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This reference provides guidelines for management of infections in critically ill patients. It provides disease mechanisms of sepsis as well as clinical diagnosis, treatment and management, and the authors also explain the proper guidelines for assessment and treatment protocols in the ICU. They have designed this resource specifically to handle the common infectious problems. Included are evolving concepts from multiple pertinent disciplines such as: basic microbiology, outcome measures, pharmacology and epidemiology statistics.
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The specialty of critical care medicine is, in large part, devoted to the care and treatment of patients with sepsis and the consequences of systemic infection. Tissue hypoperfusion and organ-system derangements are the hallmarks of severe sepsis and also the main causes of morbidity and mortality in the disorder. One of the leaders in defining the clinical manifestations of sepsis was Roger C. Bone. He was instrumental in organizing the American College of Chest Physicians and Society of Critical Care Medicine Consensus Panel to develop working definitions of sepsis and multiorgan failure. Therefore, it is most appropriate that this textbook is dedicated to Dr. Bone and that he served as one of its editors. Each of the seven contributing editors is an internationally known expert, having made substantial scientific contributions to our knowledge of sepsis and its clinical consequences.
Although we have witnessed important advances during the past two decades in defining sepsis and related disease processes, and in understanding its basic pathophysiology, our therapeutic options are still limited. The current management of sepsis centers on draining protected sites of infection and administering antimicrobial agents. Therefore, a textbook of this caliber, outlining our current knowledge of this disease in a way that will help move us into the next century, is timely. As is alluded to throughout this book, advances in the prevention, diagnosis, management, and treatment of sepsis and multiorgan failure over the next decade should allow clinicians more therapeutic options and result in improved outcomes.
Despite its increasing prevalence, there has been considerable controversy and disagreement regarding the pathophysiology of sepsis and the criteria for diagnosing the condition. In large part, the lack of a validated classification system for patients with sepsis has been linked to the negative results of numerous trials of novel therapeutic agents for this disease. One of the main contributions of this textbook is to provide a systematic approach to classifying patients with sepsis. Appropriately, the chapter outlining this classification was written by Dr. Bone. A better understanding of the epidemiology and natural history of sepsis should assist clinicians in treating patients with this disorder and aid researchers in their evaluation of new medical therapies. Sepsis and Multiorgan Failure provides a detailed and understandable discussion of all the major therapeutic issues related to the systemic manifestations of infection, including the use of antibiotics, supportive therapies (e.g., nutritional support and fluid resuscitation), and surgery. In addition, respiratory therapists, nurses, and hospital administrators will find in this textbook interesting discussions of the economics and cost-effective treatment of sepsis, appropriate management of ventilation for patients with sepsis, and the use of salvage therapies such as nitric oxide for acute lung injury. However, one important area that does not appear to be adequately addressed is nosocomial sepsis due to antibiotic-resistant pathogens. The increasing morbidity caused by antibiotic-resistant infections and their economic impact warrant additional discussion of this important topic in future editions.
After a discussion of the epidemiology and microbiology of sepsis, Sepsis and Multiorgan Failure moves into the important area of molecular biology. Subsequent sections deal with cellular physiology, reviews of individual organ-system derangements, the current treatment of sepsis and multiorgan failure, and new frontiers in research on sepsis. Today's intensive care unit is a place with two main goals: to reverse the underlying disease when possible, and to permit dying patients, those without hope of recovery, a dignified death. Identifying patients who are likely to die in the intensive care unit has become an extremely important issue, and an important section of this textbook is devoted to it. There is also a chapter concerning ethical considerations when continued medical care appears unlikely to return the patient to a meaningful existence. Any clinician who deals with critically ill patients with sepsis will find this textbook useful because of its broad coverage of this topic. Readers will be able to define the clinical manifestations of sepsis, organ system by organ system, and to adopt organ-system-specific treatment strategies for their patients.
As a practicing intensivist who cares for patients with sepsis and multiorgan failure on a daily basis, I found this book rich in clinically useful information. In addition, this book enumerates the important research questions remaining to be answered. The evenhanded treatment of clinical research and basic science research is readily evident. The past two decades have demonstrated that improved understanding of the pathophysiology of disorders such as sepsis often does not easily result in the rapid development of new treatments. Therefore, additional emphasis needs to be placed on finding new therapies that are likely to improve the outcomes of patients with sepsis. As part of this endeavor, the design of clinical trials needs to be improved so that important therapeutic advances in sepsis are not missed. This is even more important now that funds for clinical research are becoming more difficult to obtain.
Reviewed by Marin H. Kollef, M.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
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