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Query: UMLS:C0036690 (sepsis)
 59,461 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The assessment of severity is one of the most important issues in the management of the patient with community-acquired pneumonia. If forms the basis of decisions about hospitalization or admission to an intensive care unit. Age, comorbid illness and vital sign abnormalities have been shown to represent the principal criteria of pneumonia severity. Severe community-acquired pneumonia is characterized by one or more of the following criteria: acute respiratory failure, haemodynamic compromise, severe sepsis and septic shock, multilobar radiographic infiltrates, plus some additional laboratory parameters (blood urea nitrogen > 7 mM, lactate dehydrogenase > 260 U.L-1 and low serum albumin at admission). Several sets of corresponding simple clinical and laboratory criteria have consistently been shown to have considerable potential in predicting death caused by pneumonia. It was recently found that the tentative definition of severe community-acquired pneumonia provided by the American Thoracic Society guidelines is highly sensitive but poorly specific. An alternative rule, defining severe pneumonia as the presence of two of three minor criteria (systolic blood pressure < 90 mmHg, multilobar involvement and arterial oxygen tension/inspiratory oxygen fraction < 250) or one of two major criteria (mechanical ventilation and septic shock), had a sensitivity of 78%, a specificity of 94%, a positive predictive value of 75% and a negative predictive value of 95%. When validated in an independent patient population, this rule may contribute to a more uniform definition of severe community-acquired pneumonia.
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PMID:Severe community-acquired pneumonia: how to assess illness severity. 1044 81

Sepsis and its complications are severe clinical syndrome that is caused by systemic inflammatory response of the host to infection. Despite the use of common and numerous new therapeutic protocols, mortality from this severe disease is still very high. In the study are presented 155 patients (111 males, 44 females) of average age 49.6 years with mean septic score 12.9 (2-40). Mortality in our patients was 20.6%, septic shock developed in 31.6%, ARF in 20.0%, DIC in 12.9%, and MODS in 25.8% of patients. Positive correlation existed between initial sepsis score and mortality. Older age and the presence of primary diseases (34.2% of patients) were associated with significantly higher septic score and were good prognostic factor for the poor outcome of sepsis. Between mean arterial pressure in the first 24 h after the admission and mortality existed negative correlation (p < 0.05). Positive hemocultures were found in 69.7%, and bacterial infection in 78.7% of patients. GP bacteremia was found in 55.6% of patients and GN in 45.4% of all positive hemocultures. Confirmed bacteremia and bacteremia caused by GPB were associated with the higher mortality rate compared to the patients with negative hemocultures and GN bacteremia (p < 0.05). Concentrations of fibrinogen and urea in the blood at the admission in the patients with sepsis were very good prognostic factors of the disease outcome, and leukopenia, leukocytosis and neutropenia were associated with the increased mortality. Negative correlation existed between fibrinogen concentration and mortality (p < 0.001), while positive correlation (p < 0.001) existed between urea concentration and mortality. In the absence of more efficacious therapeutic protocols, fast recognition of the sepsis, evaluation of its severity, knowledge of the risk factors for its poor outcome and aggressive use of antibiotic and existing supportive therapy can significantly decrease high mortality of this too severe clinical syndrome.
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PMID:[Significance of determination of certain clinical and laboratory parameters in the evaluation of severity and outcome in sepsis]. 1070 10

A Multivariate analysis was done in all patients who developed post operative ARF, during the period 1990-1995 to determine the etiological spectrum and to identify various variables affecting the outcome. Of 140 patients (110 operated at SGPGI and 30 operated outside) 116 underwent elective surgery. The different types of surgery leading to ARF were urosurgery (3.5%), open heart surgery (32.9%), gastrosurgery (16.4%), pancreatic surgery (9.3%), obstetrical surgery (3.6%) and others (2.8%). The incidence of ARF in SGPGI patients was highest in pancreatic surgery group (8.2%) followed by open heart surgery (3%). The different etiological factors responsible for ARF were perioperative hypotension (67.1%), sepsis (63.6%) and exposure to nephrotoxic drugs (29.3%). Sixty-four patients (45.7%) required dialysis. The overall mortality was 45%. The mortality was highest in patients who underwent open heart surgery (89.1%) followed by pancreatic surgery (84.6%). The factors associated with high mortality, other than the type of surgery, were preoperative hypotension (p < 0.05), oliguria (p < 0.01), need for dialysis (p < 0.05) and multiorgan failure (p < 0.001). AM following emergency surgery had poor outcome, though not statistically significant. Perioperative sepsis (p < 0.05) and preoperative use of aminoglycoside (p < 0.05) were significantly higher in patients operated outside SGPGI. This was associated with higher incidence of ARF. Thus we conclude that presence of multiorgan failure, oligoanuria, preoperative hypotension and need far dialysis are poor prognostic markers in ARF following surgery.
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PMID:Etiology, prognosis, and outcome of post-operative acute renal failure. 1071 85

Acute respiratory failure is the most common problem seen in the preterm and term infants admitted to neonatal intensive care units. In preterm infants, the most common cause of acute respiratory failure is respiratory distress syndrome caused by surfactant deficiency. Acute respiratory failure in term and near term infants is usually a result of meconium aspiration syndrome, sepsis, pulmonary hypoplasia, and primary pulmonary hypertension of the newborn. The response to various methods of treatment may vary, depending on the severity of respiratory failure and the cause of the acute respiratory failure. We reviewed the evidence for efficacy and current utilization of newer treatment modalities, including exogenous surfactant administration, high frequency ventilation, inhaled nitric oxide therapy, antenatal steroids for the prevention of respiratory distress syndrome, and use of postnatal steroids for the prevention of chronic lung disease.
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PMID:Neonatal acute respiratory failure. 1083 58

Although hypophosphatemia is relatively uncommon, it may be seen in anywhere from 20% to 80% of patients who present to the ED with alcoholic emergencies, diabetic ketoacidosis (DKA), and sepsis. Severe hypophosphatemia, as defined by a serum level below 1.0 mg/dL, may cause acute respiratory failure, myocardial depression, or seizures. Because hypophosphatemia is not as often treated by ED physicians, becoming familiar with a single intravenous phosphate solution and specific guidelines for phosphate repletion are essential. One mL of the most commonly available phosphate solution (K2PO4) contains 4.4 meq of potassium and 3 mmol (93 mgs) of phosphate. Administering K2PO4 at a rate of 1 mL per hour is almost always a very safe and appropriate treatment for hypophosphatemia. This article provides guidelines for phosphate therapy in hypophosphatemic ED patients including those in DKA, those presenting with alcohol-related complaints including alcoholic ketoacidosis and patients with acute exacerbation of asthma and chronic obstructive pulmonary disease.
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PMID:Hypophosphatemia in the emergency department therapeutics. 1091 39

Cytoreductive surgery and perioperative intraperitoneal chemotherapy with mitomycin C and 5-fluorouracil may be considered as an accepted treatment for appendiceal malignancy with mucinous peritoneal carcinomatosis or for pseudomyxoma peritonei. This aggressive approach has been successfully utilized in approximately 500 patients with an acceptable mortality (1.5%) and morbidity (27%). Although pulmonary complications are frequently recorded, life-endangering acute respiratory failure in the absence of pulmonary infection or an obvious source of systemic sepsis has not been previously described. An extensive clinical review of two patients who had a clinical course compatible with acute respiratory distress syndrome without obvious cause except for the cytoreductive surgery and perioperative intraperitoneal chemotherapy itself was undertaken. These two patients developed gradually increasing respiratory distress in the postoperative period. No bacterial or fungal infections of lungs or intra-abdominal sites or sepsis were discovered. These two patients were unusual in that they had extensive cytoreduction, maximal heat with the mitomycin C chemotherapy, and perfusion of both the abdominal cavity and the right pleural space. Reoperation in both patients failed to show a septic source within the abdomen for progressive adult respiratory distress syndrome. We conclude that aggressive cytoreductive surgery plus perioperative intraperitoneal and intrapleural chemotherapy was associated with life-endangering respiratory failure in two patients. No other cause for this condition was evident from an exhaustive review of the clinical course of these two patients. It is possible that this aggressive approach to appendix malignancy with carcinomatosis is sufficiently traumatic to be considered a cause of adult respiratory distress syndrome.
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PMID:Adult respiratory distress syndrome occurring in two patients undergoing cytoreductive surgery plus perioperative intraperitoneal chemotherapy: case reports and a review of the literature. 1109 13

Early recognition and determination of the cause of renal failure in patients with ESLD can be difficult because of the potential interplay among various factors and the wide array of differential diagnoses. A systematic approach, however, assists clinicians to identify common and potentially reversible causes of ARF. It is crucial to distinguish patients with functional renal failure, such as HRS, from those with advanced irreversible renal disease. Isolated liver transplantation is the treatment of choice for the former, and CLKT may be a therapeutic option for the latter. Because of the ever-increasing shortage of donor organs, CLKT must be used judiciously. Kidney biopsy may resolve diagnostic dilemmas. Management of renal complications post-OLT remains a challenge for the physician caring for transplant patients. Modification of nephrotoxic immunosuppressive regimens to avoid postoperative ARF/CRI has met with variable results. Azathioprine has been used in place of cyclosporine. Therapy with polyclonal antilymphocyte preparations or anti-OKT3 monoclonal antibodies (Orthoclone) should be reserved for patients with delayed graft function and for the treatment of acute rejection. The routine use of these agents as prophylactic therapy is not recommended. Data on the impact of renal insufficiency on patient and allograft outcome are inconsistent. Nonetheless, the authors' literature review suggests that renal failure associated with sepsis and, except for patients with HRS, renal failure requiring dialysis are the most consistent features associated with a worse outcome. The need for preoperative or postoperative dialysis has no adverse effect on survival in patients with HRS. On long-term follow-up, despite a greater percentage of patients reaching ESRD in patients with HRS compared with their non-HRS counterparts, the overall outcome in patients with HRS following OLT is favorable. In patients with HRS requiring prolonged dialysis (i.e., greater than 4 weeks), however, irreversible renal failure may develop, necessitating CLKT. Ideally, timely referral of patients for OLT may avoid this complication and obviate the need for double organ transplantation.
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PMID:The kidney in liver transplantation. 1123 62

In current guidelines for the management of adults with community-acquired pneumonia (CAP), the triaging decision about hospitalization or intensive care unit (ICU) admission, and, as a consequence, selection of initial antimicrobial treatment is largely based on the assessment of pneumonia severity. The proposed severity criteria are mainly derived from studies determining predictors of adverse outcome. These include age, male sex, comorbidity, acute respiratory failure, severe sepsis and septic shock, extension of radiographic infiltrates, bacteraemia and CAP through several different pathogens such as Streptococcus pneumoniae, Staphylococcus aureus, Gram-negative enteric bacilli (GNEB), and signs of disease progression within the first 48-72 h. In addition, prediction rules and need for a complicated course in ambulatory and hospitalized patients, for the individual risk of death have been developed which may be helpful in determining the patient who might require hospitalization or intensive care, respectively. Risk classifications such as the scores developed by FINE et al. [40] are not only useful for identifying low risk patients who might safely be treated as outpatients, but apparently they will also play a major role in the evaluation of processes and outcomes of care for patients with CAP. Recent investigations have provided objective criteria for the definition of severe CAP requiring ICU admission. Whether the detection of infiltrates in the chest radiographs of patients with acute lower respiratory tract infection (LRTI) suggestive of mild pneumonia has an independent prognostic impact which fundamentally affects the concept of mild LRTI remains to be seen. Based on objective criteria for severity assessment it will be possible to define interventions aimed at reducing hospital admission rates, define a risk-adapted antimicrobial treatment regimen, reduce costs for antimicrobial treatment and supportive measures, shorten hospital stay, and, thereby, improve the quality of care for patients with community-acquired pneumonia.
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PMID:Severity assessment in community-acquired pneumonia. 1129 26

Based on the recognition of the main pathophysiologic features of pneumonia and currently available data on prognosis and clinical severity assessment, key points for a definition of severe pneumonia are as follows: 1. Independent predictors of pneumonia severity are factors reflecting acute respiratory failure and severe sepsis or septic shock. 2. In view of the dependence of the development of acute respiratory failure on pulmonary comorbidities, radiographic extension may prove to be an additional independent predictor of severe respiratory compromise. 3. Vital sign abnormalities other than acute respiratory failure and severe hypotension may be independent predictors of severity, particularly in patients presenting in early and asymptomatic stages of severe sepsis. 4. Several pathogens have been shown to have adverse prognostic potential. Because the cause is unknown at the initial evaluation, however, pathogens cannot form part of the criteria for the initial severity assessment. 5. Because pneumonia is a dynamic process, any assessment of severity takes place at an arbitrary point of disease evolution. It would be desirable to define a set of parameters reflecting initial severity as well as a state of increased risk for early deterioration toward severe pneumonia. 6. Severity stratification within the population of patients with severe pneumonia may open the prospect of identifying patients who may have the greatest benefit from intensive care.
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PMID:Defining severe community-acquired pneumonia. 1168 Jan 10

Lung and breast cancer are responsible for the majority of malignant pleural effusions. The diagnosis of a malignant pleural effusion signifies a limited survival for most patients. During their final months, dyspnea is the most common symptom and requires palliation. A decision relating to palliation and the modality of therapy should be based on total assessment of the patient and not a single variable. Local treatment remains the most common and effective palliation. Assessing the response to therapeutic thoracentesis determines the degree of relief of dyspnea and the time-course of recurrence. Lack of a beneficial effect suggests the patient may have a trapped lung, atelectasis, lymphangitic carcinomatosis, or tumor embolism. Short-term chest tube drainage has variable results and is not recommended. Chemical pleurodesis through a standard chest tube or small-bore catheter is a commonly used and effective treatment. Talc slurry consistently produces the highest success rates, followed by the tetracyclines and bleomycin. Although acute respiratory failure has been reported following talc pleurodesis, these episodes represent a very small percentage of the total reported cases of talc poudrage and slurry pleurodesis. Whether acute respiratory failure is directly related to talc in the absence of other risk factors remains unclear. Other possible causes for acute respiratory failure following pleurodesis include re-expansion pulmonary edema, excessive premedication, severe comorbid disease, and sepsis from unsterile talc or poor chest tube technique. Factors that need to be considered before recommending chemical pleurodesis include response to therapeutic thoracentesis, general health of the patient, performance status, pleural space elastance, the primary malignancy, and pleural fluid pH. Chronic indwelling catheters have been shown to be effective alternatives to chemical pleurodesis. Pleuroperitoneal shunting can provide palliation to patients with a trapped lung, a malignant chylothorax, or others who have failed pleurodesis. Parietal pleurectomy should be reserved only for patients who have failed chemical pleurodesis or have a trapped lung with an expected survival > 6 months. To provide the highest quality of life for patients with malignant pleural effusions, the least invasive, morbid and costly therapy should be used. Success of the initial procedure is important, as repeat procedures are associated with additional hospitalization, patient discomfort, and increased expense; therefore, the selection of patients for palliation and the modality utilized is critical to avoiding further hardship to the patient.
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PMID:Management of malignant pleural effusions. 1188 96


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