Zusammenfassung
Fieber geht bei kritisch kranken Patienten mit einer Erhöhung der Mortalität und der Morbidität einher. Was jedoch dabei nach wie vor unklar bleibt, ist die Frage, ob Fieber nur als Symptom einer Grunderkrankung zu werten ist, die für die erhöhte Risikosituation verantwortlich ist, oder ob Fieber selber die pathophysiologischen Veränderungen induziert, die dieses Phänomen verursacht. Eine Hyperthermie geht mit einigen für einen kritisch kranken und septischen Patienten potenziell gefährdenden pathophysiologischen Veränderungen einher, die durch antipyretische Therapiemaßnahmen gebessert werden können. Hier sind insbesondere die durch den stark erhöhten Energieumsatz verursachten kardiopulmonalen Belastungen zu nennen. Andererseits ruft Fieber jedoch auch einige Veränderungen hervor, die die Immunantwort und damit die Abwehrlage des Patienten erheblich zu optimieren vermögen. Insbesondere der septische Patient, bei dem eine Infektion zumindest wahrscheinlich ist, würde gegebenenfalls durch fiebersenkende Therapiemaßnahmen dieser Immunkompetenz beraubt und eventuell zusätzlich gefährdet. Es lässt sich aus den bisher verfügbaren Erkenntnissen ableiten, dass sich eine Temperatur oberhalb von 40°C negativ auf den Krankheitsverlauf und die Abwehrkraft des Patienten auswirkt, sodass hier durchaus eine Behandlungsschwelle genannt werden kann. Nach jetziger Kenntnis ist bei septischen Patienten ein Temperaturbereich zwischen 36–39°C anzustreben. Es gibt jedoch bisher keine klinischen Daten, die die Überlegenheit irgendeiner antipyretischen Therapiemaßnahme bei septischem Krankheitsbild belegen können. Diesen Nachweis zu führen, ist unter Berücksichtigung der vielfältigen Ursachen einer fieberhaften Reaktion bei kritisch Kranken mit Sepsis sowie des multifaktoriellen Krankheitsbildes der Sepsis ein ausgeprochen schwieriger Weg.
Abstract
In critically ill patients fever is associated with an increased morbidity and mortality rate. However, it remains unclear whether fever is an associated symptom of the underlying severe disease or a stimulator of specific pathophysiological cascades considered responsible for a deleterious outcome. Hyperthermia per se induces systemic changes like increased energy and oxygen demands, tachycardia, or fluid loss which might be harmful especially in septic patients due to congestion of the cardiovascular system. In this constellation a reduction of fever by antipyretic strategies might be indicated to decrease oxygen and energy demands. On the other hand the increasing body temperature obviously plays an important role in the inflammatory hemostasis during infections. Fever optimises humoral and cellular responses to infection and has some direct effects on bacteria and other microorganisms. Therefore, in severe sepsis or septic shock, fever reduction might impair the immune competency of the patients. According to the currently available evidence a body temperature higher than 40°C is definitely harmful and should be treated in any case. A temperature range between 36°C and 39°C should be achieved for patients with severe sepsis and septic shock. At present there are no data showing the superiority of any of the different antipyrectic strategies in septic patients. Hence, external cooling with cold blankets or other devices may induce shivering of the muscles with a substantial increase of oxygen demand and is hardly tolerated in conscious patients. However, antipyretic therapy in patients with severe sepsis or septic shock should be indicated while considering the individual pathophysiology of every patient.
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Theilen, H., Ragaller, M. Therapie der Hyperthermie bei Sepsis und septischem Schock. Anaesthesist 56, 949–956 (2007). https://doi.org/10.1007/s00101-007-1211-z
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DOI: https://doi.org/10.1007/s00101-007-1211-z