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Sepsis, An Issue of Clinics in Chest Medicine, E-Book

Sepsis, An Issue of Clinics in Chest Medicine, E-Book

Julie A. Bastarache | Eric J. Seeley

(2016)

Additional Information

Book Details

Abstract

This issue of Clinics in Chest Medicine focuses on Sepsis. Articles include: The changing epidemiology and definition of sepsis; risk stratification and prognosis in sepsis: what have we learned from biomarkers and microarrays?; Sepsis outside the ICU: development and implementation of sepsis alert systems; The use of ultrasound in caring for the septic patient; Sepsis resuscitation: Fluid choice and dose; Beyond the golden hours: caring for the septic patient after the initial resuscitation; Vasopressors during sepsis: selection and targets; Dysglycemia and glucose control during sepsis; Cardiac function and dysfunction in sepsis;Goal Directed Resuscitation in Septic Shock; and more!

Table of Contents

Section Title Page Action Price
Front Cover Cover
Sepsis\r i
Copyright\r ii
Contributors iii
EDITORS iii
AUTHORS iii
Contents vii
Preface: Sepsis\r vii
The Changing Epidemiology and Definitions of Sepsis\r vii
Therapeutic Targets in Sepsis: Past, Present, and Future\r vii
Early Identification and Treatment of Pathogens in Sepsis: Molecular Diagnostics and Antibiotic Choice\r vii
Risk Stratification and Prognosis in Sepsis: What Have We Learned from Microarrays?\r vii
Development and Implementation of Sepsis Alert Systems\r viii
Goal-Directed Resuscitation in Septic Shock: A Critical Analysis\r viii
Sepsis Resuscitation: Fluid Choice and Dose\r viii
Vasopressors During Sepsis: Selection and Targets\r viii
Endothelial and Microcirculatory Function and Dysfunction in Sepsis\r ix
Management of Acute Kidney Injury and Acid-Base Balance in the Septic Patient\r ix
Cardiac Function and Dysfunction in Sepsis\r ix
The Use of Ultrasound in Caring for Patients with Sepsis\r ix
Dysglycemia and Glucose Control During Sepsis\r x
Metabolism, Metabolomics, and Nutritional Support of Patients with Sepsis\r x
Neuroanatomy and Physiology of Brain Dysfunction in Sepsis\r x
Beyond the Golden Hours: Caring for Septic Patients After the Initial Resuscitation\r x
Short-term Gains with Long-term Consequences: The Evolving Story of Sepsis Survivorship\r xi
CME Accreditation Page xii
PROGRAM OBJECTIVE xii
TARGET AUDIENCE xii
LEARNING OBJECTIVES xii
ACCREDITATION xii
DISCLOSURE OF CONFLICTS OF INTEREST xii
UNAPPROVED/OFF-LABEL USE DISCLOSURE xiii
TO ENROLL xiii
METHOD OF PARTICIPATION xiii
CME INQUIRIES/SPECIAL NEEDS xiii
Preface:\rSepsis xv
The Changing Epidemiology and Definitions of Sepsis 165
Key points 165
INTRODUCTION 165
UNITED STATES TRENDS IN INCIDENCE AND MORTALITY FROM SEPSIS 165
GLOBAL EPIDEMIOLOGY OF SEPSIS 170
FACTORS ASSOCIATED WITH AN INCREASED INCIDENCE OF SEPSIS 170
CLINICAL CORRELATIONS AND THE FUTURE OF SEPSIS EPIDEMIOLOGY 171
SUMMARY 177
REFERENCES 177
Therapeutic Targets in Sepsis 181
Key points 181
INTRODUCTION 181
EVOLUTION OF SEPSIS THERAPY 182
Fluids 182
Antibiotics 182
Supporting Injured Organs 182
THE GOLDEN AGE OF CYTOKINES 183
HUMAN SEPSIS TRIALS: FROM OPTIMISM TO DISAPPOINTMENT 183
Blocking Lipopolysaccharide and Tumor Necrosis Factor 183
Why Did These Therapies Fail? 183
QUANTITATIVE RESUSCITATION REEXAMINED 184
FUTURE TARGETS 184
Healing the Injured Epithelium 184
Late Mediators of Septic Organ Injury 185
Large-Scale Screens of Compounds Safe for Human Use 185
OPTIMIZING TRIAL DESIGN 186
Reducing Heterogeneity 186
Innovative Trial Designs 186
SUMMARY 187
REFERENCES 187
Early Identification and Treatment of Pathogens in Sepsis 191
Key points 191
INTRODUCTION 191
MOLECULAR METHODS FOR DETECTION OF BACTEREMIA 192
NONAMPLIFIED, GROWTH-DEPENDENT METHODS 192
Pathogen-Specific Methods 192
Broad-Based Methods 196
AMPLIFIED METHODS: GROWTH REQUIRED 197
Pathogen-Specific Real-time Methods 197
Broad-based Technologies 198
BROAD-BASED TECHNOLOGIES DIRECTLY FROM WHOLE BLOOD 198
T2 Candida Magnetic Resonance Assay 200
IRIDICA BAC-BSI Assay 201
POTENTIAL ECONOMIC IMPACT OF RAPID MOLECULAR DIAGNOSTIC METHODS AND BENEFITS FOR ANTIMICROBIAL STEWARDSHIP PROGRAMS 201
SUMMARY 204
REFERENCES 204
Risk Stratification and Prognosis in Sepsis 209
Key points 209
INTRODUCTION 209
PROGNOSTICATION OF MORTALITY AT ADMISSION: GENE EXPRESSION AT THE ONSET OF SEPSIS 210
THE IMPORTANCE OF TIME IN STUDIES OF ACUTE CRITICAL ILLNESS 212
FINDINGS FROM LONGITUDINAL STUDIES: PREDICTING HOSPITAL-ACQUIRED SEPSIS 212
IMMUNE PARALYSIS IN SEPSIS: AN UPDATED VIEW 212
MARKERS OF ORGAN-SPECIFIC OUTCOMES IN PERIPHERAL BLOOD 214
UNSUPERVISED LEARNING OF SEPSIS SUBTYPES 215
CAVEATS IN GENE EXPRESSION PROFILING: CONSIDERATIONS FOR FUTURE STUDIES 216
WHAT IS LEARNED SO FAR AND FUTURE DIRECTIONS 216
SUMMARY 217
REFERENCES 217
Development and Implementation of Sepsis Alert Systems 219
Key points 219
INTRODUCTION 219
DEVELOPMENT AND IMPLEMENTATION OF SEPSIS ALERT SYSTEMS 220
BARRIERS TO DEVELOPMENT AND IMPLEMENTATION OF CLINICALLY USEFUL SEPSIS ALERT SYSTEMS 220
Clinical Diagnostic Cues Not Available in the Electronic Medical Record 220
Algorithm Alert Performance 221
Information Overload and Alert Fatigue 221
Variability in the Systems of Health Care Delivery 221
POTENTIAL SOLUTIONS TO DEVELOPMENT AND IMPLEMENTATION OF CLINICALLY USEFUL SEPSIS ALERT SYSTEMS 224
Improved Alert Performance: Mathematical Modeling and Machine Learning 224
Alert Delivery and Integration into Workflow 224
Reengineering the Hospital Environment 226
SUMMARY 226
REFERENCES 227
Goal-Directed Resuscitation in Septic Shock 231
Key points 231
A BRIEF HISTORY OF GOAL-DIRECTED RESUSCITATION 231
Early Identification, Intravenous Fluid Resuscitation, and Empiric Antibiotics 232
Early identification 232
Intravenous fluid resuscitation 232
Empiric antibiotics 233
Optimizing Preload 234
Vasopressor Support 234
Assessing Oxygen Delivery and the Use of Packed Red Blood Cells and Dobutamine 235
Moving Forward 237
REFERENCES 237
Sepsis Resuscitation 241
Key points 241
INTRODUCTION 241
PHYSIOLOGY OF FLUID RESUSCITATION IN SEPSIS 241
FLUID DOSE 242
Fluid Administration in Sepsis Resuscitation 242
Fluid Management in Sepsis After Resuscitation 244
FLUID CHOICE 245
Crystalloids 245
Hyperchloremic metabolic acidosis 245
Acute kidney injury 245
Isotonic crystalloids in sepsis 245
Colloids 247
Albumin 247
Semisynthetic colloids 247
SUMMARY 249
REFERENCES 249
Vasopressors During Sepsis 251
Key points 251
INTRODUCTION 251
HYPOTENSION, SHOCK, AND MEASUREMENT OF ARTERIAL PRESSURE 251
Recommendation for Clinical Practice 252
WHAT IS THE TARGET MEAN ARTERIAL PRESSURE FOR SEPTIC SHOCK? 252
Recommendation for Clinical Practice 253
COMPARISONS OF VASOPRESSORS FOR SEPTIC SHOCK 253
Recommendation for Clinical Practice 254
GOAL-DIRECTED THERAPIES 254
Recommendation for Clinical Practice 257
IMPROVED OUTCOMES OF SEPSIS AND SEPTIC SHOCK 257
Endothelial and Microcirculatory Function and Dysfunction in Sepsis 263
Key points 263
ANATOMY AND FUNCTION OF THE MICROVASCULATURE 263
THE NORMAL MICROVASCULAR RESPONSE TO INFECTION 263
Leukocyte Adhesion 264
Tissue Edema 264
Coagulation 264
EVIDENCE OF MICROVASCULAR DYSFUNCTION DURING SEPSIS 264
MEASURING SEPTIC MICROVASCULAR DYSFUNCTION IN HUMANS 264
PATHOGENESIS OF MICROVASCULAR DYSFUNCTION DURING SEPSIS 266
ENDOTHELIAL GLYCOCALYX AND THE SEPTIC MICROCIRCULATION 267
THERAPEUTIC TARGETING OF THE MICROCIRCULATION IN SEPSIS 268
NOVEL MICROCIRCULATION-PROTECTIVE THERAPIES 270
SUMMARY 271
REFERENCES 271
Management of Acute Kidney Injury and Acid-Base Balance in the Septic Patient 277
Key points 277
INTRODUCTION 277
Definitions 277
Epidemiology 277
Pathophysiology 278
Risk Factors 279
MANAGEMENT GOALS 279
“Euvolemia” 279
Mean Arterial Pressure Goals 280
Nephrotoxins 281
PHARMACOLOGIC STRATEGIES 282
NONPHARMACOLOGIC STRATEGIES 282
Renal Replacement Therapy 282
Indications 282
Timing (early vs late) 282
Modality (intermittent vs continuous) 282
Dose 283
Antibiotic dosing during renal replacement therapy 283
Acid-Base Balance 283
pH goal 283
Buffers 283
Avoidance of hyperchloremic solutions 284
FUTURE DIRECTIONS 284
SUMMARY 284
REFERENCES 284
Cardiac Function and Dysfunction in Sepsis 289
Key points 289
INTRODUCTION 289
PATHOPHYSIOLOGY 289
Functional Abnormalities 289
Genetics 290
Molecular 290
Metabolic 290
Structural Abnormalities 290
Necrosis and apoptosis 292
Myocardial infiltration 292
Hemodynamic Abnormalities 292
Contractile dysfunction 292
MECHANISMS OF CARDIAC DYSFUNCTION 293
Impact of Chronic Heart Disease on Acute Hemodynamics 293
Laboratory Studies 293
Imaging Studies 295
Management Goals and Treatment 295
SUMMARY 296
REFERENCES 296
The Use of Ultrasound in Caring for Patients with Sepsis 299
Key points 299
INTRODUCTION 299
KEYS TO LEARNING AND UNDERSTANDING CRITICAL CARE ULTRASOUND 300
Basic Critical Care Echocardiography 300
Advanced Critical Care Echocardiography 300
Main Views and Echocardiographic Parameters Useful for Hemodynamic Evaluation 301
DIFFERENT HEMODYNAMIC PROFILES DETECTED BY ECHOCARDIOGRAPHY 302
Hypovolemia or Fluid Responsiveness Status 302
Cardiac Failure, Also Called Septic Cardiomyopathy 303
Left ventricular systolic dysfunction 303
Left ventricular diastolic dysfunction 303
Right ventricular dysfunction 304
IN PRACTICE 304
SUMMARY 305
REFERENCES 305
Dysglycemia and Glucose Control During Sepsis 309
Key points 309
INTRODUCTION 309
DEFINITIONS, PREVALENCE, AND PATHOGENESIS 309
Stress Hyperglycemia 309
Mechanism of Stress-Induced Hyperglycemia 310
Harm Secondary to Hyperglycemia 310
Diabetes and the Impact of Chronic Hyperglycemia 311
Unrecognized Diabetes 313
Hypoglycemia 313
Glycemic Variability 314
GLUCOSE TARGETS 314
INTERPRETATION 316
SUMMARY 316
REFERENCES 317
Metabolism, Metabolomics, and Nutritional Support of Patients with Sepsis 321
Key points 321
INTRODUCTION 321
METABOLIC CHANGES IN SEPSIS 322
Mediators of Altered Metabolism in Sepsis 322
Altered endocrine physiology 322
Activation of the adrenergic nervous system 322
Metabolic effects of cytokine release 322
Mechanisms of Altered Cellular Metabolism in Sepsis 323
Macronutrients 323
Micronutrients 324
METABOLIC CHANGES AS BIOMARKERS IN SEPSIS 324
Lactate: the Prototypical Biomarker for Sepsis Diagnosis and Prognosis 324
Lactate as a biomarker in the diagnosis of sepsis 324
Lactate as a prognostic biomarker in sepsis 324
Broader Metabolic Profiling in Sepsis 325
NUTRITION IN PATIENTS WITH SEPSIS 327
Timing of Nutrition 327
Enteral Versus Parenteral Nutrition 328
Role of Macronutrient and Micronutrient Replacement 328
SUMMARY 328
REFERENCES 329
Neuroanatomy and Physiology of Brain Dysfunction in Sepsis 333
Key points 333
INTRODUCTION 333
CLINICAL PRESENTATION 333
Acute Brain Response During Sepsis 333
Neurophysiologic Tests and Neuroimaging Procedures 334
Short- and Long-term Outcomes 335
PATHOPHYSIOLOGY OF SEPSIS-ASSOCIATED ENCEPHALOPATHY 335
Neuroinflammation 335
Microglia 336
Astrocytes 336
Cellular metabolism 338
Ischemic Process 338
The gliovascular unit 338
Neurovascular coupling 338
Neuronal Dysfunction 339
FUNCTIONAL ANATOMY OF THE CENTRAL NERVOUS SYSTEM DURING SEPSIS 339
Brainstem 339
Hypothalamus and Pituitary Gland 339
Hippocampus, Frontal Cortex, and Amygdala 340
SUMMARY 341
ACKNOWLEDGMENTS 341
REFERENCES 341
Beyond the Golden Hours 347
Key points 347
INTRODUCTION 347
AGITATION AND DELIRIUM 348
Importance of Agitation and Delirium 348
Treatment of Pain, Agitation, and Delirium 348
Early mobilization and exercise 349
Spontaneous breathing trials and decreased sedation 349
Specific Medications for Sedation, Agitation, and Delirium 349
Dexmedetomidine 349
Propofol 349
Haloperidol and other delirium medication 349
Ramelteon and melatonin receptor agonists 352
MECHANICAL VENTILATION 352
Small Tidal Volumes, Low Plateau Pressures 352
Earliest Possible Extubation 352
Noninvasive Positive Pressure Ventilation 352
Selection of patients for noninvasive positive pressure 352
Current guidelines for noninvasive positive pressure ventilation in sepsis 353
HEMODYNAMIC MANAGEMENT: FLUIDS AND VASOPRESSORS 353
Fluid Choice 353
How Much Volume Resuscitation? 354
Intravascular Volume Assessment 354
BLOOD TRANSFUSION 354
Transfusion Threshold 355
Leukodepletion of Blood Products/Age of Blood 355
NUTRITION 355
Enteral Nutrition 355
Gastric Residuals 356
Parenteral Nutritional Support 356
VIRAL REACTIVATION 356
SUMMARY 358
REFERENCES 358
Short-term Gains with Long-term Consequences 367
Key points 367
LONG-TERM NEUROPSYCHOLOGICAL AND PHYSICAL IMPAIRMENTS 368
Cognitive Impairment 368
Psychological Morbidity 369
Physical Impairment and Functional Disability 369
Qualitative Experience of Sepsis Survivors 370
SEPSIS-INDUCED INFLAMMATION AND CARDIOVASCULAR RISK 371
SEPSIS-INDUCED IMMUNOSUPPRESSION 371
HEALTH CARE RESOURCE USE IN SEPSIS SURVIVORS 371
Post–Acute Care Use 372
Hospital-Based Acute Care Use 372
Emergency Department Visits 372
Hospital Readmissions 372
Risk factors 372
Readmission causes 373
Outcomes associated with hospital readmissions after sepsis 373
Hospital-level variation in hospital readmissions after sepsis 373
Long-term Health-related Quality of Life and Mortality 374
IMPROVING LONG-TERM OUTCOMES AFTER SEPSIS 375
SUMMARY 376
ACKNOWLEDGMENTS 376
REFERENCES 376
Index 381