Der Klinikarzt 2014; 43(6): 308-312
DOI: 10.1055/s-0034-1384304
Schwerpunkt
© Georg Thieme Verlag Stuttgart · New York

Kreislauf- und Volumenmanagement bei Sepsis – Was ist zu beachten?

Circulation and volume management in sepsis – What are the key issues?
Axel Nierhaus
1   Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
,
Stefan Kluge
1   Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
› Author Affiliations
Further Information

Publication History

Publication Date:
18 June 2014 (online)

Die führenden Ziele der Therapie mittels Flüssigkeitssubstitution und vasoaktiven Substanzen im septischen Schock sollten die Wiederherstellung einer effektiven Gewebsperfusion und die Normalisierung des zellulären Metabolismus sein. Hierbei müssen sowohl die globale, als auch die regionale Hämodynamik berücksichtigt werden. Ohne eine frühzeitige und adäquate Volumentherapie ist eine Behandlung mit Katecholaminen und Vasopressoren allerdings grob unvollständig und wenig erfolgversprechend.

Die therapeutischen Endpunkte sind jedoch nach wie vor nicht exakt definiert und Gegenstand aktueller und zukünftiger Studien. Dynamische, flussorientierte Monitoring- und Therapieansätze scheinen gegenüber statischen, druckorientierten Vorgehensweisen von Vorteil zu sein.

The top priority objective of therapy for septic shock with fluid replacement and vasoactive substances should always be to restore an effective tissue perfusion and to normalize the cellular metabolism. In these cases, special attention must be paid not only to the global but also the regional hemodynamics. In the absence of an early and adequate volume therapy, however, treatment with catecholamines and vasopressors is crassly incomplete and has little hope of success.

The therapeutic endpoints, however, are still not precisely defined and remain a topic for current and future studies. Dynamic, flow-oriented monitoring and therapeutic strategies seem to have advantages over static, pressure-oriented procedures.

 
  • Literatur

  • 1 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
  • 2 Beck GC, Brinkkoetter P, Hanusch C et al. Clinical review: immunomodulatory effects of dopamine in general inflammation. Crit Care 2004; 8: 485-491
  • 3 Bouchard J, Soroko SB, Chertow GM et al. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 2009; 76: 422-427
  • 4 Boyd JH, Forbes J, Nakada TA et al. Fluid resuscitation in septic shock: a positive fluid balance and elevated central venous pressure are associated with increased mortality. Crit Care Med 2011; 39: 259-265
  • 5 Brunkhorst FM, Engel C, Bloos F et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139
  • 6 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
  • 7 De Backer D, Biston P, Devriendt J et al. Comparison of dopamine and norepinephrine in the treatment of shock. N Engl J Med 2010; 362: 779-789
  • 8 Dellinger RP. Cardiovascular management of septic shock. Crit Care Med 2003; 31: 946-955
  • 9 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
  • 10 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
  • 11 Marik PE, Cavallazzi R. Does the central venous pressure predict fluid responsiveness? An updated meta-analysis and a plea for some common sense. Crit Care Med 2013; 41: 1774-1781
  • 12 Perner A, Haase N, Guttormsen AB et al. Hydroxyethyl starch 130/0.42 versus Ringer's acetate in severe sepsis. N Engl J Med 2012; 367: 124-134
  • 13 Reinhart K, Brunkhorst FM, Bone HG et al. Prevention, diagnosis, treatment, and follow-up care of sepsis. First revision of the S2k Guidelines of the German Sepsis Society (DSG) and the German Interdisciplinary Association for Intensive and Emergency Care Medicine (DIVI). Anaesthesist 2010; 59: 347-370
  • 14 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
  • 15 Russell JA, Walley KR, Singer J et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med 2008; 358: 877-887
  • 16 Yealy DM, Kellum JA, Huang DT et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014; 370: 1683-1693