The main pathophysiological feature of sepsis is the uncontrollable activation of both pro-and anti-inflammatory responses arising from the overwhelming pro-duction of mediators such as pro-and anti-inflammatory cytok...The main pathophysiological feature of sepsis is the uncontrollable activation of both pro-and anti-inflammatory responses arising from the overwhelming pro-duction of mediators such as pro-and anti-inflammatory cytokines. Such an uncontrollable inflammatory response would cause many kinds of metabolic derangements. One such metabolic derangement is hyperglycemia. Accordingly, control of hyperglycemia in sepsis is considered to be a very effective therapeutic approach. However, despite the initial enthusiasm, recent studies reported that tight glycemic control with intensive insulin therapy failed to show a beneficial effect on mortality of patients with severe sepsis and septic shock. One of the main reasons for this disappointing result is the incidence of harmful hypoglycemia during intensive insulin therapy. Therefore, avoidance of hypoglycemia during intensive insulin therapy may be a key issue in effective tight glycemic control. It is generally accepted that glycemic control aimed at a blood glucose level of 80-100 mg/dL, as initially proposed by van den Berghe, seems to be too tight and that such a level of tight glycemic control puts septic patients at increased risk of hypoglycemia. Therefore, now many researchers suggest less strict glycemic control with a target blood glucose level of 140-180 mg/dL. Also specific targeting of glycemic control in diabetic patients should be considered. Since there is a significantcorrelation between success rate of glycemic control and the degree of hypercytokinemia in septic patients, some countermeasures to hypercytokinemia may be an important aspect of successful glycemic control. Thus, in future, use of an artificial pancreas to avoid hypoglycemia during insulin therapy, special consideration of septic diabetic patients, and control of hypercytokinemia should be considered for more effective glycemic control in patients with severe sepsis and septic shock.展开更多
AIM To study the management, complications and outcomes of adult patients admitted with hemophagocytic lymphohistiocytosis(HLH) in the intensive care unit(ICU).METHODS We performed a retrospective observational study ...AIM To study the management, complications and outcomes of adult patients admitted with hemophagocytic lymphohistiocytosis(HLH) in the intensive care unit(ICU).METHODS We performed a retrospective observational study of adult patients with the diagnosis of "HLH" admitted to the two academic medical ICUs of Baylor College of Medicine between 01/01/2013 to 06/30/2017. HLH was diagnosed using the HLH-2004 criteria proposed by the Histiocyte Society.RESULTS Sixteen adult cases of HLH were admitted to the medical ICUs over 4 years.Median age of presentation was 49 years and 10(63%) were males. Median Sequential Organ Failure Assessment(SOFA) score at the time of ICU admission was 10. Median ICU length of stay(LOS) was 11.5 d and median hospital LOS was 29 d. Septic shock and acute respiratory failure accounted for majority of diagnoses necessitating ICU admission. Septic shock was the most common ICU complication seen in(88%) patients, followed by acute kidney injury(81%) and acute respiratory failure requiring mechanical ventilation(75%). Nine patients(56%) developed disseminated intravascular coagulation and eight(50%) had acute liver failure. 10 episodes of clinically significant bleeding were observed.Multi system organ failure was the most common cause of death seen in 12(75%)patients. The 30 d mortality was 37%(6 cases) and 90 d mortality was 81%(13 cases). There was no difference in mortality based on age(above or less than 50 years), SOFA score on ICU admission(more than or less than 10),immunosuppression, time to diagnose HLH or direct ICU admission versus floor transfer.CONCLUSION HLH is a devastating disease associated with poor outcomes in ICU. Intensivists need to have a high degree of clinical suspicion for HLH in patients with septic shock/multi system organ failure and progressive bi/pancytopenia who are not responding to standard management in ICU.展开更多
文摘The main pathophysiological feature of sepsis is the uncontrollable activation of both pro-and anti-inflammatory responses arising from the overwhelming pro-duction of mediators such as pro-and anti-inflammatory cytokines. Such an uncontrollable inflammatory response would cause many kinds of metabolic derangements. One such metabolic derangement is hyperglycemia. Accordingly, control of hyperglycemia in sepsis is considered to be a very effective therapeutic approach. However, despite the initial enthusiasm, recent studies reported that tight glycemic control with intensive insulin therapy failed to show a beneficial effect on mortality of patients with severe sepsis and septic shock. One of the main reasons for this disappointing result is the incidence of harmful hypoglycemia during intensive insulin therapy. Therefore, avoidance of hypoglycemia during intensive insulin therapy may be a key issue in effective tight glycemic control. It is generally accepted that glycemic control aimed at a blood glucose level of 80-100 mg/dL, as initially proposed by van den Berghe, seems to be too tight and that such a level of tight glycemic control puts septic patients at increased risk of hypoglycemia. Therefore, now many researchers suggest less strict glycemic control with a target blood glucose level of 140-180 mg/dL. Also specific targeting of glycemic control in diabetic patients should be considered. Since there is a significantcorrelation between success rate of glycemic control and the degree of hypercytokinemia in septic patients, some countermeasures to hypercytokinemia may be an important aspect of successful glycemic control. Thus, in future, use of an artificial pancreas to avoid hypoglycemia during insulin therapy, special consideration of septic diabetic patients, and control of hypercytokinemia should be considered for more effective glycemic control in patients with severe sepsis and septic shock.
文摘AIM To study the management, complications and outcomes of adult patients admitted with hemophagocytic lymphohistiocytosis(HLH) in the intensive care unit(ICU).METHODS We performed a retrospective observational study of adult patients with the diagnosis of "HLH" admitted to the two academic medical ICUs of Baylor College of Medicine between 01/01/2013 to 06/30/2017. HLH was diagnosed using the HLH-2004 criteria proposed by the Histiocyte Society.RESULTS Sixteen adult cases of HLH were admitted to the medical ICUs over 4 years.Median age of presentation was 49 years and 10(63%) were males. Median Sequential Organ Failure Assessment(SOFA) score at the time of ICU admission was 10. Median ICU length of stay(LOS) was 11.5 d and median hospital LOS was 29 d. Septic shock and acute respiratory failure accounted for majority of diagnoses necessitating ICU admission. Septic shock was the most common ICU complication seen in(88%) patients, followed by acute kidney injury(81%) and acute respiratory failure requiring mechanical ventilation(75%). Nine patients(56%) developed disseminated intravascular coagulation and eight(50%) had acute liver failure. 10 episodes of clinically significant bleeding were observed.Multi system organ failure was the most common cause of death seen in 12(75%)patients. The 30 d mortality was 37%(6 cases) and 90 d mortality was 81%(13 cases). There was no difference in mortality based on age(above or less than 50 years), SOFA score on ICU admission(more than or less than 10),immunosuppression, time to diagnose HLH or direct ICU admission versus floor transfer.CONCLUSION HLH is a devastating disease associated with poor outcomes in ICU. Intensivists need to have a high degree of clinical suspicion for HLH in patients with septic shock/multi system organ failure and progressive bi/pancytopenia who are not responding to standard management in ICU.
