Sekundäre Peritonitis

 

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Zusammenfassung

Hintergrund: Bis heute ist nicht genau bekannt, in wieweit chirurgische bzw. intensivmedizinische Determinanten für die Prognose von Patienten mit intensivpflichtiger sekundärer Peritonitis und ­konsekutivem Organversagen relevant sind. Ferner ist unklar, ob sich die Prognose dieser ­Patienten seit 2002 durch die Einführung neuer intensiv­medizinischer Therapien („Surviving Sepsis Campaign“) verbessert hat. Material und Methodik: MEDLINE, EMBASE und Cochrane-Datenbanken wurden anhand der Stichwörter „source control“, „peritonitis“, „operation“, critical care“ und „antibiotics“ nichtsystematisch nach Publikationen durchsucht, die zwischen 1985 und 2010 erschienen waren. Wir berichten auch über Erfahrungen bei entsprechenden Hochrisikopatienten aus unserer eigenen Klinik. Ergebnisse: Sowohl eine fehlende Fokuskontrolle als auch eine inadäquate empirische antimikro­bielle Therapie verschlechtert die Akutprognose. In Abhängigkeit vom initialen Befund sind die programmierte Lavage und die „On-demand“-Relaparotomie sich ergänzende Konzepte. Die prognostische Bedeutung der Zahl der Revisionseingriffe ist bisher ungeklärt. Eine Behandlung nach 2002 ist mit einer deutlich besseren Akutprognose verbunden. Im Gegensatz zur Fokuskontrolle sind die Mechanismen, durch die sich bei inadäquater empirischer antimik­robieller Therapie die Letalität erhöht, unklar. Schlussfolgerung: Die Fokuskontrolle ist die wichtigste Determinante der Akutletalität und muss deswegen in der klinisch-therapeutischen Hierarchie an erster Stelle stehen. Die Zahl der zur Fokuskontrolle nötigen Revisionseingriffe kann nicht als Entscheidungshilfe bez. Fortführung oder Abbruch der Therapie herangezogen werden. Die Verbesserung der Prognose in den letzten Jahren bestätigt die Effizienz neuer intensivmedizinischer Thera­pien bei diesem Hochrisikokollektiv auch im klinischen Alltag. 

Abstract

Background: There is some controversy regarding concepts currently propagated for an optimal surgical and antibiotic therapy in patients with sec­ondary peritonitis and organ failure. It is not known whether the recent general progress in criti­cal care (“Surviving Sepsis Campaign”) has also improved outcome of this particular patient group. Methods: MEDLINE, EMBASE and Cochrane databases were non-systematically searched from 1985 through January 2010 using the words “source control”, “peritonitis”, “operation”, “critical care” and “antibiotics”. We also present experiences in corresponding high risk patients from our institution. Results: The inability to obtain source control and an inadequate initial antibiotic therapy were ­associated with a clearly higher mortality. De­pending on the initial intraoperative finding, planned and on demand relaparotomy do not conflict, but complement one another. The importance of the number of surgical revisions remains to be determined. Treatment after 2002 was associated with an improved prognosis. In contrast to source control, the mechanisms of increasing mortality with an inadequate initial antibiotic therapy remain controversial. Conclusion: Source control is the most important determinant for acute survival and has to be placed on top of the therapeutic priority list. The number of revisions needed to obtain source control, however, does not vary with survival and cannot guide decisions on therapy withdrawal or continuation. The recent prognostic improvement indicates the efficiency of new adjuvant therapeutic measures in unselected surgical high-risk patients. 

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Prof. W. Hartl

Chirurgische Klinik der Universität · Campus Großhadern · LMU München

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