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Application of Newer Principles in Sepsis Treatment

　　 Gregory Schmidt, MD,[12] of the University of Chicago, Chicago, Illinois, presented 2 representative cases and discussed the "real-time" applicability of the newer principles of sepsis therapy.
　　The first case was a female patient with a history of ethanol abuse presenting with pneumonia caused by Streptococcus pneumoniae leading to septic shock. She was intubated and was mechanically ventilated using a low tidal volume in accordance with the data from the ARDSNetwork trial[13] in which mechanical ventilation with a lower tidal volume than that traditionally used resulted in decreased mortality and fewer number of days requiring ventilatory support. This trial had to be stopped after the enrollment of 861 patients because a significant difference in mortality favoring the lower tidal volume group was observed (31.0% vs 39.8% for the conventional tidal volume ventilation, P = .007). The patient was given appropriate antibiotics and supportive therapy. Despite her coagulopathy and her low platelet count, the decision to administer drotrecogin alfa (activated) was made. She started improving the next day after the infusion without any significant bleeding. According to the study by Kress and colleagues,[14] her sedation was interrupted and her mental status was evaluated. In this study, daily interruption of sedation decreased the duration of mechanical ventilation and the length of stay of mechanically ventilated ICU patients. The patient slowly improved. She was extubated on hospital day 8 and was transferred to a rehabilitation facility on day 15.
　　The second case was a 37-year-old male with end-stage renal disease, cadaveric renal transplant, hypertension, and diabetes. The patient went into septic shock after he was operated for an elective hernia repair secondary to a duodenal laceration. Although he had recently had an operation, he was given drotrecogin alfa (activated) after discussing the risks with the surgical team. Steroids were stopped as the patient responded adequately to the short ACTH stimulation test. Given the low mixed venous oxygen saturation, dobutamine was added to his regimen with subsequent increase of the value. The patient had to be re-explored because he was worsening. Abdominal wall necrotizing fasciitis was found, and it was debrided and left to heal by secondary intention. Drotrecogin alfa (activated) was held 2 hours before laparotomy and was resumed 12 hours afterward. There were no serious bleeding events, and the patient gradually recovered and was extubated on the ninth hospital day. In conclusion, individualization of patient management decisions should always be made. The patient's prognosis with and without treatment should always be considered; and open discussions with colleagues and surrogates should take place. Patient safety should be a continuous concern.