Die postoperative Sepsis: Diagnose, Besonderheiten, Management

Zusammenfassung

Die postoperative Sepsis gilt es vor allem früh zu erkennen. Es kann schwierig sein, die Sepsis vom normalen postoperativen SIRS zu unterscheiden. Häufige Frühzeichen sind Verwirrtheit und respiratorische Insuffizienz. Sie sollten Anlass geben, aggressiv nach einem Sepsisfokus zu fahnden, insbesondere aus dem Operationsgebiet. Rasche Sicherung der Oxygenierung, Stabilisierung des Kreislaufes nach definierten Zielkriterien, Breitspektum-Antibiotika-Applikation innerhalb der ersten Stunde und zügige Fokussanierung unter Berücksichtigung der Vorteile und Risiken des gewählten Vorgehens sind die Eckpunkte der Sepsistherapie. Bei abdominalem Fokus hat sich das Konzept der Relaparotomie on demand durchgesetzt.

Abstract

A high level of suspicion is necessary to detect postoperative sepsis in good time. It may be difficult to differentiate sepsis from normal SIRS in the postoperative setting. Early signs and symptoms include delirium and respiratory compromise. These should trigger the search for a septic focus aggressively with special attention to the original site of surgery. Key recommendations include early goal-directed resuscitation of the septic patient, administration of broad-spectrum antibiotic therapy within 1 hour of diagnosis, and source control with attention to the balance of risks and benefits of the chosen method. In cases of severe abdominal sepsis the concept of relaparotomy on-demand has become most popular.

Schlüsselwörter

postoperative Peritonitis - Sepsis - Komplikation - Anastomoseninsuffizienz - Antibiotikatherapie

Key words

postoperative peritonitis - sepsis - complications - anastomotic insufficiency - antibiotic treatment

Literatur

• 1 Dellinger R P, Carlet J M, Masur H et al. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock.  Intensive Care Med. 2004;  30 536-555
• 2 Reinhart K, Brunkhorst F, Bone H et al. Diagnose und Therapie der Sepsis: Leitlinien der Deutschen Sepsis-Gesellschaft und der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI).  Anaesthesist. 2006;  55 Suppl 1 43-56
• 3 Bone R C, Balk R A, Cerra F B et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP / SCCM Consensus Conference Committee. American College of Chest Physicians / Society of Critical Care Medicine.  Chest. 1992;  101 1644-1655
• 4 Marshall J C, Vincent J L, Fink M P et al. Measures, markers, and mediators: toward a staging system for clinical sepsis. A report of the Fifth Toronto Sepsis Roundtable, Toronto, Ontario, Canada, October 25–26, 2000.  Crit Care Med. 2003;  31 1560-1567
• 5 Angus D C, Burgner D, Wunderink R et al. The PIRO concept: P is for predisposition.  Crit Care. 2003;  7 248-251
• 6 Levy M M, Fink M P, Marshall J C et al. 2001 SCCM / ESICM / ACCP / ATS / SIS International Sepsis Definitions Conference.  Intensive Care Med. 2003;  29 530-538
• 7 Hillas G, Vassilakopoulos T, Plantza P et al. CRP and PCT as predictors of survival and septic shock in ventilator-associated pneumonia.  Eur Respir J. 2010;  35 805-811
• 8 Oh J S, Kim S U, Oh Y M et al. The usefulness of the semiquantitative procalcitonin test kit as a guideline for starting antibiotic administration.  Am J Emerg Med. 2009;  27 859-863
• 9 Venkatesh B, Kennedy P, Kruger P S et al. Changes in serum procalcitonin and C-reactive protein following antimicrobial therapy as a guide to antibiotic duration in the critically ill: a prospective evaluation.  Anaesth Intensive Care. 2009;  37 20-26
• 10 Sakr Y, Burgett U, Nacul F E et al. Lipopolysaccharide binding protein in a surgical intensive care unit: a marker of sepsis?.  Crit Care Med. 2008;  36 2014-2022
• 11 Tasabehji W R, Al-Quobaili F A, Al-Daher N A. Usefulness of procalcitonin and some inflammatory parameters in septic patients.  Saudi Med J. 2008;  29 520-525
• 12 Nobre V, Harbarth S, Graf J D et al. Use of procalcitonin to shorten antibiotic treatment duration in septic patients: a randomized trial.  Am J Respir Crit Care Med. 2008;  177 498-505
• 13 Cheval C, Timsit J F, Garrouste-Orgeas M et al. Procalcitonin (PCT) is useful in predicting the bacterial origin of an acute circulatory failure in critically ill patients.  Intensive Care Med. 2000;  26 Suppl 2 153-158
• 14 Bouadma L, Luyt C E, Tubach F et al. Use of procalcitonin to reduce patients’ exposure to antibiotics in intensive care units (PRORATA trial): a multicentre randomised controlled trial.  Lancet. 2010;  375 463-474
• 15 Giamarellos-Bourboulis E J, Giannopoulou P, Grecka P et al. Should procalcitonin be introduced in the diagnostic criteria for the systemic inflammatory response syndrome and sepsis?.  J Crit Care. 2004;  19 152-157
• 16 Brunkhorst F M, Karzai W, Reinhart K. Aktuelle Aspekte zur Sepsisdiagnose.  Zentralbl Chir. 2002;  127 165-173
• 17 Norwood M G, Bown M J, Lloyd G et al. The clinical value of the systemic inflammatory response syndrome (SIRS) in abdominal aortic aneurysm repair.  Eur J Vasc Endovasc Surg. 2004;  27 292-298
• 18 Sprung C L, Sakr Y, Vincent J L et al. An evaluation of systemic inflammatory response syndrome signs in the Sepsis Occurrence In Acutely Ill Patients (SOAP) study.  Intensive Care Med. 2006;  32 421-427
• 19 Vincent J L, Sakr Y, Sprung C L et al. Sepsis in European intensive care units: results of the SOAP study.  Crit Care Med. 2006;  34 344-353
• 20 Dellinger R P, Vincent J L. The Surviving Sepsis Campaign sepsis change bundles and clinical practice.  Crit Care. 2005;  9 653-654
• 21 Parker M M, Shelhamer J H, Bacharach S L et al. Profound but reversible myocardial depression in patients with septic shock.  Ann Intern Med. 1984;  100 483-490
• 22 Annane D, Bellissant E, Cavaillon J M. Septic shock.  Lancet. 2005;  365 63-78
• 23 Rivers E, Nguyen B, Havstad S et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock.  N Engl J Med. 2001;  345 1368-1377
• 24 Brunkhorst F M, Engel C, Ragaller M et al. Practice and perception – a nationwide survey of therapy habits in sepsis.  Crit Care Med. 2008;  36 2719-2725
• 25 Kumar A, Haery C, Parrillo J E. Myocardial dysfunction in septic shock.  Crit Care Clin. 2000;  16 251-287
• 26 Wiedemann H P, Wheeler A P, Bernard G R et al. Comparison of two fluid-management strategies in acute lung injury.  N Engl J Med. 2006;  354 2564-2575
• 27 Stewart R M, Park P K, Hunt J P et al. Less is more: improved outcomes in surgical patients with conservative fluid administration and central venous catheter monitoring.  J Am Coll Surg. 2009;  208 725-735 ,  discussion 735–737
• 28 Zander R. Flüssigkeitstherapie. 2. erweiterte Auflage ed. Melsungen: Bibliomed – Med. Verlagsgesellschaft mbH; 2009
• 29 Finfer S, Bellomo R, Boyce N et al. A comparison of albumin and saline for fluid resuscitation in the intensive care unit.  N Engl J Med. 2004;  350 2247-2256
• 30 Perel P, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill patients. Cochrane Database Syst Rev 2007: CD000567
• 31 Brunkhorst F M, Engel C, Bloos F et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis.  N Engl J Med. 2008;  358 125-139
• 32 Zander R, Boldt J, Engelmann L et al. Studienprotokoll der VISEP-Studie. Eine kritische Stellungnahme.  Anaesthesist. 2007;  56 71-77
• 33 The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.  N Engl J Med. 2000;  342 1301-1308
• 34 Petrucci N, Iacovelli W. Ventilation with lower tidal volumes versus traditional tidal volumes in adults for acute lung injury and acute respiratory distress syndrome. Cochrane Database Syst Rev 2003: CD003844
• 35 Kumar A, Roberts D, Wood K E 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
• 36 Sturkenboom M C, Goettsch W G, Picelli G et al. Inappropriate initial treatment of secondary intra-abdominal infections leads to increased risk of clinical failure and costs.  Br J Clin Pharmacol. 2005;  60 438-443
• 37 Roberts J A, Roberts M S, Robertson T A et al. Piperacillin penetration into tissue of critically ill patients with sepsis – bolus versus continuous administration?.  Crit Care Med. 2009;  37 926-933
• 38 Bodi M, Ardanuy C, Olona M et al. Therapy of ventilator-associated pneumonia: the Tarragona strategy.  Clin Microbiol Infect. 2001;  7 32-33
• 39 Vogel F, Bodmann K F. Empfehlungen zur kalkulierten parenteralen Initialtherapie bakterieller Erkrankungen bei Erwachsenen.  Chemotherapie Journal. 2004;  13 46-105
• 40 Wiessner R, Gierer P, Schaser K et al. Sublinguale Mikrozirkulationsstörungen bei Patienten im septischen Schock: Untersuchungen mittels OPS-Imaging-System und PiCCO-Monitoring.  Zentralbl Chir. 2009;  134 231-236
• 41 Connors Jr A F, Speroff T, Dawson N V et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT Investigators.  Jama. 1996;  276 889-897
• 42 Dellinger R P, Levy M M, Carlet J M et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.  Crit Care Med. 2008;  36 296-327
• 43 Meier-Hellmann A. Katecholamintherapie in der Sepsis.  Anaesthesist. 2000;  49 1069-1076
• 44 Russell J A, Walley K R, Singer J et al. Vasopressin versus norepinephrine infusion in patients with septic shock.  N Engl J Med. 2008;  358 877-887
• 45 Marshall J C, Maier R V, Jimenez M et al. Source control in the management of severe sepsis and septic shock: an evidence-based review.  Crit Care Med. 2004;  32 513-526
• 46 Pacelli F, Doglietto G B, Alfieri S et al. Prognosis in intra-abdominal infections. Multivariate analysis on 604 patients.  Arch Surg. 1996;  131 641-645
• 47 Brandstrup B, Tonnesen H, Beier-Holgersen R et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial.  Ann Surg. 2003;  238 641-648
• 48 Tambyraja A L, Sengupta F, MacGregor A B et al. Patterns and clinical outcomes associated with routine intravenous sodium and fluid administration after colorectal resection.  World J Surg. 2004;  28 1046-1051 ,  discussion 1051–1052
• 49 de Aguilar-Nascimento J E, Diniz B N, do Carmo A V et al. Clinical benefits after the implementation of a protocol of restricted perioperative intravenous crystalloid fluids in major abdominal operations.  World J Surg. 2009;  33 925-930
• 50 Nahtomi-Shick O, Kostuik J P, Winters B D et al. Does intraoperative fluid management in spine surgery predict intensive care unit length of stay?.  J Clin Anesth. 2001;  13 208-212
• 51 Gonzalez-Fajardo J A, Mengibar L, Brizuela J A et al. Effect of postoperative restrictive fluid therapy in the recovery of patients with abdominal vascular surgery.  Eur J Vasc Endovasc Surg. 2009;  37 538-543
• 52 Marjanovic G, Villain C, Juettner E et al. Impact of different crystalloid volume regimes on intestinal anastomotic stability.  Ann Surg. 2009;  249 181-185
• 53 Kimberger O, Arnberger M, Brandt S et al. Goal-directed colloid administration improves the microcirculation of healthy and perianastomotic colon.  Anesthesiology. 2009;  110 496-504
• 54 Shoemaker W C, Elwyn D H, Levin H et al. Use of nonparametric analysis of cardiorespiratory variables as early predictors of death and survival in postoperative patients.  J Surg Res. 1974;  17 1-12
• 55 Shoemaker W C, Czer L S. Evaluation of the biologic importance of various hemodynamic and oxygen transport variables: which variables should be monitored in postoperative shock?.  Crit Care Med. 1979;  7 424-431
• 56 Shoemaker W C, Chang P, Bland R et al. Cardiorespiratory monitoring in postoperative patients: II. Quantitative therapeutic indices as guides to therapy.  Crit Care Med. 1979;  7 243-249
• 57 Connors Jr A F. The role of right heart catheterization in the care of the critically ill: benefits, limitations, and risks.  Int J Cardiol. 1983;  4 474-477
• 58 Spohr F, Hettrich P, Bauer H et al. Comparison of two methods for enhanced continuous circulatory monitoring in patients with septic shock.  Intensive Care Med. 2007;  33 1805-1810
• 59 Uchino S, Kellum J A, Bellomo R et al. Acute renal failure in critically ill patients: a multinational, multicenter study.  Jama. 2005;  294 813-818
• 60 Bagshaw S M, Laupland K B, Doig C J et al. Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study.  Crit Care. 2005;  9 R700-R709
• 61 Bagshaw S M, Bellomo R, Kellum J A. Oliguria, volume overload, and loop diuretics.  Crit Care Med. 2008;  36 S172-S178
• 62 Ghaferi A A, Birkmeyer J D, Dimick J B. Complications, failure to rescue, and mortality with major inpatient surgery in medicare patients.  Ann Surg. 2009;  250 1029-1034
• 63 Schein Moshe M J. Source control. A guide to the management of surgical infections. Berlin, Heidelberg, New York. Springer 2003
• 64 Rau B, Uhl W, Buchler M W et al. Surgical treatment of infected necrosis.  World J Surg. 1997;  21 155-161
• 65 Marshall J C, Cook D J, Christou N V et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome.  Crit Care Med. 1995;  23 1638-1652
• 66 Vincent J L, Moreno R, Takala J et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine.  Intensive Care Med. 1996;  22 707-710
• 67 van Ruler O, Mahler C W, Boer K R et al. Comparison of on-demand vs. planned relaparotomy strategy in patients with severe peritonitis: a randomized trial.  Jama. 2007;  298 865-872
• 68 Bernard G R, Vincent J L, Laterre P F et al. Efficacy and safety of recombinant human activated protein C for severe sepsis.  N Engl J Med. 2001;  344 699-709
• 69 Barie P S, Williams M D, McCollam J S et al. Benefit/risk profile of drotrecogin alfa (activated) in surgical patients with severe sepsis.  Am J Surg. 2004;  188 212-220
• 70 Vincent J L, Bernard G R, Beale R et al. Drotrecogin alfa (activated) treatment in severe sepsis from the global open-label trial ENHANCE: further evidence for survival and safety and implications for early treatment.  Crit Care Med. 2005;  33 2266-2277
• 71 Abraham E, Laterre P F, Garg R et al. Drotrecogin alfa (activated) for adults with severe sepsis and a low risk of death.  N Engl J Med. 2005;  353 1332-1341
• 72 Utzolino S, Baier P, Hopt U T. Die Identifikation chirurgischer Patienten für die Therapie mit aktiviertem Drotrecogin alfa.  Anaesthesist. 2006;  55 Suppl 1 30-35
• 73 Annane D, Briegel J, Sprung C L. Corticosteroid insufficiency in acutely ill patients.  N Engl J Med. 2003;  348 2157-2159
• 74 Sprung C L, Annane D, Keh D et al. Hydrocortisone therapy for patients with septic shock.  N Engl J Med. 2008;  358 111-124
• 75 Stumpf M, Junge K, Wendlandt M et al. Risikofaktoren für das Auftreten postoperativer Anastomoseninsuffizienzen nach kolorektalen Resektionen.  Zentralbl Chir. 2009;  134 242-248
• 76 van den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in the critically ill patients.  N Engl J Med. 2001;  345 1359-1367
• 77 Finfer S, Chittock D R, Su S Y et al. Intensive versus conventional glucose control in critically ill patients.  N Engl J Med. 2009;  360 1283-1297
• 78 Angstwurm M W, Engelmann L, Zimmermann T et al. Selenium in Intensive Care (SIC): results of a prospective randomized, placebo-controlled, multiple-center study in patients with severe systemic inflammatory response syndrome, sepsis, and septic shock.  Crit Care Med. 2007;  35 118-126
• 79 Forceville X, Laviolle B, Annane D et al. Effects of high doses of selenium, as sodium selenite, in septic shock: a placebo-controlled, randomized, double-blind, phase II study.  Crit Care. 2007;  11 R73
• 80 Bloos F, Reinhart K. Neue Therapieansätze bei Sepsis.  Zentralbl Chir. 2002;  127 174-179
• 81 Kramer A, Schilling M, Heidecke C D. Infektionspräventions-Check-in und Infektionspräventions-Check-out zur Prävention nosokomialer Infektionen.  Zentralbl Chir. 2010;  135 44-48