1.
Adjunctive treatments for the management of septic shock - a narrative review of the current evidence.
Donovan, K, Shah, A, Day, J, McKechnie, SR
Anaesthesia. 2021;(9):1245-1258
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Abstract
Septic shock is a leading cause of death and morbidity worldwide. The cornerstones of management include prompt identification of sepsis, early initiation of antibiotic therapy, adequate fluid resuscitation and organ support. Over the past two decades, there have been considerable improvements in our understanding of the pathophysiology of sepsis and the host response, including regulation of inflammation, endothelial disruption and impaired immunity. This has offered opportunities for innovative adjunctive treatments such as vitamin C, corticosteroids and beta-blockers. Some of these approaches have shown promising results in early phase trials in humans, while others, such as corticosteroids, have been tested in large, international, multicentre randomised controlled trials. Contemporary guidelines make a weak recommendation for the use of corticosteroids to reduce mortality in sepsis and septic shock. Vitamin C, despite showing initial promise in observational studies, has so far not been shown to be clinically effective in randomised trials. Beta-blocker therapy may have beneficial cardiac and non-cardiac effects in septic shock, but there is currently insufficient evidence to recommend their use for this condition. The results of ongoing randomised trials are awaited. Crucial to reducing heterogeneity in the trials of new sepsis treatments will be the concept of enrichment, which refers to the purposive selection of patients with clinical and biological characteristics that are likely to be responsive to the intervention being tested.
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Acute diarrhea: evidence-based management.
Brandt, KG, Castro Antunes, MM, Silva, GA
Jornal de pediatria. 2015;(6 Suppl 1):S36-43
Abstract
OBJECTIVES To describe the current recommendations on the best management of pediatric patients with acute diarrheal disease. DATA SOURCE PubMed, Scopus, Google Scholar. DATA SUMMARY There has been little progress in the use of oral rehydration salts (ORS) in recent decades, despite being widely reported by international guidelines. Several studies have been performed to improve the effectiveness of ORS. Intravenous hydration with isotonic saline solution, quickly infused, should be given in cases of severe dehydration. Nutrition should be ensured after the dehydration resolution, and is essential for intestinal and immune health. Dietary restrictions are usually not beneficial and may be harmful. Symptomatic medications have limited indication and antibiotics are indicated in specific cases, such as cholera and moderate to severe shigellosis. CONCLUSIONS Hydration and nutrition are the interventions with the greatest impact on the course of acute diarrhea.
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[Probiotics, prebiotics and zinc in the therapy and prevention of acute infectious diarrhoea in children: state of the art].
Salvatore, S, Luini, C, Arrigo, S, Salmaso, M, Morando, L, Nespoli, L, Vandenplas, Y
Minerva pediatrica. 2007;(6):775-86
Abstract
Selected probiotics (mainly Lactobacilli, and particularly LGG, and Saccharomyces boulardii) have recently demonstrated a therapeutic efficacy in acute diarrhoea, if used in the early phase of infection and at high concentration. Further data are needed to clarify their effect for prevention and travellers' diarrhoea. The mechanisms of action of probiotics need to be fully elucidated but seem to include a complex interaction of epithelial, molecular, metabolic and immune responses. There is an increasing evidence that different micro-organisms show different properties and efficacy. An accurate identification and selection of the strains, the dose and the patients are thus crucial for a correct therapeutic approach. Prebiotics can modify the intestinal flora and interact with the immune system of the host against specific pathogens. However, clinical trials are currently limited and a beneficial effect of prebiotics in acute diarrhoea is still lacking. In developing countries zinc supplementation demonstrated a significant reduction of fecal excretion, duration, severity and persistency of diarrhoea. Moreover, zinc may improve immune status, intestinal permeability, epithelial and enzymatic functions, and transport of electrolytes. The use of zinc in addition to oral rehydration solution (ORS) could thus theoretically improve the treatment and reduce the complications of diarrhoea worldwide. However, in developed countries, no trial using zinc supplementation in patients with acute diarrhoea has been published yet and the cost-benefit ratio of zinc supplementation needs to be assessed.