Sepsis and Organ Dysfunction: Epidemiology and Scoring Systems Pathophysiology and Therapy

177 Pages·1998·4.66 MB·English

by  J. Takala (auth.)

Sepsis and Organ Dysfunction
Epidemiology and Scoring Systems
Pathophysiology and Therapy
Springer
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Berlin
Heidelberg
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Budapest
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London
Paris
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Singapore
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A.E. Bane
G. Berlot
A. Gullo (Eds.)
Sepsis and
Organ Dysfunction
Epidemiology and Scoring Systems
Pathophysiology and Therapy
ORGAN FAILURE ACADEMY
Springer
A.E. BAUEM.D.
Department of Surgery, Saint Louis University, Health Sciences Center, St. Louis - USA
G. BERLOT M.D.
Department of Anaesthesia, Intensive Care and Pain Therapy
University of Trieste, Cattinara Hospital, Trieste - Italy
A. GULLO M.D.
Department of Anaesthesia, Intensive Care and Pain Therapy
University of Trieste, Cattinara Hospital, Trieste - Italy
O.F.A. - ORGAN FAILURE ACADEMY, VIA BATTISTI, 1 - 34125 TRIESTE (ITALY)
Steering Committee
A.E. Baue M.D., Department of Surgery, Saint Louis University
Health Sciences Center, St. Louis - USA
G. Berlot M.D., Department of Anaesthesia, Intensive Care and Pain Therapy
University of Trieste, Cattinara Hospital, Trieste - Italy
A. Gullo M.D., Department of Anaesthesia, Intensive Care and Pain Therapy
University of Trieste, Cattinara Hospital, Trieste - Italy
L. Silvestri M.D., Department of Anaesthesia, Intensive Care and Pain Therapy
University of Trieste, Cattinara Hospital, Trieste - Italy
G. Sganga M.D., Department of Surgery, and C.N.R. Shock Centre
Catholic University of Sacro Cuore, Rome - Italy
© Springer-Verlag Italia, Milano 1998
ISBN 978-88-470-0297-5 ISBN 978-88-470-2271-3 (eBook)
DOl 10.1007/978-88-470-2271-3
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SPIN: 10662618
Sepsis and organ dysfunction are different entities. In leU patients these condi-
tions may appear concomitantly more often than would normally be the case for
other pathophysiological and clilJ,ical manifestations. The development of orga-
nized intensive care units around the world over the past decades has increased
the possibility for survival in patients ranging from the newborn to the oldest
critically ill. Researchers and clinicians have developed a whole set of strategies
for the prevention and management of sepsis and organ failure. Advances in
biotechnology became indispensable to monitor organ function and provide
long-term support in multiple organ dysfunction. The prevention of infections -
whenever possible - is a golden standard. Its implementation, however, though
easy in theory, may come up against some concrete difficulties in practice. So,
Systemic Inflammatory Response Syndrome (SIRS) remains a mysterious condi-
tion, while for sepsis it is still very difficult to reach consensus on its definition,
on the procedures used to perform a correct diagnosis, or the administration of
a selective antibiotic, or the timing of re-laparotomy. Besides, the mortality rate
for patients suffering from sepsis and organ dysfunction remains high. The epi-
demiological aspects and the complexities of sepsis and organ dysfunction are a
well-known phenomenon. The use of prognostic indexes may be an important
tool for patient selection. To date, however, it is not yet clear whether the use of
scores is of actual benefit to individual patients or if it improves therapy. Media-
tors are regarded as vital elements for survival. However, these molecules are
often messengers ofillfate in terms of patient outcome. The problem is to under-
stand how they work, so the enigma remains unsolved. Procalcitonin is one of
the latest mediators to have been proposed as an important marker of infection.
Prostaglandins are a more persistent finding in the bloodstream, so modulat-
ing prostaglandin metabolism in sepsis has provided few answers so far and
many questions remain open. The issue of oxygen delivery optimization in sepsis
is of paramount importance. General consensus has now been achieved con-
cerning the role of inotropic and vasoactive drugs to maintain pressure in the
cardiovascular system. The maintenance of organ peifusion is a different matter,
so oxygen delivery and consumption ratios in sepsis remain controversial. In re-
cent years monoclonal antibodies and receptor blocking agents have represent-
ed important potential advances in the management of sepsis, though unfortu-
VI
nately in many international trials the large amounts of negative data outweigh
the encouraging results obtained in some sub-groups of patients.
So, the high cost of research and the difficulties encountered in enrolling pa-
tients have led to what some, termed the Bermuda Triangle for pharmaceutical
industries. Measuring ipH is a valid tool to monitor gastrointestinal peliusion,
and experimental and clinical data on hepatosplanchnic circulation is very en-
couraging. Systemic Digestive Decontamination (SDD) has proven to be effec-
tive in the prevention of Gram-negative infections. On the other hand, however,
the role of bacterial translocation needs to be confirmed in the clinical setting.
Consumption coagulopathy is a complication leading per se to multiple organ
failure; heparin, aprotinin and antifibrinolytic agents often represent the treat-
ment of choice, even though the mortality rate remains high.
In conclusion, it can be stated that there is no magic recipe for the preven-
tion and treatment of sepsis and organ dysfunction. So it can be said that the
future is likely to be characterized by both favourable and unfavourable devel-
opments. Actually, multiple therapeutic agents offer a series of options, but the
answers for the future will come from a better understanding of the mec'ha-
nisms regulating cellular functions, from the discovery of new mediators able
to prevent apoptosis, as well as the ability to correctly explore immunologic
dissonance.
Monitoring organ functional reserve and understanding messages in their
mutual relationships are the next steps ahead. Some of the tasks outlined abJve
represent a real challenge for researchers and clinicians at the dawn of the
XXlst Century.
Arthur E. Baue
Giorgio Berlot
Antonino Gullo
Trieste. 19th November 1997
Table of Contents
EPIDEMIOLOGY AND CLINICAL COURSE OF SEPSIS AND MODS
Epidemiology and Clinical Course of Sepsis
L. ILKKA, AND J. TAKALA ...•.•.............•......................................................•.•..•.........•........•.......... 15
The Complexities of Sepsis and Organ Dysfunction
A.E. BAUE .................................................................................................................................... 23
SCORING SYSTEMS
An Overview to Introduce Prognostic Indexes in MODS
A.E. BAUE.................................................................................................................................... 35
Multiple Organ Dysfunction (MOD) Score
J.C. MARSHALL............................................................................................................................ 45
The Logistic Organ Dysfunction (LOD) System
J.R. LE GALL, J. KLAR, AND S. LEMESHOW .................................................................................. 53
Will the Use of Scores Benefit the Individual Patient and Improve Therapy?
R. LEFERING, AND R.J.A. GORIS .................................................................................................. 65
MEDIATORS AND PROSTAGLANDINS
Old and New Mediators in Sepsis. The Enigma Is Not Yet Resolved
M. ANTONELLI, AND M. PASSARIELLO .......................................................................................... 73
Modulating Prostaglandin Metabolism in Sepsis
M.R. PINSKY ..........•.••••...•...............••..•••..•.•....•...........•....••••••••......•.•......•.•....•.•..•....•........•..•......• 81
DOlV02 IN SEPSIS
Oxygen Delivery and Consumption Relationships in Sepsis
The Role of Inotropic and Vasoactive Drugs
O. BOyD ....................................................................................................................................... 91
COAGULATION
Disturbances and Modulators of Coagulation and Fibrinolysis in Sepsis
L.G. THus .................................................................................................................................... 99
VIII
EXPERIMENTAL AND CLINICAL APPROACH
Therapies Directed against TNF- a and IL-t during Sepsis
K. REINHART, AND W. KARzAI...................................................................................................... 115
Effects of Adrenergic Agents on the Hepato-Splanchnic Circulation: An Update
D. DE BACKER, AND J.-L. VINCENT •••..••••••.••.••••.•..•.•••••..•..••.•.•.•..•.•.•..•.•.•..•..•....•..•••...•.•.••.•.•.•....•. 123
When to Operate or to Stop Operating and to Plan a Reoperation
A.E. BAUE .....••••.•.•..•...•••••••••..•...........••....•.•.......•..•..•..•..•..•..•.•.....••••••....•.........•••....•....•....•••......•. 131
Multiple Therapeutic Agents - Are We Making Progress?
A.E. BAUE, AND H. REDL •............................................•...............•.•.•.................•.............•.•......... 145
NEUROMUSCULAR DYSFUNCTION
SIRS and Sepsis-Induced Neuromuscular Dysfunctions
C.F. BOLTON ....••••.•.•.........•..•.....•..•......•....•....•....•.....•..••••..•........•..•...•.••.•.....•.............•....•.•.•......•. 155
PREVENTION AND MANAGEMENT OF SEPSIS AND MODS
Lights and Shadows in Sepsis and Multiple Organ Dysfunction Syndrome (MODS)
G. BERLOT, L. SILVESTRI, F. IsCRA, G. SGANGA, AND A. GULLO .......•.......................................... 167
Index ........................................................................................................................................... 189
Authors Index
Adriaensen H.
Dept. of Anaesthesiology, University Hospital Antwerp, Edegem (Belgium)
Antonelli M.
Dept. of Anaesthesiology and Intensive Care, La Sapienza University, Rome (Italy)
BaueA.E.
Dept. of Surgery, St. Louis University Health Sciences Center and the Veterans Administration Medical
Center, St. Louis (U.S.A.)
Berlot G.
Dept. of Anaesthesiology and Intensive Care, Trieste University School of Medicine, Trieste (Italy)
Bolton C.F.
London Health Sciences Centre, Victoria Campus, University of Western Ontario, London (Canada)
BoydO.
Dept. of Anaesthesia, St. George's Hospital, London (U.K.)
De BaekerD.
Dept. of Intensive Care, Free University of Bruxelles, Erasme Hospital, Bruxelles (Belgium)
Goris R.J.A.
Dept. of Surgery, Nijmegen St. Radboud University Hospital, Nijmegen (The Netherlands)
Gullo A.
Dept. of Anaesthesiology and Intensive Care, Trieste University School of Medicine, Trieste (Italy)
llkkaL.
Division of Intensive Care, Dept. of Anaesthesiology and Intensive Care, Kuopio University Hospital,
Kuopio (Finland)
Isera F.
Dept. of Anaesthesiology and Intensive Care, Trieste University School of Medicine, Trieste (Italy)
Karzai W.
Dept. of Anaesthesiology and Intensive Care Therapy, Friedrich Schiller University Hospital, lena (Germany)
Klar J.
Dept. of Intensive Care, St. Louis Hospital, Pmis (France)
Le Gall J.R.
Dept. of Intensive Care, St. Louis Hospital, Paris (France)
Lefering R.
Biochemical and Experimental Division, 2nd Dept. of Surgery, KOin University, Koln (Gernlany)
LemeshowS.
Dept. of Intensive Care, St. Louis Hospital, Paris (France)
x
Marshall J.e.
Dept. of Surgery, University of Toronto, Toronto (Canada)
Passariello M.
Dept. of Anaesthesiology and Intensive Care, La Sapienza University, Rome (Italy)
PinskyM.R.
Dept. of Anesthesiology and Critical Care Medicine, University of Pittsburgh, Pittsburgh (U.S.A.)
RedlH.
Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna (Austria)
ReinhartK.
Dept. of Anaesthesiology and Intensive Care Therapy, Friedrich Schiller University Hospital, Jena (Germany)
SgangaG.
Dept. of Surgery, Catholic University of Sacro Cuore, Rome (Italy)
Silvestri L.
Dept. of Anaesthesiology and Intensive Care, Trieste University School of Medicine, Trieste (Italy)
TakalaJ.
Division of Intensive Care, Dept. of Anaesthesiology and Intensive Care, Kuopio University Hospital,
Kuopio (Finland)
Thijs L.G.
Medical Intensive Care Unit, University Hospital, Amsterdam (The Netherlands)
Vincent J.-L.
Dept. of Intensive Care, Free University of Bruxelles, Erasme Hospital, Bruxelles (Belgium)