Systemic inflammatory response syndrome, sepsis, severe sepsis and septic shock: incidence, morbidities and outcomes in surgical ICU patients

An evaluation of the Charlson co-morbidity score for predicting sepsis after elective major surgery

BACKGROUND AND AIMS

Severe sepsis is a significant cause of morbidity and mortality following major surgery. The Charlson co-morbidity score (CCS) has been shown to be associated with severe sepsis following major surgery for cancer. This prospective observational study investigated the effect of patient factors (CCS, gender, age and malignancy) and intraoperative factors (duration of surgery and allogeneic blood transfusion) on the incidence of sepsis after elective major surgery, and the impact of patient co-morbidities on length of stay in critical care.

MATERIALS AND METHODS

We prospectively identified a cohort of 101 patients undergoing elective major surgery in a university teaching hospital. The CCS was calculated before surgery, and the incidence of sepsis was documented following surgery. We investigated whether age, malignancy, intraoperative allogeneic blood transfusion, length of surgery or gender were associated with sepsis following surgery.

RESULTS

Twenty-seven (27%) patients developed sepsis. Using multivariate logistic regression, the duration of surgery was associated with the development of sepsis after surgery (P = 0.054, odds ratio 1.2). The CCS was not associated with sepsis in this population of cancer and non-cancer patients undergoing elective major surgery, but was associated with longer length of stay in the intensive care unit (P = 0.016).

CONCLUSIONS

Duration of surgery, but not patient co-morbidity as assessed by the CCS, may predict the postoperative incidence of sepsis. CCS could be used as a guide to predict consumption of critical care resources by elective surgical patients. A higher CCS was associated with a longer ICU stay. Resources, such as postoperative goal directed therapy, may be useful in reducing length of stay, hospital costs and risks of infective complications in this subgroup of patients with higher CCS.

Total Thyroidectomy in the Mouse: the Feasibility Study in the Non-thyroidal Tumor Model Expressing Human Sodium/Iodide Symporter Gene

PURPOSE

This study sought to probe the feasibility of performing total thyroidectomy in the mouse using a non-thyroidal hNIS expressing tumor model.

MATERIALS AND METHODS

Our thyroidectomy protocol included thorough excision of both lobes and the isthmus. For evaluating the completeness of thyroidectomy, we compared the (99m)Tc-pertechnetate scans taken before and after thyroidectomy. The prostate cancer cell line was subcutaneously inoculated 2 weeks after the thyroidectomy. When the tumor reached 5-10 mm in diameter, Ad5/35-E4PSESE1a-hNIS was injected intratumorally, and (131)I scans were performed. The radioiodine uptakes of the neck and the tumor were compared with those of the other regions.

RESULTS

Total thyroidectomy was performed in 13 mice. Although 38.5% died during or just after thyroidectomy, the others survived in good health for 2 months. Thyroid tissue was completely eliminated using our protocol; the residual uptake of (99m)Tc-pertechnetate was minimal in the neck area. The neck/background uptake ratio after thyroidectomy was significantly lower than that before thyroidectomy (p < 0.05). Non-thyroidal tumor models were successfully established in all the surviving mice. Radioiodine accumulation in the tumors was visualized on (131)I scans, and the neck uptakes were minimal.

CONCLUSION

Using our total thyroidectomy protocol, we successfully established a hNIS-transfected prostate cancer model with a minimal accumulation of radioiodine in the neck. The relatively high mortality after surgery can be a problem, and this might be reduced by minimizing the surgical stress.

Postoperative sepsis in the United States

OBJECTIVES

To evaluate the incidence of postoperative sepsis after elective procedures, to define surgical procedures with the greatest risk for developing sepsis, and to evaluate patient and hospital confounders.

BACKGROUND DATA

The development of sepsis after elective surgical procedures imposes a significant clinical and resource utilization burden in the United States. We evaluated the development of sepsis after elective procedures in a nationally representative patient cohort and assessed the effect of sociodemographic and hospital characteristics on the development of postoperative sepsis.

METHODS

The Nationwide inpatient sample was queried between 2002 and 2006 and patients developing sepsis after elective procedures were identified using the patient safety indicator "Postoperative Sepsis" (PSI-13). Case-mix adjusted rates were calculated by using a multivariate logistic regression model for sepsis risk and an indirect standardization method.

RESULTS

A total of 6,512,921 weighted elective surgical cases met the inclusion criteria and 78,669 cases (1.21%) developed postoperative sepsis. Case-mix adjustment for age, race, gender, hospital bed size, hospital location, hospital teaching status, and patient income demonstrated esophageal, pancreatic, and gastric procedures represented the greatest risk for the development of postoperative sepsis. Thoracic, adrenal, and hepatic operations accounted for the greatest mortality rates if sepsis developed. Increasing age, Blacks, Hispanics, and men were more likely to develop sepsis. Decreased median household income, larger hospital bed size, urban hospital location, and nonteaching status were associated with greater rates of postoperative sepsis.

CONCLUSIONS

The development of postoperative sepsis is multifactorial and procedures, most likely to develop sepsis, did not demonstrate the greatest mortality after sepsis developed. Factors associated with the development of sepsis included race, age, hospital size, hospital location, and patient income. Further evaluation of high-risk procedures, populations, and environments may assist in reducing this costly complication.

Systemic inflammatory response syndrome score at admission predicts injury severity, organ damage and serum neutrophil elastase production in trauma patients

BACKGROUND

Systemic inflammatory response syndrome (SIRS) is a clinical condition representing the culmination of the activation of a complex network of acute endogenous mediators.

MATERIALS AND METHODS

We investigated both the relationship between the results of SIRS assessments in 212 trauma patients at the time of hospital arrival and measures of trauma severity determined using the Injury Severity Score (ISS) and the Revised Trauma Score (RTS). We then considered the possibility of whether this assessment could be used to predict the development of organ dysfunction as a complication in trauma patients after admission. The serum neutrophil elastase (SNE) level was also measured in 47 cases.

RESULTS

The cases with SIRS had a significantly higher ISS and a lower RTS. Organ dysfunction occurred in 22 cases, and a significant correlation was noted between the development of organ dysfunction and the presence of SIRS (86.4%; 19 cases/22 cases, p=0.0007) at the time of arrival. The SNE level was significantly higher among the patients who fulfilled the four SIRS criteria than among the other patients (p=0.0301).

CONCLUSION

We concluded that the greater the SIRS score at the time of hospital arrival, the greater the anatomical and physiological severity of the trauma patient's condition.

Pathogenesis and diagnosis of hepatic encephalopathy

Hepatic encephalopathy (HE) is a common and potentially devastating neuropsychiatric complication of acute liver failure and cirrhosis. Even in its mildest form, minimal HE (MHE), the syndrome significantly impacts daily living and heralds progression to overt HE. There is maturity in the scientific understanding of the cellular processes that lead to functional and structural abnormalities in astrocytes. Hyperammonemia and subsequent cell swelling is a key pathophysiological abnormality, but this aspect alone is insufficient to fully explain the complex neurotransmitter abnormalities that may be observable using sophisticated imaging techniques. Inflammatory cytokines, reactive oxygen species activation and the role of neurosteroids on neurotransmitter binding sites are emerging pathological lines of inquiry that have yielded important new information on the processes underlying HE and offer promise of future therapeutic targets. Overt HE remains a clinical diagnosis and the neurophysiological and imaging modalities used in research studies have not transferred successfully to the clinical situation. MHE is best characterized by psychometric evaluation, but these tests can be lengthy to perform and require specific expertise to interpret. Simpler computer-based tests are now available and perhaps offer an opportunity to screen, diagnose and monitor MHE in a clinical scenario, although large-scale studies comparing the different techniques have not been undertaken. There is a discrepancy between the depth of understanding of the pathophysiology of HE and the translation of this understanding to a simple, easily understood diagnostic and longitudinal marker of disease. This is a present area of focus for the management of HE.

Disruption of sarcolemmal dystrophin and beta-dystroglycan may be a potential mechanism for myocardial dysfunction in severe sepsis

Evidence from our laboratory has shown alterations in myocardial structure in severe sepsis/septic shock. The morphological alterations are heralded by sarcolemmal damage, characterized by increased plasma membrane permeability caused by oxidative damage to lipids and proteins. The critical importance of the dystrophin-glycoprotein complex (DGC) in maintaining sarcolemmal stability led us to hypothesize that loss of dystrophin and associated glycoproteins could be involved in early increased sarcolemmal permeability in experimentally induced septic cardiomyopathy. Male C57Bl/6 mice were subjected to sham operation and moderate (MSI) or severe (SSI) septic injury induced by cecal ligation and puncture (CLP). Using western blot and immunofluorescence, a downregulation of dystrophin and beta-dystroglycan expression in both severe and moderate injury could be observed in septic hearts. The immunofluorescent and protein amount expressions of laminin-alpha2 were similar in SSI and sham-operated hearts. Consonantly, the evaluation of plasma membrane permeability by intracellular albumin staining provided evidence of severe injury of the sarcolemma in SSI hearts, whereas antioxidant treatment significantly attenuated the loss of sarcolemmal dystrophin expression and the increased membrane permeability. This study offers novel and mechanistic data to clarify subcellular events in the pathogenesis of cardiac dysfunction in severe sepsis. The main finding was that severe sepsis leads to a marked reduction in membrane localization of dystrophin and beta-dystroglycan in septic cardiomyocytes, a process that may constitute a structural basis of sepsis-induced cardiac depression. In addition, increased sarcolemmal permeability suggests functional impairment of the DGC complex in cardiac myofibers. In vivo observation that antioxidant treatment significantly abrogated the loss of dystrophin expression and plasma membrane increased permeability supports the hypothesis that oxidative damage may mediate the loss of dystrophin and beta-dystroglycan in septic mice. These abnormal parameters emerge as therapeutic targets and their modulation may provide beneficial effects on future cardiovascular outcomes and mortality in sepsis.

Bacteremia, acute physiology and chronic health evaluation II and modified end stage liver disease are independent predictors of mortality in critically ill nontransplanted patients with acute on chronic liver failure

OBJECTIVES

To determine what physiological and biochemical factors predict development of bacteremia in nontransplanted patients with acute on chronic liver failure and, on diagnosis of bacteremia, what is the natural history of bacteremic patients versus control subjects (acute on chronic liver failure).

INTERVENTIONS

None.

DESIGN

Retrospective analysis of data collected prospectively and entered into a dedicated physiology database.

SETTING

Specialist liver intensive therapy unit.

PATIENTS

Critically ill non-transplanted patients with acute on chronic liver failure admitted between January 2003 and July 2005.

MEASUREMENTS AND MAIN RESULTS

One hundred eighty-four patients were defined with acute on chronic liver failure; 67 (36%) had bacteremia. One hundred seventeen (64%) patients did not (acute on chronic liver failure). Fifty-eight percent of isolates were Gram-negative organisms, 36% were Gram-positives, and 6% fungemia. Median time to first bacteremia was 8 days (range, 3-12 days). On admission (univariate), bacteremic patients had significantly higher Modified End Stage Liver Disease scores (27 vs. 24, p = .037), Acute Physiology and Chronic Health Evaluation II scores (23 vs. 21, p = .049), and greater degrees of encephalopathy (Glasgow Coma Scale score 10 vs. 12, p = .001). During their liver intensive therapy unit course, bacteremic patients had significantly greater requirements for renal replacement therapy (64% vs. 49%, p = .043), mechanical ventilation (88% vs. 68%, p = .002), and a longer median liver intensive therapy unit stay (16 vs. 5 days, p < .001). Survival to hospital discharge was worse in the bacteremic group (25% vs. 56%, p < .001). Multivariate analysis (logistic regression) was performed separately modeling with Acute Physiology and Chronic Health Evaluation II and Modified End Stage Liver Disease. In the first model, Acute Physiology and Chronic Health Evaluation II (odds ratio 1.24) and bacteremia (2.24) were independent predictors of mortality. In the later model, Modified End Stage Liver Disease (odds ratio, 1.06), requirement for renal replacement therapy (3.08), Glasgow Coma Scale (0.72), and bacteremia (2.30) were significant. Both models performed similarly (Modified End Stage Liver Disease area under the receiver operating characteristic curve, 0.864; Acute Physiology and Chronic Health Evaluation II, 0.862).

CONCLUSIONS

In nontransplanted patients with acute on chronic liver failure, bacteremia was associated with increased severity of illness on admission, greater requirements for organ support, and independently adversely impacted on survival. Higher Acute Physiology and Chronic Health Evaluation II and Modified End Stage Liver Disease scores were also independently predictive of mortality.

Bacteremia in Stevens-Johnson syndrome and toxic epidermal necrolysis: epidemiology, risk factors, and predictive value of skin cultures

Toxic epidermal necrolysis (TEN) is a rare drug-related life-threatening acute condition. Sepsis is the main cause of mortality. Skin colonization on top of impaired barrier function promotes bloodstream infections (BSI). We conducted this study to describe the epidemiology, identify early predictors of BSI, and assess the predictive value for bacteremia of routine skin surface cultures. We retrospectively analyzed the charts of all patients with Stevens-Johnson syndrome (SJS) and TEN hospitalized over an 11-year period. Blood cultures and skin isolates were recovered from the microbiology laboratory database. Early predictors of BSI were identified using a Cox model. Sensitivity, specificity, and negative and positive predictive values of skin cultures for the etiology of BSI were assessed. The study included 179 patients, classified as having SJS (n = 54; 30.2%), SJS/TEN overlap (n = 59; 33.0%), and TEN (n = 66; 36.9%). Forty-eight episodes of BSI occurred, yielding a rate of 15.5/1000 patient days. In hospital mortality was 13.4% (24/179). Overall, 70 pathogens were recovered, mainly Staphylococcus aureus (n = 23/70; 32.8%), Pseudomonas aeruginosa (n = 15/70; 21.4%), and Enterobacteriaceae organisms (n = 17/70; 24.3%). Variables associated with BSI in multivariate analysis included age >40 years (hazard ratio [HR], 2.5; 95% confidence interval [CI], 1.35-4.63), white blood cell count >10,000/mm3 (HR, 1.9; 95% CI, 0.96-3.61), and percentage of detached body surface area >or=30% (HR, 2.5; 95% CI, 1.13-5.47). Skin cultures had an excellent negative predictive value for bacteremia due to S aureus (especially methicillin-resistant strains) and P aeruginosa, but not for those due to Enterobacteriaceae organisms. In contrast, the positive predictive value was low for all pathogens studied.To our knowledge, this is the largest study describing the epidemiology and risk factors of BSI in patients with SJS/TEN. The body surface area involved is the main predictor of BSI. Excellent negative predictive values of skin cultures for S aureus and P aeruginosa bacteremia should help clinicians consider targeted empirical antibiotic choices when appropriate.

Systemic inflammatory response syndrome outcome in surgical patients

INTRODUCTION

The problems of inflammation and infection as a leading cause of organ dysfunction and failure is a major problem after injury or operations. When systemic inflammatory response syndrome (SIRS) progress to multiple organ failure (MOF), the mortality reach up to 30-80% depending on the number of failed organs. Recent discoveries and improvement in patient care, a reasonable question then arises, are the incidence of MOF decreasing? The literature suggests a decrease in mortality of patients with severe organ failure and a decrease in elective surgical mortality in patients.

METHODS

This is prospective study of 50 patients who underwent surgical procedure. They were followed up till date of termination with daily SIRS monitoring, development of MODS and MOF. Risk factors for MOF are addressed.

RESULTS

There are total 31 patients who develop SIRS, of whom 7 patients develop severe sepsis and 4 went into MOF.

CONCLUSION

Early detection of SIRS helps us to prevent multiple organ dysfunction syndrome (MODS)/MOF, leading to lesser hospital stay and better outcome.

Predictors of bacteraemia and mortality in patients with acute liver failure

PURPOSE

To determine what physiological and biochemical factors predict development of bacteraemia and mortality in patients with acute liver failure (ALF).

METHODS

Retrospective analysis of 206 ALF patients admitted to a specialist liver intensive therapy unit (LITU) from January 2003 to July 2005 (data collected prospectively).

RESULTS

A total of 206 patients were defined with ALF: 72 (35%) suffered bacteraemia (BAClf) and 134 (65%) did not (NBAClf). Gram positive organisms were observed in 44% of isolates, gram negatives in 52% and fungaemia in 4%. Median time to first bacteraemia was 10 (7-16) days. On admission, BAClf patients had higher SIRS scores and degrees of hepatic encephalopathy (HE). During their LITU course, BAClf patients had significantly increased requirements for renal replacement therapy (RRT), mechanical ventilation, and longer median LITU stay. Multivariate analysis (logistical regression) demonstrated significant predictors of bacteraemia on admission were HE grade >2 (Odds Ratio 1.6) and SIRS score >1 (OR 2.7). In all patients, independent predictors of mortality (logistical) were age (OR 1.41), maximum HE grade pre-intubation (1.76), Lactate (1.14) and Acute Physiology and Chronic Health Evaluation II score (APACHEII) (1.09), but not bacteraemia. Transplantation was protective (OR 0.20).

CONCLUSION

In this study, severity of hepatic encephalopathy and SIRS score >1 were predictive of bacteraemia. APACHEII was independently predictive of mortality in all ALF patients but not bacteraemia.

Procalcitonin as a prognostic and diagnostic tool for septic complications after major trauma

OBJECTIVE

The primary aim of this study was to investigate the diagnostic value of procalcitonin (PCT) and C-reactive protein (CRP) in septic complications after major trauma. A secondary aim was to determine whether there was a prognostic value of PCT for severity of injury, organ dysfunction, and sepsis.

DESIGN

Prospective study.

SETTING

Medical/surgical intensive care unit (ICU).

PATIENTS

Ninety-four patients with consecutive trauma >or=16 years who were admitted to the ICU for an expected stay of >24 hours.

INTERVENTIONS

None.

MEASUREMENTS

PCT and CRP were collected at admission and every day thereafter. The American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference definition was used to identify sepsis criteria. The Sequential Organ Failure Assessment score was used to describe the severity of organ dysfunction. We retrospectively analyzed the occurrence of systemic inflammatory response syndrome and sepsis using the collected variables (criteria fulfilled at least during three continuous days).

MAIN RESULTS

Patients with trauma presented an early and significant increase in PCT at the moment of septic complications compared with concentrations measured 1 day before the diagnosis of sepsis: 0.85 vs. 3.32 ng/mL for PCT (p < 0.001) and 135 vs. 175 mg/L for CRP (p = not significant). The areas under the respective curve at admission in the diagnosis of sepsis were 0.787 (p < 0.001) and 0.489 for PCT and CRP, respectively.

CONCLUSION

PCT plasma reinduction marks possible septic complication during systemic inflammatory response syndrome after major trauma. In addition, high PCT concentration at admission after trauma in ICU patients indicates an increased risk of septic complications.

[Early alterations in rat brain protein expression during sepsis]

INTRODUCTION

Sepsis still has a high mortality in critically-ill patients. Here, analysis of early alterations in cerebral proteome may lead to a better understanding of the molecular basis of cerebral dysfunction. The aim of the present study was therefore to analyze cerebral protein dynamics during emerging sepsis in an established rat model.

MATERIAL AND METHODS

To induce sepsis, an established coecal ligature and double puncture (coecal ligature and puncture, CLP) model was used on Wistar rats. After 12 hours, surviving rats (sepsis: n=6 and sham: n=6) were decapitated and their brains prepared for gel electrophoresis (2DE) and subsequent mass spectrometry. Biological function of differentially regulated proteins (t-test, p<0.01) was then analyzed using bioinformatic network analysis (ingenuity pathways analysis, IPA).

RESULTS

Mortality was 40 % in the sepsis-group and no rat of the sham-group died. Altogether, nine significantly regulated proteins were identified (4 up-regulated, 5 down-regulated). IPA then detected eight network proteins and interpreted them in the context of established protein alterations for sepsis.

CONCLUSION

The combination of proteomics and IPA could identify proteins in rat brain, whose expression was significantly regulated during sepsis. The methodological approach applied in the present study may facilitate the quest for novel sepsis-induced protein alterations in the future.

Procalcitonin (PCT) is useful in predicting the bacterial origin of an acute circulatory failure in critically ill patients

OBJECTIVE

To evaluate the accuracy of procalcitonin (PCT) in predicting bacterial infection in ICU medical and surgical patients.

SETTING

A 10-bed medical surgical unit.

DESIGN

PCT, C-reactive protein (CRP), interleukin 6 (IL-6) dosages were sampled in four groups of patients: septic shock patients (SS group), shock without infection (NSS group), patients with systemic inflammatory response syndrome related to a proven bacterial infection (infect. group) and ICU patients without shock and without bacterial infection (control group).

RESULTS

Sixty patients were studied (SS group:n=16, NSS group,n=18, infect. group,n=16, control group,n=10). The PCT level was higher in patients with proven bacterial infection (72+/-153 ng/ml vs 2.9+/-10 ng/ml,p=0.0003). In patients with shock, PCT was higher when bacterial infection was diagnosed (89 ng/ml+/-154 vs 4.6 ng/ml+/-12,p=0.0004). Moreover, PCT was correlated with severity (SAPS:p=0.00005, appearance of shock:p=0.0006) and outcome (dead: 71.3 g/ml, alive: 24.0 g/ml,p=0.006). CRP was correlated with bacterial infection (p<10(-5)) but neither with SAPS nor with day 28 mortality. IL-6 was correlated with neither infection nor day 28 mortality but was correlated with SAPS. Temperature and white blood cell count were unable to distinguish shocked patients with or without infection. Finally, when CRP and PCT levels were introduced simultaneously in a stepwise logistic regression model, PCT remained the unique marker of infection in patients with shock (PCT> or =5 ng/ml, OR: 6.2, 95% CI: 1.1-37,p=0.04).

CONCLUSION

The increase of PCT is related to the appearance and severity of bacterial infection in ICU patients. Thus, PCT might be an interesting parameter for the diagnosis of bacterial infections in ICU patients.

A prospective, observational registry of patients with severe sepsis: the Canadian Sepsis Treatment and Response Registry

OBJECTIVE

To determine the location of acquisition, timing, and outcomes associated with severe sepsis in community and teaching hospital critical care units.

DESIGN

Prospective, observational study.

SETTING

Twelve Canadian community and teaching hospital critical care units.

PATIENTS

All patients admitted between March 17, 2003, and November 30, 2004 to the study critical care units with at least a 24-hr length of stay or severe sepsis identified during the first 24 hrs.

INTERVENTIONS

Daily monitoring for severe sepsis.

MEASUREMENTS AND MAIN RESULTS

We recorded data describing characteristics of patients, infections, systemic responses, and organ dysfunction. Severe sepsis occurred in 1238 patients (overall rate, 19.0%; range, 8.2%-35.3%). Hospital mortality was 38.1% (95% confidence interval [CI]: 35.4-40.8). Median intensive care unit length of stay was 10.3 days (interquartile range: 5.5, 17.9). Variables associated with mortality in multivariable analysis included age (odds ratio [OR] by decade 1.50; 95% CI: 1.36-1.65), acquisition location of severe sepsis (with community as the reference-hospital [OR: 1.69; CI: 1.16-2.46], early intensive care unit [OR: 2.15; CI: 1.42-3.25], late intensive care unit [OR: 2.65; CI: 1.82-3.87]), late intensive care unit (OR: 2.65; CI: 1.82-3.87), any comorbidity (OR: 1.42; CI: 1.04-1.93), chronic renal failure (OR: 2.03; CI: 1.10-3.76), oliguria (OR: 1.34; CI: 1.02-1.76), thrombocytopenia (OR: 2.12; CI: 1.43-3.13), metabolic acidosis (OR: 1.54; CI: 1.13-2.10), Multiple Organ Dysfunction Score (OR: 1.15; CI: 1.09-1.21) and Acute Physiology and Chronic Health Evaluation II predicted risk (OR: 3.75; CI: 2.08-6.76).

CONCLUSION

These data confirm that sepsis is common and has high mortality in general intensive care unit populations. Our results can inform healthcare system planning and clinical study designs. Modifiable variables associated with worse outcomes, such as nosocomial infection (hospital acquisition), and metabolic acidosis indicate potential targets for quality improvement initiatives that could decrease mortality and morbidity.

Trends in postoperative sepsis: are we improving outcomes?

BACKGROUND AND PURPOSE

Each year, as many as two million operations are complicated by surgical site infections in the United States, and surgical patients account for 30% of patients with sepsis. The purpose of this study was to determine recent trends in sepsis incidence, severity, and mortality rate after surgical procedures and to evaluate changes in the pattern of septicemia pathogens over time.

METHODS

Analysis of the 1990-2006 hospital discharge data from the Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases (SID) for New Jersey. Patients >or= 18 years who developed sepsis after surgery were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes as defined by the Patient Safety Indicator "Postoperative Sepsis" developed by the Agency for Healthcare Research and Quality (AHRQ). Severe sepsis was defined as sepsis complicated by organ dysfunction.

RESULTS

A total of 1,276,451 surgery discharges (537,843 elective [42.1%] and 738,608 non-elective [57.9%] procedures) were identified. After elective surgery, 5,865 patients (1.09%) developed postoperative sepsis, of whom 2,778 (0.52%) had severe sepsis. The incidence of postoperative sepsis after elective surgery increased from 0.67% to 1.74% (p < 0.0001) and severe sepsis after elective surgery from 0.22% to 1.12% (p < 0.0001). The sepsis mortality rate for elective procedures showed no significant change over time. The proportion of severe sepsis after elective cases increased from 32.9% to 64.6% (p < 0.0002). The rates of postoperative sepsis (4.24%) and severe sepsis (2.28%) were significantly greater for non-elective than for elective procedures (p < 0.0002). Non-elective surgical procedures had a significant increase in the rates of postoperative sepsis (3.74% to 4.51%) and severe sepsis (1.79% to 3.15%) over time (p < 0.0001) with the proportion of severe sepsis increasing from 47.7% to 69.9% (p < 0.0002). The in-hospital mortality rate after non-elective surgery decreased from 37.9% to 29.8% (p < 0.0001).

CONCLUSIONS

Sepsis and death were more likely after non-elective than elective surgery. Sepsis and severe sepsis has increased significantly after elective and non-elective procedures over the last 17 years. The hospital mortality rate was reduced significantly after non-elective surgery, but no improvements were found for elective surgery patients who developed sepsis. Disparities in age, sex, and ethnicity and the development of postoperative surgical sepsis were found. Population-based studies may assist in defining temporal trends, disparities, and outcomes in sepsis not elucidated in smaller studies.

PIRO: The Key to Success?

Sepsis continues to represent a major problem in intensive care units worldwide. Diagnosis and management are often complex due in part to the remarkably diverse nature of the septic patient. Indeed, sepsis can range in severity from mild systemic inflammation of little clinical importance through to a widespread severe inflammatory response with multiple organ failure and a mortality rate in excess of 50%. Sepsis can affect individuals of any age group, with no or multiple co-morbidities, and with many different ongoing diagnoses. It can occur as the result of infection by one or more of a multitude of microbial pathogens impacting on any of numerous different sites within the body. Given the huge complexity of sepsis and the diverse populations of patients it affects, simple definitions are of relatively little use and a more detailed framework which can be used to better characterize patients with sepsis has been proposed, much as the TNM classification (tumor size, nodal spread, metastases) has been successfully used in clinical oncology. In this chapter, we discuss the development of this PIRO system, and suggest how it may be used in the future to aid diagnosis, guide therapy, and improve prognostication.

The importance of immune dysfunction in determining outcome in acute liver failure

Acute liver failure (ALF) shares striking similarities with septic shock with regard to the features of systemic inflammation, progression to multiple organ dysfunction and functional immunoparesis. While the existence of opposing systemic pro- and anti-inflammatory profiles resulting in organ failure and immune dysfunction are well recognised in septic shock, characterization of these processes in ALF has only recently been described. This review explores the evolution of the systemic inflammation in acute liver failure, its relation to disease progression, exacerbation of liver injury and development of innate immune dysfunction and extra-hepatic organ failure as sequelae. Defects in innate immunity are described in hepatic and extra-hepatic compartments. Clinical studies measuring levels of pro- and anti-inflammatory cytokines and expression of the antigen presentation molecule HLA-DR on monocytes, in combination with ex-vivo experiments, demonstrate that the persistence of a compensatory anti-inflammatory response syndrome, leading to functional monocyte deactivation, is a central event in the evolution of systemic immune dysfunction. Accurate immune profiling in ALF may permit the development of immunomodulatory strategies in order to improve outcome in this condition.

Clinical practice guidelines for improving outcomes in sepsis

Sepsis is a common medical condition resulting from an infectious stimulus with a variable inflammatory response leading to a spectrum of clinical conditions from mild constitutional symptoms to varying degrees of organ dysfunction and death. The understanding of the patho-physiology of sepsis has lead to better treatment modalities and whilst sepsis is an increasingly more common condition world wide, the mortality from sepsis is nevertheless falling. Treatment algorithms have been promulgated over the years and levels of evidence for these have varied. This review will focus on the early management issues recently updated and released by a multi-national panel of experts based on best evidence, aimed at reducing sepsis related mortality by 25%.

A long-term follow-up study investigating health-related quality of life and resource use in survivors of severe sepsis: comparison of recombinant human activated protein C with standard care

Introduction

Recombinant human activated protein C (APC) therapy has been shown to reduce short-term mortality in patients with severe sepsis. However, survivors of sepsis may have long-term complications affecting health-related quality of life (HRQoL) and resource utilization. The objective of this study was to evaluate prospectively the effect of APC on long-term HRQoL and resource utilization compared with a nonrandomized control group that received standard care.

Methods

This was an observational cohort study at nine Canadian intensive care units. Patients with severe sepsis who survived to 28 days were recruited. Patients who received APC formed the treatment group and those that did not formed the standard care group. Patients who did not receive APC because of central nervous system bleeding risk were excluded from the standard care group. HRQoL (determined using the 36-item Short Form) and resource use were recorded at 28 days, and 3, 5 and 7 months.

Results

One hundred patients were enrolled (64 in the standard care group and 36 in the APC group), with 70 patients completing all follow-up visits. Over the 6 months of follow up, APC-treated patients exhibited statistically significantly better scores for the physical component score (P = 0.04) and trends toward improvements in physical functioning (P = 0.12), role physical (P = 0.10) and bodily pain (P = 0.14) as compared with standard care patients. Shorter hospital length of stay was observed for the APC group (36 days versus 48 days; P = 0.05).

Conclusion

These findings challenge earlier assumptions suggesting equivalent HRQoL and resource use in APC-treated and standard care patients who survive severe sepsis.

Factors associated with posttraumatic stress symptoms in a prospective cohort of patients after abdominal sepsis: a nomogram

Objective

To determine to what extent patients who have survived abdominal sepsis suffer from symptoms of posttraumatic stress disorder (PTSD) and depression, and to identify potential risk factors for PTSD symptoms.

Design and setting

PTSD and depression symptoms were measured using the Impact of Events Scale–Revised (IES-R), the Post-Traumatic Symptom Scale 10 (PTSS-10) and the Beck Depression Inventory II (BDI-II).

Patients and participants

A total of 135 peritonitis patients were eligible for this study, of whom 107 (80%) patients completed the questionnaire. The median APACHE-II score was 14 (range 12–16), and 89% were admitted to the ICU.

Measurements and results

The proportion of patients with “moderate” PTSD symptom scores was 28% (95% CI 20–37), whilst 10% (95% CI 6–17) of patients had “high” PTSD symptom scores. Only 5% (95% CI 2–12) of the patients expressed severe depression symptoms. Factors associated with increased PTSD symptoms in a multivariate ordinal regression model were younger age (0.74 per 10 years older, p = 0.082), length of ICU stay (OR = 1.4 per doubling of duration, p = 0.003) and having some (OR = 4.9, p = 0.06) or many (OR = 55.5, p < 0.001) traumatic memories of the ICU or hospital stay.

Conclusion

As many as 38% of patients after abdominal sepsis report elevated levels of PTSD symptoms on at least one of the questionnaires. Our nomogram may assist in identifying patients at increased risk for developing symptoms of PTSD.

Electronic supplementary material

The online version of this article (doi:10.1007/s00134-007-0941-3) contains supplementary material, which is available to authorized users.

Reduction of gap and adherens junction proteins and intercalated disc structural remodeling in the hearts of mice submitted to severe cecal ligation and puncture sepsis*

OBJECTIVE

The present study describes intercalated disc remodeling under both protein expression and structural features in experimental severe sepsis induced by cecal ligation and puncture in mice.

DESIGN

Controlled animal study.

SETTING

University research laboratory.

SUBJECTS

Male C57BL/6 mice.

INTERVENTIONS

Mice were submitted to moderate and severe septic injury by cecal ligation and puncture.

MEASUREMENT AND MAIN RESULTS

Severe septic injury was accompanied by a large number of bacteria in the peritoneal cavity and blood, high levels of tumor necrosis factor-alpha, and monocyte inflammatory protein-1alpha in the septic focus and serum, marked hypotension, and a high mortality rate. Western blot analysis and immunofluorescence showed a marked decrease of key gap and adherens junction proteins (connexin43 and N-cadherin, respectively) in mice submitted to severe septic injury. These changes may result in the loss of intercalated disc structural integrity, characterized in the electron microscopic study by partial separation or dehiscence of gap junctions and adherens junctions.

CONCLUSIONS

Our data provide important insight regarding the alterations in intercalated disc components resulting from severe septic injury. The intercalated disc remodeling under both protein expression and structural features in experimental severe sepsis induced by cecal ligation and puncture may be partly responsible for myocardial depression in sepsis/septic shock. Although further electrophysiological studies in animals and humans are needed to determine the effect of these alterations on myocardial conduction velocity, the abnormal variables may emerge as therapeutic targets, and their modulation might provide beneficial effects on future cardiovascular outcomes and mortality in sepsis.

Health related quality of life six months following surgical treatment for secondary peritonitis--using the EQ-5D questionnaire

BACKGROUND

To compare health related quality of life (HR-QoL) in patients surgically treated for secondary peritonitis to that of a healthy population. And to prospectively identify factors associated with poorer (lower) HR-QoL.

DESIGN

A prospective cohort of secondary peritonitis patients was mailed the EQ-5D and EQ-VAS 6-months following initial laparotomy.

SETTING

Multicenter study in two academic and seven regional teaching hospitals.

PATIENTS

130 of the 155 eligible patients (84%) responded to the HR-QoL questionnaires.

RESULTS

HR-QoL was significantly worse on all dimensions in peritonitis patients than in a healthy reference population. Peritonitis characteristics at initial presentation were not associated with HR-QoL at six months. A more complicated course of the disease leading to longer hospitalization times and patients with an enterostomy had a negative impact on the mobility (p = 0.02), self-care (p < 0.001) and daily activities: (p = 0.01). In a multivariate analysis for the EQ-VAS every doubling of hospital stay decreases the EQ-VAS by 3.8 points (p = 0.015). Morbidity during the six-month follow-up was not found to be predictive for the EQ-5D or EQ-VAS.

CONCLUSION

Six months following initial surgery, patients with secondary peritonitis report more problems in HR-QoL than a healthy reference population. Unfavorable disease characteristics at initial presentation were not predictive for poorer HR-QoL, but a more complicated course of the disease was most predictive of HR-QoL at 6 months.

Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003

OBJECTIVE

To determine recent trends in rates of hospitalization, mortality, and hospital case fatality for severe sepsis in the United States.

DESIGN

Trend analysis for the period from 1993 to 2003.

SETTING

U.S. community hospitals from the Nationwide Inpatient Sample that is a 20% stratified sample of all U.S. community hospitals.

PATIENTS

Subjects of any age with sepsis including severe sepsis who were hospitalized in the United States during the study period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Utilizing International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for septicemia and major organ dysfunction, we identified 8,403,766 patients with sepsis, including 2,857,476 patients with severe sepsis, who were hospitalized in the United States from 1993 to 2003. The percentage of severe sepsis cases among all sepsis cases increased continuously from 25.6% in 1993 to 43.8% in 2003 (p < .001). Age-adjusted rate of hospitalization for severe sepsis grew from 66.8 +/- 0.16 to 132.0 +/- 0.21 per 100,000 population (p < .001). Age-adjusted, population-based mortality rate within these years increased from 30.3 +/- 0.11 to 49.7 +/- 0.13 per 100,000 population (p < .001), whereas hospital case fatality rate fell from 45.8% +/- 0.17% to 37.8% +/- 0.10% (p < .001). During each study year, the rates of hospitalization, mortality, and case fatality increased with age. Hospitalization and mortality rates in males exceeded those in females, but case fatality rate was greater in females. From 1993 to 2003, age-adjusted rates for severe sepsis hospitalization and mortality increased annually by 8.2% (p < .001) and 5.6% (p < .001), respectively, whereas case fatality rate decreased by 1.4% (p < .001).

CONCLUSIONS

The rate of severe sepsis hospitalization almost doubled during the 11-yr period studied and is considerably greater than has been previously predicted. Mortality from severe sepsis also increased significantly. However, case fatality rates decreased during the same study period.

Prognostic values of B-type natriuretic peptide in severe sepsis and septic shock

OBJECTIVE

To investigate the changes in B-type natriuretic peptide concentrations in patients with severe sepsis and septic shock and to investigate the value of B-type natriuretic peptide in predicting intensive care unit outcomes.

DESIGN

Prospective observational study.

SETTING

General intensive care unit.

PATIENTS

Forty patients with severe sepsis or septic shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

B-type natriuretic peptide measurements and echocardiography were carried out daily for 10 consecutive days. In-hospital mortality and length of stay were recorded. The admission B-type natriuretic peptide concentrations were generally increased (747 +/- 860 pg/mL). B-type natriuretic peptide levels were elevated in patients with normal left ventricular systolic function (568 +/- 811 pg/mL), with sepsis-related reversible cardiac dysfunction (630 +/- 726 pg/mL), and with chronic cardiac dysfunction (1311 +/- 1097 pg/mL). There were no significance changes in B-type natriuretic peptide levels over the 10-day period. The daily B-type natriuretic peptide concentrations for the first 3 days neither predicted in-hospital mortality nor correlated with length of intensive care unit or hospital stay.

CONCLUSION

B-type natriuretic peptide concentrations were increased in patients with severe sepsis or septic shock regardless of the presence or absence of cardiac dysfunction. Neither the B-type natriuretic peptide levels for the first 3 days nor the daily changes in B-type natriuretic peptide provided prognostic value for in-hospital mortality and length of stay in this mixed group of patients, which included patients with chronic cardiac dysfunction.

Accuracy of procalcitonin for sepsis diagnosis in critically ill patients: systematic review and meta-analysis

Procalcitonin is widely reported as a useful biochemical marker to differentiate sepsis from other non-infectious causes of systemic inflammatory response syndrome. In this systematic review, we estimated the diagnostic accuracy of procalcitonin in sepsis diagnosis in critically ill patients. 18 studies were included in the review. Overall, the diagnostic performance of procalcitonin was low, with mean values of both sensitivity and specificity being 71% (95% CI 67-76) and an area under the summary receiver operator characteristic curve of 0.78 (95% CI 0.73-0.83). Studies were grouped into phase 2 studies (n=14) and phase 3 studies (n=4) by use of Sackett and Haynes' classification. Phase 2 studies had a low pooled diagnostic odds ratio of 7.79 (95% CI 5.86-10.35). Phase 3 studies showed significant heterogeneity because of variability in sample size (meta-regression coefficient -0.592, p=0.017), with diagnostic performance upwardly biased in smaller studies, but moving towards a null effect in larger studies. Procalcitonin cannot reliably differentiate sepsis from other non-infectious causes of systemic inflammatory response syndrome in critically ill adult patients. The findings from this study do not lend support to the widespread use of the procalcitonin test in critical care settings.

The clinical impact of bacteremia in complicated acute pyelonephritis

BACKGROUND

Bacteremia has been considered as a surrogate marker of severe infection in several infectious diseases. However, it remains uncertain whether the presence of bacteremia correlates with severe infection in patients with complicated acute pyelonephritis (APN).

METHODS

We performed a retrospective study to investigate the relationship between the presence of bacteremia and disease severity in complicated APN. To do this, we reviewed medical records from 128 patients diagnosed with complicated APN admitted to Kaohsiung Veterans General Hospital, Taiwan between January, 2003 and December, 2003. In our analysis, we compared clinical presentation, treatment response, and outcome in patients with and without bacteremia.

RESULTS

Fifty-four of 128 patients (42%) were bacteremic. This group of patients presented more frequently with severe sepsis or septic shock (P < 0.001), compared with nonbacteremic patients. Other factors that correlated with the presence of bacteremia were older age, diabetes mellitus, more band forms in neutrophil cell counts, impaired renal function, and a lower level of serum albumin. Using a multivariate logistic regression analysis, we show that lower levels of serum albumin (odds ratio, 0.18; 95% CI, 0.05-0.65; P = 0.008) and presence of severe sepsis (odds ratio, 4.76; 95% CI, 1.43-15.84; P = 0.011) were independent factors associated with bacteremia. Following treatment, the bacteremic group took a longer time to become defervescent than the nonbacteremic group (5.1 +/- 2.3 vs. 4.2 +/- 1.6 days, P = 0.023). Also, the bacteremic group had a greater mean duration of intravenous antibiotics administration and longer hospital stays (P < 0.001). Multiple logistic regression analysis shows that non-Escherichia coli bacteremia, presence of urolithiasis or hydronephrosis, shorter duration of antibiotics administration, and being male were significantly associated with recurrence of urinary tract infection within 6 months.

CONCLUSION

Bacteremia in cases of complicated APN indicates a severe disease, which is more likely to recur in patients with non-E coli bacteremia. Our study showed that bacteremia is indeed a useful clinical indicator of severe disease and, if found, should influence patient management. Therefore, we recommend that blood culture samples should be taken in all patients with complicated APN.

The association of sepsis syndrome and organ dysfunction with mortality in emergency department patients with suspected infection

STUDY OBJECTIVE

The critical care community has used standard criteria for defining the sepsis syndromes and organ dysfunction for more than 15 years; however, these criteria are not well validated in the emergency department (ED) setting. The study objectives in our ED population of patients admitted to the hospital are to determine the prevalence of the sepsis syndromes, quantify inhospital mortality and 1-year survival associated with the sepsis syndromes, and assess the inhospital and 1-year survival associated with organ dysfunctions.

METHODS

This was a prospective, observational, cohort study from February 1, 2000, to February 1, 2001 in an urban university hospital ED with 50,000 annual visits. There were 3,102 (96% of eligible) consecutive adult patients (aged 18 years or older) with suspected infection (as indicated by the clinical decision to obtain a blood culture) who were enrolled. Patients were screened for systemic inflammatory response syndrome (SIRS) (2 or more indicators of inflammatory response), sepsis (SIRS plus suspected infection), severe sepsis (sepsis plus organ dysfunction), septic shock (sepsis plus hypotension refractory to an initial fluid challenge), and number of organs with acute dysfunction. Main outcome measure was inhospital and 1-year mortality.

RESULTS

Overall inhospital mortality was 4.1% and 1-year mortality was 22%. The inhospital mortality rates were suspected infection without SIRS 2.1%, sepsis 1.3%, severe sepsis 9.2%, and septic shock 28%. Compared to suspected infection without SIRS, adjusted risks of inhospital mortality were severe sepsis (odds ratio [OR] 4.0; 95% confidence interval [CI] 2.6 to 6.3) and septic shock (OR 13.8; 95% CI 6.6 to 29). Severe sepsis (OR 2.2; 95% CI 1.8 to 2.6) and septic shock (OR 3.5; 95% CI 2.3 to 5.3) also predicted 1-year mortality. The presence of SIRS criteria alone had no prognostic value for either endpoint. Each additional organ dysfunction increased the adjusted 1-year mortality hazard by 82% (pulse rate: 1.82, 95% CI 1.7 to 2.0).

CONCLUSION

Immediate identification of acute organ dysfunction in ED patients with suspected infection may help select patients at increased short- and long-term mortality risk. SIRS criteria offered no additional prognostic value, whereas each additional organ dysfunction increased the 1-year mortality risk.

Preoperative Oral Carbohydrate Administration to ASA III-IV Patients Undergoing Elective Cardiac Surgery

In this study we investigated the effects of preoperative oral carbohydrate administration on postoperative insulin resistance (PIR), gastric fluid volume, preoperative discomfort, and variables of organ dysfunction in ASA physical status III-IV patients undergoing elective cardiac surgery, including those with noninsulin-dependent Type-2 diabetes mellitus. Before surgery, 188 patients were randomized to receive a clear 12.5% carbohydrate drink (CHO), flavored water (placebo), or to fast overnight (control). CHO and placebo were treated in double-blind format and received 800 mL of the corresponding beverage in the evening and 400 mL 2 h before surgery. Patients were monitored from induction of general anesthesia until 24 h postoperatively. Exogenous insulin requirements to control blood glucose levels <or=10.0 mmol/L were used as a marker for PIR. Gastric fluid volume was measured by passive gastric reflux and preoperative discomfort using visual analog scales. Postoperative clinical and surgical data were recorded. Blood glucose levels and insulin requirements did not differ between groups. Patients receiving CHO and placebo were less thirsty compared with controls (P < 0.01 and P = 0.06, respectively). Ingested liquids did not cause increased gastric fluid volume or other adverse events. The CHO group required less intraoperative inotropic support after initiation of cardiopulmonary bypass weaning (P < 0.05). In conclusion, preoperative CHO administration before cardiac surgery does not affect PIR. Clear fluids reduce thirst and may be recommended as a safe procedure in ASA III-IV patients. Further research is indicated to investigate possible cardioprotective effects of preoperative CHO intake.

The value of sepsis definitions in daily ICU-practice

Sepsis is a major disease entity with important clinical and economic implications. Sepsis is the hosts' reaction to infection and is characterized by a systemic inflammatory response. Because of difficulties in defining sepsis, the SIRS was introduced trying to summarize the inflammatory response in a limited set of elementary characteristics (fever or hypothermia, leucocytosis or leucopenia, tachycardia, hyperventilation). In daily practice it is essential to identify septic patients as soon as possible because early recognition results in better survival rates. However, in order to allow early detection, a more stringent description of "the septic profile" is needed. From the start, even after revision of the primary sepsis description, these definitions have caused much controversy and debate because they lack sensitivity and specificity. Conclusively, almost all patients admitted to the intensive care unit meet or develop the systemic inflammatory response syndrome. Therefore, it is difficult to distinguish patients with true sepsis from those with severe inflammation due to non-infectious causes. This review highlights the current sepsis definitions, and discusses their strengths as well as their shortcomings for daily intensive care unit practice.

Systemic Inflammatory Response Syndrome and Nosocomial Infection in Trauma

BACKGROUND

Admission systemic inflammatory response syndrome (SIRS) score has been previously reported to be an accurate predictor of infection and outcome in trauma. However, the data were limited to the first 7 days of admission. Our objective in this follow-up study was to prospectively evaluate the utility of daily SIRS scores in the second and third week of admission as compared with the first week in prediction of nosocomial infection and outcome in high-risk trauma patients.

METHODS

Prospective data were collected on 1,277 consecutive trauma patients admitted during a 28-month period to the intensive care unit. SIRS scores were calculated daily for the first week and every other day for the following 2 weeks. Patients were categorized into SIRS occurring "early" (week 1), "middle" (week 2), and "late" (week 3). Centers for Disease Control and Prevention guidelines were used for the diagnosis of infection. Multivariate linear and logistic regression analyses were utilized for statistical analyses, controlling for the covariates of age, Injury Severity Score, and admission Glasgow Coma Scale score.

RESULTS

The trauma cohort included patients with blunt injuries (84%) and penetrating injuries (16%). The mean age was 43 +/- 21 years with an overall mortality of 14.7%. Nosocomial infection developed in 580 (45.4%) of the study patients (respiratory site most common) with a total of 1,001 infections (some patients with multiple infections). SIRS (defined as SIRS score >/=2) was common, with 92.4% of patients manifesting SIRS at admission. SIRS was most prevalent during the first week postinjury (91% of patients manifesting SIRS), decreasing to 69% and 50% during postinjury weeks 2 and 3. SIRS was more common in patients who acquired nosocomial infections compared with noninfected patients. Logistic regression analysis confirmed that patients with "middle" SIRS during week 2 (odds ratio [OR] 17.62, confidence interval [CI] 12.95-23.97, p < 0.0001, receiver operating characteristic [ROC] 0.83) and "late" SIRS during week 3 (OR18.12, CI 12.71-25.84, p < 0.0001, ROC 0.81) had significantly greater risk for nosocomial infection compared with patients with "early" SIRS during week 1 (OR 4.55, CI 2.57-8.06, p < 0.0001, ROC 0.65) postinjury.

CONCLUSION

SIRS is predictive of nosocomial infection in trauma through postinjury day 21. Nosocomial infection should be considered as a treatable cause of SIRS in trauma patients, and early diagnostic interventions should be initiated to evaluate for potential causes.

Post-operative neutrophil-lymphocyte ratio predicts complications following colorectal surgery

INTRODUCTION

The neutrophil-lymphocyte ratio (NLR) correlates with serial organ dysfunction scores in colorectal surgical patients in critical care units. We hypothesised that the NLR on the first day after an elective colorectal resection would identify patients at increased risk of subsequent complications.

METHODS

With Ethics Committee approval, 100 patients were recruited to a prospective cohort study. Pre-operative test results and the full blood count on the first post-operative day were noted for all patients. The development of any pre-defined post-operative complications was recorded.

RESULTS

Elective colorectal resection was associated with an increase in mean NLR from 3.5 to 11.6 (p<0.001). Thirty patients developed at least one predefined complication. Patients with an NLR > or =9.3 on the first post-operative day had a significantly greater risk of complications (likelihood ratio 2.12; 95% confidence interval 1.366-3.253). Twenty-two patients had a white cell count > or =11 on the first post-operative day but this was not associated with a significantly increased risk of complications (likelihood ratio 1.94; 95% confidence interval 0.94-3.9).

CONCLUSION

NLR > or =9.3 on the first post-operative day is associated with an increased risk of complications. This simple derivation of routinely available data helps to identify patients at high-risk of complications, allowing targeted preventive measures.

Severe Sepsis in Community-Acquired Pneumonia

STUDY OBJECTIVES

Most natural history studies of severe sepsis are limited to ICU populations. We describe the onset and timing of severe sepsis during the hospital course for patients hospitalized with community-acquired pneumonia (CAP). We also determine the ability of the systemic inflammatory response syndrome (SIRS) and other proposed risk stratification scores measured at emergency department (ED) presentation to predict progression to severe sepsis, septic shock, or death.

DESIGN

Retrospective analysis of a prospective observational outcome study from the Pneumonia Patient Outcomes Research Team (PORT).

SETTING

Four academic medical centers in the United States and Canada between October 1991 and March 1994.

PARTICIPANTS

The 1,339 patients hospitalized for CAP in the PORT study cohort, and a random subset of 686 patients for whom we had information for SIRS criteria.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

All subjects had infection (CAP). Severe sepsis was defined as new-onset acute organ dysfunction in this cohort, using consensus criteria. Severe sepsis developed in one half of the patients (n = 639, 48%), nonpulmonary organ dysfunction developed in 520 patients (39%), and septic shock developed in 61 subjects (4.5%). Severe sepsis and septic shock were present at ED presentation in 457 patients (71% of severe sepsis cases) and 27 patients (44% of septic shock cases), respectively. While SIRS was common at presentation (82% of the subset of 686 had two SIRS criteria), it was not associated with increased odds for progression to severe sepsis (odds ratios [ORs], 0.65 and 0.89 for two or more SIRS criteria and three or more SIRS criteria, respectively), septic shock (ORs, 0.80 and 0.55), or death (ORs, 0.65 and 0.39), with poor discrimination (all receiver operating characteristic [ROC] areas under the curve < 0.5). The pneumonia severity index was associated with severe sepsis (p < 0.001) with moderate discrimination (ROC, 0.63).

CONCLUSIONS

Severe sepsis is common in hospitalized CAP patients, occurring early in the hospital course. SIRS criteria do not appear to be useful predictors for progression to severe sepsis in CAP.

PERIPHERAL HEMOPHAGOCYTOSIS

Peripheral hemophagocytosis (PHP) is seen in patients with hemophagocytic syndrome (HPS), a clinical status in which activated macrophages play a role in its pathogenesis. The inflammatory state, systemic inflammatory response syndrome (SIRS), is also associated with activated macrophages. However, the link between HPS and SIRS and the clinical implications of PHP remain to be determined. In the present work, we examined the clinical utility and impact of the detection of PHP and the link between HPS and SIRS. We studied the clinical and laboratory profiles of 322 SIRS patients (174 men; mean age, 68 +/- 22 years; range, 16-99 years) who visited an urban hospital specializing in respiratory, cardiovascular, digestive, renal diseases, general surgery, and orthopedics in Japan. Peripheral hemophagocytosis was detected in 40 (23 men; mean age, 81.3 +/- 8.7 years; range, 63-98 years) of 322 patients on 3 +/- 2 days after SIRS diagnosis as determined with a "blunt-edged-smear" method differing from the conventional "feather-edged smear" method. The incidence of advanced SIRS and ensuing death in the SIRS+ PHP- group (37 and 21 of 40, respectively) was significantly greater than in the SIRS+ PHP- group (82 and 17 of 282) (P < 0.01). The duration from SIRS diagnosis to recovery in 19 SIRS+ PHP- surviving patients (26 +/- 18 days) was longer than that in 19 age-matched SIRS+ PHP- surviving patients who initially presented comparable clinical profiles (6 +/- 3 days) (P < 0.001). Bone marrow analysis in all 7 patients having PHP and SIRS showed no HPS initially (<3% hemophagocytes), but all subsequently developed HPS at 7 +/- 1 days after the diagnosis, confirmed by the presence of 9% +/- 13% hemophagocytes in the bone marrow. Electron microscopic and immunohistochemical analyses revealed that PHP was derived from hemophagocytes in the bone marrow. The present data strongly suggest that PHP detection could serve as an early indicator for advanced SIRS and/or HPS and that the use of the blunt-edged method is preferable for PHP detection.

Systemic inflammatory response syndrome and surgical stress in thoracic surgery

PURPOSE

To evaluate the clinical usefulness of postoperative systemic inflammatory response syndrome (SIRS) as an index of surgical stress in patients undergoing thoracic surgery.

METHODS

Forty-five consecutive patients who underwent thoracic surgery with thoracotomy were enrolled. The SIRS criteria were examined daily during the first 7 postoperative days. The serum interleukin-6 (IL-6) level, operation time, intraoperative blood loss, amount of thoracic drainage, and C-reactive protein levels were also measured.

RESULTS

Sixteen cases were categorized into the SIRS group, whereas 29 cases were categorized into the non-SIRS group. Among the patients who underwent thoracic surgery, the physiological responses of the patients to the surgery, such as serum IL-6 levels and C-reactive protein levels, were significantly higher in the SIRS group than in the non-SIRS group (P = .002 and .024, respectively). The serum IL-6 level on the first postoperative day was an independent factor associated with SIRS (95% CI 1.002-1.041; P = .030). Furthermore, there was a correlation between the number of SIRS days and the duration of the postoperative hospital stay (r = 0.379, P = .012).

CONCLUSIONS

Our results demonstrated that SIRS reflected the degree of surgical stress, especially thoracotomic procedures, through the IL-6 levels, and affected the postoperative hospital stay. Systemic inflammatory response syndrome can be useful for the postoperative management of patients undergoing thoracic surgery.

An evaluation of systemic inflammatory response syndrome signs in the Sepsis Occurrence In Acutely Ill Patients (SOAP) study

OBJECTIVE

To define the frequency and prognostic implications of SIRS criteria in critically ill patients hospitalized in European ICUs.

DESIGN AND SETTING

Cohort, multicentre, observational study of 198 ICUs in 24 European countries.

PATIENTS AND INTERVENTIONS

All 3,147 new adult admissions to participating ICUs between 1 and 15 May 2002 were included. Data were collected prospectively, with common SIRS criteria.

RESULTS

During the ICU stay 93% of patients had at least two SIRS criteria [respiratory rate (82%), heart rate (80%)]. The frequency of having three or four SIRS criteria vs. two was higher in infected than non-infected patients (p < 0.01). In non-infected patients having more than two SIRS criteria was associated with a higher risk of subsequent development of severe sepsis (odds ratio 2.6, p < 0.01) and septic shock (odds ratio 3.7, p < 0.01). Organ system failure and mortality increased as the number of SIRS criteria increased.

CONCLUSIONS

Although common in the ICU, SIRS has prognostic importance in predicting infections, severity of disease, organ failure and outcome.

Perioperative myocardial infarction in non-cardiac surgery. Pathophysiology and clinical implications

Advances in surgical and anaesthetic techniques and an aging patient population have resulted in more complex procedures being performed in greater numbers of aged subjects and in patients with a high likelihood of significant cardiovascular disease. Nearly one fourth of non-cardiac surgical procedures (major intra-abdominal, thoracic, vascular, and orthopaedic procedures) performed in persons older than 65 years have been found to be associated with significant perioperative cardiovascular morbidity and mortality. During previous years the main attempt was to define strategies to accurately estimate perioperative cardiovascular risk based either on the characteristics of surgery and on patient characteristics. More recently preventive medical strategies have been proposed. Therefore, the physician has to be aware of the key elements useful to calculate the perioperative cardiovascular risk, and of the medical preventive treatment or further interventions to adopt in patients candidate to surgery.

Facing the challenge: decreasing case fatality rates in severe sepsis despite increasing hospitalizations

OBJECTIVE

To determine recent trends in severe sepsis-related rates of hospitalization, mortality, and hospital case fatality in a large geographic area and to determine the impact of age, race, and gender on these outcomes.

DESIGN

Trend analysis for the period of 1995 to 2002.

SETTING

Acute care hospitals in New Jersey.

PATIENTS

Subjects > or = 18 yrs of age with severe sepsis who were hospitalized in New Jersey during the period of 1995 to 2002.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed data from the 1995-2002 New Jersey State Inpatient Databases (SID) developed as part of the Healthcare Cost and Utilization Project (HCUP), covering all acute care hospitals in the state. On the basis of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for septicemia and organ dysfunction, we identified 87,675 patients with severe sepsis. The percentage of patients with severe sepsis among all hospitalized patients with sepsis grew steadily, from 32.7% to 44.7% (p < .0001), during these years. The crude rate of hospitalization with severe sepsis increased 54.2%, from 135.0/100,000 population in 1995 to 208.2/100,000 population in 2002 (p < .0001). Over time, the crude mortality rate rose by 35.8% (p < .0001), whereas the crude case fatality rate (number of deaths/number of cases) fell from 51.0% to 45.0% (p < .0001). For any given year, the rates of hospitalization and mortality were greater among older patients. After adjustment by age, the rates among blacks were greater than among whites, and they were greater among males than females. At the same time, there was no significant difference in the age-adjusted hospital case fatality rates with regard to gender and race. There was a significant increase in age-adjusted gender- and race-specific rates for hospitalization and mortality from 1995 to 2002. Blacks were more likely than whites to be admitted to the intensive care unit: for males, odds ratio = 1.19 (95% confidence interval, 1.13-1.26), and for females, odds ratio = 1.35 (95% confidence interval, 1.29-1.42). However, although case fatality rate was increased among patients admitted to the intensive care unit, this was not reflected in an increased case fatality among blacks. In addition, age-adjusted gender- and race-specific case fatality rates declined during 1995-2002.

CONCLUSIONS

In spite of increasing rates of hospitalization and mortality, there is a decreasing case fatality rate for severe sepsis. These data suggest that advances in critical care practice before and during the study period have resulted in improved outcomes for this population.

Sepsis: Still Going Strong

Sepsis definitions help to understand and to better define a group of syndromes secondary to an infectious insult. The hierarchical continuum of inflammatory response leads, in absence of counterregulatory forces, to organ damage and death. We have learned first the response to treatment and afterwards the pathophysiology behind it. This lesson has, of course, not always been followed by a reduction of mortality. The definition, natural history, risk factors, diagnoses, and treatment based on emerging evidence will help to improve patient outcomes and mortality. Standardized care seems to improve survival, and validation and further evaluation of this care is necessary to maximize resources and outcomes.

Carbon monoxide, but not endothelin-1, plays a major role for the hepatic microcirculation in a murine model of early systemic inflammation

OBJECTIVE

Endothelin-1 and carbon monoxide play a major role in the regulation of liver microcirculation in numerous disease states. During sepsis and endotoxemia, elevated formation of endothelin-1 results in reduced sinusoidal blood flow. However, the role of carbon monoxide and endothelin-1 and its receptors endothelin receptor A and endothelin receptor B in the deranged liver microcirculation during early systemic inflammation remains unclear.

DESIGN

Prospective, randomized, controlled experiment.

SETTING

University animal laboratory.

SUBJECTS

Male C57/BL6 mice, weighing 23-27 g.

INTERVENTIONS

To induce a systemic inflammation, mice were treated with 1 hr of bilateral hind limb ischemia followed by 3 hrs or 6 hrs of reperfusion. Animals were randomly exposed to the nonselective endothelin receptor antagonist Ro-61-6612 (Tezosentan) and/or a continuous endothelin-1 infusion. Different animals were randomized to methylene chloride gavage or carbon monoxide inhalation during the reperfusion period.

MEASUREMENTS AND MAIN RESULTS

After ischemia/reperfusion, endothelin-1 plasma concentrations, endothelin-1 messenger RNA expression, and endothelin receptor A and B messenger RNA expression revealed no significant changes when compared with sham animals. After 6 hrs of ischemia/reperfusion, hepatic microcirculatory variables (sinusoidal density, sinusoidal diameter, and red blood cell velocity) deteriorated. Tezosentan after 6 hrs of ischemia/reperfusion did not improve the liver microcirculation, whereas the continuous infusion of endothelin-1 after 6 hrs of ischemia/reperfusion further impaired sinusoidal blood flow. Tezosentan treatment did not produce any alterations in hepatocellular injury or hepatic redox status when compared with the untreated animals receiving 6 hrs of ischemia/reperfusion. Animals receiving 6 hrs of ischemia/reperfusion and exposed to methylene chloride gavage or inhaled carbon monoxide during limb reperfusion showed significantly improved microcirculatory variables, hepatic redox status, and attenuated hepatocellular injury.

CONCLUSIONS

These data suggest that endothelin-1 and the endothelin receptors A and B are not responsible for the observed hepatic microcirculatory and cellular dysfunction during early systemic inflammation, but exposure to exogenous carbon monoxide protected the hepatic microcirculation and improved the impaired hepatic cellular integrity and the hepatocellular redox status.

Epidemiology of multiple organ dysfunction syndrome in critical surgical illness

Multiple organ dysfunction syndrome (MODS) is a major cause of morbidity and mortality in surgical intensive care units (SICUs). Multiple organ dysfunction syndrome remains the most important factor associated with mortality in the SICU. Illness severity scores such as the Acute Physiology and Chronic Health Evaluation-III (APACHE III) and the magnitude of the systemic inflammatory response syndrome (SIRS) at the time of SICU admission are useful in stratifying patients at risk for MODS and subsequent mortality. Assessment of key organ systems shows that mortality correlates with the overall severity of organ dysfunction and the number of involved organ systems, as well as to individual organs that fail. Despite the prognostic utility of SIRS/MODS, definitions of dysfunction of individual organs have shortcomings. The problem with quantitating MODS lies in the inability to adequately define organ dysfunction, especially of the gastrointestinal tract, liver, and central nervous system. Biological indicators of organ dysfunction may prove to be better markers for MODS in the future.

Procalcitonin, interleukin 6 and systemic inflammatory response syndrome (SIRS): early markers of postoperative sepsis after major surgery

BACKGROUND

Patients who undergo major surgery for cancer are at high risk of postoperative sepsis. Early markers of septic complications would be useful for diagnosis and therapeutic management in patients with postoperative sepsis. The aim of this study was to investigate the association between early (first postoperative day) changes in interleukin 6 (IL-6), procalcitonin (PCT) and C-reactive protein (CRP) serum concentrations and the occurrence of subsequent septic complications after major surgery.

METHODS

Serial blood samples were collected from 50 consecutive patients for determination of IL-6, PCT and CRP serum levels. Blood samples were obtained on the morning of surgery and on the morning of the first postoperative day.

RESULTS

Sixteen patients developed septic complications during the first five postoperative days (group 1), and 34 patients developed no septic complications (group 2). On day 1, PCT and IL-6 levels were significantly higher in group 1 (P-values of 0.003 and 0.006, respectively) but CRP levels were similar. An IL-6 cut-off point set at 310 pg ml(-1) yielded a sensitivity of 90% and a specificity of 58% to differentiate group 1 patients from group 2 patients. When associated with the occurrence of SIRS on day 1 these values reached 100% and 79%, respectively. A PCT cut-off point set at 1.1 ng ml(-1) yielded a sensitivity of 81% and a specificity of 72%. When associated with the occurrence of SIRS on day 1, these values reached 100% and 86%, respectively.

CONCLUSIONS

PCT and IL-6 appear to be early markers of subsequent postoperative sepsis in patients undergoing major surgery for cancer. These findings could allow identification of postoperative septic complications.

Endovascular repair of abdominal aortic aneurysm reduces intraoperative cortisol and perioperative morbidity

BACKGROUND

The release of catabolic stress hormones because of surgical trauma leads to a breakdown of fats, proteins, and carbohydrate stores and interference with immune function. This can delay wound healing and may increase the risk of systemic inflammatory response syndrome (SIRS)/sepsis and postoperative complications. Minimally invasive surgery can attenuate this response. Our purpose was (1) to compare neuroendocrine responses in patients undergoing open abdominal aneurysm repair with those in patients undergoing endovascular aneurysm repair (EVAR), (2) to compare the incidence of SIRS/sepsis and all complications in these two groups, and (3) to look at the relationship between procedure type, neuroendocrine response, and incidence of SIRS/sepsis and complications.

METHODS

Forty-six patients who underwent open repair and 19 who underwent EVAR were studied. A baseline (T1) 24-hour urine save was undertaken in the week before admission, and a second 24-hour save (T2) commenced at anesthetic induction to measure cortisol and catecholamines. The incidences of SIRS/sepsis and complications were recorded.

RESULTS

Significant ( P </= .001) increases in cortisol and adrenaline from T1 to T2 occurred in all patients. Controlling for the type of anesthetic, the administration of exogenous inotropes, and beta-adrenoreceptor antagonists (beta-blockers), there was a significant difference in cortisol (T2) associated with the type of procedure. Responses were greater in open patients in comparison to EVAR patients (F 3,61 = 5.0; P = .03). The incidence of SIRS (50% vs 32%), sepsis (26% vs 5%), and all complications (76% vs 32%) was significantly ( P </= .02) higher in open than EVAR patients, respectively. Cortisol and adrenaline measured for 24 hours, commencing at the time of induction, tended to be higher in patients with SIRS/sepsis and all complications, but this did not reach significance.

CONCLUSIONS

An attenuated glucocorticoid surge characterizes the reduced stress response experienced by patients undergoing EVAR compared with open abdominal aortic aneurysm repair. A reduction in the occurrence of SIRS is a feature of a more favorable postoperative course after an endovascular approach.