Mikrozirkulation bei Sepsis und septischem Schock

Zusammenfassung

Die komplexe Dysregulation der Mikrozirkulation spielt eine zentrale Rolle in der Pathogenese von Sepsis und septischen Schock und führt, wenn sie nicht rechtzeitig beseitigt werden kann, zum Multiorganversagen (MOV) und Tod. Maßnahmen zur Wiederherstellung der mikrovaskulären Zirkulation (Rekrutierung von Kapillaren) sind daher logische Therapieansätze zur Überwindung der Gewebehypoxie und zur Verhinderung eines MOV.

Aufgrund guter wissenschaftlicher Evidenz kann für den klinischen Einsatz bezüglich der Restitution der Mikrozirkulation bei schwerer Sepsis und septischen Schock die frühzeitige und an hämodynamischen und metabolischen Zielen ausgerichtete Volumenersatztherapie EGDT. (early goal directed therapy) sowie die Applikation von rhAPC entsprechend der EU-Zulassungsindikationen empfohlen werden. Für die Behandlung der septisch induzierten Kardiomyopathie ist Dobutamin das Mittel der ersten Wahl, während Phosphodiesterase-III-Inhibitoren oder Levosimendan noch experimentelle Therapieoptionen darstellen. Inwieweit die direkten Effekte von Dobutamin und rhAPC auf die Mikrozirkulation klinisch relevant sind sollte in weiteren Studien geprüft werden.

Summary

The severe impairment of the microcirculation plays a substantial role in the pathogenesis of severe sepsis and septic shock, and leads to multiple organ failure and death. Therapeutic strategies to resuscitate the microcirculatory blood flow and to improve the functional capillar density are therefore essential to surmount the microcirculatory pathology and to avoid tissue hypoxia.

Based on reasonable scientific evidence, early fluid resuscitation directed by defined haemodynamic and metabolic goals (EGDT) as well as the application of activated protein C (rhAPC) according to the guidelines could be recommended. Dobutamine is the first choice to improve cardiac output and to overcome myocardial depression in septic shock whereas phosphodiesterase-III-inhibitors and levosimendane are still experimental options.

Furthermore selective inhibitors of iNOS, nitroglycerol, as well as vasopressin have to be investigated relating to their specific effects on the microcirculation and their influence on survival in severe sepsis and septic shock.

Schlüsselwörter

Mikrozirkulation - funktionelle Kapillardichte - Gewebehypoxie - Volumenersatz - Dobutamin - rhAPC

Keywords

Microcirculation - functional capillar density - tissue hypoxia - fluid resuscitation - dobutamine - rhAPC

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