Critical care nursing clinics of North America
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Septic shock remains a significant challenge for clinicians. Recent advances in cellular and molecular biology have significantly improved our understanding of its pathogenetic mechanisms. These improvements in understanding should translate to better care and improved outcomes for these patients.
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The ultimate goals of hemodynamic therapy in shock are to restore effective tissue perfusion and to normalize cellular metabolism. In sepsis, both global and regional perfusion must be considered. In addition, mediators of sepsis can perturb cellular metabolism, leading to inadequate use of oxygen and other nutrients despite adequate perfusion; one would not expect organ dysfunction mediated by such abnormalities to be corrected by hemodynamic therapy. ⋯ Specific end points for therapy are debatable and are likely to evolve. Nonetheless, 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. The practice parameters were intended to emphasize the importance of such an approach so as to provide a foundation for the rational choice of vasoactive agents in the context of evolving monitoring techniques and therapeutic approaches.
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Crit Care Nurs Clin North Am · Mar 2011
ReviewPrinciples of source control in the management of sepsis.
This brief overview of the role of source control in sepsis emphasizes the underlying principles rather than the empiric evidence from well-performed clinical studies. The reasons for this are several. First there is a paucity of high-level published evidence, with few rigorous large clinical series, and even fewer clinical trials. ⋯ Interested readers are referred to more detailed discussions such as that found in the background to the recommendations on source control in the guidelines of the Surviving Sepsis Campaign.(1) Source control is a core treatment modality in the management of the patient with severe sepsis or septic shock. Its optimal use assumes a comprehensive knowledge of biologic principles, the complexities of the septic response, and the range of surgical and nonsurgical options, and a combination of therapeutic aggressiveness and judicious caution in the clinician charged with making the decision. As every intensivist learns, appropriate source-control intervention can rapidly alter the course of sepsis to a more favorable direction, and suboptimal decision-making can change a difficult clinical challenge into a nightmare.
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Septic shock is a common and deadly disease that traditionally has been diagnosed and treated by evaluation and optimization of global hemodynamic indices. However, microcirculatory dysfunction is a critically important element in the pathophysiology of this disease. New techniques of in vivo video microscopy permit the assessment of microcirculatory function in human subjects. With the advent of these techniques, the microcirculation may represent a new frontier for developing novel therapies for sepsis.