Intensivmedizinische Betreuung des Patienten mit Sepsis

Zusammenfassung

Mit Diagnosestellung Sepsis muss auf der Intensivstation eine rasche hämodynamische und respiratorische Stabilisierung erfolgen. Als Zielparameter gilt ein MAP> 65mmHg. Hierzu erfolgt die Applikation von Vollelektrolytlösungen. Bei einem MAP<65mmHg sollten etwa 30ml/kg KG appliziert werden. Auf Volumenüberladung ist jedoch zu achten. Sollte trotz Volumen der MAP<65mmHg betragen, gilt Noradrenalin gilt als Katecholamin der 1. Wahl.

Zur Vermeidung einer Hypoxämie sollte bei SpO₂<90% O₂ appliziert werden, bei hochgradig instabilen bzw. deutlich vigilanzgeminderten Patienten ist eine invasive Beatmung indiziert. Es sollten zwei Paar Blutkulturen sowie je nach Fokus weitere mikrobiologische Diagnostik abgenommen werden. Erst danach erfolgt die Applikation von hochdosierten Breitspektrum Antibiotika (<60min nach Diagnose). Zur Fokusidentifikation muss neben Anamnese und Untersuchung zügig eine Bildgebung erfolgen und aktiv eine operative/interventionelle Fokuskontrolle (<12h nach Diagnose) geprüft werden. Patienten am Respirator sollten bezüglich Sedierung, Delir und Schmerzen mittels standardisierter Scores (RASS, CPOT, BPS, CAM-ICU) überwacht werden. Die lungenprotektive Beatmung (TV 6-8ml/kg Ideal-KG, Pmax<30mbar, PEEP) gilt als Standard und sollte mit einer möglich geringen Sedierung und frühen Mobilisation zur Ermöglichung der Spontanatmung kombiniert sein. Während der intensivmedizinischen Behandlung muss kontinuierlich auf weitere Organdysfunktionen geachtet werden. Bei Nierenschädigung ist frühzeitig eine CRRT (Dosis 20-25ml/kg/h) zu etablieren. Hierunter müssen die Antibiotika ausreichend hoch dosiert werden. Als Ernährungsoption gilt die frühe (<48h) enterale Ernährung mit 15-25kcal/kg/d als Standard, wobei mutmaßlich auch eine hypokalorische Ernährung bzw. eine parenterale Ernährung ausreichend sind. Bei Transfusionen sollte ein restriktives Regime (Trigger Hb<7g/dl) gewählt werden. Zur Vermeidung der nosokomialen Sepsis ist auf Intensivstation neben optimaler Hygiene und Antibiotic Stewardship eine ausreichende Personaldichte notwendig. Eine Qualitätssicherung in der Versorgung von Sepsispatienten schafft Transparenz und kann das Team motivieren.

Abstract

After recognition of the diagnosis sepsis early resuscitation of the patient is mandatory. Patients should have a mean arterial pressure (MAP) ≥65 mmHg. Patients with hypotension should receive initial fluid challenge with approximately 30 mL/kg of balanced electrolyte solutions. However, iatrogenic volume overload should be avoided. If MAP remains < 65mmHg despite adequate volume norepinephrine is the first choice catecholamine. Oxygen should be delivered when oxygen saturation is below 90% to avoid hypoxemia. Intubation and invasive ventilation is reasonable in hemodynamically unstable or unconscious patients. Two blood cultures should be drawn immediately in every septic patient plus further microbiological test depending on the primary focus. After that broad spectrum antibiotics should be given (<60 min after diagnosis). Strong effort must be done to identify the primary source of sepsis including examination, history and different imaging technics. Physicians have to check actively, if the source can be controlled (<12h) by surgery or intervention. Ventilated patients must be monitored for depth of sedation, pain and delir with standardized tools (RASS, CPOT, BPS, CAM-ICU). Lung protective ventilation (TV 6-8ml/kg Ideal-BW, Pmax<30mbar, application of PEEP) is standard in septic patients. It should be combined with low sedation and early mobilisation to allow spontaneous breathing. Permanent monitoring for further organ dysfunction is mandatory. In case of sepsis induced kidney injury, early CRRT should be started with an average dose of 20-25ml/kg/h. Under CRRT many antibiotics must be given at a high dose to prevent underdosing. Concerning nutrition, enteral nutrition starting with 48h is recommended with a dose of 15-25kcal/kg. However, it remains uncertain if hypocaloric nutrition or parenteral application may be equivalent. Transfusion should be done restrictively (with a trigger Hb < 7g/dl). For the prevention of nosocomial sepsis high standard hygiene and antibiotic stewardship programs as well as enough and sufficiently qualified staff are essential. Quality management for septic patients generates transparency and helps to motivate the ICU team.

Schlüsselwörter

Sepsis - septischer Schock - intensivmedizinische Therapie

Keywords

sepsis - septic shock - ICU therapy

• Literatur

• 1 Angus DC, van der Poll T. Severe sepsis and septic shock. N Engl J Med 2013; 369: 840-851
• 2 Fleischmann C, Thomas-Rueddel DO, Hartmann M et al. Hospital Incidence and Mortality Rates of Sepsis. Dtsch Arztebl Int. 2016; 113: 159-166
• 3 Dellinger RP, Levy MM, Rhodes A et al. Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013; 39: 165-228
• 4 Deutsches Institut für Medizinische Dokumentation und Information: Was versteht man unter SIRS? www.dimdi.de/static/de/klassi/faq/icd-10/icd-10-gm/maticd-sirs-def-2007–1007.pdf (Letzter Zugriff: 9.4.2016)
• 5 Kaukonen KM, Bailey M, Pilcher D et al. Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med 2015; 372: 1629-1638
• 6 Singer M, Deutschman CS, Seymour CW et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 2016; 315: 801-810
• 7 Yunos NM, Bellomo R, Hegarty C et al. Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA 2012; 308: 1566-1572
• 8 Volbeda M, Wetterslev J, Gluud C et al. Glucocorticosteroids for sepsis: systematic review with meta-analysis and trial sequential analysis. Intensive Care Med 2015; 41: 1220-1234
• 9 Seymour CW, Rosengart MR. Septic Shock: Advances in Diagnosis and Treatment. JAMA 2015; 314: 708-717
• 10 Zhang Z, Ni H, Qian Z. Effectiveness of treatment based on PiCCO parameters in critically ill patients with septic shock and / or acute respiratory distress syndrome: a randomized controlled trial. Intensive Care Med 2015; 41: 444-451
• 11 Rajaram SS, Desai NK, Kalra A et al. Pulmonary artery catheters for adult patients in intensive care. Cochrane Database Syst Rev 2013; 2: CD003408
• 12 Morelli A, Ertmer C, Westphal M et al. Effect of heart rate control with esmolol on hemodynamic and clinical outcomes in patients with septic shock: a randomized clinical trial. JAMA 2013; 310: 1683-1691
• 13 Peake SL, Delaney A, Bailey M et al. Goal-directed resuscitation for patients with early septic shock. N Engl J Med 2014; 371: 1496-1506
• 14 ProCESS Investigators, Yealy DM, Kellum JA. et al. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014; 370: 1683-1693
• 15 Mouncey PR, Osborn TM, Power GS et al. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015; 372: 1301-1311
• 16 Holst LB, Haase N, Wetterslev J et al. Lower versus higher hemoglobin threshold for transfusion in septic shock. N Engl J Med 2014; 371: 1381-1391
• 17 Kumar A, Roberts D, Wood KE et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care Med 2006; 34: 1589-1596
• 18 Ferrer R, Martin-Loeches I, Phillips G et al. Empiric antibiotic treatment reduces mortality in severe sepsis and septic shock from the first hour: results from a guideline-based performance improvement program. Crit Care Med 2014; 42: 1749-1755
• 19 Sterling SA, Miller WR, Pryor J et al. The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-Analysis. Crit Care Med 2015; 43: 1907-1915
• 20 Vesconi S, Cruz DN, Fumagalli R et al. Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury. Crit Care 2009; 13: R57
• 21 Shehabi Y, Bellomo R, Reade MC et al. Early intensive care sedation predicts long-term mortality in ventilated critically ill patients. Am J Respir Crit Care Med 2012; 186: 724-731
• 22 Tanaka LM, Azevedo LC, Park M et al. Early sedation and clinical outcomes of mechanically ventilated patients: a prospective multicenter cohort study. Crit Care 2014; 18: R156
• 23 Kress JP, Pohlman AS, O‘Connor MF et al. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000; 342: 1471-1477
• 24 Girard TD, Kress JP, Fuchs BD et al. Efficacy and safety of a paired sedation and ventilator weaning protocol for mechanically ventilated patients in intensive care (Awakening and Breathing Controlled trial): a randomised controlled trial. Lancet 2008; 371: 126-134
• 25 Mehta S, Burry L, Cook D et al. Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA 2012; 308: 1985-1992
• 26 Ortlepp JR, Luethje F, Walz R. Analgesia in intensive care medicine. Med Klin Intensivmed Notfmed 2016; 111: 6-13
• 27 Blackwood B, Burns KE, Cardwell CR et al. Protocolized versus non-protocolized weaning for reducing the duration of mechanical ventilation in critically ill adult patients. Cochrane Database Syst Rev 2014; 11: CD006904
• 28 Prowle JR, Bellomo R. Fluid administration and the kidney. Curr Opin Crit Care 2013; 19: 308-314
• 29 Mutter TC, Ruth CA, Dart AB. Hydroxyethyl starch (HES) versus other fluid therapies: effects on kidney function. Cochrane Database Syst Rev 2013; 23: CD007594
• 30 Caironi P, Tognoni G, Masson S et al. Albumin replacement in patients with severe sepsis or septic shock. N Engl J Med 2014; 370: 1412-1421
• 31 Fülöp T, Pathak MB, Schmidt DW et al. Volume-related weight gain and subsequent mortality in acute renal failure patients treated with continuous renal replacement therapy. ASAIO J 2010; 56: 333-337
• 32 Leal-Noval SR, Muñoz-Gómez M, Jiménez-Sánchez M et al. Red blood cell transfusion in non-bleeding critically ill patients with moderate anemia: is there a benefit?. Intensive Care Med 2013; 39: 445-453
• 33 Harvey SE, Parrott F, Harrison DA et al. Trial of the route of early nutritional support in critically ill adults. N Engl J Med 2014; 371: 1673-1684
• 34 Elke G, Kuhnt E, Ragaller M et al. Enteral nutrition is associated with improved outcome in patients with severe sepsis. A secondary analysis of the VISEP trial. Med Klin Intensivmed Notfmed 2013; 108: 223-233
• 35 Arabi YM, Aldawood AS, Haddad SH et al. Permissive Underfeeding or Standard Enteral Feeding in Critically Ill Adults. N Engl J Med 2015; 372: 2398-2408
• 36 Casaer MP, Mesotten D, Hermans G et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011; 365: 506-517
• 37 Lee BH, Inui D, Suh GY et al. Association of body temperature and antipyretic treatments with mortality of critically ill patients with and without sepsis: multi-centered prospective observational study. Crit Care 2012; 16: R33
• 38 Schortgen F, Clabault K, Katsahian S et al. Fever control using external cooling in septic shock: a randomized controlled trial. Am J Respir Crit Care Med 2012; 185: 1088
• 39 Darenberg J, Ihendyane N, Sjölin J et al. Intravenous immunoglobulin G therapy in streptococcal toxic shock syndrome: a European randomized, double-blind, placebo-controlled trial. Clin Infect Dis 2003; 37: 333
• 40 Linnér A, Darenberg J, Sjölin J et al. Clinical efficacy of polyspecific intravenous immunoglobulin therapy in patients with streptococcal toxic shock syndrome: a comparative observational study. Clin Infect Dis 2014; 59: 851
• 41 Alejandria MM, Lansang MA, Dans LF et al. Intravenous immunoglobulin for treating sepsis, severe sepsis and septic shock. Cochrane Database Syst Rev 2013; 9: CD001090
• 42 Price R, MacLennan G, Glen J et al. Selective digestive or oropharyngeal decontamination and topical oropharyngeal chlorhexidine for prevention of death in general intensive care: systematic review and network meta-analysis. BMJ 2014; 348: g2197
• 43 Battle CE, Davies G, Evans PA. Long term health-related quality of life in survivors of sepsis in South West Wales: an epidemiological study. PLoS One 2014; 9: e116304
• 44 Deutsches Qualitätsbündnis Sepsis – icosmos http://www.cscc.uniklinikum-jena.de/Icosmos.html (Letzter Zugriff: 10.4.2016)
• 45 Ulldemolins M, Vaquer S, Llauradó-Serra M et al. Beta-lactam dosing in critically ill patients with septic shock and continuous renal replacement therapy. Crit Care 2014; 18: 227
• 46 Roberts DM, Liu X, Roberts JA et al. A multicenter study on the effect of continuous hemodiafiltration intensity on antibiotic pharmacokinetics. Crit Care 2015; 19: 84
• 47 Fissell WH. Antimicrobial dosing in acute renal replacement. Adv Chronic Kidney Dis 2013; 20: 85-93
• 48 Zander J, Döbbeler G, Nagel D et al. Piperacillin concentration in relation to therapeutic range in critically ill patients – a prospective observational study. Crit Care 2016; 20: 79
• 49 Kuang D, Verbine A, Ronco C. Pharmacokinetics and antimicrobial dosing adjustment in critically ill patients during continuous renal replacement therapy. Clin Nephrol 2007; 67: 267-284
• 50 Lin H, Bukovskaya Y, De Moya M et al. Vancomycin continuous infusion versus intermittent infusion during continuous venovenous hemofiltration: slow and steady may win the race. Ann Intensive Care 2015; 5: 10
• 51 Spooner AM, Deegan C, D‘Arcy DM et al. An evaluation of ciprofloxacin pharmacokinetics in critically ill patients undergoing continuous veno-venous haemodiafiltration. BMC Clin Pharmacol 2011; 11: 11
• 52 Bouman CS. Antimicrobial dosing strategies in critically ill patients with acute kidney injury and high-dose continuous veno-venous hemofiltration. Curr Opin Crit Care 2008; 14: 654-659
• 53 Seyler L, Cotton F, Taccone FS et al. Recommended β-lactam regimens are inadequate in septic patients treated with continuous renal replacement therapy. Crit Care 2011; 15: R137
• 54 Roberts JA, Abdul-Aziz MH, Davis JS et al. Continuous versus Intermittent Beta-lactam Infusion in Severe Sepsis: A Meta-analysis of Individual Patient Data From Randomized Trials. Am J Respir Crit Care Med. 2016; Mar 14. [Epub ahead of print]
• 55 Patel BK, Wolfe KS, Pohlman AS et al. Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA 2016; 14: 315 2435-2441