Intensivmedizinische Therapie infektiöser Komplikationen in der pädiatrischen Hämatologie und Onkologie

Zusammenfassung

Zum septischen Schock kommt es bei 6 % der pädiatrischen hämatologisch-onkologischen Patienten mit Granulozytopenie und Fieber, mit einer Sepsisletalität von 5 % ohne und 40 % mit Knochemarktransplantation (KMT). Unter allen Kindern mit ARDS leidet ein Drittel an Störungen der Immunkompetenz. Die Letalität beträgt hier ca. 45 %, nach KMT ca. 80 %. Für den septischen Schock sind zu mehr als 75 % gramnegative Keime ursächlich. Das ARDS ist in über 50 % der Fälle Folge von Pneumonien, darunter 20 % durch opportunistische Erreger und einer Sepsis in 25 %. Die vorliegende Arbeit enthält umfassende Empfehlungen der der Arbeitsgruppe „Infektionen bei immunsupprimierten Kindern” der Deutschen Gesellschaft für Pädiatrische Infektiologie (DGPI) und der Deutschen Gesellschaft für Pädiatrische Onkologie und Hämatologie (GPOH) zur Behandlung bei septischen Schock und akutem Lungenversagen. Therapiemaßnahmen beim septischen Schock sind eine frühe Antibiotikatherapie bzw. Elimination des Herdes und die rasche Volumenexpansion (≥ 40 ml/kg in der ersten Stunde). Der Volumenrefraktäre Schock erfordert den Einsatz von Vasopressoren (Noradrenalin), gefolgt von einer differenzierten Kreislauftherapie. Die Substitution von Hydrokortison ist häufig indiziert. Grundpfeiler der ARDS-Behandlung sind die Therapie des Auslösers und eine Beatmung mit ausreichendem endexspiratorischem Druck (PEEP) und begrenzten Tidalvolumen (≤ 6 ml/kg) bzw. limitierten Spitzendrücken (< 35 cmH₂O) um eine weitere iatrogene Lungenschädigung zu minimieren. Die Volumentherapie zielt auf eine ausreichende Vorlast, um auch unter Beatmung mit hohem PEEP ein ausreichendes Herzzeitvolumen zu erhalten. Das freie Lungenwasser wird durch Gabe von Diuretika und nötigenfalls eine venovenöse Hämofiltration gesenkt. Die Gabe von Surfactant ist in refraktären Fällen zu erwägen. Steroide sind bei Pneumozystis-Infektionen und beim Engraftment-Syndrom indiziert.

Abstract

Septic shock occurs in 6 % of paediatric cancer patients with neutropenia and fever. The mortality of the septic shock is 40 % in BMT patients and 5 % in others. One third of paediatric ARDS cases affect immunocompromised individuals with a total mortality of 45 % and 80 % after BMT. Septic shock is caused by gram-negative bacteria in more than 75 %. ARDS is due to pneumonia in more than 50 %, sepsis in about 25 %. This article provides the recommendations of the Infectious Diseases Working Party of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Hematology/Oncology (GPOH) for treatment of septic shock and ARDS. Therapy of septic shock includes early antibiotic therapy and volume expansion (≥ 40 ml/kg initially). Refractory shock requires vasopressors (noradrenaline), followed by a judicious circulatory management. Hydrocortison is indicated in patients with high probability of adrenal insufficiency. Mainstay of ARDS therapy is ventilation with sufficient endexspiratory pressure (PEEP) to prevent loss of functional residual capacity and with limited tidal volumes (≤ 6 ml/kg) and limited inspiratory pressure (< 35 cmH₂O) respectively, to minimize ventilator induced lung injury. Volume therapy consists of maintenance of sufficient preload to counteract the impaired venous return, induced by positive pressure ventilation. Diuretics and eventually veno-venous haemofiltration are used to reduce free lung water. Surfactant application may be considered in severe cases. Steroids are indicated in pneumocystis carinii pneumonia and in engraftment pneumonitis.

Schlüsselwörter

septischer Schock - ARDS - Immundefizienz

Key words

septic shock - ARDS - immunodeficiency

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