Presentation of Case
A 77-year-old man is admitted to the intensive care unit (ICU) of a university hospital from the operating room. Earlier the same day, he had presented to the emergency department with abdominal pain. His medical history included treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment. In the emergency department, he was drowsy and confused when roused and was peripherally cold with cyanosis. The systemic arterial blood pressure was 75/50 mm Hg, and the heart rate was 125 beats per minute. The abdomen was tense and distended. After the administration of 1 liter of intravenous crystalloid to restore the blood pressure, a computed tomographic scan of the abdomen showed extraluminal gas and suspected extraluminal feces consistent with a perforated sigmoid colon. He was treated with intravenous antibiotics and taken to the operating room for laparotomy. During this procedure, gross fecal peritonitis from a perforated sigmoid colon was confirmed; resection of the sigmoid colon with closure of the rectal stump and creation of an end colostomy (Hartmann’s procedure) was performed with extensive peritoneal toilet and washout.
On arrival in the ICU, he is still anesthetized, the trachea is intubated, and the lungs are mechanically ventilated with a fraction of inspired oxygen of 0.4; the arterial blood pressure is supported with a norepinephrine infusion. When the patient was in the operating room, he received a total of 4 liters of crystalloid. On his arrival in the ICU, the vital signs are a blood pressure of 88/52 mm Hg, heart rate of 120 beats per minute in sinus rhythm, central venous pressure of 6 mm Hg, and temperature of 35.6°C. An analysis of arterial blood shows a pH of 7.32, a partial pressure of carbon dioxide of 28 mm Hg, a partial pressure of oxygen of 85 mm Hg, and a lactate level of 3.0 mmol per liter.
Question
What therapy should be instituted to reduce this patient’s risk of dying from septic shock? Polling and commenting are now closed. The editors’ recommendations appear below.
Answer
The patient in the vignette has septic shock, which with current treatment carries a risk of death of 25 to 40% during the index hospital admission. Available treatments that are thought to reduce the risk of death are limited to early resuscitation with fluids and vasopressors if required, control of the source of sepsis (with surgery, if indicated), and early administration of appropriate empirical antibiotics1. With the withdrawal from the market of recombinant human activated protein C, drotrecogin alfa (activated) (Xigris, Eli Lilly), there are currently no therapies that are licensed specifically for the treatment of severe sepsis and septic shock. Although the recommendation is not strong, the guidelines of the Surviving Sepsis Campaign recommend treatment with 200 mg of hydrocortisone per day if adequate fluid resuscitation and treatment with vasopressor agents do not restore hemodynamic stability. However, the guidelines stipulate that glucocorticoids should not be administered for the treatment of sepsis in the absence of shock1. Although meta-analyses have suggested that the use of polyvalent immune globulin (gamma globulin) might confer a survival advantage in patients with severe sepsis and septic shock, these conclusions are based on low-quality evidence, and such treatment is not currently recommended.2 Likewise, observational studies have suggested that patients who are treated with statins may have a reduced risk of severe sepsis and a reduced risk of sepsis-associated death. However, other studies have suggested that these observed effects may be due to a “healthy user” effect and indication bias.3 At present, the effect of statin therapy on the outcome of patients with severe sepsis and septic shock is not fully understood, but there is no robust evidence supporting the use of statins as a treatment, and the use of such agents is not currently recommended. |
发表于 2013-10-22 16:32
