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Original Article
Drotrecogin Alfa (Activated) in Adults with Septic Shock
Recombinant human activated protein C, or drotrecogin alfa (activated) (DrotAA), was approved for the treatment of severe sepsis in 2001 on the basis of the Prospective Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study, a phase 3 international, randomized,…
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Editorial
Septic Shock — Evaluating Another Failed Treatment
Sepsis, severe sepsis, and septic shock are progressively severe stages of the host's systemic inflammatory response to infection. The latter stages carry increasing rates of end-organ failure and death. The spectrum of the sepsis syndrome remains a leading cause of death in the United States, and…
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Case Records of the Massachusetts General Hospital
Case 3-2012 — A Newborn Boy with Vomiting, Diarrhea, and Abdominal Distention
Presentation of Case. Dr. Rebecca C. Bell (Pediatrics): A 6-day-old boy was admitted to this hospital because of vomiting, diarrhea, and abdominal distention. The patient was born at another hospital to a teenaged primigravida by vaginal delivery after a full-term, uncomplicated gestation. The…
Editorial
Fluid Resuscitation in Acute Illness — Time to Reappraise the Basics
Fluid resuscitation is a fundamental intervention in the treatment of critically ill patients. However, there is little conclusive evidence to guide clinicians about the best type of resuscitation fluid; the appropriate timing, volume, and rate of fluid administration; and the optimal way to…
Original Article
Mortality after Fluid Bolus in African Children with Severe Infection
Rapid, early fluid resuscitation in patients with shock, a therapy that is aimed at the correction of hemodynamic abnormalities, is one component of goal-driven emergency care guidelines. This approach is widely endorsed by pediatric life-support training programs, which recommend the…
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Case Records of the Massachusetts General Hospital
Case 9-2011 — A 37-Year-Old Man with Flushing and Hypotension
Presentation of Case. Dr. Leana S. Wen (Emergency Medicine): A 37-year-old man was admitted to the hospital because of flushing and hypotension. That morning, sneezing, rhinorrhea, scratchy throat, and subjective fever had developed. After lunch, he took an over-the-counter cold preparation that…
- CME
- Video
Case Records of the Massachusetts General Hospital
Case 6-2011 — A 77-Year-Old Man with Dyspnea, Weakness, and Diaphoresis
Presentation of Case. Dr. Gyanprakash A. Ketwaroo (Medicine): A 77-year-old man with a history of ischemic cardiomyopathy was admitted to this hospital in midspring because of increasing dyspnea, weakness, and diaphoresis. The patient had been in his usual state of health until 3 days before…
Case Records of the Massachusetts General Hospital
Case 2-2011 — A 30-Year-Old Woman with Shock after Treatment of a Furuncle
Presentation of Case. Dr. Ari Brettman (Medicine): A 30-year-old woman was transferred to this hospital because of hypotension and respiratory failure. The patient had been well until 4 days before admission, when she slipped and fell in her home, after which she reported severe posterior thoracic…
Case Records of the Massachusetts General Hospital
Case 40-2010 — A 68-Year-Old Woman with Chest Pain during an Airplane Flight
Presentation of Case. Dr. Shveta Raju (Medicine): A 68-year-old woman with a history of hypertension and hyperlipidemia was admitted to the hospital because of substernal chest pain. The patient had been well until approximately 24 hours before admission, when substernal chest pain and pressure…
- CME
- Video
A 68-year-old woman was transferred to this hospital because of substernal chest pain. An ECG showed evidence of MI. Coronary angiography was performed, with stenting of an occluded coronary artery. On the fourth hospital day, hypotension, bradycardia, and cardiac arrest occurred, and the patient died.
Case Records of the Massachusetts General Hospital
Case 25-2010 — A 24-Year-Old Woman with Abdominal Pain and Shock
Presentation of Case. Dr. Franklin W. Huang (Medicine): A 24-year-old woman was transferred to this hospital because of abdominal pain, vomiting, ascites, and shock. The patient had been well until 9 days before admission, when fatigue, fevers, headache, and diffuse body aches developed, followed…
- CME
A 24-year-old woman was transferred from another hospital because of abdominal pain and shock. Computed tomographic scans of the abdomen showed ascites, thickening of a segment of small bowel, and mesenteric lymphadenopathy. Laparotomy revealed two areas of necrotic small bowel, which were resected. Despite broad-spectrum antimicrobial therapy, she remained critically ill. On the seventh hospital day, a diagnostic test result was received.
Clinical Implications of Basic Research
Sepsis and Endothelial Permeability
Sepsis, derived from the Greek verb sepo (meaning "I rot"), has been recognized for millennia and refers to the disseminated inflammatory response elicited by microbial infections. Despite its ancient etymology, sepsis remains a current challenge: it is increasing in frequency, expensive to treat,…
Clinical Implications of Basic Research
Immunotherapy for Sepsis — A New Approach against an Ancient Foe
Septic shock is traditionally viewed as an excessive systemic inflammatory reaction to invasive microbial pathogens, yet efforts to improve the outcome of patients with sepsis by means of inhibitors of proinflammatory cytokines and mediators have been unsuccessful. Occasionally, patients present…
Editorial
Treating Shock — Old Drugs, New Ideas
Circulatory shock is a medical emergency that is characterized by hypotension and decreased tissue perfusion; if left untreated, it can lead to irreversible cellular injury and death. Hypotension associated with shock can be the result of any of a number of factors, depending on the type of shock;…
Original Article
Comparison of Dopamine and Norepinephrine in the Treatment of Shock
Circulatory shock is a life-threatening condition that is associated with high mortality. The administration of fluids, which is the first-line therapeutic strategy, is often insufficient to stabilize the patient's condition, and adrenergic agents are frequently required to correct hypotension.…
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In this comparative-effectiveness trial, there was no significant difference in the overall survival rate between patients with shock who were treated with dopamine and those who were treated with norepinephrine. However, dopamine was associated with more cardiac arrhythmias and with a higher mortality rate among patients with cardiogenic shock.
Clinical Therapeutics
Activated Protein C for Sepsis
Foreword. This Journal feature begins with a case vignette that includes a therapeutic recommendation. A discussion of the clinical problem and the mechanism of benefit of this form of therapy follows. Major clinical studies, the clinical use of this therapy, and potential adverse effects are…
A 55-year-old man presents with a small-bowel perforation, and sepsis develops. Treatment with recombinant human activated protein C is recommended. Activated protein C inhibits the procoagulant state in sepsis and may also inhibit the systemic inflammatory response. The clinical benefit and recommendations for use of recombinant human activated protein C are controversial. The risk of bleeding is increased with use of the drug.
Case Records of the Massachusetts General Hospital
Case 33-2009 — A 35-Year-Old Woman with Fever, Abdominal Pain, and Hypotension after Cesarean Section
Presentation of Case. Dr. Claudius H.O. Conrad (Surgery): A 35-year-old woman was transferred to this hospital because of abdominal pain, fever, and hypotension. Three days earlier, an elective cesarean section was performed at another hospital through a transverse incision of the lower uterine…
- Video
A 35-year-old woman was transferred to this hospital because of abdominal pain, fever, and hypotension 3 days after an elective cesarean section. On examination, she appeared acutely ill. The temperature was 39.2°C, the blood pressure 70/52 mm Hg, and the pulse 149 beats per minute. The abdomen was distended and very tender, with rebound. There was erythema and edema in the region of the surgical incision, extending to the left flank, with no drainage. A diagnostic procedure was performed.
Case Records of the Massachusetts General Hospital
Case 31-2009 — A 26-Year-Old Man with Abdominal Distention and Shock
Presentation of Case. Dr. Jeffrey S. Ustin (Trauma, Emergency Surgery, and Surgical Critical Care): A 26-year-old man was admitted to this hospital because of abdominal distention and shock. The patient had been well until the evening before admission, when mild abdominal pain developed, shortly…
A 26-year-old man was admitted to this hospital because of abdominal distention and shock. He had been well until the previous evening, when mild abdominal pain developed; the next day, the pain became severe, and he was unresponsive. In the emergency department, he was hypotensive, with a rigid, distended abdomen. Imaging revealed marked distention of the colon, without focal obstruction. He had a history of schizophrenia and was taking several medications.
