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Sepsis is the main cause of multiple organ failure and remains a concern because of the associated high morbidity and mortality. In recent years, important advances have been made in the understanding of the pathophysiology of sepsis. Sepsis and septic shock are the end result of complex interactions between infecting organisms and various elements of the host response. A key feature of the common sequence of organ failure is dysfunction of the cardiovascular system, including microcirculatory elements. Outcome improvement in sepsis is based on recognizing the process early and instituting effective therapies. The time window for intervention is relatively short, and treatment must promptly control the source of infection, restore haemodynamic homoeostasis, and support failing organ systems.
Cette thèse propose d’explorer les incertitudes et tensions normatives auxquelles sont confrontés les parents et les beaux-parents de familles recomposées, dans un contexte où la banalisation de ces formes familiales ne s’est toujours pas accompagnée de leur complète institutionnalisation. S’appuyant sur 61 entretiens biographiques menés avec des hommes et des femmes à la tête d’une famille recomposée et projetant d’avoir ou ayant eu un enfant commun, et un corpus de fils de discussion d’un forum dédié à la beau-parentalité, ce travail interroge les effets produits par ce flou normatif sur les pratiques parentales et beaux-parentales et sur les relations et la mise en signification des liens noués au sein de la constellation recomposée. Il s’agit de questionner ce qui fonde matériellement, relationnellement et symboliquement le « faire famille » et la parenté.La thèse documente d’abord comment ce flou normatif se loge dans les représentations ambivalentes dont ces familles font l’objet dans le monde social. Au niveau de leur catégorisation même, les familles investiguées sont situées à mi-chemin entre les familles nucléaires ordinaires et les familles recomposées. Elles permettent d’éclairer ce que la disjonction des trajectoires parentales antérieures produit sur une nouvelle entrée en parentalité.Devenir ou redevenir parent dans ces situations s’inscrit dans différents scripts de recomposition familiale qui révèlent des arrangements conjugaux façonnés par des normes procréatives inégales pour les hommes et pour les femmes. Au-delà de peser sur la mise à l’agenda d’un projet parental, la désynchronisation des expériences parentales donne à voir comment la parentalité est érigée comme savoir expérientiel. La mise en regard des recompositions patrilatérales et matrilatérales révèle que l’accession au statut de « primoparent » peut constituer un rite de passage qui officie différemment pour les hommes et pour les femmes. Les ressorts de cette transition statutaire font apparaître en creux des contrastes avec l’expérience de la beau-parentalité.La thèse étudie ensuite, dans une perspective matérialiste, le contenu du travail beau-parental et la manière dont ses contours résultent à la fois de normes de genre et d’une position intermédiée des beaux-parents. En saisissant la constellation recomposée comme une configuration de relations et de positions, ce travail examine comment la régulation des parentalités plurielles repose sur des ajustements complexes des différent·es protagonistes (dans et au dehors du foyer recomposé). Il montre que leurs interdépendances sont façonnées par l’idéal de coparentalité et de traitement égalitaire des enfants, et qu’elles nécessitent un important travail émotionnel et relationnel pour parvenir à « faire famille ».L’ensemble de ces régulations informe enfin sur les normes d’intelligibilité de ce qu’est la parenté et la famille pour les acteur·ices. L’exploration du contenu des relations nouées entre les enfants ou avec les « beaux-grands-parents » met en lumière leur grande résonance avec les normes relationnelles ordinairement contenues dans les liens de parenté. Toutefois, l’enquête rend dans le même temps compte que les caractéristiques structurales des liens de parenté ne sont pas pleinement transposables aux liens noués par la recomposition familiale. Si la présence d’un enfant commun met en exergue cette « incomplétude » structurale, elle contribue également à rendre la configuration recomposée plus cohésive et moins segmentée. En cela, elle révèle le primat accordé aux liens biologiques dans la compréhension de ce qui fonde les liens de parenté, sans que ceux-ci soient limitatifs : la thèse interroge en effet plus largement le poids donné à l’imaginaire associé au corps, au quotidien et à l’intentionnalité dans la fabrique de la parenté.
Vasoactive agents are commonly required in the management of septic shock not only to restore a sufficient tissue perfusion pressure but also to increase blood flow and oxygen delivery to the organs. Importantly, vasoactive agents are no substitute for fluid therapy. Defining end points for therapy remains difficult. These should be, above all, clinical. Even though the gut may play an important role in the development of multiple organ failure, the use of gastric tonometry to guide therapy cannot be recommended at this time. Study of the microcirculation at the bedside with orthogonal polarization spectral imaging may be helpful in the future. Adrenergic agents are the preferred agents for hemodynamic stabilization. Dopamine and norepinephrine are the drugs of choice to increase arterial pressure. Dobutamine remains the agent of choice to increase blood flow to the organs, including the gut and the kidneys. Many questions remain unanswered with respect to optimal hemodynamic management of septic shock.
We propose an integrated and adaptable approach to improve patient care and clinical outcomes through analgesia and light sedation, initiated early during an episode of critical illness and as a priority of care. This strategy, which may be regarded as an evolution of the Pain, Agitation and Delirium guidelines, is conveyed in the mnemonic eCASH-early Comfort using Analgesia, minimal Sedatives and maximal Humane care. eCASH aims to establish optimal patient comfort with minimal sedation as the default presumption for intensive care unit (ICU) patients in the absence of recognised medical requirements for deeper sedation. Effective pain relief is the first priority for implementation of eCASH: we advocate flexible multimodal analgesia designed to minimise use of opioids. Sedation is secondary to pain relief and where possible should be based on agents that can be titrated to a prespecified target level that is subject to regular review and adjustment; routine use of benzodiazepines should be minimised. From the outset, the objective of sedation strategy is to eliminate the use of sedatives at the earliest medically justifiable opportunity. Effective analgesia and minimal sedation contribute to the larger aims of eCASH by facilitating promotion of sleep, early mobilization strategies and improved communication of patients with staff and relatives, all of which may be expected to assist rehabilitation and avoid isolation, confusion and possible long-term psychological complications of an ICU stay. eCASH represents a new paradigm for patient-centred care in the ICU. Some organizational challenges to the implementation of eCASH are identified.
Fluid resuscitation of severe sepsis may consist of natural or artificial colloids or crystalloids. Fluid challenge should be administered and repeated based on response (increase in blood pressure and urine output) and tolerance (evidence of intravascular volume overload).
The majority of deaths on the intensive care unit now occur following a decision to limit life-sustaining therapy, and end-of-life decision making is an accepted and important part of modern intensive care medical practice. Such decisions can essentially take one of two forms: withdrawing -- the removal of a therapy that has been started in an attempt to sustain life but is not, or is no longer, effective -- and withholding -- the decision not to make further therapeutic interventions. Despite wide agreement by Western ethicists that there is no ethical difference between these two approaches, these issues continue to generate considerable debate. In this article, I will provide arguments why, although the two actions are indeed ethically equivalent, withdrawing life-sustaining therapy may in fact be preferable to withholding.
The revised Surviving Sepsis Campaign (SSC) guidelines for the management of severe sepsis and septic shock have recently been published. These guidelines represent the end product of an intense process and provide a template approach to the early resuscitation and support of patients with sepsis, based on a synthesis of evidence that has been shown to improve the outcome of the septic patient. The SSC guidelines arose from a recognition that care of the septic patient was suboptimal for at least three reasons. First, the entity of sepsis was frequently not diagnosed in a timely fashion, allowing the process to evolve into a life-threatening syndrome of major physiologic organ system dysfunction. Secondly, even when sepsis was recognized, the urgency of treatment was underappreciated – and so haemodynamic resuscitation was tentative, and the administration of effective antibiotic therapy was
In the critically ill, accurate measurements of left ventricular (LV) filling pressure using pulmonary artery occlusion pressure (Ppao) are important for diagnostic and therapeutic purposes. In patients receiving positive end-expiratory pressure (PEEP), Ppao may not reflect LV filling pressure because of elevated pericardial pressure (Ppc). It has been proposed that in humans, Ppc and right atrial pressure (PRA) are equal, so that referencing Ppao to PRA may improve the assessment of LV filling pressure when Ppc is elevated. Similarly, it has also been shown in the dog that nadir Ppao immediately after airway disconnection from PEEP (nadir Ppao), accurately reflects LV filling pressure when LV filling pressure is greater than or equal to 10 mm Hg. We examined methods of estimating LV filling pressure using Ppao measurements under conditions in which increases in Ppc were the primary determinants of differences in the two measurements. Using left atrial pressure (PLA) relative to Ppc, called transmural PLA (PLAtm), as LV filling pressure, we compared the accuracy of Ppao, nadir Ppao, and Ppao relative to PRA to reflect PLAtm in 15 postoperative cardiac surgery patients in whom an air-filled pericardial balloon catheter and a left atrial catheter were inserted during surgery. PEEP was sequentially increased from zero to 15 cm H2O. We found that PRA always exceeded Ppc (p less than 0.01) and increased less with PEEP than did Ppc (p less than 0.05). At less than or equal to 5 cm H2O PEEP, both Ppao and nadir Ppao were similar to each other and to PLAtm.(ABSTRACT TRUNCATED AT 250 WORDS)
Patients with severe sepsis typically die of multiple organ failure, refractory shock, or respiratory failure. Persistent, more than worsening, organ failure is the more common pattern before death.
