2,833 publications from this institution
Among ICU encounters with suspected infection, the predictive validity for in-hospital mortality of SOFA was not significantly different than the more complex LODS but was statistically greater than SIRS and qSOFA, supporting its use in clinical criteria for sepsis. Among encounters with suspected infection outside of the ICU, the predictive validity for in-hospital mortality of qSOFA was statistically greater than SOFA and SIRS, supporting its use as a prompt to consider possible sepsis.
Vasopressor therapy represents a key part of intensive care patient management, used to increase and maintain vascular tone and thus adequate tissue perfusion in patients with shock. Norepinephrine is the preferred first-line agent because of its reliable vasoconstrictor effects, with minimal impact on heart rate, and its mild inotropic effects, helping to maintain cardiac output. Whichever vasopressor is used, its effects on blood flow must be considered and excessive vasoconstriction avoided. Other vasoactive agents include vasopressin, which may be considered in vasodilatory states, and angiotensin II, which may be beneficial in patients with high renin levels, although more data are required to confirm this. Dobutamine should be considered, along with continued fluid administration, to help maintain adequate tissue perfusion in patients with reduced oxygen delivery. In this narrative review, we consider the different vasopressor agents, focusing on the importance of tailoring therapy to the individual patient and their hemodynamic response.
Severe sepsis is a common disease process affecting some 2-11% of hospital admissions in the US. Severe sepsis and septic shock are associated with considerable morbidity and mortality, and account for a large part of intensive care unit costs. Until recently, the management of septic shock relied on the treatment of underlying infection with antimicrobial agents and surgical removal of any infectious source, and individual support of failing organs. However, in the last few years we have seen huge strides being made in our understanding of the pathophysiology of the sepsis response, and in our ability to manipulate that response. In the last couple of years these advances have come to fruition with the development of a drug, drotrecogin alfa, which specifically reduces mortality from this all too often fatal disease. While intensive early resuscitation remains the cornerstone of management, new approaches are beginning to form part of sepsis management protocols and will lead to improved outcomes for patients with this disease process.
Reduced cardiac output is a crucial determinant in hypovolemic, cardiogenic and obstructive types of acute circulatory failure, but cardiac output is considered less meaningful in septic shock where the primary defect is thought to be peripheral. In septic states, oxygen transport values are typically elevated, and the altered oxygen extraction (ratio of oxygen uptake over oxygen supply) limits the ability of the tissues to increase their oxygen uptake in relation to high oxygen needs. To correct tissue hypoxia, oxygen consumption should be increased to a level where oxygen uptake equals oxygen demand and lactic acidosis resolves. For a given level of oxygen demand, the best option is to improve oxygen extraction so that oxygen consumption will be higher for the same level of oxygen transport. This, however, is very difficult. Another approach can consist of further increasing oxygen transport to meet the elevated oxygen demand. Whenever possible, the metabolic needs of the tissues should be restrained.
