Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016

OBJECTIVE: To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". DESIGN: A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy wasdeveloped at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroupsand among the entire committee served as an integral part of the development. METHODS: The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. RESULTS: The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. CONCLUSIONS: Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.(AU)

Autoimmune pancreatitis detected as a mass in the tail of the pancreas.

A mass in the tail of the pancreas was detected in a 62-year-old male patient who had hypergammaglobulinaemia, and was positive for antinuclear antigen and anti-SS-A antibody. Endoscopic retrograde pancreatography revealed focal irregular narrowing of the main pancreatic duct in the tail of the pancreas. Dynamic computed tomography showed swelling of the pancreatic tail, which was enhanced on delayed phase. Autoimmune pancreatitis was suspected and corticosteroid therapy was commenced. This led to significant resolution of the pancreatic stricture. It is important to recognize this clinical entity as corticosteroid therapy may avoid unnecessary surgery.

Gas exchange and hemodynamics in experimental pleural effusion.

OBJECTIVE: To investigate the cardiorespiratory effects of graded bilateral pleural effusions in the anesthetized pig. DESIGN: Prospective, randomized, controlled, laboratory study. SETTING: Animal laboratory. SUBJECTS: Eleven male Yorkshire pigs. INTERVENTIONS: Animals were anesthetized using inhaled isoflurane. Orotracheal intubation was followed by mechanical ventilation. Bilateral chest tubes were inserted, and graded increasing pleural effusions were created using saline of 0, 20, 40, and 80 mL/kg, divided equally between each side. At each pleural volume, intravascular volume was randomly altered (by phlebotomy or transfusion of colloid) to normal (unchanged), low (decreased by 10 mL/kg), or high (increased by 10 mL/kg). MEASUREMENTS AND MAIN RESULTS: Hemodynamic parameters, intrapleural pressures, hemoglobin, and blood gases were measured. At the lowest volume of pleural fluid, PaO2 was reduced by approximately 50% vs. baseline, whereas systemic hemodynamics were unchanged. PaO2 was reduced in a dose-dependent fashion as pleural volume increased but was not affected by alterations in intravascular volume. Intrapulmonary shunt was increased both by intrapleural volume in a dose-dependent fashion and by increases in intravascular volume at high levels of pleural volume. Cardiac output and systemic mean arterial pressure increased with elevated intravascular volume but were not influenced by lower levels of intrapleural volume. Mean pulmonary arterial pressure, central venous pressure, and pulmonary artery occlusion pressure were increased by elevations in both intrapleural volume and intravascular volume. Intrapleural pressure and pulmonary vascular resistance were related to intrapleural volume only. CONCLUSIONS: Hypoxemia occurs as an early event in acute bilateral pleural effusions and precedes hemodynamic decompensation. Oxygenation is independent of intravascular filling pressures, but hemodynamics are preserved with elevated filling pressures. Clinical studies should be undertaken to examine the risks/benefits of careful removal of pleural fluid in patients with pleural effusions, when oxygenation is impaired during mechanical ventilation.

[A clinical study on the cases of ischemic colitis: comparison of clinical images based on time from onset of the disease to detection of bloody stool].

A study was performed on 28 cases of ischemic colitis. The patients were divided into three groups: Group A (9 cases with bloody stool detected within 2 hours after the onset of abdominal pain), Group B (7 cases with bloody stool detected in 2 to 6 hours), and Group C (12 cases with bloody stool detected after more than 6 hours). These cases were comparatively studied. Variables used were as follows: (1) age, (2) sex, (3) constipation, (4) vomiting, (5) peak value of WBC count (/microliter) after admission, (6) peak value of log CRP (microgram/dl), (7) presence of ulcerative lesion in endoscopic findings in acute stage. Using Group A B and C as classification variables, canonical discriminant analysis was performed. As a result, clear linearity was recognized in Group A-->B-->C, and the values (5), (6) and (7) were extracted as the corresponding variables. For these variables, significant difference was also noted in multivariate analysis of covariance. These results suggest that it is possible to predict the severity of the disease to some extent as represented by objective markers of inflammation by finding the time from onset of abdominal pain to detection of bloody stool.

Splenectomy for en bloc node dissection in gastric cancer: a possible cause of portal vein thrombosis.

A 48-year-old woman underwent total gastrectomy, splenectomy, and distal pancreatectomy with en bloc regional lymph node dissection for gastric carcinoma. Dull pain in the right upper quadrant and the back developed postoperatively. Contrast-enhanced computed tomography and ultrasonography disclosed portal vein thrombosis (PVT). Heparin and urokinase were given in conjunction with antibiotics. This treatment resulted in clinical improvement, but failed to achieve complete thrombolysis. Cavernous transformation of the portal system was confirmed. Although PVT after splenectomy has been reported mainly in patients with hematological disorders, our case suggests that splenectomy for en bloc node dissection in gastric carcinoma is a possible cause of PVT.

Hemodynamic changes after ligation of a major branch of the portal vein in rats: comparison with rats with portal vein constriction.

In chronic portal-hypertensive rat models, such as portal vein constriction or cirrhosis, the portal blood flow that effectively perfuses the hepatocytes is substantially reduced because of anatomical or functional shunts. It is possible therefore that a feedback mechanism from the liver to the splanchnic bed is responsible for the splanchnic hyperemia observed in chronic portal hypertension. To investigate the possible role of such a feedback mechanism, we examined the chronological changes in both portal and systemic hemodynamics in rats after ligation of a major branch of the portal vein that supplies about 80% of the liver circulation. Rats submitted to sham surgery and portal vein-constricted rats were also studied. Blood flow and portal-systemic shunting were measured by radioactive microsphere techniques. For 7 days after portal-branch ligation, transient portal hypertension resulted from an elevated portal resistance. However, no significant changes in portal venous inflow or splanchnic arteriolar resistance were found in the portal branch-ligated rats, whereas in the portal vein-constricted rats significant hyperdynamic changes in these parameters were noted. On the other hand, transient hyperdynamic changes occurred in the systemic circulation during the period from the fourth to the sixth day after portal-branch ligation, similar to those observed in the portal vein-constricted rats. The lack of hyperdynamic changes in the portal territory of the portal branch-ligated rats suggests that the splanchnic hyperemia found in chronic portal-hypertensive states is unlikely to be caused by a feedback mechanism from the ischemic hepatic parenchyma.(ABSTRACT TRUNCATED AT 250 WORDS)

Inhalation of calcium channel blocking agents protects against methacholine-induced bronchoconstriction.

The calcium channel blockers, diltiazem and verapamil, and the beta agonist orciprenaline sulfate all demonstrated significant protection against methacholine-induced bronchoconstriction in 11 stable asthmatics (5 males and 6 females). Ten and 20 mg of inhaled diltiazem, 5 mg of verapamil or 30 mg of orciprenaline administered 15 min before stepwise increasing doses of methacholine hydrochloride produced significant reduction in respiratory resistance (Rrs), minimum dose of methacholine hydrochloride required for Rrs increase (Dmin) and bronchial reactivity measured with an Astograph. The mechanism of action of the calcium channel blockers is presumably at the level of the smooth muscle cells themselves. The combination of positive influence and lack of any adverse effect on blood pressure or heart rate with any of the agents tested indicates that their clinical application for alleviation of acute asthma can be recommended.

Nipradilol, a new beta-blocker with vasodilatory properties, in experimental portal hypertension: a comparative haemodynamic study with propranolol.

The haemodynamic effects of nipradilol, a new non-selective beta-adrenoreceptor blocker with vasodilating actions like nitroglycerin, were examined in rats with portal hypertension due to portal vein stenosis. Portal hypertensive rats were divided into five groups receiving infusion of placebo, 3 mg of propranolol, 300, 600 and 1200 micrograms of nipradilol. At its highest dose, nipradilol achieved a reduction of 34.4 +/- 4.4% in heart rate which was similar to that in the propranolol group (36.5 +/- 2.4%). Also for other systemic haemodynamic parameters, the nipradilol 1200 micrograms group exhibited changes not significantly different from those in the propranolol group; mean arterial pressure (-13 vs -14%), cardiac index (-37 vs -31%) and systemic vascular resistance (+29 vs +32%). In contrast to the similar changes in the systemic circulation, a 1200 micrograms dose of nipradilol lowered portal pressure significantly more than propranolol (-4.3 +/- 0.6 vs -2.9 +/- 0.2 mmHg, P < 0.05). Nipradilol then reduced portal blood flow by 22% (P < 0.05) without a significant change in portocollateral resistance. On the other hand, propranolol not only caused a reduction in portal blood flow of 30% (P < 0.01), but also an increase in portocollateral resistance of 21% (P < 0.05). The results suggest that nipradilol may ensure a more effective control of portal hypertension than propranolol, presumably via its venodilatory action on portocollateral vessels.

[Cooperative Study of Surgical Adjuvant Chemotherapy for Colorectal Cancer (third report): five-year results after surgery].

Beginning in January 1984, in collaboration with 357 institutions nationwide, comparative studies on curative resection cases of colorectal cancer and a control group were conducted for 2 years. The following method of administration was employed; Group A received 12 mg/m2 of MMC on the day of operation, followed by 6 mg/m2 every 2 months 6 times. From the 2nd week after the operation, 800 mg/body/day of Futraful was administered for one year. Group B received no treatment. Altogether 2786 cases were collected and, excluding ineligible cases, 2477 evaluable cases were analyzed. There was no difference in either survival rate or disease free rate, but after the bias of background factors was corrected by the hazard model, the disease free rate was better with Group A, and there was a significant difference with the rectum. According to the Dukes classification, in the Dukes C cases with the rectum Group A had higher rate of survival, disease free rate and lower rate of metastasis to the liver and local recurrence of cancer.

Relationship between esophageal varices and azygos vein evaluated by cineportography.

The relationship between esophageal varices and the azygos vein, which is generally considered to drain the major part of the variceal blood flow, was evaluated by percutaneous transhepatic cineportography in 35 patients with portal hypertension. We classified the patients into three groups. Those patients in whom most of the variceal blood drained into the azygos vein were designated the azygos-type group (n = 18). Those in whom most of the blood flowed into the brachiocephalic venous system were defined as the cervical-type group (n = 5), and those in whom the varices were drained by both the azygos vein and the brachiocephalic venous system were called the combined-type group (n = 12). Highly developed esophageal varices were recognized endoscopically in all patients in the combined-type and cervical-type groups, whereas some of the patients in the azygos-type group had less well-developed varices. In the azygos-type group, a tendency for the varices to be more severe as their drainage into the azygos vein became more cephalad was noted. Evaluation of the drainage of esophageal varices was considered useful not only for obtaining full comprehension of the significance of the azygos vein but also for assessing the suitability for sclerotherapy. Percutaneous transhepatic cineportography was useful for this purpose because it enables visualization of even the most minute amounts of blood flow.

[Three elderly cases of renal cell carcinoma with pancreatic metastasis].

Three elderly patients, (an 80-year-old female, 78-year-old female and 78-year-old male) suffering from renal cell carcinoma with pancreatic metastasis were reported. In all cases, renal cell carcinoma had been diagnosed previously. Pancreatic tumors were revealed by computed tomography and ultrasonic study during subsequent admission in all cases. In the first case, laparotomy and histological examination proved that pancreatic tumor was metastatic from renal cell carcinoma. In the other cases, according to their clinical course and other laboratory data, we considered the pancreatic tumors to be metastatics from renal cell carcinoma though histological diagnosis was not obtained.

Unresponsiveness of insulinoma cells to secretin: significance of the secretin test in patients with insulinoma.

It is well known that B cells in the pancreas release insulin when stimulated by secretin, but there have been few reports on the response of insulinoma cells to secretin. In five patients with insulinoma, changes in serum immunoreactive insulin (IRI) concentration were measured after the intravenous injection of secretin into the peripheral vein before and after extirpation of the insulinoma. The extirpated insulinomas were cultured and tested for their response to secretin. The rise in serum IRI in response to secretin in patients with insulinoma was significantly slower and smaller than in normal volunteers. After removal of the insulinoma, the response to secretin became prompt and increased with time. Cultured insulinoma cells did not release insulin when stimulated by secretin. Therefore, it is concluded that the response of insulinoma cells to secretin is quite different from that of normal beta cells, and that the function of beta cells in the insulinoma-bearing pancreas is suppressed by the autonomous hypersecretion of insulin by the insulinoma. The extent of the decrease in function of the beta cells in patients with insulinoma can be estimated by the intravenous secretin test. Thus, the secretin test is sometimes useful in the differentiation of hypoglycemia due to insulinoma from that due to beta cell hyperplasia or alimentary hyperinsulinemia.

[Xenon enhanced dynamic computed tomography of the lung; regional ventilation measurement].

CT-functional images (CT-FI's) were created from Xe-dynamic CT data of 10 patients with chronic pulmonary emphysema and 6 volunteers with normal lung. In CT-FI's of normal lungs, the values of washin and washout parameter of outer zone were larger than those of inner zone. In CT-FI's of chronic pulmonary emphysema, the values of washin parameter of inner zone were larger than those of outer zone and the value of washout parameter of outer zone were larger than those of inner zone. CT-FI's proved to helpful in evaluating the axial distribution of ventilation dynamics in chronic pulmonary emphysema.