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Lee EH, Lee KH, Lee KN, Park Y, Do Han K, Han SH. The Relation Between Cigarette Smoking and Development of Sepsis: A 10-Year Follow-Up Study of Four Million Adults from the National Health Screening Program. J Epidemiol Glob Health 2024; 14:444-452. [PMID: 38372892 PMCID: PMC11176127 DOI: 10.1007/s44197-024-00197-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 01/17/2024] [Indexed: 02/20/2024] Open
Abstract
BACKGROUND Sepsis remains a growing global health concern with soaring mortality and no direct anti-sepsis drug. Although smoking has distinct deleterious effects on chronic inflammatory illnesses and can impair immune function, a comprehensive analysis of the connection between sepsis and smoking is lacking. METHODS This large-scale longitudinal cohort study retrospectively assessed adults aged ≥ 20 years who underwent national health checkups under the Korean National Health Insurance Service between January and December 2009 (N = 4,234,415) and were followed up for 10 years. Sepsis was identified based on the International Classification of Diseases, 10th Revision codes, and smoking status, including accumulated amount, was collected through a self-administered questionnaire. The Cox proportional hazard regression model was used, adjusting for age, sex, household income, body mass index, drinking, exercise, diabetes, hypertension, dyslipidemia, and chronic renal disease. RESULTS After excluding cases with sepsis occurring before follow-up or after ≤ 1 year of follow-up, 3,881,958 participants, including non-smokers (N = 2,342,841), former smokers (N = 539,850), and active smokers (N = 999,267), were included. Compared to non-smokers, all active smokers (adjust hazard ratio: 1.41, 95% confidence interval 1.38-1.44) and former smokers (1.10, 1.07-1.14) with ≥ 20 pack-years exhibited a significantly higher risk of sepsis (p < 0.001). Smoking of ≥ 30 pack-years in former and active smokers groups significantly increased sepsis incidence (adjust hazard ratio [95% confidence interval] 1.34 [1.31-1.38], p < 0.001). CONCLUSIONS Smoking is closely associated with the incidence of sepsis. Smoking cessation may help in the primary prevention of sepsis.
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Affiliation(s)
- Eun Hwa Lee
- Divison of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Kyoung Hwa Lee
- Divison of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea
| | - Kyu-Na Lee
- Department of Preventive Medicine and Public Health, College of Medicine, Catholic University of Korea, Seoul, Republic of Korea
| | - Yebin Park
- Department of Statistics and Actuarial Science, Soongsil University, 369 Sangdo-ro, Dongjak-gu, Seoul, 06978, Republic of Korea
| | - Kyung Do Han
- Department of Statistics and Actuarial Science, Soongsil University, 369 Sangdo-ro, Dongjak-gu, Seoul, 06978, Republic of Korea.
| | - Sang Hoon Han
- Divison of Infectious Disease, Department of Internal Medicine, Yonsei University College of Medicine, 211 Eonju-ro, Gangnam-gu, Seoul, 06273, Republic of Korea.
- Institute for Innovation in Digital Healthcare, Yonsei University College of Medicine, Seoul, Republic of Korea.
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John KE, Kirkpatrick MM, Aytoda PH, Elefritz JL, Palettas M, Rosales BN, Murphy CV, Doepker BA. The effect of hydrocortisone versus hydrocortisone plus fludrocortisone on duration of shock: A propensity score-weighted analysis. Int J Crit Illn Inj Sci 2024; 14:79-85. [PMID: 39005974 PMCID: PMC11245135 DOI: 10.4103/ijciis.ijciis_66_23] [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] [Received: 11/08/2023] [Revised: 12/31/2023] [Accepted: 01/05/2024] [Indexed: 07/16/2024] Open
Abstract
Background The 2021 Surviving Sepsis Campaign Guidelines recommend the use of hydrocortisone in patients who remain hemodynamically unstable despite adequate fluid resuscitation and vasopressor therapy. Fludrocortisone has been used concomitantly with hydrocortisone in some studies without a clearly defined role or known clinical benefit. The purpose of this study was to assess the impact of fludrocortisone added to hydrocortisone on shock-free days for septic shock. Methods A single-center, retrospective propensity score-weighted study was conducted to compare hydrocortisone versus hydrocortisone plus fludrocortisone for septic shock. Adults admitted to the medical intensive care unit (ICU) from 2015 to 2020 were included in the study. All patients received ≥200 mg/day hydrocortisone for at least 24 h ± fludrocortisone initiated within 72 h of vasopressors. The primary outcome was shock-free days by day 14. The secondary outcomes included duration of shock, change in Sequential Organ Failure Assessment (SOFA) score, hospital and ICU length of stay, and all-cause inhospital mortality. Results A total of 228 patients met inclusion criteria with 212 patients retained after propensity score weighting. There was no difference between groups in 14-day shock-free days (6.3 vs. 6.1 days; P = 0.781). Furthermore, no significant differences were observed for the secondary outcomes of ICU/hospital length of stay, duration of shock, change in SOFA score, and all-cause inhospital mortality. Conclusion The addition of fludrocortisone to hydrocortisone in septic shock did not increase shock-free days by day 14. These results suggest that the use of hydrocortisone alone may be an adequate adjunctive therapy in septic shock. A prospective randomized controlled trial is needed to confirm results.
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Affiliation(s)
- Kayla E. John
- Department of Pharmacy, The University of North Carolina at Chapel Hill Medical Center, Chapel Hill, NC, USA
| | - Megan M. Kirkpatrick
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Priyanka H. Aytoda
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jessica L. Elefritz
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Marilly Palettas
- Department of Biomedical Informatics, Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Brittany N. Rosales
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Claire V. Murphy
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Bruce A. Doepker
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Song Y, Hao J, Liu Y. Role of corticosteroids in the treatment of critically ill sepsis patients: a meta-analysis review. Inflammopharmacology 2024; 32:965-974. [PMID: 38347300 DOI: 10.1007/s10787-023-01426-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 12/27/2023] [Indexed: 04/11/2024]
Abstract
OBJECTIVE It was to systematically evaluate the effect of corticosteroids on 28d all-cause mortality (ACM), in-hospital death rate, and ICU death rate in critically ill sepsis patients. METHODS PubMed, Embase, and Medline databases were used to screen the published literatures on the therapeutic effect of corticosteroids in the treatment of critically ill sepsis patients. After evaluating the quality of the included literatures, RevMan 5.3 software was used for meta-analysis. 4524 literatures regarding the application of corticosteroids to treat critically ill sepsis patients were preliminarily searched. After screening was carried out, 9 literatures were finally included. 2,850 patients were treated with corticosteroids and 2867 patients were treated with placebo. RESULTS The meta-analysis of the effect of corticosteroids versus placebo on 28dACM showed [OR = 0.87, 95% CI 0.78-0.98, Z = 2.22, P = 0.03], P < 0.05; the meta-analysis of the outcome of corticosteroids versus placebo on ICU death rate showed [OR = 0.77, 95% CI 0.63-0.94, Z = 2.60, P = 0.009], P < 0.05; and the meta-analysis of the effect of corticosteroids versus placebo on in-hospital death rate showed [OR = 0.80, 95% CI 0.66-0.96, Z = 2.34, P = 0.002], P < 0.05. CONCLUSION In summary, corticosteroids can reduce the death rate of critically ill sepsis patients to a certain extent and have good clinical application value.
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Affiliation(s)
- Yutong Song
- Department of Emergency/Critical Care Medicine, Children's Hospital of Nanjing Medical University, Nanjing, 210008, Jiangsu, China
| | - Jing Hao
- Department of Emergency/Critical Care Medicine, Children's Hospital of Nanjing Medical University, Nanjing, 210008, Jiangsu, China
| | - Yanhua Liu
- Department of Emergency/Critical Care Medicine, Children's Hospital of Nanjing Medical University, Nanjing, 210008, Jiangsu, China.
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4
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Guan X, Zhong L, Zhang J, Lu J, Yuan M, Ye L, Min J. The relationship between lactate dehydrogenase to albumin ratio and all-cause mortality during ICU stays in patients with sepsis: A retrospective cohort study with propensity score matching. Heliyon 2024; 10:e27560. [PMID: 38496890 PMCID: PMC10944236 DOI: 10.1016/j.heliyon.2024.e27560] [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: 06/15/2023] [Revised: 02/28/2024] [Accepted: 03/01/2024] [Indexed: 03/19/2024] Open
Abstract
Background Sepsis is a prevalent and severe medical condition which is frequently observed in the intensive care unit (ICU). Although numerous biomarkers have been identified to predict the prognosis of sepsis, the lactate dehydrogenase to albumin ratio (LDH/ALB ratio) has not been extensively investigated. The principal objective of this study is to assess the relationship between LDH/ALB ratio and all-cause mortality in patients with sepsis. Methods This study included all adult critically ill patients with sepsis from the Medical Information Mart for Intensive Care IV (MIMIC-IV, version 2.0) database. Propensity score matching (PSM) analysis was conducted to mitigate bias, and Kaplan-Meier curves were performed to evaluate the cumulative survival across different groups. The association between the LDH/ALB ratio and mortality was examined through restricted cubic spline (RCS) analysis and Cox regression analysis. The robustness of the findings was confirmed through subgroup analyses. Additionally, the prognostic capability of the LDH/ALB ratio was further evaluated using receiver operating characteristic (ROC) curve analysis. Results There were 6059 adult patients with sepsis enrolled in the final analysis. RCS revealed a non-linear relationship between the LDH/ALB ratio and an increased risk of ICU all-cause mortality (χ2 = 46.900, P < 0.001). Following PSM analysis, 1553 matched pairs were obtained. As comparison to the low LDH/ALB ratio group, the mortality rate in the high LDH/ALB ratio group was significantly higher (P < 0.001). Kaplan-Meier curves, both before and after PSM, revealed that the ICU cumulative survival rate for patients with sepsis was significantly lower in the high LDH/ALB ratio group compared to the low LDH/ALB ratio group (χ2 = 93.360, P < 0.001; χ2 = 14.400, P < 0.001). Even after adjusting for a range of potential confounders, multivariate Cox regression analysis indicated that an elevated LDH/ALB ratio was a significant predictor of all-cause mortality in these patients. ROC curve analysis demonstrated that the LDH/ALB ratio had an area under the ROC curve (AUC) of 0.688 for predicting ICU mortality, with a sensitivity of 69.2% and a specificity of 58.6%. Conclusions An elevated LDH/ALB ratio (≥10.57) was associated with all-cause mortality in critically ill patients with sepsis, and it might serve as a prognostic marker. Clinicians should pay closer attention to sepsis patients presenting with an LDH/ALB ratio of 10.57 or higher.
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Affiliation(s)
- Xiaoyue Guan
- Department of Hospital-Acquired Infection Control, Huzhou Central Hospital (The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University), Affiliated Central Hospital Huzhou University, Huzhou, 313000, China
| | - Lei Zhong
- Department of Intensive Care Unit, Huzhou Central Hospital (The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University), Affiliated Central Hospital Huzhou University, Huzhou, 313000, China
| | - Jinyu Zhang
- Department of Gastrointestinal Surgery, Huzhou Central Hospital (The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University), Affiliated Central Hospital Huzhou University, Huzhou, 313000, China
| | - Jianhong Lu
- Department of Intensive Care Unit, Huzhou Central Hospital (The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University), Affiliated Central Hospital Huzhou University, Huzhou, 313000, China
| | - Meng Yuan
- Department of Intensive Care Unit, Huzhou Central Hospital (The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University), Affiliated Central Hospital Huzhou University, Huzhou, 313000, China
| | - Lili Ye
- Department of Intensive Care Unit, Huzhou Central Hospital (The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University), Affiliated Central Hospital Huzhou University, Huzhou, 313000, China
| | - Jie Min
- Department of Intensive Care Unit, Huzhou Central Hospital (The Fifth School of Clinical Medicine of Zhejiang Chinese Medical University), Affiliated Central Hospital Huzhou University, Huzhou, 313000, China
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Vadhan JD, Thoppil J, Vasquez O, Suarez A, Bartels B, McDonald S, Courtney DM, Farrar JD, Thakur B. Primary Infection Site as a Predictor of Sepsis Development in Emergency Department Patients. J Emerg Med 2024:S0736-4679(24)00015-5. [PMID: 38849253 DOI: 10.1016/j.jemermed.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/20/2023] [Accepted: 01/06/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Sepsis is a life-threatening condition but predicting its development and progression remains a challenge. OBJECTIVE This study aimed to assess the impact of infection site on sepsis development among emergency department (ED) patients. METHODS Data were collected from a single-center ED between January 2016 and December 2019. Patient encounters with documented infections, as defined by the Systematized Nomenclature of Medicine-Clinical Terms for upper respiratory tract (URI), lower respiratory tract (LRI), urinary tract (UTI), or skin or soft-tissue infections were included. Primary outcome was the development of sepsis or septic shock, as defined by Sepsis-1/2 criteria. Secondary outcomes included hospital disposition and length of stay, blood and urine culture positivity, antibiotic administration, vasopressor use, in-hospital mortality, and 30-day mortality. Analysis of variance and various different logistic regression approaches were used for analysis with URI used as the reference variable. RESULTS LRI was most associated with sepsis (relative risk ratio [RRR] 5.63; 95% CI 5.07-6.24) and septic shock (RRR 21.2; 95% CI 17.99-24.98) development, as well as hospital admission rates (odds ratio [OR] 8.23; 95% CI 7.41-9.14), intensive care unit admission (OR 4.27; 95% CI 3.84-4.74), in-hospital mortality (OR 6.93; 95% CI 5.60-8.57), and 30-day mortality (OR 7.34; 95% CI 5.86-9.19). UTIs were also associated with sepsis and septic shock development, but to a lesser degree than LRI. CONCLUSIONS Primary infection sites including LRI and UTI were significantly associated with sepsis development, hospitalization, length of stay, and mortality among patients presenting with infections in the ED.
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Affiliation(s)
- Jason D Vadhan
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Joby Thoppil
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ofelia Vasquez
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Arlen Suarez
- School of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Brett Bartels
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Samuel McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - D Mark Courtney
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - J David Farrar
- Department of Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bhaskar Thakur
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas; Department of Family Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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Méndez R, Figuerola A, Ramasco F, Chicot M, Pascual NF, García Í, von Wernitz A, Zurita ND, Semiglia A, Pizarro A, Saez C, Rodríguez D. Decrease in Mortality after the Implementation of a Hospital Model to Improve Performance in Sepsis Care: Princess Sepsis Code. J Pers Med 2024; 14:149. [PMID: 38392582 PMCID: PMC10890463 DOI: 10.3390/jpm14020149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
Sepsis is a time-dependent disease whose prognosis is influenced by early diagnosis and therapeutic measures. Mortality from sepsis remains high, and for this reason, the guidelines of the Surviving Sepsis Campaign recommend establishing specific care programs aimed at patients with sepsis. We present the results of the application of a hospital model to improve performance in sepsis care, called Princess Sepsis Code, with the aim of reducing mortality. A retrospective study was conducted using clinical, epidemiological, and outcome variables in patients diagnosed with sepsis from 2015 to 2022. A total of 2676 patients were included, 32% of whom required admission to the intensive care unit, with the most frequent focus of the sepsis being abdominal. Mortality in 2015, at the beginning of the sepsis code program, was 24%, with a declining rate noted over the study period, with mortality reaching 17% in 2022. In the multivariate analysis, age > 70 years, respiratory rate > 22 rpm, deterioration in the level of consciousness, serum lactate > 2 mmol/L, creatinine > 1.6 mg/dL, and the focus of the sepsis were identified as variables independently related to mortality. The implementation of the Princess Sepsis Code care model reduces the mortality of patients exhibiting sepsis and septic shock.
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Affiliation(s)
- Rosa Méndez
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Angels Figuerola
- Department of Preventive Medicine and Public Health, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Fernando Ramasco
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Marta Chicot
- Department of Intensive Care Medicine, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Natalia F Pascual
- Department of Clinical Analysis, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Íñigo García
- Department of General Surgery, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Andrés von Wernitz
- Department of Emergency, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Nelly D Zurita
- Department of Microbiology, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Auxiliadora Semiglia
- Department of Microbiology, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Alberto Pizarro
- Department of Emergency, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Carmen Saez
- Department of Internal Medicine, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Diego Rodríguez
- Department of Intensive Care Medicine, Hospital Universitario Príncipe de Asturias, Avenida Principal de La Universidad s/n, 28805 Madrid, Spain
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7
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Liu D, Langston JC, Prabhakarpandian B, Kiani MF, Kilpatrick LE. The critical role of neutrophil-endothelial cell interactions in sepsis: new synergistic approaches employing organ-on-chip, omics, immune cell phenotyping and in silico modeling to identify new therapeutics. Front Cell Infect Microbiol 2024; 13:1274842. [PMID: 38259971 PMCID: PMC10800980 DOI: 10.3389/fcimb.2023.1274842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 12/18/2023] [Indexed: 01/24/2024] Open
Abstract
Sepsis is a global health concern accounting for more than 1 in 5 deaths worldwide. Sepsis is now defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. Sepsis can develop from bacterial (gram negative or gram positive), fungal or viral (such as COVID) infections. However, therapeutics developed in animal models and traditional in vitro sepsis models have had little success in clinical trials, as these models have failed to fully replicate the underlying pathophysiology and heterogeneity of the disease. The current understanding is that the host response to sepsis is highly diverse among patients, and this heterogeneity impacts immune function and response to infection. Phenotyping immune function and classifying sepsis patients into specific endotypes is needed to develop a personalized treatment approach. Neutrophil-endothelium interactions play a critical role in sepsis progression, and increased neutrophil influx and endothelial barrier disruption have important roles in the early course of organ damage. Understanding the mechanism of neutrophil-endothelium interactions and how immune function impacts this interaction can help us better manage the disease and lead to the discovery of new diagnostic and prognosis tools for effective treatments. In this review, we will discuss the latest research exploring how in silico modeling of a synergistic combination of new organ-on-chip models incorporating human cells/tissue, omics analysis and clinical data from sepsis patients will allow us to identify relevant signaling pathways and characterize specific immune phenotypes in patients. Emerging technologies such as machine learning can then be leveraged to identify druggable therapeutic targets and relate them to immune phenotypes and underlying infectious agents. This synergistic approach can lead to the development of new therapeutics and the identification of FDA approved drugs that can be repurposed for the treatment of sepsis.
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Affiliation(s)
- Dan Liu
- Department of Bioengineering, Temple University, Philadelphia, PA, United States
| | - Jordan C. Langston
- Department of Bioengineering, Temple University, Philadelphia, PA, United States
| | | | - Mohammad F. Kiani
- Department of Bioengineering, Temple University, Philadelphia, PA, United States
- Department of Mechanical Engineering, Temple University, Philadelphia, PA, United States
- Department of Radiation Oncology, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
| | - Laurie E. Kilpatrick
- Center for Inflammation and Lung Research, Department of Microbiology, Immunology and Inflammation, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States
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Orellana G, Josef V, Parchim NF, Mitchell JA. Current state of sepsis resuscitation in critical care. Int Anesthesiol Clin 2023; 61:43-54. [PMID: 37622346 DOI: 10.1097/aia.0000000000000416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/26/2023]
Affiliation(s)
- Gabriela Orellana
- Center for Adult Critical Care, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
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Ahmad S. Capillary Refill Time Versus Sidestream Dark Field: Think Global, Act Local. Crit Care Med 2023; 51:977-978. [PMID: 37318294 DOI: 10.1097/ccm.0000000000005877] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Affiliation(s)
- Salman Ahmad
- Division of Acute Care Surgery, Department of Surgery, University of Missouri Health Care, Columbia, MO
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Liu S, Yao C, Xie J, Liu H, Wang H, Lin Z, Qin B, Wang D, Lu W, Ma X, Liu Y, Liu L, Zhang C, Xu L, Zheng R, Zhou F, Liu Z, Zhang G, Zhou L, Liu J, Fei A, Zhang G, Zhu Y, Qian K, Wang R, Liang Y, Duan M, Wu D, Sun R, Wang Y, Zhang X, Cao Q, Yang M, Jin M, Song Y, Huang L, Zhou F, Chen D, Liang Q, Qian C, Tang Z, Zhang Z, Feng Q, Peng Z, Sun R, Song Z, Sun Y, Chai Y, Zhou L, Cheng C, Li L, Yan X, Zhang J, Huang Y, Guo F, Li C, Yang Y, Shang H, Qiu H. Effect of an Herbal-Based Injection on 28-Day Mortality in Patients With Sepsis: The EXIT-SEP Randomized Clinical Trial. JAMA Intern Med 2023; 183:647-655. [PMID: 37126332 PMCID: PMC10152378 DOI: 10.1001/jamainternmed.2023.0780] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 01/28/2023] [Indexed: 05/02/2023]
Abstract
Importance Previous research has suggested that Xuebijing injection (XBJ), an herbal-based intravenous preparation, may reduce mortality among patients with sepsis. Objective To determine the effect of XBJ vs placebo on 28-day mortality among patients with sepsis. Design, Setting, and Participants The Efficacy of Xuebijing Injection in Patients With Sepsis (EXIT-SEP) trial was a multicenter, randomized double-blind, placebo-controlled trial conducted in intensive care units at 45 sites and included 1817 randomized patients with sepsis (sepsis 3.0) present for less than 48 hours. Patients aged 18 to 75 years with a Sequential Organ Failure Assessment score of 2 to 13 were enrolled. The study was conducted from October 2017 to June 2019. The final date of follow-up was July 26, 2019. Data analysis was performed from January 2020 to August 2022. Interventions The patients were randomized to receive either intravenous infusion of XBJ (100 mL, n = 911) or volume-matched saline placebo (n = 906) every 12 hours for 5 days. Main Outcomes and Measures The primary outcome was 28-day mortality. Results Among the 1817 patients who were randomized (mean [SD] age, 56.5 [13.5] years; 1199 [66.0%] men), 1760 (96.9%) completed the trial. In these patients, the 28-day mortality rate was significantly different between the placebo group and the XBJ group (230 of 882 patients [26.1%] vs 165 of 878 patients [18.8%], respectively; P < .001). The absolute risk difference was 7.3 (95% CI, 3.4-11.2) percentage points. The incidence of adverse events was 222 of 878 patients (25.3%) in the placebo group and 200 of 872 patients (22.9%) in the XBJ group. Conclusions and Relevance In this randomized clinical trial among patients with sepsis, the administration of XBJ reduced 28-day mortality compared with placebo. Trial Registration ClinicalTrials.gov Identifier: NCT03238742.
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Affiliation(s)
- Songqiao Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Chen Yao
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Jianfeng Xie
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Hong Liu
- Department of Critical Care Medicine, The First Hospital of Shanxi Medical University, Taiyuan, Shanxi, China
| | - Hongliang Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Zhaofen Lin
- Department of Emergency and Critical Care, Shanghai Changzheng Hospital, Shanghai, China
| | - Bingyu Qin
- Department of Critical Care Medicine, Henan Provincial People’s Hospital, Zhengzhou, Henan, China
| | - Difen Wang
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Weihua Lu
- Department of Critical Care Medicine, Yijishan Hospital, The First Affiliated Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Xiaochun Ma
- Department of Critical Care Medicine, The First Affiliated Hospital, China Medical University, Shenyang, Liaoning, China
| | - Yan Liu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Ling Liu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Chi Zhang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Lei Xu
- Department of Critical Care Medicine, Tianjin Third Central Hospital, Tianjin, China
| | - Ruiqiang Zheng
- Department of Critical Care Medicine, Northern Jiangsu People’s Hospital, Yangzhou, Jiangsu, China
| | - Feihu Zhou
- Department of Critical Care Medicine, Chinese PLA General Hospital, Beijing, China
| | - Zhongmin Liu
- Department of Critical Care Medicine, The First Hospital of Jilin University, Changchun, Jilin, China
| | - Guoqiang Zhang
- Department of Emergency, China-Japan Friendship Hospital, Beijing, China
| | - Lixin Zhou
- Department of Critical Care Medicine, First People’s Hospital of Foshan, Foshan, Guangdong, China
| | - Jian Liu
- Department of Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Aihua Fei
- Department of Emergency, Xinhua Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Guoxiu Zhang
- Department of Emergency, The First Affiliated Hospital of Henan Science and Technology University, Luoyang, Henan, China
| | - Yimin Zhu
- Hunan Provincial Institute of Emergency Medicine, Hunan Provincial People’s Hospital, Changsha, Hunan, China
| | - Kejian Qian
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Ruilan Wang
- Department of Emergency, Shanghai General Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Yafeng Liang
- Department of Critical Care Medicine, Yantai Yuhuangding Hospital of Qingdao University, Yantai, Shandong, China
| | - Meili Duan
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Dawei Wu
- Department of Critical Care Medicine, Qilu Hospital of Shandong University (Qingdao), Qingdao, Shandong, China
| | - Rongqing Sun
- Department of Critical Care Medicine, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ying Wang
- Department of Respiration, Chinese PLA General Hospital of Rocket Forces, Beijing, China
| | - Xijing Zhang
- Department of Anesthesiology, Xijing Hospital, Xi'an, Shaanxi, China
| | - Quan Cao
- Department of Critical Care Medicine, Jiangsu Province Hospital, Nanjing, Jiangsu, China
| | - Mingshi Yang
- Department of Critical Care Medicine, The Third Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Minggen Jin
- Department of Critical Care Medicine, Yanbian University Hospital, Yanji, Jilin, China
| | - Yan Song
- Department of Critical Care Medicine, Central Hospital of Shenyang Medical College, Shenyang, Liaoning, China
| | - Ling Huang
- Department of Critical Care Medicine, Yantaishan Hospital, Yantai, Shandong, China
| | - Fachun Zhou
- Department of Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Dechang Chen
- Department of Critical Care Medicine, Ruijin North Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Qun Liang
- Department of Critical Care Medicine, First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, Heilongjiang, China
| | - Chuanyun Qian
- Department of Emergency, First Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Zhongzhi Tang
- Department of Emergency, Chinese PLA Wuhan General Hospital, Wuhan, Hubei, China
| | - Zhong Zhang
- Department of Critical Care Medicine, Shenzhen Traditional Chinese Medicine Hospital, Shenzhen, Guangdong, China
| | - Qiming Feng
- Department of Emergency, Shanghai Sixth People’s Hospital, Shanghai, China
| | - Zhiyong Peng
- Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Renhua Sun
- Department of Critical Care Medicine, Zhejiang Provincial People’s Hospital, Hangzhou, Zhejiang, China
| | - Zhenju Song
- Department of Emergency, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yunbo Sun
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, Shandong, China
| | - Yanfen Chai
- Department of Emergency, Tianjin Medical University General Hospital, Tianjin, China
| | - Lihua Zhou
- Department of Critical Care Medicine, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, Inner Mongolia, China
| | - Chen Cheng
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Zhangjiang Hi-Tech Park, Shanghai, China
| | - Li Li
- First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, China
| | - Xiaoyan Yan
- Peking University Clinical Research Institute, Peking University First Hospital, Beijing, China
| | - Junhua Zhang
- Evidence-Based Medicine Center, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yingzi Huang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Fengmei Guo
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Chuan Li
- State Key Laboratory of Drug Research, Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Zhangjiang Hi-Tech Park, Shanghai, China
| | - Yi Yang
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
| | - Hongcai Shang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education and Beijing, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
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Bezati S, Velliou M, Ventoulis I, Simitsis P, Parissis J, Polyzogopoulou E. Infection as an under-recognized precipitant of acute heart failure: prognostic and therapeutic implications. Heart Fail Rev 2023:10.1007/s10741-023-10303-8. [PMID: 36897491 PMCID: PMC9999079 DOI: 10.1007/s10741-023-10303-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 03/11/2023]
Abstract
As the prevalence of heart failure (HF) continues to rise, prompt diagnosis and management of various medical conditions, which may lead to HF exacerbation and result in poor patient outcomes, are of paramount importance. Infection has been identified as a common, though under-recognized, precipitating factor of acute heart failure (AHF), which can cause rapid development or deterioration of HF signs and symptoms. Available evidence indicates that infection-related hospitalizations of patients with AHF are associated with higher mortality, protracted length of stay, and increased readmission rates. Understanding the intricate interaction of both clinical entities may provide further therapeutic strategies to prevent the occurrence of cardiac complications and improve prognosis of patients with AHF triggered by infection. The purpose of this review is to investigate the incidence of infection as a causative factor in AHF, explore its prognostic implications, elucidate the underlying pathophysiological mechanisms, and highlight the basic principles of the initial diagnostic and therapeutic interventions in the emergency department.
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Affiliation(s)
- Sofia Bezati
- Emergency Medicine Department, Attikon University Hospital, Rimini 1, Chaidari, 12462, Athens, Greece.
| | - Maria Velliou
- Emergency Medicine Department, Attikon University Hospital, Rimini 1, Chaidari, 12462, Athens, Greece
| | - Ioannis Ventoulis
- Department of Occupational Therapy, University of Western Macedonia, Keptse Area, Ptolemaida, 50200, Greece
| | - Panagiotis Simitsis
- National and Kapodistrian University of Athens, 2nd Department of Cardiology, Heart Failure Unit, Attikon University Hospital, Athens, Greece
| | - John Parissis
- Emergency Medicine Department, Attikon University Hospital, Rimini 1, Chaidari, 12462, Athens, Greece.,Emergency Medicine Department, National and Kapodistrian University of Athens, Athens, Greece
| | - Effie Polyzogopoulou
- Emergency Medicine Department, Attikon University Hospital, Rimini 1, Chaidari, 12462, Athens, Greece.,Emergency Medicine Department, National and Kapodistrian University of Athens, Athens, Greece
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12
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Asllanaj B, Benge E, Bae J, McWhorter Y. Fluid management in septic patients with pulmonary hypertension, review of the literature. Front Cardiovasc Med 2023; 10:1096871. [PMID: 36937900 PMCID: PMC10017881 DOI: 10.3389/fcvm.2023.1096871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Accepted: 02/07/2023] [Indexed: 03/06/2023] Open
Abstract
The management of sepsis in patients with pulmonary hypertension (PH) is challenging due to significant conflicting goals of management and complex hemodynamics. As PH progresses, the ability of right heart to perfuse lungs at a normal central venous pressure (CVP) is impaired. Elevated pulmonary vascular pressure, due to pulmonary vasoconstriction and vascular remodeling, opposes blood flow through lungs thus limiting the ability of right ventricle (RV) to increase cardiac output (CO) and maintain adequate oxygen delivery to tissue. In sepsis without PH, avoidance of volume depletion with intravascular volume replacement, followed by vasopressor therapy if hypoperfusion persists, remains the cornerstone of therapy. Intravenous fluid (IVF) resuscitation based on individualized hemodynamic assessment can help improve the prognosis of critically ill patients. This is accomplished by optimizing CO by maintaining adequate preload, afterload and contractility. Particular challenges in patients with PH include RV failure as a result of pressure and volume overload, gas exchange abnormalities, and managing IVF and diuretic use. Suggested approaches to remedy these difficulties include early recognition of symptoms associated with pressure and volume overload, intravascular volume management strategies and serial lab monitoring to assess electrolytes and renal function.
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Affiliation(s)
- Blerina Asllanaj
- Department of Internal Medicine, HCA Healthcare, MountainView Hospital, Las Vegas, NV, United States
| | - Elizabeth Benge
- Department of Internal Medicine, HCA Healthcare, MountainView Hospital, Las Vegas, NV, United States
| | - Jieun Bae
- Kirk Kerkorian School of Medicine at UNLV, Las Vegas, NV, United States
| | - Yi McWhorter
- Department of Critical Care Medicine, HCA Healthcare, MountainView Hospital, Las Vegas, NV, United States
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13
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Li Y, He X, Li Z, Li D, Yuan X, Yang J. Construction and dual internal validation of a short-term prognostic scoring tool for sepsis. Heliyon 2023; 9:e14941. [PMID: 37025776 PMCID: PMC10070133 DOI: 10.1016/j.heliyon.2023.e14941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 03/15/2023] [Accepted: 03/22/2023] [Indexed: 03/30/2023] Open
Abstract
Background To construct and validate a simple and easily administered scoring tool for the prediction of short-term prognostic survival in adult patients with sepsis. Methods This study is a retrospective and prospective cohort study. A total of 382 patients with sepsis. 274 sepsis patients from January 2020 to December 2020 were collected as the modeling group and 54 sepsis patients from January 2021 to December 2021 and April to May 2022 in the hospital were randomly collected as the validation group. They were divided into survival and non-survival groups according to the outcome. The receiver operating characteristic (ROC) curves were plotted with subgroup analysis. The resulting models were tested using the Hosmer-Lemeshow test. The prognostic value of the variables on prognosis was expressed using the area under the receiver operating characteristic curve (AUC). A scoring tool was constructed and tested for the prognostic value of this score in the validation group. Results The model had an AUC of 0.880 [95% CI (0.838-0.922), P < 0.001], model sensitivity of 81.15%, and specificity of 80.26% for predicting short-term prognosis in patients with sepsis. Further simplifying the model scoring rules and adding the lactate variable, the AUCs was 0.876 [95% CI (0.833-0.918)], P < 0.001], sensitivity was 78.69%, specificity was 82.89%, and scoring criteria were established. the AUCs of the internally validated model in 2021 and 2022 were 0.968 [95% CI (0.916 to 1.000), P < 0.001] and 0.943 [95% CI (0.873 to 1.000), P < 0.001], indicating that the constructed scoring tool has a good predictive value for short-term survival outcomes in patients with sepsis. Conclusions Age, shock, lactate, lactate/albumin ratio (L/A), and interleukin-6 (IL-6) are five risk factors for adult sepsis prognosis in an early emergency. This scoring tool is developed to quickly assess the short-term survival outcome in adult sepsis patients. It is straightforward and easy to administer. It also has a high prognostic predictive value.The Chinese Clinical Trial Registry (ChiCTR2200058375).
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14
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Risk Factors for Mortality in Sepsis Patients without Lactate Levels Increasing Early. Emerg Med Int 2023; 2023:6620157. [PMID: 36875806 PMCID: PMC9984259 DOI: 10.1155/2023/6620157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/26/2023] Open
Abstract
Objectives Our purpose was to investigate the influencing factors for mortality in sepsis patients without lactate levels increasing in the early stage. Methods We conducted a retrospective observational study involving 830 adult sepsis patients admitted to ICU. We calculated time-weighted lactate (LacTW), a dynamic value that incorporates both the magnitude of change and the time interval of such change, to represent lactate levels in the first 24 hours. ROC curve was used to find the cutoff of LacTW for predicting mortality, and the influencing factors for lactate levels and mortality in the low lactate group were further studied. The primary outcome was hospital mortality. Results Among 830 patients, LacTW > 1.975 mmo/L was found to be the cutoff threshold for predicting mortality (AUC = 0.646, P < 0.001). The following indexes related to organ dysfunction influenced LacTW: acute physiology and chronic health evaluation II (APACHE II) score (P < 0.001), activated partial thromboplastin time (APTT) (P = 0.002), total bilirubin (P = 0.012), creatinine (P = 0.037), with hypotension (P < 0.001), chronic kidney disease (P = 0.013), and required continuous renal replacement therapy (CRRT) (P < 0.001). Of the 394 patients in the low lactate group, age (P = 0.002), malignancy (P < 0.001), lactate dehydrogenase (P = 0.006), required treatment such as mechanical ventilation (P < 0.001), CRRT (P < 0.001), vasoactive drugs (P < 0.001), and glucocorticoid (P < 0.001), and failure to reach the target fluid resuscitation of 30 ml/kg within 6 hours (P = 0.003) were independently associated with hospital mortality. Conclusions Due to the lower incidence of early organ dysfunction, lactate levels are not increased or delayed in some septic shock patients in the early stage, thus affecting the alertness of clinicians and the timeliness and adequacy of fluid resuscitation, and finally affects the prognosis.
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15
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Min J, Lu J, Zhong L, Yuan M, Xu Y. The correlation study between blood urea nitrogen to serum albumin ratio and prognosis of patients with sepsis during hospitalization. BMC Anesthesiol 2022; 22:404. [PMID: 36577937 PMCID: PMC9795581 DOI: 10.1186/s12871-022-01947-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 12/16/2022] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Sepsis is a common critical illness in intensive care unit (ICU) and seriously threatens the life of patients. Therefore, to identify a simple and effective clinical indicator to determine prognosis is essential for the management of sepsis patients. This study was mainly based on blood urea nitrogen to albumin ratio (B/A), a comprehensive index, to explore its correlation with the prognosis of sepsis patients during hospitalization. METHODS Totally, adult patients in ICU who were diagnosed with sepsis in Medical Information Mart for Intensive Care IV(MIMIC-IV) database from 2008 to 2019 were involved in this study. The study population were divided into survivors group and non-survivors group based on the prognosis during hospitalization. Restricted cubic spline (RCS) was utilized to analyze the association between B/A level and the risk of ICU all-cause mortality in patients with sepsis and determine the optimal cut-off value of B/A. The study population was divided into low B/A group and high B/A group based on the optimal cut-off value. The survival curve of ICU cumulative survival rate was draw through Kaplan-Meier method. The correlation between B/A and the prognosis of patients was conducted by multivariate Cox regression analysis. Furthermore, we performed sensitivity analyses to assess the robustness of the results. RESULTS A total of 10,578 patients with sepsis were enrolled, and the ICU all-cause mortality was 15.89%. The patients in the non-survivors group had higher B/A values and more comorbidities than those in the survivors group. RCS showed that the risk of ICU all-cause mortality increased with the B/A level, showing a non-linear trend (χ2 = 66.82, p < 0.001). The mortality rate in the high B/A group was significantly higher than that in the low B/A group (p < 0.001). Kaplan-Meier curves revealed that compared with the low B/A group, the ICU cumulative survival rate of patients with sepsis was significantly lower in the high B/A group (log-rank test, χ2 = 148.620, p < 0.001). Further analysis of multivariate Cox proportional hazards regression showed that an elevated B/A (≥ 7.93) was an independent factor associated with ICU mortality among patients with sepsis. CONCLUSIONS An elevated B/A might be a useful prognostic indicator in patients with sepsis. This study could offer a deeper insight into treating sepsis.
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Affiliation(s)
- Jie Min
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Central Hospital, Huzhou University, Huzhou, 313000 Zhejiang Province China
| | - Jianhong Lu
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Central Hospital, Huzhou University, Huzhou, 313000 Zhejiang Province China
| | - Lei Zhong
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Central Hospital, Huzhou University, Huzhou, 313000 Zhejiang Province China
| | - Meng Yuan
- Department of Intensive Care Unit, Huzhou Central Hospital, Affiliated Central Hospital, Huzhou University, Huzhou, 313000 Zhejiang Province China
| | - Yin Xu
- Department of General Practice, Huzhou Central Hospital, Affiliated Central Hospital, Huzhou University, No.1558, North Sanhuan Road, Huzhou, 313000 Zhejiang Province China
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Muacevic A, Adler JR, Al Mehmadi AE, Aldawood SM, Hawsawi A, Fatini F, Mulla ZM, Nawwab W, Alshareef A, Almhmadi AH, Ahmed A, Bokhari A, Alzahrani AG. Septic Shock: Management and Outcomes. Cureus 2022; 14:e32158. [PMID: 36601152 PMCID: PMC9807186 DOI: 10.7759/cureus.32158] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2022] [Indexed: 12/07/2022] Open
Abstract
The incidence rates of sepsis and septic shock as a complication have become more common over the past several decades. With this increase, sepsis remains the most common cause of intensive care unit (ICU) admissions and one of the most mortality factors, with a huge burden on healthcare facilities. Septic shock has devastating consequences on patients' lives, including organ failures and other long-term complications. Due to its dynamic clinical presentations, guidelines and tools have been established to improve the diagnosis and management effectively. However, there is still a need for evidence-based standardized procedures for the diagnosis, treatment, and follow-up of sepsis and septic shock patients due to the inconsistency of current guidelines and studies contrasting with each other. The standardization would help physicians better manage sepsis, minimize complications and reduce mortality. Septic shock is usually challenging to manage due to its variety of clinical characteristics and physiologic dynamics, affecting the outcomes. Therefore, this review presented the available data in the literature on septic shock diagnosis, management, and prognosis to have an overview of the updated best practice approach to septic shock.
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17
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Argaiz ER, Rola P, Haycock KH, Verbrugge FH. Fluid management in acute kidney injury: from evaluating fluid responsiveness towards assessment of fluid tolerance. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:786-793. [PMID: 36069621 DOI: 10.1093/ehjacc/zuac104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 08/23/2022] [Indexed: 06/15/2023]
Abstract
Despite the widespread use of intravenous fluids in acute kidney injury (AKI), solid evidence is lacking. Intravenous fluids mainly improve AKI due to true hypovolaemia, which is difficult to discern at the bedside unless it is very pronounced. Empiric fluid resuscitation triggered only by elevated serum creatinine levels or oliguria is frequently misguided, especially in the presence of fluid intolerance syndromes such as increased extravascular lung water, capillary leak, intra-abdominal hypertension, and systemic venous congestion. While fluid responsiveness tests clearly identify patients who will not benefit from fluid administration (i.e. those without an increase in cardiac output), the presence of fluid responsiveness does not guarantee that fluid therapy is indicated or even safe. This review calls for more attention to the concept of fluid tolerance, incorporating it into a practical algorithm with systematic venous Doppler ultrasonography assessment to use at the bedside, thereby lowering the risk of detrimental kidney congestion in AKI.
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Affiliation(s)
- Eduardo R Argaiz
- Department of Nephrology and Mineral Metabolism, National Institute of Medical Sciences and Nutrition Salvador Zubirán, Mexico City, Mexico
| | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, Montréal, QC, Canada
| | - Korbin H Haycock
- Department of Emergency Medicine, Loma Linda University Health, Loma Linda, CA, USA
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
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18
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Zhou J, Luo XY, Chen GQ, Li HL, Xu M, Liu S, Yang YL, Shi G, Zhou JX, Zhang L. Incidence, Risk Factors and Outcomes of Sepsis in Critically Ill Post-craniotomy Patients: A Single-Center Prospective Cohort Study. Front Public Health 2022; 10:895991. [PMID: 35655465 PMCID: PMC9152261 DOI: 10.3389/fpubh.2022.895991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
Background Data concerning the epidemiology of sepsis in critically ill post-craniotomy patients are scarce. This study aimed to assess the incidence, risk factors, and outcomes of sepsis in this population. Methods This was a single-center prospective cohort study. Post-craniotomy patients admitted to the intensive care unit (ICU) were screened daily for the presence of infection and sepsis. Results Of the 900 included patients, 300 developed sepsis. The cumulative incidence of sepsis was 33.3% [95% confidence interval (CI), 30.2–36.4%]. Advanced age, male, hypertension, trauma, postoperative intracranial complications, and lower Glasgow Coma Scale (GCS) on the first postoperative day were independent risk factors of sepsis. Septic patients had higher hospital mortality (13.7 vs. 8.3%, P = 0.012), longer ICU length of stay (LOS) (14 vs. 4 days, P < 0.001), longer hospital LOS (31 vs. 19 days, P < 0.001), and higher total medical cost (CNY 138,394 vs. 75,918, P < 0.001) than patients without sepsis. Conclusion Sepsis is a frequent complication in critically ill post-craniotomy patients. Advanced age, male, hypertension, trauma, postoperative intracranial complications, and lower GCS on the first postoperative day were independent risk factors of sepsis.
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Affiliation(s)
- Jianfang Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu-Ying Luo
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hong-Liang Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Xu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuai Liu
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Guijo Gonzalez P, Gracia Romero MA, Gil Cano A, Garcia Rojo M, Cecconi M, Monge Garcia IM. Hemodynamic resuscitation with fluids bolus and norepinephrine increases severity of lung damage in an experimental model of septic shock. Med Intensiva 2021; 45:532-540. [PMID: 34839884 DOI: 10.1016/j.medine.2020.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 05/18/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Hemodynamic resuscitation is considered a cornerstone of the initial treatment of septic shock. However, there is growing concern about its side effects. Our objective was to assess the relationship between fluid administration and norepinephrine infusion and the development of lung injury. DESIGN Randomized in vivo study in rabbits. SETTING University animal research laboratory. PATIENTS Eighteen New Zealand rabbits. Control group (SHAM, n=6), Sepsis group with or without hemodynamic resuscitation (ETX-R, n=6; ETX-NR, n=6). INTERVENTIONS Sepsis was induced by intravenous lipopolysaccharide administration and animals were followed-up for 4h. Hemodynamic resuscitation with Ringer lactate (20mL·kg-1) was administered and later norepinephrine was initiated 3h after sepsis induction. At the end, the left lung was excised. MAIN VARIABLES OF INTEREST An indwelling arterial catheter and an esophageal Doppler were placed. Lung mechanics were monitored with side stream spirometry. Lung damage was analyzed by histopathological examination. RESULTS The SHAM group did not show hemodynamic or respiratory changes. Lipopolysaccharide administration aimed an increase in cardiac output and arterial hypotension. In the ETX-NR group, animals remained hypotensive until the end of the experiment. Resuscitation with fluids and norepinephrine reversed arterial hypotension. Compared to the ETX-NR group, the remaining lung of the ETX-R group showed greater accumulation of neutrophils and reactive type-II pneumocytes, thicker alveolar wall, alveolar hemorrhage and non-aerated pulmonary areas. Lung injury score was larger in the ETX-R group. CONCLUSIONS In our experimental study, following a strategy with bolus fluids and late norepinephrine used in the early phase of endotoxic septic shock has a negative influence on the development of lung injury.
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Affiliation(s)
- P Guijo Gonzalez
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain; Research Group in Critical Disorders (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; Critical Care Department, Hospital del Mar, Barcelona, Spain.
| | - M A Gracia Romero
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain
| | - A Gil Cano
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain
| | - M Garcia Rojo
- Derpartment of Pathology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - M Cecconi
- Department of Anaesthesia and Intensive Care, IRCCS Instituto Clínico Humanitas, Humanitas University, Milan, Italy
| | - I M Monge Garcia
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain
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Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Crit Care Med 2021; 49:e1063-e1143. [PMID: 34605781 DOI: 10.1097/ccm.0000000000005337] [Citation(s) in RCA: 852] [Impact Index Per Article: 284.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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21
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Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C, Simpson S, Wiersinga WJ, Alshamsi F, Angus DC, Arabi Y, Azevedo L, Beale R, Beilman G, Belley-Cote E, Burry L, Cecconi M, Centofanti J, Coz Yataco A, De Waele J, Dellinger RP, Doi K, Du B, Estenssoro E, Ferrer R, Gomersall C, Hodgson C, Møller MH, Iwashyna T, Jacob S, Kleinpell R, Klompas M, Koh Y, Kumar A, Kwizera A, Lobo S, Masur H, McGloughlin S, Mehta S, Mehta Y, Mer M, Nunnally M, Oczkowski S, Osborn T, Papathanassoglou E, Perner A, Puskarich M, Roberts J, Schweickert W, Seckel M, Sevransky J, Sprung CL, Welte T, Zimmerman J, Levy M. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med 2021; 47:1181-1247. [PMID: 34599691 PMCID: PMC8486643 DOI: 10.1007/s00134-021-06506-y] [Citation(s) in RCA: 1390] [Impact Index Per Article: 463.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Accepted: 08/05/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Laura Evans
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, WA, USA.
| | - Andrew Rhodes
- Adult Critical Care, St George's University Hospitals NHS Foundation Trust & St George's University of London, London, UK
| | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Massimo Antonelli
- Dipartimento di Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Flávia R Machado
- Anesthesiology, Pain and Intensive Care Department, Federal University of São Paulo, Hospital of São Paulo, São Paulo, Brazil
| | | | | | - Hallie C Prescott
- University of Michigan and VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | | | - Steven Simpson
- University of Kansas Medical Center, Kansas City, KS, USA
| | - W Joost Wiersinga
- ESCMID Study Group for Bloodstream Infections, Endocarditis and Sepsis, Division of Infectious Diseases, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, Emirates University, Al Ain, United Arab Emirates
| | - Derek C Angus
- University of Pittsburgh Critical Care Medicine CRISMA Laboratory, Pittsburgh, PA, USA
| | - Yaseen Arabi
- Intensive Care Department, Ministry of National Guard Health Affairs, King Abdullah International Medical Research Center, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Luciano Azevedo
- School of Medicine, University of Sao Paulo, São Paulo, Brazil
| | | | | | | | - Lisa Burry
- Mount Sinai Hospital & University of Toronto (Leslie Dan Faculty of Pharmacy), Toronto, ON, Canada
| | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University Pieve Emanuele, Milan, Italy.,Department of Anaesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - John Centofanti
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
| | - Angel Coz Yataco
- Lexington Veterans Affairs Medical Center/University of Kentucky College of Medicine, Lexington, KY, USA
| | | | | | - Kent Doi
- The University of Tokyo, Tokyo, Japan
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Beijing, China
| | - Elisa Estenssoro
- Hospital Interzonal de Agudos San Martin de La Plata, Buenos Aires, Argentina
| | - Ricard Ferrer
- Intensive Care Department, Vall d'Hebron University Hospital, Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | | | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | | | - Shevin Jacob
- Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Michael Klompas
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, MA, USA
| | - Younsuck Koh
- ASAN Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Anand Kumar
- University of Manitoba, Winnipeg, MB, Canada
| | - Arthur Kwizera
- Makerere University College of Health Sciences, Kampala, Uganda
| | - Suzana Lobo
- Intensive Care Division, Faculdade de Medicina de São José do Rio Preto, São Paulo, Brazil
| | - Henry Masur
- Critical Care Medicine Department, NIH Clinical Center, Bethesda, MD, USA
| | | | | | - Yatin Mehta
- Medanta the Medicity, Gurugram, Haryana, India
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Mark Nunnally
- New York University School of Medicine, New York, NY, USA
| | - Simon Oczkowski
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Tiffany Osborn
- Washington University School of Medicine, St. Louis, MO, USA
| | | | | | - Michael Puskarich
- University of Minnesota/Hennepin County Medical Center, Minneapolis, MN, USA
| | - Jason Roberts
- Faculty of Medicine, University of Queensland Centre for Clinical Research, The University of Queensland, Brisbane, Australia.,Department of Pharmacy, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Division of Anaesthesiology Critical Care Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | | | | | | | - Charles L Sprung
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.,Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center, Jerusalem, Israel
| | - Tobias Welte
- Medizinische Hochschule Hannover and German Center of Lung Research (DZL), Hannover, Germany
| | - Janice Zimmerman
- World Federation of Intensive and Critical Care, Brussels, Belgium
| | - Mitchell Levy
- Warren Alpert School of Medicine at Brown University, Providence, Rhode Island & Rhode Island Hospital, Providence, RI, USA
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Valeanu L, Bubenek-Turconi SI, Ginghina C, Balan C. Hemodynamic Monitoring in Sepsis-A Conceptual Framework of Macro- and Microcirculatory Alterations. Diagnostics (Basel) 2021; 11:1559. [PMID: 34573901 PMCID: PMC8469937 DOI: 10.3390/diagnostics11091559] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 08/22/2021] [Accepted: 08/26/2021] [Indexed: 12/29/2022] Open
Abstract
Circulatory failure in sepsis is common and places a considerable burden on healthcare systems. It is associated with an increased likelihood of mortality, and timely recognition is a prerequisite to ensure optimum results. While there is consensus that aggressive source control, adequate antimicrobial therapy and hemodynamic management constitute crucial determinants of outcome, discussion remains about the best way to achieve each of these core principles. Sound cardiovascular support rests on tailored fluid resuscitation and vasopressor therapy. To this end, an overarching framework to improve cardiovascular dynamics has been a recurring theme in modern critical care. The object of this review is to examine the nature of one such framework that acknowledges the growing importance of adaptive hemodynamic support combining macro- and microhemodynamic variables to produce adequate tissue perfusion.
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Affiliation(s)
- Liana Valeanu
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Serban-Ion Bubenek-Turconi
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
- Department of Anesthesiology and Intensive Care, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Carmen Ginghina
- 3rd Department of Cardiology, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania;
- Department of Cardiology, University of Medicine and Pharmacy “Carol Davila”, 8 Eroii Sanitari Blvd, 050474 Bucharest, Romania
| | - Cosmin Balan
- 1st Department of Cardiovascular Anesthesiology and Intensive Care, “Prof. C. C. Iliescu” Emergency Institute for Cardiovascular Diseases, 258 Fundeni Road, 022328 Bucharest, Romania; (L.V.); (S.-I.B.-T.)
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23
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Feng J, Liu L, He Y, Wang M, Zhou D, Wang J. Novel insights into the pathogenesis of virus-induced ARDS: review on the central role of the epithelial-endothelial barrier. Expert Rev Clin Immunol 2021; 17:991-1001. [PMID: 34224287 DOI: 10.1080/1744666x.2021.1951233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: Respiratory viruses can directly or indirectly damage the pulmonary defense barrier, potentially contributing to acute respiratory distress syndrome (ARDS). Despite developments in the understanding of the pathogenesis of ARDS, the underlying pathophysiology still needs to be elucidated.Areas covered: The PubMed database was reviewed for relevant papers published up to 2021. This review summarizes the currently immunological and clinical studies to provide a systemic overview of the epithelial-endothelial barrier, given the recently published immunological profiles upon viral pneumonia, and the potentially detrimental contribution to respiratory function caused by damage to this barrier.Expert opinion: The biophysical structure of host pulmonary defense is intrinsically linked with the ability of alveolar epithelial and capillary endothelial cells, known as the epithelial-endothelial barrier, to respond to, and instruct the delicate immune system to protect the lungs from infections and injuries. Recently published immunological profiles upon viral infection, and its contributions to the damage of respiratory function, suggest a central role for the pulmonary epithelial and endothelial barrier in the pathogenesis of ARDS. We suggest a central role and common pathways by which the epithelial-endothelial barrier contributes to the pathogenesis of ARDS.
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Affiliation(s)
- Jun Feng
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lina Liu
- Department of Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yang He
- Department of Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Min Wang
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Daixing Zhou
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Junshuai Wang
- Department of Critical Care Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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25
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Time of dissociation between microcirculation, macrocirculation, and lactate levels in a rabbit model of early endotoxemic shock. Chin Med J (Engl) 2021; 133:2153-2160. [PMID: 32826608 PMCID: PMC7508437 DOI: 10.1097/cm9.0000000000000887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background The relationship between macrocirculation and microcirculation remains controversial. The loss of coherence between microcirculation and macrocirculation has already been found in late-stage sepsis shock. The objective of this study was to determine the earliest possible time of detecting the loss of coherence between microcirculation and macrocirculation in early-stage endotoxemic shock. Methods We randomized 24 female New Zealand white rabbits into two groups: endotoxemic shock group (n = 14) and control group (n = 10). Rabbits in the endotoxemic shock group were equipped with arterial and venous catheters and received an intravenous infusion of Escherichia coli lipopolysaccharide (LPS, 2 mg/kg over 10 min). Rabbits in the control group received the same dose of saline infusion. Microcirculatory perfusion parameters were assessed in the sublingual mucosa using sidestream dark-field video microscopy. Systemic hemodynamics and blood lactate levels were measured at baseline and over a 120-min period. Results Ninety minutes after completing LPS infusion, all animals in the endotoxemic shock group developed a hypodynamic septic condition, characterized by low cardiac output and increased systemic vascular resistance; 120 min after completing LPS infusion, the mean arterial pressure decreased by 25% (P = 0.01), confirming ongoing endotoxemic shock. However, significant decreases in sublingual microcirculatory parameters of small vessels (microvascular flow index, perfused vessel density, and proportion of small perfused vessels) were observed 30 min after completing LPS infusion (P = 0.01, for all), and threshold decreases of 30% were found 60 min after completing LPS infusion (P = 0.001, for all) in the endotoxemic shock group. Lactate levels significantly increased to more than 2 mm/L at 90 min and more than 4 mm/L at 120 min in the endotoxemic shock group (P = 0.02 and P = 0.01, respectively). Conclusions Changes in microcirculatory perfusion precede changes in macrocirculation and lactate levels in a rabbit model of endotoxemia shock. Microcirculation, macrocirculation, and oxygen metabolism are distinct in early-stage endotoxic shock.
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What Do We Know about Early Management of Sepsis and Septic Shock in Polish Hospitals? A Questionnaire Study. Healthcare (Basel) 2021; 9:healthcare9020140. [PMID: 33535608 PMCID: PMC7912914 DOI: 10.3390/healthcare9020140] [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: 01/07/2021] [Revised: 01/23/2021] [Accepted: 01/25/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Sepsis and septic shock are medical emergencies with a high risk of poor prognosis. We investigate the correspondence between Surviving Sepsis Campaign (SSC) guidelines and clinical practice in Poland, with special attention given to differences between ICU and non-ICU environments as well as regional variations within the country. Methods: A web-based questionnaire study was performed on a random sample of 60 hospitals from the three most populated regions in Poland—Masovia, Silesia, and Greater Poland. A 19-item questionnaire was built based on the most recent edition of SSC guidelines. Results: Sepsis diagnosis was primarily based on clinical evaluation (ICUs: 94%, non-ICUs: 62%; p = 0.02). There were significant differences between ICUs and non-ICUs regarding taking blood cultures for pathogen identification (2-times more frequent in ICUs) and having hospital-based operating procedures to adjust antimicrobial treatment to a clinical scenario (a difference of 17%). Modification of empiric antimicrobial treatment was required post-ICU admission in 70% of cases. ICUs differed from non-ICUs with regard to the methods of fluid responsiveness assessment and the types of catecholamines and fluids used to treat septic shock. The mean fluid load applied before the implementation of catecholamines was 25.8 ± 10.6 mL/kg. Norepinephrine was the first-line agent used to treat shock, and balanced crystalloids were preferred in both ICUs and non-ICUs. Conclusion: Compliance with SCC guidelines in Polish hospitals is insufficient, especially outside ICUs. There is a need for education among healthcare professionals to reach at least an acceptable level of knowledge and attitude in this field.
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27
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Chebl RB, Berbari I, Safa R, Shami A, Sabra M, Jamali S, Makki M, Tamim H, Dagher GA. Clinical Outcome of Septic Patients With Heart Failure With Preserved Ejection Fraction Presenting to the Emergency Department of a Tertiary Hospital: A Retrospective Cohort Study. Front Med (Lausanne) 2020; 7:517999. [PMID: 33195290 PMCID: PMC7662680 DOI: 10.3389/fmed.2020.517999] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 10/06/2020] [Indexed: 01/06/2023] Open
Abstract
Background: Patients with heart failure with preserved ejection fraction (HFpEF) may be at a higher risk of mortality from sepsis than patients without heart failure. Objective: The aim of this study is to compare sepsis-related morbidity and mortality between patients with HFpEF and patients without heart failure presenting to the emergency department (ED) of a tertiary medical center. Design: Single-center retrospective cohort study conducted at an academic ED between January 1, 2015 and December 31, 2018. Patients: Patients with a diagnosis of sepsis were included. Main Measures: Bivariate and multivariate analyses were performed to look at differences in demographics, infection, and treatment parameters as well as outcomes of patients with sepsis. The primary outcome of the study was in-hospital mortality. Secondary outcomes included ED mortality, lengths of stay, and treatment differences between both groups. Key Results: A total of 1,092 patients presented with sepsis to the ED, of which 305 (27.93%) had HFpEF. There was no significant difference in in-hospital mortality between the two groups (40.7% vs. 37.4%; p = 0.314). However, there was a significant increase in ED mortality for septic HFpEF patients compared to non-heart failure patients (2.4 vs. 0.4%; p = 0.003). Septic HFpEF patients presenting to the ED were older than non-heart failure patients (76.84 vs. 68.44 years old; p < 0.0001). On the other hand, there was no significant increase in the use of vasopressors in the first 24 h between both groups. There was a significantly higher rate of intubation in the first 48 h for septic HFpEF patients (17.5 vs. 8.9%; p < 0.0001). Finally, there was significantly less intravenous fluid requirement at 6 h (1.94 L vs. 2.41L; p < 0.0001) and 24 h (3.11 L vs. 3.54L; p = 0.004) for septic patients with HFpEF compared to non-heart failure patients. Conclusion: Septic HFpEF patients experienced an increase in ED mortality, intubation, and steroid use compared to septic non-heart failure patients.
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Affiliation(s)
- Ralphe Bou Chebl
- Department of Emergency Medicine, American University of Beirut Medical Center, Beiru, Lebanon
| | - Iskandar Berbari
- Department of Emergency Medicine, American University of Beirut Medical Center, Beiru, Lebanon
| | - Rawan Safa
- Department of Emergency Medicine, American University of Beirut Medical Center, Beiru, Lebanon
| | - Ali Shami
- Department of Emergency Medicine, American University of Beirut Medical Center, Beiru, Lebanon
| | - Mohammad Sabra
- Department of Emergency Medicine, American University of Beirut Medical Center, Beiru, Lebanon
| | - Sarah Jamali
- Department of Emergency Medicine, American University of Beirut Medical Center, Beiru, Lebanon
| | - Maha Makki
- Department of Emergency Medicine, American University of Beirut Medical Center, Beiru, Lebanon
| | - Hani Tamim
- Department of Emergency Medicine, American University of Beirut Medical Center, Beiru, Lebanon
| | - Gilbert Abou Dagher
- Department of Emergency Medicine, American University of Beirut Medical Center, Beiru, Lebanon
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Abstract
The syndrome of critical illness is a complex physiological stressor that can be triggered by diverse pathologies. It is widely believed that organ dysfunction and death result from bioenergetic failure caused by inadequate cellular oxygen supply. Teleologically, life has evolved to survive in the face of stressors by undergoing a suite of adaptive changes. Adaptation not only comprises alterations in systemic physiology but also involves molecular reprogramming within cells. The concept of cellular adaptation in critically ill patients is a matter of contention in part because medical interventions mask underlying physiology, creating the artificial construct of "chronic critical illness," without which death would be imminent. Thus far, the intensive care armamentarium has not targeted cellular metabolism to preserve a temporary equilibrium but instead attempts to normalize global oxygen and substrate delivery. Here, we review adaptations to hypoxia that have been demonstrated in cellular models and in human conditions associated with hypoxia, including the hypobaric hypoxia of high altitude, the intrauterine low-oxygen environment, and adult myocardial hibernation. Common features include upregulation of glycolytic ATP production, enhancement of respiratory efficiency, downregulation of mitochondrial density, and suppression of energy-consuming processes. We argue that these innate cellular adaptations to hypoxia represent potential avenues for intervention that have thus far remained untapped by intensive care medicine.
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Affiliation(s)
- Helen T McKenna
- Division of Surgery and Interventional Science, University College London, London, United Kingdom.,Royal Free Intensive Care Unit, Royal Free Hospital, London, United Kingdom
| | - Andrew J Murray
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Daniel S Martin
- Royal Free Intensive Care Unit, Royal Free Hospital, London, United Kingdom.,Peninsula Medical School, University of Plymouth, Plymouth, United Kingdom
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29
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Acute lower limb ischemia secondary to diffuse peritonitis. COR ET VASA 2020. [DOI: 10.33678/cor.2019.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Guijo Gonzalez P, Gracia Romero MA, Gil Cano A, Garcia Rojo M, Cecconi M, Monge Garcia IM. Hemodynamic resuscitation with fluids bolus and norepinephrine increases severity of lung damage in an experimental model of septic shock. Med Intensiva 2020; 45:S0210-5691(20)30178-9. [PMID: 32718740 DOI: 10.1016/j.medin.2020.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 03/23/2020] [Accepted: 05/18/2020] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Hemodynamic resuscitation is considered a cornerstone of the initial treatment of septic shock. However, there is growing concern about its side effects. Our objective was to assess the relationship between fluid administration and norepinephrine infusion and the development of lung injury. DESIGN Randomized in vivo study in rabbits. SETTING University animal research laboratory. PATIENTS Eighteen New Zealand rabbits. Control group (SHAM, n=6), Sepsis group with or without hemodynamic resuscitation (ETX-R, n=6; ETX-NR, n=6). INTERVENTIONS Sepsis was induced by intravenous lipopolysaccharide administration and animals were followed-up for 4h. Hemodynamic resuscitation with Ringer lactate (20mL·kg-1) was administered and later norepinephrine was initiated 3h after sepsis induction. At the end, the left lung was excised. MAIN VARIABLES OF INTEREST An indwelling arterial catheter and an esophageal Doppler were placed. Lung mechanics were monitored with side stream spirometry. Lung damage was analyzed by histopathological examination. RESULTS The SHAM group did not show hemodynamic or respiratory changes. Lipopolysaccharide administration aimed an increase in cardiac output and arterial hypotension. In the ETX-NR group, animals remained hypotensive until the end of the experiment. Resuscitation with fluids and norepinephrine reversed arterial hypotension. Compared to the ETX-NR group, the remaining lung of the ETX-R group showed greater accumulation of neutrophils and reactive type-II pneumocytes, thicker alveolar wall, alveolar hemorrhage and non-aerated pulmonary areas. Lung injury score was larger in the ETX-R group. CONCLUSIONS In our experimental study, following a strategy with bolus fluids and late norepinephrine used in the early phase of endotoxic septic shock has a negative influence on the development of lung injury.
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Affiliation(s)
- P Guijo Gonzalez
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain; Research Group in Critical Disorders (GREPAC), Institut Hospital del Mar d'Investigacions Mèdiques (IMIM), Barcelona, Spain; Critical Care Department, Hospital del Mar, Barcelona, Spain.
| | - M A Gracia Romero
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain
| | - A Gil Cano
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain
| | - M Garcia Rojo
- Derpartment of Pathology, Hospital Universitario Puerta del Mar, Cadiz, Spain
| | - M Cecconi
- Department of Anaesthesia and Intensive Care, IRCCS Instituto Clínico Humanitas, Humanitas University, Milan, Italy
| | - I M Monge Garcia
- Intensive Care Medicine Department, Hospital del SAS Jerez, Jerez de la Frontera, Spain
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Burla MJ, Shinthia N, Boura JA, Qu L, Berger DA. Resuscitation Resident Impact in the Treatment of Sepsis. Cureus 2020; 12:e9257. [PMID: 32821603 PMCID: PMC7431981 DOI: 10.7759/cureus.9257] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background The resuscitation of septic patients is a fundamental skill of emergency medicine (EM) training. We developed a required rotation designed to augment resident training in resuscitating critically ill patients in the emergency department (ED). The purpose of this study was to evaluate the successful completion of sepsis core measures alongside clinical outcomes between patients with a resuscitation resident (RR) involved in care versus patients without. Methods This retrospective study was conducted at a single site tertiary care Level 1 trauma center with an ED census of 130,000 visits annually. Data were collected from January 1, 2015, to December 31, 2016, using the electronic medical record (EMR) via an Epic query (Epic Systems Corp., Verona, WI). Patients admitted with severe sepsis or septic shock (Surviving Sepsis Campaign guidelines) were included and separated into two groups, one with RR involvement and one without. Emergency department length of stay, time to initial lactic acid draw, lactic acid value, time to bolus fluid initiation, time to antibiotic initiation, need for medical intensive care unit (ICU) admission, and 30-day mortality were compared between the two groups. Chi-square tests and Fisher's exact tests were used to analyze the categorical variables. Two-sided t-tests and Wilcoxon rank-sum tests were used to examine continuous variables. Results Out of 4,746 patients admitted, 101 patients had an RR participate in their care. The median time to initial lactic acid draw was shorter (0.53 vs 1.05 hours; p < 0. 0001) and the lactic acid level was higher (2.5 vs 1.8 mmol/L; p < 0. 0001) with the presence of an RR. Resuscitation resident was correlated with a decrease in time to antibiotics and appropriate 30 cc/kg bolus, however, these were not statistically significant (p = 0.10 and p = 0.09 respectively). Resuscitation resident involvement was also associated with more medical ICU (45.5% vs 18.8%; p<0.0001) admissions and a higher 30-day mortality (14.9% vs 29.7%; p < 0. 0001). All other variables were not statistically significant. Conclusion Resuscitation residents demonstrate a statistically significant impact on lactic acid-related bundle compliance and help facilitate the care of higher acuity severe sepsis and septic shock patients.
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Affiliation(s)
- Michael J Burla
- Emergency Medicine, Beaumont Health System, Royal Oak, USA.,Emergency Medicine, Southern Maine Health Care, Biddeford, USA
| | - Nashid Shinthia
- Emergency Medicine, Baylor University Medical Center, Houston, USA
| | | | - Lihua Qu
- Research, Beaumont Health System, Royal Oak, USA
| | - David A Berger
- Emergency Medicine, Beaumont Health System, Royal Oak, USA
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Abstract
PURPOSE OF REVIEW To focus on the missing link between accuracy and precision of monitoring devices and effective implementation of therapeutic strategies. RECENT FINDINGS Haemodynamic monitoring is generally considered to be an essential part of intensive care medicine. However, randomized controlled trials fail to demonstrate improved outcome unequivocally as a result of hemodynamic monitoring. This absence of solid proof renders doctors to hesitance to apply haemodynamic monitoring in clinical practise. Profound understanding of the underlying mechanisms, adequate patient selection and timing, meaningful representation and software-supported interpretation of data all play an important role. Furthermore, protocol adherence and human behaviour seem to form the often missing link between a solid physiologic principle and clinically relevant outcome. Introduction of haemodynamic monitoring should therefore not be limited to theoretical and practical issues, but also involve integration strategies. By learning from others, we might be able to implement haemodynamic monitoring in such a way that it has potential to modify the course of a disease. SUMMARY The clinical success of haemodynamic monitoring goes far beyond accuracy and precision of monitoring devices. Understanding of the factors influencing the effective implementation of therapeutic strategies plays an important role in the meaningful introduction of haemodynamic monitoring.
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McKenna HT, Murray AJ. Reconsidering critical illness as an uncharacterised acquired mitochondrial disorder. J Intensive Care Soc 2019; 21:102-104. [PMID: 32489404 DOI: 10.1177/1751143719892788] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Helen T McKenna
- Division of Surgery and Interventional Science, University College London, Royal Free Hospital, London, UK.,Intensive Care Unit, Royal Free Hospital, London, UK
| | - Andrew J Murray
- Department of Physiology, Development and Neuroscience, University of Cambridge, Cambridge, UK
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Rajdev K, Leifer L, Sandhu G, Mann B, Pervaiz S, Habib S, Siddiqui AH, Joseph B, Demissie S, El-Sayegh S. Fluid resuscitation in patients with end-stage renal disease on hemodialysis presenting with severe sepsis or septic shock: A case control study. J Crit Care 2019; 55:157-162. [PMID: 31733623 DOI: 10.1016/j.jcrc.2019.10.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/17/2019] [Accepted: 10/19/2019] [Indexed: 02/01/2023]
Abstract
Due to the potential risk of volume overload, physicians are hesitant to aggressively fluid-resuscitate septic patients with end-stage renal disease (ESRD) on hemodialysis (HD). Primary objective: To calculate the percentage of ESRD patients on HD (Case) who received ≥30 mL/Kg fluid resuscitation within the first 6 h compared to non-ESRD patients (Control) that presented with severe sepsis (SeS) or septic shock (SS). Secondary objectives: Effect of fluid resuscitation on intubation rate, need for urgent dialysis, hospital length of stay (LOS), intensive care unit (ICU) admission and LOS, need for vasopressors, and hospital mortality. Medical records of 715 patients with sepsis, SeS, SS, and ESRD were reviewed. We identified 104 Case and 111 Control patients. In the Case group, 23% of patients received ≥30 mL/Kg fluids compared to 60% in the Control group (p < 0.001). There was no significant difference in in-hospital mortality, need for urgent dialysis, intubation rates, ICU LOS, or hospital LOS between the two groups. Subgroup analysis between ESRD patients who received ≥30 mL/Kg (N = 80) vs those who received <30 mL/Kg (N = 24) showed no significant difference in any of the secondary outcomes. Compliance with 30 mL/Kg fluids was low for all patients but significantly lower for ESRD patients. Aggressive fluid resuscitation appears to be safe in ESRD patients.
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Affiliation(s)
- Kartikeya Rajdev
- Northwell Health-Staten Island University Hospital, Department of Internal Medicine, 475 Seaview Avenue, Staten Island, NY 10305, United States of America.
| | - Lazer Leifer
- Northwell Health-Staten Island University Hospital, Department of Internal Medicine, 475 Seaview Avenue, Staten Island, NY 10305, United States of America.
| | - Gurkirat Sandhu
- Northwell Health-Staten Island University Hospital, Department of Internal Medicine, 475 Seaview Avenue, Staten Island, NY 10305, United States of America.
| | - Benjamin Mann
- Northwell Health-Staten Island University Hospital, Department of Internal Medicine, 475 Seaview Avenue, Staten Island, NY 10305, United States of America.
| | - Sami Pervaiz
- Northwell Health-Staten Island University Hospital, Department of Internal Medicine, 475 Seaview Avenue, Staten Island, NY 10305, United States of America.
| | - Saad Habib
- Northwell Health-Staten Island University Hospital, Department of Internal Medicine, 475 Seaview Avenue, Staten Island, NY 10305, United States of America.
| | - Abdul Hasan Siddiqui
- Northwell Health-Staten Island University Hospital, Department of Internal Medicine, 475 Seaview Avenue, Staten Island, NY 10305, United States of America.
| | - Bino Joseph
- Northwell Health-Staten Island University Hospital, Department of Internal Medicine, 475 Seaview Avenue, Staten Island, NY 10305, United States of America.
| | - Seleshi Demissie
- Northwell Health-Staten Island University Hospital, Department of Internal Medicine, 475 Seaview Avenue, Staten Island, NY 10305, United States of America.
| | - Suzanne El-Sayegh
- Northwell Health-Staten Island University Hospital, Department of Internal Medicine, 475 Seaview Avenue, Staten Island, NY 10305, United States of America.
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Mathematical modeling of septic shock: an innovative tool for assessing therapeutic hypotheses. SN APPLIED SCIENCES 2019. [DOI: 10.1007/s42452-019-0747-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Editorial. Curr Opin Crit Care 2019; 25:244-245. [DOI: 10.1097/mcc.0000000000000606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Raps J, Groene P, Rehm M, Hofmann-Kiefer K. [52-year-old female with latent hypovolemia : Preparation for the medical specialist examination: Part 9]. Anaesthesist 2019; 68:118-122. [PMID: 30989291 DOI: 10.1007/s00101-019-0553-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- J Raps
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität, Nussbaumstr. 20, 80336, München, Deutschland
| | - P Groene
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität, Nussbaumstr. 20, 80336, München, Deutschland
| | - M Rehm
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität, Nussbaumstr. 20, 80336, München, Deutschland
| | - K Hofmann-Kiefer
- Klinik für Anaesthesiologie, Klinikum der Ludwig-Maximilians-Universität, Nussbaumstr. 20, 80336, München, Deutschland.
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Hunter CL, Silvestri S, Stone A, Shaughnessy A, Miller S, Rodriguez A, Papa L. Prehospital sepsis alert notification decreases time to initiation of CMS sepsis core measures. Am J Emerg Med 2019; 37:114-117. [DOI: 10.1016/j.ajem.2018.09.034] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/20/2018] [Accepted: 09/22/2018] [Indexed: 12/22/2022] Open
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Chidambaram S, Goh EL, Rey VG, Khan MA. Vasopressin vs noradrenaline: Have we found the perfect recipe to improve outcome in septic shock? J Crit Care 2018; 49:99-104. [PMID: 30415181 DOI: 10.1016/j.jcrc.2018.10.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Revised: 10/04/2018] [Accepted: 10/29/2018] [Indexed: 11/28/2022]
Abstract
PURPOSE The metabolic and circulatory disturbances in patients with septic shock results in a high mortality rate. There is a lack of high-level evidence on the optimal approach. We present a meta-analysis elucidating the outcomes of regimes with only noradrenaline versus a combination of noradrenaline and vasopressin in managing septic shock. METHODS A literature search of studies comparing the use of noradrenaline and vasopressin in septic shock was conducted, using MEDLINE and EMBASE databases. The primary outcome evaluated was mortality rate. Subgroup analysis of secondary measures was also conducted using Review Manager 5.3 software. RESULTS Four RCTs of 1039 patients were included. There is good evidence supporting a comparable mortality rate (RR: 0.92, 95% CI: 0.78, 1.08, p = .32, I2 = 0%), and moderate evidence supporting an equivalent length of ICU stay (MD: 0.14, 95% CI: -1.37, 1.65, p = .86, I2 = 46%) and occurrence of adverse events (RR: 1.19, 95% CI: 0.83, 1.70, p = .35, I2 = 13%) between the two cohorts. CONCLUSION The two regimes have equivalent outcomes, but vasopressin has a role in selected patients experiencing less severe septic shock beyond a 36-h period. Further work will make definitive clinical recommendations for optimal strategy of vasopressin or noradrenaline usage.
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Affiliation(s)
- Swathikan Chidambaram
- Faculty of Medicine, Imperial College London, South Kensington, London SW7 2AZ, United Kingdom
| | - En Lin Goh
- Faculty of Medicine, Imperial College London, South Kensington, London SW7 2AZ, United Kingdom
| | - Vanessa Garnelo Rey
- Department of Critical Care, Imperial College London, St Mary's Hospital, W2 1NY, London, United Kingdom
| | - Mansoor Ali Khan
- Department of Surgery and Trauma, Imperial College London, St Mary's Hospital, W2 1NY London, United Kingdom.
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Volume Based Resuscitation and Intestinal Microcirculation after Ischaemia/Reperfusion Injury: Results of an Exploratory Aortic Clamping Study in Pigs. Eur J Vasc Endovasc Surg 2018; 57:284-291. [PMID: 30309783 DOI: 10.1016/j.ejvs.2018.08.055] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 08/27/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVES In the presence of ischaemia/reperfusion (I/R) induced endothelial injury, volume administration may not correlate with increased microcirculation. The aim of this study was to evaluate intestinal microcirculation after standardised sequential volume loading in an animal model of I/R injury following supracoeliac aortic clamping. METHODS This was a prospective exploratory pilot animal study. Intestinal I/R injury was induced in eight pigs during experimental thoraco-abdominal aortic repair. After 6 h of I/R, microcirculatory blood flow (mFlux, measured in the ileum using direct laser speckle contrast imaging) and macrohaemodynamic parameters (using trans-cardiopulmonary thermodilution) were measured and measurements were repeated after each of four sequential volume loading steps (VLS1 - 4). Each load was administered over 5 min followed by another 5 min for equilibration. RESULTS All animals survived until after VLS4. After 6 h of I/R cardiac output (CO) (p < .001) and mFlux (p < .001) had both decreased. CO increased again after VLS1 (p < .001) and VLS2 (p = .036), whereas mFlux did not change. In contrast, mFlux further decreased after VLS3 (p < .01) and VLS4 (p < .001), whereas CO did not change anymore. Extravascular lung water continued to increase after VLS2 (p = .046) and VLS4 (p = .049). CONCLUSIONS I/R leads to impaired intestinal microcirculation, which was not restored by volume administration in spite of improved CO. In contrast, further volume administration exceeding preload reserves was associated with additional decreases in the intestinal microcirculation. The potentially negative effect of excessive volume resuscitation after I/R injury should encourage further translational research.
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Kim HI, Park S. Sepsis: Early Recognition and Optimized Treatment. Tuberc Respir Dis (Seoul) 2018; 82:6-14. [PMID: 30302954 PMCID: PMC6304323 DOI: 10.4046/trd.2018.0041] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2018] [Revised: 06/29/2018] [Accepted: 07/20/2018] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a life-threatening condition caused by infection and represents a substantial global health burden. Recent epidemiological studies showed that sepsis mortality rates have decreased, but that the incidence has continued to increase. Although a mortality benefit from early-goal directed therapy (EGDT) in patients with severe sepsis or septic shock was reported in 2001, three subsequent multicenter randomized studies showed no benefits of EGDT versus usual care. Nonetheless, the early administration of antibiotics and intravenous fluids is considered crucial for the treatment of sepsis. In 2016, new sepsis definitions (Sepsis-3) were issued, in which organ failure was emphasized and use of the terms "systemic inflammatory response syndrome" and "severe sepsis" was discouraged. However, early detection of sepsis with timely, appropriate interventions increases the likelihood of survival for patients with sepsis. Also, performance improvement programs have been associated with a significant increase in compliance with the sepsis bundles and a reduction in mortality. To improve sepsis management and reduce its burden, in 2017, the World Health Assembly and World Health Organization adopted a resolution that urged governments and healthcare workers to implement appropriate measures to address sepsis. Sepsis should be considered a medical emergency, and increasing the level of awareness of sepsis is essential.
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Affiliation(s)
- Hwan Il Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Sunghoon Park
- Division of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea.
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Malbrain MLNG, Van Regenmortel N, Saugel B, De Tavernier B, Van Gaal PJ, Joannes-Boyau O, Teboul JL, Rice TW, Mythen M, Monnet X. Principles of fluid management and stewardship in septic shock: it is time to consider the four D's and the four phases of fluid therapy. Ann Intensive Care 2018; 8:66. [PMID: 29789983 PMCID: PMC5964054 DOI: 10.1186/s13613-018-0402-x] [Citation(s) in RCA: 278] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 04/23/2018] [Indexed: 02/07/2023] Open
Abstract
In patients with septic shock, the administration of fluids during initial hemodynamic resuscitation remains a major therapeutic challenge. We are faced with many open questions regarding the type, dose and timing of intravenous fluid administration. There are only four major indications for intravenous fluid administration: aside from resuscitation, intravenous fluids have many other uses including maintenance and replacement of total body water and electrolytes, as carriers for medications and for parenteral nutrition. In this paradigm-shifting review, we discuss different fluid management strategies including early adequate goal-directed fluid management, late conservative fluid management and late goal-directed fluid removal. In addition, we expand on the concept of the “four D’s” of fluid therapy, namely drug, dosing, duration and de-escalation. During the treatment of patients with septic shock, four phases of fluid therapy should be considered in order to provide answers to four basic questions. These four phases are the resuscitation phase, the optimization phase, the stabilization phase and the evacuation phase. The four questions are “When to start intravenous fluids?”, “When to stop intravenous fluids?”, “When to start de-resuscitation or active fluid removal?” and finally “When to stop de-resuscitation?” In analogy to the way we handle antibiotics in critically ill patients, it is time for fluid stewardship.
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Affiliation(s)
- Manu L N G Malbrain
- Intensive Care Unit, University Hospital Brussels (UZB), Laarbeeklaan 101, 1090, Jette, Belgium. .,Faculteit Geneeskunde en Farmacie, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Niels Van Regenmortel
- Intensive Care Unit, ZiekenhuisNetwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060, Antwerpen 6, Belgium
| | - Bernd Saugel
- Department of Anesthesiology, Centre of Anesthesiology and Intensive Care Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Brecht De Tavernier
- Intensive Care Unit, ZiekenhuisNetwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060, Antwerpen 6, Belgium
| | - Pieter-Jan Van Gaal
- Intensive Care Unit, ZiekenhuisNetwerk Antwerpen, ZNA Stuivenberg, Lange Beeldekensstraat 267, 2060, Antwerpen 6, Belgium
| | | | - Jean-Louis Teboul
- Medical Intensive Care Unit, Hopitaux universitaires Paris-Sud, AP-HP, Université Paris-Sud, Le Kremlin-Bicetre, France
| | - Todd W Rice
- University College London Hospitals, National Institute of Health Research Biomedical Research Centre, London, UK
| | - Monty Mythen
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Xavier Monnet
- Medical Intensive Care Unit, Hopitaux universitaires Paris-Sud, AP-HP, Université Paris-Sud, Le Kremlin-Bicetre, France
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