Recommendations for sepsis management in resource-limited settings

PURPOSE: To provide clinicians practicing in resource-limited settings with a framework to improve the diagnosis and treatment of pediatric and adult patients with sepsis. METHODS: The medical literature on sepsis management was reviewed. Specific attention was paid to identify clinical evidence on sepsis management from resource-limited settings. RESULTS: Recommendations are grouped into acute and post-acute interventions. Acute interventions include liberal fluid resuscitation to achieve adequate tissue perfusion, normal heart rate and arterial blood pressure, use of epinephrine or dopamine for inadequate tissue perfusion despite fluid resuscitation, frequent measurement of arterial blood pressure in hemodynamically unstable patients, administration of hydrocortisone or prednisolone to patients requiring catecholamines, oxygen administration to achieve an oxygen saturation >90%, semi-recumbent and/or lateral position, non-invasive ventilation for increased work of breathing or hypoxemia despite oxygen therapy, timely administration of adequate antimicrobials, thorough clinical investigation for infectious source identification, fluid/tissue sampling and microbiological work-up, removal, drainage or debridement of the infectious source. Post-acute interventions include regular re-assessment of antimicrobial therapy, administration of antimicrobials for an adequate but not prolonged duration, avoidance of hypoglycemia, pharmacological or mechanical deep vein thrombosis prophylaxis, resumption of oral food intake after resuscitation and regaining of consciousness, careful use of opioids and sedatives, early mobilization, and active weaning of invasive support. Specific considerations for malaria, puerperal sepsis and HIV/AIDS patients with sepsis are included. CONCLUSION: Only scarce evidence exists for the management of pediatric and adult sepsis in resource-limited settings. The presented recommendations may help to improve sepsis management in middle- and low-income countries

When Less is More in the Intensive Care Unit

In parallel to technological advances in late twentieth century, medical diagnostics and therapeutic options greatly improved. A surge of evidence-based research in intensive care medicine provided additional opportunities and the “best” medical practice has been changing rapidly. However, the primary focus of Hippocrates: “Primum non nocere” (first do no harm) is often neglected at the bedside. It became apparent that lesser intervention in the ICU may actually mean more for the patient. Multiple examples of the concept “when less is more in the ICU” are described here in an ABC format. Critical care providers have an obligation to keenly and closely follow the results of new investigative studies and to carefully incorporate those into our practice. However, they have to be sensitive to individual circumstances, patient and family preferences, and avoidance of harm

Translational Science Research: Towards Better Health

Even though it is considered a 21st century term, translational research has been present for much longer. Idea of translating experimental discovery to its’ clinical application and use is old as research itself. However, it is the understanding of missing links between the basic science research and clinical research that emerged in the past decade and mobilized scientific and clinical communities and organizations worldwide. Hence term, translational research, which represents an “enterprise of harnessing knowledge from basic sciences to produce new drugs, devices, and treatment options for patients” (1). It has been also characterized as “effective translation of the new knowledge, mechanisms, and techniques generated by advances in basic science research into new approaches for prevention, diagnosis, and treatment of disease, which is essential for improving health” (2). This translation is a complex process and involves more than one step for transfer of research knowledge. At least 3 such roadblocks have been identified (Figure 1) ; T1 translation: “The transfer of new understandings of disease mechanisms gained in the laboratory into the development of new methods for diagnosis, therapy, and prevention and their first testing in humans”, T2 translation: “The translation of results from clinical studies into everyday clinical practice and health decision making”, and T3 translation: “Practice-based research, which is often necessary before distilled knowledge (e.g., systematic reviews, guidelines) can be implemented in practice” (3-5). The international research community rapidly recognized importance for promotion of translational research and made it their priority(5). In the USA, National Institutes of Health, (NIH) expects to fund 60 translational research centers with a budget of $500 million per year by 2012 (6). Besides academic centers, foundations, industry, disease-related organizations, and individual hospitals and health systems have also established translational research programs and at least 2 journals (Translational Medicine and the Journal of Translational Medicine) are devoted to the topic. In Europe, translational research has become a centerpiece of the European Commission’s €6 billion budget for health related research, and the United Kingdom has invested £450 million over 5 years to establish translational research centers (7). In this issue of Bosnian Journal of Basic Medical Sciences, members of medical section of Bosnian and Herzegovinian-American Academy of Arts and Sciences (BHAAAS), contributed their own work and expertise to bridge the gap between basic and clinical research, between inventing the treatments and getting them used in practice, and laid down foundations for future collaborative development of translational research in Bosnia and Herzegovina, as well as in the region (8). At the first glance of this issue’s table of content, a reader will easily notice the variety and breadth of topics and themes, from medical informatics and genetics, to hematology and oncology, pulmonary and critical care medicine, orthopedics, trauma surgery and neurosurgery. However, all of the articles share common ideas of translation of knowledge, from bench to bedside and back, and individualized approach to medicine, which are the true hallmarks of the 21st century medicine. Deeper under the surface and titles, there lies our common privilege and honor to be part of a broader mission of BHAAAS: to connect with our fellow physicians and scientists, and to build bridges of cooperation with our homeland, to promote the spirit of intellectual diversity and free exchange of ideas with the strong belief that this knowledge sharing will promote betterment of health in Bosnia and Herzegovin

Adjuvant Inhaled Corticosteroids in Community-Acquired Pneumonia: A Review Article

Community-acquired pneumonia is still a major cause of morbidity and mortality worldwide. Since the inflammatory response induced by the immune system is often a major contributor to the lung injury, it becomes reasonable to assess the potential benefit of anti-inflammatory agents in treating community-acquired pneumonia. The role of corticosteroids as adjunct anti-inflammatory agents in treating community-acquired pneumonia is still controversial. Several studies have assessed the benefit of their use in patients with community-acquired pneumonia. In most of those studies, the route of corticosteroids administration was systemic. The aim of this article is to provide a concise review of the role of corticosteroids in treating community-acquired pneumonia when administered via inhalational route, with the potential benefit of avoiding systemic side effects of corticosteroids while exerting the same anti-inflammatory effects on the lungs. Conclusion: the use of inhaled corticosteroids may be of benefit in certain patient subsets with community-acquired pneumonia. Further randomized controlled trials are needed for better determination of such patient subsets

Acute Respiratory Distress Syndrome: Insights Gained from Clinical and Translational Research

Acute lung injury and its more severe form acute respiratory distress syndrome (ARDS) are characterized by diffuse impairment of alveolocapillary membrane in the settings of different predisposing conditions such as sepsis, trauma and shock. Many intrahospital exposures, including aspiration, delayed resuscitation, high tidal volume mechanical ventilation and non critical use of transfusions may contribute or worsen ARDS. Therapy is targeted to treatment of predisposing condition, life supportive measures and prevention of nosocomial complications. Rigorous adherence to lung-protective mechanical ventilation is critical to prevent ventilator induced lung injury and decrease mortality. Although survival of ARDS patients has improved in the last decades ARDS mortality rates are still high and survivors encounter significant physical and psychological impairment

Emerging therapies for the prevention of acute respiratory distress syndrome

The development of acute respiratory distress syndrome (ARDS) carries significant risk of morbidity and mortality. To date, pharmacological therapy has been largely ineffective for patients with ARDS. We present our personal review aimed at outlining current and future directions for the pharmacological prevention of ARDS. Several available risk-stratification or prediction score strategies for identification of patients at risk of ARDS have been reported. Although not ready for clinical everyday use, they are and will be instrumental in the ongoing and future trials of pharmacoprevention of ARDS. Several systemic medications established the potential role in ARDS prevention based on the preclinical studies and observational data. Due to potential for systemic adverse effects to neutralize any pharmacological benefits of systemic therapy, inhaled medications appear particularly attractive candidates for ARDS prevention. This is because of their direct delivery to the site of proposed action (lungs), while the pulmonary epithelial surface is still functional. We postulate that overall morbidity and mortality rates from ARDS in the future will be contingent upon decreasing the overall incidence of ARDS through effective identification of those at risk and early application of proven supportive care and pharmacological interventions