Zusammenfassung
Überrascht wären wir wohl kaum, wenn unser Auto auf 100 km mehr verbraucht, als es der Hersteller angibt. Je nach Fahrstrecke, unserem Fahrverhalten und der Größe der Fahrgemeinschaft weicht der reale Kraftstoffverbrauch teils erheblich von den Herstellerangaben ab. Sobald aber die Autotür hinter uns ins Schloss fällt und sich die Pforte zur Intensivstation öffnet, scheinen wir all dies wieder zu verdrängen. Wir gehen zu Unrecht davon aus, dass die Boliden der Nierenersatztherapie, immer gleich gut entgiften und immer die gleiche Menge Antiinfektiva eliminieren, egal ob wir mit ihnen Vollgasblutwäsche betreiben oder sehr zurückhaltend im Schonwaschgang fahren. Anders als bei den Katecholaminen, deren Wirkung wir vom intensivmedizinischen Armaturenbrett in Form des invasiv gemessenen arteriellen Mitteldrucks direkt ablesen können, fehlt auch auf modernen Intensivstationen der Antibiotikaverbrauchsanzeiger. In der nachfolgenden Übersicht versuchen wir basale pharmakokinetische und pharmakodynamische Prinzipien zu erläutern, die es erlauben, Antibiotika insbesondere bei Patienten, die einer Nierenersatztherapie bedürfen, optimal zu dosieren. Moderne Hybridmodelle, also die Kombination von Nierenersatztherapie mit extrakorporaler Lungenunterstützung oder Adsorbertechnologien zur Entfernung von Zytokinen oder Bakterien, werden in Bezug auf den Einfluss auf die Elimination von Antiinfektiva abgehandelt. Eingehend besprechen wir das Problem der Körperdimensionen und der Körperzusammensetzung, die für die Initial- und Erhaltungsdosis von Antiinfektiva relevant ist. Abschließend erläutern wir, warum aus Sicht der Autoren eine zeitnahe zuverlässige Verfügbarkeit des therapeutischen „drug monitoring“ unabdingbar erscheint, perspektivisch sicherlich mit „point auf care“-Geräten am Patientenbett.
Abstract
We would neither be disappointed nor upset if the gas mileage on the sticker of a car didn’t match our personal, real-life fuel consumption. Depending on our daily route to work, our style of accelerating and the number of passengers in our carpool, the gas mileage will vary. As soon as the falcon wing door of our car is closed and entrance to the ICU is granted, we tend to forget all of this, even though another hot rod is waiting there for us. Renal replacement therapy is like a car; it fulfills goals, such as the removal of uremic toxins and accumulated fluids, but it also “consumes” (removes) antibiotics. Unlike catecholamines, where we have the mean arterial pressure on our ICU dashboard, we do not have a gauge to measure antibiotic “consumption”, i.e. elimination by renal replacement therapy. This manuscript describes the principles and basic knowledge to improve dosing of antibiotics in critically ill patients undergoing renal replacement therapy. As in modern cars, we briefly touch on hybrid therapies combining renal replacement therapy with extracorporeal lung support or adsorbent technologies that remove cytokines or bacteria. Further, the importance of considering body size and body composition is addressed, especially for choosing the right initial dose of antibiotics. Lastly we point out the dire need to increase the availability of timely and affordable therapeutic drug monitoring on the most commonly used antiinfectives, ideally using point-of-care devices at the bedside.
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J. T. Kielstein erhielt von Fresenius Medical Care und der Novartis GmbH Unterstützung für „investigator initited trials“. S. Scherneck erhielt Unterstützung von Auriga Service GmbH & Co. KG außerhalb der vorliegenden Arbeit. A. K. Kruse, N. Anderson und H. Vaitiekunas geben an, dass kein Interessenkonflikt besteht.
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Kielstein, J.T., Kruse, A.K., Anderson, N. et al. Boliden auf der Intensivstation. Med Klin Intensivmed Notfmed 114, 139–145 (2019). https://doi.org/10.1007/s00063-017-0303-z
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DOI: https://doi.org/10.1007/s00063-017-0303-z