Eosinophilia as a marker of adrenal insufficiency in critically ill patients with severe septic shock: 1-year prospective study

Abstract

Background The morbidity and mortality from severe sepsis depends largely on how quickly and comprehensively evidencebased therapies are administered. As such, a huge opportunity exists. However, optimal care requires not only factual knowledge, but also numerous practical strategies including the ability to recognize a disease, to identify impending crises, to communicate effectively, to run a team, to work under stress and to simultaneously coordinate multiple tasks. Medical simulation offers a way to practice these essential crisis management skills, and without any risk to patients. Methods Following a didactic lecture on the key components of the Surviving Sepsis Campaign Guidelines, we trained 20 emergency medicine residents on a portable Laerdal Patient Simulator. Pre-programmed sepsis scenarios were developed following a needs assessment and modified Delphi technique. To maximize realism, this was performed in the acute care area of the Emergency Department and included a pre-briefed respiratory therapist and nurse. We videotaped resident performance and provided nonpunitive feedback, focusing on the comprehensiveness of therapy (for example, whether broad-spectrum antibiotics were given) and crisis resource management strategies (for example, whether help was asked for and tasks were appropriately allocated). Results Evaluation using a five-point Likert scale demonstrated that participants found this very useful (4.5/5), that lessons were complementary and supplementary to those learned from lectures (4.5/5) and that medical simulation was realistic (4/5). In addition, despite prior sepsis lectures, comparison of pre-tests and posttests showed that more emergency medicine residents would: administer broad-spectrum antibiotics as soon as possible following hypotension (14/20 pre-test, compared with 16/20 posttest), administer low-dose corticosteroids for those with refractory shock (10/20 pre-test, compared with 13/20 post-test), and would favour norepinephrine as a vasopressor (8/20 pre-test, compared with 12/20 post-test). Participants specifically valued the chance to observe and practice crisis resource management skills, which they felt had not been previously addressed (19/20). Conclusion Medical simulation appears to be an effective way to change both knowledge and behaviours in the treatment of severe sepsis. Many education and licensing boards also expect trainees to become not only content experts, but also effective communicators, collaborators, resource managers and advocates. These laudable goals are difficult to capture with traditional lectures but are comparably easy using medical simulation. We hope others will consider medical simulation as a complementary teaching and quality-assurance strategy in the fight against sepsis. Background The incidence of sepsis or systemic inflammatory response syndrome in both developing countries as well as in the developed countries is rising despite the extensive research in understanding the molecular basis of sepsis pathogenesis. Sepsis is currently...

Clinical Features and Risk Factors of Adrenal Insufficiency in Patients With Cancer Admitted to the Hospitalist-Managed Medical Unit

“…It is not clear why eosinophilia was associated with AI, but the modulation of the expression of adhesion and migration factors by corticosteroids may result in a higher transition rate of eosinophils out of the bloodstream to tissues and confer an eosinopenic effect by stimulating eosinophil apoptosis. 21 22 23 Therefore, it is plausible that eosinophilia may be a direct effect of the corticosteroid deficiency caused by AI, and eosinophilia can be utilized as a marker of the possible existence of AI. Other laboratory findings that were known to be related to AI, such as hypoalbuminemia or hyponatremia, had no statistical significance in the prediction of AI; this is presumably because cancer patients often have decreased oral intake due to chemotherapy and cachexia.…”