Critical care clinics
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This article discusses the role of microcirculatory dysfunction in the pathophysiology of sepsis, reviewing the role of the endothelium in modulating microcirculatory flow, discussing the function of nitric oxide in mediating microcirculatory blood flow, and outlining means of evaluating microcirculatory function in septic patients. Finally, potential novel therapies and challenges in treating microcirculatory dysfunction in septic patients are discussed.
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When fluid administration fails to restore an adequate arterial pressure and organ perfusion in patients with septic shock, therapy with vasoactive agents should be initiated. The ultimate goals of such therapy in shock are to restore effective tissue perfusion and to normalize cellular metabolism. The efficacy of hemodynamic therapy in sepsis should be assessed by monitoring a combination of clinical and hemodynamic parameters. Although specific end points for therapy are debatable, and therapies will inevitably evolve as new information becomes available, the idea that clinicians should define specific goals and end points, titrate therapies to those end points, and evaluate the results of their interventions on an ongoing basis remains a fundamental principle.
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The term "source control" encompasses all those physical measures used to control a focus of invasive infection and to restore the optimal function of the affected area. Source-control measures can be categorized into 3 broad modalities: drainage controls the liquid component of an infection by converting a closed space infection to a controlled sinus or fistula; debridement is the physical removal of solid necrotic tissue (removal of an infected device can be considered a form of debridement); definitive measures seek to restore optimal function to the involved area. This article discusses specific approaches to source control in the abdomen, chest, and skin and soft tissues.
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Despite their potential benefits, corticosteroids have adverse affects and the benefits and risks must be balanced in determining whether they should be used or not. Some of the serious adverse affects noted in patients with critically illness have included superinfections and critical illness polyneuromyopathy. This article reviews the subject of steroid treatment of patients with septic shock and weighs the advantages and disadvantages of steroid treatment. It reviews and contrasts several low- and high-dose steroid studies, and makes recommendations for future practice.
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Standardization of definitions has been considered important in sepsis to facilitate accurate diagnosis and treatment, to clarify patient inclusion criteria for clinical trials, and to enable comparison of results from different studies. However, despite development and publication of consensus conference definitions, diagnosis of sepsis remains difficult in clinical practice and many patients do not receive the early specific therapy that could benefit them. Concepts of sepsis need to evolve such that good global definitions are accompanied by better strategies for individual diagnosis and disease characterization; patients can then be treated rapidly and appropriately to maximize their chances of survival.