Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008

Glucose control in sepsis

Hyperglycemia is common during the course of critical illness and is associated with adverse clinical outcomes. Randomized controlled trials and large observational trials of insulin therapy titrated to achieve glucose values approximating the normal range (80 to 110 mg/dL) demonstrate improved morbidity and mortality in heterogeneous populations and have led to recommendations for improved glucose control. Patients who have septic shock, however, appear to be at higher risk for hypoglycemia, and a recent randomized trial focusing exclusively on patients who had severe sepsis did not show benefit. The recent Surviving Sepsis consensus statement recommends insulin therapy using validated protocols to lower glucose (less than 150 mg/dL) pending the results of adequately powered trials to determine if normalization (less than 110 mg/dL) of glucose is needed to optimize outcomes in patients who have severe sepsis.

The heterogeneity of the microcirculation in critical illness

Microcirculation, a complex and specialized facet of organ architecture, has characteristics that vary according to the function of the tissue it supplies. Bedside technology that can directly observe microcirculation in patients, such as orthogonal polarization spectral imaging and sidestream dark field imaging, has opened the way to investigating this network and its components, especially in critical illness and surgery. These investigations have underscored the central role of microcirculation in perioperative disease states. They have also highlighted variations in the nature of microcirculation, both among organ systems and within specific organs. Supported by experimental studies, current investigations are better defining the nature of microcirculatory alterations in critical illness and how these alterations respond to therapy. This review focuses on studies conducted to date on the microcirculatory beds of critically ill patients. The functional anatomy of microcirculation networks and the role of these networks in the pathogenesis of critical illness are discussed. The morphology of microvascular beds that have been visualized during surgery and intensive care at the bedside are also described, including those of the brain, sublingual region, skin, intestine, and eyes.

Hydroxyethylstarch impairs renal function and induces interstitial proliferation, macrophage infiltration and tubular damage in an isolated renal perfusion model

Introduction

The aim of the study was to evaluate some of the underlying pathomechanisms of hydroxyethylstarch (HES) induced adverse effects on renal function using 24 porcine kidneys in an isolated perfusion model over six hours.

Methods

Infusion of either 10% HES 200/0.5, 6% HES 130/0.42 or Ringer's lactate (RL) was performed to achieve an haematocrit of 20% in eight kidneys from four animals per group. Physiological and pathophysiological parameters were determined (including N-acetyl-beta-aminoglucosidase as a marker for lysosomal tubular damage). Histological investigations and immunohistological stainings of the kidneys were performed.

Results

Initially after haemodilution, HES 130/0.42 and HES 200/0.5 reduced urine output compared with RL (P < 0.01). After six hours, N-acetyl-beta-aminoglucosidase was significantly higher in HES 200/0.5 (81 ± 23 U/L) compared with HES 130/0.42 (38 ± 12 U/L) and RL (21 ± 13 U/L; P < 0.001). Osmotic nephrosis-like lesions (OL) of the tubuli were present in all groups showing a significantly lower number of OL in RL (1.1 ± 0.4; P = 0.002) compared with both HES groups (HES 200/0.5 = 2.1 ± 0.6; HES 130/0.42 = 2.0 ± 0.5). Macrophage infiltration was significantly higher in HES 200/0.5 compared with HES 130/0.42 (1.3 ± 1.0 vs. 0.2 ± 0.04; P = 0.044). There was a significant increase in interstitial cell proliferation in the HES 200/0.5 group vs. HES 130/0.42 (18.0 ± 6.9 vs. 6.5 ± 1.6; P = 0.006) with no significant difference in RL (13.5 ± 4.0).

Conclusions

We observed impaired diuresis and sodium excretion by HES and identified renal interstitial proliferation, macrophage infiltration and tubular damage as potential pathological mechanisms of HES-induced adverse effects on renal function using an isolated porcine renal perfusion model. Furthermore, we demonstrated that 10% HES 200/0.5 had more of a pro-inflammatory effect compared with 6% HES 130/0.42 and caused more pronounced tubular damage than 6% HES 130/0.42 and RL. OL were present in all groups, but to a lesser degree after RL administration.

The significance of non-sustained hypotension in emergency department patients with sepsis

OBJECTIVE

Few studies have documented the incidence and significance of non-sustained hypotension in emergency department (ED) patients with sepsis. We hypothesized that ED non-sustained hypotension increases risk of in-hospital mortality in patients with sepsis.

METHODS

Secondary analysis of a prospective cohort study. ED patients aged > 17 years admitted to the hospital with explicitly defined sepsis were prospectively identified.

INCLUSION CRITERIA

Evidence of systemic inflammation (> 1 criteria) and suspicion for infection. Patients with overt shock were excluded. The primary outcome was in-hospital mortality.

RESULTS

Seven hundred patients with sepsis were enrolled, including 150 (21%) with non-sustained hypotension. The primary outcome of in-hospital mortality was present in 10% (15/150) of patients with non-sustained hypotension compared with 3.6% (20/550) of patients with no hypotension. The presence of non-sustained hypotension resulted in three times the risk of mortality than no hypotension (risk ratio = 2.8, 95% CI 1.5-5.2). Patients with a lowest systolic blood pressure < 80 mmHg had a threefold increase in mortality rate compared with patients with a lowest systolic blood pressure > or = 80 mmHg (5 vs. 16%). In logistic regression analysis, non-sustained hypotension was an independent predictor of in-hospital mortality.

CONCLUSION

Non-sustained hypotension in the ED confers a significantly increased risk of death during hospitalization in patients admitted with sepsis. These data should impart reluctance to dismiss non-sustained hypotension, including a single measurement, as not clinically significant or meaningful.

Extending international sepsis epidemiology: the impact of organ dysfunction

In the previous issue of Critical Care, Blanco and colleagues contributed to a growing body of literature on the international epidemiology of severe sepsis. Taken together, these studies confirm that the sepsis incidence is high, that the development of organ dysfunction is a major determinant of mortality and that the occurrence of organ dysfunction is influenced by chronic comorbid medical conditions. It is clear that early detection of organ dysfunction and serial sequential organ dysfunction scoring provides us with the best chance to optimize clinical care. Identifying factors that contribute to the development of organ dysfunction in sepsis will lead to the development of new treatment modalities that will reduce mortality. Future studies must therefore focus on the impact of new treatment modalities for preventing progression to multiple organ dysfunction syndrome and consequent mortality in sepsis.

Enhanced T-cell apoptosis in human septic shock is associated with alteration of the costimulatory pathway

T-cell apoptosis during septic shock (SS) has been associated with deleterious outcome, but the mechanisms of apoptosis are not well understood. As T-cells are not infected in bacterial infection, our hypothesis was that deleterious interactions between lymphocytes and monocytes could be involved. This is a cross-sectional study of 27 patients presenting with community-acquired SS, 23 infected patients without SS and 18 controls. Cytofluorometric techniques were used to study apoptosis, the costimulatory pathway and cytokine synthesis. Apoptosis was increased in SS compared to infected patients without SS and controls: the median values were 18, 2 and 3%, respectively, for CD4(+) T-cells (P < 0.001), and 12, 5 and 2%, respectively, for CD8(+) T-cells (P < 0.001). Patients with SS exhibited significant CD152 over-expression on T-cells, while CD86 expression was decreased on monocytes (P = 0.004). The synthesis of interleukin-2 was decreased in patients with SS compared to the other groups, while secretions of interferon-gamma and TNF-alpha were not altered. Ten surviving patients with SS showed a trend towards the normalisation of these parameters on day 7. In SS, T-cell apoptosis is related, at least in part, to the alteration of the costimulatory pathway, which, in turn, leads to significant modification of the cytokine network.

Prospectively validated dosing nomograms for maximizing the pharmacodynamics of vancomycin administered by continuous infusion in critically ill patients

The efficacy of vancomycin against methicillin-resistant Staphylococcus aureus (MRSA)-related infections has been called into question by recent findings of higher rates of failure of vancomycin treatment of infections caused by strains with high MICs. Continuous infusion may be the best way to maximize the time-dependent activity of vancomycin. The aim of this study was to create dosing nomograms in relation to different creatinine clearance (CL(Cr)) estimates for use in daily clinical practice to target the steady-state concentrations (C(ss)s) of vancomycin during continuous infusion at 15 to 20 mg/liter (after the administration of an initial loading dose of 15 mg/kg of body weight over 2 h). The correlation between vancomycin clearance (CL(v)) and CL(Cr) was retrospectively assessed in a cohort of critically ill patients (group 1, n = 70) to create a formula for dosage calculation to target C(ss) at 15 mg/liter. The performance of this formula was prospectively validated in a similar cohort (group 2, n = 63) by comparison of the observed and the predicted C(ss)s. A significant relationship between CL(v) and CL(Cr) was observed in group 1 (P < 0.001). The application of the calculated formula to vancomycin dosing in group 2 {infusion rate (g/24 h) = [0.029 x CL(Cr) (ml/min) + 0.94] x target C(ss) x (24/1,000)} led to a significant correlation between the observed and the predicted C(ss)s (r = 0.80, P < 0.001). Two dosing nomograms based on CL(Cr) were created to target the vancomycin C(ss) at 15 and 20 mg/liter in critically ill patients. These nomograms could be helpful in improving the vancomycin treatment of MRSA infections, especially in the presence of borderline-susceptible pathogens and/or of pathophysiological conditions which may enhance the clearance of vancomycin, while potentially avoiding the increased risk of nephrotoxicity observed with the use of high intermittent doses of vancomycin.

Age bias in clinical trials in sepsis: how relevant are guidelines to older people?

Severe sepsis has a high mortality, and both incidence and mortality increases with increasing age. In recent years, several specific therapies have been recommended by guidelines to reduce mortality in severe sepsis. We review the age distribution in the key clinical trials on which these recommendations are made. Many therapeutic strategies have been evaluated, mainly in younger patients, with extrapolation of evidence toward the older population. Specific evidence of benefit in the elderly is present regarding treatment with activated protein C and ventilatory strategies. In view of the pharmacokinetic and pharmacodynamic differences in older people, and the higher incidence of comorbidity in the elderly, there is a need for clinical trials in severe sepsis to specifically include older patients.

An international survey: Public awareness and perception of sepsis

BACKGROUND

Sepsis is a common cause of death throughout the world. Early treatment improves outcome; however, treatment may be delayed if the patient does not present himself/herself for medical care until late in the disease process. Lack of knowledge about the syndrome may contribute to delay in presenting for medical care. However, we need to acknowledge the complexity of sepsis. General awareness of sepsis by the public may increase political pressure for research funding. Increased public awareness of acute myocardial infarction has contributed to reduced mortality over the last 50 yrs. This example provides a rationale for future efforts to increase the public awareness of sepsis.

OBJECTIVE

The survey was designed to gain insight into public perceptions and attitudes regarding sepsis.

DESIGN

Prospective, international survey performed using structured telephone interviews.

SUBJECTS

A total of 6021 interviewees, 5021 in Europe and 1000 in the United States.

MEASUREMENTS AND MAIN RESULTS

In Italy, Spain, the United Kingdom, France and the United States, a mean of 88% of interviewees had never heard of the term "sepsis". In Germany 53% of people knew the word sepsis. In Italy, Spain, United Kingdom, France, and United States, of people who recognized the term sepsis, 58% did not recognize that sepsis is a leading cause of death.

CONCLUSIONS

There is poor public awareness about the existence of a syndrome known as sepsis. Results of this questionnaire underscore the challenges in early management and treatment of infected patients at risk for developing sepsis syndrome.

Effect of vasopressin on survival of Purkinje neurons in rat cerebellar slices after an in vitro simulated ischemia

BACKGROUND

Arginine vasopressin (AVP) is frequently used in patients under the risk of brain injury. It has been shown to induce brain injury after ischemia and reperfusion in in vivo animal models. We determined the effect of vasopressin on the brain injury after ischemia-reperfusion using in vitro model.

METHODS

Cerebellar brain slices were prepared from adult Sprague-Dawley rats. They were then subjected to simulated ischemia (oxygen-glucose deprivation) for 20 min in the absence (control) or presence of vasopressin (5, 10, 50, 100, 500 pg/ml). After being recovered in oxygenated artificial cerebrospinal fluid for 5 h, they were fixed for morphologic examination to determine the percentage of live Purkinje cells.

RESULTS

There were no differences in the survival rate of Purkinje cells among the control and vasopressin groups.

CONCLUSIONS

Vasopressin at concentrations studied has no direct effect on brain ischemia-reperfusion injury.

Postregistration trials: should we? How do we?

Postregistration trials or postmarketing or phase IV trials are tools to investigate any treatment that is already approved and is, therefore, available for prescription use. The main objectives of these trials are typical effectiveness, more structured surveillance for uncommon or rare side effects, and the potential development of new indications. Several issues need to be addressed in the postregistration phase of the evaluation of a therapeutic treatment. Among those we will focus on two ethical challenges: reporting bias from industry-sponsored research and use of placebo as one of the arms in controlled studies where proven treatment already exists. The review of this topic is particularly relevant in the field of critical care because it is ongoing in the debate about the opportunity to perform a new placebo-controlled study with the recombinant human activated protein C (activated drotrecogin alfa-activated protein C). In fact, despite the approval of activated protein C for treatment of patients with severe sepsis and high risk of death, several issues regarding the efficacy and safety of its administration have been recognized by several investigators to the point that the European Medicines Agency asked for a new placebo-controlled study to further clarify the benefit/risk profile of activated protein C.

Antibiotic management of sepsis: current concepts

BACKGROUND

The development of guidelines for sepsis management has improved disease survival and reduced treatment costs. Adequate antibiotic therapy is the cornerstone of sepsis treatment. Specific rules should be established in every institution according to its profiles.

OBJECTIVES

To review the current knowledge about the best drugs to be used as empiric treatment for sepsis based on their clinical efficacy and costs.

METHODS

Medline 1950 - 2008 was searched using the following terms: sepsis, organ failure, system failure, SIRS, septic shock, antibiotic, pneumonia, urinary tract infection, urosepsis, catheter-related infection, bloodstream, abdominal infection, and surgical wound.

RESULTS/CONCLUSION

For most septic shock patients, monotherapy is adequate and treatment should be initiated in the first hour after first sepsis-induced organ dysfunction. The drug of choice varies in different situations and choosing the right antibiotic enables better survival, fewer complications and shorter stays in intensive care.

Is reducing variability of blood glucose the real but hidden target of intensive insulin therapy?

Since the first report that intensive insulin therapy reduced mortality in selected surgical critically ill patients, lowering of blood glucose levels has been recommended as a means of improving patient outcomes. In this initial Leuven trial, blood glucose control by protocol using insulin was applied to 98.7% of patients in the intensive group but to only 39.2% (P < 0.0001) of patients in the control group. If appropriately applied, such protocols should decrease both the mean blood glucose concentration and its variability (variation of blood glucose concentration). Thus, it is logically possible that the benefit of intensive insulin therapy in the first Leuven trial was due to a decrease in mean glucose levels, a decrease in their variability, or both. Several recent studies have confirmed significant associations between variability of blood glucose levels and patient outcomes. Decreasing the variability of blood glucose levels might be an important dimension of glucose management, a possible mechanism by which an intensive insulin protocol exerts its putative beneficial effects, and an important goal of glucose management in the intensive care unit. Clinicians need to be aware of this controversy when considering the application of intensive insulin therapy and interpreting future trials.

Improving outcomes for severe sepsis and septic shock: tools for early identification of at-risk patients and treatment protocol implementation

Sepsis is a significant problem, and septicemia is the 10th leading cause of death in the United States. Sepsis incidence is increasing, and the mortality rate is 20% to 50% for patients with severe sepsis. This article identifies methods for improving outcomes of severe sepsis and septic shock. Included are recommendations for diagnosis and treatment. Case studies are included.

Acute kidney injury in septic shock: clinical outcomes and impact of duration of hypotension prior to initiation of antimicrobial therapy

OBJECTIVE

To describe the incidence and outcomes associated with early acute kidney injury (AKI) in septic shock and explore the association between duration from hypotension onset to effective antimicrobial therapy and AKI.

DESIGN

Retrospective cohort study.

SUBJECTS

A total of 4,532 adult patients with septic shock from 1989 to 2005.

SETTING

Intensive care units of 22 academic and community hospitals in Canada, the United States and Saudi Arabia.

MEASUREMENTS AND MAIN RESULTS

In total, 64.4% of patients with septic shock developed early AKI (i.e., within 24 h after onset of hypotension). By RIFLE criteria, 16.3% had risk, 29.4% had injury and 18.7% had failure. AKI patients were older, more likely female, with more co-morbid disease and greater severity of illness. Of 3,373 patients (74.4%) with hypotension prior to receiving effective antimicrobial therapy, the median (IQR) time from hypotension onset to antimicrobial therapy was 5.5 h (2.0-13.3). Patients with AKI were more likely to have longer delays to receiving antimicrobial therapy compared to those with no AKI [6.0 (2.3-15.3) h for AKI vs. 4.3 (1.5-10.8) h for no AKI, P < 0.0001). A longer duration to antimicrobial therapy was also associated an increase in odds of AKI [odds ratio (OR) 1.14, 95% CI 1.10-1.20, P < 0.001, per hour (log-transformed) delay]. AKI was associated with significantly higher odds of death in both ICU (OR 1.73, 95% CI 1.60-1.9, P < 0.0001) and hospital (OR 1.62, 95% CI, 1.5-1.7, P < 0.0001). By Cox proportional hazards analysis, including propensity score-adjustment, each RIFLE category was independently associated with a greater hazard ratio for death (risk 1.31; injury 1.45; failure 1.56).

CONCLUSION

Early AKI is common in septic shock. Delays to appropriate antimicrobial therapy may contribute to significant increases in the incidence of AKI. Survival was considerably lower for septic shock associated with early AKI, with increasing severity of AKI, and with increasing delays to appropriate antimicrobial therapy.

Presence of electroencephalogram burst suppression in sedated, critically ill patients is associated with increased mortality

OBJECTIVES

This study investigates the possibility of a relationship between oversedation and mortality in mechanically ventilated patients. The presence of burst suppression, a pattern of severely decreased brain wave activity on the electroencephalogram, may be unintentionally induced by heavy doses of sedatives. Burst suppression has never been studied as a potential risk factor for death in patients without a known neurologic disorder or injury.

DESIGN

Post hoc analysis of a prospectively observational cohort study.

SETTING

Medical intensive care units of a tertiary care, university-based medical center.

PATIENTS

A total of 125 mechanically ventilated, adult, critically ill patients.

MEASUREMENTS AND MAIN RESULTS

A validated arousal scale (Richmond Agitation-Sedation Scale) was used to measure sedation level, and the bispectral index monitor was used to capture electroencephalogram data. Burst suppression occurred in 49 of 125 patients (39%). For analysis, the patients were divided into those with burst suppression (49 of 125, 39%) and those without burst suppression (76 of 125, 61%). All baseline variables were similar between the two groups, with the overall cohort demonstrating a high severity of illness (Acute Physiology and Chronic Health Evaluation II scores of 27.4 +/- 8.2) and 98% receiving sedation. Of those with burst suppression, 29 of 49 (59%) died within 6 months compared with 25 of 76 (33%) who did not demonstrate burst suppression. Using time-dependent Cox regression to adjust for clinically important covariates (age, Charlson comorbidity score, baseline dementia, Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, coma, and delirium), patients who experienced burst suppression were found to have a statistically significant higher 6-month mortality [Hazard's ratio = 2.04, 95% confidence interval, 1.12-3.70, p = 0.02].

CONCLUSION

The presence of burst suppression, which was unexpectedly high in this medical intensive care unit population, was an independent predictor of increased risk of death at 6 months. This association should be studied prospectively on a larger scale in mechanically ventilated, critically ill patients.

Sedation practice in the intensive care unit: a UK national survey

INTRODUCTION

The purpose of this study was to evaluate sedation practice in UK intensive care units (ICUs), particularly the implementation of daily sedation holding, written sedation guidelines, sedation scoring tools and choice of agents.

METHODS

A national postal survey was conducted in all UK ICUs.

RESULTS

A total of 192 responses out of 302 addressed units were received (63.5%). Of the responding ICUs, 88% used a sedation scoring tool, most frequently the Ramsey Sedation Scale score (66.4%). The majority of units have a written sedation guideline (80%), and 78% state that daily sedation holding is practiced. A wide variety of sedating agents is used, with the choice of agent largely determined by the duration of action rather than cost. The most frequently used agents were propofol and alfentanil for short-term sedation; propofol, midazolam and morphine for longer sedation; and propofol for weaning purposes.

CONCLUSIONS

Most UK ICUs use a sedation guideline and sedation scoring tool. The concept of sedation holding has been implemented in the majority of units, and most ICUs have a written sedation guideline.

Novel potential therapies for septic shock

Sepsis is the systemic inflammatory response syndrome secondary to a local infection. Septic shock, the severe complication of sepsis associated with refractory hypotension, is frequently a near-fatal condition requiring prompt diagnosis and management. Although the recent years have been associated with considerable improvements in the knowledge of the pathophysiology of the disease and remarkable advances have been achieved in sepsis treatment, the morbidity and mortality of this disease are still unacceptably high. In this review, we will briefly discuss the ongoing standard treatment of septic shock and describe novel potential therapies, aiming to improve hemodynamic support and/or control inflammatory response in sepsis. These therapies were associated with benefits in experimental studies and have been tested or are currently under testing in randomized controlled studies with septic patients.

Pharmacological treatment of sepsis

The incidence of sepsis, the combination of a systemic inflammatory response syndrome and documented infection, is as high as up to 95 cases per 100,000 people per year. The understanding of the pathophysiology of sepsis has much increased over the last 20 years. However, sepsis combined with shock is still associated with a high mortality rate varying from 35 to 55%. Causative treatment, source control and antibiotics started as soon as possible, are the cornerstone of therapy in combination with symptomatic treatment in the ICU. The pharmacological interventions, including fluid resuscitation, vasoactive drugs and adjunctive drugs such as steroids, activated protein C are discussed. The possible beneficial role of strict glucose control is also addressed. Since many drug intervention studies were negative, lessons should be learned from earlier experiences for future trials. Source control and level of intensive care should be eliminated as confounders.

Gram-negative sepsis in the intensive care unit: avoiding therapeutic failure

PURPOSE OF REVIEW

The purpose of this review is to examine some of the latest concepts in the management of sepsis and septic shock in the Intensive Care environment, with a focus on Gram-negative infections.

RECENT FINDINGS

Recent developments in adjunctive therapies for sepsis and septic shock are discussed including protocol-driven therapies, the importance of timely appropriate antimicrobials and the growing threat and implications of rising Gram-negative antimicrobial resistance.

SUMMARY

The balance between the most effective and the most responsible prescribing is difficult to strike, but recognition of the impact of antibiotic failure makes it even more important to consider how we husband the microflora of the ICU. New therapeutic options are somewhat limited but goal-directed protocol-driven approaches linked with sound knowledge of the microflora and our impact upon it as an ecosystem is essential.

Pneumonia as a long-term consequence of chronic psychological stress in BALB/c mice

Recently, we have shown that female BALB/c mice are highly sensitive to chronic psychological stress. They develop systemic neuroendocrine disturbances, a hypermetabolic syndrome, behavioral alterations and severe immunosuppression with a reduced antibacterial response during experimental infection. Here, we show that chronically stressed mice spontaneously suffered from increased bacterial load in the liver and lung that sustained for up to 10 days after the termination of stress exposure. Immediately after the last chronic stress cycle, splenocytes had a reduced ability to produce IFNgamma after ex vivo stimulation with LPS while showing enhanced inducibility of IL-10. When healthy animals were treated with anti-IFNgamma antiserum the antibacterial response against the small numbers of endogenous bacteria that physiologically penetrate the intestinal barrier was reduced causing increased bacterial burden in the liver. Thus, a deficient antibacterial response to translocated commensals in chronically stressed animals can contribute to long-lasting pneumonia.

Year in review 2007: Critical Care--cardiology

This review summarises key research papers in the fields of cardiology and intensive care published during 2007 in Critical Care. To create a context and for comparison with the papers described in the review, we cite studies on the same subject published in other journals. The papers have been grouped into four categories: venous oximetry, cardiac surgery, perioperative fluid optimisation, and haemodynamic monitoring.

Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS)

Echocardiography is increasingly used in the management of the critically ill patient as a non-invasive diagnostic and monitoring tool. Whilst in few countries specialized national training schemes for intensive care unit (ICU) echocardiography have been developed, specific guidelines for ICU physicians wishing to incorporate echocardiography into their clinical practice are lacking. Further, existing echocardiography accreditation does not reflect the requirements of the ICU practitioner. The WINFOCUS (World Interactive Network Focused On Critical UltraSound) ECHO-ICU Group drew up a document aimed at providing guidance to individual physicians, trainers and the relevant societies of the requirements for the development of skills in echocardiography in the ICU setting. The document is based on recommendations published by the Royal College of Radiologists, British Society of Echocardiography, European Association of Echocardiography and American Society of Echocardiography, together with international input from established practitioners of ICU echocardiography. The recommendations contained in this document are concerned with theoretical basis of ultrasonography, the practical aspects of building an ICU-based echocardiography service as well as the key components of standard adult TTE and TEE studies to be performed on the ICU. Specific issues regarding echocardiography in different ICU clinical scenarios are then described. Obtaining competence in ICU echocardiography may be achieved in different ways - either through completion of an appropriate fellowship/training scheme, or, where not available, via a staged approach designed to train the practitioner to a level at which they can achieve accreditation. Here, peri-resuscitation focused echocardiography represents the entry level--obtainable through established courses followed by mentored practice. Next, a competence-based modular training programme is proposed: theoretical elements delivered through blended-learning and practical elements acquired in parallel through proctored practice. These all linked with existing national/international echocardiography courses. When completed, it is anticipated that the practitioner will have performed the prerequisite number of studies, and achieved the competency to undertake accreditation (leading to Level 2 competence) via a recognized National or European examination and provide the appropriate required evidence of competency (logbook). Thus, even where appropriate fellowships are not available, with support from the relevant echocardiography bodies, training and subsequently accreditation in ICU echocardiography becomes achievable within the existing framework of current critical care and cardiological practice, and is adaptable to each countrie's needs.

Therapeutic challenges of urosepsis

Urosepsis accounts for approximately 25% of all sepsis cases and may develop from a community or nosocomial acquired urinary tract infection (UTI). The underlying UTI is almost exclusively a complicated one with involvement of parenchymatous urogenital organs (e.g. kidneys, prostate). In urosepsis, as in other types of sepsis, the severity of sepsis depends mostly upon the host response. The treatment of urosepsis comprises four major aspects: Early goal directed therapy, early optimal pharmacodynamic exposure to antimicrobials, early control of the complicating factor in the urinary tract and specific sepsis therapy. Following these prerequisites there appear two major challenges that need to be addressed: Firstly, time from admission to therapy is critical; the shorter the time to effective treatment, the higher the success rate. This aspect has to become incorporated into the organisational process. Secondly, adequate initial antibiotic therapy has to be insured. This goal implies however, a wide array of measures to ensure rational antibiotic policy. Both challenges are best targeted if an interdisciplinary approach at any level of the process is established, encompassing urologists, intensive care specialists, radiologists, microbiologists and clinical pharmacologists working tightly together at any time.

The secondary abdominal compartment syndrome: not just another post-traumatic complication

The secondary abdominal compartment syndrome (ACS) is defined as the presence of organ dysfunction with concurrent intra-abdominal hypertension (IAH) in a scenario lacking primary intraperitoneal injury or intervention. This state appears to be related to visceral, abdominal wall and retroperitoneal edema and ascites induced by resuscitation. Despite a diverse range of associated causes such as pancreatitis, intra-abdominal sepsis, cardiac arrest, thermal injury and extraperitoneal trauma, this class of ACS is characterized by the presence of shock requiring aggressive fluid resuscitation. Secondary ACS is an extreme condition along a continuum of raised intra-abdominal pressure (IAP) that is pathoneumonic when associated with new overt organ failure. When IAP is above normal but is not associated with organ failure, IAH is diagnosed. Because these conditions are common among critically ill patients, the measurement of IAP is crucial. It is unclear whether preventing IAH reduces progression to ACS or influences outcomes. When overt ACS is confirmed, immediate surgical decompression of the patient's abdomen via a standard laparotomy is usually required. Because many disease processes resulting in critical illness require aggressive fluid resuscitation as a primary therapy, it is likely that secondary ACS is much more common than previously believed. Further study is needed.

Diabetes mellitus is an independent risk factor for ICU-acquired bloodstream infections

OBJECTIVE

To investigate the role of diabetes as risk factor for ICU-acquired bloodstream infections (BSI).

DESIGN

Prospective observational study.

SETTING

A general eight-bed ICU of a tertiary hospital.

PATIENTS

Three hundred and forty-three consecutive patients (63 diabetic and 280 nondiabetic) admitted in the ICU.

METHODS

BSI episodes in the ICU were recorded and classified as primary, secondary, catheter-related and mixed according to strict criteria. In all patients, blood glucose was strictly controlled with a continuous insulin infusion within a range of 80-120 mg/dl.

RESULTS

One-hundred and eighteen patients (34.4%) developed at least one BSI episode. Diabetic patients had an increased probability of developing at least one BSI episode compared with nondiabetic patients (hazard ratio = 1.66, 95% confidence interval 1.04-2.64, P = 0.034) in a Cox proportional hazards regression model adjusting for age, gender, admission category and APACHE II score at admission in the ICU and comorbidities.

CONCLUSIONS

Despite strict glycemic control, diabetic patients have a 1.7-fold probability of developing an ICU-acquired BSI compared to nondiabetic subjects.