Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012

OBJECTIVE: To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN: A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS: The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. RESULTS: Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO (2)/FiO (2) ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a PaO (2)/FI O (2) 180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5-10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS: Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients

Palm oil as a detoxicant of cadmium in rats

No Abstract.International Journal of Tropical Agriculture and Food Systems Vol. 1 (4) 2007: pp. 364-368Please note: AJOL received the following notification from the IJOTAFS editor:The correct citations for this article should read as shown below:J. N. Egwurugwu, C. R. Nwwokocha, C. S. Ufearo, N. N. Obaji, A. O. Ebunlomo, F. O. Amromanoh, A. O. Odetola, J. O. Duruibe and P. P. E. Mounmbegna (2007). Palm oil as a detoxicant of cadmium in rats. International Journal of Tropical Agriculture and Food Systems, 1(4): 364-368. All inconveniences are regretted, Dr. Emma U. Onweremadu  PhD Editor – In – Chief  Department of Soil Science and Technology, Federal University of Technology PMB 1526, Owerri, Nigeria Email: [email protected] &#160

Pediatric high-impact conditions in the United States: retrospective analysis of hospitalizations and associated resource use

<p>Abstract</p> <p>Background</p> <p>Child mortality in the United States has decreased over time, with advance in biomedicine. Little is known about patterns of current pediatric health care delivery for children with the leading causes of child death (high-impact conditions). We described patient and hospital characteristics, and hospital resource use, among children hospitalized with high-impact conditions, according to illness severity.</p> <p>Methods</p> <p>We conducted a retrospective study of children 0–18 years of age, hospitalized with discharge diagnoses of the ten leading causes of child death, excluding diagnoses not amenable to hospital care, using the 2006 version of the Kid’s Inpatient Database. National estimates of average and cumulative hospital length of stay and total charges were compared between types of hospitals according to patient illness severity, which was measured using all-patient refined diagnosis related group severity classification into minor-moderate, major, and extreme severity.</p> <p>Results</p> <p>There were an estimated 3,084,548 child hospitalizations nationally for high-impact conditions in 2006, distributed evenly among hospital types. Most (84.4%) had minor-moderate illness severity, 12.2% major severity, and 3.4% were extremely ill. Most (64%) of the extremely ill were hospitalized at children’s hospitals. Mean hospital stay was longest among the extremely ill (32.8 days), compared with major (9.8 days, p < 0.0001), or minor-moderate (3.4 days, p < 0.001) illness severity. Mean total hospital charges for the extremely ill were also significantly higher than for hospitalizations with major or minor-moderate severity. Among the extremely ill, more frequent hospitalization at children’s hospitals resulted in higher annual cumulative charges among children’s hospitals ($7.4 billion), compared with non-children teaching hospitals ($ 3.2 billion, p = 0.023), and non-children’s non-teaching hospitals ($ 1.5 billion, p < 0.001). Cumulative annual length of hospital stay followed the same pattern, according to hospital type.</p> <p>Conclusion</p> <p>Gradation of increasing illness severity among children hospitalized for high-impact conditions was associated with concomitantly increased resource consumption. These findings have significant implications for children’s hospitals which appear to accrue the highest resource use burden due to preferential hospitalization of the most severely ill at these hospitals.</p