulde, N., Kammerer, T. et al. Stand der Wissenschaft in der Flüssigkeits- und Volumentherapie. Anaesthesist 66, 153–167 (2017). https://doi.org/10.1007/s00101-017-0272-x

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