The Netherlands journal of medicine
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Despite important advances in critical care medicine during the last two decades, the mortality rate of sepsis has remained high, probably because the pathogenesis of sepsis is still incompletely understood. Recent studies have shown that sepsis is a bimodal entity. The first phase is characterized by the systemic release of pro-inflammatory cytokines such as tumor necrosis factor-alpha (TNF-alpha), interleukin-1 (IL-1), and IL-8, and by activation of the complement and coagulation cascades. ⋯ Recently, it has been shown that decreased expression of HLA-DR on monocytes in patients with sepsis constitutes a marker for CARS. We suggest that HLA-DR expression on monocytes might constitute a useful indicator of the immunological status of the individual patient with sepsis and a guide for treatment. Patients with CARS, as manifested by low HLA-DR expression, might benefit from immunostimulants, while patients with SIRS and normal or high monocyte HLA-DR expression should receive treatment directed to interfere with pro-inflammatory pathways.
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Infection is the most common serious complication of intravascular catheters. Most cases of catheter-related infection are caused by staphylococci that originate either from the skin of the patient and migrate along the external surface of the catheter or from a contaminated catheter hub and migrate along the internal surface of the catheter. ⋯ A number of measures have been reported in prospective, randomized clinical trials to protect against vascular catheter-related infection. This paper summarizes the clinical efficacy of various preventive measures, such as placement and maintenance of vascular catheters by a skilled infusion therapy team, institution of maximal sterile barriers, use of silver-impregnated subcutaneous cuff, antimicrobial coating of catheters with either antibiotics or antiseptics, use of an antiseptic catheter hub, application of topical disinfectants, and flushing catheters with the combination of antimicrobial and antithrombotic agents.