2020 Journal of Thoracic Disease. All rights reserved.The use of lactate as a marker of the severity of circulatory shock was popularized by Dr. Weil in the 1970's. Dr. Weil promoted the idea that blood lactate concentration increased in circulatory shock due to anaerobic metabolism following decreased oxygen delivery. This concept becomes entrenched with 1992 ACCP/SCCM consensus conference definition of sepsis. Since then, the central role of lactate in the definition and management of septic shock has only been expanded and become more ingrained. This review will discuss the wisdom of such an approach, an updated model describing the origins of hyperlactatemia in sepsis, and how such improvements in our knowledge of the underlying physiology should change our approach to resuscitation in patients presenting with septic shock. 2020 Journal of Thoracic Disease. All rights reserved.Large volume fluid resuscitation is currently viewed as the cornerstone of the treatment of septic shock. The surviving sepsis campaign (SSC) guidelines provide a strong recommendation to rapidly administer a minimum of 30 mL/kg crystalloid solution intravenously in all patients with septic shock and those with elevated blood lactate levels. However, there is no credible evidence to support this recommendation. In fact, recent findings from experimental, observational and randomized clinical trials demonstrate improved outcomes with a more restrictive approach to fluid resuscitation. Accumulating evidence suggests that aggressive fluid resuscitation is harmful. Paradoxically, excess fluid administration may worsen shock. In this review, we critically evaluate the scientific evidence for a weight-based fluid resuscitation approach. Furthermore, the potential mechanisms and consequences of harm associated with fluid resuscitation are discussed. Finally, we recommend an individualized, conservative and physiologic guided approach to fluid resuscitation. 2020 Journal of Thoracic Disease. All rights reserved.In 2015, the Centers for Medicare and Medicaid Services (CMS) instituted an all-or-none sepsis performance measure bundle (SEP-1) to promote high-quality, cost-effective care. Systematic reviews demonstrated only low-quality evidence supporting most of SEP-1's interventions. CMS has removed some but not all of these unproven components. The current SEP-1 version requires patients with suspected sepsis have a lactate level, blood cultures, broad-spectrum antibiotics and, if hypotensive, a fixed 30 mL/kg fluid infusion within 3 hours, and a repeat lactate if initially elevated within 6 hours. Experts have continued to raise concerns that SEP-1 remains overly prescriptive, lacks a sound scientific basis and presents risks (overuse of antibiotics and inappropriate fluids not titrated to need). To incentivize compliance with SEP-1, CMS now publicly publishes how often hospitals complete all interventions in individual patients. However, compliance measured across hospitals (5 studies, 48-2,851 hospitals) or patien evidence from randomized controlled trials (RCT) demonstrating its benefit and thereby safety. Otherwise we risk not only doing harm but standardizing it. 2020 Journal of Thoracic Disease. All rights reserved.The complete blood count has a longstanding role in the diagnosis of septic shock. Despite its limitations, this is a pragmatic tool because patients will generally have a blood count measured upon presentation to the hospital. Therefore, it is sensible to extract as much information from these values as possible. Although the white blood cell count continues to attract the most attention, it is the least useful. Emerging evidence suggests that emphasis should be shifted to the neutrophil to lymphocyte ratio (NLR) and perhaps the fraction of immune granulocytes. 2020 Journal of Thoracic Disease. All rights reserved.Important aspects of sepsis management include early diagnosis as well as timely and specific treatment in the first few hours of triage. However, diagnosis and differentiation from non-infectious causes often cause uncertainties and potential time delays. Correct use of antibiotics still represents a major challenge, leading to increased risk for opportunistic infections, resistances to multiple antimicrobial agents and toxic side effects, which in turn increase mortality and healthcare costs. Optimized procedures for reliable diagnosis and management of antibiotic therapy has great potential to improve patient care. Herein, biomarkers have been shown to improve infection diagnosis, help in early risk stratification and provide prognostic information which helps optimizing therapeutic decisions ("antibiotic stewardship"). In this context, the use of the blood infection marker procalcitonin (PCT) has gained much attention. There is still no gold standard for the detection of sepsis and use of conventional diaerved.Failure to deflate the angioplasty balloon following its inflation during percutaneous coronary intervention (PCI) is an unusual complication. We report a case of an undeflatable stent balloon in a 70-year-old male, who underwent PCI for the right coronary artery after failed thrombolysis with streptokinase. After many failed attempts, the patient was cautiously managed by controlled puncture with a stiff guide wire. The procedure was successful without any hemodynamic compromise and ventricular tachycardia. © 2019 The Author(s).A 55-year-old man without any cardiac history has been admitted to Ist Department of Cardiology due to anterior wall infarction. In echocardiography (ECG), local anterior wall dysfunction has been observed, with good left ventricle ejection fraction. In angiography performed immediately after transfer to hospital, long lesion in left anterior descending coronary artery has been visualized with high angiographic suspicion of dissection and intramural coronary hematoma. Intravascular ultrasound (IVUS) has been performed and further confirmed the diagnosis of hematoma - LAD was stented using three coronary stents. IVUS has confirmed good position of stents. Integrillin has been used.  https://www.selleckchem.com/products/U0126.html  Periprocedural time was uncomplicated. ECG showed resolution of myocardial infarction pattern and evolution of infarction has been observed. The patient was discharged home in good clinical condition. Coronary dissection and coronary hematoma are the potential cause of infarction and IVUS, despite optical coherence tomography being reference nowadays, is still a very valuable tool in diagnosis and treatment guiding in such cases.