Critical care clinics
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Performance improvement in medicine based on evidence-based guidelines is a persistent challenge for clinicians. Challenges include deficiencies in collaboration, resistance to change, complex algorithms, inadequate resources, and inability to collect data and provide feedback. In severe sepsis this is further compounded by the perceived importance of early intervention and considerable conflicting literature. ⋯ Time sensitive bundle indicators allow for uniform data collection and reporting. Successful modification of clinical practice may require months or years. The success of the program relies upon the cross-departmental collaboration and support generated before implementation and the ability to deliver timely feedback to facilitate change in performance.
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Critical care clinics · Oct 2009
ReviewOptimizing antimicrobial therapy in sepsis and septic shock.
This article reviews principles in the rational use of antibiotics in sepsis and septic shock and presents evidence-based recommendations for optimal antibiotic therapy. Every patient with sepsis and septic shock must be evaluated 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. ⋯ Combination therapy should be continued for no more than 3 to 5 days and deescalation should occur following availability of susceptibilities. 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 in the case of immunologic deficiencies. Antimicrobial therapy should be stopped if infection is not considered the etiologic factor for a shock state.
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Sepsis affects the cardiovascular system through multiple mechanisms, and often these derangements result in tissue hypoperfusion. Tissue hypoperfusion is often present in the setting of overt shock, but it can also be present in patients without obvious shock physiology. If left untreated, tissue hypoperfusion contributes to the development of multiple organ dysfunction and, ultimately, death. Therefore, it is critical for the clinician to understand the pathophysiology, recognition, and treatment of sepsis-induced hypoperfusion.
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In this review, we start with a general discussion of relevant factors that can determine the validity of a sepsis animal model. We briefly review some of the currently used animal models of sepsis (small animal models and large animal models). We discuss the clinical relevance of animal models in sepsis research today and address potential reasons for the apparent underperformance of animal models in predicting therapeutic success of novel drugs in clinical trials.
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Tissue hypoperfusion is an important factor in the development of multiple organ failure. Therefore, recognition of sepsis-induced tissue hypoperfusion and timely clinical intervention to prevent and correct this are fundamental aspects of managing patients with sepsis and septic shock. ⋯ However, the utility of many forms of hemodynamic monitoring that are used in management of sepsis and septic shock remain controversial and unproven. This article examines emerging technologies as well as more established techniques used to monitor hemodynamics in sepsis and assesses their potential roles in optimization of sepsis-induced tissue hypoperfusion.