Degree Of Sepsis Research Articles

The clinical, laboratory, and microbiological profile of patients with sepsis at the Internal Medicine Inpatient Unit of Dr. Cipto Mangunkusumo National General Hospital, Jakarta

At the moment, the diagnosis of sepesis is established based on the criteria of the presence of a clinical manifestation of systemic inflammatory response syndrome/SIRS, infection, and organ dysfunction. In the last two years, the idea to add several additional parameters to these criteria has developed, with the proposition to use the acronym PIRO (P: predisposition, I: infection, R: response, and O: organ failure). Clinical manifestations of sepsis at each hospital or treatment unit may differ according to the severity of sepsis, the focus of infection, comorbidity, and organ dysfunction or failure. This study evaluated the demographic, comorbidity, source of infection, SIRS manifestation, organ dysfunction, and microbiological profile of sepsis at the Internal Medicine Inpatient Ward of Dr. Cipto Mangunkusumo National General Hospital, Jakarta. A correlative, cross-sectional, descriptive study was performed on 42 subjects with sepsis, severe sepsis, and septic shock. The study was performed at the Inpatient Ward of Dr. Cipto Mangunkusumo NAtional General Hospital, Jakarta, in the year 2002. Clinical and laboratory (hematological, biochemical, and blood gas analysis) data, as well as results of aerobic cultures of the blood and other specimens were recorded. The criteria of sepsis used were based on that of the American College of Chest Physician and the Society of Critical Care Medicine in 1992. The results of the study demonstrated a proportional distribution of sepsis based on age and sex, with comorbidity in 88% of subjects, consisting of diabetes mellitus and other chronic diseases. The most common sources of infection were the lungs, skin-soft tissue, abdomen, and urinary tract, with Gram-negative bacteria more commonly found than Gram-positive bacteria. SIRS manifestation was found among over 70% of subjects, with the most common manifestations being tachycardia and tachypnea. The most common manifestations of organ dysfunction were reduced consciousness, metabolic acidosis, renal dysfunction, and a lower mean arterial pressure. There was a correlation between these parameters and the degree of sepsis. (Med J Indones 2004; 13:90-5)Keywords: sepsis, clinical manifestation, microbiology

Psoas Muscle Abscess-Diagnosis and Approaches of Treatment

Psoas muscle abscess is rare and presents a diagnostic challenge requiring a high index of suspicion. The relative obscurity of this entity, coupled with a typically insidious presentation, frequently result in diagnostic delays, attempts at conservative treatment, increased morbidity and prolong or recurrent hospitalization. Classic symptoms include fever, flank pain, abdominal pain, hip flexion contracture, sciatica and limp. Other symptoms include weight loss, abdominal mass, nausea, vomiting, diarrhea, limb mass, limb pain and chills. There were six cases of psoas muscle abscess with various degree of sepsis from January 1999 to June 2000. There was no significant risk factor to induce psoas muscle abscess except old age. The conservative and supportive treatment may stabilize the vital signs but surgical intervention and drainage must be done to treat the patients with psoas muscle abscess. The drainage procedures could be achieved via CT-guided drainage or surgical intervention. There are several methods to approach the psoas muscle, including anterior extraperitoneal, trans-abdominal, thigh and back incision. We preferred transverse back incision via the lumbar triangle to approach the psoas muscle and combined with groin incision if the erythema at the thigh is marked. Effective drainage and proper antibiotics are still the gold standard to treat the abscess resulted in the infectious diseases.

Is infection and septic shock caused by a global oxygen deficiency? An overview in 2 parts. 1: Infection and correlation between DO2 and VO2

A global hypoxia resulting in an oxygen debt is assumed to be present in patients who suffer from the different stages and degrees of sepsis including septic shock and ARDS. As a consequence, the therapeutic concept of optimal values for cardiac output and oxygen delivery for these patients was proposed. This article reviews the literature with the objective of determining whether investigations dealing with oxygen delivery and consumption and with the plasma lactate concentration support the idea of the global hypoxia in septic patients. The finding of a pathologic oxygen supply dependency and an increase in plasma lactate concentration were taken as evidence for a global hypoxia. Between 1983 and 1991, oxygen supply dependency in septic patients was reported in an increasing number of publications. The increase in plasma lactate concentration was interpreted as lactic acidosis without presentation of plasma pH values and taken as evidence of global hypoxia and oxygen debt. From 1989 on, the number of publications that failed to show oxygen supply dependency even in the presence of an increased plasma lactate concentration increased. The problem in the method of determination of oxygen supply dependency became evident. Deducing both oxygen consumption and oxygen delivery from cardiac output from a common shared variable subject to measurement error may produce errors in the calculation of the regression between oxygen delivery and consumption. Oxygen supply dependency was not demonstrated in most investigations in which oxygen delivery and consumption were measured independently of each other. No decrease in mortality could be shown in prospective randomized studies for patients with sepsis and septic shock who were treated according to the concept of the optimal values. The lactate plasma concentration was below 5 mmol/l in most studies, which represents the borderline value for a clinically significant lactic acidosis. The term acidosis is not justified without a decrease in plasma pH or a decrease in the bicarbonate plasma concentration. An increased lactate plasma concentration can be merely the result of a hypermetabolism which is often found in septic patients. There is no proven evidence for global tissue hypoxia in septic patients from the investigations of oxygen delivery and consumption. This is also true for patients in septic shock after plasma volume expansion. The dogmatic proposal to increase cardiac output and oxygen delivery to certain levels cannot be sustained. However, regional hypoperfusion (e.g., of the splanchnic vascular bed) cannot be excluded. New approaches like gastric mucosal tonometry, measurement of splanchnic blood flow, and determination of regional metabolism are currently under investigation.

The effect of fuel source on amino acid metabolism in critically III patients

The ideal energy substrate for critically ill patients receiving total parenteral nutrition (TPN) remains controversial. While glucose has been proved to have nitrogen sparing properties in postoperative patients, critically ill patients tolerate glucose loads poorly and fat appears to be an obligatory fuel in sepsis. Furthermore, it is not yet certain whether the changes in whole body protein metabolism induced by critical illness are influenced by the nature of the TPN provided. This study was conducted on patients admitted to a surgical intensive care unit (SICU) who fulfilled the criteria of requiring TPN and mechanical ventilation for at least four days. Patients were randomized to receive either glucose (G) or equicaloric proportions of glucose and lipid (GF) as an intravenous energy source. TPN was commenced early, within 24–48 hr of trauma or surgery and admission to the ICU. Nonprotein calorie intake was 125% of calculated basal energy expenditure. Nitrogen balance was calculated from 24-hr urinary urea excretion. Protein synthesis, turnover, and catabolism were measured on Day 4 of the study using an established radiolabeled C14-leucine technique. Degree of sepsis and illness were calculated using published scores. Fifty patients entered the trial but 32 were excluded by Day 4. Of the 18 patients completing an initial four day study, eight went on to complete a second study on the alternative regimen—a total of 26 studies (14 G, 12 GF). Net protein synthesis was achieved in 18 studies (12 G, 6 FG) and positive nitrogen balance by Day 4 in 22 studies. Four patients on the G regimen were withdrawn due to glucose intolerance while none of the patients on GF developed glucose intolerance or hyperlipidaemia. Both whole body protein synthesis and catabolism correlated significantly with degree of sepsis. The type of TPN fuel used, G and GF, did not appear to influence whole body protein dynamics, both regimens achieving greatly improved whole body protein kinetics.

Wound sepsis in a plastic surgery unit

Summary A survey was carried out to determine the incidence of sepsis after surgical operations in a Plastic Surgery Unit. Excess stay in hospital due to sepsis was also investigated. Some degree of sepsis was found in 31·3 per cent of patients whose stay in hospital exceeded 5 days. Patients with sepsis had, on average, an excess stay of 5·5 days over the surgeons' estimate. Patients whose wounds healed without sepsis stayed, on average, only 1·1 days longer than the predicted time. In the group of patients who developed major wound sepsis (11·2 per cent), the average excess stay was 9·0 days. There were some grounds for believing that the 543 patients investigated (patients with a stay in hospital exceeding 5 days) might have represented a selected, high-risk group and that if we had included the 1,465 short-stay patients the rate of sepsis of all degrees would have fallen to about 8·5 per cent.

SUPPURATION OF THE PETROUS PYRAMID

The subject of infection of the petrous pyramid has been discussed among otologists for a sufficient time so that the typical, clearcut condition is now rather easily recognized. Otologists are now what might be called "pyramid minded" and are on the look-out for this condition, rather than being surprised when it is encountered. The symptoms in the typical case have been repeatedly stressed: pain in the region of the eye, discharge from the ear or, its equivalent, from the mastoid wound, and some degree of sepsis. These are regarded as the cardinal signs; and yet how often is the typical case encountered? A review of the records of the last ten years shows that in approximately 50 per cent of the cases these signs are present and that in the remainder there is deviation from this pattern, often to a considerable degree. One should not expect all the signs to

PROPHYLAXIS OF PUERPERAL SEPSIS

The incidence of puerperal sepsis has shown but a moderate decrease the past few years. Even today its frequency is appalling and justifies the tremendous volume of censure to which the American medical profession is now subjected. During the past quarter of a century the surgical technic of delivery has shown definite improvement. The progress of labor is now largely determined by abdominal palpation; vaginal examinations are made with increasing care and only when a rectal examination will not furnish the desired information. But there still remains a degree of sepsis which is inconsistent with a normal physiologic process, constitutes a national peril and demands further research in contradistinction to the indifference of today. Severe and even fatal infections can and do occur in spontaneous deliveries under ideal conditions when the patient has been in labor only the average length of time and presents no history of recent coitus, douches