Detecting Sepsis in Patients with Severe Subarachnoid Hemorrhage during Critical Care

Introduction: Sepsis and septic shock continue to have a very high mortality rate. Therefore, the last consensus-based sepsis guideline introduced the sepsis related organ failure assessment (SOFA) score to ensure a rapid diagnosis and treatment of sepsis. In neurosurgical patients, especially those patients with subarachnoid hemorrhage (SAH), there are considerable difficulties in interpreting the SOFA score. Therefore, our study was designed to evaluate the applicability of the SOFA for critical care patients with subarachnoid hemorrhage. Methods: Our retrospective monocentric study was registered (NCT05246969) and approved by the local ethics committee (# 211/18). Patients admitted to the Department of Neurosurgery at the Frankfurt University Hospital were enrolled during the study period. Results: We included 57 patients with 85 sepsis episodes of which 141 patients had SOFA score-positive results and 243 SIRS positive detections. We failed to detect a correlation between the clinical diagnosis of sepsis and positive SOFA or SIRS scores. Moreover, a significant proportion of sepsis that was incorrectly detected via the SOFA score could be attributed to cerebral vasospasms (p < 0.01) or a decrease in Glasgow Coma Scale (p < 0.01). Similarly, a positive SIRS score was often not attributed to a septic episode (49.0%). Discussion: Regardless of the fact that SAH is a rare disease, the relevance of sepsis detection should be given special attention in light of the long duration of therapy and sepsis prevalence. Among the six modules represented by the SOFA score, two highly modules were practically eliminated. However, to enable early diagnosis of sepsis, the investigator’s clinical views and synopsis of various scores and laboratory parameters should be highlighted. Conclusions: In special patient populations, such as in critically ill SAH patients, the SOFA score can be limited regarding its applicability. In particular, it is very important to differentiate between CVS and sepsis.

Is Prehospital Assessment of qSOFA Parameters Associated with Earlier Targeted Sepsis Therapy? A Retrospective Cohort Study

BACKGROUND

This study aimed to determine whether prehospital qSOFA (quick sequential organ failure assessment) assessment was associated with a shortened 'time to antibiotics' and 'time to intravenous fluid resuscitation' compared with standard assessment.

METHODS

This retrospective study included patients who were referred to our Emergency Department between 2014 and 2018 by emergency medical services, in whom sepsis was diagnosed during hospitalization. Two multivariable regression models were fitted, with and without qSOFA parameters, for 'time to antibiotics' (primary endpoint) and 'time to intravenous fluid resuscitation'.

RESULTS

In total, 702 patients were included. Multiple linear regression analysis showed that antibiotics and intravenous fluids were initiated earlier if infections were suspected and emergency medical services involved emergency physicians. A heart rate above 90/min was associated with a shortened time to antibiotics. If qSOFA parameters were added to the models, a respiratory rate ≥ 22/min and altered mentation were independent predictors for earlier antibiotics. A systolic blood pressure ≤ 100 mmHg and altered mentation were independent predictors for earlier fluids. When qSOFA parameters were added, the explained variability of the model increased by 24% and 38%, respectively (adjusted R² 0.106 versus 0.131 for antibiotics and 0.117 versus 0.162 for fluids).

CONCLUSION

Prehospital assessment of qSOFA parameters was associated with a shortened time to a targeted sepsis therapy.

Effect of Probiotic Therapy on Hemodynamic Response Associated with Systemic Inflammatory Reaction and Antibiotic-Induced Dysbiosis in Chronic Experiments in Rats

The effect of probiotic therapy on the main hemodynamic parameters was studied in Wistar rats with modeled syndrome of systemic inflammatory response resulting from chemically induced colitis complicated by antibiotic-induced dysbiosis. Using a wireless telemetry monitoring system in round-the-clock mode, the mean systolic and diastolic BP, HR, and body temperature were measured over 27 days. In the group of animals receiving no probiotics, a significant decrease in feed consumption and body weight loss were observed. By the end of the experiment, BP in this group was lower by 12% and HR was higher by 10% than in the control. In animals treated with a mixture of probiotic strains Lactobacillus acidophilus and Bifidobacterium animalis subsp. lactis, all the studied parameters returned to the initial values. Thus, we demonstrated the possibility of using probiotic drugs for the treatment of acute systemic inflammatory process, which should be considered in the development of new treatment protocols in veterinary and medicine.

Selenium Levels and Antioxidant Activity in Critically Ill Patients with Systemic Inflammatory Response Syndrome

The Selenium (Se) status could be an important modifiable factor in critically ill patient outcomes due to the important role of this mineral in several functions. Although there are many clinical trials with Se interventions in the literature, the evidence is not sufficient to establish a common criterion regarding the Se status. Background and aims: An analysis was made of the evolution of selenium (Se) and antioxidant status in critically ill patients with Systemic Inflammatory Response Syndrome (SIRS) over 7 days of staying in the Intensive Care Unit (ICU). Methods: A prospective analytical study was carried out on 65 critically ill patients aged 31−77 years. A healthy control group of 56 volunteers from the same region was recruited to allow comparisons with reference normal values. The selenium levels in both the plasma and erythrocytes were analyzed by Inductively Coupled Plasma Mass Spectrometry (ICP-MS). Glutathione Peroxidase (GPx) and Superoxide Dismutase (SOD) activity and the Total Antioxidant Capacity (TAC) were measured using kinetic colorimetric methods. Results: Low erythrocyte and plasma Se levels were found at ICU admission in comparison with the healthy reference group (p < 0.001), and the levels further decreased after one week (p < 0.001). Smaller changes in the plasma Se levels were associated with greater changes in the Sequential Organ Failure Assessment (SOFA) score (p < 0.05). The GPx activity in the critically ill was lower than in the control group (p < 0.05), with an inverse correlation to the severity scores at the baseline (p < 0.05) and reaching normal values after one week (p < 0.05). SOD activity was directly correlated to TAC (p = 0.03), with both parameters exhibiting a direct correlation to albumin (p < 0.05) after 7 days of ICU stay. Conclusions: A deficient Se status was observed at ICU admission and worsened further over follow-up regardless of the evolution of the patient severity and the antioxidant parameters. Adequate Se support from the start of admission could preserve and contribute to improve the Se-related outcomes and critical patient recovery during longer periods in the ICU.

Physiological Changes in Subjects Exposed to Accidental Hypothermia: An Update

Background

Accidental hypothermia (AH) is an unintended decrease in body core temperature (BCT) to below 35°C. We present an update on physiological/pathophysiological changes associated with AH and rewarming from hypothermic cardiac arrest (HCA).

Temperature Regulation and Metabolism

Triggered by falling skin temperature, Thyrotropin-Releasing Hormone (TRH) from hypothalamus induces release of Thyroid-Stimulating Hormone (TSH) and Prolactin from pituitary gland anterior lobe that stimulate thyroid generation of triiodothyronine and thyroxine (T4). The latter act together with noradrenaline to induce heat production by binding to adrenergic β3-receptors in fat cells. Exposed to cold, noradrenaline prompts degradation of triglycerides from brown adipose tissue (BAT) into free fatty acids that uncouple metabolism to heat production, rather than generating adenosine triphosphate. If BAT is lacking, AH occurs more readily.

Cardiac Output

Assuming a 7% drop in metabolism per °C, a BCT decrease of 10°C can reduce metabolism by 70% paralleled by a corresponding decline in CO. Consequently, it is possible to maintain adequate oxygen delivery provided correctly performed cardiopulmonary resuscitation (CPR), which might result in approximately 30% of CO generated at normal BCT.

Liver and Coagulation

AH promotes coagulation disturbances following trauma and acidosis by reducing coagulation and platelet functions. Mean prothrombin and partial thromboplastin times might increase by 40–60% in moderate hypothermia. Rewarming might release tissue factor from damaged tissues, that triggers disseminated intravascular coagulation. Hypothermia might inhibit platelet aggregation and coagulation.

Kidneys

Renal blood flow decreases due to vasoconstriction of afferent arterioles, electrolyte and fluid disturbances and increasing blood viscosity. Severely deranged renal function occurs particularly in the presence of rhabdomyolysis induced by severe AH combined with trauma.

Conclusion

Metabolism drops 7% per °C fall in BCT, reducing CO correspondingly. Therefore, it is possible to maintain adequate oxygen delivery after 10°C drop in BCT provided correctly performed CPR. Hypothermia may facilitate rhabdomyolysis in traumatized patients. Victims suspected of HCA should be rewarmed before being pronounced dead. Rewarming avalanche victims of HCA with serum potassium > 12 mmol/L and a burial time >30 min with no air pocket, most probably be futile.

Systemic inflammatory response syndrome is triggered by mitochondrial damage (Review)

Mitochondria are key organelles of cellular energy metabolism; both mitochondrial function and metabolism determine the physiological function of cells and serve an essential role in immune responses. Key damage-associated molecular patterns (DAMPs), such as mitochondrial DNA and N-formyl peptides, released following severe trauma-induced mitochondrial damage may affect the respiratory chain, enhance oxidative stress and activate systemic inflammatory responses via a variety of inflammation-associated signaling pathways. Severe trauma can lead to sepsis, multiple organ dysfunction syndrome and death. The present review aimed to summarize the pathophysiological mechanisms underlying the effects of human mitochondrial injury-released DAMPs on triggering systemic inflammatory responses and to determine their potential future clinical applications in preventing and treating sepsis.

Incidence, Clinical Characteristics and Outcomes of Early Hyperbilirubinemia in Critically Ill Patients: Insights From the MARS Study

OBJECTIVE

To investigate the incidence, clinical characteristics and outcomes of early hyperbilirubinemia in critically ill patients.

DESIGN AND SETTING

This is a post hoc analysis of a prospective multicenter cohort study.

PATIENTS

Patients with measured bilirubin levels within the first 2 days after ICU admission were eligible. Patients with liver cirrhosis were excluded.

ENDPOINTS

The primary endpoint was the incidence of early hyperbilirubinemia, defined as bilirubin ≥33 μmol/L within 2 days after ICU admission. Secondary endpoints included clinical characteristics of patients with versus patients without early hyperbilirubinemia, and outcomes up to day 30.

RESULTS

Of 4,836 patients, 559 (11.6%) patients had early hyperbilirubinemia. Compared to patients without early hyperbilirubinemia, patients with early hyperbilirubinemia presented with higher severity of illness scores, and higher incidences of sepsis and organ failure. After adjustment for confounding variables, early hyperbilirubinemia remained associated with mortality at day 30 (odds ratio, 1.31 [95%-confidence interval 1.06-1.60]; P = 0.018). Patients with early hyperbilirubinemia and thrombocytopenia (interaction P-value = 0.005) had a higher likelihood of death within 30 days (odds ratio, 2.61 [95%-confidence interval 2.08-3.27]; P < 0.001) than patients with early hyperbilirubinemia and a normal platelet count (odds ratio, 1.09 [95%-confidence interval 0.75-1.55]; P = 0.655).

CONCLUSIONS

Early hyperbilirubinemia occurs frequently in the critically ill, and these patients present with higher disease severity and more often with sepsis and organ failures. Early hyperbilirubinemia has an association with mortality, albeit this association was only found in patients with concomitant thrombocytopenia.

The Effect of Rapid Initiation Versus Delayed Initiation of Antibiotics in Pediatric Patients With Sepsis

OBJECTIVE

The purpose of this study was to determine if administration of antibiotics within 1 hour of meeting sepsis criteria improved patient outcomes versus antibiotics administered greater than 1 hour after meeting sepsis criteria in pediatric patients. The Surviving Sepsis Campaign's international guidelines recommend appropriate antimicrobial therapy be administered within 1 hour of recognition of severe sepsis or septic shock. Data regarding outcomes in pediatric patients with sepsis regarding antibiotic timing are currently limited.

METHODS

This was a retrospective chart review of 69 pediatric patients admitted between July 1, 2013, and June 30, 2016, with a diagnosis of sepsis.

RESULTS

The primary outcome of in-hospital mortality was 7.1% in the within 1 hour group versus 14.6% in the greater than 1 hour group (p = 0.3399). Median hospital length of stay was significantly shorter in the within 1 hour group (15.4 versus 39.2 days, p = 0.0022). Median intensive care unit length of stay was also significantly shorter in the within 1 hour group (3.1 versus 33.6 days, p = 0.0191). There were no differences between groups for pediatric intensive care unit admission, end organ dysfunction, time to intubation, or time on the ventilator.

CONCLUSIONS

Pediatric patients who receive antimicrobial therapy within 1 hour of meeting sepsis criteria had improved hospital and intensive care unit length of stay. This study supports the Surviving Sepsis Guidelines recommendation to administer antibiotics within 1 hour in pediatric patients with sepsis or septic shock.

COVID-19 associated multisystem inflammatory syndrome in children mimicking acute appendicitis - how to differentiate and conduct pediatric patients during the pandemic? - Proposal of a management flowchart

INTRODUCTION

the new coronavirus pandemic has been a reality throughout 2020, and it has brought great challenges. The virus predominantly manifests in the pediatric population with mild symptoms. However, an increase in the incidence of Multisystemic Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 has been described in the literature. MIS-C manifests mainly with fever and gastrointestinal symptoms and may mimic acute abdomen due to acute appendicitis. The objective of this study is to propose a care flowchart for suspected cases of acute appendicitis in the initial phase in pandemic times, considering the possibility of MIS-C. This situation was brought up by a patient treated in a pediatric hospital in Brazil.

DISCUSSION

It was possible to identify common signs and symptoms in the reported patient and those published cases that may serve as alerts for early identification of MIS-C cases. Based on the literature review and on the similarities between the syndrome and the inflammatory acute abdomen in children, we elaborated an initial approach for these cases to facilitate the identification, early diagnosis, and management. The flowchart considers details of the clinical history, physical examination, and complementary exams prior to the indication of appendectomy in patients with initial phase symptoms.

CONCLUSION

MIS-C, although rare and of poorly known pathophysiology, is most often severe and has a high mortality risk. The use of the proposed flowchart can help in the diagnosis and early treatment of MIS-C.

Liver Progenitor Cells in Massive Hepatic Necrosis-How Can a Patient Survive Acute Liver Failure?

Massive hepatic necrosis is the most severe lesion in acute liver failure, yet a portion of patients manage to survive and recover from this high-risk and harsh disease syndrome. The mechanisms underlying recovery remain largely unknown to date. Recent research progress highlights a key role of liver progenitor cells, the smallest biliary cells, in the maintenance of liver homeostasis and thus survival. These stem-like cells rapidly proliferate and take over crucial hepatocyte functions in a severely damaged liver. Hence, the new findings not only add to our understanding of the huge regenerative capability of the liver, but also provide potential new targets for the pharmacological management of acute liver failure in clinical practice.

The Effect of Probiotic Strains on Myocardial Infarction Size, Biochemical and Immunological Parameters in Rats with Systemic Inflammatory Response Syndrome and Polymorbidity

Numerous experimental and clinical studies have shown the effectiveness of various probiotic strains in metabolic disorders, gastrointestinal and liver diseases, immune system pathology. The effects of probiotics on cardiovascular dysfunction are less well known. The development and validation of a new experimental model in rats, including obesity, acute colon inflammation and antibiotic-induced dysbiosis, with common characteristics of systemic inflammatory response syndrome (SIRS), became the basis for investigating the effects of probiotic drugs on myocardial resistance to ischemic-reperfusion injury (IRI) using an in vivo model of infarction after coronary occlusion. A 24% increase in myocardial infarction compared to intact animals (p < 0.05) and significant changes in leukogram, biochemical and immunological parameters were found in Wistar rats with SIRS modelling. Introduction of a mixture of strains of Lactobacillus acidophilus (LA-5) and Bifidobacterium animalis subsp. lactis (BB-12) to animals with SIRS reduced infarct size to a value close to the control. Rats treated with LA-5 and BB-12 also showed normalization of the leukocyte count, bile acids, transforming growth factor-β, interleukins: IL-1α, IL-2, IL-6, IL-8, tumor necrosis factor-α, lipopolysaccharide and monocyte chemoattractant protein-1 in blood in comparison with the SIRS group and with the groups treated with other probiotic strains. The obtained data convincingly show the prospects for further study of the cardiotropic potential of probiotic microorganisms in translational studies.

Perirenal Extravasation After Retrograde Intrarenal Surgery for Renal Stones: A Prospective Study

Background

The incidence and consequences of the perirenal extravasation of the irrigation fluid during retrograde intrarenal surgery (RIRS) are not fully elucidated. The objective of this study was to assess the incidence, risk factors, and complications of perirenal extravasation of irrigation fluid during RIRS.

Methods

This prospective observational study was conducted in the Department of Urology, Bir Hospital, Kathmandu, Nepal, from January 2020 to March 2021. Patients undergoing RIRS for renal stones less than 2 cm in diameter were included in the study. Irrigation during the procedure was performed using isotonic normal saline under gravity at 50 cm from the symphysis pubis of patients with intermittent manual compression if required. Lithotripsy was performed with 120-Watt Ho:YAG laser using 200-micron laser fiber. Retrograde pyelogram was performed after the completion of lithotripsy to document the presence or absence of extravasation on fluoroscopic images. A double-J stent was placed at the end in all patients. Patients were observed for systemic inflammatory response syndrome (SIRS) features. Postoperative abdominal ultrasonography was performed on the first postoperative day to assess the perirenal collection together with complete blood count. The visual analogue scale (VAS) was used to assess pain in postoperative period. The preoperative patient’s and stone characteristics, hydronephrosis, intraoperative characteristics, and postoperative findings were analyzed.

Results

A total of 71 patients who underwent RIRS during the study period were analyzed. The mean (SD) stone size was 13.19 (3.12) mm. Intraoperative perirenal extravasation of contrast was noted in eight (11.26%) patients; however, no patient had ipsilateral perirenal collection on ultrasonography obtained on the first postoperative day. No significant differences were observed among patients with or without perirenal extravasation in terms of mean stone size, laser settings, operative duration, and lasing duration. Use of ureteral access sheath (UAS) was associated with lower incidence of extravasation; however, it was not significant. SIRS was documented in eight patients overall, with none of the patients with extravasation having features of SIRS. Patients with extravasation experienced more postoperative flank pain (p<0.05).

Conclusion

Perirenal extravasation was common during RIRS and was associated with higher postoperative pain scores. Stone size, use of UAS, laser settings, operative duration, and lasing duration were not associated with an increased risk of extravasation. Extravasation was not associated with increased postoperative complications.

Global Myocardial Strain in Multisystem Inflammatory Syndrome in Children, Kawasaki Disease, and Healthy Children: A Network Meta-Analysis

BACKGROUND

Nearly 6,000 multisystem inflammatory syndrome in children (MIS-C) have been reported in the United States by November 2021. Left ventricular global myocardial strain has been proved to be one of the best evidence of the diagnostic and prognostic implications for cardiac dysfunction. The global myocardial strain change of MIS-C in the acute phase was still unclear.

METHODS

PubMed and other sources were searched. A network meta-analysis was conducted. MIS-C was divided into two groups according to left ventricular ejection fraction (LVEF): MIS-C with depressed ejection fraction (MIS-C dEF) and MIS-C with preserved ejection fraction (MIS-C pEF). Global longitudinal strain (GLS) and global circumferential strain (GCS) were compared among MIS-C, Kawasaki disease (KD), and healthy children.

RESULTS

In total, nine case-control studies were included, published between 2014 and 2021. These studies involved 107 patients with MIS-C, 188 patients with KD, and 356 healthy children. After Bayesian analysis, MIS-C dEF group was found to have a lower LVEF, higher GLS and GCS than the KD groups. Both MIS-C pEF and KD had similar GLS and GCS, which were higher than healthy controls. There was no difference of LVEF among MIS-C pEF, KD, and healthy controls.

CONCLUSION

MIS-C dEF was more severe than KD, both in LVEF and global myocardial strain. MIS-C pEF and KD were similar with mild impaired left ventricular myocardial strain compared with the healthy children. Global myocardial strain may be a monitoring index for MIS-C.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/], identifier [CRD42021264760].

Dynamic Nomogram for Predicting Thrombocytopenia in Adults with Acute Pancreatitis

Objective

Thrombocytopenia increases the risk of hemorrhage in patients with acute pancreatitis (AP), leading to poor clinical outcomes. Currently, there is no reliable tool for the early assessment of thrombocytopenia in these patients. We aimed to develop a nomogram based on available clinical parameters and validate its efficacy in predicting thrombocytopenia.

Methods

This was a retrospective study. All the data were extracted from an electronic database from May 2018 to May 2019. Patients with a diagnosis of AP and staying in the intensive care unit for more than 3 days were retrospectively analyzed. A clinical signature was built based on reproducible features, using the least absolute shrinkage and selection operator method (LASSO), and logistic regression established the model (P < 0.05). Nomogram performance was determined by its discrimination, calibration, and clinical usefulness.

Results

A total of 594 eligible patients were enrolled, of whom 399 were allocated to the training sets and the 195 in the test sets. The clinical features, including blood urea nitrogen (BUN), fibrinogen (FIB), and antithrombase III, were significantly associated with the incidence of thrombocytopenia after acute pancreatitis (p < 0.05) in training sets. The individualized nomogram showed good discrimination in the training sample (area under the receiver operating characteristic curve [AUC], 0.881) and in the validation sample (AUC, 0.883) with good calibration.

Conclusion

The proposed nomogram has good performance for predicting thrombocytopenia in patients with acute pancreatitis and may facilitate clinical decision-making.

Neutrophil to lymphocyte ratio as a prognostic biomarker in puppies with acute diarrhea

OBJECTIVES

To document the neutrophil to lymphocyte ratio (NLR) values in systemic inflammatory response syndrome positive (SIRS+) and negative (SIRS-) puppies presenting with acute diarrhea (AD). To determine whether the calculated canine acute diarrhea severity index (CADSI) score was associated with NLR. Also, to investigate the prognostic value of NLR in puppies with acute diarrhea.

DESIGN

Retrospective study.

SETTING

University veterinary teaching hospital.

ANIMALS

A total of 85 puppies (2-6 months old), 70 with AD and 15 healthy controls (CON).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Pertinent history, physical examination findings and results of complete blood count analysis of dogs with AD at the time of admission to the hospital were obtained from medical records. Forty-seven of the dogs with AD were SIRS+ and 23 were SIRS-. Of the puppies with AD, 11 died within 7 days after initiation of treatment, 59 survived. NLR values in dogs with AD were statistically higher (P < 0.001) than the CON group, but there was no difference (P = 0.791) between the two groups in terms of white blood cell (WBC) count. The median NLR of SIRS+ (3.66) dogs was significantly higher than the median NLRs of dogs in the SIRS- (1.88) and CON (1.35) groups. While a strong positive correlation (ρ = 0.740; P < 0.001) was found between the CADSI score and NLR in dogs with AD, the relationship between WBC and disease severity was not significant (ρ = -0.117; P = 0.336). The area under the receiver-operating characteristic curves for nonsurvival in dogs with AD was 0.710 (P = 0.039) for the NLR and 0.773 (P = 0.008) for the WBC.

CONCLUSIONS

Evaluation of NLR at hospital admission may be a useful marker of disease severity and may have prognostic value in puppies with AD. Further investigations are required to understand the implications of these findings.

The Effect of Fat Distribution on the Inflammatory Response of Multiple Trauma Patients-A Retrospective Study

Objectives In recent years; increasing evidence pointed out the clinical importance of adipose tissue (AT) distribution in various patient populations. In particular, visceral adipose tissue (VAT), when compared to subcutaneous adipose tissue (SAT), was found to play a pivotal role in the development of inflammatory reaction. The aim of the present study was to examine whether body fat distribution has an impact on the development of systemic inflammatory response syndrome (SIRS) in patients with polytrauma. Methods In our retrospective study; we filtered our institution records of the German Trauma Registry (Trauma Register DGU) from November 2018 to April 2021 and included 132 adult polytrauma patients with injury severity score (ISS) >16. Subsequently; we measured the visceral and subcutaneous adipose tissue area based on whole-body CT scan and calculated the ratio of VAT to SAT (VSr). Thereafter, the patient population was evenly divided into three groups; respectively VSr value less than 0.4 for the first group (low ratio), 0.4–0.84 for the second group (intermediate ratio), and greater than 0.84 for the third group (high ratio). Considering the other influencing factors; the groups were further divided into subgroups in the respective analysis according to gender (male/female), BMI (<25 or ≥25), and ISS (<26 or ≥26). Result VSr was an independent factor from body mass index (BMI) (r² = 0.003; p = 0.553). VSr in male patients was significantly higher (p < 0.001). Patients with low VSr had higher ISS scores (p = 0.028). Polytrauma patients with higher VSr tended to have lower SIRS scores and significant differences of SIRS score were found on multiple days during the whole hospitalization period. In the low VAT/SAT group, male patients, and patients with BMI greater than 25, both exhibited higher SIRS scores during hospital stay (day 16: p = 0.01; day 22: p = 0.048 and p = 0.011; respectively). During hospitalization, patients with higher ISS score (≥26) in the low VSr group was found to have higher SIRS score (day 16; p = 0.007). Over the hospital stay; serum markers of CRP; CK; and leukocyte in patients with low VSr were higher than those in patients in the intermediate and high VSr groups; with significant difference discovered on multiple days (day 16: 0.014; day 22: p = 0.048). Conclusion Lower VSr is associated with increased inflammatory response and worse clinical outcome in patients with polytrauma. Furthermore; VSr is an independent factor providing additional information to BMI.

Intravenous lidocaine infusion in a case of severe COVID-19 infection

A subset of patients with COVID-19 develops a severe inflammatory response that may lead to respiratory and multiorgan failure. Effective treatment strategies to mitigate or interrupt this self-destructive inflammatory process are limited. The local anesthetic lidocaine has anti-inflammatory properties in addition to its analgesic, antiarrhythmic, and sedating effects that may be beneficial in critically ill COVID-19 patients. We report the case of a patient with COVID-19 induced severe respiratory distress who was intubated and received supportive treatment including proning and neuromuscular blockade. He developed a strong inflammatory response that we treated with an intermittent lidocaine infusion resulting in subsequent resolution. This case occurred prior to emerging data from a large dexamethasone use trial that demonstrated a survival benefit from its use in hospitalized COVID-19 patients. At the time, lidocaine was the only anti-inflammatory medication our patient received.

Multiple Organ Dysfunction Syndrome Caused by Sepsis: Risk Factor Analysis

Purpose

To analyze the risk factors of multiple organ dysfunction syndromes (MODS) caused by sepsis.

Patients and Methods

A total of 180 patients with sepsis admitted to The First Affiliated Hospital of Harbin Medical University (No. 23, Post Street, Nangang District, Harbin 150001, Heilongjiang province, China) from July 2018 to June 2019 were selected and divided into a non-MODS group and a MODS group, with 90 cases in each group. Clinical data of the patients were retrospectively analyzed, and univariable and multivariable analyses were performed.

Results

The univariable analysis showed that there were no significant differences in terms of age, body temperature, heart rate, respiration, mean arterial pressure, RBC specific volume, blood sodium, serum kalium, and infection site (P > 0.05). Whereas significant differences were found between the groups in terms of gender, arterial blood pH, WBC count, Apache II score, blood glucose, creatinine, chronic medical history, surgery, and ventilator usage (P < 0.05). The growth of bacterial culture, the increase of creatinine level, chronic diseases and Apache II score were discovered to have significant effects on the occurrence of MODS through the multivariable logistic regression analysis.

Conclusion

Bacterial culture, serum creatinine level, history of chronic disease and Apache II score may be risk factors of MODS in sepsis patients.

Risk factors for infectious complications after retrograde intrarenal surgery - a systematic review and narrative synthesis

Introduction

Infectious complications are among the most frequent and significant complications in retrograde intrarenal lithotripsy. To date, review articles have covered complications after a ureteroscopy, but not after retrograde intrarenal surgery (RIRS), specifically. Because the complications and risk factors are different for a ureteroscopy and RIRS, we aimed to identify variables related to the occurrence of infectious complications post-RIRS.

Material and methods

This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. We included original studies that described 100 or more procedures published in 2014–2021. We extracted data and performed a narrative synthesis to explore and interpret differences between the studies.

Results

We selected 17 studies for analysis, including 10 from 2019–2021. Infectious complications after RIRS were observed in 2.8–7.5% of patients (mean 7.1%). We found seven independent risk factors associated with infectious complications after RIRS: long operative time, recent history of positive urine culture or urinary tract infection or antibiotic use, pyuria/nitrites, small caliber of ureteral access sheath, struvite stone, high irrigation rate, and comorbidities.

Conclusions

If an increased rate of infectious complications is found at a RIRS center, countermeasures should include restrictions on operative time and irrigation rate, and consideration of larger access sheaths, especially for patients with abnormal urine results or with struvite stones or with a history of urinary tract infection or co-morbidities.

Predictive Ability of Neutrophil-Lymphocyte Ratio in Determining Tumor Staging in Colorectal Cancer

Introduction

Tumor staging plays an important role in determining treatment in colorectal cancer. In the recent past, the neutrophil-lymphocyte ratio (NLR) has been used as a predictive marker of inflammation for different types of clinical entities. Our study aims to determine if NLR can predict tumor staging in patients with colorectal cancer.

Materials and methods

We retrospectively analyzed all cases that underwent surgical treatment for colorectal cancer from 2014 to 2020. The NLR, tumor stage, and histology report for all patients were reviewed. Recommended cut-off values for NLR for tumor stage (T), lymph node stage (N), and metastatic stage (M) were determined using receiver operating characteristic (ROC) analysis. 

Results

NLR was found to be significantly higher in patients with T3-T4 tumors as compared to T1-T2 tumors (mean: 5.8 vs. 2.6, respectively p < 0.001). The NLR values were higher in cases of N1-N2 groups as compared to N0 groups (mean: 5.7 vs. 3.5, p = 0.07). The NLR was also higher in M1 patients as compared to M0 patients (32.1 vs. 4.5, respectively, p = 0.24) but failed to show a statistical significance.

Conclusion

NLR is a useful predictor of colorectal cancer which can give us some information about the type of tumor we may encounter during surgery.

The Risk Factor and Outcome of Metachronous Periprosthetic Joint Infections: A Retrospective Analysis With a Minimum Ten-Year Follow-Up

BACKGROUND

Patients with multiple prosthetic joints are at risk of developing periprosthetic joint infections (PJIs). We aimed to determine whether PJI development at one site may lead to infection at another prosthetic joint site and assess the risk factors leading to this subsequent infection.

METHODS

We reviewed all cases (294 patients with first-time PJI [159 hips, 135 knees]) with PJI treated at our institute between January 1994 and December 2020. The average follow-up period was 11.2 years (range 10.1-23.2). Patients were included if they had at least one other prosthetic joint at the time of developing a single PJI (96 patients). Patients with synchronous PJI were excluded from the study. The incidence of metachronous PJI was assessed, and the risk factors were determined by comparing different characteristics between patients without metachronous PJI.

RESULTS

Of the 96 patients, 19.79% developed metachronous PJI. The identified causative pathogen was the same in 63.16% of the patients. The time to developing a second PJI was 789.84 days (range 10-3386). The identified risk factors were PJI with systemic inflammatory response syndrome, ≥3 stages of resection arthroplasty, and PJI caused by methicillin-resistant Staphylococcus aureus.

CONCLUSION

PJI may predispose patients to subsequent PJI in another prosthesis with identified risks. Most causative organisms of metachronous PJI were the same species as those of the first PJI. We believe that bacteremia may be involved in pathogenesis, but further research is required.

The Use of Different Sepsis Risk Stratification Tools on the Wards and in Emergency Departments Uncovers Different Mortality Risks: Results of the Three Welsh National Multicenter Point-Prevalence Studies

Supplemental Digital Content is available in the text.

To compare the performance of Sequential Organ Failure Assessment, systemic inflammatory response syndrome, Red Flag Sepsis, and National Institute of Clinical Excellence sepsis risk stratification tools in the identification of patients at greatest risk of mortality from sepsis in nonintensive care environments.

A New and Rare Presentation of Unilateral Recurrent Laryngeal Nerve Palsy in a COVID-19 Patient With No Recent History of Endotracheal Intubation

The Coronavirus disease 2019 (COVID-19) infection has classical symptoms of high fevers, diarrhea, cough, and dyspnea; however, there are cases recording more unconventional features. In this case report, we will discuss recurrent laryngeal nerve palsy as a new and unusual presentation of COVID-19. The patient was a 58-year-old African American male with a history of hypertension, type-2 diabetes mellitus, and obstructive sleep apnea presenting with dyspnea, fatigue, and nausea. The patient was initially admitted to the medical intensive care unit (MICU) for acute hypoxic respiratory failure and completed intravenous Remdesivir for COVID-19. He never got intubated during the ICU stay and his condition improved on the 34th day of admission. However, two weeks later the patient suddenly developed hoarseness of voice. A bedside laryngoscopy revealed a left-sided vocal cord paralysis but patent airway. The computed tomography (CT) scan of the neck did not show any abnormalities, including any impinging masses or structures. The patient did not have any recent intubations to suggest the paralysis was due to traumatic injury, thus favoring that his neurologic injury was likely a post-viral symptom. One possible pathophysiology would be the invasion of nerve fibers (peripheral or cranial nerves) by the virus using the same mechanism as seen in alveolar cells and finally destroying them. Another hypothesis would be the inflammatory response of the host immune system affecting the peripheral and cranial nerves. Therefore, the potential association between neuro-invasiveness of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the recurrent laryngeal nerve palsy resulting in the vocal cord paralysis should be considered and more studies need to be conducted for better understanding.

Interleukin-6 in Critical Coronavirus Disease 2019, a Driver of Lung Inflammation of Systemic Origin?

To examine whether interleukin-6 in critical coronavirus disease 2019 is higher in arterial than in central venous blood, as a sign of predominantly local pulmonal rather than systemic interleukin-6 production.

Clinical, microbiological and inflammatory markers of severe diabetic foot infections

AIMS

In addition to systemic inflammatory response syndrome (SIRS), various clinical signs, microbiological findings and inflammatory markers could be associated with severe diabetic foot infections (DFI).

METHODS

This study included a retrospective cohort of 245 patients with DFI treated at San Juan de Dios Hospital in San José de Costa Rica. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), CRP/albumin ratio, peripheral blood leucocyte ratios and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system were evaluated. Univariate analysis was carried out between moderate and severe infections. ROC curves were plotted. Cut-off value of inflammatory markers for diagnosing severe infections was established and then dichotomized to be included in a logistic regression model. A score was designed based on its results.

RESULTS

Skin necrosis (p < 0.01, OR = 8.5, 95% CI = 3.5-20.9), ESR > 94 mm/h (p < 0.01, OR = 2.5, 95% CI = 1.2-5.1), albumin < 2.8 g/dl (p = 0.04, OR = 2.0, 95% CI = 1.0-4.1) and neutrophil-to-lymphocyte ratio (NLR) > 4.52 (p < 0.01, OR = 3.3, 95% CI = 1.6-6.5) were found to be predictive of severe infections. Score >5 had a good diagnosis performance for classifying severe infections. Moderate infections with a score >5 had a worse prognosis than moderate ones.

CONCLUSIONS

We found an association of necrosis, serum albumin, ESR and NLR values with severe DFI. The presence of these predictive factors of severity in cases of moderate infections was significantly associated with a higher rate of amputations and recurrences, longer duration of antibiotic treatment and longer hospital stays. DFI could be classified as mild, moderate, severe without SIRS and severe.

Preoperative Midstream Urine Cultures vs Renal Pelvic Urine Culture or Stone Culture in Predicting Systemic Inflammatory Response Syndrome and Urosepsis After Percutaneous Nephrolithotomy: A Systematic Review and Meta-Analysis

Purpose: To compare preoperative midstream urine cultures (PMUC) and renal pelvic urine culture (RPUC) or stone culture (SC) in predicting systemic inflammatory response syndrome (SIRS) and urosepsis after percutaneous nephrolithotomy (PCNL). Methods: We searched the PubMed, Web of Science, and EMBASE databases up to September 1, 2020, for relevant published studies. Two authors independently confirmed whether the literatures met the inclusion criteria and collected the data from the selected literatures. A meta-analysis was performed with Review Manager Software 5.4.1. A total of 14 studies with 3540 patients were selected and analyzed in the meta-analysis. Results: Pooled data showed that SC was associated with a higher sensitivity (odds ratios [OR] 2.36, confidence interval [95% CI] 1.31-4.25; p < 0.00001), positive predictive value (PPV) (OR 1.54, 95% CI 1.18-2.01; p = 0.16) and negative predictive values (OR 1.17, 95% CI 1.01-1.37; p = 0.06) in the diagnosis of SIRS and urosepsis after PCNL, and RPUC provided a significantly higher specificity (OR 2.70, 95% CI 2.16-3.38; p = 0.07) and PPV (OR 2.17, 95% CI 1.49-3.15; p = 0.48) than PMUC in the diagnosis of SIRS and urosepsis after PCNL. Conclusion: Intraoperative SC and RPUC are more reliable than PMUC in predicting postoperative SIRS and urosepsis, identifying causative organisms, and directing antibiotic therapy for patients who underwent PCNL. PMUC, SC, and RPUC should be routinely collected for the diagnosis and management of SIRS and urosepsis after PCNL.

Dysregulation of human beta-defensin-3 expression in the peripheral blood of patients with sepsis

Objectives:

Sepsis is a serious medical condition caused by the body’s systemic inflammatory response to infections. The antimicrobial peptides, human beta-defensins, play a key role in modulating host immune responses, and aberrant expression of human beta-defensins has been implicated in many infections and inflammatory diseases. However, little is known about the expression of human beta-defensin-3 in systemic infectious diseases.

Methods:

We investigated the gene expression and protein level of human beta-defensin-3 in peripheral whole blood from 107 participants—67 patients with sepsis and 40 healthy controls—and evaluated the feasibility of human beta-defensin-3 as an indicator for sepsis. Total RNA was extracted from peripheral blood samples, and relative mRNA expression of human beta-defensin-3 was determined by reverse transcription-quantitative polymerase chain reaction. Plasma concentration of human beta-defensin-3 was measured by enzyme-linked immunosorbent assay. Pearson’s correlation analysis was performed to assess the relationship between human beta-defensin-3 mRNA and protein levels. Receiver operating characteristic analysis was performed to evaluate the value of human beta-defensin-3 as a biomarker for sepsis.

Results:

Human beta-defensin-3 mRNA expression was significantly downregulated in sepsis patients compared to controls (p = 0.001). The mean fold change of mRNA expression (±standard error) was 0.82 ± 0.63 in sepsis patients and 1.39 ± 1.09 in controls. Plasma concentration of human beta-defensin-3 (pg/mL) was significantly lower in sepsis patients compared to healthy controls (p = 0.039). The mean protein concentration (±standard error) was 539.6 ± 39.4 in sepsis patients and 715.5 ± 53 in controls. There was a significant correlation between human beta-defensin-3 mRNA expression and the corresponding protein level in sepsis patients (r = 0.358, p = 0.04), but not in healthy controls (r = 0.124, p = 0.51). For discriminating sepsis patients from healthy controls, the area under the receiver operating characteristic curve was 0.722 (95% confidence interval: 0.597–0.847, p = 0.002) for human beta-defensin-3 mRNA and 0.689 (95% confidence interval: 0.557–0.827, p = 0.009) for human beta-defensin-3 protein.

Conclusion:

This is the first study to show the downregulation of human beta-defensin-3 gene expression and protein level in sepsis, which may contribute to the complex immunological imbalance in sepsis. The significant correlation between human beta-defensin-3 mRNA expression and protein concentration suggests that mRNA expression could be used to predict protein level. Our study also showed a potential role of human beta-defensin-3 as a blood-based biomarker for sepsis. More studies on the clinical significance of human beta-defensin-3 in sepsis could further support a biomarker development.

Pretreatment Neutrophil-to-Lymphocyte Ratio: A Prognostic Biomarker of Survival in Patients With Epithelial Ovarian Cancer

Background

Inflammation is pathognomonic of all stages of tumor formation, and therefore, there is renewed interest in systemic inflammatory response (SIR) markers including haematological inflammatory markers such as neutrophil-to-lymphocyte ratio (NLR) as prognostic predictors in several cancers.

Aim

This study was aimed to investigate the effect of pretreatment peripheral blood NLR on the survival prognosis of patients with epithelial ovarian cancer (EOC).

Methods

We identified 93 patients with a complete clinical record from a cohort of 155 patients who received treatment for EOC between 2009 and 2018. Patients’ sociodemographic and clinicopathologic characteristics, and updated three-year follow-up status were extracted from medical records. Pretreatment peripheral blood NLR was calculated by dividing the neutrophil count by the lymphocyte count. We employed the receiver operating characteristic (ROC) curve to identify the optimal cut-off value of the NLR in estimating progression-free survival (PFS) and overall survival (OS). The PFS and OS were assessed using the Kaplan-Meier method, and survival differences were compared using the Log Rank (Mantel-Cox) test. Independent prognostic predictors were determined using Cox regression analysis.

Results

According to the ROC curves, the optimal cut-off values for the NLR were 2.23 and 1.93 for PFS and OS, respectively. A high NLR was associated with poor PFS (P = 0.033) and OS (P = 0.013) in the univariate analyses. In the multivariate analyses, a high NLR was still an independent predictor of OS (hazard ratio [HR] = 2.23; 95% CI, 1.08 to 4.61) but not PFS (hazard ratio [HR] = 2.43; 95% CI, 0.95 to 6.27).

Conclusion

The NLR at an optimum cut-off value of 1.93 is an independent prognostic predictor of OS in patients with EOC.

Diagnostic Accuracy and Prognostic Value of Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Septic Patients outside the Intensive Care Unit

Background and Objectives: The aim of this study was to evaluate the diagnostic accuracy and prognostic value of neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios and to compare them with other biomarkers and clinical scores of sepsis outside the intensive care unit. Materials and methods: In this retrospective study, 251 patients with sepsis and 126 patients with infection other than sepsis were enrolled. NLR and PLR were calculated as the ratio between absolute values of neutrophils, lymphocytes, and platelets by complete blood counts performed on whole blood by Sysmex XE-9000 (Dasit, Italy) following the manufacturer’s instruction. Results: The best NLR value in diagnosis of sepsis was 7.97 with sensibility, specificity, AUC, PPV, and NPV of 64.26%, 80.16%, 0.74 (p < 0.001), 86.49%, and 53.18%, respectively. The diagnostic role of NLR significantly increases when PLR, C-reactive protein (PCR), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) values, as well as systemic inflammatory re-sponse syndrome (SIRS), sequential organ failure assessment (SOFA), and quick-sequential organ failure assessment (qSOFA) scores, were added to the model. The best value of NLR in predicting 90-day mortality was 9.05 with sensibility, specificity, AUC, PPV, and NPV of 69.57%, 61.44%, 0.66 (p < 0.0001), 28.9%, and 89.9%, respectively. Sensibility, specificity, AUC, PPV, and NPV of NLR increase if PLR, PCR, PCT, MR-proADM, SIRS, qSOFA, and SOFA scores are added to NLR. Conclusions: NLR and PLR represent a widely useful and cheap tool in diagnosis and in predict-ing 90-day mortality in patients with sepsis.

[Systematic review and sequential analysis of Xuebijing Injection in treatment of systemic inflammatory response syndrome]

To systematically review the efficacy of Xuebijing Injection combined with western medicine in the treatment of systemic inflammatory response syndrome(SIRS). In this study, CBM, CNKI, Wanfang, VIP, PubMed and EMbase databases were retrieved for clinical randomized controlled trials on the effect of Xuebijing Injection combined with western medicine in the treatment of SIRS from the establishment of the database to July 31, 2020. After screening, Meta-analysis was conducted by RevMan 5.3 software, trial sequential analysis was conducted by TSA 0.9.5.10 beta software, and the evidence quality level was evaluated by GRADEprofiler 3.6.1 software. Meta-analysis showed that Xuebijing Injection combined with western medicine could reduce white blood cell count(MD=-2.32, 95%CI[-2.44,-2.21], P<0.000 01), C-reactive protein count(MD=-22.70, 95%CI[-29.61,-15.79], P<0.000 01), APACHE Ⅱ score(MD=-2.15, 95%CI[-2.43,-1.87], P<0.000 01), tumor necrosis factor alpha count(SMD=-1.23, 95%CI[-1.48,-0.99], P<0.000 01) and interleukin-6 count(SMD=-0.92, 95%CI[-1.15,-0.69], P<0.000 01), improve treatment efficiency(RR=1.39, 95%CI[1.23, 1.56], P<0.000 01), reduce incidence of multiple organ dysfunction(RR=0.47, 95%CI[0.35, 0.64], P<0.000 01) and mortality(RR=0.22, 95%CI[0.13, 0.37], P<0.000 01), which were better than western medicine treatment alone. Trial sequential analysis showed that in terms of reducing the incidence of multiple organ dysfunction and C-reactive protein count, the cumulative Z value passed through the traditional threshold, TSA threshold and expected information value, and reached the required number of cases. GRADE evaluation showed that the level of evidence was low or very low. According to the findings, Xuebijing Injection combined with western medicine is effective in treating SIRS. However, as the low quality of the included studies may affect the reliability of the conclusion, more high-quality studies shall be included for further verification in the future, so as to provide better suggestions for clinical medication.

Predictive Model for Systemic Infection After Percutaneous Nephrolithotomy and Related Factors Analysis

Objectives: To investigate the factors associated with systemic infection after percutaneous nephrolithotomy (PCNL) and establish a predictive model to provide theoretical basis for the prevention of systemic inflammatory response syndrome (SIRS) and urosepsis correlate to percutaneous nephrostomy.

Methods: Patients received PCNL between January 2016 and December 2020 were retrospectively enrolled. All patients were categorized into groups according to postoperative SIRS and urosepsis status. Single factor analysis and multivariate logistic regression analysis were performed to determine the predictive factors of SIRS and urosepsis after PCNL. The nomograms were generated using the predictors respectively and the discriminative ability of was assessed by analyses of receiver operating characteristic curves (ROC curves).

Results: A total of 758 PCNL patients were enrolled in this study, including 97 (12.8%) patients with SIRS and 42 (5.5%) patients with urosepsis. Multivariate logistic regression analysis suggested that there were 5 factors related to SIRS, followed by preoperative neutrophil to lymphocyte ratio (NLR) (odds ratio, OR = 1.721, 95% confidence interval, CI [1.116–2.653], p = 0.014), S.T.O.N.E. score (OR = 1.902, 95% CI [1.473–2.457], p < 0.001), female gender (OR = 2.545, 95% CI [1.563–4.144], p < 0.001), diabetes history (OR = 1.987, 95% CI [1.051–3.755], p = 0.035), positive urine culture (OR = 3.184, 95% CI [1.697–5.974], p < 0.001). And there were four factors related to urosepsis, followed by preoperative NLR (OR = 1.604, 95% CI [1.135–2.266], p = 0.007), S.T.O.N.E. score (OR = 1.455, 95% CI [1.064–1.988], p = 0.019), female gender (OR = 2.08, 95% CI [1.063–4.07], p = 0.032), positive urine culture (OR = 2.827, 95% CI [1.266–6.313], p = 0.011). A nomogram prediction model was established to calculate the cumulative probability of SIRS and urosepsis after PCNL and displayed favorable fitting by Hosmer–Lemeshow test (p = 0.953, p = 0.872). The area under the ROC curve was 0.784 (SIRS) and 0.772 (urosepsis) respectively.

Conclusion: Higher preoperative NLR, higher S.T.O.N.E. score, female gender, and positive urine culture are the most significant predictors of SIRS and urosepsis. Diabetes history is the predictor of SIRS. These data will help identify high-risk individuals and facilitate early detection of SIRS and urosepsis post-PCNL.

Enhanced intestinal permeability and intestinal co-morbidities in heat strain: A review and case for autodigestion

Enhanced intestinal permeability is a pervasive issue in modern medicine, with implications demonstrably associated with significant health consequences such as sepsis, multiorgan failure, and death. Key issues involve the trigger mechanisms that could compromise intestinal integrity and increase local permeability allowing the passage of larger, potentially dangerous molecules. Heat stress, whether exertional or environmental, may modulate intestinal permeability and begs interesting questions in the context of global climate change, increasing population vulnerabilities, and public health. Emerging evidence indicates that intestinal leakage of digestive enzymes and associated cell dysfunctions--a process referred to as autodigestion--may play a critical role in systemic physiological damage within the body. This increased permeability is exacerbated in the presence of elevated core temperatures. We employed Latent Dirichlet Allocation (LDA) topic modeling methods to analyze the relationship between heat stress and the nascent theory of autodigestion in a systematic, quantifiable, and unbiased manner. From a corpus of 11,233 scientific articles across four relevant scientific journals (Gut, Shock, Temperature, Gastroenterology), it was found that over 1,000 documents expressed a relationship between intestine, enhanced permeability, core temperature, and heat stress. The association has grown stronger in recent years, as heat stress and potential autodigestion are investigated in tandem, yet still by a limited number of specific research studies. Such findings justify the design of future studies to critically test novel interventions against digestive enzymes permeating the intestinal tract, especially the small intestine.

Evaluation of Plasmatic Procalcitonin in Healthy, and in Systemic Inflammatory Response Syndrome (SIRS) Negative or Positive Colic Horses

Simple Summary

Procalcitonin (PCT) increased in the case of systemic inflammatory response syndrome (SIRS), especially due to bacterial infection. The correlation between SIRS score and plasma PCT levels in horses have not been evaluated, and no studies investigated plasma PCT concentration over time. In the present study, PCT and SIRS score were evaluated in colic horses at admission to the hospital and at 24, 48, 72 and 96 h. Statistically differences were detected between healthy vs. all colic horses and between healthy vs. SIRS positive or SIRS negative horses. No correlation was observed between SIRS score and PCT. This suggests a role of plasmatic PCT as good biomarker for colic.

Abstract

Colic horses show systemic inflammatory response syndrome (SIRS) clinical signs. Procalcitonin (PCT) showed increased circulating levels in sick horses. This study compares plasma PCT concentrations in healthy vs. SIRS negative/positive colic horses over time, and evaluates PCT and SIRS score potential correlation, to verify the usefulness of PCT for the evaluation of SIRS severity. Ninety-one horses were included; 43/91 were healthy, on basis of physical examination, blood work and SIRS score (score = 0), while 48/91 were sick colic horses, classified as SIRS-negative (score < 2) and positive (score ≥ 2). Moreover, a 0–6 point-scale SIRS score was calculated (assessing mucous membrane color and blood lactate concentration). PCT was evaluated at admission, and at 24, 48, 72 and 96 h, using a commercial kit for equine species. We verified by the ANOVA test PCT differences between healthy vs. colic horses, healthy vs. SIRS-negative or SIRS-positive colic horses, at all sampling times, and the correlation between the SIRS score at admission with the SIRS score. Statistically significant differences were detected between healthy vs. all colic horses and between healthy vs. SIRS-positive or negative horses at all sampling times. No correlation was observed between the SIRS score at admission and PCT values. PCT was statistically higher in colic horses compared to the healthy ones, suggesting a role as a biomarker for colic.

Renal Resistive Index: Not Only for Kidney Clinics

Renal Resistive Index (RRI) is a measurement of the resistance of the renal blood flow. A value higher than 0.70 is a marker of increased resistance and is correlated with kidney injury and its severity. Additionally, it may be associated with the mortality rate in the post-surgery population. In COVID-19 subjects, we found that high RRI has been associated with high levels of serum C-reactive protein, a marker of systemic inflammatory reaction syndrome. Finally, we propose RRI not only as a marker of kidney injury, but also as a tool to evaluate the course of critical illness.

Ruptured Degenerating Fibroid Causing Preterm Labour and Systemic Inflammatory Response Syndrome

BACKGROUND

Fibroids are present in at least 10% of pregnancies and are recognized to cause a variety of complications. A few case reports have described fibroids as an etiological factor in uterine rupture, sometimes with life-threatening hemorrhage.

CASE

A 28-year-old G1, P0 woman at 20 weeks gestation developed systemic inflammatory response syndrome with acute renal failure and massive ascites secondary to a ruptured degenerated fibroid. This resulted in preterm delivery and neonatal death. At 6 weeks postpartum, she successfully underwent an abdominal myomectomy.

CONCLUSION

This is a rare case of uterine fibroid rupture causing preterm labour and systemic inflammatory response syndrome. This report discusses the diagnosis of uterine rupture related to the fibroid with imaging and subsequent management, which included fertility-preserving surgery.

Opportunities, controversies, and challenges of extracorporeal hemoadsorption with CytoSorb during ECMO

Extracorporeal membrane oxygenation (ECMO) is frequently used in many centers around the globe for various indications. However, prognosis is often poor even with all supportive therapies, and in many cases, clinical deterioration is associated with inflammation. Hemoadsorption with CytoSorb is a novel approach to limit the inflammatory response, and the device can be safely and easily installed into ECMO circuits. CytoSorb has been used more than 130.000 times to date, but because randomized controlled trials are largely lacking, there is substantial debate on its use. Here, experts from critical care medicine, cardiology, cardiac surgery, and perfusion technology discuss the pros and cons of this novel therapy and outline the future aspects for its clinical application and research.

Paediatrics: how to manage septic shock

Background

Septic shock is a common critical illness associated with high morbidity and mortality in children. This article provides an updated narrative review on the management of septic shock in paediatric practice.

Methods

A PubMed search was performed using the following Medical Subject Headings: "sepsis", "septic shock" and "systemic inflammatory response syndrome". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies and reviews. The search was limited to the English literature and specific to children.

Results

Septic shock is associated with high mortality and morbidity. The outcome can be improved if the diagnosis is made promptly and treatment initiated without delay. Early treatment with antimicrobial therapy, fluid therapy and vasoactive medications, and rapid recognition of the source of sepsis and control are the key recommendations from paediatric sepsis management guidelines.

Conclusion

Most of the current paediatric sepsis guideline recommendations are based on the adult population; therefore, the research gaps in paediatric sepsis management should be addressed.

Comparison of the quick Sepsis-related Organ Failure Assessment and adult sepsis pathway in predicting adverse outcomes among adult patients in general wards: a retrospective observational cohort study

BACKGROUND

Quick Sepsis-related Organ Failure Assessment (qSOFA) is recommended for use by the most recent international sepsis definition taskforce to identify suspected sepsis in patients outside the intensive care unit (ICU) at risk of adverse outcomes. Evidence of its comparative effectiveness with existing sepsis recognition tools is important to guide decisions about its widespread implementation.

AIM

To compare the performance of qSOFA with the adult sepsis pathway (ASP), a current sepsis recognition tool widely used in NSW hospitals and systemic inflammatory response syndrome criteria in predicting adverse outcomes in adult patients on general wards.

METHODS

A retrospective observational cohort study was conducted which included all adults with suspected infections admitted to a Sydney teaching hospital between December 2014 and June 2016. The primary outcome was in-hospital mortality with two secondary composite outcomes.

RESULTS

Among 2940 patients with suspected infection, 217 (7.38%) died in-hospital and 702 (23.88%) were subsequently admitted to ICU. The ASP showed the greatest ability to correctly discriminate in-hospital mortality and secondary outcomes. The area under the receiver-operating characteristic curve for mortality was 0.76 (95% confidence interval (CI): 0.74-0.78), compared to 0.64 for the qSOFA tool (95% CI: 0.61-0.67, P < 0.0001). Median time from the first ASP sepsis warning to death was 8.21 days (interquartile range (IQR): 2.29-16.75) while it was 0 days for qSOFA (IQR: 0-2.58).

CONCLUSIONS

The ASP demonstrated both greater prognostic accuracy and earlier warning for in-hospital mortality for adults on hospital wards compared to qSOFA. Hospitals already using ASP may not benefit from switching to the qSOFA tool.

Establishment of a Mass-Spectrometry-Based Method for the Identification of the In Vivo Whole Blood and Plasma ADP-Ribosylomes

Blood and plasma proteins are heavily investigated as biomarkers for different diseases. However, the post-translational modification states of these proteins are rarely analyzed since blood contains many enzymes that rapidly remove these modifications after sampling. In contrast to the well-described role of protein ADP-ribosylation in cells and organs, its role in blood remains mostly uncharacterized. Here, we discovered that plasma phosphodiesterases and/or ADP-ribosylhydrolases rapidly demodify in vitro ADP-ribosylated proteins. Thus, to identify the in vivo whole blood and plasma ADP-ribosylomes, we established a mass-spectrometry-based workflow that was applied to blood samples collected from LPS-treated pigs (Sus scrofa domesticus), which serves as a model for human systemic inflammatory response syndrome. These analyses identified 60 ADP-ribosylated proteins, 17 of which were ADP-ribosylated plasma proteins. This new protocol provides an important step forward for the rapidly developing field of ADP-ribosylation and defines the blood and plasma ADP-ribosylomes under both healthy and disease conditions.

Population Pharmacokinetics and Outcomes of Critically Ill Pediatric Patients Treated with Intravenous Colistin at Higher Than Recommended Doses

Limited pharmacokinetic (PK) data suggest that currently recommended pediatric dosages of colistimethate sodium (CMS) by the Food and Drug Administration and European Medicines Agency may lead to suboptimal exposure, resulting in plasma colistin concentrations that are frequently <2 mg/liter. We conducted a population PK study in 17 critically ill patients 3 months to 13.75 years (median, 3.3 years) old who received CMS for infections caused by carbapenem-resistant Gram-negative bacteria. CMS was dosed at 200,000 IU/kg/day (6.6 mg colistin base activity [CBA]/kg/day; 6 patients), 300,000 IU/kg/day (9.9 mg CBA/kg/day; 10 patients), and 350,000 IU/kg/day (11.6 mg CBA/kg/day; 1 patient). Plasma colistin concentrations were determined using ultraperformance liquid chromatography combined with electrospray ionization-tandem mass spectrometry. Colistin PK was described by a one-compartment disposition model, including creatinine clearance, body weight, and the presence or absence of systemic inflammatory response syndrome (SIRS) as covariates (P < 0.05 for each). The average colistin plasma steady-state concentration (C_ss,avg) ranged from 1.11 to 8.47 mg/liter (median, 2.92 mg/liter). Ten patients had C_ss,avg of ≥2 mg/liter. The presence of SIRS was associated with decreased apparent clearance of colistin (47.8% of that without SIRS). The relationship between the number of milligrams of CBA per day needed to achieve each 1 mg/liter of plasma colistin C_ss,avg and creatinine clearance (in milliliters per minute) was described by linear regression with different slopes for patients with and without SIRS. Nephrotoxicity, probably unrelated to colistin, was observed in one patient. In conclusion, administration of CMS at the above doses improved exposure and was well tolerated. Apparent clearance of colistin was influenced by creatinine clearance and the presence or absence of SIRS.

Presepsin as a Diagnostic and Prognostic Biomarker in Sepsis

Sepsis is a condition characterized by high morbidity and mortality which is commonly encountered in an emergency and critical care setting. Despite a substantial body of research, the ideal biomarker for the diagnosis and prognostic stratification of septic patients remains unknown. This review aimed to summarize the publications referring to the validity of the biomarker presepsin when used for the detection, monitoring and prognosis in patients suffering with sepsis.

This work is a narrative review based on a PubMed/Medline search conducted in order to identify all relevant publications referring to the use of presepsin in sepsis. Search was not limited by year of publication so all articles archived in the database would be retrieved. No article from before 2010 was identified.

A total of 57 publications of the last decade were included, all of which support the use of presepsin as a biomarker for the assessment of septic patients. It has been used alone or in combination with commonly used biomarkers in the evaluation of patients with sepsis in settings such as the emergency department and the intensive care unit. It is useful in the initial workup of patients with suspected sepsis in the emergency setting and may be a predictive factor of mortality and the most severe complication of sepsis.

Presepsin seems to be a valuable tool for the laboratory workup of sepsis, especially when used in conjunction with other biomarkers and clinical rating scores with an established role in this population. Further research is needed to evaluate the clinical implications of utilizing presepsin measurements in the workup of sepsis.

Thrombin Aggravates Hypoxia/Reoxygenation Injury of Cardiomyocytes by Activating an Autophagy Pathway-Mediated by SIRT1

BACKGROUND Acute myocardial infarction is the leading cause of mortality among adults worldwide. The present study aimed to investigate the role and mechanism of thrombin and SIRT1 in hypoxia/reoxygenation (H/R) injury. MATERIAL AND METHODS H9c2 cardiomyocytes were used to create an H/R model to simulate in vivo ischemia/reperfusion injury. The MTT assay was used to measure cell viability, qRT-PCR was used to detect the level of SIRT1, thrombin, and PAR-1, and western blot analysis was conducted for evaluation of thrombin, PAR-1, SIRT1, LC3I, LC3II, and Beclin1. ELISA was applied for determination of IL-1ß, IL-6, TNF-alpha, MMP-9, and ICAM-1. After the establishment of the H/R model, superoxide dismutase (SOD) activity was evaluated by the xanthine oxidase method, malondialdehyde content was detected by thiobarbituric acid assay, and reactive oxygen species generation was measured by CM-H2DCFDA. RESULTS The findings showed that thrombin enhanced inflammatory factor secretion and oxidative stress but inhibited cell viability in H/R-injured cardiomyocytes. We also observed that thrombin promoted autophagy in H/R-injured cardiomyocytes. In addition, thrombin enhanced the upregulation of SIRT1 expression by H/R. However, it was found that inhibition of SIRT1 could suppress the effect of thrombin on inflammatory factor secretion, oxidative stress, and cell viability. Moreover, downregulation of SIRT1 suppressed the inhibitory effect of thrombin on autophagy in H/R injury. CONCLUSIONS Thrombin aggravates H/R injury of cardiomyocytes by activating an autophagy pathway mediated by SIRT1. These findings might provide a potential target therapy for the treatment of ischemia/reperfusion injury in future clinical work.

Therapeutic plasma-exchange improves systemic inflammation and survival in acute-on-chronic liver failure: A propensity-score matched study from AARC

BACKGROUND AND AIM

Plasma-exchange (PE) has improved survival in acute liver failure by ameliorating systemic inflammatory response syndrome (SIRS). We evaluated PE and compared it to Fractional Plasma Separation and Adsorption (FPSA) and standard medical treatment (SMT) in a large multinational cohort of ACLF patients.

METHODS

Data were prospectively collected from the AARC database and analysed. Matching by propensity risk score (PRS) was performed. Competing risk survival analysis was done to identify deaths because of multiorgan failure (MOF). In a subset of 10 patients, we also evaluated the mechanistic basis of response to PE.

RESULTS

ACLF patients (n = 1866, mean age 44.3 ± 12.3 yrs, 93% males, 65% alcoholics) received either artificial liver support (ALS) (n = 162); [PE (n = 131), FPSA (n = 31)] or were continued on standard medical therapy (SMT) (n = 1704). In the PRS-matched cohort (n = 208, [ALS-119; PE-94, FPSA-25)], SMT-89). ALS therapies were associated with a significantly higher resolution of SIRS (Odd's ratio 9.23,3.42-24.8), lower and delayed development of MOF (Hazard ratio 7.1, 4.5-11.1), and lower liver-failure-related deaths as compared to FPSA and SMT (P < .05). PE cleared inflammatory cytokines, damage-associated molecular patterns, and endotoxin in all patients. Responders improved monocyte phagocytic function and mitochondrial respiration and increased the anti-inflammatory cytokine interleukin-1 receptor antagonist (IL-1RA) compared to non-responders. PE was associated with lesser adverse effects as compared to FPSA.

CONCLUSIONS

PE improves systemic inflammation and lowers the development of MOF in patients with ACLF. Plasma-exchange provides significant survival benefit over FPSA and could be a preferred modality of liver support for ACLF patients.

[Systemic inflammatory response syndrome in pancreatic necrosis: triggers and organ damage]

OBJECTIVE

To determine the main trigger mechanisms of multiple organ failure in acute severe pancreatitis.

MATERIAL AND METHODS

An experimental study included 26 dogs with pancreatic necrosis. We assessed homeostasis disorders and functional changes in the pancreas, bowel, liver, kidneys, lungs and heart. Forty-six patients with severe acute pancreatitis were examined. We studied homeostasis disorders and functional state of the organs, endotoxemia, lipid peroxidation, phospholipase activity, coagulation system and hypoxia.

RESULTS

Injury of various organs and systems due to systemic inflammatory response at the early stage of disease is an important aspect in progression of acute pancreatitis. Membrane destabilizing phenomena and disturbances in tissue component of coagulation system are the most significant factors. Patients with severe acute pancreatitis had significant changes in homeostasis. We distinguished two subgroups of patients. The course of disease was different. In the first subgroup, changes in homeostatic parameters were 15.4-24.2% less than in the second subgroup. This largely determined treatment outcomes as a whole. In the first subgroup, therapy was effective in most cases, in the second one - less effective that required surgical interventions. In the first subgroup, mortality and hospital-stay were less compared to the second subgroup.

CONCLUSION

Oxidative stress, hypoxia, activation of phospholipases, and coagulation abnormalities are important in the development of systemic inflammatory response syndrome following acute pancreatitis. These factors are triggers for a cascade of the same kind of pathophysiological phenomena contributing to multiple organ failure and pancreatitis. In the tissues of various organs, proportional growth of these markers is observed until the 6^th day, while in the blood - until the 4^th day.

Clinical Characteristics of Severe COVID-19 Patients Admitted to an Intensive Care Unit in Lombardy During the Italian Pandemic

Italy was one of the worst affected European countries during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. More than 50% of Italian cases occurred in the northern region of Lombardy, where the saturation of health services between March and April 2020 forced hospitals to allocate patients according to available resources. Eighteen severe coronavirus disease 2019 (COVID-19) patients were admitted to our hospital needing intensive support. Given the disease fatality, we investigated the patients' characteristics to identify mortality predictors. We counted seven deaths from multiple organ failure, two from septic shock, and two from collapsed lungs. The maximum case fatality was observed in patients who contracted SARS-CoV-2 in hospitals. The fatal outcome was associated with the following baseline characteristics: polymorbidity (OR 2.519, p = 0.048), low body mass index (OR 2.288, p = 0.031), low hemoglobin (OR 3.012, p = 0.046), and antithrombin III (OR 1.172, p = 0.048), along with a worsening of PaO₂/FiO₂ ratio in the first 72 h after admission (OR 1.067, p = 0.031). The occurrence of co-infections during hospitalization was associated with a longer need for intensive care (B = 4.511, p = 0.001). More information is needed to inform intensive care for patients with severe COVID-19, but our findings would certainly contribute to shed some light on this unpredictable and multifaceted disease.

AdipoRon Attenuates Inflammation and Impairment of Cardiac Function Associated With Cardiopulmonary Bypass-Induced Systemic Inflammatory Response Syndrome

Background

Cardiac surgery using cardiopulmonary bypass (CPB) frequently provokes a systemic inflammatory response syndrome, which is triggered by TLR4 (Toll‐like receptor 4) and TNF‐α (tumor necrosis factor α) signaling. Here, we investigated whether the adiponectin receptor 1 and 2 agonist AdipoRon modulates CPB‐induced inflammation and cardiac dysfunction.

Methods and Results

Rats underwent CPB with deep hypothermic circulatory arrest and were finally weaned from the heart‐lung machine. Compared with vehicle, AdipoRon application attenuated the CPB‐induced impairment of mean arterial pressure following deep hypothermic circulatory arrest. During the weaning and postweaning phases, heart rate and mean arterial pressure in all AdipoRon animals (7 of 7) remained stable, while cardiac rhythm was irretrievably lost in 2 of 7 of the vehicle‐treated animals. The AdipoRon‐mediated improvements of cardiocirculatory parameters were accompanied by increased plasma levels of IL (interleukin) 10 and diminished concentrations of lactate and K⁺. In myocardial tissue, AdipoRon activated AMP‐activated protein kinase (AMPK) while attenuating CPB‐induced degradation of nuclear factor κB inhibitor α (IκBα), upregulation of TNF‐α, IL‐1β, CCL2 (C‐C chemokine ligand 2), nicotinamide adenine dinucleotide phosphate (NADPH) oxidase, and inducible nitric oxide synthase. Correspondingly, in cultured cardiac myocytes, cardiac fibroblasts, and vascular endothelial cells, AdipoRon activated AMPK, upregulated IL‐10, and attenuated activation of nuclear factor κB, as well as upregulation of TNF‐α, IL‐1β, CCL2, NADPH oxidase, and inducible nitric oxide synthase induced by lipopolysaccharide or TNF‐α. In addition, the treatment of cardiac myocytes with the AMPK activator 5‐aminoimidazole‐4‐carboxamide 1‐β‐D‐ribofuranoside resulted in a similar inhibition of lipopolysaccharide‐ and TNF‐α–induced inflammatory cell phenotypes as for AdipoRon.

Conclusions

Our observations indicate that AdipoRon attenuates CPB‐induced inflammation and impairment of cardiac function through AMPK‐mediated inhibition of proinflammatory TLR4 and TNF‐α signaling in cardiac cells and upregulation of immunosuppressive IL‐10.

Neuroprotective effect of ketamine against TNF-α-induced necroptosis in hippocampal neurons

Tumour necrosis factor‐α (TNF‐α), a crucial cytokine, has various homeostatic and pathogenic bioactivities. The aim of this study was to assess the neuroprotective effect of ketamine against TNF‐α‐induced motor dysfunction and neuronal necroptosis in male C57BL/6J mice in vivo and HT‐22 cell lines in vitro. The behavioural testing results of the present study indicate that ketamine ameliorated TNF‐α‐induced neurological dysfunction. Moreover, immunohistochemical staining results showed that TNF‐α‐induced brain dysfunction was caused by necroptosis and microglial activation, which could be attenuated by ketamine pre‐treatment inhibiting reactive oxygen species production and mixed lineage kinase domain‐like phosphorylation in hippocampal neurons. Therefore, we concluded that ketamine may have neuroprotective effects as a potent inhibitor of necroptosis, which provides a new theoretical and experimental basis for the application of ketamine in TNF‐α‐induced necroptosis‐associated diseases.

Evaluation of an augmented emergency department electronic medical record-based sepsis alert

OBJECTIVE

Electronic medical records-based alerts have shown mixed results in identifying ED sepsis. Augmenting clinical patient-flagging with automated alert systems may improve sepsis screening. We evaluate the performance of a hybrid alert to identify patients in ED with sepsis or in-hospital secondary outcomes from infection.

METHODS

We extracted a dataset of all patients with sepsis during the study period at five participating Western Sydney EDs. We evaluated the hybrid alert's performance for identifying patients with a discharge diagnosis related to infection and modified sequential sepsis-related organ functional assessment (mSOFA) score ≥2 in ED and also compared the alert to rapid bedside screening tools to identify patients with infection for secondary outcomes of all-cause in-hospital death and/or intensive care unit admission.

RESULTS

A total of 118 178 adult patients presented to participating EDs during study period with 1546 patients meeting ED sepsis criteria. The hybrid alert had a sensitivity - 71.2% (95% confidence interval 68.8-73.4), specificity - 96.4% (95% confidence interval 96.3-96.5) for identifying ED sepsis. Clinician flagging identified additional alert-negative 232 ED sepsis and 63 patients with secondary outcomes and 112 alert-positive patients with infection and ED mSOFA score <2 went on to die in hospital.

CONCLUSION

The hybrid alert performed modestly in identifying ED sepsis and secondary outcomes from infection. Not all infected patients with a secondary outcome were identified by the alert or mSOFA score ≥2 threshold. Augmenting clinical practice with auto-alerts rather than pure automation should be considered as a potential for sepsis alerting until more reliable algorithms are available for safe use in clinical practice.

Comparison of SOFA Score, SIRS, qSOFA, and qSOFA + L Criteria in the Diagnosis and Prognosis of Sepsis

Objective

Sepsis has been defined as a life-threatening organ dysfunction that develops as a result of impaired host response to infection. This study aimed to investigate sequential organ failure assessment (SOFA) score, systemic inflammatory response syndrome (SIRS), quick SOFA (qSOFA), and qSOFA + lactate criteria (qSOFA+L) in the diagnosis and prognosis of sepsis.

Materials and Methods

A retrospective study was performed that included all patients diagnosed with sepsis between January 1, 2013 and December 31, 2017 in Izmir Tepecik Training and Research Hospital Infectious Diseases and Clinical Microbiology Clinic.

Results

A total of 976 patients diagnosed with sepsis (mean age 72.5±13.7 years, 52.7% women) over five years were included in this study. Of all patients admitted to the emergency department and diagnosed with sepsis, 37.4% (n=365) were hospitalized and 52.3% (n=191) of these patients died. Emergency department mortality was 12.5% (n=122). The mortality rate was higher in patients with qSOFA and qSOFA+L criteria ≥2 in the emergency department. There was no statistically significant difference in terms of SIRS, qSOFA, or qSOFA+L criteria among patients who died in the hospital. The SOFA score (area under receiver operator characteristic curve, AUC=0.89) was highly discriminative in predicting sepsis. When the SOFA score was>11, its sensitivity and negative predictive values were both 100%. The SOFA score (AUC=0.75 and 0.72, respectively) was also highly discriminative in predicting emergency and in-hospital mortality. When the SOFA score was>11, the sensitivity and specificity of predicting emergency department mortality were 63.5% and 78.8%, respectively. The sensitivity was 65.8% and the specificity was 75.5% when describing in-hospital mortality for SOFA scores>9.

Conclusion

The SOFA score was highly sensitive and predictive in the diagnosis of sepsis. The SOFA score had a high discriminative ability to predict emergency and in-hospital mortality.

Retrospective evaluation of the use of hydrocortisone for treatment of suspected critical illness-related corticosteroid insufficiency (CIRCI) in dogs with septic shock (2010-2017): 47 cases

OBJECTIVE

To evaluate characteristics of septic shock patients treated with hydrocortisone (HC) due to suspicion of critical illness-related corticosteroid insufficiency (CIRCI) as compared to septic shock patients without suspicion of CIRCI.

DESIGN

Retrospective study between February 2010 and October 2017.

SETTING

University teaching hospital ICU.

ANIMALS

Data were collected for 47 dogs with septic shock. Twenty-one dogs were treated with HC (HC-treated) due to suspicion of CIRCI. Twenty-six dogs did not receive HC (non-HC-treated).

INTERVENTIONS

HC was administered either as an intermittent IV bolus or as a constant rate infusion (CRI) to those patients with suspected CIRCI.

MEASUREMENTS AND MAIN RESULTS

Significantly higher baseline APPLE_full scores and predicted mortality were detected in the HC-treated patients compared to non-HC-treated patients (0.87 vs 0.44 for predicted mortality, P = 0.039). Patients in the HC-treated group were on more vasopressors and cardiotonics than those in the non-HC-treated group (2.5 vs 1.5, P <0 .001). All patients initially responded to vasopressor administration, with average time to resolution of hypotension being 90 minutes for the HC-treated group compared to 60 minutes for the non-HC-treated group (P = 0.640). However, HC-treated patients took significantly longer to have a sustained resolution (a systolic blood pressure > 90 mm Hg or a mean blood pressure > 65 mm Hg for at least 4 h) of their hypotension after starting vasopressors, as compared to their non-HC-treated counterparts (8.5 vs 4 h, P = 0.001). Three (14.3%) HC-treated patients survived to discharge compared to 9 (34.6%) non-HC-treated patients, but this was not statistically significant.

CONCLUSIONS

HC-treated patients had a higher baseline risk of mortality than non-HC-treated patients. There was no significant difference in survival between the HC-treated and non-HC-treated septic shock patients. Further studies are needed to evaluate the use of HC in patients with suspected CIRCI.