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Caironi P, Latini R, Struck J, Hartmann O, Bergmann A, Maggio G, Cavana M, Tognoni G, Pesenti A, Gattinoni L, Masson S, Masson S, Caironi P, Spanuth E. Circulating Biologically Active Adrenomedullin (bio-ADM) Predicts Hemodynamic Support Requirement and Mortality During Sepsis. Chest 2017; 152:312-320. [DOI: 10.1016/j.chest.2017.03.035] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/30/2017] [Accepted: 03/20/2017] [Indexed: 12/29/2022] Open
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Prasad V, Lynch JC, Pasakarnis CL, Thorsen JE, Filbin MR, Reisner AT, Heldt T. Classification models to predict vasopressor administration for septic shock in the emergency department. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:2650-2653. [PMID: 29060444 DOI: 10.1109/embc.2017.8037402] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Optimal management of sepsis and septic shock in the emergency department (ED) involves timely decisions related to intravenous fluid resuscitation and initiation of vasoactive medication support. A decision-support tool trained on electronic health record data, can help improve this complex decision. We retrospectively extracted vital signs, lab measurements, and fluid administration information from 807 patient visits over a two-year period to a major ED. Patients selected for inclusion had a high likelihood of septic shock. We trained binary classifiers to discriminate between patients administered vasopressors in the ED and those not administered vasopressors at any point. Using features extracted from the entire ED visit record yielded a maximum area under the receiver-operating characteristic curve (AUC) of 0.798 (95% CI 0.725-0.849) in a hold-out test set. In a separate task, we used individual vital signs observations with lab results to predict vasopressor administration, yielding a maximum AUC of 0.762 (95% CI 0.748-0.777). Lastly, we trained separate classifiers for different subgroups of vital signs observations. These subgroups were defined by the cumulative number of fluid boluses delivered at the time of the observation. The maximum AUC achieved by any of these classifiers was 0.815 (95% CI 0.784-0.853), occurring for vital signs observations made after 2 bolus administrations. Classifiers in all tasks significantly outperformed existing clinical tools for assessing prognosis in ED sepsis. This work shows how relatively few features can provide instantaneous and accurate prediction of need for an intervention that is typically a complex clinical decision.
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Auchet T, Regnier MA, Girerd N, Levy B. Outcome of patients with septic shock and high-dose vasopressor therapy. Ann Intensive Care 2017; 7:43. [PMID: 28425079 PMCID: PMC5397393 DOI: 10.1186/s13613-017-0261-x] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 03/23/2017] [Indexed: 12/29/2022] Open
Abstract
Background Despite the dissemination of international guidelines, mortality from septic shock remains high. Norepinephrine is recommended as first-line vasopressor therapy with a target mean arterial pressure of 65 mmHg. High-dose vasopressor (HDV) may also be required. This study aimed to assess survival in patients with septic shock requiring HDV. We conducted a retrospective study of patients admitted between January 2008 and December 2013 to a 13-bed ICU for septic shock and receiving high-dose vasopressor therapy (defined by a dose >1 µg/kg/min). Primary outcome was 28-day mortality (D28). Secondary outcomes were 90-day mortality (D90), organ failure score (SOFA), duration of organ failure, duration and dosage of vasopressor agent and ischemic complications. Results In our cohort of 106 patients, mortality reached 60.4% at D28 and 66.3% at D90. One in two patients died before D10. The weight-based mean dose of vasopressor (WMD) represented the best prognostic factor. Using a cutoff of 0.75 µg/kg/min, WMD was associated with mortality with a sensitivity of 73% and specificity of 74%. The mortality rate reached 86.4% when WMD was above the cutoff value and associated with a SOFA score >10. Digital or limb necrosis was documented in 6 patients (5.7%). Conclusions In total, 40% of septic shock patients receiving high-dose vasopressor therapy survived at day 28 after admission. A WMD cutoff value of 0.75 µg/kg/min, associated with a >10 SOFA score, was a strong predictor of death. These results provide insights into outcome of refractory septic shock, showing that administration of high-dose vasopressor may indeed be useful in these patients.
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Affiliation(s)
- Thomas Auchet
- Service de Réanimation Médicale Brabois, Pôle Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, CHU Nancy, 54511, Vandoeuvre les Nancy, France.,Université de Lorraine, 54000, Nancy, France
| | - Marie-Alix Regnier
- Anesthesiology and Surgical Intensive Care, Central Hospital, Nancy, University Hospital, Nancy, France
| | - Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Bruno Levy
- Service de Réanimation Médicale Brabois, Pôle Cardiovasculaire et Réanimation Médicale, Hôpital Brabois, CHU Nancy, 54511, Vandoeuvre les Nancy, France. .,Université de Lorraine, 54000, Nancy, France. .,INSERM, Groupe Choc, U1116, Faculté de Médecine, CHU Nancy, 54511, Vandoeuvre les Nancy, France.
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154
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Impact of duration of hypotension prior to norepinephrine initiation in medical intensive care unit patients with septic shock: A prospective observational study. J Crit Care 2017; 40:178-183. [PMID: 28412642 DOI: 10.1016/j.jcrc.2017.04.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 03/13/2017] [Accepted: 04/07/2017] [Indexed: 01/16/2023]
Abstract
PURPOSE To determine the impact of duration of hypotension prior to norepinephrine initiation on outcomes in MICU patients with septic shock. We hypothesized increased duration of hypotension prior to norepinephrine initiation would be associated with an increased risk for ICU mortality. MATERIALS AND METHODS We conducted a prospective-observational study in the MICU of a single-center tertiary academic medical center. We enrolled 160 adults ≥18years old with septic shock. Descriptive statistics were computed for demographic and outcome variables. Primary logistic regression analysis was adjusted for severity of illness. RESULTS The mean age of our patients was 59years (±17); 42% were female; the mean APACHE II score was 24.1 (±8.0), and the mean SOFA score was 9.6 (±4.0). Median duration of hypotension prior to norepinephrine initiation was 3.6h (IQR 1.6-9.9). Duration of hypotension prior to norepinephrine did not increase the risk for ICU mortality (OR 1.03 per hour after hypotension, 95% CI: 0.98-1.09, p=0.20). CONCLUSION Duration of hypotension less than one hour and greater than one hour prior to norepinephrine initiation in MICU patients with septic shock is not associated with an increased risk for ICU mortality.
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155
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Jozwiak M, Monnet X, Teboul JL. Early goal-directed therapy et choc septique — 15 ans après la Rivers’ study, ARISE, ProCESS et ProMISe. MEDECINE INTENSIVE REANIMATION 2017. [DOI: 10.1007/s13546-017-1261-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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156
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Mas-Font S, Ros-Martinez J, Pérez-Calvo C, Villa-Díaz P, Aldunate-Calvo S, Moreno-Clari E. Prevention of acute kidney injury in Intensive Care Units. Med Intensiva 2017; 41:116-126. [PMID: 28190602 DOI: 10.1016/j.medin.2016.12.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 11/29/2016] [Accepted: 12/01/2016] [Indexed: 12/13/2022]
Abstract
Acute kidney injury (AKI) is a growing concern in Intensive Care Units. The advanced age of our patients, with the increase in associated morbidity and the complexity of the treatments provided favor the development of AKI. Since no effective treatment for AKI is available, all efforts are aimed at prevention and early detection of the disorder in order to establish secondary preventive measures to impede AKI progression. In critical patients, the most frequent causes are sepsis and situations that result in renal hypoperfusion; preventive measures are therefore directed at securing hydration and correct hemodynamics through fluid perfusion and the use of inotropic or vasoactive drugs, according to the underlying disease condition. Apart from these circumstances, a number of situations could lead to AKI, related to the administration of nephrotoxic drugs, intra-tubular deposits, the administration of iodinated contrast media, liver failure and major surgery (mainly heart surgery). In these cases, in addition to hydration, there are other specific preventive measures adapted to each condition.
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Affiliation(s)
- S Mas-Font
- Intensive Care Medicine, Hospital General Universitario de Castellón, Spain.
| | - J Ros-Martinez
- Intensive Care Medicine, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - C Pérez-Calvo
- Intensive Care Medicine, Hospital Universitario Fundación Jiménez Díaz, Madrid, Spain
| | - P Villa-Díaz
- Intensive Care Medicine, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
| | - S Aldunate-Calvo
- Intensive Care Medicine, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - E Moreno-Clari
- Intensive Care Medicine, Hospital General Universitario de Castellón, Spain
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157
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Hariyanto H, Yahya CQ, Widiastuti M, Wibowo P, Tampubolon OE. Fluids and sepsis: changing the paradigm of fluid therapy: a case report. J Med Case Rep 2017; 11:30. [PMID: 28159011 PMCID: PMC5291951 DOI: 10.1186/s13256-016-1191-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2016] [Accepted: 12/27/2016] [Indexed: 12/11/2022] Open
Abstract
Background Over the past 16 years, sepsis management has been guided by large-volume fluid administration to achieve certain hemodynamic optimization as advocated in the Rivers protocol. However, the safety of such practice has been questioned because large-volume fluid administration is associated with fluid overload and carries the worst outcome in patients with sepsis. Researchers in multiple studies have declared that using less fluid leads to increased survival, but they did not describe how to administer fluids in a timely and appropriate manner. Case presentation An 86-year-old previously healthy Sundanese man was admitted to the intensive care unit at our institution with septic shock, acute kidney injury, and respiratory distress. Standard care was implemented during his initial care in the high-care unit; nevertheless, his condition worsened, and he was transferred to the intensive care unit. We describe the timing of fluid administration and elaborate on the amount of fluids needed using a conservative fluid regimen in a continuum of resuscitated sepsis. Conclusions Because fluid depletion in septic shock is caused by capillary leak and pathologic vasoplegia, continuation of fluid administration will drive intravascular fluid into the interstitial space, thereby producing marked tissue edema and disrupting vital oxygenation. Thus, fluids have the power to heal or kill. Therefore, management of patients with sepsis should entail early vasopressors with adequate fluid resuscitation followed by a conservative fluid regimen.
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Affiliation(s)
- Hori Hariyanto
- Department of Anesthesiology and Critical Care Medicine, 3rd floor, Siloam Hospitals Lippo Village, Jalan Siloam No. 6, Karawaci, 15811, Tangerang, Banten, Indonesia.
| | - Corry Quando Yahya
- Department of Anesthesiology, Faculty of Medicine, Universitas Pelita Harapan, Jalan Boulevard Jendral Sudirman, Lippo Karawaci, Tangerang, 15811, Indonesia
| | - Monika Widiastuti
- Department of Anesthesiology, Faculty of Medicine, Universitas Pelita Harapan, Jalan Boulevard Jendral Sudirman, Lippo Karawaci, Tangerang, 15811, Indonesia
| | - Primartanto Wibowo
- Department of Anesthesiology and Critical Care Medicine, 3rd floor, Siloam Hospitals Lippo Village, Jalan Siloam No. 6, Karawaci, 15811, Tangerang, Banten, Indonesia
| | - Oloan Eduard Tampubolon
- Department of Anesthesiology and Critical Care Medicine, 3rd floor, Siloam Hospitals Lippo Village, Jalan Siloam No. 6, Karawaci, 15811, Tangerang, Banten, Indonesia
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159
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Abstract
Resuscitation goals for the patient with sepsis and septic shock are to return the patient to a physiologic state that promotes adequate end-organ perfusion along with matching metabolic supply and demand. Ideal resuscitation end points should assess the adequacy of tissue oxygen delivery and oxygen consumption, and be quantifiable and reproducible. Despite years of research, a single resuscitation end point to assess adequacy of resuscitation has yet to be found. Thus, the clinician must rely on multiple end points to assess the patient's overall response to therapy. This review will discuss the role and limitations of central venous pressure (CVP), mean arterial pressure (MAP), and cardiac output/index as macrocirculatory resuscitation targets along with lactate, central venous oxygen saturation (ScvO2), central venous-arterial CO2 gradient, urine output, and capillary refill time as microcirculatory resuscitation endpoints in patients with sepsis.
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Affiliation(s)
- John C Greenwood
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Ground Ravdin, Philadelphia, PA 19014, USA; Department of Anesthesiology & Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Ground Ravdin, Philadelphia, PA 19014, USA.
| | - Clinton J Orloski
- Department of Emergency Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, Ground Ravdin, Philadelphia, PA 19104, USA
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160
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Lewis T, Merchan C, Altshuler D, Papadopoulos J. Safety of the Peripheral Administration of Vasopressor Agents. J Intensive Care Med 2017; 34:26-33. [PMID: 28073314 DOI: 10.1177/0885066616686035] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Vasopressors are an integral component of the management of septic shock and are traditionally given via a central venous catheter (CVC) due to the risk of tissue injury and necrosis if extravasated. However, the need for a CVC for the management of septic shock has been questioned, and the risk of extravasation and incidence of severe injury when vasopressors are given via a peripheral venous line (PVL) remains poorly defined. We performed a retrospective chart review of 202 patients who received vasopressors through a PVL. The objective was to describe the vasopressors administered peripherally, PVL size and location, the incidence of extravasation events, and the management of extravasation events. The primary vasopressors used were norepinephrine and phenylephrine. The most common PVL sites used were the forearm and antecubital fossa. The incidence of extravasation was 4%. All of the events were managed conservatively; none required an antidote or surgical management. Vasopressors were restarted at another peripheral site in 88% of the events. The incidence of extravasation was similar to prior studies. The use of a PVL for administration of vasopressors can be considered in patients with a contraindication to a CVC.
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Affiliation(s)
- Tyler Lewis
- Department of Pharmacy, NYU Langone Medical Center, New York, NY, USA
| | - Cristian Merchan
- Department of Pharmacy, NYU Langone Medical Center, New York, NY, USA
| | - Diana Altshuler
- Department of Pharmacy, NYU Langone Medical Center, New York, NY, USA
| | - John Papadopoulos
- Department of Pharmacy, NYU Langone Medical Center, New York, NY, USA
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161
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Don't Go Chasing Waterfalls: Excessive Fluid Resuscitation in Severe Sepsis and Septic Shock. Crit Care Nurs Q 2016; 39:34-7. [PMID: 26633156 DOI: 10.1097/cnq.0000000000000094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Aggressive fluid resuscitation is the mainstay therapy in modern sepsis management. Its efficacy was demonstrated in the landmark study by Emmanuel Rivers in 2001. However, more recent evidence largely shows that a positive fluid balance increases mortality in critically ill patients with sepsis. This article examines the theoretical benefits of fluid resuscitation and physiological responses to it that may negatively affect patients' outcome.
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162
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Glassford NJ, Bellomo R. The Complexities of Intravenous Fluid Research: Questions of Scale, Volume, and Accumulation. Korean J Crit Care Med 2016. [DOI: 10.4266/kjccm.2016.00934] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
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163
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Vincent JL, Leone M. Optimum treatment of vasopressor-dependent distributive shock. Expert Rev Anti Infect Ther 2016; 15:5-10. [DOI: 10.1080/14787210.2017.1252673] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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164
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Long B, Koyfman A, Modisett KL, Woods CJ. Practical Considerations in Sepsis Resuscitation. J Emerg Med 2016; 52:472-483. [PMID: 27823892 DOI: 10.1016/j.jemermed.2016.10.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/27/2016] [Accepted: 10/03/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Sepsis is a common condition managed in the emergency department, and the majority of patients respond to resuscitation measures, including antibiotics and i.v. fluids. However, a proportion of patients will fail to respond to standard treatment. OBJECTIVE This review elucidates practical considerations for management of sepsis in patients who fail to respond to standard treatment. DISCUSSION Early goal-directed therapy revolutionized sepsis management. However, there is a paucity of literature that provides a well-defined treatment algorithm for patients who fail to improve with therapy. Refractory shock can be defined as continued patient hemodynamic instability (mean arterial pressure, ≤ 65 mm Hg, lactate ≥ 4 mmol/L, altered mental status) after adequate fluid loading (at least 30 mL/kg i.v.), the use of two vasopressors (with one as norepinephrine), and provision of antibiotics. When a lack of improvement is evident in the early stages of resuscitation, systematically considering source control, appropriate volume resuscitation, adequate antimicrobial coverage, vasopressor selection, presence of metabolic pathology, and complications of resuscitation, such as abdominal compartment syndrome and respiratory failure, allow emergency physicians to address the entire clinical scenario. CONCLUSIONS The care of sepsis has experienced many changes in recent years. Care of the patient with sepsis who is not responding appropriately to initial resuscitation is troublesome for emergency physicians. This review provides practical considerations for resuscitation of the patient with septic shock. When a septic patient is refractory to standard therapy, systematically evaluating the patient and clinical course may lead to improved outcomes.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
| | - Katharine L Modisett
- Department of Pulmonary and Critical Care Medicine, MedStar Georgetown University/MedStar Washington Hospital Center, Washington, District of Columbia
| | - Christian J Woods
- Sections of Infectious Diseases and Pulmonary Critical Care, MedStar Washington Hospital Center, Washington, District of Columbia
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165
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Jozwiak M, Monnet X, Teboul JL. Implementing sepsis bundles. ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:332. [PMID: 27713890 DOI: 10.21037/atm.2016.08.60] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Sepsis bundles represent key elements of care regarding the diagnosis and treatment of patients with septic shock and allow ones to convert complex guidelines into meaningful changes in behavior. Sepsis bundles endorsed the early goal-directed therapy (EGDT) and their implementation resulted in an improved outcome of septic shock patients. They induced more consistent and timely application of evidence-based care and reduced practice variability. These benefits mainly depend on the compliance with sepsis bundles, highlighting the importance of dedicated performance improvement initiatives, such as multifaceted educational programs. Nevertheless, the interest of early goal directed therapy in septic shock patients compared to usual care has recently been questioned, leading to an update of sepsis bundles in 2015. These new sepsis bundles may also exhibit, as the previous bundles, some limits and pitfalls and the effects of their implementation still needs to be evaluated.
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Affiliation(s)
- Mathieu Jozwiak
- Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin Bicêtre, France;; Inserm UMR S_999, Paris-South University, Le Kremlin Bicêtre, France
| | - Xavier Monnet
- Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin Bicêtre, France;; Inserm UMR S_999, Paris-South University, Le Kremlin Bicêtre, France
| | - Jean-Louis Teboul
- Medical Intensive Care Unit, Bicêtre Hospital, Le Kremlin Bicêtre, France;; Inserm UMR S_999, Paris-South University, Le Kremlin Bicêtre, France
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166
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Chaari A, Abdel Hakim K, Bousselmi K, Etman M, El Bahr M, El Saka A, Hamza E, Ismail M, Khalil EM, Kauts V, Casey WF. Pancreatic injury in patients with septic shock: A literature review. World J Gastrointest Oncol 2016; 8:526-531. [PMID: 27559431 PMCID: PMC4942740 DOI: 10.4251/wjgo.v8.i7.526] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/26/2016] [Accepted: 05/27/2016] [Indexed: 02/05/2023] Open
Abstract
Sepsis and septic shock are life threatening condition associated with high mortality rate in critically-ill patients. This high mortality is mainly related to the inadequacy between oxygen delivery and cellular demand leading to the onset of multiorgan dysfunction. Whether this multiorgan failure affect the pancreas is not fully investigated. In fact, pancreatic injury may occur because of ischemia, overwhelming inflammatory response, oxidative stress, cellular apoptosis and/or metabolic derangement. Increased serum amylase and/or lipase levels are common in patients with septic shock. However, imaging test rarely reveal significant pancreatic damage. Whether pancreatic dysfunction does affect the prognosis of patients with septic shock or not is still a matter of debate. In fact, only few studies with limited sample size assessed the clinical relevance of the pancreatic injury in this group of patients. In this review, we aimed to describe the epidemiology and the physiopathology of pancreatic injury in septic shock patients, to clarify whether it requires specific management and to assess its prognostic value. Our main finding is that pancreatic injury does not significantly affect the outcome in septic shock patients. Hence, increased serum pancreatic enzymes without clinical features of acute pancreatitis do not require further imaging investigations and specific therapeutic intervention.
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167
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Stabile AM, Moreto V, Batalhão ME, Rocha MJ, Antunes-Rodrigues J, Cárnio EC. Differential Role of Neurohypophysial Hormones in Hypotension and Nitric Oxide Production During Endotoxaemia. J Neuroendocrinol 2016; 28. [PMID: 27037598 DOI: 10.1111/jne.12391] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/29/2016] [Accepted: 03/30/2016] [Indexed: 11/27/2022]
Abstract
Besides their well-established endocrine roles, vasopressin and oxytocin are also important regulators of immune function, participating in a complex neuroendocrine-immune network. In the present study, we investigated whether and how vasopressin and oxytocin could modulate lipopolysaccharide (LPS)-induced nitric oxide (NO) production in a well-established model of experimental endotoxaemia. Male Wistar rats were previously treated i.v. with vasopressin V1 or oxytocin receptor antagonists and then received either an i.v. LPS injection to induce endotoxaemia or a saline imjection as a control. The animals were divided into two groups: in the first group, blood was collected at 2, 4 and 6 h after LPS injection; in the second group, mean arterial blood pressure (MABP) and heart rate (HR) were recorded over 6 h. Plasma vasopressin and oxytocin values were higher in LPS- compared to saline-injected animals at 2 and 4 h but returned to basal levels at 6 h. NO levels exhibited an opposite pattern, showing a progressive increase over the entire period. The previous administration of a vasopressin V1 receptor antagonist significantly reduced NO plasma concentrations at 2 and 4 h but not at 6 h. By contrast, oxytocin receptor agonist pre-treatment had no effect on the NO plasma concentration. In relation to MABP, previous treatment with vasopressin V1 receptor antagonist reversed the LPS-induced hypotension at 4 h, although this was not the case for oxytocin antagonist-treated animals. None of the antagonists affected HR. Our findings indicate that vasopressin (but not oxytocin) has effects on NO production during endotoxaemia in rats, although they do not lend support to the proposed anti-inflammatory actions of vasopressin during endotoxaemia.
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Affiliation(s)
- A M Stabile
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - V Moreto
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - M E Batalhão
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - M J Rocha
- School of Dentistry of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - J Antunes-Rodrigues
- Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - E C Cárnio
- Ribeirão Preto College of Nursing, University of São Paulo, Ribeirão Preto, SP, Brazil
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168
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Idrees M, Macdonald SP, Kodali K. Sepsis Early Alert Tool: Early recognition and timely management in the emergency department. Emerg Med Australas 2016; 28:399-403. [PMID: 27147126 DOI: 10.1111/1742-6723.12581] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 01/29/2016] [Accepted: 02/16/2016] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The Surviving Sepsis Campaign guidelines recommend administration of appropriate antibiotics within 1 h in patients with severe sepsis, with two sets of blood cultures taken prior to administration. OBJECTIVE We evaluated the effect of introducing a Sepsis Early Alert Tool (SEAT) in the ED. Outcomes were antibiotic timing, antibiotic choice and obtaining adequate blood cultures. METHODS A retrospective chart review compared consecutive severe sepsis presentations admitted to ICU via the ED during two equivalent 6 month periods before and after SEAT introduction. RESULTS The analyses included 55 patients before and 45 following SEAT introduction. The groups were similar in age, sex, triage category, sepsis source, Acute Physiology and Chronic Health Evaluation III scores and hospital mortality. The percentage receiving antibiotics within 60 min of triage increased from 24% (95% CI 13-37%) to 44% (95% CI 30-60%), P = 0.03. Median time from triage to first antibiotic was 105 (IQR 65-170) min and 85 (IQR 50-140) min before and after SEAT introduction, respectively, P = 0.15. Percentages receiving antibiotics within 60 min of first recognition of severe sepsis were 67% (95% CI 53-79%) and 71% (95% CI 56-84%) before and after SEAT introduction, P = 0.83. The percentage having two sets of blood cultures drawn prior to antibiotic administration increased from 18% (95% CI 9-34%) to 44% (95% CI 27-60%), P = 0.008. Appropriateness of antibiotics was 58% (95% CI 44-71%) and 75% (95% CI 60-87%) before and after SEAT implementation, P = 0.09. CONCLUSION The introduction of a SEAT in the ED is associated with earlier recognition of severe sepsis and improvements in quality of care.
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Affiliation(s)
- Marwan Idrees
- Emergency Department, Armadale Health Service, Perth, Western Australia, Australia
| | - Stephen Pj Macdonald
- Emergency Department, Armadale Health Service, Perth, Western Australia, Australia.,Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia.,Discipline of Emergency Medicine, University of Western Australia, Perth, Western Australia, Australia
| | - Kiren Kodali
- Emergency Department, Armadale Health Service, Perth, Western Australia, Australia
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169
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Abstract
Jean-Louis Vincent outlines why combinations of biomarkers will be central to the future of sepsis diagnosis.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
- * E-mail:
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170
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Abstract
Early and adequate resuscitation of patients with acute circulatory failure is important to restore the balance between oxygen needs and delivery. Haemodynamic management can globally be separated into three categories according to the VIP mnemonic - Ventilate, Infuse, Pump - which should be considered simultaneously in the patient with shock. Sufficient oxygen should be given early, and endotracheal intubation and mechanical ventilation performed without hesitation if there is any indication that oxygenation is inadequate. Fluids should be administered using the SOSD mnemonic - Salvage, Optimization, Stabilization, De-escalation. After initial liberal administration, ongoing requirements should be guided by repeated fluid challenges using a combination of balanced crystalloid solutions and colloid. Noradrenaline is the vasopressor of choice and should be started early. Dobutamine may be needed to improve myocardial contractility and cardiac output. Haemodynamic support should be personalized according to individual patient characteristics and global and regional parameters of haemodynamic and oxygenation status.
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Affiliation(s)
- Jean-Louis Vincent
- Erasme University Hospital, université libre de Bruxelles, Department of Intensive Care, route de Lennik 808, 1070 Brussels, Belgium.
| | - Diego Orbegozo Cortés
- Erasme University Hospital, université libre de Bruxelles, Department of Intensive Care, route de Lennik 808, 1070 Brussels, Belgium
| | - Angela Acheampong
- Erasme University Hospital, université libre de Bruxelles, Department of Intensive Care, route de Lennik 808, 1070 Brussels, Belgium
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171
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Belsky JB, Morris DC, Bouchebl R, Filbin MR, Bobbitt KR, Jaehne AK, Rivers EP. Plasma levels of F-actin and F:G-actin ratio as potential new biomarkers in patients with septic shock. Biomarkers 2016; 21:180-5. [PMID: 26754286 DOI: 10.3109/1354750x.2015.1126646] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To compare plasma levels of F-actin, G-actin and thymosin beta 4 (TB4) in humans with septic shock, noninfectious systemic inflammatory response syndrome (SIRS) and healthy controls. RESULTS F-actin was significantly elevated in septic shock as compared with noninfectious SIRS and healthy controls. G-actin levels were greatest in the noninfectious SIRS group but significantly elevated in septic shock as compared with healthy controls. TB4 was not detectable in the septic shock or noninfectious SIRS group above the assay's lowest detection range (78 ng/ml). CONCLUSIONS F-actin is significantly elevated in patients with septic shock as compared with noninfectious SIRS. F-actin and the F:G-actin ratio are potential biomarkers for the diagnosis of septic shock.
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Affiliation(s)
- Justin B Belsky
- a Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Daniel C Morris
- b Department of Emergency Medicine , Henry Ford Hospital , Detroit , MI , USA
| | - Ralph Bouchebl
- c Department of Emergency Medicine , American University of Beirut , Beirut , Lebanon
| | - Michael R Filbin
- a Department of Emergency Medicine , Massachusetts General Hospital , Boston , MA , USA
| | - Kevin R Bobbitt
- d Department of Public Health Sciences , Henry Ford Hospital , Detroit , MI , USA , and
| | - Anja K Jaehne
- b Department of Emergency Medicine , Henry Ford Hospital , Detroit , MI , USA .,e Department of Quality , Northstar Health System , Iron River , MI , USA
| | - Emanuel P Rivers
- b Department of Emergency Medicine , Henry Ford Hospital , Detroit , MI , USA
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172
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Abstract
PURPOSE OF REVIEW This review highlights the recent evidence describing the outcomes associated with fluid overload in critically ill patients and provides an overview of fluid management strategies aimed at preventing fluid overload during the resuscitation of patients with shock. RECENT FINDINGS Fluid overload is a common complication of fluid resuscitation and is associated with increased hospital costs, morbidity and mortality. SUMMARY Fluid management goals differ during the resuscitation, optimization, stabilization and evacuation phases of fluid resuscitation. To prevent fluid overload, strategies that reduce excessive fluid infusions and emphasize the removal of accumulated fluids should be implemented.
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173
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Fluid Therapy: Double-Edged Sword during Critical Care? BIOMED RESEARCH INTERNATIONAL 2015; 2015:729075. [PMID: 26798642 PMCID: PMC4700172 DOI: 10.1155/2015/729075] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Accepted: 11/25/2015] [Indexed: 12/11/2022]
Abstract
Fluid therapy is still the mainstay of acute care in patients with shock or cardiovascular compromise. However, our understanding of the critically ill pathophysiology has evolved significantly in recent years. The revelation of the glycocalyx layer and subsequent research has redefined the basics of fluids behavior in the circulation. Using less invasive hemodynamic monitoring tools enables us to assess the cardiovascular function in a dynamic perspective. This allows pinpointing even distinct changes induced by treatment, by postural changes, or by interorgan interactions in real time and enables individualized patient management. Regarding fluids as drugs of any other kind led to the need for precise indication, way of administration, and also assessment of side effects. We possess now the evidence that patient centered outcomes may be altered when incorrect time, dose, or type of fluids are administered. In this review, three major features of fluid therapy are discussed: the prediction of fluid responsiveness, potential harms induced by overzealous fluid administration, and finally the problem of protocol-led treatments and their timing.
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174
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Arslantas MK, Gul F, Kararmaz A, Sungur F, Ayanoglu HO, Cinel I. Early administration of low dose norepinephrine for the prevention of organ dysfunctions in patients with sepsis. Intensive Care Med Exp 2015. [PMCID: PMC4798466 DOI: 10.1186/2197-425x-3-s1-a417] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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175
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176
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DellaVolpe JD, Moore JE, Pinsky MR. Arterial blood pressure and heart rate regulation in shock state. Curr Opin Crit Care 2015; 21:376-80. [DOI: 10.1097/mcc.0000000000000239] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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177
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Gupta RG, Hartigan SM, Kashiouris MG, Sessler CN, Bearman GML. Early goal-directed resuscitation of patients with septic shock: current evidence and future directions. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:286. [PMID: 26316210 PMCID: PMC4552276 DOI: 10.1186/s13054-015-1011-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Severe sepsis and septic shock are among the leading causes of mortality in the intensive care unit. Over a decade ago, early goal-directed therapy (EGDT) emerged as a novel approach for reducing sepsis mortality and was incorporated into guidelines published by the international Surviving Sepsis Campaign. In addition to requiring early detection of sepsis and prompt initiation of antibiotics, the EGDT protocol requires invasive patient monitoring to guide resuscitation with intravenous fluids, vasopressors, red cell transfusions, and inotropes. The effect of these measures on patient outcomes, however, remains controversial. Recently, three large randomized trials were undertaken to re-examine the effect of EGDT on morbidity and mortality: the ProCESS trial in the United States, the ARISE trial in Australia and New Zealand, and the ProMISe trial in England. These trials showed that EGDT did not significantly decrease mortality in patients with septic shock compared with usual care. In particular, whereas early administration of antibiotics appeared to increase survival, tailoring resuscitation to static measurements of central venous pressure and central venous oxygen saturation did not confer survival benefit to most patients. In the following review, we examine these findings as well as other evidence from recent randomized trials of goal-directed resuscitation. We also discuss future areas of research and emerging paradigms in sepsis trials.
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Affiliation(s)
- Ravi G Gupta
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA.
| | - Sarah M Hartigan
- Division of General Internal Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980070, Richmond, VA, 23298, USA
| | - Markos G Kashiouris
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA
| | - Curtis N Sessler
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA
| | - Gonzalo M L Bearman
- Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980019, Richmond, VA, 23298, USA
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178
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Dong W, Zhang G, Qu F. Effects of Ringer's sodium pyruvate solution on serum tumor necrosis factor-α and interleukin-6 upon septic shock. Pak J Med Sci 2015; 31:672-7. [PMID: 26150866 PMCID: PMC4485293 DOI: 10.12669/pjms.313.7170] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Revised: 02/16/2015] [Accepted: 03/11/2015] [Indexed: 02/03/2023] Open
Abstract
Objective: To study the effects of Ringer’s sodium pyruvate solution on tumor necrosis factor-α (TNF-α) and interleukin-6 (IL-6) upon septic shock. Methods: Ninety emergency patients with septic shock were divided into a treatment group and a control group by random draw. The control group was resuscitated with 50 ml of compound sodium chloride (Ringer’s solution), and the treatment group was given 50 ml of Ringer’s sodium pyruvate solution. Both groups were basically treated. Results: All patients were successfully resuscitated. After treatment, extravascular lung water index, intrathoracic blood volume index, systemic vascular resistance index and cardiac index of the two groups were significantly improved compared with those before treatment (P<0.05). However, there were no significant inter-group differences at different time points (P>0.05). Blood lactic acid level, central venous oxygen saturation index and urine output were also improved after treatment, with significant inter-group differences (P<0.05). Serum TNF-α and IL-6 levels of both groups significantly decreased after treatment (P<0.05), and the levels of the treatment group were significantly lower than those of the control group (P<0.05). During 28 days of follow-up, the mortality rate of the treatment group (4.4%) was significantly lower than that of the control group (20.0%) (P<0.05). Conclusion: Patients with septic shock are complicated with disordered expressions of inflammatory factors. During resuscitation, Ringer’s sodium pyruvate solution can effectively promote blood circulation, mitigate inflammation and maintain acid-base equilibrium, thus decreasing the prognostic mortality rate.
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Affiliation(s)
- Wei Dong
- Wei Dong, Department of Critical Care Medicine, Second District, Shandong Jining No. 1 People's Hospital, Jining 272011, China
| | - Guannan Zhang
- Guannan Zhang Shandong Jining No. 1 People's Hospital, Jining 272011, China
| | - Feng Qu
- Feng Qu, Chief Physician, Department of Critical Care Medicine, Second District, Shandong Jining No. 1 People's Hospital, Jining 272011, China
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179
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MARIK PE. The demise of early goal-directed therapy for severe sepsis and septic shock. Acta Anaesthesiol Scand 2015; 59:561-7. [PMID: 25656742 DOI: 10.1111/aas.12479] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 12/29/2014] [Indexed: 12/29/2022]
Abstract
A protocol for the quantitative resuscitation of severe sepsis and septic shock known as early goal-directed therapy (EGDT) was published in 2001. Despite serious limitations, this study became widely adopted around the world and formed the basis of the Surviving Sepsis Campaign 6 h resuscitation bundle. Subsequently, a large number of observational before-and-after studies were published which demonstrated that EGDT reduced mortality. However, during this time period, there has been a substantial reduction in the mortality from sepsis in many Western nations that appears unrelated to EGDT. Recently, the Protocolized Care for Early Septic Shock (ProCESS) and The Australasian Resuscitation in Sepsis Evaluation (ARISE) trials failed to demonstrate any outcome benefit from EGDT. These two large, multicenter, randomized controlled studies raise serious questions regarding the validity of the original EGDT study and the scientific rigor of the uncontrolled, largely retrospective before-after clinical studies. Furthermore, accruing data suggest an association between the amount of fluid administered in the first 72 h and the mortality of patients with severe sepsis. Patients in all arms of the ProCESS and ARISE trials received substantial and nearly equivalent amounts of fluid. It is proposed that a more conservative fluid strategy and the earlier use of norepinephrine in patients with septic shock may be associated with further improvements in the outcome of patients with sepsis.
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Affiliation(s)
- P. E. MARIK
- Division of Pulmonary and Critical Care Medicine; Eastern Virginia Medical School; Norfolk VA USA
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180
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Ekaney ML, Bockmeyer CL, Sossdorf M, Reuken PA, Conradi F, Schuerholz T, Blaess MF, Friedman SL, Lösche W, Bauer M, Claus RA. Preserved Expression of mRNA Coding von Willebrand Factor-Cleaving Protease ADAMTS13 by Selenite and Activated Protein C. Mol Med 2015; 21:355-63. [PMID: 25860876 DOI: 10.2119/molmed.2014.00202] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 04/03/2015] [Indexed: 12/16/2022] Open
Abstract
In sepsis, the severity-dependent decrease of von Willebrand factor (VWF)-inactivating protease, a disintegrin and metalloproteinase with thrombospondin motifs 13 (ADAMTS13), results in platelet aggregation and consumption, leading to sepsis-associated thrombotic microangiopathy (TMA) and organ failure. Previous reports assessing its functional deficiency have pinpointed involvement of autoantibodies or mutations to propagate thrombotic thrombocytopenic purpura (TTP). However, mechanisms of acquired ADAMTS13 deficiency during host response remain unclear. To enhance understanding of ADAMTS13 deficiency in sepsis, we evaluated changes in expression of mRNA coding ADAMTS13 during septic conditions using primary cellular sources of the protease. We hypothesized that proinflammatory cytokines and constituents of serum from septic patients affect the transcriptional level of ADAMTS13 in vitro, and previously recommended therapeutic agents as adjunctive therapy for sepsis interact therewith. Cultured hepatic stellate cells (HSCs), endothelial cells (HMEC) and human precision-cut liver slices as an ex vivo model were stimulated with sepsis prototypic cytokines, bacterial endotoxin and pooled serum obtained from septic patients. Stimulation resulted in a significant decrease in ADAMTS13 mRNA between 10% and 80% of basal transcriptional rates. Costimulation of selenite or recombinant activated protein C (APC) with serum prevented ADAMTS13 decrease in HSCs and increased ADAMTS13 transcripts in HMEC. In archived clinical samples, the activity of ADAMTS13 in septic patients treated with APC (n = 5) increased with an accompanying decrease in VWF propeptide as surrogate for improved endothelial function. In conclusion, proinflammatory conditions of sepsis repress mRNA coding ADAMTS13 and the ameliorating effect by selenite and APC may support the concept for identification of beneficial mechanisms triggered by these drugs at a molecular level.
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Affiliation(s)
- Michael L Ekaney
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | | | - Maik Sossdorf
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Philipp A Reuken
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Florian Conradi
- Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Tobias Schuerholz
- Department for Interdisciplinary Intensive Care, University Hospital Aachen, Aachen, Germany
| | - Markus F Blaess
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Scott L Friedman
- Mount Sinai School of Medicine, New York, New York, United States of America
| | - Wolfgang Lösche
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Michael Bauer
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Ralf A Claus
- Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany.,Clinic for Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
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181
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Rachoin JS, Dellinger RP. Timing of norepinephrine in septic patients: NOT too little too late. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:691. [PMID: 25672524 PMCID: PMC4331139 DOI: 10.1186/s13054-014-0691-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
After years and years of consensus expert opinion as to mean arterial pressure (MAP) target and vasopressor choice in septic shock management, literature is now emerging that supports the MAP target of 65 mm Hg and norepinephrine as the vasopressor choice. However, the literature remains sparse as to the timing of vasopressors relative to fluid resuscitation and how MAP support is balanced between the choices of vasopressor versus fluid resuscitation. Bai and colleagues report data that reveal an association between earlier vasopressor initiation in septic shock and better outcome. Whether this is a linkage to better care, is related to improved early tissue perfusion, or relates to sparing of fluids to reach the MAP target is not yet known.
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