Download PDF
Intensivmedizin up2date 2016; 12(04): 391-403
DOI: 10.1055/s-0042-108702
Operative Intensivmedizin
© Georg Thieme Verlag KG Stuttgart · New York

Das akute Abdomen auf der Intensivstation

Lars Fischer
,
Martin Apitz
,
Adrian Billeter
,
Stefan Hofer
,
Beat P. Müller-Stich
Further Information

Publication History

Publication Date:
11 November 2016 (online)

Also available at
    Permissions and Reprints All articles of this category
Kernaussagen

  • Die Diagnose und die Therapie der Sepsis erfordert eine intensive und interdisziplinäre Zusammenarbeit zwischen Intensivpflege, Anästhesisten, Chirurgen, Radiologen und Mikrobiologen.

  • Das akute Abdomen in der Intensivtherapie erfordert zwingend eine unverzügliche Diagnostik und falls notwendig eine chirurgische Sanierung.

  • Bei Anzeichen einer Sepsis muss man frühzeitig mit der leitliniengerechten, antibiotischen und hämodynamischen Therapie beginnen. Patienten mit persistierend hohen postoperativen laborchemischen Entzündungswerten oder steigenden Entzündungswerten unter antibiotischer Therapie sollten frühzeitig einer Ursachendiagnostik mit Bildgebung (CT und Sonografie) und ggf. Exploration unterzogen werden.

  • Die sekundäre Peritonitis ist eine häufige Ursache der Sepsis bei chirurgischen Patienten. Zuerst sollte man daher operationsbedingte Komplikationen ausschließen. Hierzu ist eine frühzeitige interdisziplinäre Kommunikation mit den beteiligten Chirurgen zur Fokussuche und Fokussanierung dringend gefordert.

  • Die chirurgische Therapie zielt auf eine definitive Beseitigung der Sepsisursache mit primärem Bauchdeckenverschluss ab. Postoperativ ist der Patient auf ein abdominelles Kompartmentsyndrom oder eine persistierende Sepsis und Peritonitis zu überwachen. Mögliche Folge-Laparotomien und Re-Explorationen müssen frühzeitig eingeleitet werden.

 

  • Literatur

  • 1 Engel C, Brunkhorst FM, Bone HG et al. Epidemiology of sepsis in Germany: results from a national prospective multicenter study. Intensive Care Med 2007; 33: 606-618
    CrossrefPubMedGoogle Scholar
  • 2 Angus DC, Linde-Zwirble WT, Lidicker J et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29: 1303-1310
    CrossrefPubMedGoogle Scholar
  • 3 Ranieri VM, Thompson BT, Barie PS et al. Drotrecogin alfa (activated) in adults with septic shock. N Engl J Med 2012; 366: 2055-2064
    CrossrefPubMedGoogle Scholar
  • 4 Lamme B, Boermeester MA, Belt EJT et al. Mortality and morbidity of planned relaparotomy versus relaparotomy on demand for secondary peritonitis. Br J Surg 2004; 91: 1046-1054
    CrossrefPubMedGoogle Scholar
  • 5 van Ruler O, Mahler CW, Boer KR et al. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA 2007; 298: 865-872
    CrossrefPubMedGoogle Scholar
  • 6 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
  • 7 Moore LJ, Moore FA. Early diagnosis and evidence-based care of surgical sepsis. Journal of Intensive Care Med 2013; 28: 107-117
    PubMedGoogle Scholar
  • 8 Cardoso LTQ, Grion CMC, Matsuo T et al. Impact of delayed admission to intensive care units on mortality of critically ill patients: a cohort study. Critical Care (London, England) 2011; 15: R28
    CrossrefPubMedGoogle Scholar
  • 9 Kumar A, Roberts D, Wood KE. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Annals of Internal Medicine 2007; 147: 413
    PubMedGoogle Scholar
  • 10 de Dombal FT. The OMGE acute abdominal pain survey. Progress report, 1986. Scand J Gastroenterology 1988; 144 (Supp.) 35-42
    PubMedGoogle Scholar
  • 11 Gajic O, Urrutia LE, Sewani H et al. Acute abdomen in the medical intensive care unit. Crit Care Med 2002; 30: 1187-1190
    CrossrefPubMedGoogle Scholar
  • 12 Brewer BJ, Golden GT, Hitch DC et al. Abdominal pain. An analysis of 1,000 consecutive cases in a University Hospital emergency room. Am J Surg 1976; 131: 219-223
    CrossrefPubMedGoogle Scholar
  • 13 Grundmann RT, Petersen M, Lippert H et al. Das akute (chirurgische) Abdomen - Epidemiologie, Diagnostik und allgemeine Prinzipien des Managements. Zeitschrift für Gastroenterologie 2010; 48: 696-706
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Beyer K, Menges P, Kessler W et al. Pathophysiology of peritonitis. Chirurg 2016; 87: 5-12
    CrossrefPubMedGoogle Scholar
  • 15 Wittmann DH, Schein M, Condon RE. Management of secondary peritonitis. Annals of Surgery 1996; 224: 10-18
    CrossrefPubMedGoogle Scholar
  • 16 Weiss G, Steffanie W, Lippert H. Die Peritonitis – Hauptursache schwerer Sepsis auf chirurgischer Intensivstation. Zentralblatt für Chirurgie 2007; 132: 130-137
    PubMedGoogle Scholar
  • 17 Chavez-Tapia NC, Soares-Weiser K, Brezis M et al. Antibiotics for spontaneous bacterial peritonitis in cirrhotic patients. The Cochrane database of systematic reviews 2009; DOI: 10.1002/14651858.CD002232.pub2. Cd002232
    PubMedGoogle Scholar
  • 18 Eckmann C. Antibiotikatherapie intraabdomineller Infektionen im Zeitalter der Multiresistenz. Chirurg 2016; 87: 26-33
    CrossrefPubMedGoogle Scholar
  • 19 Seiler CA, Brügger L, Forssmann U et al. Conservative surgical treatment of diffuse peritonitis. Surgery 2000; 127: 178-184
    CrossrefPubMedGoogle Scholar
  • 20 Evans HL, Raymond DP, Pelletier SJ et al. Tertiary peritonitis (recurrent diffuse or localized disease) is not an independent predictor of mortality in surgical patients with intraabdominal infection. Surgical Infections 2001; 2: 255-263 discussion 264–255
    CrossrefPubMedGoogle Scholar
  • 21 Malangoni MA. Evaluation and management of tertiary peritonitis. American Surgeon 2000; 66: 157-161
    PubMedGoogle Scholar
  • 22 Lamme B, Mahler CW, van Ruler O et al. Clinical predictors of ongoing infection in secondary peritonitis: systematic review. World Journal of Surgery 2006; 30: 2170-2181
    CrossrefPubMedGoogle Scholar
  • 23 Singer M, Deutschman CS, Seymour CW et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315: 801-810
    CrossrefPubMedGoogle Scholar
  • 24 Welsch T, Frommhold K, Hinz U et al. Persisting elevation of C-reactive protein after pancreatic resections can indicate developing inflammatory complications. Surgery 2008; 143: 20-28
    CrossrefPubMedGoogle Scholar
  • 25 Ortega-Deballon P, Radais F, Facy O et al. C-reactive protein is an early predictor of septic complications after elective colorectal surgery. World Journal of Surgery 2010; 34: 808-814
    CrossrefPubMedGoogle Scholar
  • 26 Hochreiter M, Köhler T, Schweiger A et al. Procalcitonin to guide duration of antibiotic therapy in intensive care patients: A randomized prospective controlled trial. Critical Care 2009; 13: R83
    CrossrefPubMedGoogle Scholar
  • 27 Wacker C, Prkno A, Brunkhorst FM et al. Procalcitonin as a diagnostic marker for sepsis: A systematic review and meta-analysis. Lancet Infectious Diseases 2013; 13: 426-435
    CrossrefPubMedGoogle Scholar
  • 28 Simon L, Gauvin F, Amre DK et al. Serum procalcitonin and C-reactive protein levels as markers of bacterial infection: A systematic review and meta-analysis. Clinical Infectious Diseases 2004; 39: 206-217
    CrossrefPubMedGoogle Scholar
  • 29 Bader FG, Schröder M, Kujath P et al. Diffuse postoperative peritonitis – value of diagnostic parameters and impact of early indication for relaparotomy. Eur J Med Res 2009; 14: 491-496
    CrossrefPubMedGoogle Scholar
  • 30 Sartelli M, Viale P, Catena F et al. 2013 WSES guidelines for management of intra-abdominal infections. World Journal of Emergency Surgery 2013; 8: 3
    CrossrefPubMedGoogle Scholar
  • 31 Doria AS, Moineddin R, Kellenberger CJ et al. US or CT for Diagnosis of Appendicitis in Children and Adults? A Meta-Analysis. Radiology 2006; 241: 83-94
    CrossrefPubMedGoogle Scholar
  • 32 Schreiber J, Nierhaus A, Vettorazzi E et al. Rescue bedside laparotomy in the intensive care unit in patients too unstable for transport to the operating room. Critical Care (London, England) 2014; 18: R123
    CrossrefPubMedGoogle Scholar
  • 33 Hecker A, Uhle F, Schwandner T et al. Diagnostics, therapy and outcome prediction in abdominal sepsis: current standards and future perspectives. Langenbeckʼs Archives of Surgery 2014; 399: 11-22
    PubMedGoogle Scholar
  • 34 Champagne BJ, Darling RC, Daneshmand M et al. Outcome of aggressive surveillance colonoscopy in ruptured abdominal aortic aneurysm. Journal of Vascular Surgery 2004; 39: 792-796
    CrossrefPubMedGoogle Scholar
  • 35 Lin CC, Lee YC, Lee H et al. Bedside colonoscopy for critically ill patients with acute lower gastrointestinal bleeding. Intensive Care Med 2005; 31: 743-746
    CrossrefPubMedGoogle Scholar
  • 36 Church J, Kao J. Bedside colonoscopy in intensive care units: Indications, techniques, and outcomes. Surgical Endoscopy 2014; 28: 2679-2682
    CrossrefPubMedGoogle Scholar
  • 37 Anderson JL, Halperin JL, Albert N et al. Management of Patients With Peripheral Artery Disease (Compilation of 2005 and 2011 ACCF/AHA Guideline Recommendations). J Am Coll Cardiol 2013; 61: 1555-1570
    CrossrefPubMedGoogle Scholar
  • 38 Brower RG, Lanken PN, MacIntyre N et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004; 351: 327-336
    CrossrefPubMedGoogle Scholar
  • 39 Network ARDS. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med 2000; 342: 1301-1308
    CrossrefPubMedGoogle Scholar
  • 40 Solomkin JS, Mazuski JE, Bradley JS et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Clinical Infectious Diseases 2010; 50: 133-164
    CrossrefPubMedGoogle Scholar
  • 41 Bassetti M, Marchetti M, Chakrabarti A et al. A research agenda on the management of intra-abdominal candidiasis: Results from a consensus of multinational experts. Intensive Care Med 2013; 39: 2092-2106
    CrossrefPubMedGoogle Scholar
  • 42 de With K, Allerberger F, Amann S et al. Strategies to enhance rational use of antibiotics in hospital: a guideline by the German Society for Infectious Diseases. Infection 2016; 44: 395-439
    CrossrefPubMedGoogle Scholar
  • 43 Cobos-Trigueros N, Solé M, Castro P et al. Evaluation of a Mixing versus a Cycling Strategy of Antibiotic Use in Critically-Ill Medical Patients: Impact on Acquisition of Resistant Microorganisms and Clinical Outcomes. PLOS ONE 2016; 11: e0150274
    CrossrefPubMedGoogle Scholar
  • 44 Hughes MG, Evans HL, Chong TW et al. Effect of an intensive care unit rotating empiric antibiotic schedule on the development of hospital-acquired infections on the non-intensive care unit ward. Crit Care Med 2004; 32: 53-60
    CrossrefPubMedGoogle Scholar
  • 45 Gruson D, Hilbert G, Vargas F et al. Strategy of antibiotic rotation: Long-term effect on incidence and susceptibilities of Gram-negative bacilli responsible for ventilator-associated pneumonia. Crit Care Med 2003; 31: 1908-1914
    CrossrefPubMedGoogle Scholar
  • 46 de Jong E, van Oers JA, Beishuizen A et al. Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial. The Lancet Infectious diseases 2016; 16: 819-827
    CrossrefPubMedGoogle Scholar
  • 47 Bouadma L, Luyt CE, Tubach F et al. Use of procalcitonin to reduce patients' exposure to antibiotics in intensive care units (PRORATA trial): A multicentre randomised controlled trial. Lancet 2010; 375: 463-474
    CrossrefPubMedGoogle Scholar
  • 48 Prkno A, Wacker C, Brunkhorst FM et al. Procalcitonin-guided therapy in intensive care unit patients with severe sepsis and septic shock – a systematic review and meta-analysis. Critical Care 2013; 17: R291
    CrossrefPubMedGoogle Scholar
  • 49 Marshall JC, Innes M. Intensive care unit management of intra-abdominal infection. Crit Care Med 2003; 31: 2228-2237
    CrossrefPubMedGoogle Scholar
  • 50 Weber DG, Bendinelli C, Balogh ZJ. Damage control surgery for abdominal emergencies. Br J Surgery 2014; 101: e109-e118
    CrossrefPubMedGoogle Scholar
  • 51 Strobel O, Werner J, Büchler MW. Chirurgische Therapie der Peritonitis. Der Chirurg 2011; 82: 242-248
    CrossrefPubMedGoogle Scholar
  • 52 Polk HC, Fry DE. Radical peritoneal debridement for established peritonitis. The results of a prospective randomized clinical trial. Annals of Surgery 1980; 192: 350-355
    CrossrefPubMedGoogle Scholar
  • 53 Malbrain MLNG, Cheatham ML, Kirkpatrick A et al. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. Intensive Care Med 2006; 32: 1722-1732
    CrossrefPubMedGoogle Scholar
  • 54 Cheatham ML, Malbrain MLNG, Kirkpatrick A et al. Results from the International Conference of Experts on Intra-abdominal Hypertension and Abdominal Compartment Syndrome. Intensive Care Med 2007; 33: 951-962
    CrossrefPubMedGoogle Scholar
  • 55 Atema JJ, Gans SL, Boermeester MA. Systematic Review and Meta-analysis of the Open Abdomen and Temporary Abdominal Closure Techniques in Non-trauma Patients. World Journal of Surgery 2015; 39: 912-925
    CrossrefPubMedGoogle Scholar
  • 56 Correa JC, Mejía DA, Duque N et al. Managing the open abdomen: Negative pressure closure versus mesh-mediated fascial traction closure: a randomized trial. Hernia 2016; 20: 221-229
    CrossrefPubMedGoogle Scholar
  • 57 Lamme B, Boermeester MA, Reitsma JB et al. Meta-analysis of relaparotomy for secondary peritonitis. Br J Surg 2002; 89: 1516-1524
    CrossrefPubMedGoogle Scholar
  • 58 Kirkpatrick AW, Roberts DJ, Waele Jd et al. Intra-abdominal hypertension and the abdominal compartment syndrome: Updated consensus definitions and clinical practice guidelines from the World Society of the Abdominal Compartment Syndrome. Intensive Care Med 2013; 39: 1190-1206
    CrossrefPubMedGoogle Scholar