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Renal effects of synthetic colloids and crystalloids in patients with severe sepsis: A prospective sequential comparison*. Crit Care Med 2011; 39:1335-42. [DOI: 10.1097/ccm.0b013e318212096a] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Abstract
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.
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Abstract
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.
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Affiliation(s)
- F M Brunkhorst
- Paul-Martini-Forschergruppe für klinische Sepsisforschung, Klinik für Anästhesiologie und Intensivtherapie, Klinikum der Friedrich-Schiller-Universität Jena, Erlanger Allee 101, 07743 , Jena, Deutschland.
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Abstract
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.
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Affiliation(s)
- F M Brunkhorst
- Paul-Martini-FG Klinische Sepsisforschung, Klinik für Anästhesiologie und Intensivtherapie, Klinikum der Friedrich-Schiller-Universität Jena, Erlanger Allee 101, 07743, Jena, Deutschland.
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Giessler GA, Mayer T, Trupkovic T. [Burn trauma--Part 2. Anesthesiological, surgical and intensive care management]. Anaesthesist 2009; 58:474-84. [PMID: 19384454 DOI: 10.1007/s00101-009-1535-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- G A Giessler
- Abt. für Plastische, Hand- und Rekonstruktive Mikrochirurgie, Berufsgenossenschaftliche Unfallklinik Murnau, Professor Kuentscher Str. 8, 82418 Murnau am Staffelsee, Deutschland.
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The authors reply:. Crit Care Med 2009. [DOI: 10.1097/ccm.0b013e31819bb742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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The author replies:. Crit Care Med 2009. [DOI: 10.1097/ccm.0b013e31819bb775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ellger B, Westphal M, Stubbe HD, Van den Heuvel I, Van Aken H, Van den Berghe G. [Glycemic control in sepsis and septic shock: friend or foe?]. Anaesthesist 2008; 57:43-8. [PMID: 18034219 DOI: 10.1007/s00101-007-1285-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- B Ellger
- Klinik und Poliklinik für Anästhesiologie und operative Intensivmedizin, Universitätsklinikum Münster, Albert-Schweitzer-Strasse 33, 48149 Münster, Deutschland.
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Nguyen HB, Oh J, Otero RM, Burroughs K, Wittlake WA, Corbett SW. Standardization of severe sepsis management: a survey of methodologies in academic and community settings. J Emerg Med 2008; 38:122-30, quiz 130-2. [PMID: 18650051 DOI: 10.1016/j.jemermed.2007.10.087] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Revised: 10/10/2007] [Accepted: 10/23/2007] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- H Bryant Nguyen
- Department of Emergency Medicine, Loma Linda University, Loma Linda, California 92354, USA
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Current practice in nutritional support and its association with mortality in septic patients—Results from a national, prospective, multicenter study*. Crit Care Med 2008; 36:1762-7. [DOI: 10.1097/ccm.0b013e318174dcf0] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Goetz AE, Heckel K. [Perioperative fluid and volume management. Goal-directed therapy necessary!]. Anaesthesist 2008; 56:745-6. [PMID: 17673957 DOI: 10.1007/s00101-007-1243-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- A E Goetz
- Klinik und Poliklinik für Anästhesiologie, Universitätsklinikum Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg.
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Waeschle RM, Moerer O, Hilgers R, Herrmann P, Neumann P, Quintel M. The impact of the severity of sepsis on the risk of hypoglycaemia and glycaemic variability. Crit Care 2008; 12:R129. [PMID: 18939991 PMCID: PMC2592768 DOI: 10.1186/cc7097] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Revised: 09/11/2008] [Accepted: 10/21/2008] [Indexed: 01/04/2023] Open
Abstract
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.
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Affiliation(s)
- Reiner M Waeschle
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Robert-Koch-Strasse 40, Goettingen, 37075, Germany
| | - Onnen Moerer
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Robert-Koch-Strasse 40, Goettingen, 37075, Germany
| | - Reinhard Hilgers
- Department of Medical Statistics, University of Goettingen, Humboldtallee 32, Goettingen, 37073, Germany
| | - Peter Herrmann
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Robert-Koch-Strasse 40, Goettingen, 37075, Germany
| | - Peter Neumann
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Robert-Koch-Strasse 40, Goettingen, 37075, Germany
| | - Michael Quintel
- Department of Anaesthesiology, Emergency and Intensive Care Medicine, University of Goettingen, Robert-Koch-Strasse 40, Goettingen, 37075, Germany
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Simpson SQ, Peterson DA, O'Brien-Ladner AR. Development and implementation of an ICU quality improvement checklist. AACN Adv Crit Care 2007; 18:183-9. [PMID: 17473547 DOI: 10.1097/01.aacn.0000269262.37288.bf] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Steven Q Simpson
- Division of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd, Kansas City, KS 66160, USA.
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Westerholt A, Maier S, Traeger T, Gründling M, Heidecke CD. Management bei abdomineller Sepsis. Visc Med 2007. [DOI: 10.1159/000100519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Schwere Sepsis und septischer Schock. Notf Rett Med 2006. [DOI: 10.1007/s10049-006-0848-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Thiel M. Qualitätsmanagement bei Sepsis. Anaesthesist 2006. [DOI: 10.1007/s00101-006-1057-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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