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DOI: 10.1055/a-0625-5521
Sepsis-Update: evidenzbasierte Therapie
Sepsis Update: Evidence-Based TherapyPublication History
Publication Date:
08 January 2019 (online)
![](https://www.thieme-connect.de/media/ains/201901/lookinside/thumbnails/10-1055-a-0625-5521_ai_martin-1.jpg)
Zusammenfassung
Sepsis und septischer Schock stellen medizinische Notfälle dar, die einer kompetenten Früherkennung und eines entsprechenden sofortigen, zielgerichteten Managements bedürfen. Die Therapie der Sepsis und des septischen Schocks hat sich während der letzten Jahre kontinuierlich weiterentwickelt. Dieser Beitrag gibt einen Überblick über die aktuelle Evidenz der Therapie der Sepsis und des septischen Schocks und deren Umsetzung in die klinische Praxis.
Abstract
Like polytrauma, acute myocardial infarction or stroke, sepsis and septic shock are medical emergencies that require adequate early detection and immediate, targeted management. The therapy of sepsis and septic shock has developed continuously in recent years. This article provides an overview of the current evidence of sepsis and septic shock therapy and its implementation into clinical practice.
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Sepsis und septischer Schock stellen einen medizinischen Notfall dar.
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Das „1-h-Bündel“ der SSC-Leitlinie soll als Referenz die Behandelnden im frühen Management der Therapie der Sepsis und des septischen Schocks leiten.
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Die Zeit stellt nicht nur bei der Fokussanierung, sondern auch bei der Initiierung der antimikrobiellen Therapie sowie der adäquaten Volumen- und Katecholamin-Therapie eine kritische Variable für den Therapieerfolg der Sepsis und des septischen Schocks dar.
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Ein mittlerer arterieller Blutdruck von > 65 mmHg ist der Zielwert bei Patienten mit septischem Schock.
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Zur hämodynamischen Stabilisierung sind balancierte Kristalloide (30 ml/kgKG binnen der ersten 3 h) sowie Noradrenalin Mittel der Wahl.
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Kristalloide sind, wenn möglich, gegenüber halbsynthetischen Kolloiden zu bevorzugen.
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Wenn nach Einschätzung des Arztes eine akute Hypovolämie allein mit Kristalloiden nicht ausreichend therapiert werden kann, können darüber hinaus Gelatine und Humanalbumin zum Einsatz kommen.
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Auf den Einsatz von HES soll ausdrücklich verzichten werden.
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Falls eine hämodynamische Stabilisierung trotz adäquater Volumen- und Katecholamin-Therapie nicht erreicht werden kann, kann der Einsatz von Hydrokortison erwogen werden.
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Literatur
- 1 Dellinger RP, Carlet JM, Masur H. et al.. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 2004; 32: 858-873
- 2 Dellinger RP, Levy MM, Carlet JM. et al.. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 2008; 36: 296-327 doi:10.1097/01.Ccm.0000298158.12101.41
- 3 Dellinger RP, Levy MM, Rhodes A. et al.. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013; 39: 165-228 doi:10.1007/s00134-012-2769-8
- 4 Levy MM, Rhodes A, Phillips GS. et al.. Surviving Sepsis Campaign: association between performance metrics and outcomes in a 7.5-year study. Crit Care Med 2015; 43: 3-12 doi:10.1097/ccm.0000000000000723
- 5 Rhodes A, Evans LE, Alhazzani W. et al.. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med 2017; 43: 304-377 doi:10.1007/s00134-017-4683-6
- 6 Levy MM, Evans LE, Rhodes A. The Surviving Sepsis Campaign Bundle: 2018 update. Intensive Care Med 2018; 44: 925-928 doi:10.1007/s00134-018-5085-0
- 7 Casserly B, Phillips GS, Schorr C. et al.. Lactate measurements in sepsis-induced tissue hypoperfusion: results from the Surviving Sepsis Campaign database. Crit Care Med 2015; 43: 567-573 doi:10.1097/ccm.0000000000000742
- 8 Zhang Z, Xu X. Lactate clearance is a useful biomarker for the prediction of all-cause mortality in critically ill patients: a systematic review and meta-analysis. Crit Care Med 2014; 42: 2118-2125 doi:10.1097/ccm.0000000000000405
- 9 Rivers E, Nguyen B, Havstad S. et al.. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001; 345: 1368-1377 doi:10.1056/NEJMoa010307
- 10 Mouncey PR, Osborn TM, Power GS. et al.. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015; 372: 1301-1311 doi:10.1056/NEJMoa1500896
- 11 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 doi:10.1056/NEJMoa1404380
- 12 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 doi:10.1056/NEJMoa1401602
- 13 Marx G, Schindler AW, Mosch C. et al.. Intravascular volume therapy in adults: Guidelines from the Association of the Scientific Medical Societies in Germany. Eur J Anaesthesiol 2016; 33: 488-521 doi:10.1097/eja.0000000000000447
- 14 Textoris J, Fouche L, Wiramus S. et al.. High central venous oxygen saturation in the latter stages of septic shock is associated with increased mortality. Crit Care 2011; 15: R176 doi:10.1186/cc10325
- 15 Lu Y, Zhang H, Teng F. et al.. Early Goal-Directed Therapy in Severe Sepsis and Septic Shock: A Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials. J Intens Care Med 2018; 33: 296-309 doi:10.1177/0885066616671710
- 16 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: R42 doi:10.1186/cc13755
- 17 Azuhata T, Kinoshita K, Kawano D. et al.. Time from admission to initiation of surgery for source control is a critical determinant of survival in patients with gastrointestinal perforation with associated septic shock. Crit Care 2014; 18: R87 doi:10.1186/cc13854
- 18 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 doi:10.1097/ccm.0000000000000330
- 19 Lee A, Mirrett S, Reller LB. et al.. Detection of Bloodstream Infections in Adults: How Many Blood Cultures Are Needed?. J Clin Microbiol 2007; 45: 3546-3548 doi:10.1128/jcm.01555-07
- 20 Opota O, Croxatto A, Prodʼhom G. et al.. Blood culture-based diagnosis of bacteraemia: state of the art. Clin Microbiol Infect 2015; 21: 313-322
- 21 Bloos F, Ruddel H, Thomas-Ruddel D. et al.. Effect of a multifaceted educational intervention for anti-infectious measures on sepsis mortality: a cluster randomized trial. Intensive Care Med 2017; 43: 1602-1612 doi:10.1007/s00134-017-4782-4
- 22 Goncalves-Pereira J, Povoa P. Antibiotics in critically ill patients: a systematic review of the pharmacokinetics of beta-lactams. Crit Care 2011; 15: R206 doi:10.1186/cc10441
- 23 Abdul-Aziz MH, Dulhunty JM, Bellomo R. et al.. Continuous beta-lactam infusion in critically ill patients: the clinical evidence. Ann Intensive Care 2012; 2: 37 doi:10.1186/2110-5820-2-37
- 24 Roberts JA, Abdul-Aziz MH, Lipman J. et al.. Individualised antibiotic dosing for patients who are critically ill: challenges and potential solutions. Lancet Infect Dis 2014; 14: 498-509 doi:10.1016/s1473-3099(14)70036-2
- 25 Brinkmann A, Rohr AC, Koberer A. et al.. Adäquate Antiinfektivatherapie: Bedeutung der individuellen Dosierung und Applikation. Anaesthesist 2018; 67: 461-476 doi:10.1007/s00101-018-0443-4
- 26 Investigators P, Rowan KM, Angus DC. et al.. Early, Goal-Directed Therapy for Septic Shock – A Patient-Level Meta-Analysis. N Engl J Med 2017; 376: 2223-2234 doi:10.1056/NEJMoa1701380
- 27 Leisman DE, Goldman C, Doerfler ME. et al.. Patterns and Outcomes Associated With Timeliness of Initial Crystalloid Resuscitation in a Prospective Sepsis and Septic Shock Cohort. Crit Care Med 2017; 45: 1596-1606 doi:10.1097/ccm.0000000000002574
- 28 Hjortrup PB, Haase N, Bundgaard H. et al.. Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial. Intensive Care Med 2016; 42: 1695-1705 doi:10.1007/s00134-016-4500-7
- 29 Cecconi M, Hofer C, Teboul JL. et al.. Fluid challenges in intensive care: the FENICE study: A global inception cohort study. Intensive Care Med 2015; 41: 1529-1537 doi:10.1007/s00134-015-3850-x
- 30 Monnet X, Marik P, Teboul JL. Passive leg raising for predicting fluid responsiveness: a systematic review and meta-analysis. Intensive Care Med 2016; 42: 1935-1947 doi:10.1007/s00134-015-4134-1
- 31 Vincent JL, De Backer D. Saline versus balanced solutions: are clinical trials comparing two crystalloid solutions really needed?. Crit Care 2016; 20: 250 doi:10.1186/s13054-016-1435-x
- 32 Semler MW, Self WH, Wanderer JP. et al.. Balanced Crystalloids versus Saline in Critically Ill Adults. N Engl J Med 2018; 378: 829-839 doi:10.1056/NEJMoa1711584
- 33 Self WH, Semler MW, Wanderer JP. et al.. Balanced Crystalloids versus Saline in Noncritically Ill Adults. N Engl J Med 2018; 378: 819-828 doi:10.1056/NEJMoa1711586
- 34 Caironi P, Tognoni G, Masson S. et al.. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med 2014; 370: 1412-1421 doi:10.1056/NEJMoa1305727
- 35 Finfer S, Bellomo R, Boyce N. et al.. A comparison of albumin and saline for fluid resuscitation in the intensive care unit. N Engl J Med 2004; 350: 2247-2256 doi:10.1056/NEJMoa040232
- 36 Brown RM, Semler MW. Fluid management in sepsis. J Intensive Care Med 2018; DOI: 10.1177/0885066618784861.
- 37 Asfar P, Meziani F, Hamel JF. et al.. High versus low blood-pressure target in patients with septic shock. N Engl J Med 2014; 370: 1583-1593 doi:10.1056/NEJMoa1312173
- 38 Lamontagne F, Meade MO, Hebert PC. et al.. Higher versus lower blood pressure targets for vasopressor therapy in shock: a multicentre pilot randomized controlled trial. Intensive Care Med 2016; 42: 542-550 doi:10.1007/s00134-016-4237-3
- 39 Liu ZM, Chen J, Kou Q. et al.. Terlipressin versus norepinephrine as infusion in patients with septic shock: a multicentre, randomised, double-blinded trial. Intensive Care Med 2018; DOI: 10.1007/s00134-018-5267-9.
- 40 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 doi:10.1016/s0140-6736(07)61344-0
- 41 Martin L, Derwall M, Thiemermann C. et al.. Herz in der Sepsis. Molekulare Mechanismen, Diagnose und Therapie der septischen Kardiomyopathie. Anaesthesist 2017; 66: 479-490 doi:10.1007/s00101-017-0329-x
- 42 Gordon AC, Perkins GD, Singer M. et al.. Levosimendan for the Prevention of Acute Organ Dysfunction in Sepsis. N Engl J Med 2016; 375: 1638-1648 doi:10.1056/NEJMoa1609409
- 43 Schürholz T. Sepsis und Multiorganversagen – Therapeutische Möglichkeiten. Anasthesiol Intensivmed Notfallmed Schmerzther 2015; 50: 132-140 doi:10.1055/s-0041-100302
- 44 Venkatesh B, Finfer S, Cohen J. et al.. Adjunctive glucocorticoid therapy in patients with septic shock. N Engl J Med 2018; 378: 797-808 doi:10.1056/NEJMoa1705835
- 45 Annane D, Renault A, Brun-Buisson C. et al.. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock. N Engl J Med 2018; 378: 809-818 doi:10.1056/NEJMoa1705716
- 46 Loisa P, Parviainen I, Tenhunen J. et al.. Effect of mode of hydrocortisone administration on glycemic control in patients with septic shock: a prospective randomized trial. Crit Care 2007; 11: R21 doi:10.1186/cc5696
- 47 Hoang H, Wang S, Islam S. et al.. Evaluation of hydrocortisone continuous infusion versus intermittent boluses in resolution of septic shock. Pharm Ther 2017; 42: 252-255