Blood glucose control in patients with severe sepsis and septic shock

The main pathophysiological feature of sepsis is the uncontrollable activation of both pro-and anti-inflammatory responses arising from the overwhelming pro-duction of mediators such as pro-and anti-inflammatory cytokines. Such an uncontrollable inflammatory response would cause many kinds of metabolic derangements. One such metabolic derangement is hyperglycemia. Accordingly, control of hyperglycemia in sepsis is considered to be a very effective therapeutic approach. However, despite the initial enthusiasm, recent studies reported that tight glycemic control with intensive insulin therapy failed to show a beneficial effect on mortality of patients with severe sepsis and septic shock. One of the main reasons for this disappointing result is the incidence of harmful hypoglycemia during intensive insulin therapy. Therefore, avoidance of hypoglycemia during intensive insulin therapy may be a key issue in effective tight glycemic control. It is generally accepted that glycemic control aimed at a blood glucose level of 80-100 mg/dL, as initially proposed by van den Berghe, seems to be too tight and that such a level of tight glycemic control puts septic patients at increased risk of hypoglycemia. Therefore, now many researchers suggest less strict glycemic control with a target blood glucose level of 140-180 mg/dL. Also specific targeting of glycemic control in diabetic patients should be considered. Since there is a significantcorrelation between success rate of glycemic control and the degree of hypercytokinemia in septic patients, some countermeasures to hypercytokinemia may be an important aspect of successful glycemic control. Thus, in future, use of an artificial pancreas to avoid hypoglycemia during insulin therapy, special consideration of septic diabetic patients, and control of hypercytokinemia should be considered for more effective glycemic control in patients with severe sepsis and septic shock.

Effects of therapeutic plasma exchange on survival in patients with postoperative liver failure:a retrospective single-center study

Background:Recent decreases in the incidence of postoperative liver failure(POLF)have been attributed to advances in surgical techniques,critical care,and postoperative management.However,POLF management remains a challenge,and worsening POLF is a significant cause of morbidity and mortality.Therapeutic plasma exchange(TPE)is used as a salvage strategy for POLF in some countries,and several studies conducted between 1980 and 1990 have reported the use of TPE for POLF.We conducted this retrospective single-center study to investigate the outcomes of patients with POLF treated with TPE.Methods:We retrospectively reviewed the charts of patients with POLF admitted to the intensive care unit who underwent TPE between November 2010 and March 2017.POLF was defined as the presence of persistent hyperbilirubinemia.Data on patient demographics,Glasgow Coma Scale score,platelet count,prothrombin time,and serum total bilirubin level were collected,and their Sequential Organ Failure Assessment scores were calculated.The lengths of postoperative hospital stays,lengths of post-TPE hospital stays,and patient outcomes were also analyzed.Results:TPE was performed in 20 patients with POLF during the study period.TPE was initiated on the 49th postoperative day and was performed for a median of five sessions.TPE improved hyperbilirubinemia and coagulopathy but had no effect on neurological and clinical symptoms.All 20 patients treated with TPE died after the 36th day(median)from the initial TPE.Conclusions:Although TPE may improve laboratory values in patients with POLF,the current study suggests that it has no survival benefit.