Critical care nursing clinics of North America
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Arterial waveform analysis that does not require continuous calibration, impedance cardiography, electrical cardiometry, velocity-encoded phase contrast magnetic resonance imaging (MRI), pulsed dye densitometry, noninvasive pulse pressure analysis using tonometry, suprasternal Doppler, partial CO2 rebreathing techniques, and transcutaneous Doppler are just some of the other emerging technologies not described in this review that may be used routinely in the management of sepsis and septic shock in the very near future. These innovative approaches may further increase our ability to optimize patients' fluid status and hemodynamics. We also have ability to monitor the microcirculation. ⋯ It remains unproven that hemodynamic monitoring of disease progression can effectively change patient outcome. However, despite our increased understanding of sepsis pathophysiology, mortality and morbidity from the disease remains high. Therefore, the search for the optimal parameters in resuscitation and the best way they can be monitored will continue.
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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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Steroid therapy in patients with septic shock has been controversial for decades. Although treatment with high-doses of corticosteroids for patients with septic shock has been shown not to be beneficial, it was believed that therapy with low-doses would be helpful. ⋯ For the majority of septic shock patients, corticosteroids should not be used, as the benefit of reversing shock is not worth the complications of superinfection, new sepsis, and septic shock. Finally, steroid therapy should not be guided by corticotropin test results.
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Crit Care Nurs Clin North Am · Mar 2011
ReviewOptimizing antimicrobial therapy in sepsis and septic shock.
Every patient with sepsis and septic shock must be evaluated thoroughly 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. ⋯ Combination therapy should be continued for no more than 3 to 5 days and de-escalation 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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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.