Effect of adjunctive corticosteroid on 28-day mortality in neutropenic patients with septic shock

Serum ACTH and Cortisol Level is Associated with the Acute Gastrointestinal Injury Grade in ICU Patients

Background

The relationship between acute gastrointestinal symptoms and cortisol or adrenocorticotropic hormone (ACTH) levels has rarely been reported. We hypothesized that the elevation of serum cortisol or ACTH levels may be correlated with the severity of the acute gastrointestinal injury grade (AGI).

Methods

This study was an observational study. All patients were admitted to the ICU between 2019.1.1 and 2020.1.1.. Serum ACTH and cortisol levels and clinical data were collected from the electronic medication records. The highest AGI grade during the ICU stay was the major endpoint to observe. The patient was treated in a standard procedure in the ICU.

Results

A total of 235 patients were included in our study, 132 of whom developed AGI. In univariate regression, cortisol level was found to be a risk factor for 28-day mortality. Serum cortisol and ACTH levels correlated with APACHE II, AGI grade, PCT, and CRP levels. Spearman analysis and partial correlation analysis indicated that cortisol and ACTH levels were correlated with AGI grade.

Conclusion

The ACTH and cortisol levels were positively correlated with the higher severity of AGI grade. The cortisol level may be a useful way to access the GI injury.

Management of the kidney transplant recipient in the intensive care unit

PURPOSE OF REVIEW

Kidney transplantation is the ideal treatment for patients with chronic kidney disease and end stage renal disease. While centers are performing more transplants every year, the need for organ transplantation outpaces the supply of organ donors. Due to a growing population of patients with advanced kidney disease and a scarcity of kidneys from deceased donors, patients face extended wait times. By the time patients approach transplantation they have multiple comorbidities, in particular cardiovascular complications. Their risk of complications is further compounded by exposure to immunosuppression post kidney transplantation. Kidney transplant recipients (KTRs) are medically complex and may require acute management in the intensive care unit (ICU), as a result of cardiovascular complications, infections, and/or respiratory compromise from lung infections and/or acute pulmonary edema. Acute complication of immunosuppression, such as thrombotic microangiopathy and posterior reversible encephalopathy syndrome may also warrant ICU admission. This review will cover assessment of high-risk complications and management strategies following kidney transplantation.

RECENT FINDINGS

For intensivists caring for KTRs, it is imperative to understand anatomical considerations of the transplanted kidney, unique infectious risks faced by this population, and appropriate modulation of immunosuppression.

SUMMARY

Recognizing potential complications and implementing appropriate management strategies for KTRs admitted to the ICU will improve kidney allograft and patient survival outcomes.

Efficacy and safety of corticosteroids for septic shock in immunocompromised patients: A cohort study from MIMIC

BACKGROUND

Corticosteroids have been widely used as adjunct therapy for septic shock for many decades, but both the efficacy and safety remain unclear. The study was designed to investigate overall benefits and potential risks of corticosteroids in immunocompromised patients with septic shock.

METHODS

The Medical Information Mart for Intensive Care III (MIMIC-III) database was employed to conduct a cohort study. Immunocompromised patients with septic shock were enrolled and categorized by whether exposure to intravenous corticosteroids. Cox Proportional-Hazards models were used to control for confounders and assess the relationship between corticosteroids use and mortality.

RESULTS

A total of 866 patients were enrolled in this study, including 395 in the corticosteroids group and 471 in the non-corticosteroids group. Corticosteroids infusion was not associated with improved 30-day mortality in overall immunocompromised population [34.7% vs 32.1%; adjusted hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.87-1.43, p = 0.37]. The mortality effects were similar in 90-day, 180-day, 1-year and hospital mortality. For the subgroup of patients with metastatic cancer, corticosteroids infusion was associated with a statistically significant increase in the 30-day mortality risk (HR 1.58, 95% CI 1.06-2.37; p = 0.02). Corticosteroids had adverse effects on hemodynamic stability, prolonged ICU and hospital duration, and increased risk of hyperglycemia.

CONCLUSIONS

Corticosteroids therapy for the maintenance of blood pressure was not associated with improved mortality or hemodynamic stability in overall immunocompromised population with septic shock. Future randomized clinical trials are required to validate the effects of corticosteroids for septic shock in the special immunocompromised population.