View - Anaesthesia, Pain & Intensive Care

83 Pages·2011·1.33 MB·English

ISSN 1607-8322
ISSN (Online) 2220-5799
ANAESTHESIA, PAIN
& INTENSIVE CARE
An International Journal of Anaesthesiology, Pain
Management, Intensive Care & Resuscitation
Vol. 15, No. 1 June 2011
ANAESTHESIA, PAIN
& INTENSIVE CARE
An International Journal of Anesthesiology, Pain Management, Intensive Care & Resuscitation
VOL. 15, NO. 1 June 2011
‘Anaesthesia, Pain & Intensive Care’ is indexed by PakMediNet, Medlip. Managing Editor:
Index Medicus, Index Copernicus, Embase & EMCare. Indexation by Medline, Tariq Hayat Khan
CINAHL, ExtraMed and others pending.
Editor-in-Chief:
Listed with: National Library of Medicine Catalogue
Brig. M. Salim, SI(M)
NLM ID: 101313795 [Serial]
Editors:
Registered by Pakistan Medical & Dental Council (PMDC).
Tariq Hayat Khan
Recognized by Higher Education Commision.
Permission granted by District Magistrate Islamabad for publication. Said Abuhasna
General Information: The journal is published twice a year in the months Assistant Editors:
of June and December. Please direct inquiries regarding subscriptions, single Samina Ismail
copies and back issues, changes of addresses, and other correspondence to Dr. Pranav Bansal
the Publications Office. Advertising inquiries should also be sent to the same
address. The 'Anaesthesia, Pain & Intensive Care' is published every six Statisticians:
months. See us at FACE BOOK. All articles represent the opinions of the Nadia Nisar
authors and do not reflect official policy of the journal. All rights are reserved Irum Abid
to the publisher. No part of the journal may be reproduced or transmitted in
any form or by any means, electronic or mechanical, including photocopying, Editorial Advisory Board:
regarding, or via any retrieval system, without written permission from the PAKISTAN:
publisher.
Khalid Bashir
Subscription Rates: The rates for a one-year subscription of the Journal are Iqbal Memon
Pak Rupees 1000 for subscribers in Pakistan, Pak Rupees 2000 for institutions Waqas Ahmed Qazi
in Pakistan, Pak Rupees 2000 for subscribers from SAARC countries and Saeeda Hayder
Pak Rupees 4000 from elsewhere. Gohar Afshan
Shahab Naqvi
Fazal Hameed
Rana Altaf Ahmad
Salman Waris
Faisal Salim
INDIA:
S. K. Malhotra
Pramila Bajaj
UK:
Ikhlaq Din
Cover Design: First Intubation Robot USA:
Photo credits: Dr. Thomas M. Hemmerling Rashed A. Hasan
Mailing Address: Editor ‘APICARE’, KSA:
Ehsan ul Haque
60-A, Nazim-ud-Din Road, F-8/4, Islamabad (Pakistan)
IRAN:
E-mail: [email protected] Abdul Hameed Ch.
[email protected]
Web: www.apicareonline.com
www.apicare.net.pk
Phone: [phone]
‘Anaesthesia, Pain & Intensive Care’ is the official journal of;
Society for Treatment & Study Pakistan Society of Pakistan Resuscitation
of Pain (STSP Anaesthesiologists (PSA) Society (PARES)
Published by: Dr. Tariq Hayat Khan
CONTENTS
EDITORIAL VIEWS
Low sodium; a high risk in perioperative Zulfiqarr Ahmed 1
pediatric patients
Sepsis in my view Said Abuhasna 4
ORIGINAL ARTICLES
A comparison of APACHE II and APACHE IV Tülin Akarsu Ayazoglu 7
scoring systems in predicting outcome in patients
admitted with wtroke to an intensive care unit
A comparative study of supraclavicular versus Safdar Hussain 13
infraclavicular approach for central venous Riaz Ahmed Khan
catheterization
Oral gabapentin reduces hemodynamic response Tahira Iftikhar, Arshad Taqi 17
to direct laryngoscopy and tracheal intubation Asiya Sibtain, Suhail Anjum,
Iftikhar Awan
Comparison of prophylactic ephedrine against prn Abdul Rehman, Harris Baig 21
ephedrine during spinal anesthesia for caesarian M. Zameer Rajput, Huma Zeb
sections
Endotracheal reintubatioin in post-operative Abdul-Zahoor 25
cardiac surgical patients Nor Azlina
Influence of working conditioins on job satisfactioin Shidhaye, Divekar 30
in Indian anesthesiologists: a cross sectioinal survey Gaurav Goel, Shidhaye Rabul
An audit on ventilator associated pneumonia in the Asoka Gunaratne 38
Intensive Care Unit at Teaching Hospital Karapitiya, Dhammika Vidanagama
Galle, Sri Lanka
CASE REPORTS
Development of negative pressure pulmonary oedema Muhammad Saqib, Maqsood Ahmad 42
secondary to postextubation laryngospasm Raheel Azhar Khan
ANAESTH, PAIN & INTENSIVE CARE 2011;15(1) JUNE 2011
Perioperative anaphylactic shock in patient with Iclal Ozdemir Kol, Cevdet Duger 45
unruptured hepatic hydatic cyst: a case report Kenan Kaygusuz, Sinan Gursoy
Cengiz Aydin, Caner Mimaroglu
Removal of a large hydatid cyst in spleen Maqsood Ahmad, Muhammad Saqib 48
Mumtaz Ahmad, Muhammad Raees
Dental braces bracing a throat pack to cause difficulty Mansoor Aqil 51
in its removal
Anesthetic management of the parturient with combined Tahira Batool, Bushra Babur 54
protein C an dS dificiency Shahida Tasneem
Tension pneumothorax caused by ventilating rigit Safdar Hussain, Riaz Ahmed Khan 57
bronchoscopy for removal of foreign body Muhammad Iqbal
CASE SERIES
Intenventional pain management techniques can be Ishrat Bano, Waqas Ashraf Chaudhary 60
helpful in headache management Muhammad Ashfaq
REVIEW ARTICLES
The causes, prevention and management of post spinal Muhammad Kashif Rafique 65
backache: an overview Arshad Taqi
CLINIQUIZ
Radiofrequency Neurotomy Tariq Hayat Khan 70
LETTERS TO EDITOR
Need to close the ‘closed suction in-line catheter’ port! Manpreet Singh, Dheeraj Kapoor 72
TRENDS & TECHNOLOGY 73
ACADEMIC ACTIVITIES 75
CALENDAR 76
CLINIPICS
Intubating robot 77
ANAESTH, PAIN & INTENSIVE CARE 2011;15(1) JUNE 2011
INSTRUCTIONS FOR AUTHORS
The ‘APICARE’ agrees to accept manuscripts prepared in accordance x 17.3 cm) in size. These may be in black and white or in colour.
with the Uniform Requirement for Submission of Manuscripts Submitted Negatives, transparencies, and X-ray films should not be submitted.
to Biomedical Journals published in the British Medical Joumal 1991 The number of the figure, the name of the author(s) should be printed
;302:334N1, on the back of each figure/photograph, and must be cited in the text
in consecutive order. Legends must be typed on a separate sheet of
All material submitted for publication should be sent exclusively to the
paper. Legends for photographs should indicate the magnification,
‘APICARE’.
internal scale and the method of staining. Photographs in published
ETHICAL CONSIDERATIONS articles will not be returned.
If tables, illustrations or photographs, which have been already published,
REFERENCES
are included, a letter of permission for their re-publication should be
Should be numbered in the order in which they are cited in the text.
obtained from author(s) as well as the editor of the journal where it
At the end of the article, the full list of references should give the names
was previously printed. Permission to reproduce photographs of patients
and initials of all authors (unless there are more than six when only
whose identity is not disguised should be sent with the manuscript
otherwise the eyes will be blackened out. the first three should be given followed by et al). The authors’ names
are followed by the title of the article; the title of the journal abbreviated
MATERIAL FOR PUBLICATION according to the style of the Index Medicus. e.g.: Hall, RR. The heading
of tissues by Co, laser. BrJ. Surg: 1971 58:222-225. Reference to
The material submitted for publication may be in the form of an Original books should give the names of editors, place of publication, publisher,
Research, a Review Article, a Case Report, Recent Advances, New
and year.
Techniques, Debates, Book Review/CDs on Clinical/Medical Education,
or a Letter to the Editor. Original articles should normally report original PEER REVIEW
research of relevance to clinical anaesthesiology, pain management, Every paper will be reviewed by a member d the editorial review
intensive care or resuscitation, and may appear either as papers or committee, and one or more external reviewers. Statistical analysis
as short communications. The paper should be of about 2000 words, wail be examined by a statistician.
with no more than six tables or illustrations, short communications
should be of about 600 words, with one table or illustration and no ABSTRACT
more than five references. Clinical case reports and brief or negative Abstracts of onginal article should be prepared with a structured format.
research findings may appear in this section. Review article should The elements addressed could include objectives, design, setting,
consist of structured overview of some relatively narrow topic providing patients or other participants, interventions, and outcome measures,
background, recent development with refrence of original literature. the result, and conclusions. Please label each section clearly with the
appropriate subheading. Review article, Case report and other require
Letters should normally not exceed 400 words, have no more than 10
a short, unstructured abstract Commentaries do not require abstract.
references, and be signed by al the authors. An article based on
dissertation submitted as part of the requirement for a fellowship of INTRODUCTION
the postgraduate degree awarding medical institutions can be sent for
This should include the purpose of the article. The rationale for the
publication after the Research and Training Monitoring Cell (RTMC)
study or observation should be summarised; only strictly pertinent
have approved it. Editorials are written by invitation.
references should be cited; the subject should not be extensively
Each manuscript should include a title page (containing e-mail address, reviewed Data or conclusions from the work being reported should not
fax and phone numbers of the corresponding author), abstract, text, be presented.
acknowledgments, references, tables, and legends.
METHODS
Each component should begin on a new page, in the following sequence: The selection of the observational or experimental subjects (patients
title page: abstract and keywords: text; acknowledgments; references; or experimental animals, including controls) should be described clearly.
tables (each table, complete with title and footnotes, on a separate Tar is methods and the apparatus used should be identified (with the
page); and legends for illustrations. manufacturers name and address in parentheses), and procedures
described in sufficient detail to allow other workers to reproduce the
The manuscript should be typed in double spacing on 8 1/2? x 11? results References to established methods should be given, including
(21.5cm x 28.0cm) white bond paper with one-inch (2.5cm) margin on statistical methods; references and brief descriptions for methods that
both sides. It should not exceed 20 pages, excluding tables and have been published but are not wall known should be provided; new
references. There should be no more than 40 references in an Original
or substantially modified methods should be descriebed, giving reasons
Article, and no more than 100 in a Review Article.
for using them, and evaluating their limitations. All drugs and chemicals
TABLES AND ILLUSTRATIONS used should be identified precisely, including generic name(s), dose(s),
Tables and illustrations should be submitted separately, and legends and route(s) of administration.
to illustrations should be typed on a separate sheet. Each table should
RESULTS
have a title and be typed in double space without horizontal and vertical
These should be presented in a logical sequence in the text, tables,
lines on an 8 1/2? x 11? (21.5 x28.0 cm) paper.Tables should be
and illustrations. All the data in the tables or illustrations should not be
numbered consecutively with Roman numerals in the order they are
repeated in the text; only important observations should be emphasized
mentioned in the text. Page number should be in the upper right corner,
or summarised.
if abbreviations are used, they should be explained in footnotes. When
graphs, scatter grams, or histograms are submitted, the numerical
DISCUSSION
data on which they are based should be supplied.
The authors comment on the results, supported with contemporary
S.I. UNITS references, including arguments and analysis of identical work done
System Intemational (Sl) Unit measurements should be used. All drugs by other workers. A summary is notrequired. Brief acknowledgement
must be mentioned in generic form. The commercial name may, may be made at the end.
however, be mentioned with in brackets.
MODEL SUBMISSION LETTER
FIGURES AND PHOTOGRAPHS A model submission letter is available on our website:
Should be sent only when data cannot be expressed in any other form. www.apicareonline.com to be filled in and signed by the corresponding
These must be unmounted, glossy prints in sharp focus, 5? x 7?, (12.7 author. The letter is a required to the submitted with the manuscripts.
EDITORIAL VIEW
Low sodium; a high risk in perioperative pediatric patients
Zulfiqar Ahmed, M.B.,B.S. F.A.A.P.
Staff Anesthesiologist, Children's Hospital of Michigan; Director of Research/Assistant Professor of Anesthesiology,
Wayne State University, 3901 Beaubien Detroit, MI 48201-2196 (USA)
Perioperative fluid therapy is aimed at providing maintenance in this g roup of patients, the risk of preoperative
fluid requirements, at correcting fluid deficit and at providing hypoglycemia has been demonstrated to be low in normal
the volume of fluid needed to maintain adequate tissues healthy infants and children (1-2%), despite prolonged
perfusion. It gets more important in pediatric population fasting periods4-6 as energy requirements during anesthesia
as the little shift in the small total volume of intracellular are close to basal metabolic rate. Although neonates have
and extracellular compartments in these patients is multiplied a higher metabolic rate and an increased risk of perioperative
many folds in its effects. Perioperative fluid therapy has hypoglycemia and lipolysis, but during anesthesia, even in
been suggested to be a medical prescription adapted to the neonates, both oxygen consumption and metabolic rate
patient status, the type of operation and the expected are decreased, and this may lead to reduced intraoperative
events in the postoperative period of which both the
glucose requirements.
volume and the composition matter.
Hyperglycemia, on the other hand, can induce osmotic
The landmark article in which Holliday and Segar1 proposed
diuresis and consequently dehydration and electrolyte
the rate and composition of parenteral maintenance fluids
disturbances. Several animal studies have also demonstrated
for hospitalized children has been the mainstay of much
that hyperglycemia will increase the risk of hypoxic-ischemic
of our practice of fluid administration in the perioperative
brain or spinal cord damage. Conversely, administering
period even to this day. However, the glucose, electrolyte,
glucose containing solutions (to prevent hypoglycemia)
and intravascular volume requirements of the pediatric
has predisposed the pediatric patients to dangerously low
surgical patient may be quite different than the original
levels of sodium. The fact is that dextrose containing
population described, and consequently, use of traditional
solutions with low sodium is still administered as a
hypotonic fluids proposed by Holliday and Segar has been
perioperative fluid of choice in many parts of the world.
questioned, e.g. hyperglycemia and hyponatremia, in the
This practice has already led to many cases of hyponatremia
postoperative surgical patient. T here is significant
and brain injury or death7. For practical purposes, in the
controversy regarding the choice of isotonic versus
peri-operative environment, D5 0.45% solution is hypotonic.
hypotonic fluids in the postoperative period2.
The sodium in such glucose containing solutions needs to
be low to maintain isotonicity. These solutions become
Holliday and Segar calculated maintenance electrolytes
from the amount delivered by the same volume of human effectively hypotonic once the fluid enters the blood stream
milk. Daily sodium and potassium requirements are 3 and the glucose becomes metabolized. T his may occur
mmol/kg and 2 mmol/kg respectively in children. Thus, when these solutions are utilized in the intraoperative or
the combination of maintenance fluid requirements and post-operative time period. Recent studies have focused
electrolyte requirements results in a hypotonic electrolyte attention on the incidence of postoperative hyponatremia
solution. Since the publication of this paper, the usual and associated morbidity and mortality rates, generating
intravenous maintenance f luid given to c hildren by debate on the advisability of perioperative fluid therapy
pediatricians for decades has been one fourth-to one half- and calling into question both the effecti veness of this
strength saline and usually 5% dextrose3. strategy and the quantities used8.
The dextrose is added to prevent assumed hypoglycemia Improper fluid therapy has just compounded the problem
in infants and smaller children. Although, very important of hyponatremia, that may have other causes as w ell,
ANAESTH, PAIN & INTENSIVE CARE 2011;15(1) JUNE 2011 1
Low sodium; a high risk in perioperative pediatric patients
including pituitary or adrenal insufficiency, brain injuries anesthetic drugs and agents being used, thus delaying the
or brain tumors associated with salt losses, and inappropriate proper and adequate treatment of the actual cause. Often
secretion of ADH. Plasma ADH is often increased in the respiratory arrest is the first manifestation of such
postoperative period as a result of hypovolemia, stress, electrolyte imbalance because the hyponatremia progress
pain, or traction of dura mater. The combination of ADH unnoticed till it is too late . The mortality rate of
secretion and infusion of hypotonic fluids will produce hyponatremia in hospitalized patients is reported to be 7-
dilutional hyponatremia. Normally, the kidneys are able to to 60-fold more frequent compared with normonatremic
excrete in excess of 20l/d of electrolyte-free water. In controls14.
water intoxication, dilutional and hypotonic hyponatremia
ensues from a rapid intake of a large volume of parenteral Anesthesiologists should maintain an index of suspicion
electrolyte-free fluid in excess of renal excretion over a for hyponatremia from water intoxication in patients with
short period of time. As free water is retained, hyponatremia neurologic symptoms during the perioperati ve period.
develops. The resultant hyponatremia causes osmotic Routine preoperative instructions regarding maximum
movement of free water across cell membrane from perioperative water intake and inquiry into any concurrent
extracellular to intra-celllular compartment and the brain alternative medical therapies ma y help to a void this
is the most seriously damaged organ9. Some of the risk preventable complication. A careful intraoperati ve
factors are postmenarchal female gender, and prepubescent monitoring and adaptation of the infusion rate as needed
children. In post menarchal women, estrogen seems to
is crucial because the glucose and fluid requirements may
impair the ability of brain to adapt to h yponatremia.
vary widely between subjects. Conceptionally, the distinction
Children are more susceptible to brain edema then adults
between maintenance requirements, deficits and ongoing
because of the ratio of brain size and intracranial capacity.
loss is helpful. Although the pathophysiological basis for
By the age of six years, the brain size of a child is the same
parenteral fluid therapy was clarified in the first half of
size as adult while the skull continues to grow until the age
the 20th century, some aspects still remain controversial.
16 to adult size. Hence the capacity of CSF to buffer the
brain expansion is relatively less in children then adults.
Dextrose containing solutions are an inappropriate choice
for perioperative fluid losses such as blood loss and
In older infants the occurrence of iatrogenic hyponatremia
in this way has led to a critical reappraisal of the validity insensible loss and urine output, and by all means, in infants
of the Holliday-Segar method for not only calculating and young children, 5% dextrose solutions should be
maintenance fluid requirements, but also the choice of avoided; 1% or 2% dextrose in lactated Ring er may be
solution, in the postoperative period. The emphasis needs more appropriate15. Only c hildren who are risk for
to be laid, now, on prevention of hyponatremia, which is hypoglycemia should receive dextrose containing solution.
the most common electrolyte disorder in hospitalized
These children include neonates in the first few days of
patients, with an incidence of approximately 1%-4%10-13.
life, patients on total parenteral solutions, children with
In fact, excess total body water in the presence of a small
low body weight (less then 3rd percentile) or bor n to
serum sodium concentration can result in an increase of
diabetic mothers among others.
extracellular water, cerebral edema, and potential brain
herniation. Cerebral edema can manifest as nausea,
It may be reasonable to c hoose a solution for f luid
headache, confusion, lethargy, convulsions, seizures, or
replacement which has a composition comparable to the
coma. Radiological diagnosis of cerebral edema is difficult,
composition of the fluid which must be replaced. In any
if not impossible. Other signs and symptoms may include
case, only isotonic solutions should be used in clinical
hemiparesis, ataxia, nystagmus, tremor, rigidity, aphasia,
situations which are known to be associated with increases
muscle cramps, and fasciculations12,13. Severe hyponatremia
in antidiuretic hormone (ADH) secretion. In this context,
is also associated with cardiopulmonar y dysfunction,
including arrhythmias, hypotension, hypoxemia, and it is important to realize that in contrast to lactated Ringer's
pulmonary edema12. In the perioperative period, these solution, the use of normal saline can lead to hyperchloremic
signs may easily be confused with adverse effects of the acidosis in a dose-dependent fashion16.
2 ANAESTH, PAIN & INTENSIVE CARE 2011;15(1) JUNE 2011
Editorial View
In summary, administration of dextrose containing fluids 7. Lonqvist P E. Editorial: Inappropriate perioperative fluid
in pediatric patients in the peri-operati ve environment management in children: time for a solution?! Pediatric
Anesthesia 2007;17:203-205.
should be strongly discouraged and should be reserved in
patients at real risk of hypoglycemia. If in doubt blood 8. Fernández AR, Ariza MA, Casielles JL, Gutiérrez A, de las
Mulas M. Postoperative hyponatremia in pediatric patients.
glucose should be monitored and patient should be followed
Rev Esp Anestesiol R eanim. 2009;56(8):507-10.
closely in the post operative period. The fluid therapy in
pediatric patients, especially during the perioperative period, 9. Arieff A. I., Ayus J. C., Fraser C. L. Hyponatraemia and
death or permanent brain damage in healthy children. BMJ.
must be tailored to the indi vidual patient and careful
1992;304(6836):1218-1222.
monitored. Prevention of iatrogenic hyponatremia is an
10. Fraser CL, Areiff AI. Epidemiology, pathophysiology, and
easy to implement practice with a high dividend. "First of
management of hyponatremic encephalopathy. Am J Med
all, do no harm".
1997;102:67-77.
REFERENCES 11. Moritz ML, Ayus JC. Disorders of water metabolism in
children: hyponatremia and hypernatremia. Pediatr Rev
2002;23:371-80.
1. Holliday M, Segar W. The maintenance need for water in
parenteral fluid therapy. Pediatrics 1957;19:823-832.
12. Anderson RJ, Chung HM, Klug e R, Sc hrier RW.
Hyponatremia: a prospective analysis of its epidemiology
2. Bailey AG, McNaull PP, Jooste E, Tuchman JB. Perioperative
and the pathogenetic role of vasopressin. Ann Intern Med
crystalloid and colloid fluid management in children: where
1985;102:164-8.
are we and how did we get here? Anesth Analg. 2010 Feb
1;110(2):375-90. 13. Riggs JE. Neurologic manifestations of electrolyte
disturbances. Neurol Clin 2002;20:227-39.
3. Murat I, Dubois MC. Perioperative fluid therapy in pediatrics.
Pediatric Anesthesia 2008;18(5):363-370. 14. Bhananker SM, Paek R, Vavilala MS. Water Intoxication
and Symptomatic Hyponatremia After Outpatient Surgery.
4. 18. Aun CS, Panesar NS. Paediatric glucose homeostasis A & A 2004;98(5):1294-1296
during anaesthesia. Br J Anaesth 1990; 64: 413-418.
15. Sümpelmann R, Mader T, Dennhardt N, Witt L, Eich C,
5. 19. Dubois M, Gouyet L, Murat I. Lactated Ringer with 1% Osthaus WA. A novel isotonic balanced electrolyte solution
dextrose: an appropriate solution for peri-operative fluid with 1% glucose for intraoperative fluid therapy in neonates:
therapy in children.Paediatr Anaesth 1992; 2: 99-104. results of a prospecti ve multicentre observational
postauthorisation safety study (PASS). Paediatr Anaesth.
6. 20. Hongnat J, Murat I, Saint-Maurice C. Evaluation of
2011 May 13. doi: 10.1111/j.1460-9592.2011.03610.x.
current paediatric guidelines for fluid therapy using two
different dextrose hydrating solutions. Paediatr Anaesth 16. Steurer MA, Berger TM. Infusion therapy for neonates,
1991; 1: 95-100. infants and children. Anaesthesist. 2011;60(1):10-22.
APICARE UPGRADED
We proudly announce that Anaesthesia, Pain & Intensive Care has been upgraded
by Higher Education Commission of Pakistan to 'Y' category. It is indeed a great
tribute to continuous and dedicated hard work by the members of Editorial Board,
our respected reviewers, contributors, researchers as well as our sponsors.
Congratulations!
ANAESTH, PAIN & INTENSIVE CARE 2011;15(1) JUNE 2011 3
EDITORIAL VIEW
Sepsis in my view
Said Abuhasna, MD
Chairman, Department of Critical Care Medicine; Associate Professor in Medicine, FMHS - UAEU;
Chairman of Ethics and Consultation Service, Tawam Hospital, Al Ain, (United Arab Emirates)
E-mail: [email protected]
Sepsis is a disease process that exists on a spectrum that of 90,000 people eac h year in the USA alone .3 An
increases in severity from sepsis to severe sepsis to septic epidemiological survey in France of over 100,000 intensive
shock. The common thread between these elements is a care unit (ICU) admissions, indicates the incidence of septic
disseminated inf lammatory response to infection shock before or following admission to ICU is rising and
characterized by clinical and laboratory findings. Severe now affects almost 10% of this patient population.4 Given
sepsis is complicated by organ dysfunction. It is the number the scale and associated costs of this problem,3,5 it is not
one cause of death in the noncoronary intensive care unit. surprising that developing solutions has been a focus of
More than 750,000 Americans develop severe sepsis each researchers, clinicians, and the pharmaceutical industry.
year in the USA, while the w orldwide toll is unknown. The intensive care specialists took the challenge to overcome
Cases of severe sepsis are expected to rise in the future the current situation and to reduce se psis mortality
with the increase in the awareness and sensitivity for the significantly by implementing evidence based clinical
diagnosis, number of immunocompromised patients, use
standards for the diagnosis and treatment of sepsis
of invasive procedures, number of resistant microorganisms,
worldwide. New strategies, including tight glycemic control,
and the growth of the elderly populations1. Septic shock
early hemodynamic goal-directed therapy, infusion of
is sepsis with refractory hypotension. Over the last decade
activated protein C, and use of corticosteroids (still for
several strategies to manage septic patients have emerged
debate), have shown some promise in prevention and/or
and have been summarized in inter national guidelines
treatment of sepsis and septic shock..
supported by international medical specialty organizations.
Despite extensive research indicating the benefits of these Risk factors for septic shock include; diabetes, diseases of
therapies in the manag ement of sepsis, the debate is the genitourinary system or intestinal system, AIDS ,
continuing and research is gearing up2. indwelling catheters (those that remain in place for extended
periods, especially intravenous lines and urinary catheters
In the past three decades, enormous investment has been
and plastic and metal stents used for drainage), leukemia,
made in enhancing critical care resources, yet, mortality
long-term use of antibiotics, recent use of steroid
from severe sepsis ranges from 28% to 50% or greater. A
medications and many more.
2001 study reported that the treatment of severe sepsis
resulted in an average cost of $2200 per case, with a
Sepsis is defined as the presence of infection in association
nationwide annual total cost of over $16.7 billion.2,3
with SIRS. The presence of SIRS is, of course, not limited
to sepsis, but in the presence of infection, an increase in
Any type of bacteria, and fungi and (rarely) viruses may
the number of SIRS criteria observed should alert the
produce this condition. Toxins released by the bacteria or
clinician to the possibility of endothelial dysfunction,
fungi may cause tissue damage, and may lead to low blood
developing organ dysfunction, and the need for aggressive
pressure and poor organ function. Some researchers think
therapy. Certain biomarkers have been associated with the
that blood clots in small arteries are responsible for low
endothelial dysfunction of sepsis; however, the use of
blood flow and poor organ function.
sepsis-specific biomarkers has not yet translated to
Septic shock occurs most often in the very old and the establishing a clinical diagnosis of sepsis in the emergency
very young. It also occurs in people who have other illnesses; department (ED). There is a promise of procalcitonin use
and has a crude mortality rate of 45% and claims the lives as a marker in early identification of such septic patients.
4 ANAESTH, PAIN & INTENSIVE CARE 2011;15(1) JUNE 2011
Editorial View
With sepsis, at least one of the following manifestations phase of critical infection and inflammation, Rivers and
of inadequate organ function/perfusion is typically seen: colleagues demonstrated a 16% absolute reduction in in-
hospital mortality. This reduction in mor tality was
• Alteration in mental state accompanied by a decreased use of vasopressors and
mechanical ventilation over the first 72 hours of
• Hypoxemia; PaO < 72 mmHg at FO of 0.21; overt
2 i 2 hospitalization. These results spurred a renewed interest
pulmonary disease not the direct cause of hypoxemia
in improving sepsis management in the ED and led to
numerous implementation studies and quality improvement
• Elevated plasma lactate level
initiatives, showing improved in-hospital, 28 day, and up-
to-one-year mortality with implementing EGDT 5.
• Oliguria (urine output < 30 ml or 0.5 ml/kg for at
least 1 h)
We recognized more than a decade ago that the widespread
and perhaps indiscriminate use of an extremely expensive
Severe sepsis is defined as sepsis complicated by end-organ
and marginally effective therapy for septic shock could
dysfunction, as signaled by altered mental status, an episode
have serious economic implications for many hospitals.
of hypotension, elevated creatinine concentration, or
evidence of disseminated intravascular coagulopathy (DIC). One of these is Drotrecogin Alpha Activated protein C6.
Septic shock is defined as a state of acute circulatory failure Many times in humans, sepsis is caused by fungi or gram-
characterized by persistent arterial hypotension despite positive bacteria. Drugs that are effective against endotoxin
adequate fluid resuscitation or by tissue hypoperfusion or gram-negative bacteria may not have the same effect on
(manifested by a lactate concentration greater than 4 mg/dl) other pathogens. The report continues: In sepsis there are
unexplained by other causes. Patients receiving inotropic multiple clinical, microbiologic, and host derived indicators
or vasopressor agents may not be hypotensive by the time of prognosis that are difficult to control, such as severity
that they manifest hypoperfusion abnormalities or organ of underlying disease, co-morbidities, degree of organ
dysfunction. dysfunction, and adequacy of antibiotic therapy. Remarkably,
Bernard and his colleagues, in a landmark New England
We all agree that treatment strategies of sepsis should start Journal of Medicine ar ticle describing the so-called
in the emergency room and we should start the antibiotics PROWESS trial, demonstrated that drotrecogin alfa or
within the hour after blood work is drawn. The success of recombinant human activated protein C has anti-thrombotic,
treatment depends upon early detection of high-risk patients, anti-inflammatory and pro-fibrinolytic properties. Treatment
appropriate antimicrobials, source control, hemodynamic with this human activated protein C (marketed by Eli Lilly
optimization (clarity in f luid therapy and vasopressor as Xigris®), significantly reduces mortality in patients with
selection), and the results of large-scale efforts to implement severe sepsis. The treatment was effective regardless of
bundles of care. Recently, the sepsis surviving campaign age, severity of illness, the number of dysfunctional organs
has issued the latest recommendations for treatment of or systems, the site of the infection and the type of infecting
septic shock, but the debate about the use of steroids is organism.5,6
still going on. In my opinion, it has a definitive role and
should be used in refractory hypotension. At the integrated hospital system level, I believe drotrecogin
alfa requires widespread coordination of pharmacy
In 2001, a landmark paper, "Early goal-directed therapy in department efforts to appropriately utilize this new entity.
the treatment of severe sepsis and septic shock", altered Intrasystem coordination is essential in the sharing of data
the clinical landscape of sepsis management. Two hundred about the number of sepsis cases, their clinical characteristics,
and sixty-three patients with severe sepsis, defined as two and outcomes with and without the use of drotrecogin
SIRS criteria, a source of infection, and a serum lactate>4 alfa7. Integrated systems should have a systemwide approach
mmol/l, and systolic blood pressure <90 mmHg after to drotrecogin alfa use , emphasizing a judicious and
adequate fluid challenge, were randomized to receive either circumspect prescribing behavior on the part of all clinicians.
standard therapy or early goal-directed therapy (EGDT).
During the first six hours of care, patients in the EGDT A retrospective analysis using electronic database for
arm received statistically significantly more intravenous patients who received drotrecogin alfa from June 2008
fluids, inotropes, and blood transfusions. By moving an until April 2011 was conducted at our 20-bed intensive
aggressive, algorithmic resuscitation strategy to the proximal care unit (ICU) at a governmental hospital in Al Ain, United
ANAESTH, PAIN & INTENSIVE CARE 2011;15(1) JUNE 2011 5