{{infobox disease |name	Sepsis, septicemia |Image |Caption |DiseasesDB 11960 |ICD10 – |ICD9 |ICDO |OMIM |MedlinePlus 000666 |eMedicineSubj |eMedicineTopic |MeshID D018805 | }}

Sepsis (, from ''Gr.'' : the state of putrefaction or decay) is a potentially deadly medical condition that is characterized by a whole-body inflammatory state (called a systemic inflammatory response syndrome or SIRS) and the presence of a known or suspected infection. The body may develop this inflammatory response by the immune system to microbes in the blood, urine, lungs, skin, or other tissues. A lay term for sepsis is blood poisoning, also used to describe septicaemia. Severe sepsis is the systemic inflammatory response, plus infection, plus the presence of organ dysfunction.

Septicemia (also septicaemia or septicæmia [ˌsɛp.tə.ˈsi.miə],) is a related medical term referring to the presence of pathogenic organisms in the bloodstream, leading to sepsis. The term has not been sharply defined. It has been inconsistently used in the past by medical professionals, for example as a synonym of bacteremia, causing some confusion.

Severe sepsis is usually treated in the intensive care unit with intravenous fluids and antibiotics. If fluid replacement isn't sufficient to maintain blood pressure, specific vasopressor medications can be used. Mechanical ventilation and dialysis may be needed to support the function of the lungs and kidneys, respectively. To guide therapy, a central venous catheter and an arterial catheter may be placed; measurement of other hemodynamic variables (such as cardiac output, or mixed venous oxygen saturation) may also be used. Sepsis patients require preventive measures for deep vein thrombosis, stress ulcers and pressure ulcers, unless other conditions prevent this. Some patients might benefit from tight control of blood sugar levels with insulin (targeting stress hyperglycemia), low-dose corticosteroids or activated drotrecogin alfa (recombinant protein C).

Terminology

Systemic Inflammatory Response Syndrome or SIRS is evidence of the body's ongoing inflammatory response. When SIRS is suspected or known to be caused by an infection, this is sepsis. Severe sepsis occurs when sepsis leads to organ dysfunction, such as trouble breathing, coagulation or other blood abnormalities, decreased urine production, or altered mental status. If the organ dysfunction of severe sepsis is low blood pressure (hypotension), or insufficient blood flow (hypoperfusion) to one or more organs (causing, for example, lactic acidosis), this is septic shock.

Sepsis can lead to multiple organ dysfunction syndrome (MODS) (formerly known as multiple organ failure), and death. Organ dysfunction results from local changes in blood flow, from sepsis-induced hypotension (< 90 mmHg or a reduction of ≥ 40 mmHg from baseline) and from diffuse intravascular coagulation, among other things.

Sepsis can be defined as the body's response to an infection. An infection is caused by microorganisms or bacteria invading the body and can be limited to a particular body region or can be widespread in the bloodstream. Sepsis is acquired quickest with infections developed in surgery and physical contact with someone with sepsis.

Bacteremia is the presence of viable bacteria in the bloodstream. Likewise, the terms viremia and fungemia simply refer to viruses and fungi in the bloodstream. These terms say nothing about the consequences this has on the body. For example, bacteria can be introduced into the bloodstream during toothbrushing. This form of bacteremia almost never causes problems in normal individuals. However, bacteremia associated with certain dental procedures can cause bacterial infection of the heart valves (known as endocarditis) in high-risk patients. Conversely, a systemic inflammatory response syndrome can occur in patients without the presence of infection, for example in those with burns, polytrauma, or the initial state in pancreatitis and chemical pneumonitis.

Signs and symptoms

In addition to symptoms related to the provoking infection, sepsis is characterized by presence of acute inflammation present throughout the entire body, and is, therefore, frequently associated with fever and elevated white blood cell count (leukocytosis) or low white blood cell count and lower-than-average temperature, and vomiting . The modern concept of sepsis is that the host's immune response to the infection causes most of the symptoms of sepsis, resulting in hemodynamic consequences and damage to organs. This host response has been termed systemic inflammatory response syndrome (SIRS) and is characterized by an elevated heart rate (above 90 beats per minute), high respiratory rate (above 20 breaths per minute or a partial pressure of carbon dioxide in the blood of less than 32), abnormal white blood cell count (above 12,000, lower than 4,000, or greater than 10% band forms) and elevated or lowered body temperature, i.e. under or over . Sepsis is differentiated from SIRS by the presence of a known or suspected pathogen. For example SIRS and a positive blood culture for a pathogen indicates the presence of sepsis. However, in many cases of sepsis no specific pathogen is identified.

This immunological response causes widespread activation of acute-phase proteins, affecting the complement system and the coagulation pathways, which then cause damage to the vasculature as well as to the organs. Various neuroendocrine counter-regulatory systems are then activated as well, often compounding the problem. Even with immediate and aggressive treatment, this may progress to multiple organ dysfunction syndrome and eventually death.

Diagnosis

According to the American College of Chest Physicians and the Society of Critical Care Medicine, there are different levels of sepsis:

Systemic inflammatory response syndrome (SIRS). Defined by the presence of two or more of the following findings:

Body temperature < or > (hypothermia or fever).

*Heart rate > 90 beats per minute.

*Respiratory rate > 20 breaths per minute or, on blood gas, a P_aCO₂ less than 32 mm Hg (4.3 kPa) (tachypnea or hypocapnia due to hyperventilation).

*White blood cell count < 4,000 cells/mm³ or > 12,000 cells/mm³ (< 4 × 10⁹ or > 12 × 10⁹ cells/L), or greater than 10% band forms (immature white blood cells). (leukopenia, leukocytosis, or bandemia).

Sepsis. Defined as SIRS in response to a confirmed infectious process. Infection can be suspected or proven (by culture, stain, or polymerase chain reaction (PCR)), or a clinical syndrome pathognomonic for infection. Specific evidence for infection includes WBCs in normally sterile fluid (such as urine or cerebrospinal fluid (CSF)); evidence of a perforated viscus (free air on abdominal x-ray or CT scan; signs of acute peritonitis); abnormal chest x-ray (CXR) consistent with pneumonia (with focal opacification); or petechiae, purpura, or purpura fulminans.

Severe sepsis. Defined as sepsis with organ dysfunction, hypoperfusion, or hypotension.

Septic shock. Defined as sepsis with refractory arterial hypotension or hypoperfusion abnormalities in spite of adequate fluid resuscitation. Signs of systemic hypoperfusion may be either end-organ dysfunction or serum lactate greater than 4 mmol/L. Other signs include oliguria and altered mental status. Patients are defined as having septic shock if they have sepsis plus hypotension after aggressive fluid resuscitation (typically upwards of 6 liters or 40 ml/kg of crystalloid solution).

Examples of end-organ dysfunction include the following:

Lungs

*acute lung injury (ALI) (PaO₂/FiO₂ < 300) or acute respiratory distress syndrome (ARDS) (PaO₂/FiO₂ < 200)

Brain

*encephalopathy

**symptoms:

***agitation

***confusion

***coma

**etiologies:

***ischemia

***hemorrhage

***microthrombi

***microabscesses

***multifocal necrotizing leukoencephalopathy

Liver

*disruption of protein synthetic function: manifests acutely as progressive coagulopathy due to inability to synthesize clotting factors

*disruption of metabolic functions: manifests as cessation of bilirubin metabolism, resulting in elevated unconjugated serum bilirubin levels (indirect bilirubin)

Kidney

*oliguria and anuria

*electrolyte abnormalities

*volume overload

Heart

*systolic and diastolic heart failure, likely due to cytokines that depress myocyte function

*cellular damage, manifest as a troponin leak (although not necessarily ischemic in nature)

More specific definitions of end-organ dysfunction exist for SIRS in pediatrics.

Cardiovascular dysfunction (after fluid resuscitation with at least 40 ml/kg of crystalloid)

*hypotension with blood pressure < 5th percentile for age or systolic blood pressure < 2 standard deviations below normal for age, OR

*vasopressor requirement, OR

*two of the following criteria:

**unexplained metabolic acidosis with base deficit > 5 mEq/L

**lactic acidosis: serum lactate 2 times the upper limit of normal

**oliguria (urine output < 0.5 ml/kg/hr)

**prolonged capillary refill > 5 seconds

**core to peripheral temperature difference > 3°C

Respiratory dysfunction (in the absence of cyanotic heart disease or known chronic lung disease)

*the ratio of the arterial partial-pressure of oxygen to the fraction of oxygen in the gases inspired (PaO₂/FiO₂) < 300 (the definition of acute lung injury), OR

*arterial partial-pressure of carbon dioxide (PaCO₂) > 65 torr (20 mmHg) over baseline PaCO₂ (evidence of hypercapnic respiratory failure), OR

*supplemental oxygen requirement of greater than FiO₂ 0.5 to maintain oxygen saturation ≥ 92%

Neurologic dysfunction

*Glasgow Coma Score (GCS) ≤ 11, OR

*altered mental status with drop in GCS of 3 or more points in a patient with developmental delay/mental retardation

Hematologic dysfunction

*platelet count < 80,000/mm³ or 50% drop from maximum in chronically thrombocytopenic patients, OR

*international normalized ratio (INR) > 2

*Disseminated intravascular coagulation

Renal dysfunction

*serum creatinine ≥ 2 times the upper limit of normal for age or 2-fold increase in baseline creatinine in patients with chronic kidney disease

Hepatic dysfunction (only applicable to infants > 1 month)

*total serum bilirubin ≥ 4 mg/dl, OR

*alanine aminotransferase (ALT) ≥ 2 times the upper limit of normal

Consensus definitions, however, continue to evolve, with the latest expanding the list of signs and symptoms of sepsis to reflect clinical bedside experience.

Neonatal sepsis

In common clinical usage, sepsis specifically refers to the presence of a bacterial blood stream infection (BSI), such as meningitis, pneumonia, pyelonephritis, or gastroenteritis. in the setting of fever. Criteria with regards to hemodynamic compromise or respiratory failure are not useful clinically because these symptoms often do not arise in neonates until death is imminent and unpreventable.

Treatment

Adults and children

The therapy of sepsis rests on antibiotics, surgical drainage of infected fluid collections, fluid replacement and appropriate support for organ dysfunction. This may include hemodialysis in kidney failure, mechanical ventilation in pulmonary dysfunction, transfusion of blood products, and drug and fluid therapy for circulatory failure. Ensuring adequate nutrition—preferably by enteral feeding, but if necessary by parenteral nutrition—is important during prolonged illness.

A problem in the adequate management of septic patients has been the delay in administering therapy after sepsis has been recognized. Published studies have demonstrated that for every hour delay in the administration of appropriate antibiotic therapy there is an associated 7% rise in mortality. A large international collaboration was established to educate people about sepsis and to improve patient outcomes with sepsis, entitled the "Surviving Sepsis Campaign". The Campaign has published an evidence-based review of management strategies for severe sepsis, with the aim to publish a complete set of guidelines in subsequent years.

Early goal directed therapy

Early goal directed therapy (EGDT), developed at Henry Ford Hospital by Emaneul Rivers, MD, is a systematic approach to resuscitation that has been validated in the treatment of severe sepsis and septic shock. It is meant to be started in the Emergency Department. The theory is that a step-wise approach should be used, having the patient meet physiologic goals, to optimize cardiac preload, afterload, and contractility, thus optimizing oxygen delivery to the tissues. A recent meta-analysis showed that EGDT provides a benefit on mortality in patients with sepsis. some controversy around its uses remained, and a number of trials were in progress in an attempt to resolve this.

In EGDT, fluids are administered until the central venous pressure (CVP), as measured by a central venous catheter, reaches 8–12 cm of water (or 10–15 cm of water in mechanically ventilated patients). Rapid administration of several liters of isotonic crystalloid solution is usually required to achieve this. If the mean arterial pressure is less than 65 mmHg or greater than 90 mmHg, vasopressors or vasodilators are given as needed to reach the goal. Once these goals are met, the mixed venous oxygen saturation (SvO2), i.e., the oxygen saturation of venous blood as it returns to the heart as measured at the vena cava, is optimized. If the SvO2 is less than 70%, blood is given to reach a hemoglobin of 10 g/dl and then inotropes are added until the SvO2 is optimized. Elective intubation may be performed to reduce oxygen demand if the SvO2 remains low despite optimization of hemodynamics. Urine output is also monitored, with a minimum goal of 0.5 ml/kg/h. In the original trial, mortality was cut from 46.5% in the control group to 30.5% in the intervention group. The Surviving Sepsis Campaign guidelines recommend EGDT for the initial resuscitation of the septic patient with a level B strength of evidence (single randomized control trial).

Steroids

During critical illness, a state of adrenal insufficiency and tissue resistance (the word 'relative' resistance should be avoided) to corticosteroids may occur. This has been termed critical illness–related corticosteroid insufficiency. Treatment with corticosteroids might be most beneficial in those with septic shock and early severe acute respiratory distress syndrome (ARDS), whereas its role in other patients such as those with pancreatitis or severe pneumonia is unclear. These recommendations stem from studies showing benefits from low dose hydrocortisone treatment for septic shock patients and methylprednisolone in ARDS patients. However, the exact way of determining corticosteroid insufficiency remains problematic. It should be suspected in those poorly responding to resuscitation with fluids and vasopressors. ACTH stimulation testing is not recommended to confirm the diagnosis. The method of cessation of glucocorticoid drugs is variable, and it is unclear whether they should be weaned or simply stopped abruptly.

Activated protein C

Recombinant activated protein C (drotrecogin alpha) in a 2011 Cochrane review was found not to decrease mortality and thus was not recommended for use. Other reviews however comment that it may be effective in those with very severe disease.

Neonates

Note that, in neonates, sepsis is difficult to diagnose clinically. They may be relatively asymptomatic until hemodynamic and respiratory collapse is imminent, so, if there is even a remote suspicion of sepsis, they are frequently treated with antibiotics empirically until cultures are sufficiently proven to be negative.

Prognosis

Prognosis can be estimated with the Mortality in Emergency Department Sepsis (MEDS) score. Approximately 20–35% of patients with severe sepsis and 40–60% of patients with septic shock die within 30 days. Others die within the ensuing 6 months. Late deaths often result from poorly controlled infection, immunosuppression, complications of intensive care, failure of multiple organs, or the patient's underlying disease.

Prognostic stratification systems such as APACHE II indicate that factoring in the patient's age, underlying condition, and various physiologic variables can yield estimates of the risk of dying of severe sepsis. Of the individual covariates, the severity of underlying disease most strongly influences the risk of death. Septic shock is also a strong predictor of short- and long-term mortality. Case-fatality rates are similar for culture-positive and culture-negative severe sepsis.

Some patients may experience severe long-term cognitive decline following an episode of severe sepsis, but the absence of baseline neuropsychological data in most sepsis patients makes the incidence of this difficult to quantify or to study. A preliminary study of nine patients with septic shock showed abnormalities in seven patients by MRI.

Epidemiology

In the United States sepsis is the second-leading cause of death in non-coronary Intensive Care Unit (ICU) patients, and the tenth-most-common cause of death overall according to data from the Centers for Disease Control and Prevention (the first being heart disease). Sepsis is common and also more dangerous in elderly, immunocompromised, and critically ill patients. It occurs in 1–2% of all hospitalizations and accounts for as much as 25% of ICU bed utilization. It is a major cause of death in intensive-care units worldwide, with mortality rates that range from 20% for sepsis, through 40% for severe sepsis, to over 60% for septic shock.

Research

PD-1 and monocytes/macrophages activation

PD-1 was found to be up-regulated on monocytes/macrophages during sepsis in human and mice. This up-regulation was related to the up-regulation of IL-10 levels in the blood. Interestingly, Said et al. showed that activated monocytes, which is the case in sepsis, express high levels of PD-1 and that triggering monocytes-expressed PD-1 by its ligand PD-L1 induces IL-10 production which inhibits CD4 T-cell function.

Inflammatory signal blocker

A study reported in Science (journal) showed that SphK1 is highly elevated in inflammatory cells from patients with sepsis and inhibition of the molecular pathway reduced the proinflammatory response triggered by bacterial products in the human cells. Moreover, the study also showed the mortality rate of mice with experimental sepsis was reduced when treated with a SphK1 blocker. Similarly, inhibition of the p38 MAPK signaling transduction pathway may help to block enhanced procoagulatory activities during septicemia.

Nitric oxide

Medical research is focused on combating nitric oxide. Attempts to inhibit its production paradoxically led to a worsening of the organ damage and in an increased lethality, both in animal models and in a clinical trial in sepsis patients. In a study published in the Journal of Experimental Medicine, nitrite treatment, in sharp contrast with the worsening effect of inhibiting NO-synthesis, significantly attenuates hypothermia, mitochondrial damage, oxidative stress and dysfunction, tissue infarction, and mortality in mice.

See also

Immune system

Intensive care

Meningococcemia

Multiple organ dysfunction syndrome

Pathogenic bacteria

Septic shock

Systemic inflammatory response syndrome

References

External links

So More Survive – Sepsis Alliance

Surviving Sepsis Campaign

International Sepsis Forum

Sepsis can strike, kill shockingly fast – ''CNN''

Sepsis Medline Plus

Sepsis News Archive from insciences organisation

Category:Article Feedback Pilot Category:Infectious diseases Category:Medical emergencies Category:Intensive care medicine

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birth name	Mary Elizabeth Spacek
birth place	Quitman, Texas, U.S.
birth date	December 25, 1949
occupation	Actress
years active	1970–present
spouse	Jack Fisk (1974–present; 2 children) }}

Sissy Spacek (born Mary Elizabeth Spacek; December 25, 1949) is an American actress and singer. She is best known for her for role as ''Carrie White'' in the Brian De Palma's 1976 horror film ''Carrie'' (based off the first novel by Stephen King) for which she earned her first Academy Award nomination. She won the Academy Award for Best Actress for her role as country star Loretta Lynn in the 1980 film ''Coal Miner's Daughter''. She has been nominated for an Oscar a total of six times. She is also known for her role as Holly Sargis in Terrence Malick's 1973 film ''Badlands''.

Spacek is known mainly as a dramatic actress, but also has made comedies. The films that Spacek has starred in have earned more than $700 million worldwide.

Early life

Spacek was born on Christmas Day, 1949, in Quitman, Texas. She is the daughter of Virginia Frances (née Spilman) and Edwin Arnold Spacek, Sr., a county agricultural agent. Her mother, a Mayflower descendant, was from the Rio Grande Valley of Texas. Spacek's paternal grandparents, Mary Červenka and Arnold A. Špaček (who served as Mayor of Granger, Texas in Williamson County), were of Czech ancestry. She was greatly affected by the death of her 18-year old brother, Robbie, in 1967.

That same year, Spacek won the Homecoming Queen award at her high school alma mater, Quitman High School. After she graduated at the age of 17, she won a singer-songwriter contest and moved to New York City, hoping to become a singer. There she lived with her first cousin, actor Rip Torn, and his wife, actress Geraldine Page, while trying to break into music industry.

Career

Early career in New York City

For a while, she sang and played guitar in many of the Greenwich Village coffeehouses, eventually landing some paying work singing commercial jingles. In late 1968, using the pseudonym of "Rainbo", Spacek recorded a novelty song titled '"John, You've Gone Too Far This Time" which proclaimed her disillusionment and shock over John Lennon, who on the cover of his newest album ''Two Virgins'' appeared in full-frontal nudity with his then-girlfriend Yoko Ono, shocking many fans. The single did not appear on the record charts and failed to sell well, so she was dropped by the record company.

1970s and the beginning of her acting career

While singing, Spacek also worked for a time as photographic model, and worked as an extra at Andy Warhol's Factory, appearing in a non-credited role in his 1970 film ''''Trash''. With the help of Torn, she was enrolled in Lee Strasberg's Actors Studio and then the Lee Strasberg Institute in New York. Her first credited role was in the 1972 cult classic ''Prime Cut'', in which she played Poppy, a girl sold into sexual slavery. This role led to TV work, which included a guest role in ''The Waltons'', which she played twice in 1973. The role that brought her international attention came in Terrence Malick's 1973 ''Badlands,'' in which she played Holly, the narrator of the film and 15-year old girlfriend of mass-murderer Kit (played by Martin Sheen). Spacek described ''Badlands'' as the "most incredible" experience of her career. On the set of ''Badlands'', Spacek met art director Jack Fisk, whom she married.

Spacek's iconic and career-defining role came in 1976 with Brian De Palma's ''Carrie,'' in which she played Carietta "Carrie" White, a shy, troubled high school senior with telekinetic powers. Spacek had to work hard to persuade director de Palma to engage her for the role, set as he was on an alternative actress, whose identity, to this day, remains shrouded in mystery. Rubbing Vaseline into her hair, and donning an old sailor dress her mother made for her as a child, Spacek turned up at the audition with the odds against her, but won the part. She was nominated for the Academy Award for Best Actress for her work in the film. (Veteran actress Piper Laurie, who played Carrie's religious, maniacal mother Margaret White, was nominated for the Academy Award for Best Supporting Actress.)

After ''Carrie,'' Spacek played the small role of housekeeper Linda Murray in Alan Rudolph's ensemble piece ''Welcome to LA'' (1976), but cemented her reputation in independent cinema with her performance as Pinky Rose in Robert Altman's 1977 classic ''3 Women.'' Altman was deeply impressed by her performance, saying: 'She's remarkable, one of the top actresses I've ever worked with. Her resources are like a deep well.' Brian de Palma added: '[Spacek is] a phantom. She has this mysterious way of slipping into a part, letting it take over her. She's got a wider range than any young actress I know.' Spacek also helped finance then-brother-in-law David Lynch's directorial debut, ''Eraserhead'' (1976) and is thanked in the credits of the film.

In the 1979 film ''Heart Beat,'' Spacek played Carolyn Cassady, who slipped (under the influence of John Heard's Jack Kerouac and Nick Nolte's Neal Cassady) into a frustrating combination of drudgery and debauchery.

1980s and the Oscar

Spacek began the decade with an Oscar in 1980 for ''Coal Miner's Daughter,'' in which she played country music star Loretta Lynn, who approved her for the role—and in which film both she and Beverly D'Angelo, who appeared in the film as Patsy Cline, did their own singing. Film critic Roger Ebert credited the movie's success "to the performance by Sissy Spacek as Loretta Lynn. With the same sort of magical chemistry she's shown before, when she played the high school kid in ''Carrie,'' Spacek at 29 has the ability to appear to be almost any age on screen. Here, she ages from about 14 to somewhere in her 30s, always looks the age, and never seems to be wearing makeup." Spacek also was nominated for a Grammy Award for her singing on the film's soundtrack album. She followed this with her own country album, ''Hangin' Up My Heart'', in 1983; the album spawned one hit single, "Lonely But Only For You", a song written by K. T. Oslin, which reached #15 on the Billboard Country chart.

In the 1980s, she starred alongside Jack Lemmon in Constantin Costa-Gavras's political thriller ''Missing'' (1982), which in turn was based on the book ''The Execution of Charles Horman,'' Mel Gibson in the rural drama ''The River'' (1984), and Diane Keaton and Jessica Lange in 1986's ''Crimes of the Heart.'' She was nominated for the Best Actress Oscar for all of these roles. Other notable performances of the decade included poignant star turns in husband Jack Fisk's directorial debut ''Raggedy Man'' (1981) and alongside Anne Bancroft in the suicide drama '''Night Mother'' (1986). She also showed her lighter side by agreeing to play the voice of the brain in the Steve Martin comedy ''The Man with Two Brains'' (1983). By the end of 1986, Spacek had decided to focus more on her family, so she retired to her farm in Charlottesville, Virginia to raise her children, and did not appear in another film for over four years.

1990s and the comeback

The 1990s saw Spacek slowly come back to Hollywood after her self-imposed hiatus. She had a supporting role as Jim Garrison's wife (played by Kevin Costner) in Oliver Stone's ''JFK'' (1991), and she made a number of comedies, TV movies and the occasional film. Most notable of her appearances during these years was her turn as the evil Verena Talbo in the 1995 ensemble piece ''The Grass Harp,'' which reunited her with both Laurie and Lemmon, as well as a supporting performance, again alongside Nick Nolte, as the waitress Margie Fogg in Paul Schrader's father-son psychodrama ''Affliction'' (1997) and as Rose Straight in David Lynch's ''The Straight Story'' (1999).

2000s and more awards

In 2001, she was nominated again for the Academy Award for Best Actress for her work in Todd Field's ''In the Bedroom.'' New York Times film critic Stephen Holden said of her work in the film: "Ms. Spacek's performance is as devastating as it is unflashy. With the slight tightening of her neck muscles and a downward twitch of her mouth, she conveys her character's relentlessness, then balances it with enough sweetness to make Ruth seem entirely human. It is one of Ms. Spacek's greatest performances." Her performance as Ruth Fowler, a grieving mother consumed by revenge, won extraordinary praise and garnered the New York and Los Angeles Film Critics Association Award for Best Actress.

Other notable performances of this decade include unfaithful wife Ruth in Rodrigo Garcia's ''Nine Lives'' (2005) and a recent turn as a woman suffering from Alzheimer's in the television movie ''Pictures of Hollis Woods'' (2007). In 2008, Spacek had a supporting part in the Christmas comedy ''Four Christmases'' (2008) and a lead role in the independent drama, ''Lake City'' (2008).

Spacek joined the HBO drama ''Big Love'' for a multi-episode arc as a powerful Washington, D.C. lobbyist.

In 2006, she narrated the audiobook of the classic 1960 Harper Lee novel ''To Kill a Mockingbird'' and it sold over 30 million copies. It was re-released in 2010 as a 50th anniversary edition. In 2011 she received a star on Hollywood's Walk of Fame.

Personal life

Spacek married production designer and art director Jack Fisk in 1974. Fisk later directed her in the films ''Raggedy Man'' and ''Violets Are Blue'' and was Oscar nominated for his production design in 2007's ''There Will Be Blood.'' They have two daughters, Schuyler Fisk (born July 8, 1982) and Madison Fisk. Schuyler has appeared in several film roles and is pursuing a career as a singer. Spacek and her family live on a horse ranch near Charlottesville, Virginia. She also is an ardent crusader for women's rights.

Filmography

{|class="wikitable" style="font-size: 90%;" border="2" cellpadding="4" background: #f9f9f9; |- align="center" ! style="background:#B0C4DE;" | Year ! style="background:#B0C4DE;" | Film ! style="background:#B0C4DE;" | Role ! style="background:#B0C4DE;" | Notes |- |1970 |''Trash'' |Girl extra at bar |uncredited |- |1972 |''Prime Cut'' |Poppy | |- |rowspan=3|1973 |''The Girls of Huntington House'' |Sara |TV film |- |''The Waltons'' |Sarah Jane Simmonds |TV series (2 episodes) |- |''Badlands'' |Holly Sargis |Nominated — BAFTA Award for Best Newcomer |- |rowspan=2|1974 |''Ginger in the Morning'' |Ginger |TV film |- |''The Migrants'' |Wanda Trimpin | |- |1975 |''Katherine'' |Katherine Alman |TV film (also known as ''The Radical'') |- |rowspan=2|1976 |''Carrie'' |Carietta "Carrie" White |Avoriaz Fantastic Film Festival Award for Best ActressNational Society of Film Critics Award for Best ActressNominated — Academy Award for Best Actress |- |''Welcome to L.A.'' |Linda Murray | |- |1977 |''3 Women'' |Pinky Rose |New York Film Critics Circle Award for Best Supporting Actress |- |1978 |''Verna: U.S.O. Girl'' |Verna Vane |TV film |- |rowspan=2|1980 |''Coal Miner's Daughter'' |Loretta Lynn |Academy Award for Best ActressGolden Globe Award for Best Actress – Motion Picture Musical or ComedyKansas City Film Critics Circle Award for Best ActressLos Angeles Film Critics Association Award for Best ActressNational Board of Review Award for Best ActressNational Society of Film Critics Award for Best ActressNew York Film Critics Circle Award for Best ActressNominated — BAFTA Award for Best Actress in a Leading Role |- |''Heart Beat'' |Carolyn Cassady | |- |1981 |''Raggedy Man'' |Nita Longley |Nominated — Golden Globe Award for Best Actress – Motion Picture Drama |- |1982 |''Missing'' |Beth Horman |Nominated — Academy Award for Best ActressNominated — BAFTA Award for Best Actress in a Leading RoleNominated — Golden Globe Award for Best Actress – Motion Picture Drama |- |1983 |''The Man with Two Brains'' |Anne Uumellmahaye |voice (uncredited) |- |rowspan=2|1984 |''The River'' |Mae Garvey |Nominated — Academy Award for Best ActressNominated — Golden Globe Award for Best Actress – Motion Picture Drama |- |''Terror in the Aisles'' | |archival footage |- |1985 |''Marie'' |Marie Ragghianti | |- |rowspan=3|1986 |''Violets Are Blue'' |Augusta 'Gussie' Sawyer | |- |'''night, Mother'' |Jessie Cates | |- |''Crimes of the Heart'' |Babe Magrath Botrelle |Golden Globe Award for Best Actress – Motion Picture Musical or ComedyKansas City Film Critics Circle Award for Best ActressNew York Film Critics Circle Award for Best ActressNominated — Academy Award for Best Actress |- |1990 |''The Long Walk Home'' |Miriam Thompson | |- |rowspan=2|1991 |''Hard Promises'' |Christine Ann Coalter | |- |''JFK'' |Liz Garrison | |- |1992 |''A Private Matter'' |Sherri Finkbine |TV film |- |rowspan=2|1994 |''A Place for Annie'' |Susan Lansing |Hallmark Hall of Fame TV filmNominated — Screen Actors Guild Award for Outstanding Performance by a Female Actor in a Miniseries or Television Movie |- |''Trading Mom'' |Various Roles |aka ''The Mommy Market'' |- |rowspan=3|1995 |''The Good Old Boys'' |Spring Renfro |Nominated — Emmy Award for Outstanding Supporting Actress – Miniseries or a Movie |- |''The Grass Harp'' |Verena Talbo | |- |''Streets of Laredo'' |Lorena Parker |TV mini-seriesBronze Wrangler for Television Feature Film Television Feature Film |- |rowspan=2|1996 |''Beyond the Call'' |Pam O'Brien |TV film |- |''If These Walls Could Talk'' |Barbara Barrows |TV film, Segment "1974" |- |1997 |''Affliction'' |Margie Fogg | |- |rowspan=2|1999 |''Blast from the Past'' |Helen Thomas Webber |Nominated — Saturn Award for Best Supporting Actress |- |''The Straight Story'' |Rose 'Rosie' Straight |Nominated — Chlotrudis Award for Best Supporting ActressNominated — Las Vegas Film Critics Society Award for Best Supporting ActressNominated — Satellite Award for Best Supporting Actress - Motion Picture |- |2000 |''Songs in Ordinary Time'' |Marie Fermoyle |TV film |- |rowspan=2|2001 |''In the Bedroom'' |Ruth Fowler |AFI Actress of the YearBoston Society of Film Critics Award for Best ActressDallas-Fort Worth Film Critics Association Award for Best ActressFlorida Film Critics Circle Award for Best ActressGolden Globe Award for Best Actress – Motion Picture DramaIndependent Spirit Award for Best Lead FemaleLos Angeles Film Critics Association Award for Best ActressNew York Film Critics Circle Award for Best ActressSatellite Award for Best Actress - Motion Picture DramaSoutheastern Film Critics Association Award for Best ActressSpecial Jury Prize for Dramatic Acting (Shared with Tom Wilkinson)Vancouver Film Critics Circle Award for Best ActressNominated — Academy Award for Best ActressNominated — BAFTA Award for Best Actress in a Leading RoleNominated — Chicago Film Critics Association Award for Best ActressNominated — Chlotrudis Award for Best ActressNominated — Online Film Critics Society Award for Best ActressNominated — Screen Actors Guild Award for Outstanding Performance by a Female Actor in a Leading RoleNominated — Screen Actors Guild Award for Outstanding Performance by a Cast in a Motion Picture |- |''Midwives'' |Sibyl Danforth |Nominated — Satellite Award for Best Actress – Miniseries or Television FilmNominated — Screen Actors Guild Award for Outstanding Performance by a Female Actor in a Miniseries or Television Movie |- |rowspan=2|2002 |''Last Call'' |Zelda Fitzgerald |Nominated — Emmy Award for Outstanding Supporting Actress – Miniseries or a MovieNominated — Satellite Award for Best Actress – Miniseries or Television Film |- |''Tuck Everlasting'' |Mae Tuck |Nominated — Saturn Award for Best Supporting Actress |- |2004 |''A Home at the End of the World'' |Alice Glover | |- |rowspan=3|2005 |''Nine Lives |Ruth |Locarno International Film Festival Award for Best Actress EnsembleNominated — Gotham Award for Best Ensemble Cast |- |''The Ring Two'' |Evelyn | |- |''North Country'' |Alice Aimes | |- |rowspan=2|2006 |''An American Haunting'' |Lucy Bell | |- |''Summer Running: The Race to Cure Breast Cancer'' |Mrs. Flora Good | |- |rowspan=3|2007 |''Gray Matters'' |Sydney | |- |''Hot Rod'' |Marie Powell | |- |''Pictures of Hollis Woods'' |Josie Cahill |Nominated — Golden Globe Award for Best Actress – Miniseries or Television Film |- |rowspan=2|2008 |''Lake City'' |Maggie | |- |''Four Christmases'' |Paula (Brad's Mom) | |- |rowspan=2|2009 |''Appalachia: A History of Mountains and People'' |Narrator |TV mini-series |- |''Get Low'' |Mattie Darrow |Nominated — Chlotrudis Award for Best Supporting Actress |- |2010–2011 |''Big Love'' |Marilyn Densham |5 episodesNominated — Primetime Emmy Award for Outstanding Guest Actress in a Drama Series |- |2011 |''The Help'' |Mrs. Walters | |- |2012 |''Blackbird'' |June | |}

Discography

Albums

! Year	! Album	Top Country Albums>US Country	! Label
1983	''Hangin' Up My Heart''		Atlantic

Singles

Year	Single	Chart Positions			Album
		! width="50"	! width="50"	CAN Country
	"Coal Miner's Daughter"
"Back in Baby's Arms"
1983	"Lonely But Only for You"
	"If I Can Just Get Through the Night"
"If You Could Only See Me Now"

References

External links

Category:Actors Studio alumni Category:American country singers Category:American film actors Category:Best Actress Academy Award winners Category:Best Drama Actress Golden Globe (film) winners Category:Best Musical or Comedy Actress Golden Globe (film) winners Category:American people of Czech descent Category:American people of English descent Category:Lee Strasberg Theatre Institute alumni Category:People from Wood County, Texas Category:People from Charlottesville, Virginia Category:Sundance Film Festival award winners Category:Actors from Texas Category:1949 births Category:Living people

ar:سيسي سبيسك an:Sissy Spacek bg:Сиси Спейсик cs:Sissy Spacek da:Sissy Spacek de:Sissy Spacek es:Sissy Spacek eo:Sissy Spacek eu:Sissy Spacek fr:Sissy Spacek hr:Sissy Spacek id:Sissy Spacek it:Sissy Spacek he:סיסי ספייסק la:Maria Elisabetha Spacek nl:Sissy Spacek ja:シシー・スペイセク no:Sissy Spacek pl:Sissy Spacek pt:Sissy Spacek ro:Sissy Spacek ru:Спейсек, Сисси simple:Sissy Spacek sr:Сиси Спејсек sh:Sissy Spacek fi:Sissy Spacek sv:Sissy Spacek tl:Sissy Spacek th:ซิสซี สเปเซก tg:Сиссӣ Спасек tr:Sissy Spacek yo:Sissy Spacek

Emanuel Rivers M.D. is a physician born and raised in River Rouge, Michigan which is a suburb of Detroit, MI. He is board certified in emergency medicine, internal medicine and critical care medicine. Rivers has published extensive work in the field of shock, sepsis and resuscitation.

Education and career

Emanuel Rivers is Vice Chairman and Director of Research for the Department of Emergency Medicine. He is a Senior Staff Attending Physician in the Surgical Critical Care Unit and the Emergency Department at Henry Ford Hospital in Detroit, Michigan.

He received his Bachelors of Science, Masters of Public Health, and Doctorate in Medicine from the University of Michigan in Ann Arbor, Michigan. He completed a residency in emergency and internal medicine at Henry Ford Hospital, Detroit, Michigan, followed by a fellowship in critical care medicine at the University of Pittsburgh, PA. He is Board certified in Critical Care Medicine, Emergency Medicine and Internal Medicine. He also has a special competency in Hyperbaric Medicine.

Rivers is a national or international research award recipient from the Society of Academic Emergency Medicine (2010), American College of Emergency Physicians (2005), Society of Academic Emergency Medicine (2000), American College of Chest Physicians (2000), Society of Critical Care Medicine and European Society of Critical Care Medicine Research Award (2000). He is a fellow of the American Academy of Emergency Medicine, American College of Chest Physicians and long standing member of the Society of Critical Care Medicine.

He was the first physician in the history of Henry Ford Hospital to be inducted into the Institute of Medicine, National Academy of Sciences in 2005 and has been called to serve on task forces to advise the United States government on health care issues. He was voted on of the Top Docs in the city of Detroit for the years 2006 to 2010. He is also a quality consultant to 3 of the top ten health care delivery systems in the United States. Rivers' practice and research are based out of the Henry Ford Hospital in Detroit, MI.

Rivers' interests include the examination and treatment of critical illness or the critically ill in the earliest stages of hospital presentation, which includes the Emergency Department and Intensive Care Unit. Diseases, which are included in this area, are patients presenting with shock of all kinds (septic or severe infection, trauma or hemorrhage, heart attacks, blood clots to the lung and other shock states such as cardiac arrest). He is examining new ways to improve upon early detection and aggressive treatment of these diseases, which cost many lives and consume tremendous health care resources. He is further interested in evaluating the number of patients who can be saved at this stage and how well were treating these patients as well as the epidemiology and outcome evaluation of early critical illness.

Contributions

The algorithm of emergent resuscitation in the setting of severe sepsis and/or septic shock has been formally conceptualized by Emanuel Rivers in a landmark paper in November 2001 using early goal directed therapy (EGDT) in the emergency department. EGDT has been used and validated for years in the intensive-care unit setting, but Rivers's paper expanded the idea to incorporate all those initially presenting to the ED with signs of severe sepsis or septic shock. Many hospitals across the United States such as Kaiser and Catholic Health Care West have rapidly incorporated the protocol developed by Rivers in their ED treatment algorithms, as well as use it as a quality improvement data point. EGDT has also been cited by the Joint Commission of Hospital Accreditation as a quality improvement initiative for the last two years.

Discussion

The EGDT study is a reflection of expert opinion for sepsis management by the American College of Critical Care Medicine. His Early Goal Directed Therapy recommendations have been replicated in over 33 publications since 2001 comprising over 8,000 patients with equal efficacy and improvement in health care costs. Rivers has not gained from any propriety research in this area and has no conflict of interest.

References

1. Gao F, Melody T, Daniels DF, Giles S, Fox S. The impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study. Crit Care 2005;9:R764-70. 2. Kortgen A, Niederprum P, Bauer M. Implementation of an evidence-based "standard operating procedure" and outcome in septic shock. Crit Care Med 2006;34:943-9. 3. Sebat F, Johnson D, Musthafa AA, et al. A multidisciplinary community hospital program for early and rapid resuscitation of shock in nontrauma patients. Chest 2005;127:1729-43. 4. Shapiro NI, Howell MD, Talmor D, et al. Implementation and outcomes of the Multiple Urgent Sepsis Therapies (MUST) protocol. Crit Care Med 2006;34:1025-32. 5. Trzeciak S, Dellinger RP, Abate NL, et al. Translating research to clinical practice: a 1-year experience with implementing early goal-directed therapy for septic shock in the emergency department. Chest 2006;129:225-32. 6. Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 2001;345:1368-77. 7. Lin SM, Huang CD, Lin HC, Liu CY, Wang CH, Kuo HP. A modified goal-directed protocol improves clinical outcomes in intensive care unit patients with septic shock: a randomized controlled trial. Shock 2006;26:551-7. 8. Micek ST, Roubinian N, Heuring T, et al. Before-after study of a standardized hospital order set for the management of septic shock. Crit Care Med 2006;34:2707-13. 9. Nguyen HB, Corbett SW, Steele R, et al. Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality*. Crit Care Med 2007. 10. Sebat F, Musthafa AA, Johnson D, et al. Effect of a rapid response system for patients in shock on time to treatment and mortality during 5 years*. Crit Care Med 2007. 11. Chen ZQ, Jin YH, Chen H, Fu WJ, Yang H, Wang RT. [Early goal-directed therapy lowers the incidence, severity and mortality of multiple organ dysfunction syndrome]. Nan Fang Yi Ke Da Xue Xue Bao 2007;27:1892-5. 12. He ZY, Gao Y, Wang XR, Hang YN. [Clinical evaluation of execution of early goal directed therapy in septic shock]. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 2007;19:14-6. 13. Qu HP, Qin S, Min D, Tang YQ. [The effects of earlier resuscitation on following therapeutic response in sepsis with hypoperfusion.]. Zhonghua Wai Ke Za Zhi (Chinese Journal of Surgery) 2006;44:1193-6. 14. Castro R, Regueira T, Aguirre ML, et al. An evidence-based resuscitation algorithm applied from the emergency room to the ICU improves survival of severe septic shock. Minerva Anestesiol 2008. 15. Akinnusi ME, Alsawalha L, Pineda LA, El Solh AA. Outcome of septic shock in the elderly following the implementation of the sepsis bundle: a propensity-adjusted analysis. Chest 2007;132:494-. 16. Jones AE, Focht A, Horton JM, Kline JA. Prospective external validation of the clinical effectiveness of an emergency department-based early goal-directed therapy protocol for severe sepsis and septic shock. Chest 2007;132:425-32. 17. Ferrer R, Artigas A, Levy MM, et al. Improvement in process of care and outcome after a multicenter severe sepsis educational program in Spain. Jama 2008;299:2294-303. 18. Zubrow MT, Sweeney TA, Fulda GJ, et al. Improving care of the sepsis patient. Jt Comm J Qual Patient Saf 2008;34:187-91. 19. Zambon M, Ceola M, Almeida-de-Castro R, Gullo A, Vincent JL. Implementation of the Surviving Sepsis Campaign guidelines for severe sepsis and septic shock: we could go faster. J Crit Care 2008;23:455-60. 20. Thiel SW, Asghar MF, Micek ST, Reichley RM, Doherty JA, Kollef MH. Hospital-wide impact of a standardized order set for the management of bacteremic severe sepsis. Crit Care Med 2009;37:819-24. 21. Focht A, Jones AE, Lowe TJ. Early goal-directed therapy: improving mortality and morbidity of sepsis in the emergency department. Jt Comm J Qual Patient Saf 2009;35:186-91. 22. Moore LJ, Jones SL, Kreiner LA, et al. Validation of a screening tool for the early identification of sepsis. J Trauma 2009;66:1539-46; discussion 46-7. 23. Wang JL, Chin CS, Chang MC, et al. Key process indicators of mortality in the implementation of protocol-driven therapy for severe sepsis. J Formos Med Assoc 2009;108:778-87. 24. Castellanos-Ortega A, Suberviola B, Garcia-Astudillo LA, et al. Impact of the surviving sepsis campaign protocols on hospital length of stay and mortality in septic shock patients: Results of a 3-year follow-up quasi-experimental study. Crit Care Med 2010. 25. Puskarich MA, Marchick MR, Kline JA, Steuerwald MT, Jones AE. One year mortality of patients treated with an emergency department based early goal directed therapy protocol for severe sepsis and septic shock: a before and after study. Crit Care 2009;13:R167. 26. Li X, Fan QX, Wang J. [Clinical observation of early goal-directed therapy in patients with septic shock]. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 2009;21:742-3. 27. Cardoso T, Carneiro AH, Ribeiro O, Teixeira-Pinto A, Costa-Pereira A. Reducing mortality in severe sepsis with the implementation of a core 6-hour bundle: results from the Portuguese community-acquired sepsis study (SACiUCI study). Crit Care 2010;14:R83. 28. Lefrant JY, Muller L, Raillard A, et al. Reduction of the severe sepsis or septic shock associated mortality by reinforcement of the recommendations bundle: A multicenter study. Ann Fr Anesth Reanim 2010. 29. Gurnani PK, Patel GP, Crank CW, et al. Impact of the implementation of a sepsis protocol for the management of fluid-refractory septic shock: A single-center, before-and-after study. Clin Ther 2010;32:1285-93. 30. Macredmond R, Hollohan K, Stenstrom R, Nebre R, Jaswal D, Dodek P. Introduction of a comprehensive management protocol for severe sepsis is associated with sustained improvements in timeliness of care and survival. Qual Saf Health Care 2010. 31. Permpikul C, Tongyoo S, Ratanarat R, Wilachone W, Poompichet A. Impact of septic shock hemodynamic resuscitation guidelines on rapid early volume replacement and reduced mortality. J Med Assoc Thai 2010;93 Suppl 1:S102-9. 32. [The effect of early goal-directed therapy on treatment of critical patients with severe sepsis/septic shock: a multi-center, prospective, randomized, controlled study.]. Zhongguo Wei Zhong Bing Ji Jiu Yi Xue 2010;22:331-4. 33. de Oliveira CF, de Oliveira DS, Gottschald AF, et al. ACCM/PALS haemodynamic support guidelines for paediatric septic shock: an outcomes comparison with and without monitoring central venous oxygen saturation. Intensive Care Med 2008.

Category:American physicians Category:Intensive care medicine Category:Living people