Skip to main content
Log in

Spezielle Aspekte bei Sepsispatienten

Initiale Phase auf der Notaufnahme, Lebensalter, Geschlecht, Postintensivphase

Specific aspects in septic patients: initial phase in the emergency department, age, sex and post-ICU-care

  • Schwerpunkt: Sepsis
  • Published:
Der Internist Aims and scope Submit manuscript

Zusammenfassung

In diesem Beitrag werden spezielle Aspekte des Sepsispatienten und seiner Betreuung betrachtet. Der Patient mit ambulant erworbener schwerer Sepsis in der Notaufnahme hat bei sofortigem und adäquatem Behandlungsbeginn (Antibiotikum innerhalb der 1. Stunde, frühzeitige zielorientierte Herz-Kreislauf-Therapie) wesentlich bessere Überlebenschancen als der Patient mit protrahierter schwerer Sepsis auf der Intensivstation. Das durchschnittliche Alter unserer Patienten mit schwerer Sepsis und septischem Schock steigt aufgrund der demographischen Entwicklung immer weiter an. Dies kann ein möglicherweise atypisches Erscheinungsbild der Sepsis zur Folge haben und die Anpassung der Pharmakotherapie an die im Alter eingeschränkten Organfunktionen erforderlich machen. Auch mit einem aufgrund der Komorbidität protrahierten Krankheitsverlauf ist zu rechnen. Frauen haben infolge des sexuellen Dimorphismus des Immunsystems bei Sepsis bessere Überlebenschancen. Eine Aktivierung des Östrogenrezeptors β ist zumindest tierexperimentell als Sepsistherapieprinzip erfolgreich. In den ersten 6 Monaten nach Entlassung des Sepsispatienten aus dem Krankenhaus muss mit einer anhaltenden Morbidität und Letalität gerechnet werden. Die Betreuung des Sepsispatienten in einer Postintensivambulanz lässt diese Gefahren rechtzeitig erkennen und ermöglicht eine frühzeitige Behandlung.

Abstract

This article deals with specific aspects of the patient with sepsis and his treatment. With adequate therapy (antibiotics started within the first hour, early goal-directed therapy) initiated as early as possible, the patient with community-aquired severe sepsis in the emergency department has a considerable better chance to survive than the patient with prolonged severe sepsis in the ICU. The average age of patients with severe sepsis and septic shock treated at the ICU is rising, with consequences like oligosymptomatic presentation, altered pharmakokinetics according to older-age-induced reduced organ functions and prolonged stay at the ICU due to comorbidity. Due to sexual dimorphisms of the immune system, women have a better prognosis in sepsis than men. In an animal sepsis model activation of the estrogen receptor beta improves prognosis. Within six months after having survived severe sepsis, morbidity and mortality is still increased. Taking care for the patient in a post-ICU outpatient department during this time will help to recognize these problems and to effectively treat the patient as soon as possible.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Abb. 1
Abb. 2
Abb. 3

Literatur

  1. Angele MK, Schwacha MG, Ayala A, Chaudry IH (2000) Effect of gender and sex hormones on immune responses following shock. Shock 14: 81–90

    Article  PubMed  CAS  Google Scholar 

  2. Barrow RE, Herndon DN (1990) Incidence of mortality in boys and girls after severe thermal burns. Surg Gynecol Obstet 170: 295–298

    PubMed  CAS  Google Scholar 

  3. Brunner-Ziegler S, Heinze G, Ryffel M et al. (2007) Oldest old patients in intensive care: prognosis and therapeutic activity. Wien Klin Wochenschr 119: 14–19

    Article  PubMed  Google Scholar 

  4. Chan YL, Tseng CP, Tsay PK et al. (2004) Procalcitonin as a marker of bacterial infection in the emergency department: an observational study. Crit Care 8: R12–R20

    Article  PubMed  Google Scholar 

  5. Cristofaro PA, Opal SM, Palardy JE et al. (2006) WAY 202196, a selective estrogen receptor-beta agonist, protects against death in experimental septic shock. Crit Care Med 34: 2188–2193

    Article  PubMed  CAS  Google Scholar 

  6. Dowdy DW, Eid MP, Dennison CR et al. (2006) Quality of life after acute respiratory distress syndrome: a meta-analysis. Intensive Care Med 32: 1115–1124

    Article  PubMed  Google Scholar 

  7. Engel C, Brunkhorst FM, Bone H-G (2007) Epidemiology of sepsis in Germany: results from a national prospective multicenter study. Intensive Care Med 33: 606–618

    Article  PubMed  Google Scholar 

  8. Farmer JC (ed) Levy MM, Curtis JR (Co-eds) (2006) Improving the quality of end-of-life care in the ICU. Crit Care Med 34 (Suppl 11): S301–S420

    Article  Google Scholar 

  9. Fowler RA, Sabur N, Li P et al. (2007) Sex- and age-based differences in the delivery and outcomes of critical care. CMAJ 177: 1513–1519

    PubMed  Google Scholar 

  10. Franceschi C, Bonafe M, Valensin S et al. (2000) Inflamm-aging. An evolutionary perspective on immunosenescence. Ann N Y Acad Sci 908: 244–254

    Article  PubMed  CAS  Google Scholar 

  11. Herridge MS, Cheung AM, Tansey et al.; Canadian Critical Care Trials Group (2003) One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 348: 683–693

    Article  PubMed  Google Scholar 

  12. Heyland DK, Hopman W, Coo H et al. (2000) Long-term health-related quality of life in survivors of sepsis. Short Form 36: a valid and reliable measure of health-related quality of life. Crit Care Med 28: 3599–3605

    Article  PubMed  CAS  Google Scholar 

  13. Howell MD, Donnino MW, Talmor D et al. (2007) Performance of severity of illness scoring systems in emergency department patients with infection. Acad Emerg Med 14: 709–714

    Article  PubMed  Google Scholar 

  14. Hubacek JA, Stüber F, Fröhlich D et al. (2001) Gene variants of the bactericidal/permeability increasing protein and lipopolysaccharide binding protein in sepsis patients: Gender-specific genetic predisposition to sepsis. Crit Care Med 29: 557–561

    Article  PubMed  CAS  Google Scholar 

  15. HudsonLD, Lee CM (2003) Neuromuscular sequelae of critical illness. N Engl J Med 348: 745–747

    Article  Google Scholar 

  16. Jarrar D, Kuebler JF, Wing P et al. (2001) DHEA: a novel adjunct for the treatment of male trauma patients. Trends Mol Med 7: 81–85

    Article  PubMed  CAS  Google Scholar 

  17. Kaarlola A, Tallgren M, Pettilä V (2006) Long-term survival, quality of life and quality-adjusted life-years among critically ill elderly patients. Crit Care Med 34: 2120–2126

    Article  PubMed  Google Scholar 

  18. Marik PE (2006) Management of the critically ill geriatric patient. Crit Care Med 34 (Suppl): S176–S182

    Article  PubMed  Google Scholar 

  19. Martin GS, Mannino DM, Moss M (2006) The effect of age on the development and outcome of adult sepsis. Crit Care Med 34: 15–21

    Article  PubMed  Google Scholar 

  20. NiskanenK, Kari A, Halonen P; Finnish ICU Study Group (1996) Five year survival after intensive care – Comparison of 12,128 patients with the general population. Crit Care Med 24: 1962–1967

    Article  Google Scholar 

  21. Niskanen M, Ruokonen E, Takala J et al. (1999) Quality of life after prolonged intensive care. Crit Care Med 27: 1132–1139

    Article  PubMed  CAS  Google Scholar 

  22. Oberholzer A, Keel M, Zellweger R et al. (2000) Incidence of septic complications and multiple organ failure in severely injured patients is sex specific. J Trauma 48: 932–937

    Article  PubMed  CAS  Google Scholar 

  23. Offner PJ, Moore EE, Biffl WL (1999) Male gender is a risk factor for major infections after surgery. Arch Surg 134: 935–940

    Article  PubMed  CAS  Google Scholar 

  24. Perl TM, Dvorak L, Hwang T, Wenzel RP (1995) Long-term survival and function after suspected gram-negative sepsis. JAMA 274: 338–345

    Article  PubMed  CAS  Google Scholar 

  25. Quartin AA, Schein RM, Kett DH, Peduzzi PN (1997) Magnitude and duration of the effect of sepsis on survival. Department of Veterans Affairs Systemic Sepsis Cooperative Studies Group. JAMA 277: 1058–1063

    Article  PubMed  CAS  Google Scholar 

  26. Sacanella E, Pérez-Castejón JM, Nicolás JM et al. (2009) Mortality in healthy elderly patients after ICU admission. Intensive Care Med 35: 550–555

    Article  PubMed  Google Scholar 

  27. Sasse KC, Nauenberg E, Long A et al. (1995) Long-term survival after intensive care unit admission with sepsis. Crit Care Med 23: 1040–1047

    Article  PubMed  CAS  Google Scholar 

  28. Schmidt H, Flieger RR, Hennen R et al. (2005) Reversible autonome Dysfunktion bei einer jungen Patientin mit septischem Multiorgan-Dysfunktionssyndrom. Dtsch Med Wochenschr 130: 648–651

    Article  PubMed  CAS  Google Scholar 

  29. Schröder J, Kahlke V, Book M, Stüber F (2000) Gender differences in sepsis: genetically determined? Shock 14: 307–311

    Article  PubMed  Google Scholar 

  30. Schröder J, Kahlke V, Staubach KH et al. (1998) Gender differences in human sepsis. Arch Surg 133: 1200–1205

    Article  PubMed  Google Scholar 

  31. Seferian EG, Afessa B (2006) Demographic and clinical variation of adult intensive care unit utilization from a geographically defined population. Crit Care Med 34: 2113–2119

    Article  PubMed  Google Scholar 

  32. Shapiro NI, Wolfe RE, Moore RB et al. (2003) Mortality in Emergency Department Sepsis (MEDS) score: A prospectively derived and validated clinical prediction rule. Crit Care Med 31: 670–675

    Article  PubMed  Google Scholar 

  33. Stüber F, Petersen M, Bokelmann F, Schade U (1996) A genomic polymorphism within the tumor necrosis factor locus influences plasma tumor necrosis factor-α concentrations and outcome of patients with severe sepsis. Crit Care Med 24: 381–384

    Article  PubMed  Google Scholar 

  34. Valentin A (2007) Intensivmedizin im höchsten Lebensalter: Errungenschaft oder Fehlentwicklung? Intensiv News 11: 19–20

    Google Scholar 

  35. VanEijk LT, Dorresteijn MJ, Smits P et al. (2007) Gender differences in the innate immune response and vascular reactivity following the administration of endotoxin to human volunteers. Crit Care Med 35: 1464–1469

    Article  CAS  Google Scholar 

  36. Vincent JL (2009) Elderly care. ICU Manag 9: 1–15

    Google Scholar 

  37. Wehler M, Strauß R, Hahn EG (2004) Weiterleben nach dem Überleben – körperliche, neuropsychologische und soziale Folgen intensivmedizinischer Behandlung. Intensiv Notfallbehandlung 29: 173–187

    Google Scholar 

  38. Werdan K, Schuster HP, Müller-Werdan U (2005) Sepsis und MODS, 4. Auf. Springer, Heidelberg Berlin New York

  39. Wichmann MW, Inthorn D, Andress HJ, Schildberg FW (2000) Incidence and mortality of severe sepsis in surgical intensive care patients: the influence of patient gender on disease process and outcome. Intensive Care Med 26: 167–172

    Article  PubMed  CAS  Google Scholar 

  40. Wilhelm J, Werdan K (2009) Sepsis. In: Madler C, Jauch KW, Werdan K et al. (Hrsg) Akutmedizin der ersten 24 Stunden – DAS NAW-Buch, 4. Aufl. Elsevier Urban & Fischer, München, S 655–676

  41. Witthaut R, Busch C, Fraunberger P et al. (2003) Plasma atrial natriuretic peptide and brain natriuretic peptide are increased in septic shock: impact of interleukin-6 and sepsis-associated left ventricular dysfunction. Intensive Care Med 29: 1696–1702

    Article  PubMed  Google Scholar 

Download references

Interessenkonflikt

Die korrespondierende Autorin weist auf folgende Beziehungen hin:

Forschungsunterstützung: Biotest, Novartis. Vortragshonorare: Berlin-Chemie, Serumwerke Bernburg, Servier.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to U. Müller-Werdan.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Müller-Werdan, U., Wilhelm, J., Hettwer, S. et al. Spezielle Aspekte bei Sepsispatienten. Internist 50, 828–840 (2009). https://doi.org/10.1007/s00108-008-2288-4

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00108-008-2288-4

Schlüsselwörter

Keywords

Navigation