[Diagnosis and therapy of sepsis. Guidelines of the German Sepsis Society Inc. and the German Interdisciplinary Society for Intensive and Emergency Medicine]

[Urosepsis and treatment]

Urosepsis is one of the most frequent sepsis entities. Mortality from urosepsis is nowadays mostly lower than from other entities. Sepsis syndrome is pathophysiologically characterized by a generalized infection and immune dysregulation. Exogenous microbiological and active or passive endogenous factors released from body cells initiate and accompany the immune dysregulation. Diagnosis and therapy of urosepsis need to be instigated as early as possible (within the first hour), in order to prevent cell and tissue damage in the early phase. For this reason a series of measures is started, aimed at achieving early control of the focus of infection, providing antibiotic treatment, and stabilizing respiratory and cardiovascular function in order to optimize tissue oxygenation. A significant clinical problem ensues due to increasing antibiotic resistance mainly of enterobacteria. The choice of antibiotic therefore is made on the basis of local antibiotic resistance statistics. Dosage is determined on an individual basis, as well as according to current pharmacokinetic/pharmacodynamic knowledge. The intensive care of the septic patient needs to be started as early as on patient admission and, where necessary, continued on the intensive care ward.

[Diagnosis and causal treatment of sepsis]

The high mortality and morbidity of severe sepsis and septic shock had not been reduced during the two recent decades, despite a number of advances in the field of supportive and adjunctive sepsis therapies. The reason might be that important steps towards overcoming of sepsis - early diagnosis, the surgical resection of the infectious focus and an adequate antibiotic treatment - at present are still suboptimal and have to be improved. However, worldwide growing resistances of pathogens against the common antibiotics are detected. In opposite, no major progress in the development of new antibiotics, mainly for the treatment of Gram-negative non-fermenter infections like Pseudomonas aeruginosa, can be predicted for the next years. Therefore, sepsis treatment must be focused on prevention of infection, and on an optimised application of current antibiotic substances. The key factors are a broad, high dose, and early applicated initial treatment, a de-escalation strategy according to the clinical course supported by the application of novel molecular markers, and - with exceptions - a limitation of treatment to 7 to 10 days. A closer cooperation between microbiologists, infection control specialists and clinical infectious disease consultants may be a key factor to overcome the raising problems in the future.

[Supportive and adjunctive sepsis therapy]

Severe sepsis and septic shock have an increasing incidence but an unchanged mortality. It has been demonstrated that the time until the start of supportive therapy affects the progress of multiorgan failure and patient outcome. Early goal-directed therapy guided by central venous oxygen saturation is associated with a significant reduction in mortality, as is the use of lung-protective mechanical ventilation and recombinant activated protein C (rhAPC) in eligible patients. The use of starches for volume resuscitation, low-dose dopamine and hydrocortison as well as an intensive insulin protocol for restoration of euglycemia is not recommended. The German Competence Network Sepsis (SepNet) is currently studying further relevant questions.

[Burn trauma--Part 2. Anesthesiological, surgical and intensive care management]

After initial stabilization of burn victims at the scene and in the trauma room, a tight cooperation and communication between anesthesiologists, plastic surgeons and intensive care specialists is needed for further therapy. Interdisciplinary communication about preoperative planning, timing of necrectomy and intensive care therapy is vital regarding functional and aesthetic outcome and survival rate. During burn surgery attention has to be paid to excessive blood loss and the danger of hypothermia. The main problems of intensive care therapy involve the evaluation of volume status, high demands for analgesia and sedation, high incidence of septic multiorgan failure and therapy and prophylaxis of the effects of hypermetabolism.

[Glycemic control in sepsis and septic shock: friend or foe?]

INTRODUCTION

Intensive care patients commonly suffer from hyperglycemia. Evidence is growing that strictly maintaining normoglycemia by intensive insulin therapy (IIT) ameliorates outcome in these patients. Whether or not this also holds true for patients with sepsis and septic shock is the issue of this post-hoc analysis of the database (2,748 patients) of 2 recent prospective clinical trials.

MATERIAL AND METHODS

A total of 950 patients suffering from sepsis were identified and of these 462 fulfilled the diagnostic criteria of septic shock upon admission to the intensive care unit (ICU). Patients were treated by either IIT [mean glycemia 5.88 mmol/l (106 mg/dl)] or conventional glucose management [mean glycemia 8.44 mmol/l (152 mg/dl)].

RESULTS

Under IIT the mortality of patients treated for more than 3 days in the ICU was lowered by 7.6% (p=0.03) in septic patients and by 8.7% (p=0.08) in septic shock patients. Polyneuropathy occurred less frequently under IIT compared to conventional glucose management (sepsis -9.8%, septic shock -14%; p<0.001). The incidence of acute renal failure was not affected by either treatment regimen (sepsis -3.3%, septic shock -3.1%; p<0.25). Intensive insulin therapy was associated with an increased risk of hypoglycemia (sepsis +16.7%, septic shock +18.8; p<0.0001) which did not, however, directly affect morbidity nor mortality.

CONCLUSIONS

These data suggest that IIT improves outcome of patients with sepsis or septic shock. Hypoglycemia is a frequent complication, but its clinical relevance remains to be defined.

Standardization of severe sepsis management: a survey of methodologies in academic and community settings

BACKGROUND

Evidence-based therapies for severe sepsis include early antibiotics, early goal-directed therapy, corticosteroids, recombinant human activated protein C, glucose control, and lung protective strategies.

OBJECTIVE

The objective of this study was to analyze methods, challenges, and outcomes observed by hospitals that implemented a hospital-wide sepsis management protocol incorporating evidence-based therapies.

METHODS

In a cross-sectional multi-center telephone survey over a 4-month period, clinicians (participants) responsible for developing a hospital sepsis protocol were questioned regarding its development and outcomes.

RESULTS

Participants completing surveys represented 40 hospitals (20 academic and 20 community). Twenty-seven percent of protocol champions were Emergency physicians or nurses. Sixty-three percent reported protocol development time of 6-12 months. Eighty-eight percent of participants reported protocol initiation in the Emergency Department. Three participants reported hiring a nurse educator to implement the protocol. Ninety-five percent of participants measure lactate as part of patient screening. Protocol therapies reported included early antibiotics (98%), early goal directed-therapy (EGDT) (98%), corticosteroids (80%), and activated protein C (73%). Contributions to success included having a protocol champion (85%) and sepsis education program (65%). Twenty-one participants had recorded patient-level data, totaling 2319 protocol patients, compared to 1719 non-protocol patients, with in-hospital mortality of 23% and 44%, respectively.

CONCLUSIONS

Implementation of a sepsis management protocol incorporating evidence-based therapies can be accomplished in both academic and community hospitals, with minimal additional staffing. The presence of a protocol champion and education program is crucial to success, and may result in improved patient outcome.

The impact of the severity of sepsis on the risk of hypoglycaemia and glycaemic variability

INTRODUCTION

The purpose of this study was to assess the relation between glycaemic control and the severity of sepsis in a cohort of patients treated with intensive insulin therapy (IIT).

METHODS

In a prospective, observational study, all patients in the intensive care unit (ICU) (n = 191) with sepsis, severe sepsis or septic shock were treated with IIT (target blood glucose (BG) level 80 to 140 mg/dl instead of strict normoglycaemia). BG values were analysed by calculating mean values, rate of BG values within different ranges, rate of patients experiencing BG values within different levels and standard deviation (SD) of BG values as an index of glycaemic variability.

RESULTS

The number of patients with hypoglycaemia and hyperglycaemia was highly dependent on the severity of sepsis (critical hypoglycaemia < or = 40 mg/dl: sepsis: 2.1%, severe sepsis: 6.0%, septic shock: 11.5%, p = 0.1497; hyperglycaemia: >140 mg/dl: sepsis: 76.6%, severe sepsis: 88.0%, septic shock: 100%, p = 0.0006; >179 mg/dl: sepsis: 55.3%, severe sepsis: 73.5%, septic shock: 88.5%, p = 0.0005; >240 mg/dl: sepsis: 17.0%, severe sepsis: 48.2%, septic shock: 45.9%, p = 0.0011). Multivariate analyses showed a significant association of SD levels with critical hypoglycaemia especially for patients in septic shock (p = 0.0197). In addition, SD levels above 20 mg/dl were associated with a significantly higher mortality rate relative to those with SD levels below 20 mg/dl (24% versus 2.5%, p = 0.0195).

CONCLUSIONS

Patients with severe sepsis and septic shock who were given IIT had a high risk of hypoglycaemia and hyperglycaemia. Among these patients even with a higher target BG level, IIT mandates an increased awareness of the occurrence of critical hypoglycaemia, which is related to the severity of the septic episode.

Development and implementation of an ICU quality improvement checklist

Hospitals, especially their intensive care units, are not particularly safe for patients. Life-threatening mistakes and omissions in care can and do occur. To deter omissions and mistakes wherever possible, our medical intensive care team developed a checklist of care issues that must be addressed daily for every patient in our intensive care unit. The checklist augments our daily, multidisciplinary quality rounds and informs all personnel when important items have been missed. It is too soon to tell whether the checklist has had an impact on our survival rate or length of stay, but we have documented clear improvement in our attention to these core intensive care issues. In addition, our team's collegiality and team bonding are enhanced by using an evidence-based tool to achieve our care goals. We share our checklist, so that others can use and/or adapt it in their pursuit of optimal care for their critically ill patients.