Critical care nursing clinics of North America
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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.
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The understanding of sepsis is continuously evolving. An overview of sepsis-induced tissue hypoperfusion has been provided herein. It is of critical importance that the clinician understands the pathophysiology of this emergent condition and is able to synthesize the available data in a rapid fashion so that tissue hypoperfusion is readily detected. Once detected, aggressive and endpoint-directed resuscitation should be implemented to reverse the hypoperfusion and to prevent further deterioration, organ dysfunction, and death.
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Sepsis guidelines, although creating a base to allow change in health care practitioner behavior, do not, in and of themselves, effect change. Change only comes with institution of a PI program, converting a core of key goals of guideline recommendations to quality indicators, and giving feedback on performance. ⋯ When combining multispecialty and multidisciplinary champions in the ED, hospital wards, ICU, and hospital administrative leadership with timely performance feedback, case failure analysis, and re-education, an opportunity to succeed in decreasing mortality in severe sepsis can be achieved. Sepsis bundle indicators require updating as new evidence emerges and new guidelines are published.(30,31)
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Crit Care Nurs Clin North Am · Mar 2011
Historical ArticleThe evolution of the understanding of sepsis, infection, and the host response: a brief history.
Sepsis is the ultimate clinical expression of the deleterious clash between the host immune response and invasive microorganisms.(72,73) At the beginning of the twentieth century, infections were by far the most common causes of death of Americans. By the beginning of the twenty-first century, the average lifespan of United States citizens had increased by over 30 years, with infections now accounting for a small minority of death.(74,75) Despite advances in public health, sanitation, vaccines, and antituberculosis chemotherapy and other antimicrobial agents, sepsis continues to account for an increasing number of deaths in critically ill patients. ⋯ A remarkable history of scientific inquiry into the fundamental nature of microbes and immune defenses preceded much of the current advances in the treatment of infectious diseases. Much work remains before the benefits of these discoveries can be thoughtfully applied to the management of severe sepsis and septic shock worldwide.
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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.