Physiologic Support of the Septic Patient

Grading of severity of the condition in burn patients by serum protein and albumin/globulin studies

Capillary permeability increases after inflammation with consequent leak of fluid, electrolytes, and proteins. The albumin molecule size being smaller (69 kDa) than the globulin molecule (90-156 kDa) will leak relatively at an early stage of the disease (with moderate increase in capillary pore size) than globulin leading to albumin/globulin reversal. In cases with severe permeability changes with rapid progression to larger pore size with simultaneous leak of both albumin and globulin, albumin/globulin reversal will not occur. In this study estimation the serum protein and albumin/globulin (A/G) ratio at frequent intervals was done to grade the severity of the condition of burn patients by assessing the severity of capillary leak.A total of 61 admitted patients (from March 2002 to December 2004) based on the protein values were divided into 3 groups (group 1: 6-8 g/dL, group 2: 5.1-5.9 g/dL, group 3: < or =5.0 g/dL), and all the patients who showed change in their protein levels during the study were shifted to appropriate group and were classified as group shifters. The mean survival time and mortality of various groups were compared, and A/G ratio of all the expired cases was analyzed.Group 3 patients showed higher mortality (95%) as compared to that in other groups (group 1 and 2: 0% each and group shifters: 30.2%). Median survival time of group 3 was significantly low as compared to that of group 1 (P < 0.0026), group 2 (P < 0.0006), and group shifters (P < 0.0000). In group shifters the mean time (days) required for shifting from one group to other just before death or discharge in survivors was significantly higher than that in expired cases. Of 26 cases expired during the study, initial A/G ratio at the time of first assigning the group was not reversed in 22 cases (84.6%).The study concluded that the severity (indicated by lower serum protein values) and speed (judged by A/G ratio changes and median survival time analysis) of capillary permeability changes were associated with high mortality, and therefore, it is possible to grade the severity of the condition in burn patients.

State-of-the-art therapy for severe sepsis and multisystem organ dysfunction

Despite spectacular advances in life-support technology, the management of patients with severe sepsis continues to be a significant health care challenge because of the associated major morbidity, high mortality, and health economic implications. Severe sepsis with associated multisystem organ dysfunction (MOD) is the leading cause of death in the intensive care unit. Recent understanding of the pathophysiology now demonstrates that the syndrome of severe sepsis after a major physiologic insult is characterized by the activation of multiple overlapping and interacting cascades leading to systemic inflammation, a procoagulant state, and decreased fibrinolysis, which if unchecked leads to the progressive functional deterioration of multiple interdependent organs. This review will highlight the epidemiology, current understanding of the pathophysiology, management, and prevention of the syndrome of severe sepsis with MOD.

Necrotizing soft tissue infections of the chest wall

BACKGROUND

Necrotizing soft tissue infections of the chest wall are uncommon, and they have received little discussion in the medical literature.

METHODS

We performed a collective review of the literature to summarize information on etiology, prevention, treatment, complications, and outcome of chest wall necrotizing soft tissue infections. Manual, Medline, and Current Contents searches of the English-language medical literature were done.

RESULTS

There were 9 reported cases of necrotizing soft tissue infection of the chest wall. Eight were complications of invasive procedures and operations. Tube thoracostomy for empyema (4 patients) was the most common antecedent procedure. Excessive soft tissue dissection during chest tube insertion was implicated in the genesis of these infections. Necrotizing infections complicated esophageal operations in 2 patients. Overall mortality was 89%. Only 3 of the 9 patients underwent early and adequate debridement. Chest wall stability and wound reconstruction were problematic in patients who survived the initial septic illness.

CONCLUSIONS

Necrotizing soft tissue infections of the chest wall are highly lethal infections that require urgent and aggressive debridement. Diagnostic delay and inadequate debridement are common reasons for treatment failure. Repetitive surgical debridement is often needed to control sepsis. Wound closure is challenging in patients who survive the initial septic phase of their illness.

Neutrophil-induced lung damage after hepatic ischemia and endotoxemia

Administration of Salmonella enteritidis endotoxin (0.5 mg ET/kg) during reperfusion (RP) after short-term hepatic ischemia (20 min) caused severe liver injury induced by Kupffer cells and neutrophils and a high mortality rate. To investigate potential lung damage in this model, lung wet-to-dry weight ratios (W/D) and broncho-alveolar lavage (BAL) protein content were determined after 4 h of reperfusion. Both parameters increased significantly during RP/ET (W/D: 4.4 +/- 0.1; BAL: 639 +/- 30 micrograms/ml) compared to controls (W/D: 3.5 +/- 0.1; BAL: 332 +/- 17). The antioxidants Trolox or tirilazad mesylate (U-74006F) effectively reduced the BAL protein increase. Alveolar macrophages were not activated; however, neutrophils isolated from the lung microvasculature of RP/ET animals showed a 300% increase of spontaneous and PMA-induced superoxide formation compared to controls (spontaneous: 1.4 +/- 0.5 nmol O2-/h/10(6) cells; PMA: 2.2 +/- 0.4). Complement factors and TNF-alpha injection induced a similar priming of vascular neutrophils for superoxide generation. Vascular neutrophil activation highly correlated with the severity of lung injury. It is concluded that neutrophils accumulated in the lung microvasculature were the major source of the oxidant stress and mainly responsible for lung injury under these conditions. Antioxidants such as tirilazad mesylate (U-74006F) may have therapeutic potential for attenuating lung injury induced by remote organ trauma and a systemic inflammatory response.