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Sepsis

Aktuelle Aspekte zu Pathophysiologie, Diagnostik und Therapie

Sepsis

Update on pathophysiology, diagnostics and therapy

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Es ist nicht genug zu wissen, man muss auch anwenden. (J.W. von Goethe).

Zusammenfassung

Sepsis ist als Resultante aus Infektion und Wirtsantwort definiert. Die Fehlfunktion von Abwehr- und Reparatursystemen, wie Immunsystem und Gerinnung, ist für die Prognose bestimmend; hierbei ist die Letalitätsrate der schweren Sepsis mit 54% inakzeptabel hoch. Aufgrund verbesserter pathophysiologischer Kenntnisse versucht man daher, modulierend in die Wirtsantwort einzugreifen. Eine Vielzahl Erfolg versprechender präklinischer Studienergebnisse konnte in großen multizentrischen Interventionsstudien nicht bestätigt werden. Deshalb beinhalten viele der evidenzbasierten Empfehlungen den Verzicht auf häufig teure adjunktive Therapiestrategien. Dennoch hat die Etablierung neuer supportiver und adjunktiver Strategien, insbesondere die frühe zielgerichtete Kreislauftherapie, die niedrig dosierte Hydrokortisonsubstitution sowie die Anwendung von aktiviertem Protein C, nach Jahren der Stagnation zu Fortschritten geführt. Parallel belegen Ergebnisse zur Versorgungsforschung des deutschen Kompetenznetzwerks Sepsis („SepNet“) eindrucksvoll, dass einer guten Kenntnis der aktuellen Studienlage und dem erklärten Willen, diese zu implementieren, eine mangelhafte Umsetzung in die Routine gegenübersteht. Hier ist durch „change management“ (wie Einführung von „sepsis bundles“) ein erhebliches Potenzial für Verbesserungen im Hinblick auf die durch die „surviving sepsis campaign“ angestrebte Verringerung der Sterblichkeitsrate um 25% innerhalb der nächsten 5 Jahre zu erwarten.

Abstract

Sepsis results from the host response to infection. While a localized and controlled inflammatory reaction helps to control infection, a dysregulated response may lead to multiple organ failure and determines the course and prognosis of the septic patient. Despite intensive care, mortality remains as high as 54% for severe sepsis and septic shock. As the mechanisms are becoming better defined, interventions aiming to interfere with the host response have been undertaken, largely with dissappointing results. Thus, many evidence-based recommendations suggest waiving of resource-consuming interventions. Nevertheless, several seminal studies have indicated that early and systematic supportive therapy according to pathophysiological principles, most notably early goal-directed therapy, low-dose hydrocortisone and activated protein C, can disrupt dysfunctional cascades and can favourably influence the course of the disease. In parallel, efforts to better define nationwide epidemiology and treatment habits for severe sepsis by the German competence network “SepNet” indicate that therapy of severe sepsis is generally in poor compliance with guidelines, while the personal perception of physicians in charge would suggest high rates of adherence. Thus, strategies of change management, such as implementation of sepsis bundles are warranted to achieve a better standard of care toward the aim of the “surviving sepsis campaign”, i.e. a reduction of mortality by 25% within the next 5 years.

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Authors and Affiliations

  1. Klinik für Anästhesiologie und Intensivtherapie, Klinikum der Friedrich-Schiller-Universität, Erlanger Allee 101, 07740, Jena

    M. Bauer, F. Brunkhorst & K. Reinhart

  2. Abteilung Pneumologie, Medizinische Hochschule, Hannover

    T. Welte

  3. Vivantes Klinikum Neukölln, Klinik für Anästhesiologie und Intensivtherapie, Berlin

    H. Gerlach

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  1. M. Bauer
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  2. F. Brunkhorst
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  3. T. Welte
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  4. H. Gerlach
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  5. K. Reinhart
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Correspondence to M. Bauer.

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Unterstützt durch das Bundesministerium für Bildung und Forschung (BMBF), Förderkennzeichen: 01KI 0106.

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Bauer, M., Brunkhorst, F., Welte, T. et al. Sepsis. Anaesthesist 55, 835–845 (2006). https://doi.org/10.1007/s00101-006-1034-3

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