Invasive und nichtinvasive Diagnostik der Hypovolämie bei akuter Pankreatitis

 

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Zusammenfassung

Die akute Pankreatitis ist bei schwerem Verlauf mit einem ausgeprägten intraperitonealen Flüssigkeitsverlust verbunden, welcher zu einem Volumenmangelschock führen kann. Die Sequestration von Flüssigkeit kann bis zu 40 Prozent des zirkulierenden Blutvolumens betragen. Die Menge der erforderlichen Flüssigkeits- und Elektrolytersatztherapie wird daher häufig deutlich unterschätzt, was sich auf die Rate der Organkomplikationen und die Gesamtmortalität der Erkrankung auswirkt. Außerdem scheint eine rasche und adäquate Volumentherapie durch Verbesserung der Organperfusion und Oxygenierung des Pankreas den prognostischen Verlauf einer akuten Pankreatitis zu beeinflussen. Auf der anderen Seite droht vor allem bei kardialen und pulmonalen Komorbiditäten eine Volumenüberladung mit daraus resultierender kardiopulmonaler Dekompensation. Dies macht die sorgfältige Bilanzierung und engmaschige Kontrolle der hämodynamischen Parameter, bei schwerem Verlauf der Erkrankung unter intensivmedizinischen Bedingungen, zu einem wichtigen Bestandteil der Therapie. Im klinischen Alltag wird der dominierende Anteil der Patienten mit akuter Pankreatitis allerdings unter normal stationären Bedingungen behandelt, sodass ein differenziertes und vor allem kontinuierliches hämodynamisches Monitoring nur begrenzt möglich ist. Neben der Überwachung der Vitalparameter sowie der Messung des zentralen Venendrucks existieren verschiedene andere klinische, laborchemische und bildgebende diagnostische Möglichkeiten, um das Ausmaß des intravasalen Flüssigkeitsdefizits und den individuellen Volumenbedarf eines Patienten mit akuter Pankreatitis orientierend zu ermitteln. Prospektive Studien für ein pankreatitisspezifisches Volumenmanagement fehlen bislang. In dieser Übersicht sollen daher die wichtigsten invasiven und nichtinvasiven diagnostischen Methoden zur Erfassung der zirkulatorischen Hypovolämie bei akuter Pankreatitis aufgezeigt werden.

Abkürzungen

Acute Physiology And Chronic Health Evaluation-II-Score; APACHE-II-Score; akutes Nierenversagen, ANV; Acute Respiratory Distress Syndrome, ARDS; Atrial Natriuretic Peptide (ANP); Brain Natriuretic Peptide (BNP); Bodymass-Index, BMI; Collapsibility Index, CI; C-reaktives Protein, CRP; glomeruläre Filtrationsrate, GFR; Herzfrequenz, Hf; Herzzeitvolumen, HZV; extravasales Lungenwasser, EVLW; Interleukin, Il; intrathorakales Blutvolumen, ITBV; Multiorganversagen, MOV; Pulse Contour Cardiac Output, PCCO; Plättchenaktivierungsfaktor, PAF; Pulmonaliskatheter, PAK; Systemic Inflammatory Response Syndrome, SIRS; transösophageale Echokardiographie, TEE; Tumornekrosefaktor, TNF; Velocity-Time-Integral, VTI; zentraler Venendruck, ZVD, zentraler Venenkatheter, ZVD

Abstract

Severe acute pancreatitis leads to a dramatic fluid loss in the intraperitoneal space which may result in circulatory decompensation. Sequestration of fluid can amount up to 40 percent of the circulating blood volume. The amount of fluid and electrolyte replacement is often misjudged leading to a higher rate of complications and a higher mortality rate of the disease. Furthermore, subsequent and adequate fluid resuscitation seems to influence the prognostic course of the disease by improving the perfusion and oxygenation of the pancreas. Otherwise volume overload may cause cardiopulmonary decompensation in the case of synchronous cardiopulmonary comorbidities. Therefore, an important part of treatment relies on careful haemodynamic monitoring, if necessary managed in an intensive care unit. Usually most patients with acute pancreatitis will be treated on a non-intensive medical ward which allows a differentiated and continuous haemodynamic monitoring only to a limited extent. Apart from monitoring circulatory parameters and measuring central venous pressure, there are other clinical methods, laboratory tests and radiological diagnostic procedures to determine the amount of intravascular fluid deficit and the individual volume demand of patients with acute pancreatitis. Prospective clinical trials for evaluation of pancreatitis-specific volume management do not exist so far. The aim of this review is to provide background information on invasive and non-invasive diagnostic methods for detection of circulatory hypovolemia in acute pancreatitis.

Abbreviations

Acute Physiology And Chronic Health Evaluation-II-Score; APACHE-II-Score; Acute renal failure, ARF; Acute Respiratory Distress Syndrome, ARDS; Atrial Natriuretic Peptide (ANP); Brain Natriuretic Peptide (BNP); Body Mass Index, BMI; Cardiac volume, CV; Central Venous Pressure, CVP; Central Venous Catheter, CVC; Collapsibility Index, CI; C-reaktive Protein, CRP; Glomerular Filtration Rate, GFR; Heart Rate, HR; Extravascular Lung Water, EVLW; Interleucin, Il; Intrathoracic Blood Volume, ITBV; Multiorgan Failure, MOF; Pulse Contour Cardiac Output, PCCO; Platelet-Activating Factor, PAF; Pulmonary Artery Catheter, PAC; Systemic Inflammatory Response Syndrome, SIRS; Transoesophageal Echokardiography, TEE; Tumor-Necrosis Factor, TNF; Velocity-Time-Integral, VTI

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Dr. Felix Gundling

Second Department of Medicine, Bogenhausen Academic Teaching Hospital, Technical University of Munich

Englschalkinger Straße 77

81925 Munich

Phone: ++49/89/92 70 20 61

Fax: ++49/89/92 70 24 86

Email: Gastroenterologie@kh-bogenhausen.de