Skip to main content
SpringerLink
Log in

Was ist gesichert in der Therapie der Sepsis?

What is evidence-based in the treatment of sepsis?

  • Schwerpunkt: Was ist gesichert in der Therapie?
  • Published:
Der Internist Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Der Begriff Sepsis ist 2016 als eine „lebensbedrohliche Organdysfunktion hervorgerufen durch eine inadäquate Wirtsantwort auf eine Infektion“ neu definiert worden. Die deutsche S3-Leitlinie zur Behandlung der Sepsis ist 2018 erschienen.

Fragestellung

Welche Evidenz gibt es in der Therapie des Patienten mit Sepsis?

Material und Methoden

Diskussion der S3-Leitlinie, Inklusion von Studienergebnissen nach 2018

Ergebnisse

Grundpfeiler der Sepsisbehandlung sind weiterhin die frühe hämodynamische Stabilisierung, die Fokussanierung inklusive antiinfektiver Therapie sowie organunterstützende Verfahren. Supportive sowie extrakorporale Therapien werden kontrovers diskutiert und weiter intensiv untersucht.

Schlussfolgerungen

Trotz eines verbesserten pathophysiologischen Verständnisses existiert noch keine effektive kausale, das heißt gegen die pathologische Wirtsreaktion gerichtete Sepsistherapie. Somit basiert die Behandlung des Patienten mit Sepsis weiter auf den Grundprinzipien Korrektur des Volumendefizits, Antiinfektiva, Fokussanierung und Organunterstützung inklusive der symptomatischen Behandlung der Vasoplegie mit Katecholaminen.

Abstract

Background

The term sepsis was redefined in 2016 as a life-threatening organ dysfunction caused by an inadequate host response to an infection. The German S3 guidelines for the treatment of sepsis were published in 2018.

Objective

What is evidence-based in the treatment of patients with sepsis?

Material and methods

Discussion of the S3 guidelines and inclusion of study results after 2018.

Results

The cornerstones for the treatment of sepsis continue to consist of early hemodynamic stabilization, anti-infection treatment and organ support procedures. Supportive and extracorporeal treatments are controversially discussed and continue to be intensively investigated.

Conclusion

Despite an improved understanding of the pathophysiology, there is still no effective causal sepsis treatment, i.e. directed against the pathological host reaction. The treatment of patients with sepsis is therefore still based on the basic principles of correction of volume deficits, anti-infective agents, source control and organ support, including the symptomatic treatment of vasoplegia with catecholamines.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2

Literatur

  1. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M et al (2016) The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA 315(8):801–810

    Article  CAS  Google Scholar 

  2. Angus DC, van der Poll T (2013) Severe sepsis and septic shock. N Engl J Med 369(21):2063

    CAS  PubMed  Google Scholar 

  3. Brunkhorst FM, Weigand MA, Pletz M, Gastmeier P, Lemmen SW, Meier-Hellmann A et al (2020) S3 guideline sepsis-prevention, diagnosis, therapy, and aftercare : long version. Med Klin Intensivmed Notfmed 115(Suppl 2):37–109

    Article  CAS  Google Scholar 

  4. Ferrer R, Martin-Loeches I, Phillips G, Osborn TM, Townsend S, Dellinger RP et al (2014) 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 42(8):1749–1755

    Article  CAS  Google Scholar 

  5. de Jong E, van Oers JA, Beishuizen A, Vos P, Vermeijden WJ, Haas LE et al (2016) Efficacy and safety of procalcitonin guidance in reducing the duration of antibiotic treatment in critically ill patients: a randomised, controlled, open-label trial. Lancet Infect Dis 16(7):819–827

    Article  Google Scholar 

  6. Lamontagne F, Richards-Belle A, Thomas K, Harrison DA, Sadique MZ, Grieve RD et al (2020) Effect of reduced exposure to vasopressors on 90-day mortality in older critically ill patients with vasodilatory hypotension: a randomized clinical trial. JAMA 323(10):938–949

    Article  CAS  Google Scholar 

  7. Gu WJ, Zhang Z, Bakker J (2015) Early lactate clearance-guided therapy in patients with sepsis: a meta-analysis with trial sequential analysis of randomized controlled trials. Intensive Care Med 41(10):1862–1863

    Article  Google Scholar 

  8. Yunos NM, Bellomo R, Hegarty C, Story D, Ho L, Bailey M (2012) Association between a chloride-liberal vs chloride-restrictive intravenous fluid administration strategy and kidney injury in critically ill adults. JAMA 308(15):1566–1572

    Article  CAS  Google Scholar 

  9. Annane D, Siami S, Jaber S, Martin C, Elatrous S, Declère AD et al (2013) Effects of fluid resuscitation with colloids vs crystalloids on mortality in critically ill patients presenting with hypovolemic shock: the CRISTAL randomized trial. JAMA 310(17):1809–1817

    Article  CAS  Google Scholar 

  10. Myburgh JA, Higgins A, Jovanovska A, Lipman J, Ramakrishnan N, Santamaria J (2008) A comparison of epinephrine and norepinephrine in critically ill patients. Intensive Care Med 34(12):2226–2234

    Article  Google Scholar 

  11. Gordon AC, Mason AJ, Thirunavukkarasu N, Perkins GD, Cecconi M, Cepkova M et al (2016) Effect of early vasopressin vs norepinephrine on kidney failure in patients with septic shock: the VANISH randomized clinical trial. JAMA 316(5):509–518

    Article  CAS  Google Scholar 

  12. Khanna A, English SW, Wang XS, Ham K, Tumlin J, Szerlip H et al (2017) Angiotensin II for the Treatment of Vasodilatory Shock. N Engl J Med 377(5):419–430

    Article  CAS  Google Scholar 

  13. Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J (2000) Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group. Lancet 356(9248):2139–2143

    Article  CAS  Google Scholar 

  14. Fichtner F, Moerer O, Laudi S, Weber-Carstens S, Nothacker M, Kaisers U (2018) Mechanical ventilation and extracorporeal membrane oxygena tion in acute respiratory insufficiency. Dtsch Arztebl Int 115(50):840–847

    PubMed  PubMed Central  Google Scholar 

  15. Bein T, Bischoff M, Brückner U, Gebhardt K, Henzler D, Hermes C et al (2015) Short version S2e guidelines: “Positioning therapy and early mobilization for prophylaxis or therapy of pulmonary function disorders”. Anaesthesist 64(8):596–611

    Article  CAS  Google Scholar 

  16. Bellani G, Laffey JG, Pham T, Madotto F, Fan E, Brochard L et al (2017) Noninvasive ventilation of patients with acute respiratory distress syndrome. Insights from the LUNG SAFE study. Am J Respir Crit Care Med 195(1):67–77

    Article  Google Scholar 

  17. Bagshaw SM, Wald R, Adhikari NKJ, Bellomo R, da Costa BR, Dreyfuss D et al (2020) Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med 383(3):240–251

    Article  CAS  Google Scholar 

  18. Schumer W (1976) Steroids in the treatment of clinical septic shock. Ann Surg 184(3):333–341

    Article  CAS  Google Scholar 

  19. Volbeda M, Wetterslev J, Gluud C, Zijlstra JG, van der Horst IC, Keus F (2015) Glucocorticosteroids for sepsis: systematic review with meta-analysis and trial sequential analysis. Intensive Care Med 41(7):1220–1234

    Article  CAS  Google Scholar 

  20. Venkatesh B, Finfer S, Cohen J, Rajbhandari D, Arabi Y, Bellomo R et al (2018) Adjunctive glucocorticoid therapy in patients with septic shock. N Engl J Med 378(9):797–808

    Article  CAS  Google Scholar 

  21. Annane D, Renault A, Brun-Buisson C, Megarbane B, Quenot JP, Siami S et al (2018) Hydrocortisone plus fludrocortisone for adults with septic shock. N Engl J Med 378(9):809–818

    Article  CAS  Google Scholar 

  22. Shankar-Hari M, Culshaw N, Post B, Tamayo E, Andaluz-Ojeda D, Bermejo-Martín JF et al (2015) Endogenous IgG hypogammaglobulinaemia in critically ill adults with sepsis: systematic review and meta-analysis. Intensive Care Med 41(8):1393–1401

    Article  CAS  Google Scholar 

  23. Cui J, Wei X, Lv H, Li Y, Li P, Chen Z et al (2019) The clinical efficacy of intravenous IgM-enriched immunoglobulin (pentaglobin) in sepsis or septic shock: a meta-analysis with trial sequential analysis. Ann Intensive Care 9(1):27

    Article  Google Scholar 

  24. Welte T, Dellinger RP, Ebelt H, Ferrer M, Opal SM, Singer M et al (2018) Efficacy and safety of trimodulin, a novel polyclonal antibody preparation, in patients with severe community-acquired pneumonia: a randomized, placebo-controlled, double-blind, multicenter, phase II trial (CIGMA study). Intensive Care Med 44(4):438–448

    Article  CAS  Google Scholar 

  25. Beitland S, Sandven I, Kjærvik LK, Sandset PM, Sunde K, Eken T (2015) Thromboprophylaxis with low molecular weight heparin versus unfractionated heparin in intensive care patients: a systematic review with meta-analysis and trial sequential analysis. Intensive Care Med 41(7):1209–1219

    Article  CAS  Google Scholar 

  26. Arabi YM, Khedr M, Dara SI, Dhar GS, Bhat SA, Tamim HM et al (2013) Use of intermittent pneumatic compression and not graduated compression stockings is associated with lower incident VTE in critically ill patients: a multiple propensity scores adjusted analysis. Chest 144(1):152–159

    Article  Google Scholar 

  27. Dupuis C, Sonneville R, Adrie C, Gros A, Darmon M, Bouadma L et al (2017) Impact of transfusion on patients with sepsis admitted in intensive care unit: a systematic review and meta-analysis. Ann Intensive Care 7(1):5

    Article  Google Scholar 

  28. Krag M, Marker S, Perner A, Wetterslev J, Wise MP, Schefold JC et al (2018) Pantoprazole in patients at risk for gastrointestinal bleeding in the ICU. N Engl J Med 379(23):2199–2208

    Article  CAS  Google Scholar 

  29. Young PJ, Bagshaw SM, Forbes AB, Nichol AD, Wright SE, Bailey M et al (2020) Effect of stress ulcer prophylaxis with proton pump inhibitors vs histamine‑2 receptor blockers on in-hospital mortality among ICU patients receiving invasive mechanical ventilation: the PEPTIC randomized clinical trial. JAMA 323(7):616–626

    Article  CAS  Google Scholar 

  30. Reignier J, Mercier E, Le Gouge A, Boulain T, Desachy A, Bellec F et al (2013) Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA 309(3):249–256

    Article  CAS  Google Scholar 

  31. Bloos F, Trips E, Nierhaus A, Briegel J, Heyland DK, Jaschinski U et al (2016) Effect of sodium selenite administration and Procalcitonin-guided therapy on mortality in patients with severe sepsis or septic shock: a randomized clinical trial. JAMA Intern Med 176(9):1266–1276

    Article  Google Scholar 

  32. Fowler AA 3rd, Truwit JD, Hite RD, Morris PE, DeWilde C, Priday A et al (2019) Effect of vitamin C infusion on organ failure and biomarkers of inflammation and vascular injury in patients with sepsis and severe acute respiratory failure: the CITRIS-ALI randomized clinical trial. JAMA 322(13):1261–1270

    Article  Google Scholar 

  33. Moskowitz A, Huang DT, Hou PC, Gong J, Doshi PB, Grossestreuer AV et al (2020) Effect of ascorbic acid, corticosteroids, and thiamine on organ injury in septic shock: the ACTS randomized clinical trial. JAMA 324(7):642–650

    Article  CAS  Google Scholar 

  34. Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V et al (2009) Intensive versus conventional glucose control in critically ill patients. N Engl J Med 360(13):1283–1297

    Article  Google Scholar 

  35. Seeliger B, Stahl K, David S (2020) Extracorporeal techniques for blood purification in sepsis: an update. Internist. https://doi.org/10.1007/s00108-020-00862-5

    Article  Google Scholar 

  36. David S, Stahl K (2019) To remove and replace—a role for plasma exchange in counterbalancing the host response in sepsis. Crit Care 23(1):14

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover (MHH), Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland

    K. Stahl

  2. Klinik für Pneumologie, Medizinische Hochschule Hannover, Hannover, Deutschland

    B. Seeliger

  3. Klinik für Nieren- und Hochdruckerkrankungen, Medizinische Hochschule Hannover, Hannover, Deutschland

    S. David &  J. Schmidt

  4. Institut für Intensivmedizin, Universitätsspital Zürich, Rämistrasse 100, Zürich, Schweiz

    S. David

Authors
  1. K. Stahl
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. B. Seeliger
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. S. David
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. J. Schmidt
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding authors

Correspondence to K. Stahl or S. David.

Ethics declarations

Interessenkonflikt

K. Stahl, B. Seeliger, S. David und J. Schmidt geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

Additional information

Redaktion

H. Haller, Hannover

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Stahl, K., Seeliger, B., David, S. et al. Was ist gesichert in der Therapie der Sepsis?. Internist 61, 1238–1248 (2020). https://doi.org/10.1007/s00108-020-00895-w

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00108-020-00895-w

Schlüsselwörter

Keywords

Search

Navigation