Die extrakorporale Therapie septischer Patienten

摘要

Despite numerous therapeutic advances in critical care medicine, the treatment of patients with severe sepsis and septic shock remains a major medical challenge. In the pathogenetic course of systemic inflammation (SIRS), excessive release of endogenous and exogenous pro-inflammatory mediators such as lipopolysaccharides (LPS), tumor necrosis factor (TNF)-α, interleukin (IL)-1 and IL-6 occurs and multiple organ failure (MOF) develops. This leads to devastating clinical outcomes. In a complex dynamic control system, pro-inflammatory stimuli yield upregulation of anti-inflammatory mediators (IL-10, transforming growth factor-beta [TGF-β]) which induce a counter-regulatory anti-inflammatory response. This eventually yields monocytic deactivation leading to failure of the cell-mediated immune system (immunoparalysis). To reduce levels of circulating inflammatory and anti-inflammatory mediators, various approaches have been investigated, including selective and unselective intermittent and continuous extracorporeal treatment devices. Today, new blood purification technologies such as selective plasmapheresis and adsorption techniques provide new therapeutic avenues to target key mediators in septic patients. In this review, current and future adjunctive extracorporeal treatment strategies are discussed in the context of recent clinical trials.