Objective:To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008.Design:A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at ke

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

To provide an update to the “Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock,” last published in 2008. A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7–9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a Pao
 2/Fio
 2 ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a Pao
 2/Fi
 o
 2 180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5–10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven “absolute”’ adrenal insufficiency (2C). Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe 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 this important group of critically ill patients.

/pdf/surviving-sepsis-campaign-international-guidelines-for-229kg8suph.pdf

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012

The acute respiratory distress syndrome is a common, devastating clinical syndrome of acute lung injury that affects both medical and surgical patients. Since the last review of this syndrome appeared in the Journal, 1 more uniform definitions have been devised and important advances have occurred in the understanding of the epidemiology, natural history, and pathogenesis of the disease, leading to the design and testing of new treatment strategies. This article provides an overview of the definitions, clinical features, and epidemiology of the acute respiratory distress syndrome and discusses advances in the areas of pathogenesis, resolution, and treatment. Historical Perspective and Definitions . . .

/pdf/the-acute-respiratory-distress-syndrome-4dksnctehq.pdf

The acute respiratory distress syndrome

To provide an update to “Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012”. 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 was developed 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 subgroups and among the entire committee served as an integral part of the development. 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. 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. 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.

https://link.springer.com/content/pdf/10.1007%2Fs00134-017-4683-6.pdf

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

Objective
To provide an update to the original Surviving Sepsis Campaign clinical management guidelines, “Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock,” published in 2004.

/pdf/surviving-sepsis-campaign-international-guidelines-for-lbjfg8yybt.pdf

Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008.

An artificial lung system for a patient having a membrane lung system having an gas inlet, a blood inlet, a blood outlet, and an exhaust; a gas system operably coupled to the gas inlet of the membrane lung system; a gas phase CO2 sensor disposed downstream of the exhaust of the membrane lung system and monitoring an exhaust gas CO2 (EGCO2) level and/or an blood oxygen saturation sensor disposed upstream of the blood inlet of the membrane lung system and monitoring a blood oxygen saturation level; and a feedback controller receiving the CO2 signal and/or blood oxygen saturation signal and outputting a control signal to control gas flow and/or blood flow.

Smart artificial lung and perfusion systems

Effect of paraffin on cholesterol extraction.

Measuring infant metabolism: Design and testing of a miniature gas exchange monitor

Purpose: Current clinical Extra Corporeal CO2 removal systems rely on human intervention to adjust to changes in patient activity. Previous studies have investigated the use of capnography for measurement of arterial blood carbon dioxide tension (PaCO2) using artificial lungs (AL). The presented work demonstrates an initial implementation of a controller that directly monitors and regulates PaCO2 using exhaust gas CO2 (EGCO2) measurements. Method: The system operates through two cycles, namely measurement and control. First, the sweep gas flow through the AL is temporarily (~60s) reduced to ~400 mL/min to allow the CO2 concentration on the blood and gas phase of the AL to equilibrate. This allows for EGCO2 (measured via a CO2Meter GC-0017) values to be used as an estimate of PaCO2. The control cycle is based on Proportional-Integral-Derivative (PID) principle wherein the system automatically modulates sweep gas flows through the AL to minimize the difference between the desired PaCO2 and the estimated PaCO2 (i.e., measured EGCO2). Blood samples were intermittently collected at the inlet of the AL to monitor actual PaCO2 (measured via a Radiometer ABL800 Flex blood gas analyzer). The in vitro study setup (Fig. 1) consists of a Novalung iLA oxygenator (main AL) and a Capiox RX25 oxygenator (conditioning AL) connected in parallel to model a typical ECMO circuit. The blood reservoir mimics the blood volume (7 L) while the centrifugal pump simulates cardiac output (fixed at ~5 L/min) of a patient. Blood flow through the main AL (AV shunt) was regulated at ~1 L/min using a Hoffman clamp. CO2 concentration in the sweep gas through the conditioning AL was modulated to simulate metabolic activity. The baseline CO2 concentration measured at the outlet of the conditioning AL that projects reservoir PaCO2 level when the main AL is not operational. The baseline blood concentration was varied between 45 and 90 mmHg representing all levels of normocapnia and hypercapnia. Results: Prior to the controller testing, a feasibility study was performed to determine the accuracy of capnography technique in calculating the PaCO2 using the AL. A total of forty-two blood samples were collected at blood flow rates of 0.5, 0.6 and 1.0 L/min. The results show a good correlation between PaCO2 and EGCO2 (r2=0.824, P<0.001). There was a reasonable degree of agreement between the PaCO2 and EGCO2 with accuracy (bias or mean difference between PaCO2 and EGCO2) of 6.04 mmHg with a precision (95% limits of agreement) of ± 9.62 mmHg (Fig. 2). Despite the limitation of the AL in estimating PaCO2 using EGCO2, the PID controller implementation demonstrated that average reservoir CO2 concentration can be maintained at 44.23 ± 8.7 mmHg for a target PaCO2 of 40 mmHg (Fig. 3),against baseline blood reservoir PaCO2 of 60.76 ± 13.81 mmHg.Figure 1. Image showing in vitro test setup. The bovine blood in the test circuit was anticoagulated (ACT > 1200s) with heparin and maintained at 37°C.Figure 2. a) The regression curve generated between PaCO2 samples and measured EGCO2 b) Agreement between PaCO2 samples and measured EGCO2.Figure 3. a) In vitro test results showing changes in all PaCO2 concentrations in the circuit b) Result summary comparing average reservoir PaCO2 level with target PaCO2 

PULM7: Toward Automatic Control Of Arterial Blood Paco2 Using Artificial Lung Exhaust Gas CO2 As A Surrogate

An artificial lung including a housing having a circular outer wall being enclosed by a first surface and a second surface to define an interior volume, a blood inlet port to permit inlet flow of blood to the housing, a blood outlet port to permit outlet flow of the blood from the housing, a gas inlet port to permit inlet flow of a gas to the housing, a gas outlet port to permit outlet flow of the gas from the housing, and a plurality of baffles concentrically disposed within the housing. The baffles are positioned to define a flow path between the blood inlet port and the blood outlet port. Each of the baffles includes a gate opening to permit flow of the blood along the flow path. A fiber bundle is disposed between the baffles within the flow create mixing and improve gas exchange efficiency.

Robert H. Bartlett

Papers

Smart artificial lung and perfusion systems

Effect of paraffin on cholesterol extraction.

Measuring infant metabolism: Design and testing of a miniature gas exchange monitor

PULM7: Toward Automatic Control Of Arterial Blood Paco2 Using Artificial Lung Exhaust Gas CO2 As A Surrogate

Gated-concentric artificial lung