With reference to the optimal management of patients with sepsis in the intensive care unit, all of the following interventions are evidence-based except:
Ans. c. Intensive blood glucose monitoring and prevention of hyperglycemia improves survival in critically ill patients (Ref: Harrison 19/e p1751, 18/e p2954-2957)Low tidal volume during assisted ventilation prevents acute lung injury:The results of recent studies favor the use of low tidal volumes 6 mL/kg of ideal body weight as low as 4mL/kg if plateau pressure exceeds 30 cm H2O in order to reduce the risk of ventilator induced Acute Lung Injury (ALI).For optimal (outcome) of goal-oriented management of sepsis patients, monitoring of central venous pressure, hourly urine output and blood pressure is adequate:Circulatory adequacy is assessed by measurement of arterial blood pressure and monitoring of parameters such as mentation, urine output and skin perfusion.To avoid pulmonary edema CVP should be maintained at 8-12 cm H2O.Intensive blood glucose monitoring and prevention of hyperglycemia improves survival in critically ill patients:The role of tight control of blood glucose concentration in recovery from critical illness has been addressed in numerous controlled trials.Meta analysis of these trials have concluded that use of insulin to lower blood glucose levels to 100-120 mg/dL is potentially harmful and does not improve survival rates.Most experts now recommend using insulin only if it is needed to maintain the blood glucose concentration below 150 mg/dL.Patients receiving insulin must be monitored frequently every 1-2 h for hypoglycemia.The use of drotrecogin-alpha is restricted to severely ill patients with APACHE score > 25:Drotecogin-alpha (activated protein C) was the first drug to be approved by US FDA for treatment of patients with severe sepsis or septic shock.Approval was based on the result of single RCT in which drug was given within 24 hrs.Of the patient's first sepsis related organ dysfunction: 28 day survival rate was significantly higher among recipients who were very sick APACHE II score >25.Subsequent trails failed to show any benefit in patients less sick APACHE II score < 25 or in children.
Low tidal volume during assisted ventilation prevents acute lung injury
For outcome of goal-oriented management of sepsis patients, monitoring of central venous pressure, hourly urine output and blood pressure is adequate
Intensive blood glucose monitoring and prevention of hyperglycemia improves survival in critically ill patients
The use of drotrecogin-alpha is restricted to severely ill patients with APACHE score > 25
Miscellaneous (Infection)