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Intensivmedizin up2date 2014; 10(01): 17-38
DOI: 10.1055/s-0033-1359270
Allgemeine Prinzipien der Intensivmedizin
© Georg Thieme Verlag KG Stuttgart · New York

Sepsis mit intraabdominellem Fokus – eine interdisziplinäre Herausforderung

Emmanuel Schneck
,
Franziska Schneck
,
Julia P. Holler
,
Thilo Schwandner
,
Fritz Roller
,
Christoph Lichtenstern
,
Mira Küllmar
,
Markus Alexander Weigand
,
Winfried Padberg
,
Andreas Hecker
Further Information

Publication History

Publication Date:
11 February 2014 (online)

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Kernaussagen

  • Die Sepsis mit intraabdominellem Fokus ist ein chirurgischer Notfall und muss innerhalb von 1 h antibiotisch und innerhalb von 12 h chirurgisch behandelt werden. Um dies zu erreichen, sind klinikinterne Diagnostik- und Behandlungsabläufe zu empfehlen.

  • Die sekundäre Peritonitis ist die häufigste Ursache einer Sepsis mit intraabdominellem Fokus und oft durch Hohlorganperforationen oder postoperative Anastomoseninsuffizienzen bedingt.

  • Die Diagnose der Peritonitis wird klinisch gestellt. Eine apparative Diagnostik darf die antibiotische Therapie nicht verzögern.

  • Diagnostikum der Wahl ist nach der Sonografie die CT. Mit ihr ist eine exakte Lokalisation, aber auch die interventionelle Drainage des Infektionsherdes möglich.

  • Zur erfolgreichen Therapie der Sepsis mit intraabdominellem Fokus ist ein hohes Maß an Interdisziplinarität gefordert.

Die Literatur zu diesem Beitrag finden Sie unter http://dx.doi.org/10.1055/s-0033-1359270.

 

  • Literatur

  • 1 Schramm GE, Kashyap R, Mullon JJ et al. Septic shock: a multidisciplinary response team and weekly feedback to clinicians improve the process of care and mortality. Crit Care Med 2011; 39: 252-258
    CrossrefPubMedGoogle Scholar
  • 2 Rivers E et al. Early goal-directed Therapy in the Treatment of severe Sepsis and septic Shock. N Engl J Med 2001; 345: 1368-1377
    CrossrefPubMedGoogle Scholar
  • 3 Hagel S, Pletz MW, Brunkhorst FM et al. Bakteriämie und Sepsis. Internist (Berl) 2013; 54: 399-407
    CrossrefPubMedGoogle Scholar
  • 4 Dellinger RP et al. Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012. Crit Care Med 2013; 41: 580-637
    CrossrefPubMedGoogle Scholar
  • 5 Engel C et al. Epidemiology of sepsis in Germany: results from a national prospective multicenter study. Intensive Care Med 2007; 33: 606-618
    CrossrefPubMedGoogle Scholar
  • 6 Engel C, Brunkhorst FM, Löffler M. Diagnose und Epidemiologie der Sepsis. Ärzteblatt Thüringen 2007; 7: 414-417
    PubMedGoogle Scholar
  • 7 Hartl W, Kuppinger D, Vilsmaier M. Sekundäre Peritonitis. Zentralbl Chir 2011; 136: 11-7
    Article in Thieme ConnectPubMedGoogle Scholar
  • 8 Strobel O, Werner J, Büchler MW. Chirurgische Therapie der Peritonitis. Chirurg 2011; 82: 242-248
    CrossrefPubMedGoogle Scholar
  • 9 Peter FW, Häring R, Hirner A et al. Frühe Relaparotomie bei postoperativer Peritonitis. Zentralbl Chir 1989; 114: 844-850
    PubMedGoogle Scholar
  • 10 Knaebel HP, Seiler CM, Weigand MA et al. Aktueller Stand der Diagnostik und Therapie der Peritonitis. Zentralbl Chir 2007; 132: 419-426
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Vollmar B. Pathophysiologische Grundlagen der chirurgisch-bedingten Sepsis. Chirurg 2011; 82: 199-207
    CrossrefPubMedGoogle Scholar
  • 12 Boomer JS et al. Immunosuppression in patients who die of sepsis and multiple organ failure. JAMA 2011; 306: 2594-2605
    CrossrefPubMedGoogle Scholar
  • 13 Wenzel RP, Edmond MB. Septic shock – evaluating another failed treatment. N Engl J Med 2012; 366: 2122-2124
    CrossrefPubMedGoogle Scholar
  • 14 Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med 2013; 369: 840-851
    CrossrefPubMedGoogle Scholar
  • 15 Hotchkiss RS, Monneret G, Payen D. Immunosuppression in sepsis: a novel understanding of the disorder and a new therapeutic approach. Lancet Infect Dis 2013; 13: 260-268
    CrossrefPubMedGoogle Scholar
  • 16 Hotchkiss RS et al. Apoptotic cell death in patients with sepsis, shock, and multiple organ dysfunction. Crit Care Med 1999; 27: 1230-1251
    CrossrefPubMedGoogle Scholar
  • 17 Hotchkiss RS et al. Sepsis-induced apoptosis causes progressive profound depletion of B and CD4+ T lymphocytes in humans. J Immunol 2001; 166: 6952-6963
    CrossrefPubMedGoogle Scholar
  • 18 Hotchkiss RS et al. Depletion of dendritic cells, but not macrophages, in patients with sepsis. J Immunol 2002; 168: 2493-2500
    PubMedGoogle Scholar
  • 19 Luyt CE et al. Herpes simplex virus lung infection in patients undergoing prolonged mechanical ventilation. Am J Respir Crit Care Med 2007; 175: 935-942
    CrossrefPubMedGoogle Scholar
  • 20 Limaye AP et al. Cytomegalovirus reactivation in critically ill immunocompetent patients. JAMA 2008; 300: 413-422
    CrossrefPubMedGoogle Scholar
  • 21 Otto GP et al. The late phase of sepsis is characterized by an increased microbiological burden and death rate. Crit Care 2011; 15: R183
    CrossrefPubMedGoogle Scholar
  • 22 Kollef KE et al. Predictors of 30-day mortality and hospital costs in patients with ventilator-associated pneumonia attributed to potentially antibiotic-resistant gram-negative bacteria. Chest 2008; 134: 281-287
    CrossrefPubMedGoogle Scholar
  • 23 Brenner T et al. Viral infections in septic shock (VISS-trial)-crosslinks between inflammation and immunosuppression. J Surg Res 2012; 176: 571-582
    CrossrefPubMedGoogle Scholar
  • 24 Adib-Conquy M, Cavaillon JM. Compensatory anti-inflammatory response syndrome. Thromb Haemost 2009; 101: 36-47
    PubMedGoogle Scholar
  • 25 Bianchi ME. DAMPs, PAMPs and alarmins: all we need to know about danger. J Leukoc Biol 2007; 81: 1-5
    CrossrefPubMedGoogle Scholar
  • 26 Weber GF, Swirski FK. Immunopathogenesis of abdominal sepsis. Langenbecks Arch Surg 2013; DOI: 10.1007/s00423-013-1129-7.
    PubMedGoogle Scholar
  • 27 Ward P. Sepsis, apoptosis and complement. Biochem Pharmacol 2008; 76: 1383-1388
    CrossrefPubMedGoogle Scholar
  • 28 Huber-Lang M et al. Role of C5a in multiorgan failure during sepsis. J Immunol 2001; 166: 1193-1199
    PubMedGoogle Scholar
  • 29 Huber-Lang MS et al. Complement-induced impairment of innate immunity during sepsis. J Immunol 2002; 169: 3223-3231
    PubMedGoogle Scholar
  • 30 Niederbichler AD et al. An essential role for complement C5a in the pathogenesis of septic cardiac dysfunction. J Exp Med 2006; 203: 53-61
    CrossrefPubMedGoogle Scholar
  • 31 Nakae H et al. Serum complement levels and severity of sepsis. Res Commun Chem Pathol Pharmacol 1994; 84: 189-195
    PubMedGoogle Scholar
  • 32 Unsinger J et al. IL-7 promotes T cell viability, trafficking, and functionality and improves survival in sepsis. J Immunol 2010; 184: 3768-3779
    CrossrefPubMedGoogle Scholar
  • 33 Meisel C et al. Granulocyte-macrophage colony-stimulating factor to reverse sepsis-associated immunosuppression: a double-blind, randomized, placebo-controlled multicenter trial. Am J Respir Crit Care Med 2009; 180: 640-648
    CrossrefPubMedGoogle Scholar
  • 34 Ukleja A. Altered GI motility in critically Ill patients: current understanding of pathophysiology, clinical impact, and diagnostic approach. Nutr Clin Pract 2010; 25: 16-25
    CrossrefPubMedGoogle Scholar
  • 35 Clark JA, Coopersmith CM. Intestinal crosstalk: a new paradigm for understanding the gut as the “motor” of critical illness. Shock 2007; 28: 384-393
    CrossrefPubMedGoogle Scholar
  • 36 Weismüller K, Hofer S, Weigand MA. Perioperative Darmprotektion. Anaesthesist 2012; 61: 722-727
    CrossrefPubMedGoogle Scholar
  • 37 Bruewer M et al. Proinflammatory cytokines disrupt epithelial barrier function by apoptosis-independent mechanisms. J Immunol 2003; 171: 6164-6172
    PubMedGoogle Scholar
  • 38 Anderson JM, Van Itallie CM. Tight junctions and the molecular basis for regulation of paracellular permeability. Am J Physiol 1995; 269: G467-475
    PubMedGoogle Scholar
  • 39 Bodmann KF. Komplizierte intraabdominelle Infektionen: Erreger, Resistenzen. Chirurg 2010; 81: 38-49
    CrossrefPubMedGoogle Scholar
  • 40 Roehrborn A et al. The microbiology of postoperative peritonitis. Clin Infect Dis 2001; 33: 1513-1519
    CrossrefPubMedGoogle Scholar
  • 41 Pieracci FM, Barie PS. Intra-abdominal infections. Curr Opin Crit Care 2007; 13: 440-449
    CrossrefPubMedGoogle Scholar
  • 42 Harris AD et al. Universal glove and gown use and acquisition of antibiotic-resistant bacteria in the ICU: a randomized trial. JAMA 2013; 310: 1571-1580
    PubMedGoogle Scholar
  • 43 Climo MW et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med 2013; 368: 533-542
    CrossrefPubMedGoogle Scholar
  • 44 Huang SS et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med 2013; 368: 2255-2265
    CrossrefPubMedGoogle Scholar
  • 45 Vincent JL et al. Sepsis in European intensive care units: results of the SOAP study. Crit Care Med 2006; 34: 344-353
    CrossrefPubMedGoogle Scholar
  • 46 Lichtenstern C et al. Update: invasive Pilzinfektionen. Anaesthesist 2010; 59: 30-52
    CrossrefPubMedGoogle Scholar
  • 47 Welsch T et al. Persisting elevation of C-reactive protein after pancreatic resections can indicate developing inflammatory complications. Surgery 2008; 143: 20-28
    CrossrefPubMedGoogle Scholar
  • 48 Fleig V, Brenck F, Wolff M et al. Scoring-Systeme in der Intensivmedizin. Anaesthesist 2011; 60: 963-974
    CrossrefPubMedGoogle Scholar
  • 49 Bader FG et al. Diffuse postoperative peritonitis – value of diagnostic parameters and impact of early indication for relaparotomy. Eur J Med Res 2009; 14: 491-496
    CrossrefPubMedGoogle Scholar
  • 50 Reinhart K, Brunkhorst FM, Bone HG et al. Prävention, Diagnose, Therapie und Nachsorge der Sepsis – Leitlinien der Deutschen Sepsis-Gesellschaft und der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin. Anaesthesist 2010; 59: 347-370
    CrossrefPubMedGoogle Scholar
  • 51 von Mikulicz-Radecki J. Weitere Erfahrungen über die operative Behandlung der Perforationsperitonitis. Arch Klin Chir 1889; 39: 756-784
    PubMedGoogle Scholar
  • 52 Marshall JC, Maier RV, Jimenez M et al. Source control in the management of severe sepsis and septic shock: an evidence-based review. Crit Care Med 2004; 32: 513-26
    CrossrefPubMedGoogle Scholar
  • 53 Marshall JC, Al Naqbi A. Principles of source control in the management of sepsis. Crit Care Nurs Clin North Am 2011; 23: 99-114
    CrossrefPubMedGoogle Scholar
  • 54 De Waele JJ. Early source control in sepsis. Langenbecks Arch Surg 2010; 395: 489-494
    CrossrefPubMedGoogle Scholar
  • 55 Mier J, Leon EL, Castillo A et al. Early versus late necrosectomy in pancreatits. Am J Surg 1997; 173: 71-75
    CrossrefPubMedGoogle Scholar
  • 56 Polk HC, Fry DE. Radical peritoneal debridement for established peritonitis. The results of a prospective randomized clinical trial. Ann Surg 1980; 192: 350-355
    CrossrefPubMedGoogle Scholar
  • 57 Allemann P, Probst H, Demartines N et al. Prevention of infectious complications after laparoscopic appendectomy for complicated acute appendicitis--the role of routine abdominal drainage. Langenbecks Arch Surg 2011; 396: 63-68
    CrossrefPubMedGoogle Scholar
  • 58 Hau T, Ohmann C, Wolmershäuser A et al. Planned Relaparotomy vs Relaparotomy on Demand in the Treatment of Intra-abdominal Infections. Arch Surg 1995; 130: 1193-1197
    CrossrefPubMedGoogle Scholar
  • 59 Van Ruler O et al. Comparison of on-demand vs planned relaparotomy strategy in patients with severe peritonitis: a randomized trial. JAMA 2007; 298: 865-872
    CrossrefPubMedGoogle Scholar
  • 60 Koperna T, Schulz F. Relaparotomy in peritonitis: prognosis and treatment of patients with persisting intraabdominal infection. World J Surg 2000; 24: 32-37
    CrossrefPubMedGoogle Scholar
  • 61 Funk D, Sebat F, Kumar A. A systems approach to the early recognition and rapid administration of best practice therapy in sepsis and septic shock. Curr Opin Crit Care 2009; 15: 301-307
    CrossrefPubMedGoogle Scholar
  • 62 Bodman KF, Grabein B. Empfehlungen zur kalkulierten parenteralen Initialtherapie bakterieller Erkrankungen bei Erwachsenen – Update 2010. Rheinbach: Paul-Ehrlich-Gesellschaft für Chemotherapie e.V; 2010
    Google Scholar
  • 63 Cornely OA et al. ESCMID Guideline for the diagnosis and management of Candida diseases 2012: non-neutropenic adult patients. Clin Microbiol Infect 2012; 18: 19-37
    CrossrefPubMedGoogle Scholar
  • 64 Calandra T, Bille J, Schneider R et al. Clinical significance of Candida isolated from peritoneum in surgical patients. Lancet 1989; 2: 1437-1440
    PubMedGoogle Scholar
  • 65 Pappas PG et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America. Clin Infect Dis 2009; 48: 503-535
    CrossrefPubMedGoogle Scholar
  • 66 Solomkin JS et al. Diagnosis and management of complicated intra-abdominal infection in adults and children: guidelines by the Surgical Infection Society and the Infectious Diseases Society of America. Surg Infect (Larchmt) 2010; 1: 79-109
    PubMedGoogle Scholar
  • 67 European Medicines Agency (EMA). Hydroxyethyl-starch solutions (HES) should no longer be used in patients with sepsis or burn injuries or in critically ill patients – CMDh endorses PRAC recommendations. 2013 Im Internet: http://www.ema.europa.eu/docs/en_GB/document_library/Referrals_document/Solutions_for_infusion_containing_hydroxyethyl_starch/Position_provided_by_CMDh/WC500153119.pdf ; Stand: 01.11.2013
    PubMedGoogle Scholar
  • 68 The Royal College of Anaesthesists. Risk Benefit of HES Solutions questioned by EMA – Position Statement by the Faculty of Intensive Care Medicine, the Royal College of Anaesthesists, the Intensive Care Society and the College of Emergency Medicine. 2013 Im Internet: http://www.rcoa.ac.uk/news-and-bulletin/rcoa-news ; Stand: 01.11.2013
    PubMedGoogle Scholar
  • 69 Bundesministerium für Arzneimittel und Medizinprodukte. Hydroxyethylstärke (HES): Start eines europäischen Risikobewertungsverfahrens. 2013 Im Internet: www.bfarm.de/SharedDocs/Risikoinformationen/DE/RV_STP/RV-hes.html ; Stand: 01.11.2013
    PubMedGoogle Scholar
  • 70 DGAI, BDA, DAAF. Hydroxyethylstärke Stellungnahme der Präsidenten der DGAI und des BDA sowie der Präsidentin der DAAF. Notfall + Rettungsmedizin 2013; 16: 429-430
    CrossrefPubMedGoogle Scholar
  • 71 Rehm M. Anwendungsbeschränkung für Hydroxyäthylstärke. Anaesthesist 2013; 62: 644-655
    CrossrefPubMedGoogle Scholar
  • 72 Brunkhorst FM et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125-139
    CrossrefPubMedGoogle Scholar
  • 73 Perner A et al. Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med 2012; 367: 124-134
    CrossrefPubMedGoogle Scholar
  • 74 Myburgh JA, Finfer S, Billot L. Hydroxyethyl starch or saline in intensive care. N Engl J Med 2013; 368: 775
    CrossrefPubMedGoogle Scholar
  • 75 Annane D et al. Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock: The CRISTAL Randomized Trial. JAMA 2013;
    PubMedGoogle Scholar
  • 76 Schummer W. Central venous pressure. Validity, informative value and correct measurement. Anaesthesist 2009; 58: 499-505
    CrossrefPubMedGoogle Scholar
  • 77 Marik PE, Baram M, Vahid B. Does central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest 2008; 134: 172-178
    CrossrefPubMedGoogle Scholar
  • 78 Carl M et al. Guidelines for intensive care in cardiac surgery patients: haemodynamic monitoring and cardio-circulatory treatment guidelines of the German Society for Thoracic and Cardiovascular Surgery and the German Society of Anaesthesiology and Intensive Care Medicine. Thorac Cardiovasc Surg 2007; 55: 130-148
    Article in Thieme ConnectPubMedGoogle Scholar
  • 79 Nguyen VT, Ho JE, Ho CY et al. Handheld echocardiography offers rapid assessment of clinical volume status. Am Heart J 2008; 156: 537-542
    CrossrefPubMedGoogle Scholar
  • 80 Litton E, Morgan M. The PiCCO monitor: a review. Anaesth Intensive Care 2012; 40: 393-409
    PubMedGoogle Scholar
  • 81 Behnia M, Powell S, Fallen L et al. Correlation of Stroke Volume Measurement between Sonosite Portable Echocardiogram and Edwards Flotrac Sensor-Vigileo Monitor in an Intensive Care Unit. Clin Med Insights Circ Respir Pulm Med 2013; 7: 45-51
    PubMedGoogle Scholar
  • 82 Zhang Z, Lu B, Sheng X et al. Accuracy of stroke volume variation in predicting fluid responsiveness: a systematic review and meta-analysis. J Anesth 2011; 25: 904-916
    CrossrefPubMedGoogle Scholar
  • 83 Pope JV et al. Multicenter study of central venous oxygen saturation (ScvO(2)) as a predictor of mortality in patients with sepsis. Ann Emerg Med 2010; 55: 40-46
    CrossrefPubMedGoogle Scholar
  • 84 Lemyze M, Mallat J, Thevenin D. Prone positioning in the acute respiratory distress syndrome. N Engl J Med 2013; 369: 980
    PubMedGoogle Scholar
  • 85 Kaplan J, Sarnaik S, Gitlin J et al. Diminished helper/suppressor lymphocyte ratios and natural killer activity in recipients of repeated blood transfusions. Blood 1984; 64: 308-310
    Google Scholar
  • 86 Desachy A et al. Initial efficacy and tolerability of early enteral nutrition with immediate or gradual introduction in intubated patients. Intensive Care Med 2008; 34: 1054-1059
    CrossrefPubMedGoogle Scholar
  • 87 Brégeon F et al. Role of proinflammatory activity contained in gastric juice from intensive care unit patients to induce lung injury in a rabbit aspiration model. Crit Care Med 2008; 36: 3205-3212
    CrossrefPubMedGoogle Scholar
  • 88 Heidegger CP et al. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet 2013; 381: 385-393
    CrossrefPubMedGoogle Scholar
  • 89 Casaer MP et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011; 365: 506-517
    CrossrefPubMedGoogle Scholar
  • 90 Doig GS et al. Early parenteral nutrition in critically ill patients with short-term relative contraindications to early enteral nutrition: a randomized controlled trial. JAMA 2013; 309: 2130-2138
    CrossrefPubMedGoogle Scholar
  • 91 Schortgen F et al. Fever control using external cooling in septic shock: a randomized controlled trial. Am J Respir Crit Care Med 2012; 185: 1088-1095
    CrossrefPubMedGoogle Scholar
  • 92 Mourvillie B et al. Induced Hypothermia in Severe Bacterial Meningitis: A Randomized Clinical Trial. JAMA 2013; DOI: 10.1001/jama.2013.280506.
    PubMedGoogle Scholar
  • 93 Nadel S et al. Drotrecogin alfa (activated) in children with severe sepsis: a multicentre phase III randomised controlled trial. Lancet 2007; 369: 836-843
    CrossrefPubMedGoogle Scholar
  • 94 Abraham E et al. Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death. N Engl J Med 2005; 353: 1332-1341
    CrossrefPubMedGoogle Scholar
  • 95 Werdan K et al. Score-based immunoglobulin G therapy of patients with sepsis: the SBITS study. Crit Care Med 2007; 35: 2693-2701
    CrossrefPubMedGoogle Scholar
  • 96 Alejandria MM, Lansang MAD, Dans LF et al. Intravenous immunoglobulin for treating sepsis, severe sepsis and septic shock. Cochrane database Syst Rev 2013; 9
    PubMedGoogle Scholar
  • 97 Berger M, Eggimann P, Heyland D. Reduction of nosocomial pneumonia after major burns by trace element supplementation: aggregation of two randomised trials. Crit Care 2006; 10: R153
    CrossrefPubMedGoogle Scholar
  • 98 Mishra V et al. Effect of selenium supplementation on biochemical markers and outcome in critically ill patients. Clin Nutr 2007; 26: 41-50
    Google Scholar
  • 99 Heyland D et al. A randomized trial of glutamine and antioxidants in critically ill patients. N Engl J Med 2013; 368: 1489-1497
    CrossrefPubMedGoogle Scholar
  • 100 Rayman MP. The importance of selenium to human health. Lancet 2000; 356: 233-241
    CrossrefPubMedGoogle Scholar
  • 101 Wischmeyer PE. Glutamine: mode of action in critical illness. Crit Care Med 2007; 35: 541-544
    CrossrefPubMedGoogle Scholar
  • 102 Heyland DK, Dhaliwal R. Role of glutamine supplementation in critical illness given the results of the REDOXS study. J Parenter Enteral Nutr 2013; 37: 442-443
    CrossrefPubMedGoogle Scholar
  • 103 Oudemans-van Straaten HM, Bosman RJ, Treskes M et al. Plasma glutamine depletion and patient outcome in acute ICU admissions. Intensive Care Med 2001; 27: 84-90
    CrossrefPubMedGoogle Scholar