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.
Schlüsselwörter
septischer Schock - Flüssigkeitshaushalt - transthorakale Echokardiografie
Keywords
septic shock - fluid balance - transthoracic echocardiography
