Current advances in sepsis and septic shock with particular emphasis on the role of insulin.

Sepsis and septic shock account for substantial morbidity and mortality in the intensive care units. NF-kappaB activation, and elevated concentrations of macrophage migration inhibitory factor (MIF), tumor necrosis factor-a (TNF-alpha), interleukin-1 (IL-1), IL-6, free radicals, inducible nitric oxide (iNO), and stress hyperglycemia are some of the factors that induce systemic inflammatory response and myocardial depression seen in sepsis. Conversely, adenosine, activated protein C, oxidized phospholipids, w-3 fatty acids, and insulin have beneficial effects in sepsis and septic shock. These molecules and in particular insulin have the ability to suppress synthesis of MIF, TNF-alpha, IL-1, IL-6, and free radicals, enhance endothelial NO production, and enhance the production of anti-inflammatory cytokines IL-10, and IL-4. In addition, insulin corrects stress hyperglycemia and improves myocardial function. Thus insulin, adenosine, activated protein C, oxidized phospholipids, and w-fatty acids show anti-inflammatory actions and explain why and how they are useful in sepsis and septic shock and possibly, other inflammatory conditions. Hence, their combined use may be of significant benefit in sepsis and septic shock.