Diagnostik und Management der Sepsis außerhalb der Intensivstation

 

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Zusammenfassung

Sepsis ist definiert als „Syndrom mit physiologischen, pathologischen und biochemischen Fehlregulationen als Antwort auf eine Infektion“. Bei zusätzlichem Vorliegen einer Organdysfunktion ist Sepsis mit einer hohen Krankenhaussterblichkeit von mehr als 10% assoziiert.

Die Einführung von standardisierten Diagnostik- und Behandlungsstandards auf Intensivstationen haben zu keiner wesentlichen Reduzierung der Krankenhaussterblichkeit bei Sepsis geführt. Da über 80 % der Sepsispatienten über Notaufnahmen oder Normalstationen auf eine Intensivstation aufgenommen werden, liegt ein mögliches Verbesserungspotential in einer strukturierten Diagnostik und Therapie außerhalb der Intensivstation. Die Erfassung des „quick sequential organ failure assessment“ (qSOFA: zwei der folgenden Kriterien müssen erfüllt sein: Atemfrequenz >22/min; systolischer Blutdruck <100mmHg; Vorliegen einer Bewusstseinsstörung) unterstützt bereits beim Erstkontakt mit dem Patienten, dessen Gefährdung zu erkennen. Eine nachfolgende, standardisierte Therapie unter Berücksichtigung der aktuellen Leitlinien senkt die Krankenhaussterblichkeit. Die Einführung dieser strukturierten Maßnahmen senkte in unserer Klinik die Krankenhaussterblichkeit bei ambulant erworbener Pneumonie um über 20%.

Zusammenfassend werden die Weichen für ein optimales Sepsismanagement bereits außerhalb der Intensivstation gestellt. Bereits in der prähospitalen Versorgung bzw. in Notaufnahmen sollten Patienten mit V.a. Sepsis ein strukturiertes und standardisiertes Sepsismanagement erhalten.

Abstract

Sepsis is defined as „life-threatening organ dysfunction caused by a dysregulated host-response to infection“. Presence of organ dysfunction is associated with a mortality of 10% and higher in hospitalized sepsis patients.

Introduction of standards in diagnosis and treatment of sepsis in intensive care units has not considerably reduced sepsis mortality. About 80% of patients with sepsis are transferred to intensive care units from usual care wards and emergency departments. Thus, it is tempting to speculate whether opportunities for further improvement of sepsis management exist outside of intensive care units. Performing a „quick sequential organ assessment“ (qSOFA; two of following criteria have to be present: respiratory rate >22/min; sytolic blood pressure <100mmHg; altered mental status) supports to identify patients with suspicion of an infection and an increased risk of death within the hospital. Subsequent treatment according to current guidelines on sepsis management will reduce in-hospital mortality of sepsis patients. Indeed, we were able to show a substantial decrease of in-hospital mortality of about 20% in patients presenting with community acquired pneumonia to the emergency department.

In summary, decision of further management of sepsis patients has to be done outside intensive care units at the time of initial presentation to professional care givers. Sepsis management in acute care settings should include a structured and standardized protocol to further improve survival in affected patients with even mild organ dysfunction.

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