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Boontoterm P, Sakoolnamarka S, Urasyanandana K, Fuengfoo P. One-Hour Bundle Protocols for Surgical Sepsis and Septic Shock in Surgical Intensive Care Unit: Clinical Outcome Aspects in the Thai Context. Cureus 2024; 16:e62215. [PMID: 39006639 PMCID: PMC11240193 DOI: 10.7759/cureus.62215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2024] [Indexed: 07/16/2024] Open
Abstract
BACKGROUND Surgical sepsis is a syndrome occurring during the perioperative period with a high mortality rate. Since the one-hour bundle protocol was recommended to decrease sepsis-related morbidity and mortality in clinical practice, the protocol has been applied to surgical patients with sepsis and septic shock. However, clinical outcomes in these surgical patients remain unknown. Thus, this study aimed to compare survival outcomes in patients before and after the implementation of one-hour bundle care in clinical practice. METHODS In this prospective cohort study, 401 surgical patients with sepsis were divided into two groups, with 195 patients undergoing the one-hour bundle from December 25, 2021, to March 31, 2024, and 206 patients undergoing usual care from January 1, 2018, to December 24, 2021, before the one-hour bundle protocol was implemented by the Surviving Sepsis Campaign (SSC). Demographic data, treatment processes, and clinical outcomes were recorded. RESULTS After the one-hour bundle protocol was applied in surgical practice, the median survival time was significantly increased in surgical patients who underwent one-hour bundle care (95% confidence interval (CI): 12.32-19.68) (p= 0.016). Factors influencing the increase in the mortality rate were delays in fluid resuscitation of >2 hours, vasopressor initiation of >2 hours, and empirical antibiotics of >5 hours (p= 0.017, 0.028, and 0.008, respectively). CONCLUSION One-hour bundle care for surgical patients with sepsis resulted in an increased median survival time. Delays in fluid resuscitation (>2 hours), vasopressor initiation (>2 hours), and empirical antibiotics (>5 hours) were factors associated with mortality.
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Affiliation(s)
- Panu Boontoterm
- Neurological Surgery, Phramongkutklao Hospital, Bangkok, THA
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Tan F, Li X, Wang Z, Li J, Shahzad K, Zheng J. Clinical applications of stem cell-derived exosomes. Signal Transduct Target Ther 2024; 9:17. [PMID: 38212307 PMCID: PMC10784577 DOI: 10.1038/s41392-023-01704-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 10/15/2023] [Accepted: 11/12/2023] [Indexed: 01/13/2024] Open
Abstract
Although stem cell-based therapy has demonstrated considerable potential to manage certain diseases more successfully than conventional surgery, it nevertheless comes with inescapable drawbacks that might limit its clinical translation. Compared to stem cells, stem cell-derived exosomes possess numerous advantages, such as non-immunogenicity, non-infusion toxicity, easy access, effortless preservation, and freedom from tumorigenic potential and ethical issues. Exosomes can inherit similar therapeutic effects from their parental cells such as embryonic stem cells and adult stem cells through vertical delivery of their pluripotency or multipotency. After a thorough search and meticulous dissection of relevant literature from the last five years, we present this comprehensive, up-to-date, specialty-specific and disease-oriented review to highlight the surgical application and potential of stem cell-derived exosomes. Exosomes derived from stem cells (e.g., embryonic, induced pluripotent, hematopoietic, mesenchymal, neural, and endothelial stem cells) are capable of treating numerous diseases encountered in orthopedic surgery, neurosurgery, plastic surgery, general surgery, cardiothoracic surgery, urology, head and neck surgery, ophthalmology, and obstetrics and gynecology. The diverse therapeutic effects of stem cells-derived exosomes are a hierarchical translation through tissue-specific responses, and cell-specific molecular signaling pathways. In this review, we highlight stem cell-derived exosomes as a viable and potent alternative to stem cell-based therapy in managing various surgical conditions. We recommend that future research combines wisdoms from surgeons, nanomedicine practitioners, and stem cell researchers in this relevant and intriguing research area.
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Affiliation(s)
- Fei Tan
- Department of ORL-HNS, Shanghai Fourth People's Hospital, and School of Medicine, Tongji University, Shanghai, China.
- Plasma Medicine and Surgical Implants Center, Tongji University, Shanghai, China.
- The Royal College of Surgeons in Ireland, Dublin, Ireland.
- The Royal College of Surgeons of England, London, UK.
| | - Xuran Li
- Department of ORL-HNS, Shanghai Fourth People's Hospital, and School of Medicine, Tongji University, Shanghai, China
- Plasma Medicine and Surgical Implants Center, Tongji University, Shanghai, China
| | - Zhao Wang
- Department of ORL-HNS, Shanghai Fourth People's Hospital, and School of Medicine, Tongji University, Shanghai, China
| | - Jiaojiao Li
- Department of ORL-HNS, Shanghai Fourth People's Hospital, and School of Medicine, Tongji University, Shanghai, China
- Plasma Medicine and Surgical Implants Center, Tongji University, Shanghai, China
| | - Khawar Shahzad
- Department of ORL-HNS, Shanghai Fourth People's Hospital, and School of Medicine, Tongji University, Shanghai, China
- Plasma Medicine and Surgical Implants Center, Tongji University, Shanghai, China
| | - Jialin Zheng
- Center for Translational Neurodegeneration and Regenerative Therapy, Tongji Hospital affiliated to Tongji University School of Medicine, Shanghai, China
- Shanghai Frontiers Science Center of Nanocatalytic Medicine, Tongji University, Shanghai, China
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Gao L, Liu JJ, Fan QC, Ling LT, Ding HB. Association of obesity and mortality in sepsis patients: A meta-analysis from observational evidence. Heliyon 2023; 9:e19556. [PMID: 37809532 PMCID: PMC10558781 DOI: 10.1016/j.heliyon.2023.e19556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/08/2023] [Accepted: 08/25/2023] [Indexed: 10/10/2023] Open
Abstract
The project aims to investigate the correlation between obesity, overweight, or low body weight and the risk of mortality in sepsis patients. We performed a rigorous and thorough search of major electronic databases, including PubMed, Web of Science, EMBASE, and Cochrane Library, from the inception of these databases up to March 28, 2023. The data were analyzed with Stata software (version 16.0). Twelve studies incorporating 521,207 individuals were enrolled. The results demonstrated that obesity (OR = 0.82; 95% CI: 0.69-0.97; P < 0.001) or overweight (OR = 0.83; 95% CI: 0.73-0.94; P < 0.001) decreased the risk of mortality in sepsis patients. Instead, the reverse phenomena existed in patients with a low weight (OR = 1.43; 95%CI: 1.16-1.76; P = 0.038). There is an "obesity paradox" phenomenon in the mortality of obese and overweight patients with sepsis, but low body weight is an independent risk factor for the mortality of sepsis patients. This study demonstrated that the mortality in sepsis patients and obesity or overweight were negatively correlated, but displayed a significant positive relation to low weight.
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Affiliation(s)
- Liang Gao
- Department of Infectious Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Infectious Disease, National Regional Medical Center, Binhai Campus, of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Jun jin Liu
- Department of Infectious Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Infectious Disease, National Regional Medical Center, Binhai Campus, of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Qi chao Fan
- Department of Infectious Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Infectious Disease, National Regional Medical Center, Binhai Campus, of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Li ting Ling
- Department of Infectious Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Infectious Disease, National Regional Medical Center, Binhai Campus, of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
| | - Hai bo Ding
- Department of Infectious Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, China
- Department of Infectious Disease, National Regional Medical Center, Binhai Campus, of the First Affiliated Hospital, Fujian Medical University, Fuzhou 350212, China
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Kent I, Ghuman A, Sadran L, Rov A, Lifschitz G, Rudnicki Y, White I, Goldberg N, Avital S. Emergency Colectomies in the Elderly Population—Perioperative Mortality Risk-Factors and Long-Term Outcomes. J Clin Med 2023; 12:jcm12072465. [PMID: 37048549 PMCID: PMC10095288 DOI: 10.3390/jcm12072465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/05/2023] [Accepted: 03/13/2023] [Indexed: 03/28/2023] Open
Abstract
Background: As the population ages emergency surgeries among the elderly population, including colonic resections, is also increasing. Data regarding the short- and long-term outcomes in this population is scarce. Methods: A retrospective study was performed to investigate mortality and mortality risk factors associated with emergent colectomies in older compared to younger patients in a single university affiliated tertiary hospital. Patients with metastatic disease, colectomy due to trauma or index colectomy within 30 days prior to emergent surgery were excluded. Results: Operative outcomes compared among age groups, included 30-day mortality, mortality risk-factors and long-term survival. 613 eligible patients were included in the cohort. Mean age was 69.4 years, 45.1% were female. Patients were divided into four age groups: 18–59, 60–69, 70–79 and ≥80-years. Thirty-day mortality rates were 3.2%, 11%, 29.3% and 37.8%, respectively and 22% for the entire cohort. Risk-factors for perioperative death in the younger group were related to severity of ASA score and WBC count. In groups 60–69, 70–79, main risk-factors were ADL dependency and ASA score. In the ≥80 group, risk-factors affecting perioperative mortality, included ASA score, pre-operative albumin, creatinine, WBC levels, cancer etiology, ADL dependency, and dementia. Long-term survival differed significantly between age groups. Conclusion: Perioperative mortality with emergency colectomy increases with patients’ age. Patients older than eighty-years undergoing urgent colectomies have extremely high mortality rates, leading to a huge burden on medical services. Evaluating risk-factors for mortality and pre-operative discussion with patients and families is important. Screening the elderly population for colonic pathologies can result in early diagnosis potentially leading to elective surgeries with decreased mortality.
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Merry M, Hartawan IGAGU, Aryabiantara IW, Dewi DAMS. Profile of Sepsis Patients Treated in Intensive Care Unit of Sanglah Hospital Denpasar. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.7690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND: Primary data regarding sepsis patients in Indonesia, especially in Denpasar, are still limited in number in reporting. The lack of information about sepsis made the authors interested in conducting this study.
AIM: The aim of the study was to obtain more in-depth information about the profile of sepsis patients treated in Sanglah Hospital, Denpasar.
MATERIALS AND METHODS: This was a cross-sectional descriptive research. Target population in this study are data on patient registers that are included in the inclusion criteria from June 1, 2019 to June 30, 2021, at intensive care unit Sanglah Hospital, Denpasar. The variables in this study included: Demographic conditions such as age, gender, and address, qSOFA score, comorbidities, ventilator, and patient’s outcome (survival or non-survival).
RESULTS: A total samples were 173 patients. The average age of patients in this study was 54 years old with 56.6% male and 32.9% lived in Denpasar. Patients suspected of having early sepsis had a qSOFA 0 score of 35.3%, qSOFA 1 was 33.5%, qSOFA 2 was 23.7%, and qSOFA 3 was 7.5%. Patients with sepsis and suspected sepsis with comorbidities were 96% and 79.8% of patients were on a ventilator. The mortality rate in this study was 67.1%.
CONCLUSION: These primary data hopefully become references for the future research.
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Peden CJ, Aggarwal G, Aitken RJ, Anderson ID, Bang Foss N, Cooper Z, Dhesi JK, French WB, Grant MC, Hammarqvist F, Hare SP, Havens JM, Holena DN, Hübner M, Kim JS, Lees NP, Ljungqvist O, Lobo DN, Mohseni S, Ordoñez CA, Quiney N, Urman RD, Wick E, Wu CL, Young-Fadok T, Scott M. Guidelines for Perioperative Care for Emergency Laparotomy Enhanced Recovery After Surgery (ERAS) Society Recommendations: Part 1-Preoperative: Diagnosis, Rapid Assessment and Optimization. World J Surg 2021; 45:1272-1290. [PMID: 33677649 PMCID: PMC8026421 DOI: 10.1007/s00268-021-05994-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Enhanced Recovery After Surgery (ERAS) protocols reduce length of stay, complications and costs for a large number of elective surgical procedures. A similar, structured approach appears to improve outcomes, including mortality, for patients undergoing high-risk emergency general surgery, and specifically emergency laparotomy. These are the first consensus guidelines for optimal care of these patients using an ERAS approach. METHODS Experts in aspects of management of the high-risk and emergency general surgical patient were invited to contribute by the International ERAS® Society. Pubmed, Cochrane, Embase, and MEDLINE database searches on English language publications were performed for ERAS elements and relevant specific topics. Studies on each item were selected with particular attention to randomized controlled trials, systematic reviews, meta-analyses and large cohort studies, and reviewed and graded using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. Recommendations were made on the best level of evidence, or extrapolation from studies on non-emergency patients when appropriate. The Delphi method was used to validate final recommendations. The guideline has been divided into two parts: Part 1-Preoperative Care and Part 2-Intraoperative and Postoperative management. This paper provides guidelines for Part 1. RESULTS Twelve components of preoperative care were considered. Consensus was reached after three rounds. CONCLUSIONS These guidelines are based on the best available evidence for an ERAS approach to patients undergoing emergency laparotomy. Initial management is particularly important for patients with sepsis and physiological derangement. These guidelines should be used to improve outcomes for these high-risk patients.
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Affiliation(s)
- Carol J. Peden
- Department of Anesthesiology and Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
- Department of Anesthesiology, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
| | - Geeta Aggarwal
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Guildford, Surrey, UK
| | - Robert J. Aitken
- Sir Charles Gardiner Hospital, Hospital Avenue, Nedlands, WA 6009 Australia
| | - Iain D. Anderson
- Salford Royal NHS Foundation Trust, Stott La, Salford, M6 8HD UK
- University of Manchester, Manchester, UK
| | | | - Zara Cooper
- Harvard Medical School, Kessler Director, Center for Surgery and Public Health, Brigham and Women’s Hospital and Division of Trauma, Burns, Surgical Critical Care, and Emergency Surgery, Brigham and Women’s Hospital, 1620, Tremont Street, Boston, MA 02120 USA
| | - Jugdeep K. Dhesi
- Faculty of Life Sciences and Medicine, School of Population Health & Environmental Sciences, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London, Division of Surgery & Interventional Science, University College London, London, UK
| | - W. Brenton French
- Department of Surgery, Virginia Commonwealth University Health System, 1200 E. Broad Street, Richmond, VA 23298 USA
| | - Michael C. Grant
- Department of Anesthesiology and Critical Care Medicine, Department of Surgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287 USA
| | - Folke Hammarqvist
- Department of Emergency and Trauma Surgery, Karolinska University Hospital, CLINTEC, Karolinska Institutet, Stockholm, Sweden
- Karolinska University Hospital, Huddinge Hälsovägen 3. B85, S 141 86, Stockholm, Sweden
| | - Sarah P. Hare
- Department of Anaesthesia, Perioperative Medicine and Critical Care, Medway Maritime Hospital, Windmill Road, Gillingham, Kent, ME7 5NY UK
| | - Joaquim M. Havens
- Division of Trauma, Burns and Surgical Critical Care, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115 USA
| | - Daniel N. Holena
- Department of Surgery and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA 19104 USA
| | - Martin Hübner
- Department of Visceral Surgery, Lausanne University Hospital CHUV, University of Lausanne (UNIL), Rue du Bugnon 46, 1011 Lausanne, Switzerland
| | - Jeniffer S. Kim
- Gehr Family Center for Health Systems Science & Innovation, Keck School of Medicine, University of Southern California, 2020 Zonal Avenue IRD 322, Los Angeles, CA 90033 USA
| | - Nicholas P. Lees
- Department of General & Colorectal Surgery, Salford Royal NHS Foundation Trust, Scott La, Salford, M6 8HD UK
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Dileep N. Lobo
- Gastrointestinal Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
- MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen’s Medical Centre, Nottingham, NG7 2UH UK
| | - Shahin Mohseni
- Division of Trauma and Emergency Surgery, Department of Surgery, Orebro University Hospital & School of Medical Sciences, Örebro University, 701 85 Örebro, Sweden
| | - Carlos A. Ordoñez
- Division of Trauma and Acute Care Surgery, Department of Surgery, Fundación Valle del Lili, Cra 98 No. 18 – 49, 760032 Cali, Colombia
- Sección de Cirugía de Trauma Y Emergencias, Universidad del Valle – Hospital Universitario del Valle, Cl 5 No. 36-08, 760032 Cali, Colombia
| | - Nial Quiney
- Department of Anesthesia and Intensive Care Medicine, Royal Surrey County Hospital, Egerton Road, Guildford, Surrey, GU5 7XX UK
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital / Harvard Medical School, 75 Francis Street, Boston, MA 02115 USA
| | - Elizabeth Wick
- Department of Surgery, University of California San Francisco, 513 Parnassus Ave HSW1601, San Francisco, CA 94143 USA
| | - Christopher L. Wu
- Department of Anesthesiology, Critical Care and Pain Medicine-Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
- Department of Anesthesiology, Weill Cornell Medicine, 535 East 70th Street, New York, NY 10021 USA
| | - Tonia Young-Fadok
- Division of Colon and Rectal Surgery, Department of Surgery, Mayo Clinic College of Medicine, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ 85054 USA
| | - Michael Scott
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 USA
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Beetz O, Bajunaid A, Meißler L, Vondran FWR, Kleine M, Cammann S, Hanke JS, Schmitto JD, Haverich A, Klempnauer J, Ringe KI, Oldhafer F, Timrott K. Abdominal Surgery in Patients with Ventricular Assist Devices: a Single-Center Report. ASAIO J 2020; 66:890-898. [PMID: 32740349 DOI: 10.1097/mat.0000000000001085] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
This study was performed to evaluate the incidence and outcome of patients with ventricular assist devices (VADs) undergoing abdominal surgery at our institution. A total of 604 adult patients who underwent VAD implantation between February 2004 and February 2018 were analyzed retrospectively with a median follow-up time of 66 (6-174) months. Thirty-nine patients (6.5%) underwent abdominal surgery. Elective surgical procedures were performed in 22 patients (56.4%), mainly for abdominal wall hernia repairs, partial colectomies, and cholecystectomies. Early after elective abdominal surgery no patient died, resulting in a median survival of 23 (1-78) months. Emergency surgery was performed in 17 patients (43.6%). The most common emergency indications were intestinal ischemia and/or perforation. Eight patients undergoing emergent surgery (44.4%) died within the first 30 days after primary abdominal operation, mainly due to sepsis and consecutive multiple organ failure, resulting in a dismal median survival of one month (0-52). Patients undergoing abdominal surgery had significantly lower rates of realized heart-transplantation (p = 0.031) and a significantly higher rate of VAD exchange, before or after abdominal surgery, due to thromboses or infections (p = 0.037). Nonetheless, overall survival after primary VAD implantation in these patients (median 38 months; 0-107) was not significantly impaired when compared to all other patients undergoing VAD implantation (median 30 months; 0-171). In summary, elective abdominal surgery can be performed safely when well planned by an experienced multidisciplinary team. Abdominal complications in VAD patients requiring emergent surgery, however, lead to a significant increase in short-term morbidity and a high 30-day mortality rate.
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Affiliation(s)
- Oliver Beetz
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Anwar Bajunaid
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Luise Meißler
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Florian W R Vondran
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Moritz Kleine
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Sebastian Cammann
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Jasmin S Hanke
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jürgen Klempnauer
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Kristina I Ringe
- Department of Diagnostic and Interventional Radiology, Hannover Medical School, Hannover, Germany
| | - Felix Oldhafer
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
| | - Kai Timrott
- From the Department of General, Visceral and Transplant Surgery, Hannover Medical School, Hannover, Germany
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Gabriel V, Grigorian A, Nahmias J, Pejcinovska M, Smith M, Sun B, Won E, Bernal N, Barrios C, Schubl SD. Risk Factors for Post-Operative Sepsis and Septic Shock in Patients Undergoing Emergency Surgery. Surg Infect (Larchmt) 2019; 20:367-372. [PMID: 30950768 DOI: 10.1089/sur.2018.186] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Sepsis after emergency surgery is associated with a higher mortality rate than elective surgery, and total hospital costs increase by 2.3 times. This study aimed to identify risk factors for post-operative sepsis or septic shock in patients undergoing emergency surgery. Methods: A retrospective cohort analysis was performed using the National Surgical Quality Improvement Program (NSQIP) by identifying patients undergoing emergency surgery between 2012 and 2015 and comparing those who developed post-operative sepsis or septic shock (S/SS) with those who did not. Patients with pre-operative sepsis or septic shock were excluded. Multiple logistic regression was used to identify risk factors for the development of S/SS in patients undergoing non-elective surgery. Results: Of 122,281 patients who met the inclusion criteria, 2,399 (2%) developed S/SS. Risk factors for S/SS were American Society of Anesthesiologists Physical Status (ASA PS) class 2 or higher (odds ratio [OR] 2.57; 95% confidence interval [CI] 2.19-3.02; p < 0.0001), totally dependent (OR 2.00, 95% CI 1.38-2.83; p = 0.00021) or partially dependent (OR 1.62, 95% CI 1.35-2.00; p < 0.0001) functional status, and male gender (OR 1.31; 95% CI 1.18-1.45; p < 0.0001). Compared with colorectal procedures, patients undergoing pancreatic (OR 2.33, CI 1.40-3.87; p = 0.00108) and small intestine (OR 1.27; CI 1.12-1.44; p = 0.00015) surgery were more likely to develop S/SS. Patients undergoing biliary surgery (OR 0.38; CI 0.30-0.48; p < 0.0001) were less likely to develop S/SS. Conclusions: Risk factors for the development of sepsis or septic shock are ASA PS class 2 or higher, partially or totally dependent functional status, and male gender. Emergency pancreatic or small intestinal procedures may confer a higher risk. Greater vigilance and early post-operative screening may be of benefit in patients with these risk factors.
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Affiliation(s)
- Viktor Gabriel
- 1 Department of Surgery, University of California, Irvine, Orange, California
| | - Areg Grigorian
- 1 Department of Surgery, University of California, Irvine, Orange, California
| | - Jeffry Nahmias
- 1 Department of Surgery, University of California, Irvine, Orange, California
| | - Marija Pejcinovska
- 2 Department of Statistics UC Irvine Center for Statistical Consulting, University of California, Irvine, Orange, California
| | - Megan Smith
- 2 Department of Statistics UC Irvine Center for Statistical Consulting, University of California, Irvine, Orange, California
| | - Beatrice Sun
- 3 School of Medicine, University of California, Irvine, Orange, California
| | - Eugene Won
- 1 Department of Surgery, University of California, Irvine, Orange, California
| | - Nicole Bernal
- 4 Division of Trauma, Burns, Acute Care Surgery, and Surgical Critical Care, University of California, Irvine, Orange, California
| | - Cristobal Barrios
- 4 Division of Trauma, Burns, Acute Care Surgery, and Surgical Critical Care, University of California, Irvine, Orange, California
| | - Sebastian D Schubl
- 4 Division of Trauma, Burns, Acute Care Surgery, and Surgical Critical Care, University of California, Irvine, Orange, California
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Vázquez-Martínez ER, García-Gómez E, Camacho-Arroyo I, González-Pedrajo B. Sexual dimorphism in bacterial infections. Biol Sex Differ 2018; 9:27. [PMID: 29925409 PMCID: PMC6011518 DOI: 10.1186/s13293-018-0187-5] [Citation(s) in RCA: 76] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 06/08/2018] [Indexed: 12/21/2022] Open
Abstract
Background Sex differences are important epidemiological factors that impact in the frequency and severity of infectious diseases. A clear sexual dimorphism in bacterial infections has been reported in both humans and animal models. Nevertheless, the molecular mechanisms involved in this gender bias are just starting to be elucidated. In the present article, we aim to review the available data in the literature that report bacterial infections presenting a clear sexual dimorphism, without considering behavioral and social factors. Main body The sexual dimorphism in bacterial infections has been mainly attributed to the differential levels of sex hormones between males and females, as well as to genetic factors. In general, males are more susceptible to gastrointestinal and respiratory bacterial diseases and sepsis, while females are more susceptible to genitourinary tract bacterial infections. However, these incidences depend on the population evaluated, animal model and the bacterial species. Female protection against bacterial infections and the associated complications is assumed to be due to the pro-inflammatory effect of estradiol, while male susceptibility to those infections is associated with the testosterone-mediated immune suppression, probably via their specific receptors. Recent studies indicate that the protective effect of estradiol depends on the estrogen receptor subtype and the specific tissue compartment involved in the bacterial insult, suggesting that tissue-specific expression of particular sex steroid receptors contributes to the susceptibility to bacterial infections. Furthermore, this gender bias also depends on the effects of sex hormones on specific bacterial species. Finally, since a large number of genes related to immune functions are located on the X chromosome, X-linked mosaicism confers a highly polymorphic gene expression program that allows women to respond with a more expanded immune repertoire as compared with men. Conclusion Notwithstanding there is increasing evidence that confirms the sexual dimorphism in certain bacterial infections and the molecular mechanisms associated, further studies are required to clarify conflicting data and to determine the role of specific hormone receptors involved in the gender bias of bacterial infections, as well as their potential as therapeutic targets.
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Affiliation(s)
- Edgar Ricardo Vázquez-Martínez
- Unidad de Investigación en Reproducción Humana, Instituto Nacional de Perinatología-Facultad de Química, Universidad Nacional Autónoma de México (UNAM), Ciudad de México, Mexico
| | - Elizabeth García-Gómez
- Unidad de Investigación en Reproducción Humana, Consejo Nacional de Ciencia y Tecnología (CONACyT)-Instituto Nacional de Perinatología, Ciudad de México, Mexico
| | - Ignacio Camacho-Arroyo
- Unidad de Investigación en Reproducción Humana, Instituto Nacional de Perinatología-Facultad de Química, Universidad Nacional Autónoma de México (UNAM), Ciudad de México, Mexico
| | - Bertha González-Pedrajo
- Departamento de Genética Molecular, Instituto de Fisiología Celular, UNAM, Ciudad Universitaria, Av. Universidad 3000, Coyoacán, 04510, Ciudad de México, Mexico.
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Sanderson M, Chikhani M, Blyth E, Wood S, Moppett IK, McKeever T, Simmonds MJ. Predicting 30-day mortality in patients with sepsis: An exploratory analysis of process of care and patient characteristics. J Intensive Care Soc 2018; 19:299-304. [PMID: 30515239 DOI: 10.1177/1751143718758975] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Background Sepsis represents a significant public health burden, costing the NHS £2.5 billion annually, with 35% mortality in 2006. The aim of this exploratory study was to investigate risk factors predictive of 30-day mortality amongst patients with sepsis in Nottingham. Methods Data were collected prospectively from adult patients with sepsis in Nottingham University Hospitals NHS Trust as part of an on-going quality improvement project between November 2011 and March 2014. Patients admitted to critical care with the diagnosis of sepsis were included in the study. In all, 97 separate variables were investigated for their association with 30-day mortality. Variables included patient demographics, symptoms of systemic inflammatory response syndrome, organ dysfunction or tissue hypoperfusion, locations of early care, source of sepsis and time to interventions. Results A total of 455 patients were included in the study. Increased age (adjOR = 1.05 95%CI = 1.03-1.07 p < 0.001), thrombocytopenia (adjOR = 3.10 95%CI = 1.23-7.82 p = 0.016), hospital-acquired sepsis (adjOR = 3.34 95%CI = 1.78-6.27 p < 0.001), increased lactate concentration (adjOR = 1.16 95%CI = 1.06-1.27 p = 0.001), remaining hypotensive after vasopressors (adjOR = 3.89 95%CI = 1.26-11.95 p = 0.02) and mottling (adjOR = 3.80 95%CI = 1.06-13.55 p = 0.04) increased 30-day mortality odds. Conversely, fever (adjOR = 0.46 95%CI = 0.28-0.75 p = 0.002), fluid refractory hypotension (adjOR = 0.29 95%CI = 0.10-0.87 p = 0.027) and being diagnosed in surgical wards (adjOR = 0.35 95%CI = 0.15-0.81 p = 0.015) were protective. Treatment timeliness were not significant factors. Conclusion Several important predictors of 30-day mortality were found by this research. Retrospective analysis of our sepsis data has revealed mortality predictors that appear to be more patient-related than intervention-specific. With this information, care can be improved for those identified most at risk of death.
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Affiliation(s)
| | | | - Esme Blyth
- Sheffield Teaching Hosptials NHS Foundation Trust, UK
| | - Sally Wood
- Nottingham University Hospitals NHS Trust, UK
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Yoo RN, Kye BH, Kim G, Kim HJ, Cho HM. Mortality risk factor analysis in colonic perforation: would retroperitoneal contamination increase mortality in colonic perforation? Ann Surg Treat Res 2017; 93:203-208. [PMID: 29094030 PMCID: PMC5658302 DOI: 10.4174/astr.2017.93.4.203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/28/2017] [Accepted: 04/07/2017] [Indexed: 02/06/2023] Open
Abstract
Purpose Colonic perforation is a lethal condition presenting high morbidity and mortality in spite of urgent surgical treatment. This study investigated the surgical outcome of patients with colonic perforation associated with retroperitoneal contamination. Methods Retrospective analysis was performed for 30 patients diagnosed with colonic perforation caused by either inflammation or ischemia who underwent urgent surgical treatment in our facility from January 2005 to December 2014. Patient characteristics were analyzed to find risk factors correlated with increased postoperative mortality. Using the Physiological and Operative Severity Score for the Enumeration of Mortality and Morbidity (POSSUM) audit system, the mortality and morbidity rates were estimated to verify the surgical outcomes. Patients with retroperitoneal contamination, defined by the presence of retroperitoneal air in the preoperative abdominopelvic CT, were compared to those without retroperitoneal contamination. Results Eight out of 30 patients (26.7%) with colonic perforation had died after urgent surgical treatment. Factors associated with mortality included age, American Society of Anesthesiologists (ASA) physical status classification, and the ischemic cause of colonic perforation. Three out of 6 patients (50%) who presented retroperitoneal contamination were deceased. Although the patients with retroperitoneal contamination did not show significant increase in the mortality rate, they showed significantly higher ASA physical status classification than those without retroperitoneal contamination. The mortality rate predicted from Portsmouth POSSUM was higher in the patients with retroperitoneal contamination. Conclusion Patients presenting colonic perforation along with retroperitoneal contamination demonstrated severe comorbidity. However, retroperitoneal contamination was not found to be correlated with the mortality rate.
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Affiliation(s)
- Ri Na Yoo
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Bong-Hyeon Kye
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Gun Kim
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Hyung Jin Kim
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Hyeon-Min Cho
- Department of Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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12
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López-Mestanza C, Andaluz-Ojeda D, Gómez-López JR, Bermejo-Martín JF. Clinical factors influencing mortality risk in hospital-acquired sepsis. J Hosp Infect 2017; 98:194-201. [PMID: 28882641 DOI: 10.1016/j.jhin.2017.08.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 08/29/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND Identification of factors that confer an increased risk of mortality in hospital-acquired sepsis (HAS) is necessary to help prevent, and improve the outcome of, this condition. AIM To evaluate the clinical characteristics and factors associated with mortality in patients with HAS. METHODS Retrospective study of patients with HAS in a major Spanish Hospital from 2011 to 2015. Data from adults receiving any of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes associated with sepsis were collected. Those fulfilling the SEPSIS-2 definition with no evidence of infection during the first 48 h following hospitalization were included (N = 196). Multivariate analysis was employed to identify the risk factors of mortality. FINDINGS HAS patients were found to have many of the risk factors associated with cardiovascular disease (male sex, ageing, antecedent of cardiac disease, arterial hypertension, dyslipidaemia, smoking habit) and cancer. Vascular disease or chronic kidney disease were associated with 28-day mortality. Time from hospital admission to sepsis diagnosis, and the presence of organ failure were risk factors for 28-day and hospital mortality. Experiencing more than one episode of sepsis increased the risk of hospital mortality. 'Sepsis code' for the early identification of sepsis was protective against hospital mortality. CONCLUSION This study identifies several major factors associated with mortality in patients suffering from HAS. Implementation of surveillance programmes for the early identification and treatment of sepsis translate into a clear benefit.
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Affiliation(s)
- C López-Mestanza
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario de Valladolid, SACYL, Valladolid, Spain.
| | - D Andaluz-Ojeda
- Critical Care Medicine Service, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - J R Gómez-López
- General Surgery Service, Hospital de Medina del Campo, SACYL, Medina del Campo-Valladolid, Spain
| | - J F Bermejo-Martín
- BIO∙SEPSIS (Laboratory of Biomedical Research in Sepsis), Hospital Clínico Universitario de Valladolid, SACYL, Valladolid, Spain
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Mulvey CL, Brant JA, Bur AM, Chen J, Fischer JP, Cannady SB, Newman JG. Complications Associated with Mortality after Head and Neck Surgery: An Analysis of the NSQIP Database. Otolaryngol Head Neck Surg 2017; 156:504-510. [DOI: 10.1177/0194599816686958] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective To determine which complications, as defined by the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database, correlate with 30-day mortality in surgery for malignancies of the head and neck. Study Design Retrospective review of prospectively collected national database. Setting NSQIP. Subjects and Methods NSQIP data from 2005 to 2014 were queried for ICD-9 codes head and neck malignancies. Multivariate logistic regression was used to examine the correlation of individual complications with 30-day mortality. Results In total, 15,410 cases met criteria with 3499 complications in 2235 cases. After controlling for patient and surgical variables, postoperative pneumonia ( P = .02; odds ratio [OR], 2.39; 95% confidence interval [CI], 1.15-4.72), progressive renal insufficiency ( P < .001; OR, 21.28; 95% CI, 4.22-87.94), bleeding requiring transfusion ( P = .02; OR, 2.10; 95% CI, 1.12-3.84), sepsis ( P = .02; OR, 2.86; 95% CI, 1.15-6.46), septic shock ( P = .045; OR, 2.87; 95% CI, 0.98-7.81), stroke ( P < .001; OR, 19.81; 95% CI, 6.23-56.03), and cardiac arrest ( P < .001; OR, 135.59; 95% CI, 65.00-286.48) were independently associated with increased odds of 30-day mortality. Conclusion The NSQIP database has been extensively validated and used to examine surgical complications, yet there is little analysis on which complications are associated with death. This study identified complications associated with increased risk of 30-day mortality following head and neck cancer surgery. These associations may be used as a measure of complication severity and should be considered when using the NSQIP database to evaluate outcomes in head and neck surgery.
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Affiliation(s)
- Carolyn L. Mulvey
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason A. Brant
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrés M. Bur
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jinbo Chen
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - John P. Fischer
- Division of Plastic and Reconstructive Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Steven B. Cannady
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jason G. Newman
- Department of Otorhinolaryngology: Head and Neck Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Wawrose R, Baraniuk M, Standiford L, Wade C, Holcomb J, Moore L. Comparison of Sepsis Screening Tools' Ability to Detect Sepsis Accurately. Surg Infect (Larchmt) 2016; 17:525-9. [PMID: 27447053 DOI: 10.1089/sur.2015.069] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Sepsis is the primary cause of perioperative mortality among general surgery patients and is the leading cause of death in non-cardiac intensive care units. To address this issue, the Surviving Sepsis Campaign Guidelines advocate for sepsis screening. However, there is little information in the current medical literature to suggest which sepsis screening tool is optimal. The purpose of this study was to compare a sepsis screening tool that we have validated and published previously, the Sepsis Screening Score (SSS), with a commercially available sepsis screening tool, the St. John's Sepsis Agent (SJSA) developed by Cerner (Kansas City, MO). METHODS This prospective observational study compares the accuracy of the SSS with that of the SJSA in the same patient population. The SSS was performed on each patient in our surgical intermediate care unit (SIMU) twice daily. The SJSA monitored these same patients continuously via the electronic medical record (EMR). Epidemiologic data related to sepsis were collected prospectively, and the performance characteristics of the two tests were compared using the two-sample test of proportions. RESULTS A total of 348 patients were included in the study, and 47 (13.5%) of these patients developed sepsis. The SJSA was determined to have a sensitivity of 44.7%, a specificity of 84.7%, a positive predictive value (PPV) of 31.3%, and a negative predictive value (NPV) of 90.7%, while the SSS was determined to have a sensitivity of 74.5%, a specificity of 86.4%, a PPV of 46.1%, and an NPV of 95.6%. The differences in sensitivity (p < 0.001), PPV (p < 0.001), and NPV (p = 0.011) were found to be statistically significant. CONCLUSION Despite the fact that SJSA had constant surveillance over patients' EMRs, it still detected fewer septic patients than the SSS, which was performed twice per day. The difference in sensitivities and NPVs between the two tests is of particular importance, because this indicates that the SSS is more effective in identifying patients with sepsis. This study establishes a basis for the utilization of the SSS instead of the SJSA.
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Affiliation(s)
- Richard Wawrose
- 1 The University of Texas Health Science Center at Houston , Houston, Texas
| | - Mary Baraniuk
- 1 The University of Texas Health Science Center at Houston , Houston, Texas
| | | | - Charles Wade
- 1 The University of Texas Health Science Center at Houston , Houston, Texas
| | - John Holcomb
- 1 The University of Texas Health Science Center at Houston , Houston, Texas
| | - Laura Moore
- 1 The University of Texas Health Science Center at Houston , Houston, Texas
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Probiotics and Synbiotics Decrease Postoperative Sepsis in Elective Gastrointestinal Surgical Patients: a Meta-Analysis. J Gastrointest Surg 2016; 20:1123-31. [PMID: 27073082 DOI: 10.1007/s11605-016-3142-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 03/28/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND The health benefits of probiotics and synbiotics are well established in healthy adults, but their role in preventing postoperative sepsis remains controversial. This meta-analysis assesses the impact of probiotics and synbiotics on the incidence of postoperative sepsis in gastrointestinal (GI) surgical patients. METHODS A comprehensive literature search of all published randomized control trials (RCTs) was conducted using PubMed, Cochrane Central Registry of Controlled Trials, and Google Scholar (1966-2015). Inclusion criteria included RCTs comparing the use of any strain or dose of a specified probiotic/synbiotic with placebo or a "no treatment" control group. The incidence of postoperative sepsis (within 1 month of surgery) and postoperative mortality were analyzed. RESULTS Fifteen RCTs involving 1201 patients (192 receiving probiotics, 413 receiving synbiotics, and 596 receiving placebo) were analyzed. Overall, probiotic and synbiotic uses significantly reduced the risk of developing postoperative sepsis by 38 % (relative risk (RR) = 0.62, 95 % confidence interval (CI) 0.52-0.74, p < 0.001). CONCLUSIONS The use of probiotic/synbiotic supplementation is associated with a significant reduction in the risk of developing postoperative sepsis in patients undergoing elective GI surgery. Probiotic/synbiotic supplementation is a valuable adjunct in the care of patients undergoing GI surgery. Additional studies are required to determine the optimal dose and strain of probiotic/synbiotic.
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16
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Epidemiology of sepsis in ICUs of Western China. JOURNAL OF ACUTE DISEASE 2016. [DOI: 10.1016/j.joad.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Hiong A, Thursky KA, Teh BW, Haeusler GM, Slavin MA, Worth LJ. Sepsis following cancer surgery: the need for early recognition and standardised clinical care. Expert Rev Anti Infect Ther 2016; 14:425-33. [PMID: 26882129 DOI: 10.1586/14787210.2016.1154787] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Despite the implementation of multimodal bundles of care in hospitalised patients, post-operative sepsis in patients with cancer still accounts for a significant burden of illness and substantial healthcare costs. Patients undergoing surgery for cancer are at particular risk of sepsis due to underlying malignancy, being immunocompromised associated with cancer management and the complexity of surgical procedures performed. In this review, we evaluate the burden of illness and risks for sepsis following surgery for cancer. Current evidence supporting standardised strategies for sepsis management (including early recognition and resuscitation) is examined together with challenges in implementing quality improvement programs.
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Affiliation(s)
- A Hiong
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Victoria , Australia
| | - K A Thursky
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Victoria , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Victoria , Australia.,d National Centre for Antimicrobial Stewardship , Royal Melbourne Hospital at the Doherty Institute , Melbourne , Victoria , Australia
| | - B W Teh
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Victoria , Australia
| | - G M Haeusler
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Victoria , Australia
| | - M A Slavin
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Victoria , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Victoria , Australia.,d National Centre for Antimicrobial Stewardship , Royal Melbourne Hospital at the Doherty Institute , Melbourne , Victoria , Australia
| | - L J Worth
- a Department of Infectious Diseases and Infection Prevention , Peter MacCallum Cancer Centre , Melbourne , Victoria , Australia.,b Department of Medicine , University of Melbourne , Melbourne , Victoria , Australia.,c Victorian Healthcare Associated Infection Surveillance System (VICNISS) Coordinating Centre , Melbourne , Victoria , Australia
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18
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The Sex Differences of Morphology and Immunology of SIRS of Newborn Wistar Rats. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2014; 2014:190749. [PMID: 27350991 PMCID: PMC4897487 DOI: 10.1155/2014/190749] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 10/13/2014] [Accepted: 10/13/2014] [Indexed: 12/20/2022]
Abstract
The sex differences of infection and inflammatory diseases particularly appear at reproductive age and depend on the sex hormone level, varied between male and female. There are a few sets of data about the sex differences of infection and inflammatory diseases course, including systemic inflammatory response syndrome (SIRS) and sepsis, of newborns. The aim of our research was the estimation of morphological and immunological manifestation of SIRS of the newborn Wistar rats. Investigations were carried out on male and female two-day-old Wistar rats (10–12 g). SIRS was modeled by intraperitoneal injection of LPS (E. coli, O26: B6 strain, Sigma) in high dose—15 mg/kg. We did not find out any sex differences of the liver lesions severity between newborn males and females after LPS injection. The levels of endotoxin and estradiol in the serum, as the number of neutrophils in the intra-alveolar septa of the lungs, were higher in males than females with SIRS. Production of IL-2 and TNF-α by the spleen cells of males was higher than that in control group that reflects polarization predominantly on the Th1-type immune response. The secretion of IL-2, TNF-α, and IFN-γ by ConA activated spleen cells of females decreased that reflects the suppression of Th1-type immune response. We suppose that the LPS administration in the high dose causes the multidirectional reaction of the immune system of neonatal males and females Wistar rats.
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Abstract
Intra-abdominal infections are multifactorial, but all require prompt identification, diagnosis, and treatment. Resuscitation, early antibiotic administration, and source control are crucial. Antibiotic administration should initially be broad spectrum and target the most likely pathogens. When cultures are available, antibiotics should be narrowed and limited in duration. The method of source control depends on the anatomic site, site accessibility, and the patient's clinical condition. Patient-specific factors (advanced age and chronic medical conditions) as well as disease-specific factors (health care-associated infections and inability to obtain source control) combine to affect patient morbidity and mortality.
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Affiliation(s)
- Gina R Shirah
- Division of Trauma & Critical Care Surgery, Department of Surgery, Maricopa Medical Center, 2601 East Roosevelt Street, Phoenix, AZ 85008, USA
| | - Patrick J O'Neill
- Trauma Department, West Valley Hospital, 13677 W McDowell Road, Goodyear, AZ 85395, USA.
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Luo L, Zhang S, Wang Y, Rahman M, Syk I, Zhang E, Thorlacius H. Proinflammatory role of neutrophil extracellular traps in abdominal sepsis. Am J Physiol Lung Cell Mol Physiol 2014; 307:L586-96. [DOI: 10.1152/ajplung.00365.2013] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Excessive neutrophil activation is a major component in septic lung injury. Neutrophil-derived DNA may form extracellular traps in response to bacterial invasions. The aim of the present study was to investigate the potential role of neutrophil extracellular traps (NETs) in septic lung injury. Male C57BL/6 mice were treated with recombinant human (rh)DNAse (5 mg/kg) after cecal ligation and puncture (CLP). Extracellular DNA was stained by Sytox green, and NET formation was quantified by confocal microscopy and cell-free DNA in plasma, peritoneal cavity, and lung. Blood, peritoneal fluid, and lung tissue were harvested for analysis of neutrophil infiltration, NET levels, tissue injury, as well as CXC chemokine and cytokine formation. We observed that CLP caused increased formation of NETs in plasma, peritoneal cavity, and lung. Administration of rhDNAse not only eliminated NET formation in plasma, peritoneal cavity, and bronchoalveolar space but also reduced lung edema and tissue damage 24 h after CLP induction. Moreover, treatment with rhDNAse decreased CLP-induced formation of CXC chemokines, IL-6, and high-mobility group box 1 (HMGB1) in plasma, as well as CXC chemokines and IL-6 in the lung. In vitro, we found that neutrophil-derived NETs had the capacity to stimulate secretion of CXCL2, TNF-α, and HMGB1 from alveolar macrophages. Taken together, our findings show that NETs regulate pulmonary infiltration of neutrophils and tissue injury via formation of proinflammatory compounds in abdominal sepsis. Thus we conclude that NETs exert a proinflammatory role in septic lung injury.
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Affiliation(s)
- Lingtao Luo
- Department of Clinical Sciences Malmö, 1Section for Surgery and
| | - Su Zhang
- Department of Clinical Sciences Malmö, 1Section for Surgery and
| | - Yongzhi Wang
- Department of Clinical Sciences Malmö, 1Section for Surgery and
| | - Milladur Rahman
- Department of Clinical Sciences Malmö, 1Section for Surgery and
| | - Ingvar Syk
- Department of Clinical Sciences Malmö, 1Section for Surgery and
| | - Enming Zhang
- Islet Pathophysiology, Lund University, Malmö, Sweden
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Fisher OM, Oberkofler CE, Raptis DA, Soll C, Béchir M, Schiesser M, Graf R. Pancreatic stone protein (PSP) and pancreatitis-associated protein (PAP): a protocol of a cohort study on the diagnostic efficacy and prognostic value of PSP and PAP as postoperative markers of septic complications in patients undergoing abdominal surgery (PSP study). BMJ Open 2014; 4:e004914. [PMID: 24604486 PMCID: PMC3948573 DOI: 10.1136/bmjopen-2014-004914] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Major abdominal surgery leads to a postoperative systemic inflammatory response, making it difficult to discriminate patients with systemic inflammatory response syndrome from those with a beginning postoperative infectious complication. At present, physicians have to rely on their clinical experience to differentiate between the two. Pancreatic stone protein (PSP) and pancreatitis-associated protein (PAP), both secretory proteins produced by the pancreas, are dramatically increased during pancreatic disease and have been shown to act as acute-phase proteins. Increased levels of PSP have been detected in polytrauma patients developing sepsis and PSP has shown a high diagnostic accuracy in discriminating the severity of peritonitis and in predicting death in intensive care unit patients. However, the prognostic value of PSP/PAP for infectious complications among patients undergoing major abdominal surgery is unknown. METHODS AND ANALYSIS 160 patients undergoing major abdominal surgery will be recruited preoperatively. On the day before surgery, baseline blood values are attained. Following surgery, daily blood samples for measuring regular inflammatory markers (c-reactive protein, procalcitonin, interleukin-6, tumour necrosis factor-α and leucocyte counts) and PSP/PAP will be acquired. PSP/PAP will be measured using a validated ELISA developed in our research laboratory. Patient's discharge marks the end of his/her trial participation. Complication grade including mortality and occurrence of infectious postoperative complications according to validated diagnostic criteria will be correlated with PSP/PAP values. Total intensive care unit days and total length of stay will be recorded as further outcome parameters. ETHICS AND DISSEMINATION The PSP trial is a prospective monocentric cohort study evaluating the prognostic value of PSP and PAP for postoperative infectious complications. In addition, a comparison with established inflammatory markers in patients undergoing major abdominal surgery will be performed to help evaluate the role of these proteins in predicting and diagnosing infectious and other postoperative complications. INSTITUTION ETHICS BOARD APPROVAL ID KEKZH-Nr. STV 11-2009. TRIAL REGISTRATION ClinicalTrials.gov: NCT01258179.
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Affiliation(s)
| | | | | | - Christopher Soll
- Department of Surgery, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Markus Béchir
- Surgical Intensive Care Unit, University Hospital Zurich, Zurich, Switzerland
| | - Marc Schiesser
- Department of Surgery, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | - Rolf Graf
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
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Zhang S, Ren L, Li Y, Wang J, Yu W, Li N, Li J. Bacteriology and drug susceptibility analysis of pus from patients with severe intra-abdominal infection induced by abdominal trauma. Exp Ther Med 2014; 7:1427-1431. [PMID: 24940451 PMCID: PMC3991502 DOI: 10.3892/etm.2014.1609] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 03/04/2014] [Indexed: 11/20/2022] Open
Abstract
The aim of the present study was to retrospectively analyze the bacteriology and drug susceptibility of pus flora from abdominal trauma patients with severe intra-abdominal infection (SIAI). A total of 41 patients with SIAI induced by abdominal trauma were enrolled in the study, from which 123 abdominal pus samples were obtained. The results from laboratory microbiology and drug sensitivity were subjected to susceptibility analysis using WHONET software. A total of 297 strains were isolated in which Gram-negative bacteria, Gram-positive bacteria and fungi accounted for 53.5 (159/297), 44.1 (131/297) and 0.7% (2/297), respectively. Anaerobic bacteria accounted for 1.7%. The five predominant bacteria were Escherichia coli (E. coli), Staphylococcus aureus (S. aureus), Klebsiella pneumoniae (K. pneumoniae), Enterococcus faecalis and Pseudomonas aeruginosa (P. aeruginosa). E. coli was highly susceptible to cefoperazone (91%) and imipenem (98%), while Gram-positive cocci were highly susceptible to teicoplanin (100%) and linezolid (100%). S. aureus was 100% susceptible to vancomycin and K. pneumoniae was highly susceptible to imipenem (100%) and amikacin (79%). P. aeruginosa was the most susceptible to ciprofloxacin (90%). Gram-negative bacterial infection was present in the majority of cases of SIAI. However, a large number of patients were infected by Gram-positive bacteria, particularly S. aureus that exhibited significant resistance to penicillin (100%), oxacillin (100%) and a third-generation cephalosporin antibiotic cefotaxime (95%). Amongst the pathogenic bacteria that cause SIAI, both Gram-negative and Gram-positive bacteria account for a high proportion, so high-level and broad-spectrum antibiotics should be initially used.
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Affiliation(s)
- Shaoyi Zhang
- Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, P.R. China
| | - Lele Ren
- Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, P.R. China
| | - Yousheng Li
- Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, P.R. China
| | - Jian Wang
- Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, P.R. China
| | - Wenkui Yu
- Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, P.R. China
| | - Ning Li
- Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, P.R. China
| | - Jieshou Li
- Department of Surgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu 210002, P.R. China
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Acute kidney injury is surprisingly common and a powerful predictor of mortality in surgical sepsis. J Trauma Acute Care Surg 2013; 75:432-8. [PMID: 24089113 DOI: 10.1097/ta.0b013e31829de6cd] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common and often catastrophic complication in hospitalized patients; however, the impact of AKI in surgical sepsis remains unknown. We used Risk, Injury, Failure, Loss, End stage (RIFLE) consensus criteria to define the incidence of AKI in surgical sepsis and characterize the impact of AKI on patient morbidity and mortality. METHODS Our prospective, institutional review board-approved sepsis research database was retrospectively queried for the incidence of AKI by RIFLE criteria, excluding those with chronic kidney disease. Patients were grouped into sepsis, severe sepsis, and septic shock by refined consensus criteria. Data including demographics, baseline biomarkers of organ dysfunction, and outcomes were compared by Student's t test and χ test. Multivariable regression analysis was performed for the effect of AKI on mortality adjusting for age, sex, African-American race, elective surgery, Acute Physiology and Chronic Health Evaluation II score, septic shock versus severe sepsis, and sepsis source. RESULTS During the 36-month study period ending on December 2010, 246 patients treated for surgical sepsis were evaluated. AKI occurred in 67% of all patients, and 59%, 60%, and 88% of patients had sepsis, surgical sepsis, and septic shock, respectively. AKI was associated with Hispanic ethnicity, several baseline biomarkers of organ dysfunction, and a greater severity of illness. Patients with AKI had fewer ventilator-free and intensive care unit-free days and a decreased likelihood of discharge to home. Morbidity and mortality increased with severity of AKI, and AKI of any severity was found to be a strong predictor of hospital mortality (odds ratio, 10.59; 95% confidence interval, 1.28-87.35; p = 0.03) in surgical sepsis. CONCLUSION AKI frequently complicates surgical sepsis, and serves as a powerful predictor of hospital mortality in severe sepsis and septic shock. LEVEL OF EVIDENCE Prognostic and epidemiologic study, level III.
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Hecker A, Uhle F, Schwandner T, Padberg W, Weigand MA. Diagnostics, therapy and outcome prediction in abdominal sepsis: current standards and future perspectives. Langenbecks Arch Surg 2013; 399:11-22. [PMID: 24186147 DOI: 10.1007/s00423-013-1132-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/07/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE In the perioperative phase, sepsis and sepsis-associated death are the most important problems for both the surgeon and the intensivist. Critically ill patients profit from an early identification and implementation of an interdisciplinary therapy. The purpose of this review on septic peritonitis is to give an update on the diagnosis and its evidence-based treatment. RESULTS Rapid diagnosis of sepsis is essential for patient´s survival. A bundle of studies was performed on early recognition and on new diagnostic tools for abdominal sepsis. Although surgical intervention is considered as an essential therapeutic step in sepsis therapy the time-point of source control is still controversially discussed in the literature. Furthermore, the Surviving Sepsis Campaign (SSC) guidelines were updated in 2012 to facilitate evidence-based medicine for septic patients. CONCLUSION Despite many efforts, the mortality of surgical septic patients remains unacceptably high. Permanent clinical education and further surgical trials are necessary to improve the outcome of critically ill patients.
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Affiliation(s)
- A Hecker
- Department of General and Thoracic Surgery, University Hospital Giessen, Giessen, Germany,
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Leichtle SW, Kaoutzanis C, Brandt MM, Welch KB, Purtill MA. Tissue oxygen saturation for the risk stratification of septic patients. J Crit Care 2013; 28:1111.e1-5. [PMID: 24011754 DOI: 10.1016/j.jcrc.2013.07.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 06/15/2013] [Accepted: 07/23/2013] [Indexed: 01/27/2023]
Abstract
PURPOSE Peripheral tissue oxygen saturation (Sto2) has shown promise as an early indicator of tissue hypoperfusion and as a risk stratification tool in various forms of shock. The purpose of this study was to determine if Sto2 would predict admission to an intensive (ICU) or progressive care unit in patients with early signs of sepsis. METHODS In this prospective observational study, a rapid response team measured Sto2 levels in patients screening positive for sepsis. Using a logistic regression model, the value of Sto2 as a predictor for ICU admission within 72 hours of the initial assessment was determined. RESULTS The 31 (47%) of 66 patients who required ICU admission within 72 hours of evaluation had a significantly lower Sto2 value (median, 78% vs 81%; P = .05). All patients with Sto2 less than 70% required ICU admission. A 1-point increase in Sto2 was associated with a 7% decrease in the odds of requiring ICU admission, and the area under the curve for Sto2 was 0.64 (0.51-0.77, P = .01). CONCLUSIONS Low Sto2 levels in patients screening positive for sepsis are associated with an increased risk of ICU admission, but their reliability as a predictor is rather low. An Sto2 below 70% might be an interesting cutoff value for further study.
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Affiliation(s)
- Stefan W Leichtle
- Section of Surgical Critical Care, St Joseph Mercy Health System, Ann Arbor, MI 48106, USA.
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Kuperman EF, Showalter JW, Lehman EB, Leib AE, Kraschnewski JL. The impact of obesity on sepsis mortality: a retrospective review. BMC Infect Dis 2013; 13:377. [PMID: 23957291 PMCID: PMC3765286 DOI: 10.1186/1471-2334-13-377] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Accepted: 07/17/2013] [Indexed: 01/30/2023] Open
Abstract
Background Recent sepsis guidelines have focused on the early identification and risk stratification of patients on presentation. Obesity is associated with alterations in multiple inflammatory regulators similar to changes seen in sepsis, suggesting a potential interaction between the presence of obesity and the severity of illness in sepsis. Methods We performed a retrospective chart review of patients admitted with a primary billing diagnosis of sepsis at a single United States university hospital from 2007 to 2010. Seven hundred and ninety-two charts were identified meeting inclusion criteria. Obesity was defined as a body mass index (BMI) ≥ 30 kg/m2. The data recorded included age, race, sex, vital signs, laboratory values, length of stay, comorbidities, weight, height, and survival to discharge. A modified APACHE II score was calculated to estimate disease severity. The primary outcome variable was inpatient mortality. Results Survivors had higher average BMI than nonsurvivors (27.6 vs. 26.3 kg/m2, p = 0.03) in unadjusted analysis. Severity of illness and comorbid conditions including cancer were similar across BMI categories. Increased incidence of diabetes mellitus type 2 was associated with increasing BMI (p < 0.01) and was associated with decreased mortality, with an odds ratio of 0.53 compared with nondiabetic patients. After adjusting for age, gender, race, severity of illness, length of stay, and comorbid conditions, the trend of decreased mortality for increased BMI was no longer statistically significant, however diabetes continued to be strongly protective (odds ratio 0.52, p = 0.03). Conclusions This retrospective analysis suggests obesity may be protective against mortality in septic inpatients. The protective effect of obesity may be dependent on diabetes, possibly through an unidentified hormonal intermediary. Further prospective studies are necessary to elaborate the specific mechanism of this protective effect.
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Sartelli M, Viale P, Catena F, Ansaloni L, Moore E, Malangoni M, Moore FA, Velmahos G, Coimbra R, Ivatury R, Peitzman A, Koike K, Leppaniemi A, Biffl W, Burlew CC, Balogh ZJ, Boffard K, Bendinelli C, Gupta S, Kluger Y, Agresta F, Di Saverio S, Wani I, Escalona A, Ordonez C, Fraga GP, Junior GAP, Bala M, Cui Y, Marwah S, Sakakushev B, Kong V, Naidoo N, Ahmed A, Abbas A, Guercioni G, Vettoretto N, Díaz-Nieto R, Gerych I, Tranà C, Faro MP, Yuan KC, Kok KYY, Mefire AC, Lee JG, Hong SK, Ghnnam W, Siribumrungwong B, Sato N, Murata K, Irahara T, Coccolini F, Lohse HAS, Verni A, Shoko T. 2013 WSES guidelines for management of intra-abdominal infections. World J Emerg Surg 2013; 8:3. [PMID: 23294512 PMCID: PMC3545734 DOI: 10.1186/1749-7922-8-3] [Citation(s) in RCA: 165] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Accepted: 01/02/2013] [Indexed: 12/11/2022] Open
Abstract
Despite advances in diagnosis, surgery, and antimicrobial therapy, mortality rates associated with complicated intra-abdominal infections remain exceedingly high.The 2013 update of the World Society of Emergency Surgery (WSES) guidelines for the management of intra-abdominal infections contains evidence-based recommendations for management of patients with intra-abdominal infections.
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Affiliation(s)
| | - Pierluigi Viale
- Clinic of Infectious Diseases, Department of Internal Medicine Geriatrics and Nephrologic Diseases, St Orsola-Malpighi University Hospital, Bologna, Italy
| | - Fausto Catena
- Emergency Surgery, Maggiore Parma Hospital, Parma, Italy
| | - Luca Ansaloni
- Department of General Surgery, Ospedali Riuniti, Bergamo, Italy
| | - Ernest Moore
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | | | | | - George Velmahos
- Harvard Medical School, Division of Trauma, Emergency Surgery and Surgical Critical Care Massachusetts General Hospital, Boston, MA, USA
| | - Raul Coimbra
- Department of Surgery, UC San Diego Health System, San Diego, CA, USA
| | - Rao Ivatury
- Department of Surgery, Virginia Commonwealth University Medical Center, Richmond, VA, USA
| | - Andrew Peitzman
- Division of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kaoru Koike
- Department of Primary Care & Emergency Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ari Leppaniemi
- Department of Abdominal Surgery, University Hospital Meilahti, Helsinki, Finland
| | - Walter Biffl
- Department of Surgery, Denver Health Medical Center, Denver, CO, USA
| | | | - Zsolt J Balogh
- Department of Surgery, University of Newcastle, Newcastle, NSW, Australia
| | - Ken Boffard
- Department of Surgery, Charlotte Maxeke Johannesburg Hospital University of the Witwatersrand, Johannesburg, South Africa
| | - Cino Bendinelli
- Department of Surgery, University of Newcastle, Newcastle, NSW, Australia
| | - Sanjay Gupta
- Department of Surgery, Govt Medical College and Hospital, Chandigarh, India
| | - Yoram Kluger
- Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | | | - Imtiaz Wani
- Department of Digestive Surgery Faculty of Medicine Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alex Escalona
- Department of Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Carlos Ordonez
- Department of Surgery, Universidad del Valle, Fundacion Valle del Lili, Cali, Colombia
| | - Gustavo P Fraga
- Division of Trauma Surgery, Hospital de Clinicas - University of Campinas, Campinas, Brazil
| | | | - Miklosh Bala
- Department of General Surgery, Hadassah Medical Center, Jerusalem, Israel
| | - Yunfeng Cui
- Department of Surgery, Tianjin Nankai Hospital, Nankai Clinical School of Medicine, Tianjin Medical University, Tianjin, China
| | - Sanjay Marwah
- Department of Surgery, Pt BDS Post-graduate Institute of Medical Sciences, Rohtak, India
| | - Boris Sakakushev
- First Clinic of General Surgery, University Hospital /UMBAL/ St George Plovdiv, Plovdiv, Bulgaria
| | - Victor Kong
- Department of Surgery, Edendale Hospital, Pietermaritzburg, Republic of South Africa
| | - Noel Naidoo
- Department of Surgery, Port Shepstone Hospital, Kwazulu Natal, South Africa
| | - Adamu Ahmed
- Department of Surgery, Ahmadu Bello University Teaching Hospital Zaria, Kaduna, Nigeria
| | - Ashraf Abbas
- Department of Surgery, Mansoura University Hospital, Mansoura, Egypt
| | | | | | - Rafael Díaz-Nieto
- Department of General and Digestive Surgery, University Hospital, Malaga, Spain
| | - Ihor Gerych
- Department of General Surgery, Lviv Emergency Hospital, Lviv, Ukraine
| | | | - Mario Paulo Faro
- Division of General and Emergency Surgery, Faculdade de Medicina da Fundação do ABC, São Paulo, Santo André, Brazil
| | - Kuo-Ching Yuan
- Department of Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | | | | | - Jae Gil Lee
- Department of Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Suk-Kyung Hong
- Division of Trauma and Surgical Critical Care, Department of Surgery, University of Ulsan, Seoul, Republic of Korea
| | - Wagih Ghnnam
- Wagih Ghnnam, Department of Surgery, Khamis Mushayt General Hospital, Khamis Mushayt, Saudi Arabia
| | - Boonying Siribumrungwong
- Boonying Siribumrungwong, Department of Surgery, Thammasat University Hospital, Pathumthani, Thailand
| | - Norio Sato
- Division of General Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kiyoshi Murata
- Department of Acute and Critical Care Medicine, Tokyo Medical and Dental University, Tokyo, Japan
| | - Takayuki Irahara
- Department of Emergency and Critical Care Medicine, Nippon Medical School, Emergency and Critical Care Center of Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan
| | | | | | - Alfredo Verni
- Department of Surgery, Cutral Co Clinic, Neuquen, Argentina
| | - Tomohisa Shoko
- The Shock Trauma and Emergency Medical Center, Matsudo City Hospital, Chiba, Japan
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Systemic inflammation worsens outcomes in emergency surgical patients. J Trauma Acute Care Surg 2012; 72:1140-9. [PMID: 22673238 DOI: 10.1097/ta.0b013e3182516a97] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Acute care surgeons are uniquely aware of the importance of systemic inflammatory response and its influence on postoperative outcomes; concepts like damage control have evolved from this experience. For surgeons whose practice is mostly elective, the significance of such systemic inflammation may be underappreciated. This study sought to determine the influence of preoperative systemic inflammation on postoperative outcome in patients requiring emergent colon surgery. METHODS Emergent colorectal operations were identified in the American College of Surgeons National Surgical Quality Improvement Program 2008 dataset. Four groups were defined by the presence and magnitude of the inflammatory response before operation: no inflammation, systemic inflammatory response syndrome (SIRS), sepsis, or severe sepsis/septic shock. Thirty-day survival was analyzed by Kaplan-Meier method. RESULTS A total of 3,305 patients were identified. Thirty-day survival was significantly different (p < 0.0001) among the four groups; increasing magnitudes of preoperative inflammation had increasing probability of mortality (p < 0.0001). Hazard ratios indicated that, compared with patients without preoperative systemic inflammation, the relative risk of death from SIRS was 1.9 (p < 0.0001), from sepsis was 2.5 (p < 0.0001), and from severe sepsis/septic shock was 6.7 (p < 0.0001). Operative time of <150 minutes was associated with decreased risk of morbidity (odds ratio = 0.64; p < 0.0001). CONCLUSIONS Upregulation of the systemic inflammatory response is the primary contributor to death in emergency surgical patients. In SIRS or sepsis patients, operations <2.5 hours are associated with fewer postoperative complications. These results further reinforce the concept of timely surgical intervention and suggest a potential role for damage control operations in emergency general surgery. LEVEL OF EVIDENCE II, prognostic study.
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Implementation of molecular phenotyping approaches in the personalized surgical patient journey. Ann Surg 2012; 255:881-9. [PMID: 22156927 DOI: 10.1097/sla.0b013e31823e3c43] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The present review describes commonly employed metabolic profiling platforms and discusses the current and likely future application of these technologies in surgery. BACKGROUND The metabolic adaptations that occur in response to surgical illness and trauma are incompletely understood. Evaluating these will be critical to the development of personalized surgical health solutions. Metabonomics is an advancing field in systems biology, which provides a means of interrogating these metabolic shifts. METHODS Recent literature regarding metabolic profiling technologies and their applications in surgical practice are discussed. Future strategies are proposed for the incorporation of these and next-generation technologies in the evaluation of all steps in the patient surgical pathway. RESULTS Metabolite-based profiling has provided valuable insights into the metabolic irregularities that occur in cancer development and progression across a variety of cancer subclasses including colorectal, breast, prostate, and lung cancers. In addition, metabolic modeling has shown considerable promise in other surgical conditions including trauma and sepsis and in the assessment of pharmacotherapeutic efficacy. DISCUSSION Metabonomics offers a posttranscriptional view of system activity providing functional information downstream of the genome and proteome. Information at this level will provide the surgeon with a novel means of evaluating major socioeconomic problems such as cancer and sepsis. In addition, the rapid nature of emerging next generation profiling platforms provides a viable means of "real-time" perioperative metabolic assessment and optimization.
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Availability of acute care surgeons improves outcomes in patients requiring emergent colon surgery. Am J Surg 2011; 202:837-42. [PMID: 22014648 DOI: 10.1016/j.amjsurg.2011.07.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Revised: 07/29/2011] [Accepted: 07/29/2011] [Indexed: 11/20/2022]
Abstract
BACKGROUND The need for emergent colon surgery is a common cause of severe sepsis/septic shock and mortality among surgical patients. We wanted to benchmark our outcomes against those of the National Surgical Quality Improvement Program (NSQIP). We hypothesized that having acute care surgeons to provide comprehensive perioperative care and rapid source control surgery would improve outcome. METHODS We queried the 2005 to 2007 NSQIP dataset and our prospective database for patients with severe sepsis/septic shock requiring emergency colon surgery. Demographics, Acute Physiology and Chronic Health Evaluation II score, sepsis source, and hospital mortality data were obtained for all patients. RESULTS Both cohorts were similar with regard to age and sex. The overall mortality rate for patients in our dataset was 28.3% compared with 40.1% in the NSQIP dataset (P = .06). The average Acute Physiology and Chronic Health Evaluation II score for our patients was 31 ± 8.2 with a predicted mortality rate of 73% (P < .0001 when compared with actual mortality rate of 28.3%). CONCLUSIONS Patients with severe sepsis/septic shock requiring emergent colon surgery have a high mortality rate. Delivery of comprehensive emergency surgical care by acute care surgeons appears to improve survival.
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Zhang P, Yang Y, Lv R, Zhang Y, Xie W, Chen J. Effect of the intensity of continuous renal replacement therapy in patients with sepsis and acute kidney injury: a single-center randomized clinical trial. Nephrol Dial Transplant 2011; 27:967-73. [PMID: 21891773 DOI: 10.1093/ndt/gfr486] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is a major complication in patients with sepsis and is an independent predictor of mortality. However, the optimal intensity of renal replacement therapy for such patients is still controversial. METHODS From 1 January 2004 to 30 September 2009, we randomly assigned 280 patients with sepsis and AKI to continuous renal replacement therapy by high-volume hemofiltration (50 mL/kg/h, HVHF) or extra high-volume hemofiltration (85 mL/kg/h, EHVHF). The primary study outcome was death from any cause within 28, 60 and 90 days. Results were analyzed by univariate and multivariate methods and by Kaplan-Meier survival curves. RESULTS A total of 141 patients were given EHVHF and 139 were given HVHF. The two groups had similar baseline characteristics and received treatment for an average of 9.38 days (EHVHF group) and 8.88 days (HVHF group). There were no significant differences between the groups in number of deaths at 28, 60 or 90 days. There were also no differences between the groups in renal outcome of survivors at 90 days. Multivariate analysis indicated that inotropic support by norepinephrine, time in hospital of >7 days, blood platelet count <8 × 10(9)/L, Acute Physiological and Chronic Health Evaluation (APACHE) II score >25, total bilirubin >100 μmol/L, prothrombin time >18 s, serum creatinine <250 μmol/L and blood urea nitrogen >20 mmol/L were independent risk factors for death at 90 days after initiation of renal replacement therapy. CONCLUSIONS In patients with sepsis and AKI, increasing the intensity of renal replacement therapy from 50 (HVHF) to 85 mL/kg/h (EHVHF) had no effect on survival at 28 and 90 days.
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Affiliation(s)
- Ping Zhang
- Kidney Disease Centre, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, People’s Republic of China
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Abstract
BACKGROUND Sepsis is increasing in hospitalized patients. Our purpose is to describe its current epidemiology in a general surgery (GS) intensive care unit (ICU) where patients are routinely screened and aggressively treated for sepsis by an established protocol. METHODS Our prospective, Institutional Review Board-approved sepsis research database was queried for demographics, biomarkers reflecting organ dysfunction, and mortality. Patients were grouped as sepsis, severe sepsis, or septic shock using refined consensus criteria. Data are compared by analysis of variance, Student's t test, and χ test (p<0.05 significant). RESULTS During 24 months ending September 2009, 231 patients (aged 59 years ± 3 years; 43% men) were treated for sepsis. The abdomen was the source of infection in 69% of patients. Several baseline biomarkers of organ dysfunction (BOD) correlated with sepsis severity including lactate, creatinine, international normalized ratio, platelet count, and d-dimer. Direct correlation with mortality was noted with particular baseline BODs including beta natriuretic peptide, international normalized ratio, platelet count, aspartate transaminase, alanine aminotransferase, and total bilirubin. Most patients present with severe sepsis (56%) or septic shock (26%) each with increasing multiple BODs. Septic shock has prohibitive mortality rate (36%), and those who survive septic shock have prolonged ICU stays. CONCLUSION In general surgery ICU patients, sepsis is predominantly caused by intra-abdominal infection. Multiple BODs are present in severe sepsis and septic shock but are notably advanced in septic shock. Despite aggressive sepsis screening and treatment, septic shock remains a morbid condition.
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Computer protocol facilitates evidence-based care of sepsis in the surgical intensive care unit. ACTA ACUST UNITED AC 2011; 70:1153-66; discussion 1166-7. [PMID: 21610430 DOI: 10.1097/ta.0b013e31821598e9] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Care of sepsis has been the focus of intense research and guideline development for more than two decades. With ongoing success of computer protocol (CP) technology and with publication of Surviving Sepsis Campaign (SSC) guidelines, we undertook protocol development for management of sepsis of surgical intensive care unit patients in mid-2006. METHODS A sepsis protocol was developed and implemented in The Methodist Hospital (TMH) (Houston, TX) surgical intensive care unit (27 beds) together with a sepsis research database. We compare paper-protocol (PP) (2008) and CP (2009) performance and results of the SSC guideline performance improvement initiative (2005-2008). TMH surgical intensive care unit sepsis protocol was developed to implement best evidence and to standardize decision making among surgical intensivists, nurse practitioners, and resident physicians. RESULTS The 2008 and 2009 sepsis protocol cohorts had very similar number of patients, age, % male gender, Acute Physiology and Chronic Health Evaluation scoring system II, and Sequential Organ Failure Assessment scores. The 2008 PP patients had greater baseline lactate concentration consistent with greater mortality rate. Antibiotic agents were administered to 2009 CP cohort patients sooner than 2008 PP cohort patients. Both cohorts received similar volume of intravenous fluid boluses. Comparing 6-hour resuscitation bundle compliance, the 2009 CP cohort was substantially greater than SSC eighth quarter and 2008 PP cohorts (79% vs. 31% vs. 29%), and mortality rate was much less when using the CP (14% vs. 31% vs. 24%). CONCLUSIONS Our comprehensive sepsis protocol has enabled rapid and consistent implementation of evidence-based care, and, implemented as a bedside CP, contributed to decreased mortality rate for management of surgical sepsis.
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Moore LJ, Moore FA. Early Diagnosis and Evidence-Based Care of Surgical Sepsis. J Intensive Care Med 2011; 28:107-17. [DOI: 10.1177/0885066611408690] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Sepsis continues to be a common and serious problem among surgical patients. It is a leading cause of both morbidity and mortality in the perioperative period. The early identification of sepsis and the early implementation of evidence-based care can improve outcomes. This focused review will identify ways to improve the early identification of sepsis and discuss the current evidence-based guidelines for the early management of sepsis, severe sepsis, and septic shock in the surgical patients.
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Affiliation(s)
- Laura J. Moore
- Department of Surgery, The University of Texas Health Science Center, Houston, USA
| | - Frederick A. Moore
- Department of Surgery, The University of Texas Health Science Center, Houston, USA
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Roy SK, Kendrick D, Sadowitz BD, Gatto L, Snyder K, Satalin JM, Golub LM, Nieman G. Jack of all trades: pleiotropy and the application of chemically modified tetracycline-3 in sepsis and the acute respiratory distress syndrome (ARDS). Pharmacol Res 2011; 64:580-9. [PMID: 21767646 DOI: 10.1016/j.phrs.2011.06.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Sepsis is a disease process that has humbled the medical profession for centuries with its resistance to therapy, relentless mortality, and pathophysiologic complexity. Despite 30 years of aggressive, concerted, well-resourced efforts the biomedical community has been unable to reduce the mortality of sepsis from 30%, nor the mortality of septic shock from greater than 50%. In the last decade only one new drug for sepsis has been brought to the market, drotrecogin alfa-activated (Xigris™), and the success of this drug has been limited by patient safety issues. Clearly a new agent is desperately needed. The advent of recombinant human immune modulators held promise but the outcomes of clinical trials using biologics that target single immune mediators have been disappointing. The complex pathophysiology of the systemic inflammatory response syndrome (SIRS) is self-amplifying and redundant at multiple levels. In this review we argue that perhaps pharmacologic therapy for sepsis will only be successful if it addresses this pathophysiologic complexity; the drug would have to be pleiotropic, working on many components of the inflammatory cascade at once. In this context, therapy that targets any single inflammatory mediator will not adequately address the complexity of SIRS. We propose that chemically modified tetracycline-3, CMT-3 (or COL-3), a non-antimicrobial modified tetracycline with pleiotropic anti-inflammatory properties, is an excellent agent for the management of sepsis and its associated complication of the acute respiratory distress syndrome (ARDS). The purpose of this review is threefold: (1) to examine the shortcomings of current approaches to treatment of sepsis and ARDS in light of their pathophysiology, (2) to explore the application of COL-3 in ARDS and sepsis, and finally (3) to elucidate the mechanisms of COL-3 that may have potential therapeutic benefit in ARDS and sepsis.
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Affiliation(s)
- Shreyas K Roy
- Department of Surgery, Upstate University Hospital, 750 East Adams Street, Syracuse, NY 13210, USA.
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Moore LJ, Turner KL, Todd SR, McKinley B, Moore FA. Computerized clinical decision support improves mortality in intra abdominal surgical sepsis. Am J Surg 2011; 200:839-43; discussion 843-4. [PMID: 21146030 DOI: 10.1016/j.amjsurg.2010.07.036] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Revised: 07/08/2010] [Accepted: 07/08/2010] [Indexed: 10/18/2022]
Abstract
BACKGROUND The management of surgical sepsis is challenging because of the complexity of interventions. The authors therefore created a computerized clinical decision support program to facilitate this process, with the goal of improving abdominal sepsis mortality. METHODS The authors evaluated a prospective database for all patients requiring surgery for abdominal sepsis. Patient demographics, Acute Physiology and Chronic Health Evaluation II score, sepsis source, and hospital mortality data were obtained. Observed mortality was compared with predicted mortality using Fisher's exact test. RESULTS Eighty-seven patients met the inclusion criteria. The average age was 59 ± 17.0 years, and 39% were men. The most common source of infection was the colon (45%). The average Acute Physiology and Chronic Health Evaluation II score was 27.6 ± 9.72. The overall actual mortality rate for the cohort was 24% compared with a predicted Acute Physiology and Chronic Health Evaluation II mortality of 62.5% (P < .0001). CONCLUSION The use of computerized clinical decision support results in significantly improved survival in patients with intra-abdominal surgical sepsis.
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Affiliation(s)
- Laura Jane Moore
- Weill Cornell Medical College, Surgical Critical Care and Acute Care Surgery, Department of Surgery, Houston, TX, USA.
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Sartelli M, Viale P, Koike K, Pea F, Tumietto F, van Goor H, Guercioni G, Nespoli A, Tranà C, Catena F, Ansaloni L, Leppaniemi A, Biffl W, Moore FA, Poggetti R, Pinna AD, Moore EE. WSES consensus conference: Guidelines for first-line management of intra-abdominal infections. World J Emerg Surg 2011; 6:2. [PMID: 21232143 PMCID: PMC3031281 DOI: 10.1186/1749-7922-6-2] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 01/13/2011] [Indexed: 12/11/2022] Open
Abstract
Intra-abdominal infections are still associated with high rate of morbidity and mortality.A multidisciplinary approach to the management of patients with intra-abdominal infections may be an important factor in the quality of care. The presence of a team of health professionals from various disciplines, working in concert, may improve efficiency, outcome, and the cost of care.A World Society of Emergency Surgery (WSES) Consensus Conference was held in Bologna on July 2010, during the 1st congress of the WSES, involving surgeons, infectious disease specialists, pharmacologists, radiologists and intensivists with the goal of defining recommendations for the early management of intra-abdominal infections.This document represents the executive summary of the final guidelines approved by the consensus conference.
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39
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White LE, Chaudhary R, Moore LJ, Moore FA, Hassoun HT. Surgical sepsis and organ crosstalk: the role of the kidney. J Surg Res 2010; 167:306-15. [PMID: 21324390 DOI: 10.1016/j.jss.2010.11.923] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2010] [Revised: 11/19/2010] [Accepted: 11/29/2010] [Indexed: 02/06/2023]
Abstract
Acute kidney injury (AKI) is a common complication of hospitalized patients, and clinical outcomes remain poor despite advances in renal replacement therapy. The accepted pathophysiology of AKI in the setting of sepsis has evolved from one of simple decreased renal blood flow to one that involves a more complex interaction of intra-glomerular microcirculatory vasodilation combined with the local release of inflammatory mediators and apoptosis. Evidence from preclinical AKI models suggests that crosstalk occurs between kidneys and other organ systems via soluble and cellular inflammatory mediators and that this involves both the innate and adaptive immune systems. These interactions are reflected by genomic changes and abnormal rates of cellular apoptosis in distant organs including the lungs, heart, gut, liver, and central nervous system. The purpose of this article is to review the influence of AKI, particularly sepsis-associated AKI, on inter-organ crosstalk in the context of systemic inflammation and multiple organ failure (MOF).
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Affiliation(s)
- Laura E White
- Department of Surgery, The Methodist Hospital and Research Institute, Houston Texas, USA
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