Russell JA: Management of sepsis

University of British Columbia, Critical Care Medicine, St. Paul's Hospital, Vancouver, BC, Canada.
New England Journal of Medicine (Impact Factor: 55.87). 11/2006; 355(16):1699-713. DOI: 10.1056/NEJMra043632
Source: PubMed


Optimal management of sepsis requires early, goal-directed therapy; lung-protective ventilation; antibiotics; and possibly activated protein C. 56 The use of corticosteroids, vasopressin, and intensive insulin therapy requires further study. Later in the course of sepsis, appropriate management necessitates organ support and prevention of nosocomial infection. Studies focused on novel targets, mechanisms of action, and combination therapy may improve current treatment.

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    • "Perioperative nutrition will therefore decrease albumin losses not only by increasing hepatic synthesis as described above but also by decreasing losses in the extravascular space[20,34]. Since the physiological efflux rate of 5%/h already represents about 10 times the rate of albumin synthesis and catabolism, it appears thatcapillary leak due to the metabolic stress response probably represents the principal mechanism of postoperative albumin drops[28,34,41]. A previous study estimated that 77% of the postoperative albumin decrease was due to redistribution , while 18% and 6% were attributed to blood loss and catabolism, respectively,[22]. "
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    ABSTRACT: . Surgical stress during major surgery may be related to adverse clinical outcomes and early quantification of stress response would be useful to allow prompt interventions. The aim of this study was to evaluate the acute phase protein albumin in the context of the postoperative stress response. Methods . This prospective pilot study included 70 patients undergoing frequent abdominal procedures of different magnitude. Albumin (Alb) and C-reactive protein (CRP) levels were measured once daily starting the day before surgery until postoperative day (POD) 5. Maximal Alb decrease (Alb Δ min) was correlated with clinical parameters of surgical stress, postoperative complications, and length of stay. Results . Albumin values dropped immediately after surgery by about 10 g/L ( 42.2 ± 4.5 g/L preoperatively versus 33.8 ± 5.3 g/L at day 1, P < 0.001 ). Alb Δ min was correlated with operation length (Pearson ρ = 0.470 , P < 0.001 ), estimated blood loss ( ρ = 0.605 , P < 0.001 ), and maximal CRP values ( ρ = 0.391 , P = 0.002 ). Alb Δ min levels were significantly higher in patients having complications ( 10.0 ± 5.4 versus 6.1 ± 5.2 , P = 0.005 ) and a longer hospital stay ( ρ = 0.285 , P < 0.020 ). Conclusion . Early postoperative albumin drop appeared to reflect the magnitude of surgical trauma and was correlated with adverse clinical outcomes. Its promising role as early marker for stress response deserves further prospective evaluation.
    Full-text · Article · Jan 2016 · Gastroenterology Research and Practice
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    • "The definition of septic shock includes a systolic blood pressure (SBP) <90 mmHg, after adequate fluid replacement (commonly >30 mL⋅kg-1 in <6 h) and the need for vasopressor drugs for more than 1 h [4] or for 4 h (minimal requirements of NA >0.05 í µí¼‡g⋅kg-1⋅min-1). Earlier series have reported a death toll of ≈70% [5] and recent series still report a high mortality (27% [6], 20% [7], and 16% [8]). Refractory septic shock is defined as a requirement for NA >0.25 í µí¼‡g⋅kg-1⋅min-1 (>1 mg⋅h-1/70 kg) [9] or > 0.5 í µí¼‡g⋅kg-1⋅min-1 [10]. "
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    ABSTRACT: Progress over the last 50 years has led to a decline in mortality from ≈70% to ≈20% in the best series of patients with septic shock. Nevertheless, refractory septic shock still carries a mortality close to 100%. In the best series, the mortality appears related to multiple organ failure linked to comorbidities and/or an intense inflammatory response: shortening the period that the subject is exposed to circulatory instability may further lower mortality. Treatment aims at reestablishing circulation within a “central” compartment (i.e., brain, heart, and lung) but fails to reestablish a disorganized microcirculation or an adequate response to noradrenaline, the most widely used vasopressor. Indeed, steroids, nitric oxide synthase inhibitors, or donors have not achieved overwhelming acceptance in the setting of septic shock. Counterintuitively , α 2 -adrenoceptor agonists were shown to reduce noradrenaline requirements in two cases of human septic shock. This has been replicated in rat and sheep models of sepsis. In addition, some data show that α 2 -adrenoceptor agonists lead to an improvement in the microcirculation. Evidence-based documentation of the effects of alpha-2 agonists is needed in the setting of human septic shock.
    Full-text · Article · Dec 2015
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    • "The mortality rate of severe sepsis ranges from 25% to 70% when complicated by shock and multiple organ failure [4] [5]. The incidence of sepsis and septic shock has increased significantly over the past two decades with high economic cost [6]. "
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    ABSTRACT: . Elevated cytokines levels correlate with sepsis severity and mortality but their role in the diagnosis is controversial, whereas Procalcitonin (PCT) has been largely used. Recently, the mid-regional proadrenomedullin (MR-proADM) has been combined with PCT for diagnosis optimization. In this study the combined measurement of PCT, MR-proADM, and cytokines in patients with sepsis was evaluated. Methods . One hundred and four septic patients and 101 controls were enrolled. Receiver operating characteristic (ROC) analysis and multiple logistic regression were used to evaluate applicant markers for sepsis diagnosis. Markers with best Odds Ratio (OR) were combined, and the posttest probability and a composite score were computed. Results . Based upon ROC curves analysis, PCT, MR-proADM, IL-6, IL-10, TNF- α , and MCP-1 were considered applicant for sepsis diagnosis. Among these PCT, MR-proADM , IL-6, and TNF- α showed the best OR. A better posttest probability was found with the combination of PCT with MR-proADM and PCT with IL-6 or TNF- α compared to the single marker. A composite score of PCT, MR-proADM, and TNF- α showed the best ROC curve in the early diagnosis of sepsis. Conclusion . The combination of PCT with other markers should expedite diagnosis and treatment of sepsis optimizing clinical management.
    Full-text · Article · Nov 2015 · Disease markers
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