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Maisat W, Yuki K. Narrative review of systemic inflammatory response mechanisms in cardiac surgery and immunomodulatory role of anesthetic agents. Ann Card Anaesth 2023; 26:133-142. [PMID: 37706376 PMCID: PMC10284469 DOI: 10.4103/aca.aca_147_22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 12/05/2022] [Accepted: 12/18/2022] [Indexed: 09/15/2023] Open
Abstract
Although surgical techniques and perioperative care have made significant advances, perioperative mortality in cardiac surgery remains relatively high. Single- or multiple-organ failure remains the leading cause of postoperative mortality. Systemic inflammatory response syndrome (SIRS) is a common trigger for organ injury or dysfunction in surgical patients. Cardiac surgery involves major surgical dissection, the use of cardiopulmonary bypass (CPB), and frequent blood transfusions. Ischemia-reperfusion injury and contact activation from CPB are among the major triggers for SIRS. Blood transfusion can also induce proinflammatory responses. Here, we review the immunological mechanisms of organ injury and the role of anesthetic regimens in cardiac surgery.
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Affiliation(s)
- Wiriya Maisat
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, USA
- Department of Anaesthesia, Harvard Medical School, Boston, USA
- Department of Immunology, Harvard Medical School, Boston, USA
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Koichi Yuki
- Division of Cardiac Anesthesia, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, USA
- Department of Anaesthesia, Harvard Medical School, Boston, USA
- Department of Immunology, Harvard Medical School, Boston, USA
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2
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Narayan S, Petersen TL. Uncommon Etiologies of Shock. Crit Care Clin 2022; 38:429-441. [DOI: 10.1016/j.ccc.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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3
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Chou RH, Tsai CT, Lu YW, Guo JY, Lu CT, Tsai YL, Wu CH, Lin SJ, Lien RY, Lu SF, Yang SF, Huang PH. Elevated serum galectin-1 concentrations are associated with increased risks of mortality and acute kidney injury in critically ill patients. PLoS One 2021; 16:e0257558. [PMID: 34559847 PMCID: PMC8462742 DOI: 10.1371/journal.pone.0257558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 09/05/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Galectin-1 (Gal-1), a member of the β-galactoside binding protein family, is associated with inflammation and chronic kidney disease. However, the effect of Gal-1 on mortality and acute kidney injury (AKI) in critically-ill patients remain unclear. METHODS From May 2018 to March 2020, 350 patients admitted to the medical intensive care unit (ICU) of Taipei Veterans General Hospital, a tertiary medical center, were enrolled in this study. Forty-one patients receiving long-term renal replacement therapy were excluded. Serum Gal-1 levels were determined within 24 h of ICU admission. The patients were divided into tertiles according to their serum Gal-1 levels (low, serum Gal-1 < 39 ng/ml; median, 39-70 ng/ml; high, ≥71 ng/ml). All patients were followed for 90 days or until death. RESULTS Mortality in the ICU and at 90 days was greater among patients with elevated serum Gal-1 levels. In analyses adjusted for the body mass index, malignancy, sepsis, Sequential Organ Failure Assessment (SOFA) score, and serum lactate level, the serum Gal-1 level remained an independent predictor of 90-day mortality [median vs. low: adjusted hazard ratio (aHR) 2.11, 95% confidence interval (CI) 1.24-3.60, p = 0.006; high vs. low: aHR 3.21, 95% CI 1.90-5.42, p < 0.001]. Higher serum Gal-1 levels were also associated with a higher incidence of AKI within 48 h after ICU admission, independent of the SOFA score and renal function (median vs. low: aHR 2.77, 95% CI 1.21-6.34, p = 0.016; high vs. low: aHR 2.88, 95% CI 1.20-6.88, p = 0.017). The results were consistent among different subgroups with high and low Gal-1 levels. CONCLUSION Serum Gal-1 elevation at the time of ICU admission were associated with an increased risk of mortality at 90 days, and an increased incidence of AKI within 48 h after ICU admission.
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Affiliation(s)
- Ruey-Hsing Chou
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chuan-Tsai Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ya-Wen Lu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jiun-Yu Guo
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chi-Ting Lu
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Yi-Lin Tsai
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Cheng-Hsueh Wu
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Shing-Jong Lin
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
- Taipei Heart Institute, Taipei Medical University, Taipei, Taiwan
- Division of Cardiology, Heart Center, Cheng-Hsin General Hospital, Taipei, Taiwan
| | - Ru-Yu Lien
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shu-Fen Lu
- Department of Nursing, Taipei Veterans General Hospital, Taipei, Taiwan
- School of Nursing, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shang-Feng Yang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Division of Nephrology, Department of Medicine, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Po-Hsun Huang
- Division of Cardiology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Cardiovascular Research Center, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Department of Critical Care Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
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Gorecki G, Cochior D, Moldovan C, Rusu E. Molecular mechanisms in septic shock (Review). Exp Ther Med 2021; 22:1161. [PMID: 34504606 PMCID: PMC8393902 DOI: 10.3892/etm.2021.10595] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 06/10/2021] [Indexed: 12/29/2022] Open
Abstract
Sepsis is a clinical syndrome defined by the presence of infection and systemic inflammatory response to infection and results from a complex interaction between the host and infectious agents. It is characterized by the activation of multiple inflammatory pathways, with an increased risk of mortality. The incidence of sepsis has been on an ever-increasing pathway in recent years. Sepsis can be induced by several clinical situations that predispose to its occurrence: malignant tumors, organ transplantation, AIDS, radiation therapy, burns, sores, polytrauma, diabetes mellitus, hepatic failure, renal failure, malnutrition, catheters or different invasive devices, and urinary catheters. The microorganisms involved in the pathogenesis of sepsis are Gram-positive cocci (Staphylococci, Streptococci) and Gram-negative bacilli (Klebsiella, Pseudomonas aeruginosa, E. coli), fungi (Candida), parasites, and viruses. Among mechanisms involved in septic shock production, two pathological phenomena appear: the profound decompensation of circulation and metabolic disturbances that evolve towards an irreversible state. The intimate mechanism of shock involves the activation of monocytes, macrophages and neutrophils by lipopolysaccharides of Gram-negative bacteria. The microvascular bed is directly involved in the etiopathogenesis of disorders of acute inflammatory states associated with or without sepsis. A better comprehension of sepsis pathophysiology, especially the molecular mechanisms of septic shock, allows for new therapeutic perspectives.
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Affiliation(s)
- Gabriel Gorecki
- Medicine Doctoral School, 'Titu Maiorescu' University of Bucharest, 040317 Bucharest, Romania
| | - Daniel Cochior
- Faculty of Medicine, 'Titu Maiorescu' University of Bucharest, 031593 Bucharest, Romania.,General Surgery, 'Monza' Clinical Hospital, 021967 Bucharest, Romania.,General Surgery, 'Sanador' Clinical Hospital, 010991 Bucharest, Romania
| | - Cosmin Moldovan
- Faculty of Medicine, 'Titu Maiorescu' University of Bucharest, 031593 Bucharest, Romania.,General Surgery Ward, 'Witting' Clinical Hospital, 010243 Bucharest, Romania
| | - Elena Rusu
- Faculty of Medicine, 'Titu Maiorescu' University of Bucharest, 031593 Bucharest, Romania
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van Groenendael R, Beunders R, Hemelaar P, Hofland J, Morshuis WJ, van der Hoeven JG, Gerretsen J, Wensvoort G, Kooistra EJ, Claassen WJ, Waanders D, Lamberts MGA, Buijsse LSE, Kox M, van Eijk LT, Pickkers P. Safety and Efficacy of Human Chorionic Gonadotropin Hormone-Derivative EA-230 in Cardiac Surgery Patients: A Randomized Double-Blind Placebo-Controlled Study. Crit Care Med 2021; 49:790-803. [PMID: 33591006 PMCID: PMC8043513 DOI: 10.1097/ccm.0000000000004847] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVES To determine the safety and efficacy of human chorionic gonadotropin hormone-derivative EA-230 in cardiac surgery patients. Cardiac surgery induces systemic inflammation and may impair renal function, affecting patient outcome. EA-230 exerted immunomodulatory and renoprotective effects in preclinical models and was safe and showed efficacy in phase I and II human studies. DESIGN Double-blinded, placebo-controlled, randomized study. SETTING Collaboration of the Cardiothoracic Surgery, Anesthesiology, and the Intensive Care departments of a tertiary hospital in the Netherlands. PATIENTS One hundred eighty patients undergoing an on-pump coronary artery bypass procedure with or without concomitant valve surgery. INTERVENTIONS Ninety mg/kg/hr EA-230 or placebo administered during surgery. MEASUREMENTS AND MAIN RESULTS During the study, no safety concerns emerged. EA-230 did not modulate interleukin-6 plasma concentrations (area under the curve 2,730 pg/mL × hr [1,968-3,760] vs 2,680 pg/mL × hr [2,090-3,570] for EA-230 and placebo group, respectively; p = 0.80). Glomerular filtration rate increased following surgery (mean ± sem increase in the EA-230 vs placebo groups: glomerular filtration rateiohexol measured using iohexol plasma clearance: 19 ± 2 vs 16 ± 2 mL/min/1.73 m2; p = 0.13 and estimated glomerular filtration rate with the Modification of Diet in Renal Disease equation using creatinine: 6 ± 1 vs 2 ± 1 mL/min/1.73 m2; p = 0.01). The "injury" stage of the Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease criteria for acute kidney injury was 7% in the EA-230 group versus 18% in the placebo group (p = 0.07). In addition, EA-230-treated patients had a less positive fluid balance compared with placebo-treated patients (217 ± 108 vs 605 ± 103 mL; p = 0.01), while the use of vasoactive agents was similar in both groups (p = 0.39). Finally, hospital length of stay was shorter in EA-230 treated patients (8 d [7-11] vs 10 d [8-12]; p = 0.001). Efficacy results were more pronounced in patients that had longer duration of surgery and thus longer duration of study drug infusion. CONCLUSIONS EA-230 was safe in patients undergoing on-pump cardiac surgery. It did not modulate interleukin-6 plasma concentrations but appeared to exert beneficial renal and cardiovascular effects and shortened in-hospital length of stay.
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Affiliation(s)
- Roger van Groenendael
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Remi Beunders
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pleun Hemelaar
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jan Hofland
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim J. Morshuis
- Department of Cardiothoracic Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Johannes G. van der Hoeven
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jelle Gerretsen
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gert Wensvoort
- Exponential Biotherapies, Inc. (EBI), The Hague, The Netherlands
| | - Emma J. Kooistra
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wout J. Claassen
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Denise Waanders
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Maud G. A. Lamberts
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Leonie S. E. Buijsse
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lucas T. van Eijk
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
- Radboud Institute for Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
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Ma C, Lu J, Zhu Y, Huo Y, Xia S, Shao Y. Systemic Inflammatory Response Syndrome Combined with Pre- and Postoperative White Blood Cell Ratio Is a Better Criterion to Identify Septic Shock Patients After Flexible Ureteroscopic Lithotripsy. J Endourol 2020; 35:973-978. [PMID: 33218256 DOI: 10.1089/end.2020.1002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Objective: To find out a better criterion to identify septic shock patients after flexible ureteroscopic lithotripsy (FUL). Materials and Methods: In total, 2364 patients who underwent the FUL procedure were enrolled in the study. The demographics and preoperative results of laboratory tests of the patients were collected. The postoperative white blood cell (WBC), systemic inflammatory response syndrome (SIRS), and quick sequential (sepsis-related) organ failure assessment score (qSOFA) were assessed 2 hours after FUL. The predictive efficacy was measured by sensitivity, specificity, positive and negative predictive value, and area under the receiver's operating characteristic curve (AUROC). Results: A total of 15 (0.63%) patients developed septic shock. There were 86 (3.64%) patients who were SIRS positive and 69 (2.92%) patients who were qSOFA positive. The pre- and postoperative WBC ratios in septic shock patients and normal patients were 2.50 ± 1.55 and 0.69 ± 0.24, respectively (p < 0.001). For sensitivity and negative predictive value, all reached 100%. For specificity, qSOFA was 97.70%, SIRS was 96.98%, and SIRS combining pre- and postoperative WBC ratio (the new criterion) was 99.79%. The new criterion had statistically significant higher specificity than SIRS or qSOFA (p < 0.001 for both), but when comparing SIRS and qSOFA, it had statistically insignificant specificity (p = 0.142). For positive predictive value, qSOFA was 21.73%, SIRS was 17.44%, and the new criterion was 75%. qSOFA and SIRS had similar AUROC (0.989 for qSOFA and 0.985 for SIRS), both lower than the new criterion (AUROC: 0.999). Conclusions: SIRS combined with pre- and postoperative WBC ratio has a much better specificity and positive predictive value than SIRS or qSOFA alone. It has 99.79% specificity and 75% positive predictive value, and as high as 100% sensitivity and negative predictive value.
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Affiliation(s)
- Cheng Ma
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine (originally named "Shanghai First People's Hospital"), Shanghai, China
| | - Jun Lu
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine (originally named "Shanghai First People's Hospital"), Shanghai, China
| | - Yiyong Zhu
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine (originally named "Shanghai First People's Hospital"), Shanghai, China
| | - Yujia Huo
- Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shujie Xia
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine (originally named "Shanghai First People's Hospital"), Shanghai, China
| | - Yi Shao
- Department of Urology, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine (originally named "Shanghai First People's Hospital"), Shanghai, China
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Koch C, Edinger F, Fischer T, Brenck F, Hecker A, Katzer C, Markmann M, Sander M, Schneck E. Comparison of qSOFA score, SOFA score, and SIRS criteria for the prediction of infection and mortality among surgical intermediate and intensive care patients. World J Emerg Surg 2020; 15:63. [PMID: 33239088 PMCID: PMC7687806 DOI: 10.1186/s13017-020-00343-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 11/05/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND It is crucial to rapidly identify sepsis so that adequate treatment may be initiated. Accordingly, the Sequential Organ Failure Assessment (SOFA) and the quick SOFA (qSOFA) scores are used to evaluate intensive care unit (ICU) and non-ICU patients, respectively. As demand for ICU beds rises, the intermediate care unit (IMCU) carries greater importance as a bridge between the ICU and the regular ward. This study aimed to examine the ability of SOFA and qSOFA scores to predict suspected infection and mortality in IMCU patients. METHODS Retrospective data analysis included 13,780 surgical patients treated at the IMCU, ICU, or both between January 01, 2012, and September 30, 2018. Patients were screened for suspected infection (i.e., the commencement of broad-spectrum antibiotics) and then evaluated for the SOFA score, qSOFA score, and the 1992 defined systemic inflammatory response syndrome (SIRS) criteria. RESULTS Suspected infection was detected in 1306 (18.3%) of IMCU, 1365 (35.5%) of ICU, and 1734 (62.0%) of IMCU/ICU encounters. Overall, 458 (3.3%) patients died (IMCU 45 [0.6%]; ICU 250 [6.5%]; IMCU/ICU 163 [5.8%]). All investigated scores failed to predict suspected infection independently of the analyzed subgroup. Regarding mortality prediction, the qSOFA score performed sufficiently within the IMCU cohort (AUCROC SIRS 0.72 [0.71-0.72]; SOFA 0.52 [0.51-0.53]; qSOFA 0.82 [0.79-0.84]), while the SOFA score was predictive in patients of the IMCU/ICU cohort (AUCROC SIRS 0.54 [0.53-0.54]; SOFA 0.73 [0.70-0.77]; qSOFA 0.59 [0.58-0.59]). CONCLUSIONS None of the assessed scores was sufficiently able to predict suspected infection in surgical ICU or IMCU patients. While the qSOFA score is appropriate for mortality prediction in IMCU patients, SOFA score prediction quality is increased in critically ill patients.
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Affiliation(s)
- Christian Koch
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany. .,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany.
| | - Fabian Edinger
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany
| | - Tobias Fischer
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Florian Brenck
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Andreas Hecker
- Department of General and Thoracic Surgery, University Hospital of Giessen, Giessen, Germany
| | - Christian Katzer
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Melanie Markmann
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany
| | - Michael Sander
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany
| | - Emmanuel Schneck
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen, Rudolf-Buchheim-Street 7, 35392, Giessen, Germany.,German Center of Infection Research (DZIF), Partner Site Giessen/Marburg/Langen, Giessen, Germany
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8
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van Groenendael R, Beunders R, Kox M, van Eijk LT, Pickkers P. The Human Chorionic Gonadotropin Derivate EA-230 Modulates the Immune Response and Exerts Renal Protective Properties: Therapeutic Potential in Humans. Semin Nephrol 2020; 39:496-504. [PMID: 31514913 DOI: 10.1016/j.semnephrol.2019.06.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The extent of the systemic inflammatory response following infectious or noninfectious insults is related to impaired patient outcome. Pregnancy is associated with immunotolerance and an increased glomerular filtration rate. EA-230 is a newly developed synthetic linear tetrapeptide derived from the "pregnancy hormone" human chorionic gonadotropin. In this review, we describe the immunomodulatory and renoprotective properties of EA-230 in preclinical animal models, phase 1 studies in humans and phase 2a studies performed during human experimental endotoxemia. In addition, details pertaining to the design of a recently completed phase 2b study in 180 patients who underwent cardiac surgery to investigate the safety and immunomodulatory and renoprotective properties of EA-230 are discussed.
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Affiliation(s)
- Roger van Groenendael
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute for Molecular Life Sciences, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands; Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute of Molecular Life Sciences (RIMLS), Nijmegen, the Netherlands
| | - Remi Beunders
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute for Molecular Life Sciences, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute for Molecular Life Sciences, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands
| | - Lucas T van Eijk
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute for Molecular Life Sciences, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands; Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute of Molecular Life Sciences (RIMLS), Nijmegen, the Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, the Netherlands; Radboud Institute for Molecular Life Sciences, Radboud Center for Infectious Diseases (RCI), Nijmegen, the Netherlands.
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9
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Predictive Validity of Sepsis-3 Definitions and Sepsis Outcomes in Critically Ill Patients: A Cohort Study in 49 ICUs in Argentina. Crit Care Med 2019; 46:1276-1283. [PMID: 29742584 DOI: 10.1097/ccm.0000000000003208] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES The new Sepsis-3 definitions have been scarcely assessed in low- and middle-income countries; besides, regional information of sepsis outcomes is sparse. Our objective was to evaluate Sepsis-3 definition performance in Argentina. DESIGN Cohort study of 3-month duration beginning on July 1, 2016. SETTINGS Forty-nine ICUs. PATIENTS Consecutive patients admitted to the ICU with suspected infection that triggered blood cultures and antibiotic administration. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patients were classified as having infection, sepsis (infection + change in Sequential Organ Failure Assessment ≥ 2 points), and septic shock (vasopressors + lactate > 2 mmol/L). Patients on vasopressors and lactate less than or equal to 2 mmol/L (cardiovascular dysfunction) were analyzed separately, as those on vasopressors without serum lactate measurement. Systemic inflammatory response syndrome was also recorded. Main outcome was hospital mortality. Of 809 patients, 6% had infection, 29% sepsis, 20% cardiovascular dysfunction, 40% septic shock, and 3% received vasopressors with lactate unmeasured. Hospital mortality was 13%, 20%, 39%, 51%, and 41%, respectively (p = 0.000). Independent predictors of outcome were lactate, Sequential Organ Failure Assessment score, comorbidities, prior duration of symptoms (hr), mechanical ventilation requirement, and infection by highly resistant microorganisms. Area under the receiver operating characteristic curves for mortality for systemic inflammatory response syndrome and Sequential Organ Failure Assessment were 0.53 (0.48-0.55) and 0.74 (0.69-0.77), respectively (p = 0.000). CONCLUSIONS Increasing severity of Sepsis-3 categories adequately tracks mortality; cardiovascular dysfunction subgroup, not included in Sepsis-3, has distinct characteristics. Sequential Organ Failure Assessment score shows adequate prognosis accuracy-contrary to systemic inflammatory response syndrome. This study supports the predictive validity of Sepsis-3 definitions.
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Kelly B, Patlak J, Shaefi S, Boone D, Mueller A, Talmor D. Evaluation of qSOFA as a Predictor of Mortality Among ICU Patients With Positive Clinical Cultures-A Retrospective Cohort Study. J Intensive Care Med 2019; 35:1278-1284. [PMID: 31208272 DOI: 10.1177/0885066619856852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare the discriminative value of the quick-sequential organ failure assessment score (qSOFA) to SOFA in a critically ill population, in which a microbial pathogen was isolated within 48 hours of admission to intensive care. DESIGN Retrospective cohort study. SETTING Academic tertiary referral center from July 2008 to June 2017. PATIENTS Hospitalized patients admitted to intensive care unit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was in-hospital mortality for all patients with confirmed positive microbiological cultures within 48 hours of admission to intensive care unit (ICU). Subgroup analysis was performed on patients with pathogenic bacteremia or positive cultures in cerebrospinal fluid. Of the 11 415 patients analyzed with positive microbiology specimens within 48 hours of admission, 2933 (25.7%) had a qSOFA ≥2. Of these, 16.6% reached the primary outcome of in-hospital mortality. Unsurprisingly, the discriminative value of qSOFA on admission was significantly worse than that of SOFA (0.73 vs 0.76; P = .0004), despite observing a significant association between qSOFA category and in-hospital mortality (P < .0001). In secondary analyses, similar observations were found using qSOFA within 6 and 24 hours of ICU admission. When analysis was focused on patients with pathogenic bacteremia or positive cerebrospinal fluid (CSF) cultures (n = 1646), there was no significant difference between the discriminative value of qSOFA and SOFA (0.75 vs 0.78; P = .17). CONCLUSIONS Quick-sequential organ failure assessment score at admission was not superior to SOFA in predicting in-hospital mortality in patients with positive clinical cultures within 48 hours of admission to ICU. Quick-sequential organ failure assessment score at admission to the ICU was associated with mortality and showed reasonable calibration and discrimination. When the analysis was focused on patients with pathogenic bacteremia or positive CSF cultures, qSOFA performed similarly to SOFA in discriminatory those who will die from sepsis.
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Affiliation(s)
- Barry Kelly
- The Department of Anesthesia, Critical Care and Pain Medicine at 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Johann Patlak
- The Department of Anesthesia, Critical Care and Pain Medicine at 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Shahzad Shaefi
- The Department of Anesthesia, Critical Care and Pain Medicine at 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Dustin Boone
- The Department of Anesthesia, Critical Care and Pain Medicine at 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ariel Mueller
- The Department of Anesthesia, Critical Care and Pain Medicine at 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Daniel Talmor
- The Department of Anesthesia, Critical Care and Pain Medicine at 1859Beth Israel Deaconess Medical Center, Boston, MA, USA
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van Groenendael R, Aarnoutse R, Kox M, van Eijk L, Pickkers P. Pharmacokinetics, safety and tolerability of the novel β-hCG derived immunomodulatory compound, EA-230. Br J Clin Pharmacol 2019; 85:1572-1584. [PMID: 30924163 PMCID: PMC6595371 DOI: 10.1111/bcp.13942] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 02/28/2019] [Accepted: 03/08/2019] [Indexed: 12/01/2022] Open
Abstract
Aims EA‐230 is a newly developed synthetic linear tetrapeptide (AQGV) derived from the chorionic gonadotropin hormone (β‐hCG). We investigated the pharmacokinetics, safety and tolerability of EA‐230 in healthy subjects using different administration strategies. Methods Double‐blind, randomized, placebo‐controlled, dose‐escalating phase I studies in healthy subjects using intravenous administration were conducted. In the single dosage study, 32 subjects were assigned to four single dosage groups (1, 3, 10 or 30 mg/kg). In the multiple dosage study, 24 subjects were assigned to three dosage groups (10, 20 or 30 mg/kg, thrice daily for 3 days). In the continuous dosage study, 24 subjects were assigned to three dosage groups (15, 30, or 90 mg/kg/hour for 2 hours). Pharmacokinetics, safety and tolerability assessments were performed up to 14 days. Results The highest dosage of EA‐230 (continuous infusion of 90 mg/kg/hour for 2 hours) showed more than proportional increases in exposure (Cmax136%; AUC0‐last137%), a large volume of distribution (geometric mean and 95% CI: 13 [3–58] L/kg), a high clearance rate (26 [15–43] L/h/kg), and a short half‐life (0.35 [0.13–1.0] minutes). EA‐230 was well tolerated and no safety concerns were observed. Conclusion These dose‐escalating phase I studies with different administration strategies reveal a pharmacokinetic profile of EA‐230 with a large volume of distribution and a short half‐life. Furthermore, EA‐230 was well tolerated and no safety issues emerged. These results have enabled further clinical development in a phase IIa trial assessing the pharmacodynamics of this compound during systemic inflammation described elsewhere in this issue.
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Affiliation(s)
- Roger van Groenendael
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Molecular Life Sciences, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands.,Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute of Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Rob Aarnoutse
- Radboud Institute for Molecular Life Sciences, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands.,Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Molecular Life Sciences, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
| | - Lucas van Eijk
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Molecular Life Sciences, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands.,Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute of Molecular Life Sciences (RIMLS), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Institute for Molecular Life Sciences, Radboud Center for Infectious Diseases (RCI), Nijmegen, The Netherlands
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12
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Cervellin G, Schuetz P, Lippi G. Toward a holistic approach for diagnosing sepsis in the emergency department. Adv Clin Chem 2019; 92:201-216. [PMID: 31472754 DOI: 10.1016/bs.acc.2019.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
| | - Philipp Schuetz
- Department of Internal Medicine, Kantonsspital Aarau and University of Basel, Basel, Switzerland
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Italy.
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13
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van Groenendael R, Kox M, Leijte G, Koeneman B, Gerretsen J, van Eijk L, Pickkers P. A randomized double-blind, placebo-controlled clinical phase IIa trial on safety, immunomodulatory effects and pharmacokinetics of EA-230 during experimental human endotoxaemia. Br J Clin Pharmacol 2019; 85:1559-1571. [PMID: 30919998 PMCID: PMC6595370 DOI: 10.1111/bcp.13941] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 02/28/2019] [Accepted: 03/08/2019] [Indexed: 12/18/2022] Open
Abstract
AIMS EA-230 is a human chorionic gonadotropin hormone-derived linear tetrapeptide, developed for the treatment of systemic inflammation-related disorders. EA-230 has shown promising immunomodulatory and tissue-protective effects in animals and an excellent safety profile in human phase I studies that we performed. The present phase IIa study follows-up on these results by investigating the safety, efficacy and pharmacokinetics of EA-230 under systemic inflammatory conditions induced by experimental human endotoxaemia. METHODS In this randomized, double blind, placebo-controlled phase IIa study, systemic inflammation was induced by intravenous administration of Escherichia coli-derived lipopolysaccharide (LPS). At t = 0 hours, 36 healthy male volunteers received 2 ng/kg LPS, followed by a 2-hour continuous infusion of EA-230 (15, 45 and 90 mg/kg/h, n = 8 per group) or placebo (n = 12). RESULTS EA-230 was well tolerated and showed a favourable safety profile. Treatment with the highest dose of EA-230 resulted in a significant attenuation of the LPS-induced increase in plasma levels of inflammatory mediators interleukin (IL)-6, IL-8, IL-1 receptor antagonist, monocyte chemoattractant protein-1, macrophage inflammatory proteins-1α and -1β, and vascular cell adhesion protein-1 (% reduction of 48, 28, 33, 28, 14, 16 and 19 respectively, p < .01), and reduced fever (peak decrease from 1.8 ± 0.1°C to 1.3 ± 0.2°C, P < .05) and symptom scores (peak decrease from 7.4 ± 1.0 to 4.0 ± 1.2 points, P < .05). EA-230 exhibited a very short elimination half-life and a large volume of distribution in the highest dosage group (geometric mean and 95% confidence interval: 0.17 [0.12-0.24] hours and 2.2 [1.3-3.8] L/kg, respectively). CONCLUSION Administration of EA-230 is safe and results in attenuation of the systemic inflammatory response in humans.
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Affiliation(s)
- Roger van Groenendael
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Guus Leijte
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bouke Koeneman
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jelle Gerretsen
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lucas van Eijk
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands.,Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases (RCI), Radboud University Medical Center, Nijmegen, The Netherlands
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14
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Acute Noncardiac Organ Failure in Acute Myocardial Infarction With Cardiogenic Shock. J Am Coll Cardiol 2019; 73:1781-1791. [DOI: 10.1016/j.jacc.2019.01.053] [Citation(s) in RCA: 122] [Impact Index Per Article: 24.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 01/03/2019] [Accepted: 01/08/2019] [Indexed: 11/24/2022]
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15
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van Groenendael R, Beunders R, Hofland J, Morshuis WJ, Kox M, van Eijk LT, Pickkers P. The Safety, Tolerability, and Effects on the Systemic Inflammatory Response and Renal Function of the Human Chorionic Gonadotropin Hormone-Derivative EA-230 Following On-Pump Cardiac Surgery (The EASI Study): Protocol for a Randomized, Double-Blind, Placebo-Controlled Phase 2 Study. JMIR Res Protoc 2019; 8:e11441. [PMID: 30724734 PMCID: PMC6381408 DOI: 10.2196/11441] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 11/06/2018] [Accepted: 11/10/2018] [Indexed: 12/11/2022] Open
Abstract
Background The cardiac surgery–induced systemic inflammatory response may induce postoperative hemodynamic instability and impairment of renal function. EA-230, a linear tetrapeptide (A-Q-G-V), is derived from the beta chain of the human chorionic gonadotropin pregnancy hormone. It has shown immunomodulatory and renoprotective effects in several animal models of systemic inflammation. In phase 1 and phase 2a studies, these immunomodulatory effects were confirmed during human experimental endotoxemia, and EA-230 was found to have an excellent safety profile. Objective The objective of this first in-patient study is to test the safety and tolerability as well as the immunomodulatory and renoprotective effects of EA-230 in a proof-of-principle design in patients with systemic inflammation following on-pump cardiac surgery. Methods We describe a prospective, randomized, double-blind, placebo-controlled study in which 180 elective patients undergoing on-pump coronary artery bypass grafting, with or without concomitant valve surgery, are enrolled. Patients will be randomized in a 1:1 ratio and will receive either EA-230 (90 mg/kg/hour) or a placebo. These will be infused at the start of the surgical procedure until the end of the use of the cardiopulmonary bypass. The primary focus of this first-in-patient study will be on safety and tolerability of EA-230. The primary efficacy end point is the modulation of the inflammatory response by EA-230 quantified as the change in interleukin-6 plasma concentrations after surgery. The key secondary end point is the effect of EA-230 on renal function. The study will be conducted in 2 parts to enable an interim safety analysis by an independent data monitoring committee at a sample size of 60. An adaptive design is used to reassess statistical power halfway through the study. Results This study has been approved by the independent competent authority and ethics committee and will be conducted in accordance with the ethical principles of the Declaration of Helsinki, guidelines of Good Clinical Practice, and European Directive 2001/20/CE regarding the conduct of clinical trials. Results of this study will be submitted for publication in a peer-reviewed scientific journal. Enrollment of this study commenced in July 2016, and results are expected at the end of 2018. Conclusions This adaptive phase 2 clinical study is designed to test the safety and tolerability of EA-230 in patients undergoing cardiac surgery. In addition, efficacy end points focused on the effect of the systemic inflammatory response and renal function are investigated. Trial Registration ClinicalTrials.gov NCT03145220; https://clinicaltrials.gov/ct2/show/NCT03145220 (Archived by WebCite at http://www.webcitation.org/74JPh8GNN) International Registered Report Identifier (IRRID) DERR1-10.2196/11441
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Affiliation(s)
- Roger van Groenendael
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands.,Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Remi Beunders
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Jan Hofland
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Wim J Morshuis
- Department of Cardiac Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
| | - Lucas T van Eijk
- Department of Anesthesiology, Pain and Palliative Medicine, Radboud University Medical Center, Nijmegen, Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, Netherlands
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16
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Udy A, Roberts JA, Boots RJ, Lipman J. You Only Find what you Look for: The Importance of High Creatinine Clearance in the Critically Ill. Anaesth Intensive Care 2019; 37:11-3. [DOI: 10.1177/0310057x0903700123] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A. Udy
- University of Queensland Burns Trauma Critical Care Research Centre Department of Intensive Care Medicine Royal Brisbane and Women's Hospital Herston, Queensland
| | - J. A. Roberts
- University of Queensland Burns Trauma Critical Care Research Centre Department of Intensive Care Medicine Royal Brisbane and Women's Hospital Herston, Queensland
| | - R. J. Boots
- University of Queensland Burns Trauma Critical Care Research Centre Department of Intensive Care Medicine Royal Brisbane and Women's Hospital Herston, Queensland
| | - J. Lipman
- University of Queensland Burns Trauma Critical Care Research Centre Department of Intensive Care Medicine Royal Brisbane and Women's Hospital Herston, Queensland
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17
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Development of a Malawi Intensive care Mortality risk Evaluation (MIME) model, a prospective cohort study. Int J Surg 2018; 60:60-66. [PMID: 30395945 DOI: 10.1016/j.ijsu.2018.10.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 10/17/2018] [Accepted: 10/28/2018] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Intensive care medicine can contribute to population health in low-income countries by reducing premature mortality related to surgery, trauma, obstetrical and other medical emergencies. Quality improvement is guided by risk stratification models, which are developed primarily within high-income settings. Models validated for use in low-income countries are needed. METHODS This prospective cohort study consisted of 261 patients admitted to the intensive care unit (ICU) of Kamuzu Central Hospital in Malawi, from September 2016 to March 2018. The primary outcome was in-hospital mortality. We performed univariable analyses on putative predictors and included those with a significance of 0.15 in the Malawi Intensive care Mortality risk Evaluation model (MIME). Model discrimination was evaluated using the area under the curve. RESULTS Males made up 37.9% of the study sample and the mean age was 34.4 years. A majority (73.9%) were admitted to the ICU after a recent surgical procedure, and 59% came directly from the operating theater. In-hospital mortality was 60.5%. The MIME based on age, sex, admitting service, systolic pressure, altered mental status, and fever during the ICU course had a fairly good discrimination, with an AUC of 0.70 (95% CI 0.63-0.76). CONCLUSIONS The MIME has modest ability to predict in-hospital mortality in a Malawian ICU. Multicenter research is needed to validate the MIME and assess its clinical utility.
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18
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Wulff A, Haarbrandt B, Tute E, Marschollek M, Beerbaum P, Jack T. An interoperable clinical decision-support system for early detection of SIRS in pediatric intensive care using openEHR. Artif Intell Med 2018; 89:10-23. [PMID: 29753616 DOI: 10.1016/j.artmed.2018.04.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 04/26/2018] [Accepted: 04/30/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Clinical decision-support systems (CDSS) are designed to solve knowledge-intensive tasks for supporting decision-making processes. Although many approaches for designing CDSS have been proposed, due to high implementation costs, as well as the lack of interoperability features, current solutions are not well-established across different institutions. Recently, the use of standardized formalisms for knowledge representation as terminologies as well as the integration of semantically enriched clinical information models, as openEHR Archetypes, and their reuse within CDSS are theoretically considered as key factors for reusable CDSS. OBJECTIVE We aim at developing and evaluating an openEHR based approach to achieve interoperability in CDSS by designing and implementing an exemplary system for automated systemic inflammatory response syndrome (SIRS) detection in pediatric intensive care. METHODS We designed an interoperable concept, which enables an easy integration of the CDSS across different institutions, by using openEHR Archetypes, terminology bindings and the Archetype Query Language (AQL). The practicability of the approach was tested by (1) implementing a prototype, which is based on an openEHR based data repository of the Hannover Medical School (HaMSTR), and (2) conducting a first pilot study. RESULTS We successfully designed and implemented a CDSS with interoperable knowledge bases and interfaces by reusing internationally agreed-upon Archetypes, incorporating LOINC terminology and creating AQL queries, which allowed retrieving dynamic facts in a standardized and unambiguous form. The technical capabilities of the system were evaluated by testing the prototype on 16 randomly selected patients with 129 days of stay, and comparing the results with the assessment of clinical experts (leading to a sensitivity of 1.00, a specificity of 0.94 and a Cohen's kappa of 0.92). CONCLUSIONS We found the use of openEHR Archetypes and AQL a feasible approach to bridge the interoperability gap between local infrastructures and CDSS. The designed concept was successfully transferred into a clinically evaluated openEHR based CDSS. To the authors' knowledge, this is the first openEHR based CDSS, which is technically reliable and capable in a real context, and facilitates clinical decision-support for a complex task. Further activities will comprise enrichments of the knowledge base, the reasoning processes and cross-institutional evaluations.
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Affiliation(s)
- Antje Wulff
- Peter L. Reichertz Institute for Medical Informatics, University of Braunschweig - Institute of Technology and Hannover Medical School, Hannover, Germany.
| | - Birger Haarbrandt
- Peter L. Reichertz Institute for Medical Informatics, University of Braunschweig - Institute of Technology and Hannover Medical School, Hannover, Germany
| | - Erik Tute
- Peter L. Reichertz Institute for Medical Informatics, University of Braunschweig - Institute of Technology and Hannover Medical School, Hannover, Germany
| | - Michael Marschollek
- Peter L. Reichertz Institute for Medical Informatics, University of Braunschweig - Institute of Technology and Hannover Medical School, Hannover, Germany
| | - Philipp Beerbaum
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Germany
| | - Thomas Jack
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Germany
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19
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Khwannimit B, Bhurayanontachai R, Vattanavanit V. Comparison of the performance of SOFA, qSOFA and SIRS for predicting mortality and organ failure among sepsis patients admitted to the intensive care unit in a middle-income country. J Crit Care 2017; 44:156-160. [PMID: 29127841 DOI: 10.1016/j.jcrc.2017.10.023] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/06/2017] [Accepted: 10/17/2017] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The Sepsis-3 definition provides a change of two or more scores from zero or a known baseline of the Sequential Organ Failure Assessment (SOFA) as criteria of sepsis. The aim of this study was to compare the SOFA score and the quick SOFA (qSOFA) to Systemic Inflammatory Response Syndrome (SIRS) criteria in predictive ability of mortality and organ failure. METHODS A-10year retrospective cohort study was conducted in a teaching hospital in Thailand. RESULTS A total of 2350 of mixed sepsis patients by Sepsis-2 definition were included. The all-cause hospital mortality rate was 44.5%. Of the total sample, 95.6% (n=2247) of patients met criteria for sepsis under the Sepsis-3 definition. The SOFA score presented the best discrimination with an area under the receiver operating characteristic curve (AUC) of 0.839. The AUC of SOFA score for hospital mortality was significantly higher than qSOFA (AUC 0.814, P=0.003) and SIRS (AUC 0.587, P<0.0001). Also, the SOFA score had superior performance than other scores for predicting intensive care unit (ICU) mortality and organ failure. CONCLUSIONS The SOFA is a superior prognostic tool for predicting mortality and organ failure than qSOFA and SIRS criteria among sepsis patients admitted to the ICU.
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Affiliation(s)
- Bodin Khwannimit
- Division of Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand.
| | - Rungsun Bhurayanontachai
- Division of Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
| | - Veerapong Vattanavanit
- Division of Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, 90110, Thailand
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20
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Abstract
Three therapeutic principles most substantially improve organ dysfunction and survival in sepsis: early, appropriate antimicrobial therapy; restoration of adequate cellular perfusion; timely source control. The new definitions of sepsis and septic shock reflect the inadequate sensitivity, specify, and lack of prognostication of systemic inflammatory response syndrome criteria. Sequential (sepsis-related) organ failure assessment more effectively prognosticates in sepsis and critical illness. Inadequate cellular perfusion accelerates injury and reestablishing perfusion limits injury. Multiple organ systems are affected by sepsis and septic shock and an evidence-based multipronged approach to systems-based therapy in critical illness results in improve outcomes.
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Affiliation(s)
- Bracken A Armstrong
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S Medical Arts Building 404, Nashville, TN 37212, USA.
| | - Richard D Betzold
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S Medical Arts Building 404, Nashville, TN 37212, USA
| | - Addison K May
- Division of Trauma and Surgical Critical Care, Department of Surgery, Vanderbilt University Medical Center, 1211 21st Ave S Medical Arts Building 404, Nashville, TN 37212, USA
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21
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Taniguchi LU, Pires EMC, Vieira JM, Azevedo LCPD. Systemic inflammatory response syndrome criteria and the prediction of hospital mortality in critically ill patients: a retrospective cohort study. Rev Bras Ter Intensiva 2017; 29:317-324. [PMID: 28977100 PMCID: PMC5632974 DOI: 10.5935/0103-507x.20170047] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 04/18/2017] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE This study intended to determine whether the systemic inflammatory response syndrome criteria can predict hospital mortality in a Brazilian cohort of critically ill patients. METHODS We performed a retrospective cohort study at a private tertiary hospital in São Paulo (SP), Brazil. We extracted information from the adult intensive care unit database (Sistema EpimedTM). We compared the SAPS 3 and the systemic inflammatory response syndrome model as dichotomous (≥ 2 criteria: systemic inflammatory response syndrome -positive versus 0 - 1 criterion: systemic inflammatory response syndrome -negative) and ordinal variables from 0 to 4 (according to the number of systemic inflammatory response syndrome criteria met) in the prediction of hospital mortality at intensive care unit admission. Model discrimination was compared using the area under the receiver operating characteristics (AUROC) curve. RESULTS From January to December 2012, we studied 932 patients (60.4% were systemic inflammatory response syndrome -positive). systemic inflammatory response syndrome -positive patients were more critically ill than systemic inflammatory response syndrome -negative patients and had higher hospital mortality (16.9% versus 8.1%, p < 0.001). In the adjusted analysis, being systemic inflammatory response syndrome -positive independently increased the risk of death by 82% (odds ratio 1.82; 95% confidence interval [CI] 1.12 - 2.96, p = 0.016). However, the AUROC curve for the SAPS 3 model was higher (0.81, 95%CI 0.78 - 0.85) compared to the systemic inflammatory response syndrome model with the systemic inflammatory response syndrome criteria as a dichotomous variable (0.60, 95%CI 0.55 - 0.65) and as an ordinal variable (0.62, 95%CI 0.57 - 0.68; p < 0.001) for hospital mortality. CONCLUSION Although systemic inflammatory response syndrome is associated with hospital mortality, the systemic inflammatory response syndrome criteria show low accuracy in the prediction of mortality compared with the SAPS 3.
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Affiliation(s)
- Leandro Utino Taniguchi
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Disciplina de Emergências Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - José Mauro Vieira
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | - Luciano Cesar Pontes de Azevedo
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Disciplina de Emergências Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
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Association between mRNA expression of CD74 and IL10 and risk of ICU-acquired infections: a multicenter cohort study. Intensive Care Med 2017; 43:1013-1020. [PMID: 28477143 PMCID: PMC5487586 DOI: 10.1007/s00134-017-4805-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/12/2017] [Indexed: 01/22/2023]
Abstract
Purpose Intensive care unit (ICU)-acquired infections (IAI) result in increased hospital and ICU stay, costs and mortality. To date, no biomarker has shown sufficient evidence and ease of application in clinical routine for the identification of patients at risk of IAI. We evaluated the association of the systemic mRNA expression of two host response biomarkers, CD74 and IL10, with IAI occurrence in a large cohort of ICU patients. Methods ICU patients were prospectively enrolled in a multicenter cohort study. Whole blood was collected on the day of admission (D1) and on day 3 (D3) and day 6 (D6) after admission. Patients were screened daily for IAI occurrence and data were censored after IAI diagnosis. mRNA expression levels of biomarkers were measured using RT-qPCR. Fine and Gray competing risk models were used to assess the association between gene expression and IAI occurrence. Results A total of 725 patients were analyzed. At least one IAI episode occurred in 137 patients (19%). After adjustment for shock and sepsis status at admission, CD74 and IL10 levels were found to be significantly associated with IAI occurrence [subdistribution hazard ratio (95% confidence interval) 0.67 (0.46–0.97) for CD74 D3/D1 expression ratio and 2.21 (1.63–3.00) for IL10 at D3]. IAI cumulative incidence was significantly different between groups stratified according to CD74 or IL10 expression (Gray tests p < 0.001). Conclusion Our results suggest that two immune biomarkers, CD74 and IL10, could be relevant tools for the identification of IAI risk in ICU patients. Electronic supplementary material The online version of this article (doi:10.1007/s00134-017-4805-1) contains supplementary material, which is available to authorized users.
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23
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Weon Choi J, Hee Lee M, Fujii T, Fujii N. Delta index of the estimated glomerular filtration rate to amend the overestimated Neutrophil Gelatinase-Associated Lipocalin (NGAL) level in systemic inflammatory response syndrome. J Appl Biomed 2017. [DOI: 10.1016/j.jab.2016.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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24
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Plasma Phospholipid Fatty Acid Profile is Altered in Both Septic and Non-Septic Critically Ill: A Correlation with Inflammatory Markers and Albumin. Lipids 2016; 52:245-254. [DOI: 10.1007/s11745-016-4226-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 12/12/2016] [Indexed: 12/31/2022]
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25
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Douglas L, Casamento A, Jones D. Point prevalence of general ward patients fulfilling criteria for systemic inflammatory response syndrome. Intern Med J 2016; 46:223-5. [PMID: 26899889 DOI: 10.1111/imj.12968] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 11/19/2015] [Accepted: 11/22/2015] [Indexed: 11/30/2022]
Abstract
The systemic inflammatory response syndrome (SIRS) is defined by abnormal temperature, heart rate, minute ventilation or white cell count and can be due to infectious or non-infectious causes. In a single day, 23% of hospital ward patients fulfilled SIRS criteria. Patients with SIRS were more likely to be under medical than surgical units. One-third of the patients had evidence of infection. There was no association between SIRS criteria and increased mortality or hospital length of stay.
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Affiliation(s)
- L Douglas
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - A Casamento
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - D Jones
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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26
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Ward L, Paul M, Andreassen S. Automatic learning of mortality in a CPN model of the systemic inflammatory response syndrome. Math Biosci 2016; 284:12-20. [PMID: 27833000 DOI: 10.1016/j.mbs.2016.11.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 11/02/2016] [Accepted: 11/05/2016] [Indexed: 12/25/2022]
Abstract
The aim of this paper is to apply machine learning as a method to refine a manually constructed CPN for the assessment of the severity of the systemic inflammatory response syndrome (SIRS).The goal of tuning the CPN is to create a scoring system that uses only objective data, compares favourably with other severity-scoring systems and differentiates between sepsis and non-infectious SIRS. The resulting model, the Learned-Age (LA) -Sepsis CPN has good discriminatory ability for the prediction of 30-day mortality with an area under the ROC curve of 0.79. This result compares well to existing scoring systems. The LA-Sepsis CPN also has a modest ability to discriminate between sepsis and non-infectious SIRS.
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Affiliation(s)
- Logan Ward
- Centre for Model-based Medical Decision Support, Aalborg University, Fredrik Bajers Vej 7 E4, 9220 Aalborg Ø, Denmark.
| | - Mical Paul
- Unit of Infectious Diseases, Rambam Health Care Campus, HaAliya HaShniya St 8, Haifa, Israel.
| | - Steen Andreassen
- Centre for Model-based Medical Decision Support, Aalborg University, Fredrik Bajers Vej 7 E4, 9220 Aalborg Ø, Denmark; Treat Systems, Hasserisvej 125, 9000 Aalborg, Denmark.
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Vincent JL, Martin GS, Levy MM. qSOFA does not replace SIRS in the definition of sepsis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:210. [PMID: 27423462 PMCID: PMC4947518 DOI: 10.1186/s13054-016-1389-z] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Greg S Martin
- Division of Pulmonary, Allergy and Critical Care, Emory University School of Medicine, Grady Memorial Hospital, 615 Michael Street, Suite 205, Atlanta, GA, 30322, USA
| | - Mitchell M Levy
- Division of Pulmonary, Critical Care and Sleep Medicine, Alpert Medical School at Brown University, 593 Eddy Street, Providence, RI, 02903, USA
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Trivedi S, Al-Nofal A, Kumar S, Tripathi S, Kahoud RJ, Tebben PJ. Severe non-infective systemic inflammatory response syndrome, shock, and end-organ dysfunction after zoledronic acid administration in a child. Osteoporos Int 2016; 27:2379-2382. [PMID: 26892041 DOI: 10.1007/s00198-016-3528-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 02/04/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Zoledronic acid is an intravenous bisphosphonate used to increase bone mineral density and reduce the risk of fractures. Its safety profile compares well with pamidronate in pediatric patients. We describe an acute, severe, life-threatening, inflammatory reaction in a child. METHODS A 7-year-old boy with complex medical problems and chronic ventilator requirements was admitted to the pediatric intensive care unit (due to ventilator needs) for zoledronic acid infusion and subsequent monitoring. His history was significant for osteoporosis secondary to immobilization with multiple fractures since 2 years of age, hypoxic-ischemic encephalopathy, quadriplegic cerebral palsy, seizure disorder, ventilator dependence, and pulmonary hypertension. He had previously been treated with four cycles of pamidronate without adverse events. He received 0.013 mg/kg of zoledronic acid infused over 30 minutes. Beginning 3 hours after completion of the infusion, he developed progressive tachycardia, fever, hypotension requiring vasopressor infusion, and increasing oxygen requirements. Laboratory studies revealed leukopenia, thrombocytopenia, elevated C-reactive protein, abnormal coagulation profile, metabolic acidosis, and negative cultures. The following day, he developed moderate acute respiratory distress syndrome and pulmonary hemorrhage requiring higher ventilatory settings, and subsequently diarrhea and abdominal distension. Initial clinical resolution was noted from the third day onward, and he was discharged on the sixth day after zoledronate administration. RESULTS Our pediatric patient demonstrated an acute, severe, life-threatening reaction to zoledronic acid requiring intensive cardiorespiratory support without an underlying pre-existing inflammatory disorder. CONCLUSION Our case highlights the importance of careful monitoring of children following zoledronic acid therapy. We recommend inpatient observation after an initial infusion of zoledronic acid in medically complex children. Children and their parents should be thoroughly counseled on the potential risks of bisphosphonate treatment, which can sometimes be severe and life threatening.
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Affiliation(s)
- S Trivedi
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Critical Care, Mayo Clinic, Rochester, MN, USA
| | - A Al-Nofal
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - S Kumar
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - S Tripathi
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Critical Care, Mayo Clinic, Rochester, MN, USA
| | - R J Kahoud
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Critical Care, Mayo Clinic, Rochester, MN, USA
| | - P J Tebben
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Endocrinology, Mayo Clinic, Rochester, MN, USA.
- Departments of Medicine and Pediatric and Adolescent Medicine, Division of Endocrinology, Mayo Clinic, 200 First ST SW, Rochester, MN, 55905, USA.
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Friggeri A, Cazalis MA, Pachot A, Cour M, Argaud L, Allaouchiche B, Floccard B, Schmitt Z, Martin O, Rimmelé T, Fontaine-Kesteloot O, Page M, Piriou V, Bohé J, Monneret G, Morisset S, Textoris J, Vallin H, Blein S, Maucort-Boulch D, Lepape A, Venet F. Decreased CX3CR1 messenger RNA expression is an independent molecular biomarker of early and late mortality in critically ill patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:204. [PMID: 27364780 PMCID: PMC4929760 DOI: 10.1186/s13054-016-1362-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 05/27/2016] [Indexed: 01/31/2023]
Abstract
Background Chemokine (C-X3-C motif) receptor 1 (CX3CR1) was identified as the most differentially expressed gene between survivors and non-survivors in two independent cohorts of septic shock patients and was proposed as a marker of sepsis-induced immunosuppression. Whether such a biomarker is associated with mortality in the heterogeneous group of critically ill patients is unknown. The primary objective of this study was to evaluate the association between CX3CR1 messenger RNA (mRNA) expression and mortality in intensive care unit (ICU) patients. The secondary objective was to evaluate similar endpoints in the subgroup of septic shock patients. Methods We performed a prospective, multicentre, non-interventional study in six ICUs of university hospitals in Lyon, France. Every consecutive adult patient with systemic inflammatory response syndrome and an expected length of stay in the ICU over 2 days was included. Whole-blood CX3CR1 mRNA expression was measured by quantitative real-time polymerase chain reaction at day 1 (D1) and D3 after inclusion. Results In ICU patients (n = 725), decreased CX3CR1 mRNA expression at D1 was associated with high D7 mortality (AUC 0.70, adjusted OR [aOR] 2.03, 95 % CI 1.19–3.46), while decreased expression at D3 was associated with increased D28 mortality (AUC 0.64, aOR 2.34, 95 % CI 1.45–3.77). In septic shock patients (n = 279), similar associations were observed between decreased D1 CX3CR1 mRNA expression and D7 mortality (AUC 0.69, aOR 2.76, 95 % CI 1.32–5.75) as well as decreased D3 expression and D28 mortality (AUC 0.72, aOR 3.98, 95 % CI 1.72–9.23). These associations were independent of lactacidaemia, Simplified Acute Physiology Score II, Sepsis-related Organ Failure Assessment score and Charlson comorbidity index. Conclusions This study represents the largest evaluation of such an mRNA marker in a heterogeneous cohort of severely injured patients. Our results show that decreased CX3CR1 mRNA expression is associated with increased mortality in ICU patients. This suggests a link between injury-induced immunosuppression and mortality in critically ill patients. In this context, the monitoring of such a host response molecular biomarker could prove very helpful for the identification of patients at high risk of death in the ICU. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1362-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Arnaud Friggeri
- Hospices Civils de Lyon, Intensive Care Unit, Centre Hospitalier Lyon Sud, Pierre Bénite, France.,Hospices Civils de Lyon-bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - Marie-Angélique Cazalis
- Hospices Civils de Lyon-bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - Alexandre Pachot
- Hospices Civils de Lyon-bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - Martin Cour
- Hospices Civils de Lyon, Medical Intensive Care Unit, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Medical Intensive Care Unit, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - Bernard Allaouchiche
- Hospices Civils de Lyon, Intensive Care Unit, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Bernard Floccard
- Hospices Civils de Lyon, Department of Anaesthesiology and Critical Care Medicine, Groupement Hospitalier Edouard Herriot, University Claude Bernard Lyon 1, Lyon, France
| | - Zoé Schmitt
- Hospices Civils de Lyon, Intensive Care Unit, Hôpital de la Croix Rousse, Lyon, France
| | - Olivier Martin
- Hospices Civils de Lyon, Department of Anaesthesiology and Critical Care Medicine, Groupement Hospitalier Edouard Herriot, University Claude Bernard Lyon 1, Lyon, France
| | - Thomas Rimmelé
- Hospices Civils de Lyon-bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France.,Hospices Civils de Lyon, Department of Anaesthesiology and Critical Care Medicine, Groupement Hospitalier Edouard Herriot, University Claude Bernard Lyon 1, Lyon, France
| | | | - Mathieu Page
- Hospices Civils de Lyon, Department of Anaesthesiology and Critical Care Medicine, Groupement Hospitalier Edouard Herriot, University Claude Bernard Lyon 1, Lyon, France
| | - Vincent Piriou
- Hospices Civils de Lyon, Intensive Care Unit, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Julien Bohé
- Hospices Civils de Lyon, Intensive Care Unit, Centre Hospitalier Lyon Sud, Pierre Bénite, France
| | - Guillaume Monneret
- Hospices Civils de Lyon-bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France.,Hospices Civils de Lyon, Immunology Laboratory, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - Stéphane Morisset
- Hospices Civils de Lyon-bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - Julien Textoris
- Hospices Civils de Lyon-bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France.,Hospices Civils de Lyon, Department of Anaesthesiology and Critical Care Medicine, Groupement Hospitalier Edouard Herriot, University Claude Bernard Lyon 1, Lyon, France
| | - Hélène Vallin
- Hospices Civils de Lyon, Intensive Care Unit, Centre Hospitalier Lyon Sud, Pierre Bénite, France.,Hospices Civils de Lyon-bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - Sophie Blein
- Hospices Civils de Lyon-bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - Delphine Maucort-Boulch
- Hospices Civils de Lyon, Université Lyon 1, CNRS, UMR5558, Service de Biostatistique et Laboratoire de Biométrie et Biologie Evolutive, Equipe Biostatistique-Santé, Lyon, France
| | - Alain Lepape
- Hospices Civils de Lyon, Intensive Care Unit, Centre Hospitalier Lyon Sud, Pierre Bénite, France.,Hospices Civils de Lyon-bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France
| | - Fabienne Venet
- Hospices Civils de Lyon-bioMérieux Joint Research Unit, Groupement Hospitalier Edouard Herriot, Lyon, France. .,Hospices Civils de Lyon, Immunology Laboratory, Groupement Hospitalier Edouard Herriot, Lyon, France. .,Immunology Laboratory, Hôpital E. Herriot - Hospices Civils de Lyon, 5 place d'Arsonval, 69437, Lyon Cedex 03, France.
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Besen BAMP, Gobatto ALN, Melro LMG, Maciel AT, Park M. Fluid and electrolyte overload in critically ill patients: An overview. World J Crit Care Med 2015; 4:116-129. [PMID: 25938027 PMCID: PMC4411563 DOI: 10.5492/wjccm.v4.i2.116] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 12/24/2014] [Accepted: 03/05/2015] [Indexed: 02/06/2023] Open
Abstract
Fluids are considered the cornerstone of therapy for many shock states, particularly states that are associated with relative or absolute hypovolemia. Fluids are also commonly used for many other purposes, such as renal protection from endogenous and exogenous substances, for the safe dilution of medications and as “maintenance” fluids. However, a large amount of evidence from the last decade has shown that fluids can have deleterious effects on several organ functions, both from excessive amounts of fluids and from their non-physiological electrolyte composition. Additionally, fluid prescription is more common in patients with systemic inflammatory response syndrome whose kidneys may have impaired mechanisms of electrolyte and free water excretion. These processes have been studied as separate entities (hypernatremia, hyperchloremic acidosis and progressive fluid accumulation) leading to worse outcomes in many clinical scenarios, including but not limited to acute kidney injury, worsening respiratory function, higher mortality and higher hospital and intensive care unit length-of-stays. In this review, we synthesize this evidence and describe this phenomenon as fluid and electrolyte overload with potentially deleterious effects. Finally, we propose a strategy to safely use fluids and thereafter wean patients from fluids, along with other caveats to be considered when dealing with fluids in the intensive care unit.
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31
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Zarbock A, Van Aken H, Schmidt C. Remote ischemic preconditioning and outcome. Curr Opin Anaesthesiol 2015; 28:165-71. [DOI: 10.1097/aco.0000000000000161] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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32
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Ward L, Andreassen S. A Bayesian Approach to Model-Development: Automatic Learning for Tuning Predictive Performance. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.ifacol.2015.10.187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Liao MM, Lezotte D, Lowenstein SR, Howard K, Finley Z, Feng Z, Byyny RL, Sankoff JD, Douglas IS, Haukoos JS. Sensitivity of systemic inflammatory response syndrome for critical illness among ED patients. Am J Emerg Med 2014; 32:1319-25. [PMID: 25205616 DOI: 10.1016/j.ajem.2014.07.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 07/28/2014] [Accepted: 07/29/2014] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Little is known about the diagnostic accuracy of systemic inflammatory response syndrome (SIRS) criteria for critical illness among emergency department (ED) patients with and without infection. Our objective was to assess the diagnostic accuracy of SIRS criteria for critical illness in ED patients. METHODS This was a retrospective cohort study of ED patients at an urban academic hospital. Standardized chart abstraction was performed on a random sample of all adult ED medical patients admitted to the hospital during a 1-year period, excluding repeat visits, transfers, ED deaths, and primary surgical or psychiatric admissions. The binary composite outcome of critical illness was defined as 24 hours or longer in intensive care or inhospital death. Presumed infection was defined as receiving antibiotics within 48 hours of admission. Systemic inflammatory response syndrome criteria were calculated using ED triage vital signs and initial white blood cell count. RESULTS We studied 1152 patients; 39% had SIRS, 27% had presumed infection, and 23% had critical illness (2% had inhospital mortality, and 22% had ≥24 hours in intensive care). Of patients with SIRS, 38% had presumed infection. Of patients without SIRS, 21% had presumed infection. The sensitivity of SIRS criteria for critical illness was 52% (95% confidence interval [CI], 46%-58%) in all patients, 66% (95% CI, 56%-75%) in patients with presumed infection, and 43% (95% CI, 36%-51%) in patients without presumed infection. CONCLUSIONS Systemic inflammatory response syndrome at ED triage, as currently defined, has poor sensitivity for critical illness in medical patients admitted from the ED.
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Affiliation(s)
- Michael M Liao
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO.
| | - Dennis Lezotte
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO
| | - Steven R Lowenstein
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Community and Behavioral Health, Colorado School of Public Health, Aurora, CO
| | | | | | - Zipei Feng
- University of Colorado Boulder, Boulder, CO
| | - Richard L Byyny
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Jeffrey D Sankoff
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Ivor S Douglas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Denver Health Medical Center, Denver, CO; Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Jason S Haukoos
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Epidemiology, Colorado School of Public Health, Aurora, CO; Department of Integrated Physiology, University of Colorado Boulder, Boulder, CO
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Bartels K, Karhausen J, Clambey ET, Grenz A, Eltzschig HK. Perioperative organ injury. Anesthesiology 2014; 119:1474-89. [PMID: 24126264 DOI: 10.1097/aln.0000000000000022] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Despite the fact that a surgical procedure may have been performed for the appropriate indication and in a technically perfect manner, patients are threatened by perioperative organ injury. For example, stroke, myocardial infarction, acute respiratory distress syndrome, acute kidney injury, or acute gut injury are among the most common causes for morbidity and mortality in surgical patients. In the current review, the authors discuss the pathogenesis of perioperative organ injury, and provide select examples for novel treatment concepts that have emerged over the past decade. Indeed, the authors are of the opinion that research to provide mechanistic insight into acute organ injury and identification of novel therapeutic approaches for the prevention or treatment of perioperative organ injury represent the most important opportunity to improve outcomes of anesthesia and surgery.
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Affiliation(s)
- Karsten Bartels
- * Fellow in Critical Care Medicine and Cardiothoracic Anesthesiology, † Assistant Professor of Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina. ‡ Assistant Professor of Anesthesiology, § Associate Professor of Anesthesiology, ‖ Professor of Anesthesiology, Department of Anesthesiology, University of Colorado Denver, Aurora, Colorado
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Fullerton JN, O'Brien AJ, Gilroy DW. Lipid mediators in immune dysfunction after severe inflammation. Trends Immunol 2013; 35:12-21. [PMID: 24268519 PMCID: PMC3884129 DOI: 10.1016/j.it.2013.10.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Revised: 09/16/2013] [Accepted: 10/22/2013] [Indexed: 12/21/2022]
Abstract
Aberrant LM levels contribute to immune dysfunction in CI. Aberrance reflects dysregulation of inflammatory resolution pathways or their failure. Targeted manipulation of LMs restores immune competence and outcomes in animal models. Stratified resolution-based immunomodulatory strategies hold therapeutic potential.
Sepsis, trauma, burns, and major surgical procedures activate common systemic inflammatory pathways. Nosocomial infection, organ failure, and mortality in this patient population are associated with a quantitatively different reprioritization of the circulating leukocyte transcriptome to the initial inflammatory insult, greater in both magnitude and duration, and secondary to multiple observed defects in innate and adaptive immune function. Dysregulation of inflammatory resolution processes and associated bioactive lipid mediators (LMs) mechanistically contribute to this phenotype. Recent data indicate the potential efficacy of therapeutic interventions that either reduce immunosuppressive prostaglandins (PGs) or increase specialized proresolving LMs. Here, we reassess the potential for pharmacological manipulation of these LMs as therapeutic approaches for the treatment of critical illness (CI).
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Affiliation(s)
- James N Fullerton
- Centre for Clinical Pharmacology, Division of Medicine, Rayne Institute, 5 University Street, University College London, London, WC1E 6JF, UK.
| | - Alastair J O'Brien
- Centre for Clinical Pharmacology, Division of Medicine, Rayne Institute, 5 University Street, University College London, London, WC1E 6JF, UK
| | - Derek W Gilroy
- Centre for Clinical Pharmacology, Division of Medicine, Rayne Institute, 5 University Street, University College London, London, WC1E 6JF, UK
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36
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Fullerton JN, O'Brien AJ, Gilroy DW. Pathways mediating resolution of inflammation: when enough is too much. J Pathol 2013; 231:8-20. [PMID: 23794437 DOI: 10.1002/path.4232] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 06/11/2013] [Accepted: 06/17/2013] [Indexed: 01/22/2023]
Abstract
Patients with critical illness, and in particular sepsis, are now recognized to undergo unifying, pathogenic disturbances of immune function. Whilst scientific and therapeutic focus has traditionally been on understanding and modulating the initial pro-inflammatory limb, recent years have witnessed a refocusing on the development and importance of immunosuppressive 'anti-inflammatory' pathways. Several mechanisms are known to drive this phenomenon; however, no overriding conceptual framework justifies them. In this article we review the contribution of pro-resolution pathways to this phenotype, describing the observed immune alterations in terms of either a failure of resolution of inflammation or the persistence of pro-resolution processes causing inappropriate 'injurious resolution'-a novel hypothesis. The dysregulation of key processes in critical illness, including apoptosis of infiltrating neutrophils and their efferocytosis by macrophages, are discussed, along with the emerging role of specialized cell subtypes Gr1(+) CD11b(+) myeloid-derived suppressor cells and CD4(+) CD25(+) FoxP3(+) T-regulatory cells.
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Affiliation(s)
- James N Fullerton
- Centre for Clinical Pharmacology, Division of Medicine, University College London, London, UK.
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37
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Sakr Y, Lobo SM, Moreno RP, Gerlach H, Ranieri VM, Michalopoulos A, Vincent JL. Patterns and early evolution of organ failure in the intensive care unit and their relation to outcome. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R222. [PMID: 23158219 PMCID: PMC3672601 DOI: 10.1186/cc11868] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Accepted: 08/20/2012] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Recognition of patterns of organ failure may be useful in characterizing the clinical course of critically ill patients. We investigated the patterns of early changes in organ dysfunction/failure in intensive care unit (ICU) patients and their relation to outcome. METHODS Using the database from a large prospective European study, we studied 2,933 patients who had stayed more than 48 hours in the ICU and described patterns of organ failure and their relation to outcome. Patients were divided into three groups: patients without sepsis, patients in whom sepsis was diagnosed within the first 48 hours after ICU admission, and patients in whom sepsis developed more than 48 hours after admission. Organ dysfunction was assessed by using the sequential organ failure assessment (SOFA) score. RESULTS A total of 2,110 patients (72% of the study population) had organ failure at some point during their ICU stay. Patients who exhibited an improvement in organ function in the first 24 hours after admission to the ICU had lower ICU and hospital mortality rates compared with those who had unchanged or increased SOFA scores (12.4 and 18.4% versus 19.6 and 24.5%, P < 0.05, pairwise). As expected, organ failure was more common in sepsis than in nonsepsis patients. In patients with single-organ failure, in-hospital mortality was greater in sepsis than in nonsepsis patients. However, in patients with multiorgan failure, mortality rates were similar regardless of the presence of sepsis. Irrespective of the presence of sepsis, delta SOFA scores over the first 4 days in the ICU were higher in nonsurvivors than in survivors and decreased significantly over time in survivors. CONCLUSIONS Early changes in organ function are strongly related to outcome. In patients with single-organ failure, in-hospital mortality was higher in sepsis than in nonsepsis patients. However, in multiorgan failure, mortality rates were not influenced by the presence of sepsis.
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Phua J, Ho BC, Tee A, Chan KP, Johan A, Loo S, So CR, Chia N, Tan AY, Tham HM, Chan YH, Koh Y. The impact of clinical protocols in the management of severe sepsis: a prospective cohort study. Anaesth Intensive Care 2012; 40:663-74. [PMID: 22813495 DOI: 10.1177/0310057x1204000413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This study aimed to assess the availability of clinical protocols and their effect on compliance to the Surviving Sepsis Campaign bundles and on mortality in severe sepsis in ten Singaporean adult teaching intensive care units (ICU). The presence of 11 protocols in the ICUs, steps taken based on the Johns Hopkins University Quality and Safety Research Group's model to translate protocols into practice, and organisational characteristics were assessed. Clinical and research personnel recorded characteristics of patients with severe sepsis who were admitted in July 2009, the achievement of sepsis bundle targets and outcomes. Hospital mortality was 39% for 128 patients. Fewer than half of the ICUs had protocols for early goal-directed therapy, blood cultures, antibiotics, steroids, lung-protective ventilation and weaning. Compliance rates with the resuscitation and management bundles were 18 and 3% respectively. Units with protocols were generally not more likely to achieve associated bundle targets. Steps from the Johns Hopkins model to measure performance, engage teams and sustain and extend interventions were taken in fewer than half of the available protocols. However, on logistic regression analysis, the number of protocols available per ICU was independently and inversely associated with mortality. In conclusion, clinical protocols are infrequently available in Singapore's ICUs and when present do not generally improve compliance to the sepsis bundles. These protocols may, however, be a surrogate marker of the quality of care as they are independently associated with decreased mortality. The use of an integrated and multifaceted approach to translate protocols into practice should be considered.
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Affiliation(s)
- J Phua
- Singapore Society of Intensive Care Medicine's National Investigators for Clinical Epidemiology and Research, Singapore.
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Abstract
The aim of this study was to investigate the causes of death in patients with burns using both medicolegal autopsy reports and clinical data collected during treatment to specify irreversible organ dysfunctions leading to death. Burn deaths occurring in the Helsinki Burn Center from 1995 to 2005 were identified in the hospital database. The clinical charts and medicolegal autopsy reports were retrieved and compared. The data were evaluated by plastic surgeons specialized in burn care, an intensivist, and a pathologist, with special reference to organ-specific changes in the autopsy reports. From 1999 to 2005, there were 71 burn deaths in the Helsinki Burn Center of which 40% was caused by multiple organ failure (MOF). Death from untreatable burn injury was recorded in 28 patients, whereas other causes were scarce. MOF patients displayed approximately four organ failures on average, ranging from three to eight. All 28 MOF patients were recorded to have acute renal failure, followed by liver damage, of which four patients had acute or chronic liver failure. Sepsis was always affiliated with MOF as a cause of death. In conclusion, careful examination of MOF as a cause of death revealed several organ failures: four organ failures per patient. Acute renal failure was noted in all MOF patients. Sepsis was always affiliated with MOF.
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Schneider F, Bach C, Chung H, Crippa L, Lavaux T, Bollaert PE, Wolff M, Corti A, Launoy A, Delabranche X, Lavigne T, Meyer N, Garnero P, Metz-Boutigue MH. Vasostatin-I, a chromogranin A-derived peptide, in non-selected critically ill patients: distribution, kinetics, and prognostic significance. Intensive Care Med 2012; 38:1514-22. [PMID: 22706917 DOI: 10.1007/s00134-012-2611-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2012] [Accepted: 05/16/2012] [Indexed: 12/20/2022]
Abstract
PURPOSE Chromogranin A (CGA) is released in the plasma during life-threatening illnesses. Its N-terminal 1-76 peptide, vasostatin-I (VS-I), has never been assessed in critically ill patients. Our aim was to examine whether the admission VS-I concentration has prognostic significance without having to specify a primary diagnosis. METHODS VS-I concentrations were assessed with a new ELISA in 481 consecutive patients and 13 healthy controls. CGA and standard biological tests (including lactate) were performed; the simplified acute physiological score II (SAPS II) was calculated. Mortality was assessed at day 28. In a subgroup of 13 patients with shock, serial VS-I doses were given over 60 h. RESULTS Critically ill patients had higher admission VS-I concentrations than controls [4.06 (2.78; 7.61) vs. 2.85 (2.47; 3.22) ng/ml, p < 0.001]. The plasma VS-I concentration was significantly lower in survivors than in non-survivors [3.70 (2.67; 6.12) vs. 5.75 (3.65; 11.20) ng/ml] and in the absence of shock [3.58 (2.59; 5.05) vs. 5.93 (3.30; 11.06) ng/ml, p < 0.001]. The survival rate was better in patients with VS-I concentrations under the median value of 3.97 ng/ml (p < 0.001). Admission VS-I and lactate values were independent predictors of mortality (p < 0.01). Moreover, taking them together, combined with age, provided a better indication for predicting mortality than taking each alone (p < 0.01). CONCLUSIONS Significant amounts of VS-I are detected on admission in critically ill patients. A plasma VS-I concentration above 3.97 ng/ml is associated with poor outcome, and in routine practice simultaneous measurements of the three independent factors VS-I, lactate and age can affect the assessment of severity.
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Affiliation(s)
- Francis Schneider
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg and INSERM U977, Université de Strasbourg, Strasbourg, France
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Jack T, Boehne M, Brent BE, Hoy L, Köditz H, Wessel A, Sasse M. In-line filtration reduces severe complications and length of stay on pediatric intensive care unit: a prospective, randomized, controlled trial. Intensive Care Med 2012; 38:1008-16. [PMID: 22527062 PMCID: PMC3351606 DOI: 10.1007/s00134-012-2539-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 01/12/2012] [Indexed: 11/17/2022]
Abstract
PURPOSE Particulate contamination due to infusion therapy carries a potential health risk for intensive care patients. METHODS This single-centre, prospective, randomized controlled trial assessed the effects of filtration of intravenous fluids on the reduction of complications in critically ill children admitted to a pediatric intensive care unit (PICU). A total of 807 subjects were randomly assigned to either a control (n = 406) or filter group (n = 401), with the latter receiving in-line filtration. The primary endpoint was reduction in the rate of overall complications, which included the occurrence of systemic inflammatory response syndrome (SIRS), sepsis, organ failure (circulation, lung, liver, kidney) and thrombosis. Secondary objectives were a reduction in the length of stay on the PICU and overall hospital stay. Duration of mechanical ventilation and mortality were also analyzed. FINDINGS Analysis demonstrated a significant reduction in the overall complication rate (n = 166 [40.9 %] vs. n = 124 [30.9 %]; P = 0.003) for the filter group. In particular, the incidence of SIRS was significantly lower (n = 123 [30.3 %] vs. n = 90 [22.4 %]; P = 0.01). Moreover the length of stay on PICU (3.89 [95 % confidence interval 2.97-4.82] vs. 2.98 [2.33-3.64]; P = 0.025) and duration of mechanical ventilation (14.0 [5.6-22.4] vs. 11.0 [7.1-14.9] h; P = 0.028) were significantly reduced. CONCLUSION In-line filtration is able to avert severe complications in critically ill patients. The overall complication rate during the PICU stay among the filter group was significantly reduced. In-line filtration was effective in reducing the occurrence of SIRS. We therefore conclude that in-line filtration improves the safety of intensive care therapy and represents a preventive strategy that results in a significant reduction of the length of stay in the PICU and duration of mechanical ventilation (ClinicalTrials.gov number: NCT00209768).
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Affiliation(s)
- Thomas Jack
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Martin Boehne
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | | | - Ludwig Hoy
- Institute of Biometrics, Hannover Medical School, Hannover, Germany
| | - Harald Köditz
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Armin Wessel
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
| | - Michael Sasse
- Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, 30625 Hannover, Germany
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Phua J, Koh Y, Du B, Tang YQ, Divatia JV, Tan CC, Gomersall CD, Faruq MO, Shrestha BR, Gia Binh N, Arabi YM, Salahuddin N, Wahyuprajitno B, Tu ML, Wahab AYHA, Hameed AA, Nishimura M, Procyshyn M, Chan YH. Management of severe sepsis in patients admitted to Asian intensive care units: prospective cohort study. BMJ 2011; 342:d3245. [PMID: 21669950 PMCID: PMC3113333 DOI: 10.1136/bmj.d3245] [Citation(s) in RCA: 159] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To assess the compliance of Asian intensive care units and hospitals to the Surviving Sepsis Campaign's resuscitation and management bundles. Secondary objectives were to evaluate the impact of compliance on mortality and the organisational characteristics of hospitals that were associated with higher compliance. DESIGN Prospective cohort study. SETTING 150 intensive care units in 16 Asian countries. PARTICIPANTS 1285 adult patients with severe sepsis admitted to these intensive care units in July 2009. The organisational characteristics of participating centres, the patients' baseline characteristics, the achievement of targets within the resuscitation and management bundles, and outcome data were recorded. MAIN OUTCOME MEASURE Compliance with the Surviving Sepsis Campaign's resuscitation (six hours) and management (24 hours) bundles. RESULTS Hospital mortality was 44.5% (572/1285). Compliance rates for the resuscitation and management bundles were 7.6% (98/1285) and 3.5% (45/1285), respectively. On logistic regression analysis, compliance with the following bundle targets independently predicted decreased mortality: blood cultures (achieved in 803/1285; 62.5%, 95% confidence interval 59.8% to 65.1%), broad spectrum antibiotics (achieved in 821/1285; 63.9%, 61.3% to 66.5%), and central venous pressure (achieved in 345/870; 39.7%, 36.4% to 42.9%). High income countries, university hospitals, intensive care units with an accredited fellowship programme, and surgical intensive care units were more likely to be compliant with the resuscitation bundle. CONCLUSIONS While mortality from severe sepsis is high, compliance with resuscitation and management bundles is generally poor in much of Asia. As the centres included in this study might not be fully representative, achievement rates reported might overestimate the true degree of compliance with recommended care and should be interpreted with caution. Achievement of targets for blood cultures, antibiotics, and central venous pressure was independently associated with improved survival.
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Affiliation(s)
- Jason Phua
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, National University Health System Tower Block, Level 10, 1E Kent Ridge Road, Singapore 119228
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Lobo SM, Rezende E, Knibel MF, Silva NB, Páramo JA, Nácul FE, Mendes CL, Assunção M, Costa RC, Grion CC, Pinto SF, Mello PM, Maia MO, Duarte PA, Gutierrez F, Silva JM, Lopes MR, Cordeiro JA, Mellot C. Early Determinants of Death Due to Multiple Organ Failure After Noncardiac Surgery in High-Risk Patients. Anesth Analg 2011; 112:877-83. [DOI: 10.1213/ane.0b013e3181e2bf8e] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Dulhunty JM, Paterson D, Webb SAR, Lipman J. Antimicrobial Utilisation in 37 Australian and New Zealand Intensive Care Units. Anaesth Intensive Care 2011; 39:231-7. [DOI: 10.1177/0310057x1103900212] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
This multi-centre point prevalence study reports on antimicrobial dosing patterns, including dose, mode of administration and type of infection, in 37 Australian and New Zealand intensive care units. Of 422 patients admitted to an intensive care unit on 8 May 2007, 195 patients (46%) received antimicrobial treatment, 123 patients (29%) received no antimicrobials and 104 patients (25%) received prophylactic antimicrobials only. Dosing data were available for 331 antimicrobials used to treat 225 infections in 193 patients. Respiratory (40%), abdominal (13%) and blood stream (12%) infections were most common. For adult patients, ticarcillin/clavulanate (23% or 40/177), meropenem (20% or 35/177) and vancomycin (18% or 32/177) were the most frequently used antibiotics; vancomycin was most commonly used in children (31% or 5/16). The majority of antimicrobials were administered as bolus doses or infusions of less than two hours (98% or 317/323); only six patients received extended or continuous infusions. The mode of administration was unknown in eight cases (4.1%). The total defined daily dose for adult patients receiving antimicrobial therapy was 2051 defined daily doses per 1000 patient days. Our results confirm that the use of continuous infusions remains rare, despite increased interest in continuous infusions for time-dependent antibiotics.
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Affiliation(s)
- J. M. Dulhunty
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Research Fellow, Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, and The Burns, Trauma and Critical Care Research Centre, The University of Queensland
| | - D. Paterson
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Professor of Medicine, Department of Infectious Diseases, Royal Brisbane and Women's Hospital, and the University of Queensland Centre for Clinical Research
| | - S. A. R. Webb
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Senior Staff Specialist, Intensive Care Unit, Royal Perth Hospital, and School of Medicine and Pharmacology and School of Population Health, University of Western Australia, Perth, Western Australia
| | - J. Lipman
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, and The Burns, Trauma and Critical Care Research Centre, The University of Queensland
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Abstract
PURPOSE OF REVIEW Invasive candidiasis remains an important infection for ICU patients, associated with poor clinical outcomes. It has been increasingly recognized that the traditional paradigm of culture-directed antifungal treatment is unsatisfactory, and that earlier antifungal intervention strategies, such as prophylaxis, preemptive therapy, and empiric therapy, are required to improve patient outcomes. The purpose of this review is to summarize the recent supportive evidence for such strategies and to highlight the current challenges in their implementation. RECENT FINDINGS Despite new antifungal agents and classes, the mortality from invasive candidiasis remains high. Antifungal prophylaxis remains the best-studied early antifungal intervention strategy; however, unless targeted to patients at highest risk, is inefficient. Recent data suggests that although risk predictive models, using a combination of clinical risk factors and Candida colonization parameters, may be a relatively simple and practical approach to guide prophylaxis or preemptive therapy, further validation of these models is required. A single trial has demonstrated that empiric antifungal therapy is not of benefit when instituted to patients with antibiotic-refractory fever alone. SUMMARY On the basis of current knowledge, it is difficult to universally recommend antifungal prophylaxis, apart from patient groups with a known very high risk, such as those with necrotising pancreatitis or recurrent gastrointestinal perforations. Antifungal prophylaxis may also be reasonable where local incidence rates and epidemiology are compelling. Among stable patients with multifocal Candida colonization and/or a multitude of clinical-risk factors, preemptive therapy is currently not indicated, although the development of better risk predictive models may assist with such patients. Among patients with refractory fever despite broad-spectrum antibacterial therapy, empiric antifungal therapy may be reasonable where local incidence rates are high (e.g. >10%); however, a thorough search for alternate causes must be instituted.
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Creagh-Brown BC, Quinlan GJ, Evans TW, Burke-Gaffney A. The RAGE axis in systemic inflammation, acute lung injury and myocardial dysfunction: an important therapeutic target? Intensive Care Med 2010; 36:1644-1656. [PMID: 20631986 DOI: 10.1007/s00134-010-1952-z] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Accepted: 05/25/2010] [Indexed: 01/08/2023]
Abstract
BACKGROUND The sepsis syndromes, frequently complicated by pulmonary and cardiac dysfunction, remain a major cause of death amongst the critically ill. Targeted therapies aimed at ameliorating the systemic inflammation that characterises the sepsis syndromes have largely yielded disappointing results in clinical trials. Whilst there are many potential reasons for lack of success of clinical trials, one possibility is that the pathways targeted, to date, are only modifiable very early in the course of the illness. More recent approaches have therefore attempted to identify pathways that could offer a wider therapeutic window, such as the receptor for advanced glycation end-products (RAGE) and its ligands. PURPOSE The objectives of this study were to review the evidence supporting the role of the RAGE axis in systemic inflammation and associated acute lung injury and myocardial dysfunction, to explore some of the problems and conflicts that these RAGE studies have raised and to consider strategies by which they might be resolved. METHODS MEDLINE was searched (1990-2010) and relevant literature collected and reviewed. RESULTS AND CONCLUSION RAGE is an inflammation-perpetuating receptor with a diverse range of ligands. Evidence supporting a role of the RAGE axis in the pathogenesis of systemic inflammation, ALI and myocardial dysfunction is compelling with numerous animal experiments showing the beneficial effects of inhibiting the RAGE axis. Despite a number of unanswered questions that need to be further addressed, the potential for inhibiting RAGE-mediated inflammation in humans undoubtedly exists.
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Affiliation(s)
- Benedict C Creagh-Brown
- Unit of Critical Care, Respiratory Science, National Heart and Lung Institute Division, Faculty of Medicine, Imperial College, London, UK
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Rivera-Chavez FA, Minei JP. Soluble triggering receptor expressed on myeloid cells-1 is an early marker of infection in the surgical intensive care unit. Surg Infect (Larchmt) 2010; 10:435-9. [PMID: 19792836 DOI: 10.1089/sur.2009.030] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND To determine the value of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in early differentiation of systemic inflammatory response syndrome (SIRS) from infection in patients in a surgical intensive care unit (ICU). METHODS Patients were enrolled if there was clinical suspicion of infection and they fulfilled at least two criteria of SIRS at the time of admission to the ICU. The patients were classified as having SIRS (no infection; n = 37) or infection (n = 56) on the basis of the decision of the treating physician and bacteriological evidence of infection. The plasma concentrations of sTREM-1 in the two groups were compared. RESULTS Patients with infection had significantly higher sTREM-1 concentrations than patients with SIRS: Median 398 pg/mL (interquartile range [IQR] 302, 552) vs. 78 pg/mL (IQR 28, 150), respectively (p < 0.0001). At a cut-off of 230 pg/mL, sTREM-1 correctly identified patients suffering from infection with 96% sensitivity and 91% specificity. CONCLUSIONS In the present study, sTREM-1 was an accurate tool for differentiating SIRS from infection in patients in the surgical ICU.
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Affiliation(s)
- Fernando A Rivera-Chavez
- Department of Surgery-Burn/Trauma/Critical Care, The University of Texas Southwestern Medical Center at Dallas, Dallas, Texas 75390-9158, USA.
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Genotypes coding for low serum levels of mannose-binding lectin are underrepresented among individuals suffering from noninfectious systemic inflammatory response syndrome. CLINICAL AND VACCINE IMMUNOLOGY : CVI 2009; 17:447-53. [PMID: 20042521 DOI: 10.1128/cvi.00375-09] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Gene polymorphisms, giving rise to low serum levels of mannose-binding lectin (MBL) or MBL-associated protease 2 (MASP2), have been associated with an increased risk of infections. The objective of this study was to assess the outcome of intensive care unit (ICU) patients with systemic inflammatory response syndrome (SIRS) regarding the existence of functionally relevant MBL2 and MASP2 gene polymorphisms. The study included 243 ICU patients with SIRS admitted to our hospital, as well as 104 healthy control subjects. MBL2 and MASP2 single nucleotide polymorphisms were genotyped using a sequence-based typing technique. No differences were observed regarding the frequencies of low-MBL genotypes (O/O and XA/O) and MASP2 polymorphisms between patients with SIRS and healthy controls. Interestingly, ICU patients with a noninfectious SIRS had a lower frequency for low-MBL genotypes and a higher frequency for high-MBL genotypes (A/A and A/XA) than either ICU patients with an infectious SIRS or healthy controls. The existence of low- or /high-MBL genotypes or a MASP2 polymorphism had no impact on the mortality rates of the included patients. The presence of high-MBL-producing genotypes in patients with a noninfectious insult is a risk factor for SIRS and ICU admission.
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Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Groeneveld J, Hedenstierna G, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Metnitz P, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine, 2008: I. Brain injury and neurology, renal failure and endocrinology, metabolism and nutrition, sepsis, infections and pneumonia. Intensive Care Med 2008; 35:30-44. [PMID: 19066847 PMCID: PMC7094904 DOI: 10.1007/s00134-008-1371-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 12/01/2008] [Indexed: 12/16/2022]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy.
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