Differenzieller Einsatz von Inotropika, Vasopressoren und Inodilatoren im septischen und kardiogenen Schock

Abstract

For hemodynamic stabilization of patients in a life-threatening situation such as septic or cardiogenic shock, the use of vasopressors, inotropics and sometimes inodilators is essential although not well supported by randomized studies. As the substances used have no effect on disease progression, they can only serve as hemodynamic „bridges” to gain time for causal therapies to act or until the bodies defense mechanisms have changed the course of the disease. A differential therapeutic approach, which is useful and often necessary, takes the ventricular-arterial coupling of a damaged heart as well as the microcirculatory changes during shock, especially within the hepato-splanchnic tissue, into account. During septic shock, inotropics and vasopressors are used in an evidence-based algorithm to achieve a timely optimization of the hemodynamic situation („early goal directed therapy”). To date, noradrenalin (alternatively, adrenalin or dopamine) and dobutamin are the inotropics of choice. During cardiogenic shock, however, only the concept of early revascularization and implantation of an intra-aortic counter pulsation is established by clinical studies. Therefore, pharmacologic stabilization can only serve to bridge the time to immediate coronary angiography and revascularization. In this situation, the use of dobutamin, if necessary in combination with noradrenalin, is judged clinically (RR syst ≥ 90 mmHg). After successful revascularization, however, pharmacologic therapy should be monitored and guided via extended hemodynamic monitoring (cardiac output, wedge pressure). Noradrenalin must be added, if arterial mean pressure remains < 65 mmHg despite an adequate fluid management, dobutamine use, and intra-aortic counter pulsation. Although currently not approved in Germany, the calcium-sensitizer levosimendan represents an interesting and potent therapeutic additive (or alternative) to achieve an adequate cardiac output. The (accurately timed) use of mechanical assist devices is only indicated after failure of above-mentioned recommendations.