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When fluid administration is not sufficient to restore hemodynamic stability, inotropic agents may be given to restore the tissue perfusion pressure and to increase oxygen delivery (DO2) to the cells. Dopamine remains the drug of choice in the resuscitation of septic shock but norepinephrine can also have a place in the treatment of profound cardiovascular collapse or severe right ventricular failure. Dobutamine has become the inotropic agent of choice to increase DO2 to the tissues. Unfortunately, the beneficial effects of these agents on the extraction capabilities of the tissues are questionable. The potential of other adrenergic agents (such as dopexamine) or nonadrenergic agents (such as phosphodiesterase inhibitors) is also discussed in this article. Inotropic therapy should be guided not only by measurements of systemic BP but also by repeated assessments of the metabolic function of organs.
Comment
The magnitude of sepsis is considerable, affecting some 2–14% of ICU patients depending on the definition used. The impact of this disease process is considerable with mortality rates of around 50% depending on the definition used, and increasing with the degree of sepsis, from sepsis through sever sepsis to septic shock. With the associated morbidity, the economic costs of sepsis are also large. As the numbers of older, more debilitated patients being treated in our ICUs continues to increase, so the incidence of sepsis is increasing. While recent studies have shown some possible reductions in the mortality from sepsis, we cannot afford to be complacent. Definitions based on syndromes need to be replaced by more specific, mechanism-based entities reflecting the immunologic or biochemical changes seen in sepsis [18]; using such definitions to select more homogeneous patient populations for clinical trials, in combination with organ dysfunction scores to assess outcome, will lead to the development of effective new therapies, and the high costs of sepsis, in terms of mortality and finance, will be reduced.
The attack on the World Trade Center had the potential to overwhelm New York's health services. Sadly, however, the predicted thousands of treatable patients failed to materialize. Horror and sadness has now been replaced by anger, fear, and the determination to be better prepared next time. This determination not only exists in politics but also in health care, and as with all attempts to enforce change there needs to be a period of collecting opinions and data. This article introduces nine reviews in Critical Care offering varied health care perspectives of the events of 11 September 2001 from people who were there and from experts in disaster management.
