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Anästhesiol Intensivmed Notfallmed Schmerzther 2015; 50(2): 132-140
DOI: 10.1055/s-0041-100302
Fachwissen
Intensivmedizin: Topthema
© Georg Thieme Verlag Stuttgart · New York

Sepsis und Multiorganversagen – Therapeutische Möglichkeiten

Sepsis and multiple organfailure – Potential therapeutic interventions
Tobias Schürholz
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Publication History

Publication Date:
27 February 2015 (online)

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Zusammenfassung

Die Therapie der Sepsis hat das Ziel, den Infektionsfokus zu eliminieren sowie die Mikrozirkulation zu erhalten oder wiederherzustellen. Dabei muss eine schwere Sepsis oder ein septischer Schock ebenso rasch und aggressiv wie ein hämorrhagischer Schock behandelt werden, da die Zeit zwischen Krankheitsbeginn und Initiierung der Therapie die kritische Variable für die Überlebenswahrscheinlichkeit der Patienten ist. Die durch die „Surviving-Sepsis-Campaign“ implementierten Maßnahmen-Bündel können die Letalität signifikant reduzieren. Entscheidend sind hier vor allem die Compliance mit den Maßnahmen-Bündeln und die konsequente Schulung der Mitarbeiter für vorher festgelegte Zielparameter und Therapie-Protokolle. Die besondere Aufmerksamkeit liegt auf den in den ersten sechs Stunden zu treffenden Maßnahmen.

Abstract

Sepsis therapy is aiming to eliminate the focus of infection and to obtain or to restore microcirculation. Severe sepsis and septic shock have to be treated as fast and aggressively as hemorrhagic shock, because the time between onset of disease and initiating the therapy is crucial for the probability of survival. The bundle measures introduced by the Surviving-Sepsis-Campaign are able to reduce mortality significantly. The compliance with the bundle measures and consequent training of medical staff to predefined goal measures and therapy protocols is determining the success of sepsis therapy. The bundle measures of the first six hours (resuscitation bundle) deserve special attention.

Kernaussagen

  • Die Zeit ist eine der kritischsten Variablen für die Therapie von Patienten mit schwerer Sepsis und septischem Schock.

  • Die umgehende Fokussanierung senkt die Letalität und ist einer der Pfeiler der Sepsistherapie.

  • Je früher die antiinfektive Therapie nach der Diagnose schwere Sepsis oder septischer Schock initiiert wird, desto geringer ist die Letalität.

  • Die vollständige Durchführung der „Surviving Sepsis Campaign“-Bündel und die Compliance zu den Bündelmaßnahmen sind Faktoren, welche die Letalität reduzieren.

  • Frühzeitige Wahrnehmung der Sepsis, frühzeitige Antibiotikagabe und frühzeitige, adäquate Volumengabe sind wesentliche Elemente einer protokollbasierten Therapie.

  • Bei der Festlegung der Zielparameter für die Volumen- und Katecholamintherapie sind individuelle Risikofaktoren mit einzubeziehen.

Schlüsselwörter:

Sepsis - Therapie - Zeit - Maßnahmen-Bündel

Key words:

Sepsis - therapy - time - bundle measures

Ergänzendes Material

 

  • Literaturverzeichnis

  • 1 Schurholz T, Marx G. Sepsis – Update und Kontroversen der adjunktiven Therapie bei Sepsis. AnasthesiologieIntensivmedizin Notfallmedizin Schmerztherapie 2010; 45: 580-586
    PubMedGoogle Scholar
  • 2 Bloos F, Thomas-Ruddel D, Ruddel H et al. Impact of compliance with infection management guidelines on outcome in patients with severe sepsis: a prospective observational multi-center study. Crit Care 2014; 18
    PubMedGoogle Scholar
  • 3 Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36: 296-327
    CrossrefPubMedGoogle Scholar
  • 4 Dellinger RP, Levy MM, Rhodes A et al. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41: 580-637
    CrossrefPubMedGoogle Scholar
  • 5 Levy MM, Dellinger RP, Townsend SR et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Crit Care Med 2010; 38: 367-374
    CrossrefPubMedGoogle Scholar
  • 6 Levy MM, Rhodes A, Phillips GS et al. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study. Intensive Care Med 2014; 40: 1623-1633
    CrossrefPubMedGoogle Scholar
  • 7 Levy MM, Artigas A, Phillips GS et al. Outcomes of the Surviving Sepsis Campaign in intensive care units in the USA and Europe: a prospective cohort study. Infect Dis 2012; 12: 919-924
    PubMedGoogle Scholar
  • 8 Sandiumenge A, Diaz E, Bodi M, Rello J. Therapy of ventilator-associated pneumonia. A patient-based approach based on the ten rules of "The Tarragona Strategy". Intensive Care Med 2003; 29: 876-883
    PubMedGoogle Scholar
  • 9 Kumar A, Roberts D, Wood KE et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34: 1589-1596
    CrossrefPubMedGoogle Scholar
  • 10 Ferrer R, Martin-Loeches I, Phillips G et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med 2014; 42: 1749-1755
    CrossrefPubMedGoogle Scholar
  • 11 Brunkhorst FM, Oppert M, Marx G et al. Effect of empirical treatment with moxifloxacin and meropenem vs meropenem on sepsis-related organ dysfunction in patients with severe sepsis: a randomized trial. JAMA 2012; 307: 2390-2399
    CrossrefPubMedGoogle Scholar
  • 12 Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich M. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377
    CrossrefPubMedGoogle Scholar
  • 13 Rhodes A, Cecconi M, Hamilton M et al. Goal-directed therapy in high-risk surgical patients: a 15-year follow-up study. Intensive Care Med 2010; 36: 1327-1332
    CrossrefPubMedGoogle Scholar
  • 14 Pro CI, Yealy DM, Kellum JA et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014; 370: 1683-1693
    CrossrefPubMedGoogle Scholar
  • 15 Investigators A, Group ACT, Peake SL et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014; 371: 1496-1506
    CrossrefPubMedGoogle Scholar
  • 16 S3-Leitlinie Intravasale Volumentherapie beim Erwachsenen (AWMF-Register-Nr. 001/020). http://www.awmf.org/uploads/tx_szleitlinien/001-020k_S3_Intravasale_Volumentherapie_Erwachsenen_2014-09.pdf
    PubMedGoogle Scholar
  • 17 Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013; 41: 1774-1781
    CrossrefPubMedGoogle Scholar
  • 18 Caironi P, Tognoni G, Masson S et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl Med 2014; 370: 1412-1421
    CrossrefPubMedGoogle Scholar
  • 19 PRAC confirms that Hydroxyethyl-starch solutions (HES) should no longer be used in patients with sepsis or burn injuries or in critically ill patients. http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Solutions_for_infusion_containing_hydroxyethyl_starch/Recommendation_provided_by_Pharmacovigilance_Risk_Assessment_Committee/WC500151963.pdf
    PubMedGoogle Scholar
  • 20 Perner A, Haase N, Guttormsen AB et al. Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis. The New England journal of medicine 2012; 367: 124-134
    CrossrefPubMedGoogle Scholar
  • 21 Brunkhorst FM, Engel C, Bloos F et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. The New England journal of medicine 2008; 358: 125-139
    CrossrefPubMedGoogle Scholar
  • 22 Myburgh JA, Finfer S, Bellomo R et al. Hydroxyethyl starch or saline for fluid resuscitation in intensive care. The New England journal of medicine 2012; 367: 1901-1911
    CrossrefPubMedGoogle Scholar
  • 23 Annane D, Siami S, Jaber S et al. Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA : the journal of the American Medical Association 2013; 310: 1809-1817
    CrossrefPubMedGoogle Scholar
  • 24 Simon TP, Thiele C, Schuerholz T et al. Molecular weight and molar substitution are more important in HES-induced renal impairment than concentration after hemorrhagic and septic shock. Minerva Anestesiol 2014; Oct 9. [Epub ahead of print] 2014;
    PubMedGoogle Scholar
  • 25 Lee SJ, Ramar K, Park JG et al. Increased fluid administration in the first three hours of sepsis resuscitation is associated with reduced mortality: a retrospective cohort study. Chest 2014; 146: 908-915
    CrossrefPubMedGoogle Scholar
  • 26 Raghunathan K, Shaw A, Nathanson B et al. Association between the choice of IV crystalloid and in-hospital mortality among critically ill adults with sepsis*. Critical care medicine 2014; 42: 1585-1591
    CrossrefPubMedGoogle Scholar
  • 27 Shaw AD, Raghunathan K, Peyerl FW et al. Association between intravenous chloride load during resuscitation and in-hospital mortality among patients with SIRS. Intensive Care Med 2014; 40: 1897-1905
    CrossrefPubMedGoogle Scholar
  • 28 Annane D, Vignon P, Renault A et al. Norepinephrine plus dobutamine versus epinephrine alone for management of septic shock: a randomised trial. Lancet 2007; 370: 676-684
    CrossrefPubMedGoogle Scholar
  • 29 Asfar P, Meziani F, Hamel JF et al. High versus low blood-pressure target in patients with septic shock. The New England journal of medicine 2014; 370: 1583-1593
    CrossrefPubMedGoogle Scholar
  • 30 Devlin JW, Fraser GL, Ely EW et al. Pharmacological management of sedation and delirium in mechanically ventilated ICU patients: remaining evidence gaps and controversies. Seminars in respiratory and critical care medicine 2013; 34: 201-215
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Russell JA, Walley KR, Singer J et al. Vasopressin versus norepinephrine infusion in patients with septic shock. The New England journal of medicine 2008; 358: 877-887
    CrossrefPubMedGoogle Scholar
  • 32 Annane D, Sebille V, Charpentier C et al. Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA : the journal of the American Medical Association 2002; 288: 862-871
    CrossrefPubMedGoogle Scholar
  • 33 Sprung CL, Annane D, Keh D et al. Hydrocortisone therapy for patients with septic shock. The New England journal of medicine 2008; 358: 111-124
    CrossrefPubMedGoogle Scholar
  • 34 Beale R, Janes JM, Brunkhorst FM et al. Global utilization of low-dose corticosteroids in severe sepsis and septic shock: a report from the PROGRESS registry. Critical care 2010; 14
    PubMedGoogle Scholar
  • 35 van den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in the critically ill patients. The New England journal of medicine 2001; 345: 1359-1367
    CrossrefPubMedGoogle Scholar
  • 36 Preiser JC, Devos P, Ruiz-Santana S et al. A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study. Intensive care medicine 2009; 35: 1738-1748
    CrossrefPubMedGoogle Scholar
  • 37 Finfer S, Chittock DR, Su SY et al. Intensive versus conventional glucose control in critically ill patients. The New England journal of medicine 2009; 360: 1283-1297
    CrossrefPubMedGoogle Scholar
  • 38 Angstwurm MW, Engelmann L, Zimmermann T et al. Selenium in Intensive Care (SIC): results of a prospective randomized, placebo-controlled, multiple-center study in patients with severe systemic inflammatory response syndrome, sepsis, and septic shock. Critical care medicine 2007; 35: 118-126
    CrossrefPubMedGoogle Scholar
  • 39 Forceville X. Effects of high doses of selenium, as sodium selenite, in septic shock patients a placebo-controlled, randomized, double-blind, multi-center phase II study--selenium and sepsis. J Trace Elem Med Biol 2007; 21 (Suppl. 01) 62-65
    CrossrefPubMedGoogle Scholar