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Anästhesiol Intensivmed Notfallmed Schmerzther 2008; 43(5): 336-344
DOI: 10.1055/s-2008-1079106
Fachwissen
Intensivmedizin
© Georg Thieme Verlag Stuttgart · New York

Stressulkus–Prophylaxe bei septischen Patienten – Ein evidenzbasierter Überblick

Stress ulcer prophylaxis in septic patients. Evidence–based overviewGunnar Elke, Dirk Schädler, Günther Zick, Jens Scholz, Norbert Weiler
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Publication Date:
08 May 2008 (online)

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Zusammenfassung

Trotz sinkender Inzidenz stellen stressinduzierte gastrointestinale Blutungen nach wie vor ein klinisch bedeutsames Problem in der Intensivmedizin dar. Gerade Patienten mit schwerer Sepsis bzw. septischem Schock können im Rahmen der systemischen inflammatorischen Reaktion Läsionen des oberen Gastrointestinal–trakts mit konsekutiver Blutung entwickeln. Fundamental in der Prophylaxe stressbedingter Blutungen ist die medikamentöse Hemmung der Magensäuresekretion bzw. ihre Neutralisation. Dazu stehen verschiedene Substanzgruppen zur Verfügung. Der vorliegende Artikel gibt einen Überblick über wesentliche epidemiologische und pathophysiologische Aspekte der stressinduzierten mukosalen Erkrankung. Vor einem evidenzbasierten Hintergrund werden aktuelle Empfehlungen zur Durchführung der medikamentösen Stressulkus–prophylaxe bei septischen Patienten gegeben.

Abstract

In spite of decreasing incidence stress–related gastrointestinal bleeding is still an important problem in intensive care medicine. Especially patients with severe sepsis or septic shock are prone to develop lesions of the upper gastrointestinal tract with consecutive bleeding. In order to prevent gastrointestinal bleeding various pharmacological agents are used to either suppress gastric acid or neutralize its effect. The following article presents an update on important aspects of stress–related mucosal disease. It further reviews current literature to provide evidence–based recommendations for stress ulcer prophylaxis in septic patients.

Schlüsselwörter

stressinduzierte mukosale Erkrankung - Stressulkusprophylaxe - stressinduzierte Blutung - gastrointestinale Blutung - Sepsis

Key words

stress–related mucosal disease - stress ulcer prophylaxis - stress–induced bleeding - gastrointestinal bleeding - sepsis

Kernaussagen

  • Stressinduzierte, klinisch relevante, gastrointestinale Blutungen sind in den letzten Jahren seltener geworden (Inzidenz 4 %), aber nach wie vor mit einer erhöhten Letalität assoziiert.

  • Eindeutig definierte, unabhängige Risikofaktoren für eine gastrointestinale Blutung sind: Respiratorische Insuffizienz (Beatmung >48h), Koagulopathie (INR >1,5 oder Thrombozytenzahl <50000/mm3), akutes Nierenversagen.

  • Entscheidend in der medikamentösen Prophylaxe ist die Anhebung des Magen–pH–Werts >4 bzw. >6 zur Pepsin–Inaktivierung und Gerinnungsoptimierung sowie zur Protektion bzw. Regeneration der Mukusschicht.

  • Eine medikamentöse Stressulkus–Prophylaxe wird bei septischen Patienten empfohlen.

  • H2–RAs führen im Vergleich zu Sucralfat zu einer signifikanten Reduktion klinisch signifikanter Blutungen ohne die Pneumonierate zu erhöhen.

  • PPIs hemmen die Produktion der Magensäure effektiver und konstanter als H2–RAs.

  • PPIs senken signifikant das Risiko von Rezidivblutungen.

  • Obwohl bislang eine Zulassung fehlt, werden in Deutschland PPIs bevorzugt bei septischen Patienten eingesetzt.

  • Eine frühe enterale Ernährung hat einen zusätzlichen protektiven Effekt, reicht jedoch allein für die Prävention stressinduzierter Blutungen nicht aus.

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Dr. med. Gunnar Elke
Dr. med. Dirk Schädler
Dr. med. Günther Zick
Prof. Dr. med. Jens Scholz
Prof. Dr. med. Norbert Weiler

Email: elke@anaesthesie.uni-kiel.de

Email: schaedler@anaesthesie.uni-kiel.de

Email: zick@anaesthesie.uni-kiel.de

Email: scholz@anaesthesie.uni-kiel.de

Email: weiler@anaesthesie.uni-kiel.de

    Literaturverzeichnis
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