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Navegando por Palavras-chave "guidelines"

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Acute low back pain - Diagnostic and therapeutic practices reported by Brazilian rheumatologists
(Lippincott Williams & Wilkins, 2005-03-01) Margarido, MDS; Kowalski, S. C.; Natour, J.; Ferraz, M. B.; Universidade Federal de São Paulo (UNIFESP); Paulista Ctr Hlth Econ
Study Design. A cross-sectional study.Objectives. To assess resource utilization in the diagnosis, management, and hospitalization of patients with low back pain (LBP) as prescribed by Brazilian rheumatologists.Summary of Background Data. LBP is an important cause of disability, suffering, and social costs. Two to five percent of patients miss workdays because of LBP; it is the second highest cause of physician visits and absenteeism.Methods. Rheumatologists taking part in a national rheumatology medical congress answered a questionnaire to assess management of patients with LBP. It consisted of two hypothetical scenarios describing patients with acute LBP ( scenario 1) and sciatica ( scenario 2). There were 29 questions mainly related to education, protective measures, rest, and medication.Results. A total of 207 questionnaires were returned. in scenario 1, 70% of the participants ordered some diagnostic test at first visit; lumbar radiograph was the most ordered (92%), while more than 80% prescribed rest and 100% at least one drug. Nonsteroidal anti-inflammatory drugs were prescribed by 69% of the participants. in scenario 2, 93% of the physicians ordered diagnostic tests at first visit, with computed tomography being the most ordered test ( 69%). Rest was prescribed by 90% ( average 18 days) of the participants and physical therapy was counseled by 84%.Conclusions. Considering the hypothetical scenarios, participants overused diagnostic and therapeutic procedures. A dissemination of guidelines for optimizing resource use in LBP diagnosis and management is needed.
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Critical appraisal of published economic evaluations of home care for the elderly
(Elsevier B.V., 2004-11-01) Ramos, MLT; Ferraz, M. B.; Sesso, R.; Sao Luiz Hosp; Universidade Federal de São Paulo (UNIFESP)
The goal of the study was to appraise the economic evaluations published between 1980 and 2004 of home care for the elderly, focusing on the methodological aspects. MEDLINE was searched to identify and assess economic evaluations (defined as an analysis comparing two or more strategies, involving the assessment of both costs and consequences) related to home care exclusively for the elderly (65 years or more) and to critically appraise the methodology using five accepted principles used worldwide for conducting economic evaluations. Twenty-four economic evaluations of home care for the elderly were identified and the articles were assessed. All five principles were satisfactorily addressed in two studies (8.3%), four principles in four studies (16.7%), three principles in five studies (20.8%), two principles in eight studies (33.3%) and only one principle in five studies (20.8%). A disparity in the methodology of writing economic evaluations compromises the comparisons among outcomes and lately jeopardizes decisions on the choice of the most appropriate healthcare interventions. the methodological principles represent important guidelines but the discussion of the context of the economic evaluation and the special characteristics of some services and populations should be considered for the appropriate use of economic evaluations. (C) 2004 Elsevier Ireland Ltd. All rights reserved.
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Guidelines for treatment of hypertension in Latin America: the Brazilian experience
(Marcel Dekker Inc, 1999-07-01) Ribeiro, A. B.; Zanella, M. T.; Kohlmann, O.; Universidade Federal de São Paulo (UNIFESP)
Treatment of hypertension in most countries of Latin America, in general, follows the recommendations of guidelines generated by both: the National Institute of Health of the United States of America (Joint National Committee) and the World Hearth Organization together with the International Society of Hypertension. Few countries of Latin America, as Brazil, in the last years have generated their own guidelines for detection, evaluation and treatment of hypertension. Its described the braziliam experience in generates and distributes a guideline for treatment of hypertensive. It is also discussed the difficulties and the needs to a succesfully implement the recommendations of guideline for treatment of chronic diseases, such as hypertension.
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Investigation on Brazilian Clinical Practices in Rheumatoid Arthritis the Brazilian Rheumatoid Arthritis Clinical Practices Investigation-BRACTICE
(Lippincott Williams & Wilkins, 2011-06-01) Helfenstein Junior, Milton [UNIFESP]; Radu Halpern, Ari Stiel; Bertolo, Manoel Barros; Universidade Federal de São Paulo (UNIFESP); Universidade de São Paulo (USP); Hosp Israelita Albert Einstein; Universidade Estadual de Campinas (UNICAMP)
Rheumatoid arthritis (RA) is a systemic inflammatory autoimmune disease causing significant social, medical, and economic impact. Several therapeutic regimens are available within the medical arsenal. the rational and reasoned use of various medications approved for their treatment is imperative. This study aimed to evaluate how Brazilian rheumatologists use the drugs available to combat the disease.For this, 128 Brazilian rheumatologists from public and private health services responded to an 18-item questionnaire, sent over the Internet, about different situations of drug treatment of RA. the answers helped to confirm the trends among Brazilian rheumatologists in the drug treatment of RA.The study results have shown that most Brazilian rheumatologists follow the guidelines and consensus established by the Brazilian Society of Rheumatology for the treatment of RA. A small proportion, however, start the biologic therapy in early stages of the disease, including the very early stage, as the first treatment option. Most experts use corticosteroids in low doses early in the treatment.Conclusions: This study confirms that the majority but not all Brazilian rheumatologists follow, in their daily practice, established guidelines and consensus for the treatment of RA. However, it also shows that some few rheumatologists start with anti-tumor necrosis factor therapy in very early arthritis independently of disease severity or prognostic factors.
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Mapeamento internacional e avaliação de diretrizes de cuidados paliativos em câncer de mama
(Universidade Federal de São Paulo (UNIFESP), 2015-12-31) Santos, Adson Roberto Franca dos [UNIFESP]; Atallah, Alvaro Nagib Atallah [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)
Objective: carry out an international mapping and critically evaluate guidelines for palliative care in breast cancer. Design: mapping national and international literature during the period 2003-2014, using Cochrane Collaboration methodology with critical evaluation of the guidelines. Site: lybraries, online research sites. Participants: the author. Interventions: systematic literature search on palliative care in breast câncer and the analyses of the data collected. Key outcome measures: the studies identified would be evaluated through AGREE II instrument (The Agree Research Trust, 2009) which aims at evaluating guidelines, taking into account process elaboration methodology, transparency, and applicability, based on the best scientifficaly evidences. Results: 1477 citations were found in the databases. However, no specific palliative care guideline for breast câncer was identified, despite the relevance of the problem and the specificities and particularities of women, whether concerning physical nature, feminine identity, gender, body image, and several emotional, psychological, psychosocial, ethics and bioethics aspects, from diagnosis to death and grief, when cure is not possible. Conclusions: it was observed that the lack of specific guidilene for palliative care in breast cancer represents an important gap on patients care from diagnosis, and the several phases of treatment, as well as end of life care and grief, when cure is not possible.
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Nutritional management in children and adolescents with diabetes
(Wiley-Blackwell, 2014-09-01) Smart, Carmel E.; Annan, Francesca; Bruno, Luciana P. C. [UNIFESP]; Higgins, Laurie A.; Acerini, Carlo L.; John Hunter Childrens Hosp; Alder Hey Childrens NHS Fdn Trust; Universidade Federal de São Paulo (UNIFESP); Joslin Diabet Ctr; Univ Cambridge
Acesso aberto (Open Access)
Practical and comprehensive guidelines for bedside cerebral hemometabolic multitherapeutic optimization
(Assoc Arquivos de Neuro- Psiquiatria, 2002-09-01) Cruz, Julio [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)
In recent years, noncomprehensive guidelines were proposed for the management of severe acute brain injuries, focusing strictly on two approaches: 1) to maintain cerebral perfusion pressure anywhere above 70 mm Hg; and 2) to maintain arterial carbon dioxide tension levels above 30 torr. Strictly following these propositions, a recently reported prospective controlled study addressed mortality rates of no less than 75-76%, far worse than mortality rates reported before those guidelines were published. As a humanitarian alternative, the present comprehensive guidelines are aimed at addressing practical bedside strategies to manage no only intracranial pressure and cerebral perfusion pressure but also cerebral extraction of oxygen, based on solid previously reported papers which revealed the lowest mortality rates (below 15%) in the pertinent literature, in recent years.
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Primary care physician perceptions on the diagnosis and management of chronic obstructive pulmonary disease in diverse regions of the world
(Dove Medical Press Ltd, 2012-01-01) Aisanov, Zaurbek; Bai, Chunxue; Bauerle, Otto; Colodenco, Federico D.; Feldman, Charles; Hashimoto, Shu; Jardim, Jose Roberto [UNIFESP]; Lai, Christopher K. W.; Laniado-Laborin, Rafael; Nadeau, Gilbert; Sayiner, Abdullah; Shim, Jae Jeong; Tsai, Ying Huang; Walters, Richard D.; Waterer, Grant; Pulmonol Res Inst; Fudan Univ; Ctr Med Amer; Hosp Rehabil Resp Maria Ferrer; Charlotte Maxeke Johannesburg Hosp; Univ Witwatersrand; Nihon Univ; Universidade Federal de São Paulo (UNIFESP); Chinese Univ Hong Kong; Univ Autonoma Baja California; GlaxoSmithKline; Ege Univ; Korea Univ; Chang Gung Mem Hosp; Univ Western Australia
Chronic obstructive pulmonary disease (COPD) is a multicomponent disorder that leads to substantial disability, impaired quality of life, and increased mortality. Although the majority of COPD patients are first diagnosed and treated in primary care practices, there is comparatively little information on the management of COPD patients in primary care. A web-based pilot survey was conducted to evaluate the primary care physician's, or general practitioner's (GP's), knowledge, understanding, and management of COPD in twelve territories across the Asia-Pacific region, Africa, eastern Europe, and Latin America, using a 10-minute questionnaire comprising 20 questions and translated into the native language of each participating territory. the questionnaire was administered to a total of 600 GPs (50 from each territory) involved in the management of COPD patients and all data were collated and analyzed by an independent health care research consultant. This survey demonstrated that the GPs' understanding of COPD was variable across the territories, with large numbers of GPs having very limited knowledge of COPD and its management. A consistent finding across all territories was the underutilization of spirometry (median 26%; range 10%-48%) and reliance on X-rays (median 14%; range 5%-22%) for COPD diagnosis, whereas overuse of blood tests (unspecified) was particularly high in Russia and South Africa. Similarly, there was considerable underrecognition of the importance of exacerbation history as an important factor of COPD and its initial management in most territories (median 4%; range 0%-22%). Management of COPD was well below guideline-recommended levels in most of the regions investigated. the findings of this survey suggest there is a need for more ongoing education and information, specifically directed towards GPs outside of Europe and North America, and that global COPD guidelines appear to have limited reach and application in most of the areas studied.
Acesso aberto (Open Access)
Rede de infarto com supradesnivelamento de ST: sistematização em 205 casos diminui eventos clínicos na rede pública
(Sociedade Brasileira de Cardiologia - SBC, 2012-11-01) Caluza, Ana Christina Vellozo [UNIFESP]; Barbosa, Adriano H. [UNIFESP]; Gonçalves, Iran [UNIFESP]; Oliveira, Carlos Alexandre L. de [UNIFESP]; Matos, Lívia Nascimento de [UNIFESP]; Zeefried, Claus; Moreno, Antonio Célio C.; Tarkieltaub, Elcio; Alves, Claudia Maria Rodrigues [UNIFESP]; Carvalho, Antonio Carlos [UNIFESP]; Universidade Federal de São Paulo (UNIFESP); Serviço de Atendimento Móvel de Urgência; Prefeitura Municipal de São Paulo Secretaria de Saúde; Hospital Municipal Prof. Dr. Alípio Correa Netto
BACKGROUND: The major cause of death in the city of São Paulo (SP) is cardiac events. At its periphery, in-hospital mortality in acute myocardial infarction is estimated to range between 15% and 20% due to difficulties inherent in large metropoles. OBJECTIVE:To describe in-hospital mortality in ST-segment elevation acute myocardial infarction (STEMI) of patients admitted via ambulance or peripheral hospitals, which are part of a structured training network (STEMI Network). METHODS: Health care teams of four emergency services (Ermelino Matarazzo, Campo Limpo, Tatuapé and Saboya) of the periphery of the city of São Paulo and advanced ambulances of the Emergency Mobile Health Care Service (abbreviation in Portuguese, SAMU) were trained to use tenecteplase or to refer for primary angioplasty. A central office for electrocardiogram reading was used. After thrombolysis, the patient was sent to a tertiary reference hospital to undergo cardiac catheterization immediately (in case of failed thrombolysis) or in 6 to 24 hours, if the patient was stable. Quantitative and qualitative variables were assessed by use of uni- and multivariate analysis. RESULTS: From January 2010 to June 2011, 205 consecutive patients used the STEMI Network, and the findings were as follows: 87 anterior wall infarctions; 11 left bundle-branch blocks; 14 complete atrioventricular blocks; and 14 resuscitations after initial cardiorespiratory arrest. In-hospital mortality was 6.8% (14 patients), most of which due to cardiogenic shock, one hemorrhagic cerebrovascular accident, and one bleeding. CONCLUSION: The organization in the public health care system of a network for the treatment of STEMI, involving diagnosis, reperfusion, immediate transfer, and tertiary reference hospital, resulted in immediate improvement of STEMI outcomes.
Acesso aberto (Open Access)
Rede de infarto com supradesnivelamento de ST: sistematização em 500 casos diminui eventos clínicos na rede pública
(Universidade Federal de São Paulo (UNIFESP), 2016-08-30) Caluza, Ana Christina Vellozo [UNIFESP]; Carvalho, Antonio Carlos de Camargo [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)
Background: The major cause of deaths in the city of Sao Paulo (SP) is cardiac events. At its periphery, in-hospital mortality in acute myocardial infarction is estimated to range between 15-20% due to difficulties inherent in large metropoles. Objectives: To describe in-hospital mortality in ST Elevation acute myocardial infarction (STEMI) of patients admitted via ambulance or peripheral hospitals, which are part of a structured training network (STEMI Network). Methods: Health care teams of seven emergency services (Ermelino Matarazzo, Campo Limpo, Tatuapé, Saboya, João XXIII, Pirituba, Público municipal) of the periphery of the São Paulo and advanced ambulances of Emergency Mobile Health Care Service (abbreviation in Portuguese, SAMU) were trained to use tenecteplase or to refer for primary angioplasty. A central office for electrocardiogram reading was used. After thrombolysis, the patient was sent to a tertiary reference hospital to undergo cardiac catheterization immediately (in case of failed thrombolysis) or in to 24 hours, if the patient was stable. Quantitative and qualitative variables were assessed by use of uni and multivariate analysis. Results: From November 2009 to November consecutive patients used the STEMI network, and the findings were as follows: anterior wall infarctions, 37 complete atrioventricular blocks, 41 cases occurring cardiogenic shock PCR, 2 cases of hemorrhagic stroke and intra-hospital mortality was 6,5% (33 cases). There was no difference in mortality relation to initial reperfusion (PCIxFI), both in-hospital (>0,05) and late (p=0,566). Late mortality was 8 % and adverse events were 10.7% of angina, 4.1% reinfarction, 1.4% and 0.5 % of stroke. The late ejection fraction was higher in cases of FI (p = 0.023). Conclusions: The organization in a public health system of a network for the treatment of STEMI, involving diagnosis, reperfusion, immediate transfer and a tertiary reference hospital, resulted in immediate improvement of STEMI outcomes.
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Screening of congenital heart disease in the second trimester of pregnancy: current knowledge and new perspectives to the clinical practice
(Cambridge Univ Press, 2014-06-01) Rocha, Luciane Alves [UNIFESP]; Araujo Junior, Edward [UNIFESP]; Rolo, Liliam Cristine [UNIFESP]; Bello Barros, Fernanda Silveira [UNIFESP]; Silva, Karina Peres [UNIFESP]; Martinez, Luis Henrique [UNIFESP]; Machado Nardozza, Luciano Marcondes [UNIFESP]; Moron, Antonio Fernandes [UNIFESP]; Universidade Federal de São Paulo (UNIFESP)
ObjectiveCongenital heart diseases are common in foetuses, with an incidence greater than six times that of chromosomal abnormalities; however, experts in cardiac anatomy have evaluated only the foetuses of pregnant women with increased risk for congenital heart disease. Over the years, it has become clear that congenital heart disease occur in foetuses of low-risk women. in the mid-1980s, a proposal to expand the assessment of cardiac anatomy was presented to obstetricians in order to improve prenatal screening. With the aim to systematise and improve the diagnosis of congenital heart disease in foetuses, the International Society of Ultrasound in Obstetrics and Gynecology established an ultrasound heart examination guideline. in this review, we have described the important features of this guideline and discussed the applications of this tool in clinical practice.MethodsWe performed a literature search of the National Library of Medicine for publications released between 2000 and 2012; we used search terms pertinent to congenital heart disease, such as foetal echocardiography, foetal heart and cardiac screening examination.ResultsThe guidelines serve as a standard and help to systematise the screening for congenital heart diseases, but we think that some topics may be added to design the most appropriate screening method. However, we cannot expand the topics to be evaluated in this examination without good training of sonographers who undergo this screening.ConclusionAlthough the screening standardisation is a good tool to be used in day-to-day practice, the increment of aortic and ductal archs and colour Doppler to heart screening could be useful to detect further cardiac defects.
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Surviving sepsis campaign in Brazil
(Lippincott Williams & Wilkins, 2008-01-01) Meira Teles, Jose Mario; Silva, Eliezer; Westphal, Glauco; Costa Filho, Rubens; Machado, Flavia Ribeiro [UNIFESP]; Hosp Portugues; Universidade de São Paulo (USP); Hosp Municipal Sao Jose; Hosp Procardiaco; Universidade Federal de São Paulo (UNIFESP)
Severe sepsis and septic shock have long been a challenge in intensive care because of their common occurrence, high associated costs of care, and significant mortality. the Surviving Sepsis Campaign (SSC) was developed in an attempt to address clinical inertia in the adoption of evidence-based strategies. the campaign relies on worldwide support from professional societies and has gained consensus on the management of patients with severe sepsis. the guidelines have subsequently been deployed into two bundles, with each bundle component sharing a common relationship in time. the widespread adoption of such evidence-based practice in clinical care has been disappointingly slow despite the quantifiable benefits regarding mortality. in Brazil, a country of continental dimensions with a heterogeneous population and unequal access to health services, this reality is no different. From 2004 to 2007, four prospective studies were published describing the country's reality. in the multicenter Promoting Global Research Excellence in Severe Sepsis (PROGRESS) Study, the in-hospital mortality rate was higher in Brazil when compared with other countries: 56% against 30% in developed countries and 45% in other developing countries. During these 2.5 years of the campaign in Brazil, 43 hospitals have been receiving the necessary training to put in practice the recommended measures in all Brazilian regions, except for the North. the idea of the campaign is based on a 25% reduction in the relative risk of death from severe sepsis and septic shock within 5 years in the SSC-participating Brazilian hospitals. Ideally, the mortality rate should come to a 41.2% level subject to the 2009 deadline. This article aims to describe the actual scenario of the SSC implementation in Brazilian institutions and to report on some initiatives that have been used to overcome barriers.
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Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: 2012
(Lippincott Williams & Wilkins, 2013-02-01) Dellinger, R. Phillip; Levy, Mitchell M.; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; Opal, Steven M.; Sevransky, Jonathan E.; Sprung, Charles L.; Douglas, Ivor S.; Jaeschke, Roman; Osborn, Tiffany M.; Nunnally, Mark E.; Townsend, Sean R.; Reinhart, Konrad; Kleinpell, Ruth M.; Angus, Derek C.; Deutschman, Clifford S.; Machado, Flavia R. [UNIFESP]; Rubenfeld, Gordon D.; Webb, Steven A.; Beale, Richard J.; Vincent, Jean-Louis; Moreno, Rui; Surviving Sepsis Campaign Guidelin; Cooper Univ Hosp; Brown Univ; St George Hosp; Hop Raymond Poincare; Vivantes Klinikum Neukolln; Emory Univ Hosp; Hadassah Hebrew Univ; Denver Hlth Med Ctr; McMaster Univ; Barnes Jewish Hosp; Univ Chicago; Calif Pacific Med Ctr; Univ Jena; Rush Univ; Univ Pittsburgh; Univ Penn; Universidade Federal de São Paulo (UNIFESP); Sunnybrook Hlth Sci Ctr; Royal Perth Hosp; Guys & St Thomas Hosp Trust; Erasme Univ Hosp; Hosp Sao Jose
Objective: To provide an update to the Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock, last published in 2008.Design: A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. the entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.Methods: the authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). the potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations.Results: Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure >= 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a Pao(2) /Fio(2) ratio of <= 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao(2) /Fio(2) <150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose <= 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/ septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C).Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven absolute adrenal insufficiency (2C). Conclusions: Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients. (Crit Care Med 2013; 41: 580-637)

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