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Minerva Anestesiologica 2003 January-February;69(1-2):35-65

Copyright © 2002 EDIZIONI MINERVA MEDICA

language: English, Italian

Critical points for sepsis management at the patient bedside

Tulli G.

Department of Anaesthesia and Intensive Care “San Giovanni di Dio” Hospital, Florence, Italy

Following an inter­pre­ta­tive phi­los­o­phy, ­dyna-mic and faith­ful to the com­plex­ity the­o­ry, a clin­i­cal path­way is out­lined ­close to the real­ity, at the ­patient bed­side, ­that is com­pre­hen­sive of the diag­nos­tic pro­cess in its tem­po­ral dyna­mism, of the ther­a­peu­tic pro­cess in its spec­i­fic­ity (anti­bi­o­tic ther­a­py, sur­gi­cal ­souce con­trol), in the use of ­organs sup­por­tive ther­a­py (hae­mod­y­nam­ic, res­pir­a­to­ry, ­renal, etc.) and in the use of adjunc­tive and immu­nom­o­du­la­to­ry ther­a­pies (APC, AT, etc.). The impor­tance of the con­tex­tu­al acti­va­tion of micro­bi­o­log­i­cal, immu­no­log­i­cal and coag­u­la­tive mon­i­tor­ings is under­lined. Through a crit­i­cal ­review of the ­more ­recent lit­er­a­ture, a ­strict rela­tion­ship, in sep­sis and sep­tic ­shock, ­between inflam­ma­tion and coag­u­la­tion is ­described, ­that ­allowed the activated protein C (dro­trec­o­gin ­α acti­vat­ed) suc­cess, in ­terms of reduc­tion of the abso­lute and rel­a­tive mor­tal­ity. This ther­a­peu­tic suc­cess is con­tex­tu­al­ized ­into two oth­er impor­tant ther­a­peu­tic suc­cess­es, recent­ly ­obtained in ­severe sep­sis and sep­tic ­shock, ­based on the med­i­cal evi­dence, one ­using low dos­es of cor­ti­cos­ter­oids and the oth­er ­using the ear­ly (6 ­h) ­goal direct­ed hae­mod­y­nam­ic ther­a­py to ­restore a bal­ance ­between oxy­gen deliv­ery and oxy­gen ­demand. Once system­ic inflam­ma­tion is com­pli­cat­ed by ­organ fail­ure, ­there are few ­options. Treatment ­with acti­vat­ed pro­tein C low­ers the ­risk of ­death but is asso­ciat­ed ­with an ­increased ­risk of bleed­ing and is like­ly to be expen­sive. The strat­e­gies ­described by the ­groups of Rivers and Annane ­offer the oppor­tu­nity for ­good ther­a­peu­tic ­results, by pre­vent­ing the pro­gres­sion or ­even the devel­op­ment of sep­sis and its com­pli­ca­tions: sep­tic ­shock and mul­ti­ple ­organ dys­func­tion.