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Frühe zielorientierte Therapie bei schwerer Sepsis

Early goal directed therapy in severe sepsis

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Zusammenfassung

Hintergrund

Die Zielparameter der frühen zielorientierten Therapie („early goal directed therapy“, EGDT) sind seit nahezu 10 Jahren Bestandteil der internationalen und nationalen Empfehlungen zur Diagnostik und Therapie der Sepsis. Ungeachtet der in einer monozentrischen Studie nachgewiesenen enormen prognoseverbessernden Effekte der EGDT bei Patienten mit schwerer Sepsis und septischem Schock hat sich diese Vorgehensweise im klinischen Alltag nicht durchgesetzt. Zweifel an der Validität der Zielparameter (zentralvenöser Druck, mittlerer arterieller Druck und zentralvenöse Sauerstoffsättigung), aber auch praktische Hindernisse in der Umsetzung der Zielvorgaben in einer Notaufnahmestation sind hierfür maßgeblich.

Aktuelle Studienergebnisse

Aktuelle Ergebnisse einer großen randomisierten Studie belegen, dass die klinische Beurteilung und Steuerung der Therapie von Patienten mit schwerer Sepsis und septischem Schock in der frühen Krankheitsphase gleichwertig mit den protokollbasierten Vorgaben der EGDT-Therapie ist.

Empfehlung

Ungeachtet dieser Einschränkungen wurden in den vergangenen Jahren sog. Sepsis-Bundles entwickelt, die für die ersten Stunden der Therapie septischer Patienten pragmatische Empfehlungen zur Diagnostik, Antibiotika- und Volumentherapie aussprechen. Die Beachtung dieser Handlungsempfehlungen und die stetige Weiterentwicklung und Anpassung der einzelnen Komponenten dieser Sepsis-Bundles kann und wird die Prognose dieser schwer kranken Patienten weiter verbessern. Entscheidend und prognosebestimmend bleibt das frühzeitige Erkennen eines Patienten mit Sepsis sowie die möglichst frühe Diagnostik und Therapie.

Abstract

Backgound

The treatment of patients with severe sepsis and septic shock continues to evolve. Recent studies have enunciated the benefit of early goal-directed therapy (EGDT) during the first 6 h after recognition of the condition. With EGDT a reduction in mortality of over 16 % was shown over standard care. Thereafter the components of the EGDT were consequently implemented in the international Surviving Sepsis Campaign as well as the German sepsis guidelines. Nevertheless the medical community’s enthusiasm for EGDT has remained indecisive. There remains a profound skepticism about treatment targets such as central venous pressure or mean arterial pressure as well as central venous oxygen saturation. Moreover multiple barriers such as critical shortage of nursing staff, problems in obtaining central venous pressure monitoring or lack of agreement with the EGDT resuscitation protocol may lead to non-adherence to EGDT early in the course of sepsis.

Recent study results

In a recent multicenter trial, protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes.

Recommendation

The Severe Sepsis 3-Hour Resuscitation Bundle and the 6-Hour Septic Shock Bundle represent a distillation of the concepts and recommendations found in the practice guidelines published by the Surviving Sepsis Campaign. The bundles are designed to allow teams to follow the timing, sequence, and goals of the individual elements of care. Early recognition, early mobilization of resources, and multidisciplinary collaboration are imperative to enhance the prognosis of patients with sepsis.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. U. Janssens gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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  1. Klinik für Innere Medizin, St.-Antonius-Hospital, Dechant-Deckers-Str. 8, 52249, Eschweiler, Deutschland

    U. Janssens

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Janssens, U. Frühe zielorientierte Therapie bei schwerer Sepsis. Med Klin Intensivmed Notfmed 109, 568–576 (2014). https://doi.org/10.1007/s00063-014-0377-9

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