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Therapie des Kreislaufversagens bei Sepsis

Hemodynamic treatment in sepsis

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Intensivmedizin und Notfallmedizin

Summary

Rational hemodynamic therapy in septic patients should include the following strategies: Adequate fluid resuscitation therapy is one of the most important steps. Crystaloid or colloid solutions are considered to be equally beneficial. The underlying principle is optimization of the myocardial preload. The concept of DO2 maximization, by means of high-dose catecholamine administration, is to be dismissed. Dobutamine is the catecholamine of choice for decreased cardiac pump function treatment. In determining whether a further DO2 increase is indicated, one must follow the markers of peripheral perfusion and organ function (i. e. diuresis, lactate plasma concentration, central venous O2 saturation). Inadequate perfusion pressure should not be tolerated, just because of fear from the potentially unfavorable effects of the vasopressor agents. Perfusion pressure should also be controlled, paying close attention to the indices of peripheral perfusion and organ function. Both dopamine and noradrenaline are recommended as vasopressor agents. However, due to the potentially unfavorable effects of dopamine, noradrenaline appears to be the more suitable choice. Vasopressin should be administered, if ever, only in situations, in which adequate blood pressure cannot be achieved with the better established vasopressors, since vasopressin-induced negative effects on the microcirculation cannot be ruled out. Currently, there is no sufficiently proven therapeutic strategy, enabling a targetted improvement of the regional blood flow, other than through stabilization of the global hemodynamics. The concept of low-dose dopamine administration should be clearly dismissed from modern practice. Regarding dopexamine, there are also no data available to, justify its clinical use.

Zusammenfassung

Eine rationale Kreislauftherapie bei septischen Patienten sollte folgende Strategien beinhalten: Eine adäquate Volumentherapie ist eine der wichtigsten Maßnahmen. Kristalloide oder kolloidale Substanzen werden als gleichwertig empfohlen. Grundlegendes Prinzip ist die Optimierung der myokardialen Vorlast. Das Konzept der Maximierung des DO2 mittels hochdosierter Katecholamine ist abzulehnen. Zur Therapie der eingeschränkten Pumpfunktion ist Dobutamin Katecholamin der Wahl. Zur Entscheidung, ob ein weiterer DO2-Anstieg sinnvoll ist, müssen die Marker der peripheren Perfusion und Organfunktion (z. B. Diurese, Laktat, zentralvenöse O2-Sättigung) beachtet werden. Ein inadäquater Perfusionsdrucks sollte nicht wegen potentieller ungünstiger Effekte von Vasopressoren toleriert werden. Auch der Perfusionsdruck muss unter Beachtung von Parametern der peripheren Perfusion und Organfunktion titriert werden. Sowohl Dopamin als auch Noradrenalin werden als Vasopressoren empfohlen. Aufgrund potentiell ungünstiger Effekte von Dopamin scheint Noradrenalin aber besser geeignet. Vasopressin sollte, wenn überhaupt, nur in Situationen eingesetzt werden, in denen ein adäquater Blutdruck mittels etablierter Vasopressoren nicht zu erzielen ist, denn für Vasopressin sind negative Effekte auf die Mikrozirkulation nicht auszuschließen. Es gibt z. Z. keine hinreichend gesicherte Therapieoption, die über die Stabilisierung der globalen Hämodynamik hinaus, eine gezielte Beeinflussung der regionalen Zirkulation ermöglicht. Das Konzept einer niedrig-dosierten Dopamingabe (Low-dose Dopamin, Dopamin in Nierendosis) muss heute eindeutig abgelehnt werden. Auch für Dopexamin liegen z. Z. keine Daten vor, die den klinischen Einsatz rechtfertigen.

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  1. Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, HELIOS Klinikum Erfurt GmbH, Nordhäuser Straße 74, 99089, Erfurt, Germany

    A. Meier-Hellmann

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Serie: Die Intensivtherapie bei Sepsis und Multiorganversagen Herausgegeben von L. Engelmann (Leipzig)

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Meier-Hellmann, A. Therapie des Kreislaufversagens bei Sepsis. Intensivmed 41, 583–591 (2004). https://doi.org/10.1007/s00390-004-0514-4

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