New concepts in treatment of sepsis.
Critically ill patients still commonly die of the effects of sepsis, despite numerous interventions. Earlier trials investigated mostly anti-inflammatory strategies, based on the prevailing theory that sepsis represents an uncontrolled inflammatory response. We now know that sepsis represents a biphasic response to infection, and the initial pro-inflammatory response that we have targeted thus far is invariably followed by a prolonged period of immune suppression. Indeed, a patient may oscillate between a pro- and anti-inflammatory state repeatedly. The use of steroids remains controversial, and should probably be reserved for a select subset of patients. The coagulation cascade has a powerful effect on inflammation, and manipulation by means of Activated Protein C has been beneficial. It appears tremendously advantageous to resuscitate the critically ill patient early and aggressively to maintain normal oxidative metabolism. This, coupled with the rigorous maintenance of a physiologically neutral milieu (particularly blood glucose levels) seems to be the most powerful weapon we have to manage the critically ill patient with sepsis.