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Query: UMLS:C0243026 (sepsis)
 52,417 document(s) hit in 31,850,051 MEDLINE articles (0.00 seconds)

The hypothalamic-pituitary-adrenal axis is an essential component for the maintenance of homeostasis following trauma. Major surgical trauma often induces overwhelming inflammatory responses leading to sepsis and organ dysfunction. This study was designed to evaluate the adrenal responses both before and after various degrees of surgical trauma and to determine the incidence of postoperative relative adrenal insufficiency resulting in the marked inflammatory response often associated with postoperative complications. Fifty-one surgical patients were divided into groups who underwent major, moderate, and minor surgeries. Before the operation and during resting conditions, a short corticotropin (ACTH) stimulation test was performed in each patient. The postoperative concentrations of serum cortisol, interleukin (IL)-6, IL-10, C-reactive protein (CRP), and plasma ACTH were measured. Fifty of 51 patients were identified as responders to ACTH. The postoperative cortisol levels were the same as those obtained by ACTH stimulation in highly and moderately stressful surgeries. The increases in postoperative IL-6 and CRP levels were greatest with major surgery, intermediate with moderate surgery, and least with minor surgery. Furthermore, plasma ACTH levels increased after major and moderate surgeries; however, there was no significant differences in postoperative serum IL-10 levels. Systemic inflammatory response syndrome (SIRS) was found in 11 of 17 patients (64.7%) who underwent major surgery and in 4 of 16 patients (25%) who underwent moderate surgery (p=0.037). The duration of SIRS was significantly longer in patients undergoing major surgery (62+/-20 hrs) than in patients undergoing moderate surgery (21+/-3 hrs, p=0.038). Postoperative complications were more frequent in patients undergoing major surgery (41.2%) than in patients undergoing moderate surgery (6.3%, p=0.039). Furthermore, there were significant differences in the length of the postoperative stay among the three groups (p<0.01). One nonresponder had serious postoperative inflammatory complications. These results suggest that a short ACTH stimulation test performed preoperatively is a helpful method for determining the maximal cortisol response to surgical trauma and to identify high-risk individuals and that a relative postoperative adrenal insufficiency may be closely related to the decreased cortisol secretion following major surgical trauma.
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PMID:Surgical trauma-induced adrenal insufficiency is associated with postoperative inflammatory responses. 1787 97

Nitric oxide (NO) is produced by several cell types and has effects both detrimental and beneficial to the host. Sepsis and septic shock are conditions in which NO plays a central role in physiopathology. Stressful circumstances such as pathogens, toxins, and trauma elicit a wide variety of physiological changes. Steroid hormones and notably glucocorticoids are one of the main players in this orchestrated response. Although steroids have been used for sepsis some decades ago, their use in this condition was practically banned for several years following studies showing that high glucocorticoid doses were harmful to the host. Recently, the subject has been raised again since some studies demonstrated that adrenal insufficiency may happen in sepsis and that low dose/long-term regimen with cortisol may be beneficial to sepsis and septic shock. However, there are great gaps in our knowledge regarding the role played by steroids in sepsis, as well as the contribution of NO. In the present review, we will attempt to highlight the relationship among NO, sepsis and steroids, mainly glucocorticoids. A second purpose is to raise some unanswered questions that may provide better therapeutic alternatives to treat sepsis and septic shock.
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PMID:Steroids and nitric oxide in sepsis. 1798 61

Adrenal insufficiency is believed to occur frequently in severe sepsis and septic shock. The aim of the present study was to determine whether adrenal function is also related to the severity of community-acquired pneumonia (CAP). In total, 64 Japanese patients with CAP were consecutively enrolled in the present study, which was carried out during 2005-2006. Serum adrenocorticotropic hormone (ACTH) and cortisol were measured in each subject, as was the response of cortisol secretion when 250 mug of cosyntropin was administered. Analyses were performed comparing these values with the score calculated according to the Pneumonia Patient Outcomes Research Team (PORT) cohort study, the number of in-hospital deaths and the length of hospital stay. As the PORT score increased, serum ACTH and cortisol also increased, while the response of cortisol secretion to the administration of cosyntropin decreased. In the analysis by receiver operating characteristic curves, adrenal dysfunction was related significantly to both the number of in-hospital deaths and the length of hospital stay. Adrenal dysfunction was shown to correlate with the Pneumonia Patient Outcomes Research Team score and the clinical outcomes, while adrenal insufficiency defined by the cosyntropin stimulation test was rare in the present study.
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PMID:Adrenal function in patients with community-acquired pneumonia. 1851 53

Bacterial infections are an important complication of cirrhosis, particularly in hospitalized patients. In this article we review the prevalence, risk factors, and pathogenesis of bacterial infections in cirrhosis, focusing on the mechanisms of bacterial translocation such as impaired immunity and bacterial overgrowth, as well as maneuvers that may inhibit bacterial translocation and could be used not only to prevent infections but also to ameliorate the hyperdynamic circulatory state of cirrhosis. We also review the clinical features and management of the most common infection in cirrhosis, spontaneous bacterial peritonitis (SBP), specifically the evidence behind the therapy of acute SBP, the role of albumin, and the role of antibiotics in the prophylaxis of high-risk patients. It has been recognized that SBP and other bacterial infections lead to the systemic inflammatory response syndrome, sepsis, and multiorgan failure. We review the pathogenesis and management of these complications, the role of adrenal insufficiency, and the utility of intensive care prognostic models.
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PMID:Bacterial infections, sepsis, and multiorgan failure in cirrhosis. 1829 75

In the setting of sepsis, adrenal function can be difficult to evaluate. Cortisol levels, normally elevated by the stress of sepsis, are occasionally reduced, signifying possible adrenal dysfunction. Even elevated cortisol levels do not assure that adrenal reserve is adequate and may in fact portend a preterminal state. Bilateral adrenal hemorrhage leading to adrenal insufficiency is one complication of the sepsis syndrome. This endocrine rounds illustrates the importance in considering adrenal insufficiency and adrenal hemorrhage in patients with overwhelming sepsis while discussing the pathophysiology, clinical presentation, and therapeutic implications of this dire complication.
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PMID:Sepsis and adrenal function. 1840 25

Primary adrenal lymphoma is a rare condition. Only 70 cases were described in the literature. Adrenal lymphoma is often bilateral and in most of the cases of B-cell type. T-cell lymphoma is exceptional. The prognosis is bad and patient can die early because of acute adrenal insufficiency. We report a case of a 70-year-old man who was admitted for acute adrenal insufficiency due to primary bilateral adrenal T-cell lymphoma. He had corticotherapy and surgical exploration for intra-abdominal sepsis. He died because of multivisceral deficiency. Clinical features and imaging are not specific. (18)F-FDG PET Scan is an excellent mean to detect malignant tumor of adrenal gland. Percutaneous needle biopsy is useful to determine histology. The standard treatment is chemotherapy.
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PMID:[Primary bilateral adrenal T-cell lymphoma. A case report rarer than B-cell lymphoma]. 1845 45

Sepsis is a common clinical problem that is responsible for an increasing number of deaths. Many new therapies for severe sepsis have been developed but few have shown benefit in rigorous clinical trials. To date the most successful therapies are relatively simple clinical interventions: appropriate broad spectrum antibiotics; early goal directed therapies to restore tissue oxygen delivery; physiological dose hydrocortisone in patients with relative adrenal insufficiency; intensive insulin therapy to maintain normoglycemia; and lung-protective ventilation strategies. The only adjunctive therapy supported by strong evidence of benefit is Activated Protein C. Experimental therapies are being developed with improved in vitro and animal models and better understanding of the pathophysiology of sepsis in humans. Neutralization of the triggers of inflammation, such as endotoxin, and inhibition of the signal transduction mechanisms are promising new strategies. Statins may be beneficial in prevention of sepsis and as adjunctive treatments. Reconstitution of the immune response with interferon-gamma or granulocyte-macrophage colony stimulating factor may reverse immunoparesis in severe sepsis. Many other molecular targets have been identified for possible therapeutic intervention, but there are still fundamental difficulties to be overcome in demonstrating efficacy in clinical trials.
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PMID:New therapies for sepsis. 1847 86

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, is steroid therapy ever of benefit to patients in the intensive care unit going into septic shock? Using the reported search 1505 papers were identified. Fourteen papers represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. Recent guidelines from the Surviving Sepsis Campaign recommend using stress doses of corticosteroids for septic shock regardless of adrenal function. All patients undergoing cardiothoracic surgery are at risk of developing septic shock. The 14 papers demonstrated that 28-day mortality is unaffected by hydrocortisone, however, the time to shock reversal is significantly reduced. Steroids reduced inflammatory mediators (IL-6, IL-8 and CRP) and neutrophil activation whilst maintaining neutrophil phagocytic functions. Haemodynamically, they increased systemic vascular resistance (SVR) and mean arterial pressure (MAP) and reduced heart rate (HR) and glomerular permeability. We conclude that steroids have no effect on mortality but shorten time to shock reversal, therefore they have a limited capacity in septic shock patients. Their immunological and haemodynamic effects cannot be discounted and could benefit patients in severe septic shock with adrenal insufficiency.
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PMID:Is steroid therapy ever of benefit to patients in the intensive care unit going into septic shock. 1864 22

For more than five decades, the use of corticosteroids as an adjunctive therapy to treat severe sepsis and septic shock has incited consistent debate. Negative results of the Corticosteroid Therapy of Septic Shock (CORTICUS) study evoked a revision of Surviving Sepsis Campaign guidelines suggesting a more restricted use of low-dose hydrocortisone only in patients with severe septic shock. Hemodynamic improvement by low-dose steroids was evident and independent from adrenal insufficiency, but did not improve survival. The roles of cortisol measurement and adrenal function tests for treatment decisions have been questioned. An international task force introduced the concept of critical illness-related corticosteroid insufficiency, which challenges the predominant role of adrenal dysfunction and underscores sustained inflammation due to tissue steroid resistance. Whether moderate steroid doses induce superinfections and muscle weakness is unclear. This article reviews recent publications, actual recommendations, ongoing discussions, and future perspectives.
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PMID:Adjunctive therapies in severe sepsis and septic shock: current place of steroids. 1868 98

The role of the hypothalamic-pituitary adrenal axis in the host response to infection is crucial. The initial inflammatory response to sepsis activates the endogenous release of cortisol, which in turn modulates the synthesis and release of both pro- and anti-inflammatory mediators to restrict inflammation in infected tissues. However, a number of factors, including vascular or ischemic damage, inflammation and apoptosis within the hypothalamic-pituitary adrenal axis, as well as use of drugs that alter cortisol metabolism, may cause adrenal insufficiency. One major problem ICU physicians are faced with is the diagnosis of sepsis-induced adrenal insufficiency at the bedside. A multidisciplinary international task force has recently recommended that sepsis induced adrenal insufficiency is best recognized by basal cortisol of less than 10 microg/dl or change in cortisol of less than 9 microg/dl after administration of corticotrophin. The diagnostic value of measuring salivary free cortisol in this setting remains to be investigated. While sepsis adrenal insufficiency is undoubtedly associated with a poor prognosis, the indication and practical modalities of corticosteroids therapy remained controversial. Based on the two largest randomised, placebo-controlled trials, many investigators, myself included, contend that septic shock patients with hypotension poorly responsive to fluid replacement and vasopressors should receive a seven day treatment with the combination of hydrocortisone at a dose of 200 mg per day and fludrocortisone at the dose of 50 microg per day.
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PMID:Adrenal insufficiency in sepsis. 1869 Oct 99


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