Resuscitation therapy in systemic sepsis: evidence-based

The septic syndrome is associated with persistent high mortality, mostly due to the late diagnosis of this disease entity, and its inappropriate management. Therapies used for management of criticatly-ill patients in general, have been recently tested in systemic sepsis The present article spots light on available literature including systematic reviews and meta-analysis to explore evidence-based guidelines for resuscitation therapy in the septic syndrome. The American Society of Anesthesiologists defines practice guidelines as "systematically developed recommendations that describe a basic management strategy or a range of basic management strategies for patient care". This is because absence of proof does not mean that proof is absent. The "early" use of both global-and splanchnic oriented haemodynamic therapy, together with repeated clinical interpretations form an important cornerstone for treatment of patients with systemic sepsis. Central venous, pulmonary artery, and peripheral arterial catheters, should be placed as early as possible for diagnostic and therapeutic purposes. Fluid resuscitation by crystalloids, colloids and haemoglobin transfusion aim to therapeutically drive oxygen delivery and oxygen consumption to global and regional goals with myocardial performance being the end-point of resuscitation. Fluid challenge should be administered, and repeated based on response [increased arterial blood pressure and urine output] and tolerance [evidence of intravascular volume overload]. Norepinephrine and dopamine are the vasopressors of choice for treatment of systemic sepsis. They aim to maintain blood pressure, both during and following adequate fluid therapy. Phenylephrine and epinephrine are not recommended as first line agents for therapy. Dobutamine is recommended as the agent of choice to increase cardiac output, but if used with low mean arterial pressure, it should be combined with a vasopressor while the cardiac output is being measured. Low-dose dopamine should not be used for renal protection as part of treatment of severe sepsis. Continuous venovenous haemofiltration offers easy management of fluid balance in haemodynamically unstable septic patients. In the absence of haemodynamic instability, haemofiltration is equivalent to intermittent haemodialysis. Tight glycemic control by insulin is recommended in the septic patient. However, this should be combined with a nutritional protocol. Bicarbonate therapy is not recommended for improving haemodynamics or in reducing vasopressor requirements in the presence of lactic acidosis and PH >/= 7.15. Activated Protein-C therapy and selective digestive decontamination strategy would play important roles in the management of systemic sepsis in the near future

effect of halothane anaesthesia on blood and plasma volumes in bilharzial hepatosplenomegaly

Ten male patients with bilharzial hepatosplenomegaly were the subject of this study. Another ten male patients of nearly the same age and body weight were taken as control. The plasma and blood volumes were estimated before and 30 minutes after 2% halothane anaesthesia without any surgical interference. The plasma volume was determined by Evens blue dye method and the total blood volume was calculated from the haematocrit value. There was no significant difference between the mean blood volumes of the two groups before the administration of halothane. The 2% halothane administration for 30 minutes, significantly increased the mean total blood volumes in both groups, although the difference between the mean percent increases was not significant. The mean haematocit values of both groups did not display any significant change before or following the exposure to halothane. Patients with bilharzial hepatosplenomegaly developed more hypervolaemia during halothane anaesthesia, possibly mainly due to an increase in the plasma volume. The effect of halothane anaesthesia on the blood volume was the subject of conflicting reports. Some authors [Payne and colleagues, 1959, and Grable and associates, 1962] reported an increase in blood volume, while other [Morse and colleagues, 1963] could not detect any change in blood volume following the administration of halothane. Hepatosplenic bilharziasis is a disease associated with changes in haemodynamic pattern [Mousa, 1967] and these changes can be modified by the action of various drugs especially the vasoactive ones. The purpose of this study is to report the effect of halothane anaesthesia on the plasma and blood volumes in hepatosplenic bilharziasis