Von „in doubt give volume“ hin zur Beurteilung der Mikrozirkulation – Paradigmenwechsel in der Volumentherapie des Intensivpatienten. Von „rivers“ über die Trilogie der großen Multicenter-Studien (ARISE, PROCESS, PROMISE) und „cry my a river“ hin zu Poincare-2. Wir diskutieren in dieser Folge des Intensivtalks die wahrscheinlich anspruchsvollste Frage in der Intensivmedizin: Welche Menge an kristalloider Infusionslösung tut gut und welche Menge schadet? Zudem wie kann die Zukunft der Steuerung der Volumentherapie aussehen? Wie erfolgversprechend sind intravitale Zungenmikroskopie oder Messung der pCO2-Gap? 

Literaturangaben 

Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, et al. Early goal‐directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368–1377. 

The ARISE Investigators, ANZICS Clinical Trials Group (2014) Goal-directed resuscitation for patients with early septic shock. New Engl J Med 371:1496–1506 

The ProCESS Investigators (2014) A randomized trial of protocol-based care for early septic shock. New Engl J Med 370:1683–1693 

The ProMISe Investigators (2015) Trial of early, goal-directed resuscitation for septic shock. New Engl J Med 372:1301–1311 

Seymour, Christopher W.; Gesten, Foster; Prescott, Hallie C.; Friedrich, Marcus E.; Iwashyna, Theodore J.; Phillips, Gary S.; Lemeshow, Stanley; Osborn, Tiffany; Terry, Kathleen M.; and Levy, Mitchell M.,"Time to treatment and mortality during mandated emergency care for sepsis." The New England Journal of Medicine. 376,23. 2235-2244. (2017). 

Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI). S3-Leitlinie Intravasale Volumentherapie beim Erwachsenen. AWMF-Register 001/020. 2014 

Eskesen, T.G., Wetterslev, M. & Perner, A. Systematic review including re-analyses of 1148 individual data sets of central venous pressure as a predictor of fluid responsiveness. Intensive Care Med 42, 324–332 (2016). 

Evans, L., Rhodes, A., Alhazzani, W. et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 47, 1181–1247 (2021). 

Haas, S.A., Lange, T., Saugel, B. et al. Severe hyperlactatemia, lactate clearance and mortality in unselected critically ill patients. Intensive Care Med 42, 202–210 (2016). https://doi.org/10.1007/s00134-015-4127-0 

Groner, W., Winkelman, J., Harris, A. et al. Orthogonal polarization spectral imaging: A new method for study of the microcirculation. Nat Med 5, 1209–1212 (1999). https://doi.org/10.1038/13529 

Hernandez G et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized trial. JAMA. 2019 Feb 19;321(7):654-664 

Vellinga NAR, Boerma EC, Koopmans M, Donati A, Dubin A, Shapiro NI, Pearse RM, van der Voort PHJ, Dondorp AM, Bafi T, Fries M, Akarsu-Ayazoglu T, Pranskunas A, Hollenberg S, Balestra G, van Iterson M, Sadaka F, Minto G, Aypar U, Hurtado FJ, Martinelli G, Payen D, van Haren F, Holley A, Gomez H, Mehta RL, Rodriguez AH, Ruiz C, Canales HS, Duranteau J, Spronk PE, Jhanji S, Hubble S, Chierego M, Jung C, Martin D, Sorbara C, Bakker J, Ince C; microSOAP study group. Mildly elevated lactate levels are associated with microcirculatory flow abnormalities and increased mortality: a microSOAP post hoc analysis. Crit Care. 2017 Oct 18;21(1):255. doi: 10.1186/s13054-017-1842-7. PMID: 29047411; PMCID: PMC5646128. 

Cuschieri J, Rivers EP, Donnino MW, Katilius M, Jacobsen G, Nguyen HB, Pamukov N, Horst HM. Central venous-arterial carbon dioxide difference as an indicator of cardiac index. Intensive Care Med. 2005 Jun;31(6):818-22. doi: 10.1007/s00134-005-2602-8. Epub 2005 Apr 1. PMID: 15803301. 

Zhou J, Song J, Gong S, Li L, Zhang H, Wang M. Persistent hyperlactatemia-high central venous-arterial carbon dioxide to arterial-venous oxygen content ratio is associated with poor outcomes in early resuscitation of septic shock. Am J Emerg Med. 2017 Aug;35(8):1136-1141. doi: 10.1016/j.ajem.2017.03.027. Epub 2017 Mar 14. PMID: 28341187.