The Sepsis Text

This textbook is written at the dawn of a new era in the management of sepsis. Recent achievements in the clinical management of septic shock are the culmination of decades of basic and applied research by innovative researchers and clinical investigators worldwide. The contributing authors to this book have spearheaded much of this research and the Editors have endeavored to create a textbook that is comprehensive in nature while maintaining a specific focus upon the multitude of work that constitutes the spectrum of sepsis research including: pathophysiology; monitoring systems; general support; microbial aspects; complications; and anti-sepsis therapies.

Sepsis, defined in its broadest sense as the syndrome evoked by the host response to infection, remains one of the most challenging problems in intensive care medicine. According to the Centers for Disease Control and Prevention (CDC), 500,000 cases of sepsis occur annually in the United States, an increase of almost 140 percent over the past decade. Up to 14 percent of all patients admitted to intensive care units are affected by sepsis. When sepsis becomes severe and progresses to septic shock, multiple-organ dysfunction aggravates and prolongs the critical illness, necessitating a lengthy intensive care stay, and dramatically increases the risk of death. Although our understanding of the mechanisms underlying the evolution from infection to sepsis and multiple-organ failure has evolved substantially, mortality rates remain as high as 50 percent, depending on the definition of sepsis that is used. With the associated morbidity, the economic burden of sepsis also remains high. Novel therapies have been introduced, but many of the "magic bullets" have failed to improve the outcome. Today, after seemingly endless frustration, there finally appears to be some light at the end of the tunnel, and this book is therefore timely. The goal of the editors of the The Sepsis Text was to provide a comprehensive review of recent achievements in the management of sepsis, based on basic and applied research performed in recent years by innovative scientists and clinical investigators worldwide. Many of the 94 contributing authors, most of whom are American or European, spearheaded this research, and together with the editors, they have attempted to integrate the knowledge that they believe will soon lead to the development of effective therapies for sepsis. The book has seven sections, each of which comprises a number of brief chapters in the form of essays by experts in the field. This approach, as opposed to the classic textbook approach, inevitably results in some redundancy and overlap. In general, the chapters are well organized and thoroughly referenced, but unfortunately, the book was published just before the appearance of a few breakthrough articles. There is a paucity of tables and diagrams, and the few photographic illustrations are black and white, which makes them obscure and uninformative. Some of the more basically oriented chapters are truly outstanding and of major importance for those involved in research on sepsis. The clinical parts of the text, wherever applicable, provide published recommendations from recent consensus conferences -- useful guidelines for fellows and senior clinicians seeking to apply evidence-based medicine. Most topics are discussed in detail, and every chapter concludes with a brief, useful summary. The introductory section is on "generalities": the continuing controversy about how to define sepsis accurately, the increased incidence of sepsis and its impact on health care, diagnostic criteria, genetic predisposition, and quantification of risk. Although informative, these chapters often do not provide the depth that is achieved in later parts of the book. The section on pathophysiology is truly outstanding. I especially liked the chapter on the immunopathogenesis of gram-negative shock, with its extensive discussion of the Toll receptors, and the chapters on proinflammatory and antiinflammatory cytokines and the pathophysiology of immune depression in the critically ill. The emerging idea that cytopathic hypoxia, rather than microcirculatory failure, causes organ dysfunction in sepsis is illuminating, and its implications are discussed in depth. Unfortunately, however, this chapter was written before the publication of a report that accurately describes the mitochondrial defects in relation to sepsis-induced organ failure. The next two sections focus on clinical aspects of sepsis, critically evaluating progress and controversies with regard to monitoring systems and general support. There is new compelling evidence in favor of early goal-directed hemodynamic optimization in patients with sepsis, guided by invasive monitoring. Again, it is a pity that the book was published before these findings could be incorporated into the recommendations. The chapter on the management of respiratory disorders in patients with sepsis -- the acute respiratory distress syndrome being the most important -- does not address the results of a study showing that the prone position, which is recommended in the chapter, in fact does not improve the outcome of the acute respiratory distress syndrome. The section on specific microbiologic issues -- in particular, the chapters on catheter-related infections and on isolation procedures in the intensive care unit -- is informative and contains updated CDC guidelines for clinical practice. The section on complications of sepsis comprises several chapters dealing with organs and systems as distinct entities, an approach that is somewhat artificial and prone to overlap with previous sections. The excellent chapter on coagulation is a notable exception; it is loaded with fascinating new information, and in view of the importance of these new insights, it would have benefited from a more detailed discussion of the interaction between coagulation and inflammation in the pathophysiology of sepsis. The final section elegantly summarizes the complete set of clinical studies that have evaluated approaches to the treatment of sepsis, as well as the preclinical data on which they were based, from anticytokine therapies, corticosteroid therapy, immunonutrition, and hemofiltration to interference with the coagulation system and the development of vaccines against bacterial endotoxins. Although the results of many trials have been disappointing, some promising findings have emerged. The editors and contributing authors should be congratulated for their excellent reviews of recent progress in our understanding of sepsis and in its management. The Sepsis Text clearly conveys their enthusiasm and provides encouragement to all those working in the field. Greet Van den Berghe, M.D., Ph.D.
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