649. Khandelwal N, Kross EK, Engelberg RA, et al. 2001;16:320327. Crit Care Med. Mean glucose during ICU admission is related to mortality by a U-shaped curve in surgical and medical patients: a retrospective cohort study. While the weight of evidence supports pharmacokinetically optimized antimicrobial dosing strategies in critically ill patients with sepsis and septic shock, this is difficult to achieve on an individual level without a broader range of rapid therapeutic drug monitoring options than currently available (i.e., vancomycin, teicoplanin and aminoglycosides). 268. Dünser MW, Mayr AJ, Ulmer H, et al. Effect of Sodium Selenite Administration and Procalcitonin-Guided Therapy on Mortality in Patients With Severe Sepsis or Septic Shock: A Randomized Clinical Trial. Effect of norepinephrine on the outcome of septic shock. 300. Bollaert PE, Charpentier C, Levy B, et al. Procalcitonin to guide initiation and duration of antibiotic treatment in acute respiratory infections: an individual patient data meta-analysis. The quality of the evidence was graded as moderate to very low. 83. Shirakura Y, Kuriyama A. The selection of committee members was based on expertise in specific aspects of sepsis. System Shock takes place from a first-person perspective in a three-dimensional (3D) graphical environment. 420. Sandham JD, Hull RD, Brant RF, et al. Human trials of L-arginine supplementation have generally been small and reported variable effects on mortality (621â624). 269. Lauzier F, Lévy B, Lamarre P, et al. 202. Rattan R, Allen CJ, Sawyer RG, et al. Infection. 1988;104:199207. 2004;86485491. Antibiotic prescription patterns in the empiric therapy of severe sepsis: combination of antimicrobials with different mechanisms of action reduces mortality. Accuracy of blood-glucose measurements using glucose meters and arterial blood gas analyzers in critically ill adult patients: systematic review. 56. Ferrer R, Artigas A, Suarez D, et al. Larger abscesses and osteomyelitis have limited drug penetration and require longer therapy. Although there are only a few studies, alternative inotropic agents might be used to increase cardiac output in specific situations. 2007;35:26932701. [The impact of glutamine-enhanced enteral nutrition on clinical outcome of patients with critical illness: a systematic review of randomized controlled trials]. An analysis of nearly all the randomized trials of lung-protective ventilation suggested a benefit of higher PEEP if driving pressure fell with increased PEEP, presumably indicating increased lung compliance from opening of lung units (359). Zhonghua Shao Shang Za Zhi. Lancet. Effect of dopamine on gastrointestinal motility during critical illness. Continuous arteriovenous hemofiltration: improved survival in surgical acute renal failure? 2006;10:R111. 2012;186:724731. 1991;100:10681075. JAMA. Clin Microbiol Infect. 2013;206:3239. N Engl J Med. Lancet. Rationale: Feeding intolerance is defined as vomiting, aspiration of gastric contents, or high GRVs. Your account has been temporarily locked due to incorrect sign in attempts and will be automatically unlocked in 17CHIREC Hospitals Braine LâAlleud, Belgium. Clin Infect Dis. Sepsis and septic shock are major healthcare problems, affecting millions of people around the world each year, and killing as many as one in four (and often more) (4â6). For example, piperacillin/tazobactam can be dosed at either 4.5âg every 8 hours or 3.375âg every 6 hours for serious infections; all things being equal, the latter would achieve a higher T > MIC. The number of patients with < 7.15 pH in these studies was small, and we downgraded the certainty of evidence for serious imprecision; further, patients did not have exclusively septic shock, but also had other diseases, such as mesenteric ischemia. Am J Respir Crit Care Med. Also, no differences in secondary outcomes of development of nosocomial pneumonia or ICU LOS were found. 181. Poulikakos P, Tansarli GS, Falagas ME. 440. Jansen JP, Naci H. Is network meta-analysis as valid as standard pairwise meta-analysis? 2014;18:285290. 27. Bourgoin A, Leone M, Delmas A, et al. 2002;26:174181. Wolters Kluwer Health Blood purification and mortality in sepsis: a meta-analysis of randomized trials. Clin Microbiol Infect. 453. Kalfon P, Giraudeau B, Ichai C, et al. Our systematic review identified seven randomized trials and 2,665 patients studied (584,586â591). Therefore, specifying combination therapy to specific identified pathogens is useful only if more prolonged, targeted combination therapy is contemplated. Effects of bicarbonate therapy on hemodynamics and tissue oxygenation in patients with lactic acidosis: a prospective, controlled clinical study. Various procalcitonin-based algorithms have been used to direct de-escalation of antimicrobial therapy in severe infections and sepsis (211â216). A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. 2002;8:569576. The exact mechanism is not completely understood, but is believed to be related to disruption of protective mechanisms against gastric acid, gastric mucosal hypoperfusion, increased acid production, and oxidative injury to the digestive track (531). 98. Kreger BE, Craven DE, McCabe WR. Intensive Care Med. 2014;40:17951815. Voters could provide feedback for consideration in revising statements that did not receive consensus in up to three rounds of voting. 2014;190:855866. 2016;44:188201. This may represent an advantage over enteral nutrition, especially when patients may be underfed due to GI intolerance, which may be pertinent over the first days of care in the ICU. 510. Cooper DJ, Walley KR, Wiggs BR, et al. 208. Weiss CH, Moazed F, McEvoy CA, et al. Enteral omega-3 fatty acid, gamma-linolenic acid, and antioxidant supplementation in acute lung injury. 2005;31:638644. Studies reporting patientsâ values and preferences concerning the efficacy and safety of these agents are essentially lacking. ; CESAR trial collaboration. 2011;55:812818. No single mode of ventilation (pressure control, volume control) has consistently been shown to be advantageous when compared with any other that respects the same principles of lung protection. However, clinical trials do not demonstrate worsening of clinical outcomes. 2005;33:324330. 18. Yealy DM, Kellum JA, Huang DT, et al. JAMA. 118. Guo Y, Gao W, Yang H, et al. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. JAMA. A comparison of recommendations from 2012 to 2016 appears in Appendix 2. 2016;34119. 23University of Mississippi Medical Center Jackson, MS. 25Rush University Medical Center Chicago, IL. Myocardial dysfunction consequent to infection occurs in a subset of patients with septic shock, but cardiac output is usually preserved by ventricular dilation, tachycardia, and reduced vascular resistance (284). Balanced nutrition may be associated with a reduced risk of hypoglycemia (472). 30Saint Michaelâs Hospital Toronto, Ontario, Canada. Five randomized controlled trials (647 patients) have evaluated lactate-guided resuscitation of patients with septic shock (33â37). 1994;78:772774. 2012;3078795803. 2013;15:246252. Factors Determining Strong vs. Weak Recommendation, Comparison of 2016 Grading Terminology with Previous Alphanumeric Descriptors, Implications of the Strength of Recommendation, Important Terminology for Antimicrobial Recommendations. 406. Schuller D, Mitchell JP, Calandrino FS, et al. 2015;372:747755. 2014;40:504512. ; SEPSISPAM Investigators. View the data visualization related to this article: Data is temporarily unavailable. 1. Singer M, Deutschman CS, Seymour CW, et al. J Antimicrob Chemother. Dynamic measures of assessing whether a patient requires additional fluid have been proposed in an effort to improve fluid management and have demonstrated better diagnostic accuracy at predicting those patients who are likely to respond to a fluid challenge by increasing stroke volume. Initial management of and outcome in patients with pneumococcal bacteremia: a retrospective study at a Swiss university hospital, 2003-2009. J Crit Care. JAMA. JPEN J Parenter Enteral Nutr. 2014;68:5861. 2008;299:637645. 2005;92:326333. Crit Care Med. NIV may have theoretical benefits in patients with sepsis-induced respiratory failure, such as better communication abilities, reduced need for sedation, and avoidance of intubation. 2010;36:13861393. 488. Bartlett RH, Mault JR, Dechert RE, et al. The rationale for measurement of GRVs is to reduce the risk for aspiration pneumonia by either ceasing or modifying the enteral feeding strategy based on the detection of excess gastric residuals. Deep venous thrombosis in medical-surgical critically ill patients: prevalence, incidence, and risk factors. In addition, some meta-analyses suggest that extended/continuous infusion of β-lactams may be more effective than intermittent rapid infusion, particularly for relatively resistant organisms and in critically ill patients with sepsis (140,156â158). The results of this trial question the systematic use of this agent in patients with septic shock. 159. Roberts JA, Abdul-Aziz MH, Lipman J, et al. 1986;26:882891. The GRADE assessment of the quality of evidence is presented in Table 1. 563. Casaer MP, Mesotten D, Hermans G, et al. Mortality in patients randomized to dobutamine added to norepinephrine was no different compared to epinephrine (287), although the trial may have been underpowered. 2012;39:420423. Use of polyclonal immunoglobulins as adjunctive therapy for sepsis or septic shock. J Diabetes Sci Technol. 529. Arabi YM, Khedr M, Dara SI, et al. 2015;30:5971. Clinical experience suggests that, without adequate source control, some more severe presentations will not stabilize or improve despite rapid resuscitation and provision of appropriate antimicrobials. Differential time to positivity is not predictive for central line-related Staphylococcus aureus bloodstream infection in routine clinical care. Lancet. There was no significant effect on the risk of pneumonia or vomiting. However, parenteral delivery is more invasive and has been associated with complications, including an increased risk of infections. Of these 33 trials, 23 were at low risk of selection bias; 22 were at low risk of performance and detection bias; 27 were at low risk of attrition bias; and 14 were at low risk of selective reporting. Both studies enrolled patients with sepsis and acute kidney injury and did not demonstrate any difference in mortality associated with a higher dose of RRT. A recent patient-level mediation analysis suggested that a tidal volume that results in a driving pressure (plateau pressure minus set PEEP) below 12â15âcm H2O may be advantageous in patients without spontaneous breathing efforts (359). Is fluid gain a marker or a cause of poor outcome? Crit Care Med. One of the most important principles to understand in the management of these complex patients is the need for a detailed initial assessment and ongoing reevaluation of the response to treatment. Rationale. We considered the desirable consequences (lower risk of feeding intolerance) and the low quality of evidence showing no difference in mortality or pneumonia, and issued a weak recommendation for using prokinetic agents (metoclopramide or erythromycin) to treat feeding intolerance in patients with sepsis. In the presence of sepsis or septic shock, each hour delay in administration of appropriate antimicrobials is associated with a measurable increase in mortality (57,74). 2010;16:159164. Meta-analyses also suggest that procalcitonin can also be used to assist in differentiating infectious and noninfectious conditions at presentation (211,214,216). 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