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Dtsch Med Wochenschr 2015; 140(06): 439-442
DOI: 10.1055/s-0041-101010
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© Georg Thieme Verlag KG Stuttgart · New York

Supportive Sepsistherapie: Benutzen wir die falsche Zielgröße?

Do we use the wrong target value for the supportive therapy of sepsis?
Dieter Köhler
1   Fachkrankenhaus Kloster Grafschaft
› Institutsangaben
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Publikationsdatum:
16. März 2015 (online)

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Zusammenfassung

Die Sepsis ist eine generalisierte, meist mikrobiell ausgelöste Entzündung mit komplexer Immunantwort und einem kapillaren Leakage. Dieses verursacht einen meist schweren Blutdruckabfall mit reduzierter Perfusion und sympathischer Gegenregulation. Häufig ist auch die Lunge durch die Entzündung selber oder durch ein Acute Respiratory Distress Syndrome betroffen. Eine schwere Hypoxämie ist die Folge. Die supportive Therapie dient dazu, die Hämodynamik zu stabilisieren mit dem Ziel, den arterieller Sauerstoffpartialdruck (PaO2) im Normbereich zu halten.

Pathophysiologisch ist nicht plausibel, eine Hypoxie am PaO2 oder der arteriellen Sauerstoffsättigung (SaO2) festzumachen, da die Zahl der Sauerstoffmoleküle die Versorgung der Zellen bestimmt. Die Versogung spiegelt sich nur im Sauerstoffgehalt (CaO2) und dem hämodyamischen Transport (Herzleistung) wider. Soweit es Untersuchungen zur Hypoxietoleranz der Organe gibt, zeigen sie jedenfalls einen 5–10fach niedrigeren Grenzwert als er heute vorgegeben wird bzw. ab dem die Zellen auf anaeroben Stoffwechsel umschalten. Wäre der CaO2 die Zielgröße der supportiven Therapie, würden viele Maßnahmen zur Aufrechterhaltung einer Normoxämie entfallen. Zu diesen den Patienten oft stark belastenden Schritten gehören hohe, oft toxische inspiratorische Sauerstoffkonzentrationen, hohe Beatmungsdrücke, belastende Lagerungsmaßnahmen und eine überschießende Volumentherapie.

Es überrascht daher nicht, dass es bisher keine plausiblen Daten gibt, die einen positiven Effekt für die Zielgröße PaO2 bzw. SaO2 nachgewiesen haben. Daher sind dringend Studien zur supportiven Sepsistherapie erforderlich, in denen der CaO2 als Zielgröße mit den aktuellen Vorgaben in den Leitlinien verglichen wird. Weiterhin sind Tierversuche nötig, um den kritischen Wert für CaO2 festzulegen. Ziel ist, den Größenbereich für die Therapie von schwer hypoxämischen Patienten auf der Intensivstation abschätzen zu können.

Abstract

Sepsis is a generalized, usually infectious disease with a complex dsyregulated immune response and capillary leak. The leakage leads to a severe drop of blood pressure with hypoperfusion and sympathetic counterregulation. The lung is frequently involved either as a source of the inflammation or by emergence of an ARDS, both resulting into severe hypoxemia. The supportive therapy is used to stabilize the hemodynamics and to keep the target value partial pressure of arterial oxygen (PaO2) in the lower limit of normal.

Pathophysiologically it is not plausible to define hypoxemia on the basis of PaO2 or SaO2, because the supply of the cells is determined by the amount of oxygen molecules. This is mirrored by the oxygen content (CaO2) and the hemodynamic transport, the cardiac output. As far as data about the hypoxic tolerance of organs are available, the critical value respective the threshold for anaerobic metabolism is 5–10 folds lower than values achieved by application of current guidelines. If CaO2 would be used as the target value, a lot of measures aiming for normoxia, which potentially harm patients, could be avoided. Among these measures are high, often toxic inspiratory concentrations of oxygen, high ventilation pressure, dangerous body position changes and excessive volume administration.

It is not surprising, that there are no plausible data in the literature which have shown a positive effect for the target value PaO2 or SaO2. Studies are urgent needed to compare CaO2 as a target value to the standards in the current guidelines. Additional animal experiments should be done to get information on the critical range of CaO2, in order to translate these results into treatment strategies for intensive care unit patients with severe hypoxemia.

Schlüsselwörter

Sepsis - Hypoxie - Hypoxämie - Sauerstoffgehalt - Sauerstoffsättigung

Keywords

Sepsis - hypoxia - hypoxemia - oxygen content - oxygen saturation
 

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