Clinics in chest medicine
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Key links in the chain of survival for the management of severe sepsis and septic shock are early identification and comprehensive resuscitation of high-risk patients. Multiple studies have shown that the first 6 hours of early sepsis management are especially important from a diagnostic, pathogenic, and therapeutic perspective, and that steps taken during this period can have a significant impact on outcome. The recognition of this critical time period and the robust outcome benefit realized in previous studies provides the rationale for adopting early resuscitation as a distinct intervention. Sepsis joins trauma, stroke, and acute myocardial infarction in having "golden hours," representing a critical opportunity early on in the course of disease for actions that offer the most benefit.
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Clinics in chest medicine · Dec 2008
ReviewCorticosteroids and human recombinant activated protein C for septic shock.
This article summarizes the current knowledge on the benefit/risk profile from the use of low-dose corticosteroids and activated protein C in treating septic shock. Physicians should consider using low-dose corticosteroids and drotrecogin alpha activated in the treatment of patients who have vasopressor-dependent septic shock with persistent signs of hypoperfusion, organ dysfunction, or hypotension. The optimal timing for initiating these treatments is from 6 to 24 hours from onset of shock. When patients are receiving these drugs, physicians should systematically screen for superinfection and serious bleeding events.
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Clinics in chest medicine · Dec 2008
ReviewReducing mortality in severe sepsis: the Surviving Sepsis Campaign.
This article traces the history and evolution of the Surviving Sepsis Campaign as a public health initiative through its several stages of development. The literature that has characterized clinical experiences with interventions related to the campaign is reviewed and conclusions discussed.
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Every patient who has sepsis and septic shock must be evaluated appropriately at presentation before the initiation of antibiotic therapy. However, in most situations, an abridged initial assessment focusing on critical diagnostic and management planning elements is sufficient. Intravenous antibiotics should be administered as early as possible, and always within the first hour of recognizing severe sepsis and septic shock. ⋯ The duration of antibiotic therapy typically is limited to 7 to 10 days. Longer duration is considered if response is slow, if there is inadequate surgical source control, or if immunologic deficiencies are evident. Antimicrobial therapy should be stopped if infection is not considered the etiologic factor for a shock state.
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Hyperglycemia is common during the course of critical illness and is associated with adverse clinical outcomes. Randomized controlled trials and large observational trials of insulin therapy titrated to achieve glucose values approximating the normal range (80 to 110 mg/dL) demonstrate improved morbidity and mortality in heterogeneous populations and have led to recommendations for improved glucose control. Patients who have septic shock, however, appear to be at higher risk for hypoglycemia, and a recent randomized trial focusing exclusively on patients who had severe sepsis did not show benefit. The recent Surviving Sepsis consensus statement recommends insulin therapy using validated protocols to lower glucose (less than 150 mg/dL) pending the results of adequately powered trials to determine if normalization (less than 110 mg/dL) of glucose is needed to optimize outcomes in patients who have severe sepsis.