Current opinion in critical care
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There is considerable evidence that dysregulation of the coagulation and fibrinolytic systems plays a major role in the pathophysiology of severe sepsis, with a special focus on the protein C system. Conversely, there is an approval for use of recombinant human activated protein C in the more severe patients. This review highlights recent findings about the biology of the protein C system and of other important coagulation components such as tissue factor, platelets, and protein S, with an effort to link fundamental data and recent clinical findings. ⋯ The comprehension of the protein C pathway is undoubtedly progressing both in experimental and clinical settings. In parallel, some promising other coagulant pathways are also under investigation in the sepsis context, with a hope for major clinical implications in the future.
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Vasoactive drugs are the mainstay of hemodynamic management of vasodilatory shock when fluids fail to restore tissue perfusion. In this review, studies published during the past year that increase our understanding of the use of vasoactive drugs in the intensive care unit are discussed. ⋯ Over the last 40 years, there have been few controlled clinical trials to guide clinicians on the use of vasoactive drugs of treating shock states. It is not known whether the currently favored combination of norepinephrine and dobutamine is superior to traditional therapy with dopamine. Epinephrine is not recommended as the first-line therapy. The role of vasopressin and terlipressin remains unknown. Three large ongoing clinical trials will be completed soon and the results should clarify the role of these various agents.
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Measuring stroke volume or cardiac output is of paramount importance for the management of critically ill patients in the intensive care unit, or 'high risk' surgical patients in the operating room. The new noninvasive techniques are gaining acceptance among intensivists and anesthesiologists who have been trained almost exclusively in the pulmonary artery catheter and the thermodilution technique. ⋯ By making cardiac output easily measurable in various settings, these techniques should all contribute to improve hemodynamic management in critically ill or high-risk surgical patients.
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Curr Opin Crit Care · Oct 2005
ReviewGlucocorticoids in the treatment of severe sepsis and septic shock.
Septic shock remains one of the leading causes of death in intensive care units. In recent years, there is general use of low to moderate doses of corticosteroids in the treatment of septic shock. However, there are wide variations in the practical modality of this treatment, mainly with regard to patients' selection, treatment's dose, timing, route of administration, duration, and weaning. This review provides opinion-based guidelines for the use of corticosteroids in severe sepsis and septic shock. ⋯ In septic shock, intravenous hydrocortisone should be started immediately after a 250 microg corticotropin test, at a dose of 200-300 mg per day. When adrenal insufficiency is confirmed, treatment should be continued at full doses for 7 days. Otherwise, hydrocortisone should be stopped. It is worth considering adding enteral fludrocortisone at a dose of 50 microg per day for 7 days. In severe sepsis, despite growing evidence to support the use of a moderate dose of corticosteroids, the efficacy and safety of this treatment needs to be assessed in a large-scale study.
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The purpose of this review is to indicate recent developments in biomarkers of sepsis and to evaluate their impact on clinical use. According to the 'surviving sepsis campaign,' diagnosis of sepsis and infection is urgent; early and specific treatment is most effective to reduce complications and to decrease mortality. ⋯ Recent data and cumulative analyses indicate that biomarkers of sepsis improve diagnosis of sepsis. However, only a few markers have impact on therapy and fulfill the clinical requirements. Procalcitonin is a well-established marker, indicating infection, sepsis, and progression to the more severe stages of the disease. Today, this biomarker should be in the diagnostic portfolio of an intensive care unit or emergency ward.