Langenbeck's archives of surgery
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Langenbecks Arch Surg · Mar 1998
ReviewScope and limitations of antimicrobial therapy of sepsis in surgery.
The goal of antibiotic therapy for surgical sepsis is to kill bacteria that intermittently or continuously reach the bloodstream from the residue of an operatively treated focus. While sepsis and conditions leading to sepsis compromise the immune system, antibiotics may become a fundamental determinant of the host's defense. No data from sound prospective randomized clinical antibiotic trials dealing with sepsis are available. Therefore we tested the hypothesis that treatment recommendations can be based on pharmacodynamics comparing in vitro activity of commonly used antimicrobials with concentrations sustained in vivo to provide for full coverage for bacteria of concern. ⋯ Sepsis is defined as a whole body's inflammatory response that is characterized by systemic signs and symptoms secondary to a focal infection. While many antibiotic trials have dealt with a focal infection, no prospective randomized antibiotic trial has dealt with sepsis per se. Antibiotic trials on focal infections generally exclude patients when their focal infection has progressed to sepsis. To circumvent the lack of controlled clinical trials we show that pharmacodynamics may provide sound foundation for antibiotic choice for sepsis.
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Today a great number of problems in the field of bacterial sepsis remain to be solved. Understanding the molecular mechanisms of one of the most important bacterial products in the pathogenesis of sepsis - endotoxin may contribute to innovative and more effective therapies. Therefore, this review focuses on the structural and functional elements of endotoxin, its interaction with immune cells, and its biological activity. Finally, other bacterial components and their impact on sepsis are discussed.
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Langenbecks Arch Surg · Mar 1998
ReviewOutcome of patients with sepsis and septic shock after ICU treatment.
Today, sepsis syndrome is the leading cause of death in adult, non-coronary intensive care units (ICUs) and is of great clinical importance. The purpose of this review was to evaluate recent prospective studies concerning the short- and long-term prognosis of patients suffering from systemic inflammatory-response syndrome (SIRS), sepsis, severe sepsis and septic shock. It has been shown in multicentre prospective surveys that 1% and 0.3% of all patients admitted to hospitals suffer, respectively, from bacteraemia alone and bacteraemia with severe sepsis. This rate increases, of course, when only admissions to the ICUs are considered: the above-mentioned rates increase then by a factor of 8 and 30, respectively. Thus, approximately 10% of patients in the ICU suffer from sepsis, 6% from severe sepsis and 2-3% from septic shock. SIRS occurs more frequently and its occurrence ranges from 40% to 70% of all patients admitted to ICUs. Thereby, 40-70% suffering from SIRS progress to a more severe septic-disease state. The overall prognosis is still poor, despite the recent advances in ICU treatment. The mortality rate of SIRS ranges from 6% to 7% and in septic shock amounts to over 50%. In particular, abdominal sepsis exhibits the highest mortality rate with 72%. The long-term prognosis is equally poor; only approximately 30% survived the first year after hospital admission. ⋯ The prognosis of sepsis and septic shock remains poor, despite the advances in ICU treatment. Although prognostic factors have been identified for some patients, groups have not yet been able to identify the immediate or long-term prognosis for the majority of these septic patients.
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In this article sepsis scoring systems commonly used are presented as regards their results and shortcomings. Furthermore, in a more general context, the direct and indirect effect on the individual patients is discussed and recommendations are given on how to use scoring systems.
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Langenbecks Arch Surg · Mar 1998
Failure of Kupffer cell blockade to prevent disseminated intravascular coagulation in endotoxemic rats despite improved survival.
Studies were conducted to evaluate the impact of gadolinium chloride (GdCl3), an agent which blocks the phagocytosis of liver macrophages (Kupffer cells, KC), on the coagulation system and on mortality in a model of rats subjected to a lethal dose of Escherichia coli lipopolysaccharide (LPS) (10 mg/kg body weight, intravenously). ⋯ These results confirm reports on the protective potential of GdCl3 pretreatment in experimental endotoxemia. However, the present study does not support the concept of DIC as a strong prognostic criterion for the outcome of sepsis and septic shock. Furthermore, the results presented suggest a minor role for KC in LPS-mediated activation of coagulation and indicate an involvement of KC in LPS-associated lethality independent of the coagulation system.