Mikrozirkulation bei Sepsis und septischem Schock

M. Ragaller; H. Theilen; T. Koch

doi:10.1055/s-0037-1616901

Hämostaseologie, Table of Contents

Hamostaseologie 2007; 27(01): 59-63
DOI: 10.1055/s-0037-1616901

Orginal Articles

Schattauer GmbH

Mikrozirkulation bei Sepsis und septischem Schock

Therapeutische Ansätze zur VerbesserungTherapeutic options to improve the microcirculation in sepsis and septic shock

M. Ragaller

¹Klinik für Anästhesiologie und Intensivtherapie (Direktorin: Prof. Dr. med. T. Koch), Universitätsklinikum Carl Gustav Carus an der Medizinischen Fakultät der Technischen Universität Dresden

,

H. Theilen

¹Klinik für Anästhesiologie und Intensivtherapie (Direktorin: Prof. Dr. med. T. Koch), Universitätsklinikum Carl Gustav Carus an der Medizinischen Fakultät der Technischen Universität Dresden

,

T. Koch

¹Klinik für Anästhesiologie und Intensivtherapie (Direktorin: Prof. Dr. med. T. Koch), Universitätsklinikum Carl Gustav Carus an der Medizinischen Fakultät der Technischen Universität Dresden

› Author Affiliations

Abstract

Zusammenfassung

Die komplexe Dysregulation der Mikrozirkulation spielt eine zentrale Rolle in der Pathogenese von Sepsis und septischen Schock und führt, wenn sie nicht rechtzeitig beseitigt werden kann, zum Multiorganversagen (MOV) und Tod. Maßnahmen zur Wiederherstellung der mikrovaskulären Zirkulation (Rekrutierung von Kapillaren) sind daher logische Therapieansätze zur Überwindung der Gewebehypoxie und zur Verhinderung eines MOV.

Aufgrund guter wissenschaftlicher Evidenz kann für den klinischen Einsatz bezüglich der Restitution der Mikrozirkulation bei schwerer Sepsis und septischen Schock die frühzeitige und an hämodynamischen und metabolischen Zielen ausgerichtete Volumenersatztherapie EGDT. (early goal directed therapy) sowie die Applikation von rhAPC entsprechend der EU-Zulassungsindikationen empfohlen werden. Für die Behandlung der septisch induzierten Kardiomyopathie ist Dobutamin das Mittel der ersten Wahl, während Phosphodiesterase-III-Inhibitoren oder Levosimendan noch experimentelle Therapieoptionen darstellen. Inwieweit die direkten Effekte von Dobutamin und rhAPC auf die Mikrozirkulation klinisch relevant sind sollte in weiteren Studien geprüft werden.

Summary

The severe impairment of the microcirculation plays a substantial role in the pathogenesis of severe sepsis and septic shock, and leads to multiple organ failure and death. Therapeutic strategies to resuscitate the microcirculatory blood flow and to improve the functional capillar density are therefore essential to surmount the microcirculatory pathology and to avoid tissue hypoxia.

Based on reasonable scientific evidence, early fluid resuscitation directed by defined haemodynamic and metabolic goals (EGDT) as well as the application of activated protein C (rhAPC) according to the guidelines could be recommended. Dobutamine is the first choice to improve cardiac output and to overcome myocardial depression in septic shock whereas phosphodiesterase-III-inhibitors and levosimendane are still experimental options.

Furthermore selective inhibitors of iNOS, nitroglycerol, as well as vasopressin have to be investigated relating to their specific effects on the microcirculation and their influence on survival in severe sepsis and septic shock.

Schlüsselwörter

Mikrozirkulation - funktionelle Kapillardichte - Gewebehypoxie - Volumenersatz - Dobutamin - rhAPC

Keywords

Microcirculation - functional capillar density - tissue hypoxia - fluid resuscitation - dobutamine - rhAPC

Full Text

References

Literatur
1 Alderson P, Schierhout G, Roberts I. et al. Colloids versus cristalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev CD001319. Electronic Citation 2003
2 Bateman RM, Walley KR. Microvascular resuscitation as a therapeutic goal in severe sepsis. Crit Care 2005; 9 (Suppl. 04) 27-32.
3 Bauer A, Bruegger D, Christ F. Mikrozirkulatorisches Monitoring in der Sepsis. Anaesthesist 2005; 54: 1163-75.
4 Bernard GR, Vincent JL, Laterre PF. et al. Efficacy and safety of recombinant human activated protein C in severe sepsis. N Engl J Med 2001; 344: 699-709.
5 Boerma EC, van der Voort P, Ince C. Sublingual microcirculatory blood flow is impaired by the vasopressin -anologue terlipressin in a patient with catecholamine resistant septic shock. Acta Anaesthesiol Scand 1011/j/1399–6576. 2005. Electronic Citation.
6 Brunkhorst F, Engel C, Bone HG. and the German Competence Network Sepsis (SepNet). Epidemiology of severe sepsis and septic shock in Germany – Results from the German Prevalence Study. Infection 2005; 33 (Suppl. 01) 49.
7 Brunkhorst F, Engel C, Ragaller M. et al. Practice and perception. A nationwide survey of therapy habits in sepsis. Crit Care Med. im Druck.
8 Chen LW, Huang HL, Lee I. et al. Hypertonic saline enhances host defense to bacterial challenge by augmenting Toll-like receptors. Crit Care Med 2006; 34: 1758-68.
9 Choi PT, Yip G, Quinonez LG. et al. Crystalloids vs. colloids in fluid resuscitation: a systemic review. Crit Care Med 1999; 27: 200-10.
10 Crookes B, Cohn SM, Bloch S. et al. Can near infrared spectroscopy measurements identify the severity of shock in trauma patients?. J Trauma 2005; 58: 806-16.
11 DeBacker D, Creteur J, Dubois JM. et al. The effects of dobutamine on microcirculatory alterations in patients with septic shock are independent of its systemic effects. Crit Care Med 2006; 34: 403-8.
12 DeBacker D, Verdant C, Chierego M. et al. Effects of drotrecogin alfa activated on microcirculation alterations in patients with severe sepsis. Crit Care Med 2006; 34: 1918-24.
13 Finfer S, Bellomo R, Boyce N. et al. A comparison of albumine and saline for fluid resuscitation in intensive care unit. N Engl J Med 2004; 350: 2247-56.
14 Funk W, Baldinger V. Microcirculatory perfusion during volume therapy. A comparative study using crystalloid or colloid in awake animals. Anesthesiology 1995; 82: 975-82.
15 Garrido Andel P, Cruz Junior RJ, Poli de Figueiredo LF. et al. Small volume of hypertonic saline as the initial fluid replacement in experimental hypodynamic sepsis. Crit Care 2006; 10: 62-72.
16 Ince C. The microcirculation is the motor of sepsis. Crit Care 2005; 9 (Suppl. 04) 13-9.
17 Jonas J, Heimann A, Strecker U. et al. Hypertonic/ hyperoncotic resuscitation after intestinal superior mesenteric artery occlusion: early effects on circulation and intestinal reperfusion. Shock 2000; 14: 24-9.
18 Lam C, Tyml K, Martin C. et al. Microvasculer perfusion is impaired in a rat model of normotensive sepsis. J Clin Invest 1994; 94: 2077-83.
19 Morelli A, De Castro S, Teboul JL. et al. Effect of levosimendan on systemic and regional hemodynamics in septic myocardial depression. Intensive Care Med 2005; 31: 638-44.
20 Reinhart K, Bloos F, Engel C. for the German Competence Network.. Hydroxyethylstarch and Ringer’s lactate for fluid resuscitation in patients with severe sepsis – results from the VISEP-Study. Intensive Care Med 2006; 32: A818.
21 Reinhart K, Brunkhorst F, Bone HG. et al. Diagnose und Therapie der Sepsis. Anaesthesist 2006; 55 (Suppl. 01) 43-56.
22 Rivers E, Nguyen B, Havstad S. et al. Early goaldirected therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-77.
23 Sakr Y, Dubois J-M, DeBacker D. et al. Persistent microcirculatory alterations are associated with organ failure and death in patients with septic shock. Crit Care Med 2004; 32: 1825-31.
24 Schortgen F, Lacherade JC, Bruneel F. et al. Effects of hydroxyethylstarch and gelatin on renal function in severe sepsis: a multicentre randomised study. Lancet 2001; 357: 911-6.
25 Schwarte LA, Picker O, Bornstein SR. et al. Levosimendan is superior to milrinone and dobutamine in selectively increasing microvascular gastric mucosal oxygenation in dogs. Crit Care Med 2005; 33: 135-42.
26 Secchi A, Ortanderl JM, Schmidt W. et al. Effects of dobutamine and dopexamine on hepatic micro and macrocirculation during experimental endotoxemia: An intravital microscopic study in the rat. Crit Care Med 2001; 29: 597-600.
27 Secchi A, Wellmann R, Martin E. et al. Dobutamin maintains intestinal villus blood flow during normotensive endotoxemia: An intravital microscopic study in the rat. J Crit Care 1997; 12: 137-41.
28 Siegmund M, Schwarte LA, Emons M. et al. Selective blockade of iNOS by 1400W restores the gut oxygenation in a pig model of low dose endotoxaemia. Intensive Care Med 2005; 31: 985-92.
29 Spronk PE, Ince C, Gardien M. et al. Nitroglycerin promotes microvascular recruitment in septic shock after intravascular volume resuscitation. Lancet 2002; 360: 1395-6.