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Schwere Sepsis und disseminierte intravasale Gerinnung

Substitution von Antithrombin

Severe sepsis and disseminated intravascular coagulation

Supplementation with antithrombin

  • Intensivmedizin
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Zusammenfassung

Der Nutzen eines Antithrombin- (AT-)Konzentrats wurde in der KyberSept-Studie an einem großen Kollektiv von Patienten mit schwerer Sepsis untersucht. In der Gesamtstudie bewirkte eine AT-Gabe im Vergleich zu Placebo keine signifikante Senkung der Letalitätsrate. Allerdings waren im Protokoll der Studie vorab Subgruppen festgelegt worden, bei deren Analyse sich zeigte, dass es bei Patienten, die AT, aber nicht gleichzeitig Heparin erhalten hatten, im Vergleich zur Placebogruppe zur Senkung der Letalitätsrate kam. Die Senkung der Mortalitätsrate um absolut 15% erreichte am 90. Tag statistische Signifikanz. Auch bei Patienten, die zur Risikogruppe Stratum II gemäß Simplified Acute Physiology Score (SAPS) II gehörten, zeigte sich ohne gleichzeitige Heparingabe nach 90 Tagen eine signifikante Reduktion der Mortalitätsrate um 22%. Ein solches positives Ergebnis der AT-Gabe ohne gleichzeitige Heparintherapie findet man auch, wenn eine durch eine disseminierte intravasale Gerinnung (DIC) komplizierte Sepsis vorliegt. Hier hilft die Gerinnungsdiagnostik, eine latente oder eine fulminante DIC zu erkennen sowie deren Verlauf und Entwicklung zu überwachen. Die gefundenen Ergebnisse der AT-Substitution bei schwerer Sepsis und DIC stehen im Einklang mit früheren Studien an kleineren Patientenkollektiven und legen nahe, eine randomisierte, kontrollierte klinische Studie bei dem Subkollektiv von schwer erkrankten Patienten durchzuführen.

Abstract

Administration of high-dose antithrombin (AT) was investigated on a large collective of patients with severe sepsis in the KyberSept study. In the total study the administration of AT resulted in no significant reduction of the mortality rate in comparison to a placebo. However, in the protocol of this study subgroups were predefined, which when analyzed revealed that the group of patients who received AT but not simultaneously heparin did show a reduction of the mortality rate in comparison to the placebo group. The reduction of the absolute mortality rate of 15% reached statistical significance on day 90. Even patients classified as risk group grade II according to the Simplified Acute Physiology Score (SAPS), showed a significant reduction of the mortality rate of approximately 22% after 90 days without simultaneous administration of heparin. Such a positive result for administration of AT without simultaneous heparin treatment can also be found when severe sepsis complicated by disseminated intravascular coagulation (DIC) is present. Coagulation diagnostic assists the recognition of latent or fulminant DIC and also in surveillance of the course and development. The results of AT supplementation for severe sepsis and DIC are in agreement with earlier studies on smaller patient collectives and suggest that a randomized controlled clinical study should be carried out on a subcollective of severely ill patients.

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Authors and Affiliations

  1. Medizinische Klinik, Ziemssenstr. 1, 80336, München, Deutschland

    M. Angstwurm

  2. Chirurgische Klinik, Klinikum Großhadern, München, Deutschland

    J. Hoffmann

  3. Medizinische Klinik III, Klinikum Großhadern, München, Deutschland

    H. Ostermann

  4. Klinik für Anästhesiologie, Klinikum Großhadern, München, Deutschland

    L. Frey

  5. Abteilung Hämostaseologie und Transfusionsmedizin, Klinikum Großhadern, München, Deutschland

    M. Spannagl

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  1. M. Angstwurm
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  2. J. Hoffmann
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  3. H. Ostermann
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  4. L. Frey
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  5. M. Spannagl
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Correspondence to M. Angstwurm.

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Angstwurm, M., Hoffmann, J., Ostermann, H. et al. Schwere Sepsis und disseminierte intravasale Gerinnung. Anaesthesist 58, 171–179 (2009). https://doi.org/10.1007/s00101-008-1494-8

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