Adjunctive therapies in sepsis: An evidence-based review

Sepsis Management, Controversies, and Advancement in Nanotechnology: A Systematic Review

Sepsis is a potentially dangerous infection that requires prompt identification and treatment. Emergency medicine physicians must grasp the clinical signs and laboratory results of direct and indirect organ failure, the source of infection management, and the criteria for treating sepsis and septic shock. The pathogenesis of sepsis is connected to inflammation and an excess of reactive oxygen and nitrogen species, which activate the pathogen-associated molecular pattern (PAMP)-pattern recognition receptor (PRR) and damage-associated molecular pattern (DAMP)-PRR signaling pathways. The development of rapid, sensitive, and precise techniques for sepsis diagnosis might be aided by nanotechnology, a part of nanomedicine. Nanoparticles (NPs) such as magnetic NPs, gold NPs, fluorescent (silica and quantum dots), and lipid-based NPs have all been discussed to contribute to the detection of sepsis-related microbial infections. Because of the intrinsic and unique features of these nano-sized systems, researchers are evaluating nanotechnology-based alternatives for sepsis control. Recent advances in nanotechnology-based technologies for sepsis detection and management are discussed in this study.

Databases (PubMed, Medline, PMC, Google Scholar) were used to source various studies that were carried out on sepsis in terms of assessment, types, diagnosis, and treatment controversies, with more attention being given with a focus on the most recent data, principles, and management guidelines. Priority was also given to studies published within the last 11 years, using keywords such as "sepsis guidelines," "sepsis clinical," "septic risk factors," "sepsis and nano technology," "nano particles," "sepsis controversies," and "nano diagnostic" in the search. After a filtration process, the eight most relevant studies were selected to be included in this review. The filtration process included the use of both inclusion and exclusion criteria. The excluded studies were pediatric populations, obstetrical populations, and nanotechnology advancements dealing with other fields not relating to sepsis. The selected studies were also undertaken through a quality appraisal process using corresponding assessment tools. The selected articles were all highly informative about sepsis and the processes of diagnosis and treatment that are currently in use as well as those that are still being developed or implemented. Furthermore, we look at how nanomedicine in the application of nanomaterials can be employed to efficiently manage sepsis.

Advances in sepsis diagnosis and management: a paradigm shift towards nanotechnology

Sepsis, a dysregulated immune response due to life-threatening organ dysfunction, caused by drug-resistant pathogens, is a major global health threat contributing to high disease burden. Clinical outcomes in sepsis depend on timely diagnosis and appropriate early therapeutic intervention. There is a growing interest in the evaluation of nanotechnology-based solutions for sepsis management due to the inherent and unique properties of these nano-sized systems. This review presents recent advancements in nanotechnology-based solutions for sepsis diagnosis and management. Development of nanosensors based on electrochemical, immunological or magnetic principals provide highly sensitive, selective and rapid detection of sepsis biomarkers such as procalcitonin and C-reactive protein and are reviewed extensively. Nanoparticle-based drug delivery of antibiotics in sepsis models have shown promising results in combating drug resistance. Surface functionalization with antimicrobial peptides further enhances efficacy by targeting pathogens or specific microenvironments. Various strategies in nanoformulations have demonstrated the ability to deliver antibiotics and anti-inflammatory agents, simultaneously, have been reviewed. The critical role of nanoformulations of other adjuvant therapies including antioxidant, antitoxins and extracorporeal blood purification in sepsis management are also highlighted. Nanodiagnostics and nanotherapeutics in sepsis have enormous potential and provide new perspectives in sepsis management, supported by promising future biomedical applications included in the review.

Fluids for Prevention and Management of Acute Kidney Injury

Fluids are the only known method of attenuating renal injury. Furthermore, whether for hydration, resuscitation or renal replacement therapy, fluid prescriptions must be tailored to the fluid and electrolyte, cardiovascular status and residual renal function of the patient. Different fluids have significantly different effects both on volume expansion as well as on the electrolyte and acid-base balance; while controversial, different fluids may even influence renal function differently. This systematic review focuses on fluids for prevention and management of acute kidney injury. We have reviewed the available evidence and have made recommendations for clinical practice and future studies.

Implication of Haemodiafiltration Flow Rate on Amikacin Pharmacokinetic Parameters in Critically Ill Patients

BACKGROUND

To analyse the effect of haemodiafiltration (CVVHDF) flow rate on amikacin pharmacokinetics and blood concentrations.

METHODS

Prospective observational study. Patients receiving CVVHDF and amikacin treatment were included. Pharmacokinetic parameters were calculated using Bayesian analysis. Spearman correlation test was used in order to assess the influence of CVVHDF flux on amikacin minimum concentration (Cmin) and plasma clearance.

RESULTS

Thirty patients undergoing CVVHDF procedures were included. The treatment with amikacin started at an initial mean dose of 12.4 (4.1) mg/kg/day. An association between the flow rate and Cmin value (r = 0.261; p = 0.161) and plasma clearance was found (r = 0.268; p = 0.152). Four patients (13.3%) were not able to achieve peak concentration over MIC value higher than 8. In 4 patients, amikacin had to be discontinued due to a high Cmin value.

CONCLUSIONS

Amikacin clearance in patients with CVVHDF is affected by the flow rate used. Therefore, CVVHDF dose should be taken into account when dosing amikacin.

Clinical Benefits of High-Volume Hemofiltration in Critically Ill Pediatric Patients with Severe Sepsis: A Retrospective Cohort Study

AIMS

The study aimed to assess the clinical benefits of high-volume hemofiltration (HVHF) in pediatric patients with severe sepsis compared with standard-volume continuous veno-venous hemofiltration (CVVH).

METHODS

We retrospectively analyzed the medical records of 155 pediatric patients with severe sepsis admitted to the pediatric intensive care unit of Shanghai Children's Hospital from January 2010 to June 2016. A total of 93 patients were treated with HVHF and 62 patients were treated with CVVH.

RESULTS

HVHF treatment did not significantly reduce 28-day mortality. Moreover, there was no significant difference in reducing the plasma level of inflammatory mediators and improving hemodynamic variables between HVHF and CVVH group. However, the incidence of hyperglycemia was significantly higher in HVHF group than in CVVH group.

CONCLUSIONS

There is no evidence to indicate that HVHF is superior to CVVH in reducing 28-day mortality as an adjunct to the treatment of severe sepsis in pediatric patients.

Individualised antimicrobial dosing in critically ill patients undergoing continuous renal replacement therapy: focus on total drug clearance

Background

Continuous renal replacement therapy (CRRT) is common practice in critical care patients with acute renal failure.

Objectives

To evaluate the adequacy of antimicrobial doses calculated based on the total drug clearance and dose recommended by different guides in critically ill patients undergoing CRRT.

Methods

Retrospective observational study. Patients admitted to a critical care unit during May 2014 to May 2016 and subjected to CRRT were included. The recommended dose was established as the product of the usual dose of the drug by total drug clearance.

Results

177 antimicrobial agents, used in 64 patients were analysed; 45 (25.4%) antimicrobials were given in an insufficient dose (<20%) according to the theoretical calculation. Following the recommendations in the revised guidelines, between 10% and 20% of antimicrobials were given in insufficient doses. A higher success rate of treatment in those patients not receiving a low drug dosage was seen (35.2% vs 24.0%).

Conclusions

There is a great disparity between the antimicrobial dose prescribed, recommended and calculated based on drug clearance in critically ill patients undergoing CRRT.

The Use of Sodium Bicarbonate in the Treatment of Acidosis in Sepsis: A Literature Update on a Long Term Debate

Introduction. Sepsis and its consequences such as metabolic acidosis are resulting in increased mortality. Although correction of metabolic acidosis with sodium bicarbonate seems a reasonable approach, there is ongoing debate regarding the role of bicarbonates as a therapeutic option. Methods. We conducted a PubMed literature search in order to identify published literature related to the effects of sodium bicarbonate treatment on metabolic acidosis due to sepsis. The search included all articles published in English in the last 35 years. Results. There is ongoing debate regarding the use of bicarbonates for the treatment of acidosis in sepsis, but there is a trend towards not using bicarbonate in sepsis patients with arterial blood gas pH > 7.15. Conclusions. Routine use of bicarbonate for treatment of severe acidemia and lactic acidosis due to sepsis is subject of controversy, and current opinion does not favor routine use of bicarbonates. However, available evidence is inconclusive, and more studies are required to determine the potential benefit, if any, of bicarbonate therapy in the sepsis patient with acidosis.

Does Total Parenteral Nutrition Increase the Mortality of Patients with Severe Sepsis in the ICU?

OBJECTIVES

We aimed to evaluate the independent association between total parenteral nutrition (TPN) and nosocomial infection and intensive care unit (ICU) mortality in patients with severe pulmonary sepsis.

MATERIAL AND METHODS

The present study was designed as a retrospective observational cohort study. We enrolled all patients with severe sepsis due to pulmonary infections who stayed more than 24 h in the respiratory ICU between January 2009 and December 2010. We recorded demographic characteristics, ICU severity scores, Acute Physiologic and Chronic Health Evaluation II (APACHE II) and first day Sequential Organ Failure Assessment (SOFA) score in the ICU, TPN because of intolerance to enteral feeding, ICU data, and mortality. To evaluate the risk factors for mortality, we performed adjusted logistic regression test for TPN, nosocomial infection, and SOFA in the model.

RESULTS

Five hundred and fifty patients (males=375, females=175) with severe sepsis were involved in the study during the study period. The median and interquartile range (IQR) of age, APACHE II, and SOFA score at the time of admission to the ICU were 65 years (53-73), 20 (16-25), and 4 (3-6), respectively. Mortality rate was 18% (n=99). Adjusted odds ratio (OR), confidence intervals (CI) 95%, and p values of TPN, nosocomial infection, and first day SOFA score for mortality were as follows: OR:3.8, CI:2.3-6.1, p<0.001; OR:2.4, CI: 1.4-3.9, p<0.001; and OR: 1.3, CI:1.2-1.4, p<0.001, respectively.

CONCLUSION

Nosocomial infection and the need for TPN because of intolerance of enteral nutrition (EN) is associated with a higher mortality rate in patients with severe sepsis in the ICU. Rational use of antibiotics and application of hospital acquired infection control program will further reduce mortality.

High-volume hemofiltration for septic acute kidney injury: a systematic review and meta-analysis

Introduction

High-volume hemofiltration (HVHF) is an attractive therapy for the treatment of septic acute kidney injury (AKI). Small experimental and uncontrolled studies have suggested hemodynamic and survival benefits at higher doses of HVHF than those used for the high-intensity arms of the RENAL and ATN studies. Our aim was to evaluate the effects of high-volume hemofiltration (HVHF) compared with standard-volume hemofiltration (SVHF) for septic AKI.

Methods

A systematic review and meta-analysis of publications between 1966 and 2013 was performed. The review was limited to randomized-controlled trials that compared HVHF (effluent rate greater than 50 ml/kg per hour) versus SVHF in the treatment of sepsis and septic shock. The primary outcome assessed was 28-day mortality. Other outcomes assessed were recovery of kidney function, lengths of ICU and hospital stays, vasopressor dose reduction, and adverse events.

Results

Four trials, including 470 total participants, were included. Pooled analysis for 28-day mortality did not show any meaningful difference between HVHF compared with SVHF (OR, 0.76; 95% CI, 0.45 to 1.29). No included studies reported statistically significant differences between groups for any of the secondary outcomes. Adverse events, including hypophosphatemia and hypokalemia, were more commonly observed in HVHF-treated patients, although reporting was inconsistent across studies.

Conclusions

Insufficient evidence exists of a therapeutic benefit for routine use of HVHF for septic AKI, other than on an experimental basis. Given the logistic challenges related to patient recruitment along with an incomplete understanding of the biologic mechanisms by which HVHF may modify outcomes, further trials should focus on alternative extracorporeal therapies as an adjuvant therapy for septic AKI rather than HVHF.

Insulin promotes T cell recovery in a murine model of autoimmune myocarditis

Glucose-insulin-potassium (GIK) is a useful adjunct to myocarditis. Besides its essential action in energy metabolism, insulin also exerts an anti-inflammatory effect. This study investigated the effect of insulin on myocardial inflammation in experimental autoimmune myocarditis (EAM) in mice and its potential role in T cell regulation. Mice were divided randomly into a normal control group, a saline-treated EAM group and an insulin-treated EAM group. The histopathological changes of myocardium, α-myosin heavy chain (MyHCα)(614-629) antigen-specific autoantibody titre, the serum level of cardiac troponin I (cTnI), mitogen-activated protein kinase (MAPK) family members' activity and content were measured. Furthermore, the phenotype of T lymphocyte subsets in splenocytes was analysed to evaluate the immune status of mice. Insulin reduced serum cTnI of EAM mice on days 14 and 21 (P < 0·05) after immunization, with no changes in blood glucose and autoantibody production. Western blot revealed that extracellular signal-regulated protein kinase (ERK1/2) may be a determining factor in this process. Total ERK1/2 and phospho-ERK1/2 (p-ERK1/2) were both up-regulated in insulin-treated mice after immunization. We also found that insulin treatment promoted T cell recovery without changing the naive-to-memory T-cell ratio; in particular, CD3(+) T cells in insulin-treated mice proliferated more vigorously than in control mice (P < 0·05). We report here for the first time that insulin alleviates myocarditis in the EAM model. These data show that insulin has a direct effect on T cell proliferation in EAM. It is possible that GIK or insulin may assist T cell recovery towards normal in myocarditis, especially for diabetic or hyperglycaemic patients.

High versus standard-volume haemofiltration in hyperdynamic porcine peritonitis: effects beyond haemodynamics?

OBJECTIVE

The role of haemofiltration as an adjunctive treatment of sepsis remains a contentious issue. To address the role of dose and to explore the biological effects of haemofiltration we compared the effects of standard and high-volume haemofiltration (HVHF) in a peritonitis-induced model of porcine septic shock.

DESIGN AND SETTING

Randomized, controlled experimental study.

SUBJECTS

Twenty-one anesthetized and mechanically ventilated pigs.

INTERVENTIONS

After 12 h of hyperdynamic peritonitis, animals were randomized to receive either supportive treatment (Control, n = 7) or standard haemofiltration (HF 35 ml/kg per h, n = 7) or HVHF (100 ml/kg per hour, n = 7).

MEASUREMENTS AND RESULTS

Systemic and hepatosplanchnic haemodynamics, oxygen exchange, energy metabolism (lactate/pyruvate, ketone body ratios), ileal and renal cortex microcirculation and systemic inflammation (TNF-alpha, IL-6), nitrosative/oxidative stress (TBARS, nitrates, GSH/GSSG) and endothelial/coagulation dysfunction (von Willebrand factor, asymmetric dimethylarginine, platelet count) were assessed before, 12, 18, and 22 h of peritonitis. Although fewer haemofiltration-treated animals required noradrenaline support (86, 43 and 29% animals in the control, HF and HVHF groups, respectively), neither of haemofiltration doses reversed hyperdynamic circulation, lung dysfunction and ameliorated alterations in gut and kidney microvascular perfusion. Both HF and HVHF failed to attenuate sepsis-induced alterations in surrogate markers of cellular energetics, nitrosative/oxidative stress, endothelial injury or systemic inflammation.

CONCLUSIONS

In this porcine model of septic shock early HVHF proved superior in preventing the development of septic hypotension. However, neither of haemofiltration doses was capable of reversing the progressive disturbances in microvascular, metabolic, endothelial and lung function, at least within the timeframe of the study and severity of the model.

A pilot randomized study comparing high and low volume hemofiltration on vasopressor use in septic shock

OBJECTIVE

High volume hemofiltration (HVHF) has shown potential benefits in septic animals and a few reports suggested a hemodynamic improvement in humans. However, randomized studies are still lacking. Our goal was to evaluate the hemodynamic effects of HVHF in septic shock patients with acute renal failure (ARF).

DESIGN AND SETTING

Prospective randomized study in an intensive care unit (ICU).

PATIENTS

Twenty patients with septic shock and ARF.

INTERVENTIONS

Patients were randomized to either high volume hemofiltration [HVHF 65 ml/(kg h)] or low volume hemofiltration [LVHF 35 ml/(kg h). Vasopressor dose was adjusted to reach a mean arterial pressure (MAP) > 65 mmHg.

MEASUREMENTS AND RESULTS

We performed six hourly measurements of MAP, norepinephrine dose, PaO(2)/FiO(2) and lactate, and four daily urine output and logistic organ dysfunction (LOD) score. Baseline characteristics of the two groups were comparable on randomization. Mean norepinephrine dose decreased more rapidly after 24 h of HVHF treatment compared to LVHF treatment (P = 0.004) whereas lactate and PaO(2)/FiO(2) did not differ between the two treatment groups. During the 4-day follow-up, urine output was slightly increased in the HVHF group (P = 0.059) but the LOD score evolution was not different. Duration of mechanical ventilation, renal replacement therapy and ICU length of stay were also comparable. Survival on day 28 was not affected.

CONCLUSION

HVHF decreased vasopressor requirement and tended to increase urine output in septic shock patients with renal failure. However, a larger trial is required to confirm our results and perhaps to show a benefit in survival.

Acute renal failure in critically ill surgical patients: persistent lethality despite new modes of renal replacement therapy

OBJECTIVE

Despite improved resuscitation and sepsis care, acute renal failure (ARF) remains common in critically ill surgical patients. New methods of renal replacement therapy (RRT) are being used in surgical intensive care units (SICUs), including high-flux hemodialysis (HD) and continuous RRT (CRRT). RRT is being used increasingly early in the course of ARF, but data are scant to suggest that mortality is improved. Consequently, we determined whether outcomes were improved with CRRT in SICU patients, and hypothesized that CRRT lowers mortality for patients with ARF.

METHODS

Patients who developed ARF (acute increase in serum creatinine concentration >or=2.4 mg/dL) in the SICU from 1993 to 2004 were identified. Data collected prospectively included year of admission, age, gender, Acute Physiology and Chronic Health Evaluation (APACHE) III score, cumulative multiple organ dysfunction score and its individual components, cumulative nonrenal organ dysfunction score, and need for RRT. Patients were stratified January 1994 to January 2001 (pre-CRRT) and February 2001 to December 2004 (post-CRRT). The primary endpoint was mortality.

RESULTS

Among 8,505 SICU patients, 530 (6.2%) developed ARF. Three hundred and eleven patients were treated pre-CRRT and 219 thereafter. Female patients comprised 35% of ARF patients. The mean age was 69 years +/- 2 years, and the mean APACHE III score was 81 +/- 1 point for ARF patients. HD was performed in 15.6% of ARF patients before 2001 and 5.5% of ARF patients in 2001 and thereafter. CRRT was performed in 20.1% of ARF patients in 2001 and thereafter. Overall mortality for ARF patients was 45% (APACHE III normative predicted mortality: 55%) with no difference over time (pre-CRRT = 46.3%, post-CRRT = 45.2%, p = 0.86). Patients who required RRT had a mean APACHE III score of 91 +/- 1 point, with 61% mortality (predicted mortality: 67%), with no difference over time. Independent predictors of mortality overall and for ARF patients included age and the magnitude of renal, cardiovascular, hepatic, and neurologic dysfunction. In comparison with CRRT, HD was associated with a decreased risk of death.

CONCLUSIONS

Despite more frequent RRT and the use of CRRT, the mortality of ARF in critically ill surgical patients remains high because of nonrenal organ dysfunction. Considering that ARF-related mortality was decreased by intermittent HD, and that intermittent RRT is less costly, patients who need RRT should be treated preferentially with HD.

Lactate in veterinary critical care: pathophysiology and management

The measurement of blood lactate in people has proven to be a useful tool in the diagnosis, monitoring, and prognosis of a wide range of clinical syndromes. Its use in small animals is increasing, and several studies have been completed that demonstrate its potential role in critical care. This article summarizes the current state of knowledge regarding the physiology and pathophysiology of lactate production and lactic acidosis; current indications and the utility of measurement in a critical care setting are described; novel applications in the evaluation of cavitary effusions are highlighted; and a guide to the therapy of lactic acidosis is presented.

Pathophysiology of sepsis

Sepsis remains a critical problem with significant morbidity and mortality even in the modern era of critical care management. Multiple derangements exist in sepsis involving several different organs and systems, although controversies exist over their individual contribution to the disease process. Septic patients have substantial, life-threatening alterations in their coagulation system, and currently, there is an approved therapy with a component of the coagulation system (activated protein C) to treat patients with severe sepsis. Previously, it was believed that sepsis merely represented an exaggerated, hyperinflammatory response with patients dying from inflammation-induced organ injury. More recent data indicate that substantial heterogeneity exists in septic patients' inflammatory response, with some appearing immuno-stimulated, whereas others appear suppressed. Cellular changes continue the theme of heterogeneity. Some cells work too well such as neutrophils that remain activated for an extended time. Other cellular changes become accelerated in a detrimental fashion including lymphocyte apoptosis. Metabolic changes are clearly present, requiring close and individualized monitoring. At this point in time, the literature richly illustrates that no single mediator/system/pathway/pathogen drives the pathophysiology of sepsis. This review will briefly discuss many of the important alterations that account for the pathophysiology of sepsis.

Sepsis in critical care

Sepsis is a syndrome produced by the accelerated activity of the inflammatory immune response, the clotting cascade, and endothelial damage. It is a systematic process that can progress easily into septic shock and MODS. The chemical mediators or cytokines produce a complex self-perpetuating process that impacts all body systems. It is critical for the nurse first to identify patients at risk for developing sepsis and to assess patients who have SIRS and sepsis continually for signs and symptoms of organ involvement and organ dysfunction. Once sepsis has been diagnosed, evidence-based practice indicates initiation of fluid resuscitation. Vasopressor therapy, positive inotropic support, and appropriate antibiotic therapy should be started within the first hour. Within a 6-hour timeframe the goal is stabilization of the CVP, MAP, and UOP to prevent further organ damage. The challenge for nurses caring for septic patients is to support the treatment goals, to prevent added complications including stress ulcers, DVTs, aspiration pneumonia, and the progression to MODS, and to address the patient's and the family's psychosocial needs. As complex as the pathophysiology of sepsis is, the nursing care is equally complex but also rewarding. Patients who previously might have died now recover as vigilant nursing care combines forces with new drug therapies and evidence-based practice guidelines.

Effect of mode of hydrocortisone administration on glycemic control in patients with septic shock: a prospective randomized trial

Introduction

Low-dose hydrocortisone treatment is widely accepted therapy for the treatment of vasopressor-dependent septic shock. The question of whether corticosteroids should be given to septic shock patients by continuous or by bolus infusion is still unanswered. Hydrocortisone induces hyperglycemia and it is possible that continuous hydrocortisone infusion would reduce the fluctuations in blood glucose levels and that tight blood glucose control could be better achieved with this approach.

Methods

In this prospective randomized study, we compared the blood glucose profiles, insulin requirements, amount of nursing workload needed, and shock reversal in 48 septic shock patients who received hydrocortisone treatment either by bolus or by continuous infusion with equivalent dose (200 mg/day). Duration of hydrocortisone treatment was five days.

Results

The mean blood glucose levels were similar in the two groups, but the number of hyperglycemic episodes was significantly higher in those patients who received bolus therapy (15.7 ± 8.5 versus 10.5 ± 8.6 episodes per patient, p = 0.039). Also, more changes in insulin infusion rate were needed to maintain strict normoglycemia in the bolus group (4.7 ± 2.2 versus 3.4 ± 1.9 adjustments per patient per day, p = 0.038). Hypoglycemic episodes were rare in both groups. No difference was seen in shock reversal.

Conclusion

Strict normoglycemia is more easily achieved if the hydrocortisone therapy is given to septic shock patients by continuous infusion. This approach also reduces nursing workload needed to maintain tight blood glucose control.

Trial Registration Number

ISRCTN98820688

A practical approach to hyperglycemia management in the intensive care unit: evaluation of an intensive insulin infusion protocol

STUDY OBJECTIVES

To evaluate the effectiveness and safety of maintaining a target blood glucose concentration of 91-130 mg/dl with a standardized, nurse-managed, intensive insulin infusion protocol outside a study setting, and to determine if a statistically significant favorable effect on morbidity and mortality was achieved.

DESIGN

Retrospective, observational, chart review.

SETTING

Medical and surgical intensive care units (ICUs) in a community teaching hospital.

PATIENTS

One hundred forty-three adult patients who received insulin infusions managed at the discretion of the physician over a 1-year period before initiation of the protocol (control group), and 70 patients who received insulin infusions over a 6-month period with infusion dosages titrated by using the protocol (protocol group).

MEASUREMENTS AND MAIN RESULTS

Episodes of hypoglycemia, time within target range, mean blood glucose concentration, frequency of measurement, length of ICU stay, duration of mechanical ventilation, and overall mortality were collected. Hypoglycemic episodes were not significantly different between the groups. Blood glucose concentrations were within target range in 34% of all measurements in the protocol group compared with 23% in the control group (p<0.001, relative risk [RR] 1.48, 95% confidence interval [CI] 1.38-1.58). Once target range was reached on one measurement, 43% of concentrations remained in target range in the protocol group compared with 29% in the control group (p<0.001, RR 1.47, 95% CI 1.38-1.56). Frequency of measurements was higher in the protocol group versus control group (p=0.01); however, clinical difference was minimal. Protocol group had lower overall mortality rate (27% [19/70] vs 32% [46/143], p=0.45), reduced mean ICU length of stay (16.7 +/- 10.6 vs 18.4 +/- 16.0 days, p=0.37), and less mechanical ventilation time (16.5 +/- 9.7 vs 17.0 +/- 15.0 days, p=0.79).

CONCLUSION

The nurse-managed insulin infusion protocol improved glycemic control with minimal hypoglycemic episodes compared with baseline practice. A trend toward decreased mortality, ICU length of stay, sand days of mechanical ventilation was observed. When compared with other published protocols, our insulin protocol displays comparable effectiveness with the use of less-frequent blood glucose measurements.

Evaluation of endotoxin models for the study of sepsis

Many strategies have been proposed for the treatment of sepsis, and most of the proposed treatment modalities have failed in clinical trials. Many of the previous treatment protocols called for blocking the activity of a single, clearly defined mediator. The underlying hypothesis was that sepsis induced a specific mediator that then caused organ injury and death. This simple, linear reasoning was frequently based on cytokines that were defined using endotoxin models of sepsis. The endotoxin models were widely used to study the pathophysiology of sepsis and were felt to adequately reproduce the full spectrum of inflammatory changes observed in patients with sepsis. Based on mortality and hematologic changes, these assumptions appeared justified. As the models were examined more closely, and directly compared with focus of infection models that more accurately portray the changes in sepsis, it became apparent that the endotoxin models did not accurately mimic the patient with sepsis. In the endotoxin models, the explosive release of cytokines into the circulating blood volume was reproducibly found regardless of the species studied (human, primate, pig, rat, or mouse). This lead to a series of anticytokine sepsis trials, all of which failed. The cytokine response in focus of infection models, such as that induced by cecal ligation and puncture, was examined and found to be more similar to that observed in patients with sepsis. When cytokine inhibitor strategies were used in the cecal ligation and puncture model, they were also generally found to lack efficacy. Compounds that have been shown to be effective at reducing mortality in endotoxin models should be re-evaluated in more clinically relevant models of sepsis.

Modifications to advanced life support in renal failure

The outcome of cardiopulmonary resuscitation (CPR) has been reported to be worse in patients with renal failure compared with those with normal renal function. It is likely that this increased mortality may be at least partly attributable to sub-optimal and highly variable treatment strategies used in cardiac arrest in patients with renal failure, but this issue has not previously been explored. Such patients undoubtedly pose a challenge to advanced life support (ALS) providers, and renal unit staff are not trained to provide specialist advice after a patient has sustained a cardiac arrest. There are few studies investigating the epidemiology, safety or outcome of cardiac arrest in patients with renal failure and there are no generally accepted resuscitation guidelines for this special circumstance. In this article we discuss the unique problems of resuscitating patients with renal failure and propose a suitable management strategy.

Management of Severe Sepsis in the Surgical Patient

Sepsis and septic shock are not uncommon conditions in the surgical intensive care unit. Sepsis is a generalized activation of the immune system in the presence of clinically suspected or culture-proven infection. Severe sepsis is sepsis with organ system dysfunction. Septic shock is sepsis with hypotension (systolic blood pressure <90 mm Hg) without other causes. Although the incidence of sepsis is increasing, the case fatality rate is falling. This improvement in outcome is in part due to bold initiatives like the Surviving Sepsis Campaign from the Institute for Health Care Improvement. In this article the authors present the epidemiology of severe sepsis and evidence-based campaigns for its treatment, with a focus on the surgical patient.

Solute removal during continuous renal replacement therapy in critically ill patients: convection versus diffusion

Introduction

The best modality, for continuous renal replacement therapy (CRRT) is currently uncertain and it is poorly understood how transport of different solutes, whether convective or diffusive, changes over time.

Methods

We conducted a prospective cross over study in a cohort of critically ill patients, comparing small (urea and creatinine) and middle (β₂ microglobulin) molecular weight solute clearance, filter lifespan and membrane performance over a period of 72 hours, during 15 continuous veno-venous dialysis (CVVHD) and 15 continuous veno-venous hemofiltration (CVVH)sessions. Both modalities were administered based on a prescription of 35 ml/kg/h and using polyacrylonitrile filters.

Results

Median filter lifespan was significantly longer during CVVHD (37 hours, interquartile range (IQR) 19.5 to 72.5) than CVVH (19 hours, IQR 12.5 to 28) (p = 0.03). Median urea time weighted average (TWA) clearances were not significantly different during CVVH (31.6 ml/minute, IQR 23.2 to 38.9) and CVVHD (35.7 ml/minute, IQR 30.1 to 41.5) (p = 0.213). Similar results were found for creatinine: 38.1 ml/minute, IQR 28.5 to 39, and 35.6 ml/minute, IQR 26 to 43 (p = 0.917), respectively. Median β₂m TWA clearance was higher during convective (16.3 ml/minute, IQR 10.9 to 23) than diffusive (6.27 ml/minute, IQR 1.6 to 14.9) therapy; nonetheless this difference did not reach statistical significance (p = 0.055). Median TWA adsorptive clearance of β₂m appeared to have scarce impact on overall solute removal (0.012 ml/minute, IQR -0.09 to 0.1, during hemofiltration versus -0.016 ml/minute, IQR -0.08 to 0.1 during dialysis; p = 0.79). Analysis of clearance modification over time did not show significant modifications of urea, creatinine and β₂m clearance in the first 48 hours during both treatments. In the CVVHD group, the only significant difference was found for β₂m between 72 hours and baseline clearance.

Conclusion

Polyacrylonitrile filters during continuous hemofiltration and continuous hemodialysis delivered at 35 ml/kg/h are comparable in little and middle size solute removal. CVVHD appears to warrant longer CRRT sessions. The capacity of both modalities for removing such molecules is maintained up to 48 hours.

Management of severe sepsis and septic shock: challenges and recommendations

Sepsis and related aspects has become an area of active and intense research, leading to important advances for an early diagnosis and appropriate management useful to improve patient outcome. The septic response is an extremely complex cascade of events, including proinflammatory, anti-inflammatory, humoral, cellular, and circulatory involvement. The pathophysiology of this syndrome, its various and changing clinical aspects, and the vast variety of therapeutic options available, not always of well-proved efficacy, make its management a goal difficult to achieve.

The role of bundles in sepsis care

The understanding of the pathogenesis of sepsis has substantially changed in past years and continues to improve. New therapeutic options are being developed and incorporated into clinical practice. There are different specific interventions and therapies that benefit patients' outcome. As demonstrated by the early goal-directed therapy strategy, the success of the resuscitation treatment is strongly time dependent. The recognition of severe sepsis should be accompanied without delay by very well defined therapeutic measures. In 2002 the Surviving Sepsis Campaign was introduced with the overall goal of increasing clinicians' awareness and improving outcome in severe sepsis and septic shock.

Failure to implement evidence-based clinical guidelines for sepsis at the ED

OBJECTIVE

The main objective was to evaluate if consensus "bundle" measures to optimize the treatment of sepsis have been integrated in our routine practice. We also tried to identify variables significantly associated to mortality.

METHODS

An observational, unblinded study of those patients who, according to their physicians, met criteria for sepsis under its different stages of severity was conducted. Six items as proposed by surviving sepsis campaign were evaluated: (1) measurement of blood lactate; (2) obtaining blood samples for culture before use of antibiotics; (3) early use of antibiotics (>3 h); (4) fluid replacement with at least 20 mL/kg of crystalloids in the first hour, unless contraindicated, if hypotension or blood lactate >4 mmol/L; (5) use of vasoactive drugs, other than dopaminergic doses of dopamine, if hypotension or shock; (6) measurement of central venous pressure and central venous O2 saturation in shock. Data concerning several aspects of diagnosis, treatment, and consultation to ICU were collected.

RESULTS

Compliance with published guidelines is poor after evaluating the 6 items proposed: 12.5% of shocked patients had determinations of blood lactate; 15% of septic patients had no blood cultures drawn; 32% had received their first dose of antibiotics in the first 3 hours after admission; 46.6% of the cases of severe sepsis or shock received a fluid aggressive therapy; 43.3% of the patients with an indication for vasoactive drugs received them; no patient had central venous pressure monitoring at the ED. In addition, intensive care specialists were seldom consulted (17%). Having used dopaminergic doses of dopamine and having a respiratory focus as a source of infection were independently associated to mortality, respective OR: 21 ([1.7-254.9]; 95% CI) and 9.6 ([1.7-52]; 95% CI).

CONCLUSIONS

The "bundle" measures proposed in the surviving sepsis campaign seem not to have had enough impact in our ED. This is the start point of a "plan-do-study-act" process directed to improve the outcome of patients with sepsis at our institution.

Insulin reduces the multiple organ injury and dysfunction caused by coadministration of lipopolysaccharide and peptidoglycan independently of blood glucose: role of glycogen synthase kinase-3beta inhibition

OBJECTIVE

Insulin reduces morbidity and mortality among critically ill patients, but the molecular mechanisms of its effect remain unknown. Insulin is a well-known inhibitor of glycogen synthase kinase-3, which may play an important role in systemic inflammation and shock. Here we investigate the role of blood glucose and glycogen synthase kinase-3beta inhibition in the protective effect of insulin on the organ injury/dysfunction associated with excessive systemic inflammation.

DESIGN

Prospective, randomized study.

SETTING

University-based research laboratory.

SUBJECTS

Eighty-five anesthetized Wistar rats.

INTERVENTIONS

Rats received Escherichia coli lipopolysaccharide (1 mg/kg) and Staphylococcus aureus peptidoglycan (0.3 mg/kg) or vehicle intravenously. Insulin (1.4 units/kg intravenously) was administered in the absence or presence of continuous glucose administration (4.5 mg/kg/hr intravenously) either prophylactically or therapeutically. The potent and selective glycogen synthase kinase-3beta inhibitor TDZD-8 (1 mg/kg intravenously) or vehicle (10% dimethyl sulfoxide) was administered either prophylactically or therapeutically.

MEASUREMENTS AND MAIN RESULTS

Coadministration of lipopolysaccharide and peptidoglycan resulted in increases in the serum levels of creatinine (indicator of renal dysfunction), alanine aminotransferase, and aspartate aminotransferase (indicators of liver injury) at 6 hrs. Insulin or TDZD-8 similarly attenuated the organ injury/dysfunction caused by lipopolysaccharide and peptidoglycan when given either prophylactically or therapeutically. Continuous glucose administration had no effect on blood glucose levels or organ injury/dysfunction at 6 hrs. Treatment with insulin or TDZD-8 reduced the plasma levels of the proinflammatory cytokine interleukin-1beta. In vitro, insulin or TDZD-8 caused similar reductions in the nuclear factor-kappaB p65 activity and similar increases in the phosphorylation of Ser9 of glycogen synthase kinase-3beta.

CONCLUSIONS

Therapy with insulin or the potent and selective glycogen synthase kinase-3beta inhibitor TDZD-8 reduced the organ injury/dysfunction caused by lipopolysaccharide and peptidoglycan in the rat. We propose that the inhibitory effect of insulin on the activity of glycogen synthase kinase-3beta contributes to the protective effect of insulin against the organ injury/dysfunction caused by excessive systemic inflammation independently of any effects on blood glucose.

High-volume hemofiltration as salvage therapy in severe hyperdynamic septic shock

OBJECTIVES

To evaluate the effect of short-term (12-h) high-volume hemofiltration (HVHF) in reversing progressive refractory hypotension and hypoperfusion in patients with severe hyperdynamic septic shock. To evaluate feasibility and tolerance and to compare observed vs. expected hospital mortality.

DESIGN AND SETTING

Prospective, interventional, nonrandomized study in the surgical-medical intensive care unit of an academic tertiary center.

PATIENTS

Twenty patients with severe septic shock, previously unresponsive to a multi-intervention approach within a goal-directed, norepinephrine-based algorithm, with increasing norepinephrine (NE) requirements (>0.3 microg kg(-1) min(-1)) and lactic acidosis.

INTERVENTIONS

Single session of 12-h HVHF.

MEASUREMENTS AND RESULTS

We measured changes in NE requirements and perfusion parameters every 4h during HVHF and 6h thereafter. Eleven patients showed decreased NE requirements and lactate levels (responders). Nine patients did not fulfill these criteria (nonresponders). The NE dose, lactate levels, and heart rates decreased and arterial pH increased significantly in responders. Hospital mortality (40%) was significantly lower than predicted (60%): 67% (6/9) in nonresponders vs. 18% (2/11) in responders. Of 12 survivors 7 required only a single 12-h HVHF session. On logistic regression analysis the only statistically significant predictor of survival was theresponse to HVHF (odds ratio 9).

CONCLUSIONS

A single session of HVHF as salvage therapy in the setting of a goal-directed hemodynamic management algorithm may be beneficial in severe refractory hyperdynamic septic-shock patients. This approach may improve hemodynamics and perfusion parameters, acid-base status, and ultimately hospital survival. Moreover, it is feasible, and safe.

Severe Sepsis and Septic Shock in Adult Patients: An Approach to Management and Future Trends

Severe sepsis is sepsis associated with acute organ dysfunction. Septic shock in turn, implies severe sepsis that has led to circulatory shock refractory to fluid resuscitation alone. The immediate approach to severe sepsis follows the ABCs of resuscitation: Airway, Breathing, and Circulation. Special emphasis on the circulation involves early goal-directed therapy, adequate fluid resuscitation, and vasopressor/inotropic support. Once the patient's cardiorespiratory status is stabilized, efforts must be directed at uncovering the source and empirically yet accurately treating the infective underpinnings of severe sepsis. Following that, each of the patient's other organ systems at risk needs to be addressed: Renal/metabolic, gastrointestinal, hematological, and endocrine. Novel treatments will target both the proinflammatory and procoagulation cascades of sepsis.

Early and innovative interventions for severe sepsis and septic shock: taking advantage of a window of opportunity

The pathogenic, diagnostic and therapeutic landscape of sepsis is no longer confined to the intensive care unit: many patients from other portals of entry to care, both outside and within the hospital, progress to severe disease. Approaches that have led to improved outcomes with other diseases (e.g., acute myocardial infarction, stroke and trauma) can now be similarly applied to sepsis. Improved understanding of the pathogenesis of severe sepsis and septic shock has led to the development of new therapies that place importance on early identification and aggressive management. This review emphasizes approaches to the early recognition, diagnosis and therapeutic management of sepsis, giving the clinician the most contemporary and practical approaches with which to treat these patients.

Acute multifocal bacterial nephritis complicated with acute renal failure and thrombocytopenia

A 50-year-old woman was transferred to our hospital because of acute renal failure and thrombocytopenia. Due to rapid enlargement of the kidney, we first suspected that she had diffuse renal invasion of anaplastic carcinoma or lymphoma of the kidney. Anti-bacterial treatment for complicated urinary tract infection and hemodialysis treatment resulted in recovery of both renal function and thrombocytopenia. Serial CT study demonstrated disappearance of kidney swelling and multiple masses within the kidney. We finally made a diagnosis of acute multifocal bacterial nephritis. Timely initiation of dialysis therapy and appropriate anti-bacterial treatment was essential to rescue this case.

Pilzsepsis - Therapeutische Strategie. Fungal sepsis - therapeutical strategy

The incidence of fungal infection as well as fungal sepsis has increased dramatically during the last decade. Changes of local microbial flora after broad-spectrum antibiotic therapy allow overgrowth of Candida species. Prophylactic strategies to lower fungal infection and sepsis include adequate and restrictive antibiotic therapy. Concerning the treatment of the septic syndrome, supportive as well as adjunctive strategies like early-goal-directed cardiovascular therapy, hydrocortisone replacement therapy, intense insulin application to achieve normoglycemia as well as the application of activated Protein C besides a consequent source control regimen and standard intensive care therapy, are able to improve significantly the outcome of septic patients.