Mythos „Volumenmangel bei Sepsis“

Der septische Schock ist ein lebensbedrohlicher Zustand, der durch eine dysregulierte Immunantwort auf eine Infektion hervorgerufen wird und zu Gewebe- und Organschäden und schließlich zum Tod führen kann. Die frühzeitige Erkennung und Beseitigung einer durch Sepsis verursachten Gewebeminderdurchblutung sind Schlüsselelemente bei der Behandlung von Patienten mit septischen Schock.

Abstract

Septic shock is a life-threatening condition caused by a dysregulated immune response to an infection and can lead to tissue and organ damage and ultimately to death. Early recognition and elimination of tissue perfusion loss caused by sepsis are key elements in the treatment of patients with septic shock. Hemodynamic management is divided into four phases. 1) initial phase, 2) optimization, 3) stabilization, 4) de-escalation. Fluid therapy is widely accepted in the initial phase, but recent evidence challenges its universality, highlighting fluid overload risks and increased mortality, necessitating individualized treatment.
Recent research has identified five distinct hemodynamic phenotypes in septic shock based on echocardiographic and clinical parameters:
Phenotype 1: Well resuscitated: Patients exhibit normal cardiac output and venous oxygen saturation (ScvO₂) without signs of volume depletion or overload.
Phenotype 2: Left ventricular systolic dysfunction: Characterized by low left ventricular ejection fraction (LVEF) and cardiac output, these patients require inotropic support rather than additional fluids.
Phenotype 3: Hyperkinetic state: Marked by increased cardiac output and LVEF, these patients appear volume-responsive but do not benefit from further fluid administration.
Phenotype 4: Right ventricular failure: Patients exhibit significant right ventricular dysfunction and increased right-to-left end-diastolic area ratio, making them particularly vulnerable to fluid overload.
Phenotype 5: Still hypovolemic: Defined by low cardiac index and volume responsiveness, these patients benefit from additional fluid administration.
These phenotypes provide a framework for precision medicine in septic shock, guiding fluid and vasopressor therapy. Tools such as passive leg raise (PLR) testing and echocardiographic monitoring are essential for assessing fluid responsiveness and optimizing treatment. Additionally, early norepinephrine administration enhances fluid efficiency, preventing unnecessary volume expansion.
A patient-specific approach incorporating hemodynamic phenotyping can improve outcomes by balancing resuscitation needs with the risk of fluid overload, ultimately optimizing survival in septic shock.

Kernaussagen

• Nur 57% der Patienten im septischen Schock sind bei Aufnahme auf Intensivstation volumenreagibel (Andromeda Shock I Trial [8]).

• Eine individualisierte und frühzeitige Behandlung bei septischem Schock ist essenziell.

• Das hämodynamische Management wird in 4 Phasen unterteilt:

  • Initialphase,

  • Optimierung,

  • Stabilisierung,

  • Deeskalation.

• Volumenreagibilität regelmäßig prüfen (u. a. Passive Leg Raise Test, Echokardiografie).

• Daran denken: Ein nicht unerheblicher Anteil an Flüssigkeit wird durch Ernährung, Erhaltungsflüssigkeit und Medikamentenverdünnung verabreicht.

• Die frühzeitige Gabe von Noradrenalin kann die Wirksamkeit der Volumentherapie steigern.

Schlüsselwörter

septischer Schock - Flüssigkeitshaushalt - transthorakale Echokardiografie

Keywords

septic shock - fluid balance - transthoracic echocardiography

Publication History

Article published online:
25 November 2025

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