Respiratory failure, hypotension, sepsis, and jaundice. A clinical syndrome associated with lethal hemorrhage from acute stress ulceration of the stomach

Novel Time-dependent Multi-omics Integration in Sepsis-associated Liver Dysfunction

The recently developed technologies that allow the analysis of each single omics have provided an unbiased insight into ongoing disease processes. However, it remains challenging to specify the study design for the subsequent integration strategies that can associate sepsis pathophysiology and clinical outcomes. Here, we conducted a time-dependent multi-omics integration (TDMI) in a sepsis-associated liver dysfunction (SALD) model. We successfully deduced the relation of the Toll-like receptor 4 (TLR4) pathway with SALD. Although TLR4 is a critical factor in sepsis progression, it is not specified in single-omics analyses but only in the TDMI analysis. This finding indicates that the TDMI-based approach is more advantageous than single-omics analyses in terms of exploring the underlying pathophysiological mechanism of SALD. Furthermore, TDMI-based approach can be an ideal paradigm for insightful biological interpretations of multi-omics datasets that will potentially reveal novel insights into basic biology, health, and diseases, thus allowing the identification of promising candidates for therapeutic strategies.

Perforated Stress Ulcer of the Duodenum: a Case of an Unexpected Diagnosis in a COVID-19 Patient Following Dilatation and Curettage Procedure

Background

Stress ulcers in the upper gastrointestinal tract can arise from pathologies related to erosive or inflammatory insults in critically ill patients. The relationship between stressful bodily events and the ischemia and perforation of stress ulcers is poorly understood.

Objective

We present a case of perforated stress ulcer following an abortion that was treated by dilatation and curettage (D&C) and complicated by a coronavirus disease 2019 (COVID-19) infection.

Case presentation

A 40-year-old lady presented to the emergency room complaining of diffuse abdominal pain, she was recently diagnosed with an incomplete abortion and managed via a D&C procedure in an external hospital. A computed tomography (CT) scan was done at our center for the abdomen and pelvis, showing extensive pneumoperitoneum, which brought the radiologist's attention to suspect a small bowel perforation presumably accompanying a uterine perforation secondary to the D&C. There were no obvious signs of pelvic small bowel perforation in the initial CT images. The perforated duodenal stress ulcer was diagnosed the next day by a new CT scan following oral contrast ingestion and managed surgically by repair and omental patch, and no other bowel perforations were found upon surgical exploration. After the surgery, the patient was diagnosed with COVID-19, and her clinical status deteriorated gradually during the following week, and she passed away from a cardiac arrest.

Conclusion

It is unclear whether septic abortion or COVID-19 has resulted in stress ulcer perforation in our patient. This case report highlights the importance of raising early suspicion in the diagnosis of stress ulcer perforation in critically ill patients to reduce the risk of morbidity and mortality.

Are Proton Pump Inhibitors More Effective Than Histamine-2-Receptor Antagonists for Stress Ulcer Prophylaxis in Critically Ill Patients? A Systematic Review and Meta-Analysis of Cohort Studies

BACKGROUND

Histamine-2-receptor antagonists (H₂RAs) have been largely replaced by proton pump inhibitors (PPIs) for stress ulcer prophylaxis (SUP) despite the inconclusive evidence concerning comparative effectiveness.

OBJECTIVE

To compare the effectiveness of PPIs and H₂RAs on SUP in real-world setting.

METHODS

PubMed, Embase, and the Cochrane Library were searched from inception to September 19, 2021. We included cohort studies comparing PPIs with H₂RAs in critically ill adult patients and explicitly reporting the outcome of gastrointestinal (GI) bleeding or mortality. Newcastle-Ottawa Scale was used to assess potential risk of bias. We conducted a random-effects meta-analysis and only the studies with adjusted effect estimates were pooled. The Grading of Recommendations Assessment, Development, and Evaluation system was used to assess the overall quality of the evidence.

RESULTS

Thirteen cohort studies (N = 145 149) were eligible and 11 of them available for full texts were of low to moderate risk of bias. Meta-analysis of adjusted effect estimates indicated that PPIs were associated with a significantly higher risk of GI bleeding, compared with H₂RAs (8 studies, odds ratio [OR] = 1.98, 95% confidence interval [CI] = 1.30-3.01, low certainty). Post hoc pooling analysis also suggested that PPIs were associated with a slightly higher risk of mortality in comparison with H₂RAs (7 studies, OR = 1.27, 95% CI = 1.13-1.42, low certainty).

CONCLUSION AND RELEVANCE

The systematic review of cohort studies showed that PPIs were associated with higher risks of GI bleeding and mortality, although the certainty of evidence was low. Overall, we suggest not excluding H₂RAs for SUP, while further studies are essential for elucidating the risk stratification, optimal regimen, and specific duration.

Effects of oral/enteral nutrition alone versus plus pantoprazole on gastrointestinal bleeding in critically ill patients with low risk factor: a multicenter, randomized controlled trial

Background/aim

Critically ill patients are at risk of developing gastrointestinal (GI) bleeding due to stress causing mucosal damage. Aim of the study was to determine the effect of oral/enteral nutrition with or without concomitant pantoprazole on upper GI bleeding in low risk critically ill patients.

Materials and methods

This was a prospective, randomized, open-label, multicenter study conducted with intensive care unit (ICU) patients receiving oral/enteral nutritional support. Patients were randomly assigned into two groups including intervention group (received oral/EN plus pantoprazole) and control group (received only oral/EN).

Results

A total of 300 patients (intervention group: 152, control group: 148) participated in the study. Overall, 226 (75%) patients were fed by orally and 74 (25%) patients fed by enteral tube feeding. Median duration of nutritional support 4 (range: 2–33) days. Overt upper GI bleeding was noted only in one patient (0.65%) who was in the intervention group. The overall length of ICU stay of 4 (2–105) days, while ICU stay was significantly longer in the intervention group than in the control group (P = 0.006).

Conclusions

Our findings seems to indicate that in patients who are at low risk for GI bleeding and under oral/enteral nutritional support, the use of PPIs may not reduce the risk of bleeding, however these results are imprecise because of low event (GI bleeding) rate and limited power.

Trends and Outcomes of Gastrointestinal Bleeding Among Septic Shock Patients of the United States: A 10-Year Analysis of a Nationwide Inpatient Sample

Introduction

Gastrointestinal bleeding (GIB) complicating septic shock (SS) presents a therapeutic challenge in intensive care units. Large-scale data regarding utilization, length of stay, and cost outcomes of this association are lacking.

Methods

We queried the Healthcare Cost and Utilization Project's Nationwide Inpatient Sample from 2003 to 2012, and identified all adult patients aged ≥18 years hospitalized for SS by the International Classification of Diseases, Ninth Revision (ICD-9) diagnostic code for SS and GIB. We compared the baseline characteristics and outcomes among patients with SS plus GIB to patients with SS without GIB.

Results

The weighted sample size from 2003 to 2012 was 119,684 admissions for SS. Among them, 6,571 (5.4%) patients were found to have a GIB. The mean age of the SS population with and without GIB was (mean/standard error of mean) [70.85 (0.43) vs. 67.43 (0.13) P < 0.001, respectively]. The incidence of GIB over the course of 10 years has remained stable; however, the mortality associated with GIB among SS patients is found to be declining especially from 2008 (59.2%) to 2012 (45.1%) (P < 0.01). Patients with SS and GIB compared to patients with SS and no GIB were found to have a longer length of stay [20.56 (0.61) vs. 15.76 (0.13) P < 0.001], higher mortality [54% vs. 45% P < 0.001], and higher admission costs in United States dollar ($) (mean/SEM) [$192,524.89 (7,378.20) vs. $142,688.55 (1,336.65) P < 0.001]. Univariate analysis demonstrated that comorbid conditions like peptic ulcer disease and cirrhosis had significant odds ratios {1.56 and 1.709, P = 0.016 and 0.046 respectively} for the occurrence of GIB with SS. Gastroesophageal reflux disease was found to be associated with a lower incidence of GIB [odds ratio: 0.57, P = 0.0008]. The cause of sepsis (pneumonia, urinary tract infection, or abdominal infections) was not a significant distinguishing factor for the incidence of GIB in SS.

Conclusion

GIB continues to affect the patients with SS admitted in intensive care units in the United States. We found an incidence of 5.4% of GIB in patients with SS, and it was associated with worse outcomes.

Deadoption of low-value practices in the ICU

PURPOSE OF REVIEW

Change of practice in the ICU, particularly the discontinuation of approaches, which are no longer felt to be beneficial, can be challenging. This review will examine this issue and outline current thinking regarding how to best approach it.

RECENT FINDINGS

Practices in medicine that do not provide patients benefit and possibly cause harm exist throughout medicine and are called low-value practices. Some low-value practices have successfully been removed from the ICU whereas others remain. The process of removing these practices from established care is often called deadoption. Low-value practices that are simply ineffective but produce comparatively less harm or cost, may represent a significant challenge to deadoption. Additionally, although no single intervention has been identified as the preferred method of deadoption of a low-value practice, we advocate for a multimodal approach.

SUMMARY

Deadoption in the intensive care unit of practices that either cause harm or are significantly costly relative to their benefit remains an elusive goal. Attempts at deadoption should target local ICU circumstances, while still encompassing the spectrum of care outside the ICU, engage nursing more fully, promote the use of local champions, especially peers, and recognize the requirement to seek sustainability.

Options in extracorporeal support of multiple organ failure

Multiorgan failure is among the most frequent reasons of death in critically ill patients. Based on extensive and long-term use of renal replacement therapy, extracorporeal organ support became available for other organ failures. Initially, most of these techniques (e.g. extracorporeal membrane oxygenation, extracorporeal CO₂ removal [ECCO2R] and extracorporeal liver support) were used as stand-alone single organ support systems. Considering multiple interactions between native organs (“crosstalk”), combined or integrated extracorporeal organ support (ECOS) devices are intriguing. The concept of multiple organ support therapy (MOST) providing simultaneous and combined support for different failing organs was described more than 15 years ago by Ronco and Bellomo. This concept also implicates overcoming the “compartmentalized” approach provided by different single organ specialized professionals by a multidisciplinary and multiprofessional strategy. The idea of MOST is supported by the failure of several recent studies on single organ support including liver and lung support. Improvement of outcome by ECOS necessarily depends on optimized patient selection, integrated organ support and limitation of its side effects. This implicates challenges for engineers, industry and healthcare professionals. From a technical viewpoint, modular combination of pre-existing technologies such as renal replacement, albumin-dialysis, ECCO2R and potentially cytokine elimination can be considered as a first step. While this allows for stepwise and individual combination of standard organ support facilities, it carries the disadvantage of large extracorporeal blood volume and surfaces as well as additive costs. The more intriguing next step is an integrated platform providing the capacity of multiple organ support within one device. (This article is freely available.)

The SUP-ICU Trial: Does It Confirm or Condemn the Practice of Stress Ulcer Prophylaxis?

Purpose: Stress ulcer prophylaxis (SUP) is routinely administered to critically ill patients for the prevention of stress ulcer-induced, clinically important bleeding (CIB). Recently, the value of SUP has been questioned due to the perceived decline in CIB and the potential for infectious complications secondary to acid suppressive therapy. The SUP-ICU trial is a large, randomized controlled trial comparing intravenous pantoprazole with placebo for the indication of SUP. It is hoped that this trial would answer many of the questions pertaining to the overall value of SUP. This article will provide an in-depth assessment of the SUP-ICU trial in the context of the overall body of literature in this area. Furthermore, applications for clinical practice and recommendations on the provision of SUP are provided. Summary: The SUP-ICU trial revealed no difference in the primary outcome of 90-day mortality with pantoprazole but lower rates of CIB were noted (which was a secondary outcome). Overall, these data provide important insight into the value of SUP along with other questions related to the provision of SUP such as the relationship between CIB and mortality, infectious complications, and enteral nutrition. Conclusions: The SUP-ICU trial is a landmark trial describing the value of SUP in a modern-day setting of intensive care unit (ICU) practice. The provision of SUP should be continued in high-risk patients. Future studies are ongoing that will add further insight to this routine practice.

Sociedade Portuguesa de Cuidados Intensivos guidelines for stress ulcer prophylaxis in the intensive care unit

Critically ill patients are at risk of developing stress ulcers in the upper digestive tract. Agents that suppress gastric acid are commonly prescribed to reduce the incidence of clinically important stress ulcer-related gastrointestinal bleeding. However, the indiscriminate use of stress ulcer prophylaxis in all patients admitted to the intensive care unit is not warranted and can have potential adverse clinical effects and cost implications. The present guidelines from the Sociedade Portuguesa de Cuidados Intensivos summarizes the current evidence and gives six clinical statements and an algorithm aiming to provide a standardized prescribing policy for the use of stress ulcer prophylaxis in the intensive care unit.

Failure of gastric prophylaxis against stress bleeding reflects inadequate pH control

BACKGROUND

Gastric prophylaxis against stress ulceration with histamine 2 blockers or protein pump inhibitors is a quality standard in septic Surgical Intensive Care Unit (SICU) patients to reduce gastric pH below 3.5. This study assesses the efficacy of gastric prophylaxis with pH monitoring.

METHODS

A total of 100 patients were studied for 481 days. All received histamine 2 blockers or protein pump inhibitors. Daily pH control was judged as poor (1-3), moderate (4-5), or good (>5). Patients with poor pH received double-dose or an infusion gastric prophylaxis. Nasogastric tube bile or blood and transfusions for stress ulceration were recorded.

RESULTS

Gastric prophylaxis was poor for 37 days, moderate for 83 days, and good for 279 days. NGT blood occurred on 15 days (40%) with poor, 17 days (20%) with moderate, and 17 days (6%) with good control. Transfusions for stress ulceration occurred on 5 days (14%) during poor, 3 days (4%) during moderate, and 1 day (0.3%) during good control (P < .05). Enhanced gastric prophylaxis improved pH control and reduced nasogastric tube blood. Transfusion for stress ulceration after enhanced therapy was required on 1 day (8%) with poor control and never for moderate or good control.

CONCLUSION

Gastric prophylaxis against stress ulceration should be monitored by nasogastric tube pH.

Prophylactic Acid-Suppressive Therapy in Hospitalized Adults: Indications, Benefits, and Infectious Complications

Acid-suppressive therapy for prophylaxis of stress ulcer bleeding is commonly prescribed for hospitalized patients. Although its use in select, at-risk patients may reduce clinically significant gastrointestinal bleeding, the alteration in gastric pH and composition may place these patients at a higher risk of infection. Although any pharmacologic alteration of the gastric pH and composition is associated with an increased risk of infection, the risk appears to be highest with proton pump inhibitors, perhaps owing to the potency of this class of drugs in increasing the gastric pH. With the increased risk of infection, universal provision of pharmacologic acid suppression to all hospitalized patients, even all critically ill patients, is inappropriate and should be confined to patients meeting specific criteria. Nurses providing care in critical care areas may be instrumental in screening for appropriate use of acid-suppressive therapy and ensuring the drugs are discontinued upon transfer out of intensive care or when risk factors are no longer present.

Enteral nutrition as stress ulcer prophylaxis in critically ill patients: A randomized controlled exploratory study

PURPOSE

We investigated whether early enteral nutrition alone may be sufficient prophylaxis against stress-related gastrointestinal (GI) bleeding in mechanically ventilated patients.

MATERIALS AND METHODS

Prospective, double blind, randomized, placebo-controlled, exploratory study that included mechanically ventilated patients in medical ICUs of two academic hospitals. Intravenous pantoprazole and early enteral nutrition were compared to placebo and early enteral nutrition as stress-ulcer prophylaxis. The incidences of clinically significant and overt GI bleeding were compared in the two groups.

RESULTS

124 patients were enrolled in the study. After exclusion of 22 patients, 102 patients were included in analysis: 55 patients in the treatment group and 47 patients in the placebo group. Two patients (one from each group) showed signs of overt GI bleeding (overall incidence 1.96%), and both patients experienced a drop of >3 points in hematocrit in a 24-hour period indicating a clinically significant GI bleed. There was no statistical significant difference in the incidence of overt or significant GI bleeding between groups (p=0.99).

CONCLUSION

We found no benefit when pantoprazole is added to early enteral nutrition in mechanically ventilated critically ill patients. The routine prescription of acid-suppressive therapy in critically ill patients who tolerate early enteral nutrition warrants further evaluation.

Occult upper gastrointestinal mucosal abnormalities in critically ill patients

BACKGROUND

The objectives of this study were to estimate the frequency of occult upper gastrointestinal abnormalities, presence of gastric acid as a contributing factor, and associations with clinical outcomes.

METHODS

Data were extracted for study participants at a single centre who had an endoscopy performed purely for research purposes and in whom treating physicians were not suspecting gastrointestinal bleeding. Endoscopic data were independently adjudicated by two gastroenterologists who rated the likelihood that observed pathological abnormalities were related to gastric acid secretion using a 3-point ordinal scale (unlikely, possible or probable).

RESULTS

Endoscopy reports were extracted for 74 patients [age 52 (37, 65) years] undergoing endoscopy on day 5 [3, 9] of ICU admission. Abnormalities were found in 25 (34%) subjects: gastritis/erosions in 10 (14%), nasogastric tube trauma in 8 (11%), oesophagitis in 4 (5%) and non-bleeding duodenal ulceration in 3 (4%). The contribution of acid secretion to observed pathology was rated 'probable' in six subjects (rater #1) and five subjects (rater #2). Prior to endoscopy, 39 (53%) patients were receiving acid-suppressive therapy. The use of acid-suppressive therapy was not associated with the presence of an endoscopic abnormality (present 15/25 (60%) vs. absent 24/49 (49%); P = 0.46). Haemoglobin concentrations, packed red cells transfused and mortality were not associated with mucosal abnormalities (P = 0.83, P > 0.9 and P > 0.9 respectively).

CONCLUSIONS

Occult mucosal abnormalities were observed in one-third of subjects. The presence of mucosal abnormalities appeared to be independent of prior acid-suppressive therapy and was not associated with reduced haemoglobin concentrations, increased transfusion requirements, or mortality.

Pharmacological Approach to the Prevention and Treatment of Stress Ulcers

The mortality associated with bleeding stress ulcers in patients in intensive care units exceeds 50%. Iden tification of patients at risk and use of early and effec tive prophylaxis are necessary in the management of patients in intensive care units. The use of antacids is inconvenient, expensive, and associated with electro lyte disturbances and erratic pH control. H2-receptor antagonists are the preferred agents for stress ulcer pro phylaxis because of their proven efficacy, safety, and ease of administration. Adjunct therapy with cyto protective agents may be useful in patients with com promised mucosal defences.

Prophylactic proton pump inhibitors in femoral neck fracture patients - A life - and cost-saving intervention

Introduction Acute gastrointestinal stress ulceration is a common and serious complication of trauma. Prophylactic proton pump inhibitors (PPIs) or histamine receptor antagonists have been used in poly-trauma, burns and head and spinal injuries, as well as on intensive care units, for the prevention of acute gastric stress ulcers. Methods We prospectively studied the use of prophylactic PPIs in with femoral neck fracture patients, gathering data on all acute gastric ulcer complications, including coffee-ground vomiting, malena and haematemesis. We then implemented a treatment protocol in which all patients were given prophylactic PPIs, again prospectively collecting all data. Results Five hundred and fifteen patients were included. Prior to prophylactic PPI, 15% of patients developed gastric stress ulcer complications, with 3% requiring acute intervention with oesophagogastroduodenoscopy (OGD), 5% requiring transfusions and 4% experiencing surgical delays. All patients had delayed discharges. Following PPI implementation, no patients developed gastric stress ulcer complications. Conclusions Femoral neck fracture patients create a substantial workload for orthopaedic units. The increasingly elderly population often have comorbidities, and concomitantly use medications with gastrointestinal side effects. This, combined with the stress of a fracture and preoperative starvation periods increases the risk of gastric ulcers. Here, the use of prophylactic PPIs statistically reduced the incidence of gastric stress ulcers in patients with femoral neck fractures, resulting in fewer surgical delays, reduced length of hospital stay and reduced stress ulcer-related mortality.

Stress Ulcer Syndrome

Stress ulcer syndrome refers to gastroduodenal erosions or ulcers that develop acutely in relation to major physi ological stress, usually manifested clinically as upper gastrointestinal (UGI) bleeding. These lesions occur most often in the gastric fundus. Endoscopy has shown gastroduodenal mucosal lesions in 75 to 100% of inten sive care unit (ICU) patients within 72 hours of admis sion. Patients at high risk for stress ulcer include those with large body surface area burns, intracranial lesions associated with coma, fulminant hepatic failure, sepsis, and trauma and abdominal, cardiovascular, and thoracic surgery patients. Also considered high risk are ICU pa tients with superimposed complications such as shock, mechanical ventilation for more than 3 days, coagulopa thy, jaundice, and sepsis. Approximately 15% of ICU pa tients will experience UGI bleeding from stress ulcer. Patients bleeding from stress ulcer have an overall mor tality rate approaching 65% compared with 9 to 22% mortality in patients without stress ulcer. When strati fied according to occult blood loss versus clinically significant bleeding, mortality can be as high as 90% in patients overtly bleeding; 30% of deaths are directly related to bleeding. Both antacids and H2 receptor an tagonists are effective in prophylaxis for stress ulcer bleeding.

Stress Ulcer Prophylaxis in Hospitalized Patients, Subsequent Use in Primary Care, and Physicians' Opinions About Acid-Suppressive Therapy

OBJECTIVES

Stress ulcer prophylaxis (SUP) is not indicated in most hospitalized patients. This study determined the prevalence of the use of proton pump inhibitors (PPI) and histamine receptor 2 blockers (H2B) in hospitalized patients, continued PPI/H2B use after discharge, and physicians' opinions about SUP.

METHODS

A retrospective electronic chart review, as well as a national survey of residents and faculty in primary care residency programs to determine the appropriateness of SUP.

RESULTS

Of 753 charts reviewed, 332 hospitalized patients with outpatient follow-up were included; 303 of them had either PPI or H2B ordered during hospitalization, but only 120 patients had an indication for SUP. Stepwise logistic regression results showed patients with a history of PPI/H2B use were 16.6 times more likely to receive SUP (odds ratio 16.6; 95% confidence interval 2.2-124.7). In addition, a PPI/H2B indication also significantly predicted SUP use (odds ratio 5.1; 95% confidence interval 1.2-22.2). A total of 171 completed surveys were received: 73% residents and 27% faculty. Only 24% reported being aware of SUP guidelines; 17% reported using electronic health record order set suggestions for SUP.

CONCLUSIONS

More than 90% of hospitalized patients received SUP; less than half of them had an indication for needing SUP. A large number of patients discharged on PPI/H2B continued to receive it in the outpatient setting at 6 months follow-up. Only 24% of physicians reported using SUP based on guidelines. Physician education and evidence-based validation of electronic health record order sets are potential areas for improvement.

Unintentional Complications After Uneventful Rhinoplasty Operations: Case Reports and a Review of the Literature

INTRODUCTION

No surgical procedure is free of complications; however, some of these complications are unintentional. Plastic surgeons may be unfamiliar with certain complications after rhinoplasty operations. In this study, we aimed to present four unintentional complications that have occurred in our patients and review the literature related to these complications.

MATERIALS AND METHODS

In this study, we conducted a review of 1400 patients who were operated on from 2007 to 2015. The medical recordings of all patients were investigated. Four patients with unintentional complications after rhinoplasty operations are presented and the related literature was reviewed.

CASES

Cases 1 and 2: These patients included a 26-year-old woman and a 30-year-old man who developed herpes simplex virus (HSV) infections after a primary septorhinoplasty. Case 3: This was a 25-year-old woman who developed periorbital emphysema after a primary rhinoplasty operation. Case 4: This was a 22-year-old woman who developed a second-degree burn on the nasal dorsum. All patients healed without sequel or scars.

DISCUSSION

Many unexpected complications have been reported in the literature. Some of these complications include bleeding disorders, allergic reactions, dermatitis, visual loss, gastric bleeding, benign paroxysmal positional vertigo, false aneurysm after rhinoplasty, pneumocephalus, Tapia's syndrome, cavernous sinus syndrome, and skin reactions to prolene.

CONCLUSION

Meticulous patient histories, consistent surgical routines, careful radiologic examinations, and frequent patient visits can help surgeons control these types of complications.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Nationwide longitudinal analysis of acute liver failure in taiwan

Acute liver failure (ALF) is uncommon but fatal. Current management is based mostly on clinical experience. We aimed to investigate the incidence, etiology, outcomes, and prognostic factors of ALF in Taiwan. Patients with the admission diagnosis of ALF between January 2005 and September 2007 were identified from the Longitudinal Health Insurance Database of Taiwan. ALF was further confirmed by disease severity based on laboratory orders, prescriptions, and duration of hospital stay, and acute onset without prior liver disease. Prognostic factors were identified using Cox regression analysis. During the study period, 218 eligible cases were identified from 28,078 potential eligible ALF patients. The incidence was 80.2 per million person-years in average and increased with age. The mean age was 57.9 ± 17.1 years and median survival was 171 days. The most common etiologies were viral (45.4%, mainly hepatitis B virus) and followed by alcohol/toxin (33.0%). Independent prognostic factors included alcohol consumption (hazard ratio, HR, 1.67 [1.01-2.77]), malignancy (HR 2.90 [1.92-4.37]), frequency of checkups per week for total bilirubin (HR 1.57 [1.40-1.76]), sepsis (HR 1.85 [1.20-2.85]), and the use of hemodialysis/hemofiltration (HR 2.12 [1.15-3.9]) and proton pump inhibitor (HR 0.94 [0.90-0.98]). Among the 130 patients who survived ≥90 days, 66 (50.8%) were complicated by liver cirrhosis. Eight (3.7%) were referred for liver transplantation evaluation, but only 1 received transplantation and survived. ALF in Taiwan is mainly due to viral infection. Patients with malignancy and alcohol exposure have worst prognosis. The use of proton pump inhibitor is associated with improved survival. Half of the ALF survivors have liver cirrhosis.

Multiple organ dysfunction syndrome in humans and animals

Multiple organ dysfunction syndrome (MODS), defined as the presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention, is a cause of high morbidity and mortality in humans and animals. Many advances have been made in understanding the pathophysiology and treatment of this syndrome in human medicine, but much still is unknown. This comparative review will provide information regarding the history and pathophysiology of MODS in humans and discuss how MODS affects each major organ system in animals.

Survival in fully manifest multiple organ dysfunction syndrome

BACKGROUND

Multiple organ dysfunction syndrome (MODS) is the leading cause of death in intensive care units throughout the world. Several composite clinical scores, such as the Multiple Organ Dysfunction (MOD) score and Sequential Organ Failure Assessment (SOFA) score, have been developed to assess the severity of critical illness and predict mortality. Survival in fully manifest MODS is nearly unprecedented.

METHODS

Case report and review of the relevant literature.

CASE REPORT

A 55-year-old male was admitted to the neurologic intensive care unit with left lateral medullary syndrome, and access for permanent enteral feeding was indicated. On day 7 of the patient's hospitalization an attempt was made to place a gastrostomy tube in the patient, but the procedure was aborted after unexplained intra-operative hemodynamic instability. Eight days later the patient developed florid MODS of unclear etiology. His daily MOD and SOFA scores peaked at 16 and 20, respectively, and his cumulative MOD and SOFA scores peaked at 19 and 22, respectively, portending 100% mortality. Over the next 6 wks the patient gradually recovered nearly all organ function, until both his MOD and SOFA scores decreased to 1. He was discharged to a sub-acute rehabilitation facility.

CONCLUSIONS

This patient is the oldest patient reported to have survived fully manifest MODS. Whereas scoring systems such as the MOD and SOFA systems can be useful tools, they have several limitations and their results must be interpreted with caution.

Stress ulcer prophylaxis in the intensive care unit: is it indicated? A topical systematic review

Stress ulcer prophylaxis (SUP) is regarded as standard of care in the intensive care unit (ICU). However, recent randomized, clinical trials (RCTs) and meta-analyses have questioned the rationale and level of evidence for this recommendation. The aim of the present systematic review was to evaluate if SUP in the critically ill patients is indicated.

DATA SOURCES

 MEDLINE including MeSH, EMBASE, and the Cochrane Library.

PARTICIPANTS

patients in the ICU.

INTERVENTIONS

pharmacological and non-pharmacological SUP.

STUDY APPRAISAL AND SYNTHESIS METHODS

Risk of bias was assessed according to Grading of Recommendations Assessment, Development, and Evaluation, and risk of random errors in cumulative meta-analyses was assessed with trial sequential analysis. A total of 57 studies were included in the review. The literature on SUP in the ICU includes limited trial data and methodological weak studies. The reported incidence of gastrointestinal (GI) bleeding varies considerably. Data on the incidence and severity of GI bleeding in general ICUs in the developed world as of today are lacking. The best intervention for SUP is yet to be settled by balancing efficacy and harm. In essence, it is unresolved if intensive care patients benefit overall from SUP. The following clinically research questions are unanswered: (1) What is the incidence of GI bleeding, and which interventions are used for SUP in general ICUs today?; (2) Which criteria are used to prescribe SUP?; (3) What is the best SUP intervention?; (4) Do intensive care patients benefit from SUP with proton pump inhibitors as compared with other SUP interventions? Systematic reviews of possible interventions and well-powered observational studies and RCTs are needed.

The liver in sepsis: shedding light on the cellular basis of hepatocyte dysfunction

Liver dysfunction is believed to contribute to the metabolic derangements of critical illness. The cellular basis of liver dysfunction is poorly understood and its consequences largely unknown. Recent work by Gonnert and colleagues sheds additional light. Using two imaging techniques to track the clearance of biotransformed dyes by the liver in a rat model of intra-abdominal infection, the authors show that the predominant defect in sepsis lies in the excretion of biotransformed molecules from the hepatocyte into the bile canaliculi. Their work both points to a new aspect of hepatic dysfunction through focus on a role in the metabolic derangements of sepsis and suggests a possible strategy to diagnose and monitor this process in critically ill patients.

Weighing risks and benefits of stress ulcer prophylaxis in critically ill patients

Expanded abstract

Organ failure avoidance and mitigation strategies in surgery

Postoperative organ failure is a challenging disease process that is better prevented than treated. Providers should use close observation and clinical judgment, and checklists of best practices to minimize the risk of organ failure in their patients. The treatment of multiorgan dysfunction syndrome (MODS) generally remains supportive, outside of rapid initiation of source control (when appropriate) and targeted antibiotic therapy. More specific treatments may be developed as the complex pathophysiology of MODS is better understood and more homogenous patient populations are selected for study.

New translational research provides insights into liver dysfunction in sepsis

John Marshall discusses new research detailing the early onset in liver dysfunction in a rodent sepsis model, which he says can fundamentally change our understanding of this common clinical problem.

Rethinking platelet function: thrombocytopenia induced immunodeficiency in critical illness

Thrombocytopenia in critical illness predicts a poor clinical outcome. Apart from its role in microvascular thrombus formation, it is widely anticipated that this association is indirect rather than causal. Emerging evidence however indicates that platelets are also immune competent cells. Like traditional innate immune cells, platelets are recruited immediately into injured and inflamed tissue, they release immune mediators, express and shed immunologically active membrane receptors, they interact with other immune cells and they recognize and clear pathogens. We hypothesize that thrombocytopenia per se results in immunodeficiency through loss of platelet-mediated immune functions, and propose that thrombocytopenia induced immunodeficiency in critical illness in part explain the negative predictive value of low or declining platelet count. We propose that rethinking the risks of thrombocytopenia to include not only bleeding but also immunodeficiency and immune dysregulation along with the conduct of studies investigating mechanisms contributing to thrombocytopenia induced poor non-hemorrhagic outcome in critical illness, may be means to improve outcome in these patients through development of new treatment modalities.

After the bomb drops: a new look at radiation-induced multiple organ dysfunction syndrome (MODS)

PURPOSE

There is increasing concern that, since the Cold War era, there has been little progress regarding the availability of medical countermeasures in the event of either a radiological or nuclear incident. Fortunately, since much is known about the acute consequences that are likely to be experienced by an exposed population, the probability of survival from the immediate hematological crises after total body irradiation (TBI) has improved in recent years. Therefore focus has begun to shift towards later down-stream effects, seen in such organs as the gastrointestinal tract (GI), skin, and lung. However, the mechanisms underlying therapy-related normal tissue late effects, resulting from localised irradiation, have remained somewhat elusive and even less is known about the development of the delayed syndrome seen in the context of whole body exposures, when it is likely that systemic perturbations may alter tissue microenvironments and homeostasis.

CONCLUSIONS

The sequence of organ failures observed after near-lethal TBI doses are similar in many ways to that of multiple organ dysfunction syndrome (MODS), leading to multiple organ failure (MOF). In this review, we compare the mechanistic pathways that underlie both MODS and delayed normal tissue effects since these may impact on strategies to identify radiation countermeasures.

Feeding the patients with upper gastrointestinal bleeding

PURPOSE OF REVIEW

It is usually believed that in case of upper gastrointestinal bleeding patients must be systematically fasted. This review will focus on oral and/or enteral feeding in patients with or at risk of upper gastrointestinal bleeding.

RECENT FINDINGS

In case of upper gastrointestinal bleeding, an endoscopy is always required in order to determine the pathophysiology of the bleeding, and in some case to perform an endoscopic treatment. In patients hospitalized in ICU, enteral nutrition is the best stress ulcer prophylaxis. In patients with enteral nutrition the concomitant use of histamine-2 receptor blockers or proton-pump inhibitors may be harmful. In case of bleeding due to gastric erosions, enteral nutrition can be resumed as soon as the patient tolerates. In patients with liver cirrhosis nonbleeding oesophageal varices are not a contraindication for enteral nutrition nor nasogastric tube. In patients hospitalized for acute upper gastrointestinal bleeding due to an ulcer with high risk of rebleeding (Forrest I-IIb) or with variceal bleeding it is recommended to wait at least 48 h after endoscopic therapy before initiating oral or enteral feeding. In case of ulcer with low risk of rebleeding (Forrest IIc and III) or in patients with gastritis, Mallory-Weiss, oesophagitis, or angiodysplasia, there is no need to delay refeeding, and they can be fed as soon as tolerated.

SUMMARY

Understanding the cause of the diagnosis is always necessary to adapt nutrition in patients with upper gastrointestinal bleeding.

Stress Ulcer Prophylaxis in the New Millennium!

Clinical trials conducted in the latter part of the past millennium suggested that bleeding from gastric stress ulceration was an important cause of morbidity and mortality in intensive care unit (ICU) patients and that treatment with acid-suppressive therapy reduced the risk of clinically significant bleeding. Stress ulcer prophylaxis therefore became regarded as the standard of care in all ICU patients. However, more recent clinical trials have demonstrated that the risk of clinically significant bleeding is extremely low (about 1%) and not altered by the use of acid-suppressive therapy. Furthermore, a critical review of the “historical” clinical trials, as well as the data from experimental and more recent clinical trials, suggests that enteral feeding (gastric) is at least as effective as acid-suppressive therapy in the prevention of gastric stress ulceration and is the prophylactic measure of choice in most ICU patients.

Gastrointestinal dysfunction in the critically ill: can we measure it?

Gastrointestinal dysfunction is an intuitively important, yet descriptively elusive component of the multiple organ dysfunction syndrome. Reintam and colleagues have attempted to quantify this dimension using a combination of intolerance of enteral feeding, and the development of intra-abdominal hypertension. While they show that both parameters are associated with an increased risk of death (and therefore that, in combination, the risk of death is even greater), they fall short in developing a novel descriptor of gastrointestinal dysfunction. Nonetheless, and even with its shortcomings, their effort is a welcome contribution to the surprisingly complex process of describing the morbidity of critical illness.

Intermittent intravenous pantoprazole and continuous cimetidine infusion: effect on gastric pH control in critically ill patients at risk of developing stress-related mucosal disease

BACKGROUND

This study aimed to assess intermittent intravenous (IV) pantoprazole for control of gastric acid and the possible prevention of upper gastrointestinal (UGI) bleeding in intensive care units (ICU) patients.

METHODS

This was a multicenter, randomized, open-label, dose-ranging pilot study of IV pantoprazole (40 mg q24 hour; 40 mg q12 hour; 80 mg q24 hour; 80 mg q12 hour; 80 mg q8 hour) or continuously infused cimetidine (300 mg bolus; 50 mg/h) in patients at risk for UGI bleeding. The primary endpoint was percent time gastric pH >/=4.0. UGI bleeding and pneumonia were measured as secondary endpoints.

RESULTS

Two hundred two ICU patients were randomized. Gastric pH was well controlled by all treatments. Gastric pH control improved from day 1 to day 2 in all pantoprazole groups, whereas there was decreased pH control in the cimetidine group. There were no cases of protocol defined UGI bleeding in any treatment group. Adverse event frequency and pneumonia incidence were similar between pantoprazole and cimetidine treated patients.

CONCLUSIONS

This pilot study indicates that intermittent IV pantoprazole effectively controls gastric pH and may protect against UGI bleeding in high risk ICU patients without the development of tolerance.

Application of clinical proteomics in diagnosis and management of trauma patients

Poly-trauma remains a medical entity with major implications, for patient's morbidity, mortality and healthcare economics. Advances in molecular medicine have improved diagnostic techniques in detecting devastating complication after major trauma. Patients at high risk of multiple organ dysfunction syndrome (MODS) or adult respiratory distress syndrome (ARDS), could be identified early, monitored and treated. Proteomics is the systematic evaluation of proteins produced by the cell under normal or pathological circumstances. Investigating protein production will allow us to identify and modify disease natural history and treatment. In this review, we summarise the proteomic methods currently applied in trauma research.

MOF, MODS, and SIRS: what is in a name or an acronym?

The most prominent contributions to multiple organ failure, multiple organ dysfunction syndrome, and systemic inflammatory response syndrome are described in this article. However, it is quite possible that there are others that have been missed. The problem of organ failure continues to perplex clinicians and scientists, and it contributes to fatal outcomes for patients with illnesses, infections, and injuries after operations. Although we know a fair bit about these problems, we frequently can do little about it. The best approach remains support to prevent failure.

Epidemiology and peculiarities of pediatric multiple organ dysfunction syndrome in New Delhi, India

OBJECTIVE

Most pediatric studies on multiple organ dysfunction syndrome derive from developed countries. There is little information regarding the etiologies and outcomes of multiple organ dysfunction syndrome in critically ill children from developing countries. The objective of this study was to examine the differences in epidemiology of multiple organ dysfunction syndrome and the relationship of the Organ Failure Index (OFI) to outcomes from multiple organ dysfunction syndrome in critically ill children from a developing country.

DESIGN

Prospective observational study.

SETTING

A 10-bed tertiary pediatric intensive care unit.

PATIENTS

A total of 1722 children (1 month to 16 years of age) admitted to a pediatric intensive care unit during the study period from January 1998 to June 2003.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of all the patients admitted to the pediatric intensive care unit, 184 patients (10.6%) had persistent multiple organ dysfunction syndrome. During the study period 136 deaths (7.9%) occurred in the ICU. Multiple organ dysfunction syndrome was associated with nearly half of these deaths, 67/136 (49.2%). Overall survival of all patients with persistent multiple organ dysfunction syndrome was 64% (117/184). In addition to sepsis, falciparum malaria, fulminant hepatic failure, dengue shock syndrome, severe poisonings, post cardiopulmonary bypass, and post cardiac arrest were significant antecedents of multiple organ dysfunction syndrome . Patients with OFI scores of 2, 3, 4-5, and >5 exhibited mortalities of 9%, 29%, 58%, and 100% respectively.

CONCLUSIONS

In addition to "traditional" sepsis, common etiologies of multiple organ dysfunction syndrome included falciparum malaria, fulminant hepatic failure, and dengue shock syndrome. In developing countries like India, multiple organ dysfunction syndrome carries a significant risk of mortality which is directly related to the OFI.

Multiple organ dysfunction syndrome: past, present and future

In the past, our approach to multiple organ failure in the injured or critically ill surgical patient was driven by attempts to simplify a complex process. Early studies focused on uncontrolled invasive infection (sepsis) as the driving force of multiple organ dysfunction syndrome (MODS). However, some patients with adequately controlled infection and those without sepsis nevertheless develop MODS and signs of systemic inflammation. This discrepancy led to investigations of systemic activation of inflammation by a wider variety of biological modulators than just infection. Despite the apparent involvement of biological modulators such as endotoxin, tumor necrosis factor, and interleukin-1 receptor in MODS, agents that neutralize these modulators have failed to thwart the progression of sepsis, septic shock, and organ failure. A new paradigm suggests that, in the critically ill patient at risk for organ failure, an integrated process propagates an excessive systemic inflammatory response and/or an inadequate compensatory anti-inflammatory response. Future studies should examine the balance between these two processes at the level of the individual patient with organ failure. Careful stratification of individual patient responses to inflammatory stressors may be an essential step for creating better strategies for therapeutic interventions that can restore balance between the pro-inflammatory and anti-inflammatory processes in the critically ill patient and possibly prevent organ failure.