Articles: sepsis.
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Critical care medicine · Jun 1996
ReviewSepsis/septic shock: participation of the microcirculation: an abbreviated review.
An overview of the importance of understanding mechanisms occurring in the microcirculation during septic and endotoxic shock. The thesis of the paper is to place emphasis on this important vascular network to ultimately benefit the patient. ⋯ The purpose of this review is to draw the readers' attention to the growing list of adverse factors occurring in the microcirculation during sepsis/septic shock. A further aim is to point to the realization of the complexity of factors which may contribute to the importance of a well-functioning microcirculation.
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Hemodynamic support during sepsis should focus on aggressive resuscitation coupled with vasopressors aimed at restoration of blood pressure and end-organ perfusion and preservation. The choice of vasopressors should be based on the degree and persistence of peripheral vasodilatation as well as the degree of cardiac stimulation required. ⋯ Dopamine's role of renovascular preservation remains controversial. Therapeutic strategies aimed at supranormal improvements in cardiac index or oxygen delivery have no documented effect in septic patients and should not be part of their therapy.
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Isolated third-order pulmonary arteries and veins from sheep were examined for the effects of septicemia on norepinephrine-induced contractions, nitric oxide (NO)-mediated dilation, and basal cyclic GMP levels. The groups studied were as follows: control sheep (n = 7); sheep given live Pseudomonas aeruginosa (Ps, n = 6) for 48 h; and sheep given NG-mono-methyl-L-arginine during the last 24 h of Ps infusion (Ps-L-NMMA, n = 4). The norepinephrine-induced contractions were significantly greater (p < .05) in arteries from septic (Ps and Ps-L-NMMA) sheep. ⋯ Removal of endothelium enhanced contractions and decreased cyclic GMP in arteries and veins only from control sheep. The results show that septicemia differently affects the pulmonary artery and vein. The enhanced vasoconstriction of the artery is due to decreased endothelium-dependent NO release; the attenuated vasoconstriction of the vein is associated with NO-mediated increased cyclic GMP levels.
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Variables of the fibrinolytic system were prospectively studied in patients with haematologic malignancies in chemotherapy-induced leukocytopenia at onset and during the course of septicemia to evaluate their prognostic value. This group of patients was chosen because of their high risk of developing severe septic complications, thus allowing serial prospective testing of fibrinolytic variables prior to and during evolving sepsis or septic shock. 62 patients with febrile infectious events were accrued to the study. Of these, 13 patients progressed to severe sepsis and an additional 13 patients to septic shock as defined according to standard diagnostic criteria. ⋯ PAI activity of > 5 U/ml at onset of fever predicted a lethal outcome with a sensitivity of 92% and a specificity of 100%. Thus, septic shock in leukocytopenia is associated with significant activation of the fibrinolytic system presumably as a response of the vascular endothelium to inflammatory injury. Furthermore, PAI activity measurements are sensitive markers of an unfavourable prognosis.