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Anästhesiol Intensivmed Notfallmed Schmerzther 2013; 48(1): 18-27
DOI: 10.1055/s-0032-1333074
Fachwissen
Intensivmedizin
© Georg Thieme Verlag Stuttgart · New York

Operative Therapie und Intensivmedizin bei Schwerbrandverletzten – Teil 2: Grundzüge der Weiterversorgung

Surgical therapy and critical care medicine in severely burned patients – Part 2: the basics in definite care
Robert Deisz
,
Jens Kauczok
,
Rolf Dembinski
,
Norbert Pallua
,
Gernot Marx
Further Information

Publication History

Publication Date:
30 January 2013 (online)

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Zusammenfassung

Die intensivmedizinische Versorgung Schwerbrandverletzter muss sich an den unterschiedlichen Phasen der Verbrennungskrankheit orientieren. In diesem Sinne müssen operative und nicht-operative Maßnahmen koordiniert werden. Nachdem im ersten Teil des Beitrags (Operative Therapie und Intensivmedizin bei Schwerbrandverletzten – Teil 1: die ersten 24 Stunden, AINS 9/12) die initiale Wundversorgung und die intensivmedizinischen Therapie erläutert wurden, geht der 2. Teil des Beitrags nun auf die anschließende langdauernde rekonstruktive Phase ein. In diesem Zeitraum ist der weitere kalkulierte Ausgleich des Flüssigkeitsdefizits bzw. anhaltender Flüssigkeitsverluste durch zerstörte Haut ebenso essenziell wie die Wiederherstellung der Integrität des Integuments und die Modulation der metabolischen Konsequenzen. Besonderes Augenmerk ist auf die Prophylaxe und Therapie lokaler und systemischer Infektionen zu richten.Chirurgisch steht neben dem Ziel der Defektdeckung die Vermeidung von Lokalkomplikationenim Vordergrund, wie sie z.B. durch überschießende Narbenbildung entstehen können.

Abstract

Critical care medicine in severely burned patients should be adapted to the different pathophysiological phases. Accordingly, surgical and non-surgical therapy must be coordinated adequately. Initial stabilization of the burn victim during the first 24 hours (Surgical therapy and critical care medicine in severely burned patients - Part 1: the first 24 ours, AINS 9/12) is followed by a long lasting reconstructive period. During this time calculated fluid replacement to compensate evaporative losses by large bourn wounds is as essential as reconstruction of the integrity of the skin and the modulation of metabolic consequences following severe burn injury. Special attention has to be paid to local and systemic infections.

Kernaussagen

  • Der transdermale Flüssigkeitsverlust über Verbrennungswunden beträgt bis zu 0,8 ml/cm2 verbrannter Körperoberfläche (vKOF) pro Tag. Kalkulation des Flüssigkeits-Erhaltungsbedarfs sowie tägliche Gewichtskontrollen erleichtern die Flüssigkeitsbilanzierung. In der Resorptionsphase sollte eine Hypernatriämie vermieden werden.

  • Die obligaten Proteinverluste über die geschädigte Haut sind neben dem Verbrennungsausmaß vom Zeitpunkt nach dem Verbrennungstrauma abhängig. Diese Verluste sollten bei der Berechnung der Stickstoffbilanz berücksichtigt werden.

  • Die Blutverluste bei Nekrektomien sind neben der resezierten Fläche vom Zeitpunkt nach dem Trauma abhängig. Eine Dilutionskoagulopathie sollte unbedingt vermieden werden. Brandverletzte profitieren von einem restriktiven Transfusionsregime für Frischplasmen, Erythozytenkontentrate und vermutlich auch Humanalbumin.

  • Der Energiebedarf kann z. B. anhand der Harris-Benedict-Formel unter Berücksichtigung eines von der Verbrennungsfläche abhängigen Traumafaktors berechnet werden.

  • Die Ernährung sollte bevorzugt enteral erfolgen. Die Bestimmung des Kalorienbedarfs mittels indirekter Kalorimetrie ist möglich, bringt aber gegenüber der Kalkulation des notwendigen Energiebedarfs (s. o.) keine klinischen Vorteile.

  • Der Energiebedarf des Brandverletzten kann durch eine adäquate Analgesie, eine erhöhte Raumtemperatur von ca. 30–33 °C sowie okklusive Verbände reduziert werden.

  • Der Hypermetabolismus kann durch eine niedrig dosierte Propranolol-Therapie günstig beeinflusst werden. Der Katabolismus wird durch das oral zu verabreichende anabole Steroid Oxandrolon positiv beeinflusst.

  • Die Diagnose von Infektionen bei Brandverletzten ist erschwert aufgrund der langanhaltenden verbrennungsinduzierten Inflammation und des Hypermetabolismus. Anstelle der SIRS-Kriterien treten Organdysfunktionen im weitesten Sinne als sog. Triggerkriterien eines Infektionsverdachts in den Vordergrund.

Schlüsselwörter:

Verbrennung - Therapie - Wundversorgung - Sepsis - Flüssigkeitstherapie - Ernährung - Hypermetabolismus

Key words:

burns - therapy - wound care - sepsis - fluid replacement - nutrition - hypermetabolism

Ergänzendes Material

 

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