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Warner S, Teague HL, Ramos-Benitez MJ, Panicker S, Allen K, Gaihre S, Moyer T, Parachalil Gopalan B, Douagi I, Shet A, Kanthi Y, Suffredini AF, Chertow DS, Strich JR. R406 reduces lipopolysaccharide-induced neutrophil activation. Cell Immunol 2024; 403-404:104860. [PMID: 39084187 PMCID: PMC11387147 DOI: 10.1016/j.cellimm.2024.104860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 07/05/2024] [Accepted: 07/22/2024] [Indexed: 08/02/2024]
Abstract
Modulating SYK has been demonstrated to have impacts on pathogenic neutrophil responses in COVID-19. During sepsis, neutrophils are vital in early bacterial clearance but also contribute to the dysregulated immune response and organ injury when hyperactivated. Here, we evaluated the impact of R406, the active metabolite of fostamatinib, on neutrophils stimulated by LPS. We demonstrate that R406 was able to effectively inhibit NETosis, degranulation, ROS generation, neutrophil adhesion, and the formation of CD16low neutrophils that have been linked to detrimental outcomes in severe sepsis. Further, the neutrophils remain metabolically active, capable of releasing cytokines, perform phagocytosis, and migrate in response to IL-8. Taken together, this data provides evidence of the potential efficacy of utilizing fostamatinib in bacterial sepsis.
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Affiliation(s)
- Seth Warner
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Department, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Heather L Teague
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Department, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Marcos J Ramos-Benitez
- Basic Science Department, Microbiology Division, School of Medicine, Ponce Health Sciences University, Ponce, PR, USA
| | - Sumith Panicker
- Laboratory of Vascular Thrombosis and Inflammation, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Kiana Allen
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Department, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Salina Gaihre
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Department, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Tom Moyer
- Flow Cytometry Section, Research Technologies Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Bindu Parachalil Gopalan
- Laboratory of Sickle Thrombosis and Vascular Biology, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Iyadh Douagi
- Flow Cytometry Section, Research Technologies Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA; NIH Center for Human Immunology, Inflammation, and Autoimmunity, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Arun Shet
- Laboratory of Sickle Thrombosis and Vascular Biology, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Yogendra Kanthi
- Laboratory of Vascular Thrombosis and Inflammation, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Anthony F Suffredini
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Department, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, USA
| | - Daniel S Chertow
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Department, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, USA; Laboratory of Virology, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Jeffrey R Strich
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA; Critical Care Medicine Department, National Institutes of Health Clinical Center, National Institutes of Health, Bethesda, MD, USA.
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Raikhel AV, Collis AC, Carlbom D. Shock Simulation Day: Medical Decision-Making and Communication Skills for Managing a Hypotensive Adult in a Rapid Response. MEDEDPORTAL : THE JOURNAL OF TEACHING AND LEARNING RESOURCES 2024; 20:11430. [PMID: 39156125 PMCID: PMC11327352 DOI: 10.15766/mep_2374-8265.11430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Accepted: 04/04/2024] [Indexed: 08/20/2024]
Abstract
Introduction Shock is a life-threatening condition amongst hospitalized patients and requires urgent management to avoid mortality. Early exposure is vital for educational and patient safety purposes. Methods We developed a 90-minute shock day session that provided internal medicine interns with a cognitive framework for the initial diagnosis and management of shock, which they applied to two simulations. The first simulation involved a patient with septic shock, and the second involved a patient with cardiogenic shock. Critical action checklists were used to assess learners and guide structured debriefs after each simulation. Medical decision-making and communication frameworks were presented through a presession video and a chalk talk. The curriculum was evaluated using pre- and postintervention surveys to assess knowledge and confidence. Results Forty-eight interns participated in the session in 2022 and 2023. We observed an increase in the percentage of learners correctly answering a knowledge-based question regarding the amount of fluid administered to a patient in septic shock (pre: 33%, post: 62%, p < .01), as well as increases in learner-reported confidence in leading a rapid response (pre: 9%, post: 62%) and in managing undifferentiated shock (pre: 13%, post: 56%), septic shock (pre: 20%, post: 83%), cardiogenic shock (pre: 2%, post: 54%), hemorrhagic shock (pre: 20%, post: 73%), and anaphylactic shock (pre: 22%, post: 54%, all ps < .01). Discussion Employing a variety of pedagogical methods, we demonstrated that intern knowledge and confidence regarding the management of a hypotensive patient during a rapid response can be increased through participation in our curriculum.
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Affiliation(s)
- A. Vincent Raikhel
- Clinical Instructor, Division of General Internal Medicine, University of Washington School of Medicine and Veteran Affairs Puget Sound Healthcare System
| | - Alexandra C. Collis
- Clinical Assistant Professor, Division of General Internal Medicine and Division of Healthcare Simulation Science, University of Washington School of Medicine
| | - David Carlbom
- Associate Professor, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington Medical Center
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Zhang Y, Pan S, Hu Y, Ling B, Hua T, Tang L, Yang M. Establishing an artificial intelligence-based predictive model for long-term health-related quality of life for infected patients in the ICU. Heliyon 2024; 10:e35521. [PMID: 39170285 PMCID: PMC11336746 DOI: 10.1016/j.heliyon.2024.e35521] [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: 01/14/2024] [Revised: 07/30/2024] [Accepted: 07/30/2024] [Indexed: 08/23/2024] Open
Abstract
Objective To develop a model using a Chinese ICU infection patient database to predict long-term health-related quality of life (HRQOL) in survivors. Methods A patient database from the ICU of the Fourth People's Hospital in Zigong was analyzed, including data from 2019 to 2020. The subjects of the study were ICU infection survivors, and their post-discharge HRQOL was assessed through the SF-36 survey. The primary outcomes were the physical component summary (PCS) and mental component summary (MCS). We used artificial intelligence techniques for both feature selection and model building. Least absolute shrinkage and selection operator regression was used for feature selection, extreme gradient boosting (XGBoost) was used for model building, and the area under the receiver operating characteristic curve (AUROC) was used to assess model performance. Results The study included 917 ICU infection survivors. The median follow-up was 507.8 days. Their SF-36 scores, including PCS and MCS, were below the national average. The final prognostic model showed an AUROC of 0.72 for PCS and 0.63 for MCS. Within the sepsis subgroup, the predictive model AUROC values for PCS and MCS were 0.76 and 0.68, respectively. Conclusions This study established a valuable prognostic model using artificial intelligence to predict long-term HRQOL in ICU infection patients, which supports clinical decision making, but requires further optimization and validation.
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Affiliation(s)
- Yang Zhang
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, PR China
- Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, PR China
| | - Sinong Pan
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, PR China
- Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, PR China
| | - Yan Hu
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, PR China
- Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, PR China
| | - Bingrui Ling
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, PR China
- Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, PR China
| | - Tianfeng Hua
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, PR China
- Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, PR China
| | - Lunxian Tang
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, PR China
- Department of Internal Emergency Medicine (North), Shanghai East Hospital, Tongji University School of Medicine, Shanghai, 200120, PR China
| | - Min Yang
- The Second Department of Critical Care Medicine, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, PR China
- Laboratory of Cardiopulmonary Resuscitation and Critical Care, The Second Affiliated Hospital of Anhui Medical University, Hefei, Anhui, 230601, PR China
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Ahn C, Yu G, Shin TG, Cho Y, Park S, Suh GY. Comparison of Early and Late Norepinephrine Administration in Patients with Septic Shock: A Systematic Review and Meta-analysis. Chest 2024:S0012-3692(24)04581-1. [PMID: 38972348 DOI: 10.1016/j.chest.2024.05.042] [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: 01/12/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 07/09/2024] Open
Abstract
BACKGROUND Vasopressor administration at an appropriate time is crucial, but the optimal timing remains controversial. RESEARCH QUESTION Does early vs late norepinephrine administration impact the prognosis of septic shock? STUDY DESIGN AND METHODS Searches were conducted on PubMed, EMBASE, the Cochrane Library, and KMBASE. We included studies of adults with sepsis and categorized patients into an early and late norepinephrine group according to specific time points or differences in norepinephrine use protocols. The primary outcome was overall mortality. The secondary outcomes included length of stay in the ICU, days free from ventilator use, days free from renal replacement therapy, days free from vasopressor use, adverse events, and total fluid volume. RESULTS Twelve studies (four randomized controlled trials [RCTs] and eight observational studies) comprising 7,281 patients were analyzed. For overall mortality, no significant difference was found between the early norepinephrine group and late norepinephrine group in RCTs (OR, 0.70; 95% CI, 0.41-1.19) or observational studies (OR, 0.83; 95% CI, 0.54-1.29). In the two RCTs without a restrictive fluid strategy that prioritized vasopressors and lower IV fluid volumes, the early norepinephrine group showed significantly lower mortality than the late norepinephrine group (OR, 0.49; 95%, CI, 0.25-0.96). The early norepinephrine group demonstrated more mechanical ventilator-free days in observational studies (mean difference, 4.06; 95% CI, 2.82-5.30). The incidence of pulmonary edema was lower in the early norepinephrine group in the three RCTs that reported this outcome (OR, 0.43; 95% CI, 0.25-0.74). No differences were found in the other secondary outcomes. INTERPRETATION Overall mortality did not differ significantly between early and late norepinephrine administration for septic shock. However, early norepinephrine administration seemed to reduce pulmonary edema incidence, and mortality improvement was observed in studies without fluid restriction interventions, favoring early norepinephrine use.
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Affiliation(s)
- Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Chung-Ang University, Seoul, South Korea
| | - Gina Yu
- Department of Emergency Medicine, University of Yonsei College of Medicine, Seoul, South Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Youngsuk Cho
- Department of Emergency Medicine, Kangdong Sacred Heart Hospital, Hallym University, Seoul, South Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea; Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Xu F, Xu J, Ma J, Xu W, Gu S, Lu G, Wang J. Early versus delayed enteral nutrition in ICU patients with sepsis: a propensity score-matched analysis based on the MIMIC-IV database. Front Nutr 2024; 11:1370472. [PMID: 38978696 PMCID: PMC11228309 DOI: 10.3389/fnut.2024.1370472] [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: 01/14/2024] [Accepted: 06/05/2024] [Indexed: 07/10/2024] Open
Abstract
Background Early enteral nutrition (EN) is recommended for sepsis management, but its optimal timing and clinical benefits remain uncertain. This study evaluates whether early EN improves outcomes compared to delayed EN in patients with sepsis. Methods We analyzed data of septic patients from the MIMIC-IV 2.2 database, focusing on those in the Medical Intensive Care Unit (MICU) and Surgical Intensive Care Unit (SICU). Patients who initiated EN within 3 days were classified into the early EN group, while those who started EN between 3 and 7 days were classified into the delayed EN group. Propensity score matching was used to compare outcomes between the groups. Results Among 1,111 patients, 786 (70.7%) were in the early EN group and 325 (29.3%) were in the delayed EN group. Before propensity score matching, the early EN group demonstrated lower mortality (crude OR = 0.694; 95% CI: 0.514-0.936; p = 0.018) and shorter ICU stays (8.3 [5.2, 12.3] vs. 10.0 [7.5, 14.2] days; p < 0.001). After matching, no significant difference in mortality was observed. However, the early EN group had shorter ICU stays (8.3 [5.2, 12.4] vs. 10.1 [7.5, 14.2] days; p < 0.001) and a lower incidence of AKI stage 3 (49.3% vs. 55.5%; p = 0.030). Subgroup analysis revealed that early EN significantly reduced the 28-day mortality rate in sepsis patients with lactate levels ≤4 mmol/L, with an adjusted odds ratio (aOR) of 0.579 (95% CI: 0.361, 0.930; p = 0.024). Conclusion Early enteral nutrition may not significantly reduce overall mortality in sepsis patients but may shorten ICU stays and decrease the incidence of AKI stage 3. Further research is needed to identify specific patient characteristics that benefit most from early EN.
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Affiliation(s)
- Fuchao Xu
- Department of Emergency Medicine, Nanjing Drum Tower Hospital, Nanjing, China
| | - Jianxin Xu
- Department of Emergency Medicine, Drum Tower Hospital, Nanjing Medical University, Nanjing, China
| | - Jinjin Ma
- Department of Rehabilitation Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Wenbo Xu
- Department of Rehabilitation Medicine, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shuangshuang Gu
- Department of Emergency Medicine, Nanjing Drum Tower Hospital, Nanjing, China
| | - Geng Lu
- Department of Emergency Medicine, Nanjing Drum Tower Hospital, Nanjing, China
| | - Jun Wang
- Department of Emergency Medicine, Nanjing Drum Tower Hospital, Nanjing, China
- Department of Emergency Medicine, Drum Tower Hospital, Nanjing Medical University, Nanjing, China
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Shi X, Simms KJ, Ewing TJ, Lin YP, Chen YL, Melvan JN, Siggins RW, Zhang P. The bone marrow endothelial progenitor cell response to septic infection. Front Immunol 2024; 15:1368099. [PMID: 38665923 PMCID: PMC11044677 DOI: 10.3389/fimmu.2024.1368099] [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: 01/09/2024] [Accepted: 03/01/2024] [Indexed: 04/28/2024] Open
Abstract
Early increase in the level of endothelial progenitor cells (EPCs) in the systemic circulation occurs in patients with septic infection/sepsis. The significance and underlying mechanisms of this response remain unclear. This study investigated the bone marrow EPC response in adult mice with septic infection induced by intravenous injection (i.v.) of Escherichia coli. For in vitro experiments, sorted marrow stem/progenitor cells (SPCs) including lineage(lin)-stem cell factor receptor (c-kit)+stem cell antigen-1 (Sca-1)-, lin-c-kit+, and lin- cells were cultured with or without lipopolysaccharides (LPSs) and recombinant murine vascular endothelial growth factor (VEGF) in the absence and presence of anti-Sca-1 crosslinking antibodies. In a separate set of experiments, marrow lin-c-kit+ cells from green fluorescence protein (GFP)+ mice, i.v. challenged with heat-inactivated E. coli or saline for 24 h, were subcutaneously implanted in Matrigel plugs for 5 weeks. Marrow lin-c-kit+ cells from Sca-1 knockout (KO) mice challenged with heat-inactivated E. coli for 24 h were cultured in the Matrigel medium for 8 weeks. The marrow pool of EPCs bearing the lin-c-kit+Sca-1+VEGF receptor 2 (VEGFR2)+ (LKS VEGFR2+) and LKS CD133+VEGFR2+ surface markers expanded rapidly following septic infection, which was supported by both proliferative activation and phenotypic conversion of marrow stem/progenitor cells. Increase in marrow EPCs and their reprogramming for enhancing angiogenic activity correlated with cell-marked upregulation of Sca-1 expression. Sca-1 was coupled with Ras-related C3 botulinum toxin substrate 2 (Rac2) in signaling the marrow EPC response. Septic infection caused a substantial increase in plasma levels of IFN-γ, VEGF, G-CSF, and SDF-1. The early increase in circulating EPCs was accompanied by their active homing and incorporation into pulmonary microvasculature. These results demonstrate that the marrow EPC response is a critical component of the host defense system. Sca-1 signaling plays a pivotal role in the regulation of EPC response in mice with septic infection.
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Affiliation(s)
- Xin Shi
- Department of Integrative Medical Sciences, Department of Surgery, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, United States
| | - Kevin J. Simms
- Department of Integrative Medical Sciences, Department of Surgery, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, United States
| | - Thomas J. Ewing
- West Clinical Laboratory, Lakeland Regional Health Medical Center, Lakeland, FL, United States
| | | | - Yi-Ling Chen
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung City, Taiwan
| | - John N. Melvan
- Memorial Cardiac and Vascular Institute, Memorial Healthcare System, Hollywood, FL, United States
| | - Robert W. Siggins
- Department of Physiology, Louisiana State University Health Sciences Center, New Orleans, LA, United States
| | - Ping Zhang
- Department of Integrative Medical Sciences, Department of Surgery, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, United States
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Akatsuka M, Hasebe A, Yama N. Importance of Diagnostic Imaging Training for Intensivists: Lessons Learned From a Case. Cureus 2024; 16:e55779. [PMID: 38586700 PMCID: PMC10999110 DOI: 10.7759/cureus.55779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2024] [Indexed: 04/09/2024] Open
Abstract
Intensive care physicians are tasked with managing patients with complex organ disorders, necessitating a broad skill set and ongoing education. While simulation training often focuses on equipment handling, this case report highlights a critical instance of acute aortic dissection initially missed on imaging during intensive care unit (ICU) admission. An 86-year-old woman with multiple comorbidities presented with respiratory symptoms and electrolyte imbalances, ultimately requiring ICU admission. Despite initial inconclusive imaging and treatment for suspected conditions, further evaluation revealed a dissecting aneurysm of the descending aorta. This case underscores the importance of thorough diagnostic evaluation and ongoing vigilance, especially in older adults with multiple health conditions. It emphasizes the need for comprehensive education, including proactive training in image diagnosis, to recognize diverse medical presentations and potential complications. This case serves as a reminder of the evolving challenges in critical care and the necessity for continuous education and adaptability to ensure optimal patient outcomes.
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Affiliation(s)
- Masayuki Akatsuka
- Department of Intensive Care Medicine, Sapporo Medical University School of Medicine, Sapporo, JPN
| | - Akira Hasebe
- Center for Graduate Medical Education, Sapporo Medical University Hospital, Sapporo, JPN
| | - Naoya Yama
- Department of Diagnostic Radiology, Sapporo Medical University School of Medicine, Sapporo, JPN
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Suri TM, Hadda V, Ali S, Chopra A, Khan MA, Singh J, Ghosh T, Mittal S, Tiwari P, Madan K, Mohan A, Guleria R. Association of Leukocyte Subpopulations Identified by Flow Cytometry with Outcomes of Sepsis in a Respiratory Intensive Care Unit: An Observational Study. J Intensive Care Med 2024; 39:125-135. [PMID: 37554063 PMCID: PMC7615840 DOI: 10.1177/08850666231193962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
INTRODUCTION The dysregulated host immune response in sepsis is orchestrated by peripheral blood leukocytes. This study explored the associations of the peripheral blood leukocyte subpopulations with early clinical deterioration and mortality in sepsis. METHODS We performed a prospective observational single-center study enrolling adult subjects with sepsis within 48 h of hospital admission. Peripheral blood flow cytometry was performed for the patients at enrolment and after 5 days. The primary outcome was to explore the association between various leukocyte subpopulations at enrolment and early clinical deterioration [defined as an increase in the sequential organ failure assessment (SOFA) score between enrolment and day 5, or death before day 5]. Other pre-specified outcomes explored associations of leukocyte subpopulations at enrolment and on day 5 with in-hospital mortality. RESULTS A total of 100 patients, including 47 with septic shock were enrolled. The mean (SD) age of the patients was 53.99 (14.93) years. Among them, 26 patients had early clinical deterioration, whereas 41 died during hospitalization. There was no significant association between the leukocyte subpopulations at enrolment and early clinical deterioration on day 5. On multivariate logistic regression, a reduced percentage of CD8 + CD25+ T-cells at enrolment was associated with in-hospital mortality [odds ratio (OR), 0.82 (0.70-0.97); p-value = 0.02]. A reduced lymphocyte percentage on day 5 was associated with in-hospital mortality [OR, 0.28 (0.11-0.69); p-value = 0.01]. In a post-hoc analysis, patients with "very early" deterioration within 48 h had an increased granulocyte CD64 median fluorescent intensity (MFI) [OR, 1.07 (1.01-1.14); p-value = 0.02] and a reduced granulocyte CD16 MFI [OR, 0.97 (0.95-1.00); p-value = 0.04] at enrolment. CONCLUSIONS None of the leukocyte subpopulations showed an association with early clinical deterioration at day 5. Impaired lymphocyte activation and lymphocytopenia indicative of adaptive immune dysfunction may be associated with in-hospital mortality.
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Affiliation(s)
- Tejas Menon Suri
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Vijay Hadda
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Shadab Ali
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Anita Chopra
- Department of Laboratory Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Maroof Ahmad Khan
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Jay Singh
- Department of Laboratory Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Tamoghna Ghosh
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Mittal
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Pawan Tiwari
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Karan Madan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Anant Mohan
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Randeep Guleria
- Department of Pulmonary, Critical Care and Sleep Medicine, All India Institute of Medical Sciences, New Delhi, India
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Inoue S, Nakanishi N, Amaya F, Fujinami Y, Hatakeyama J, Hifumi T, Iida Y, Kawakami D, Kawai Y, Kondo Y, Liu K, Nakamura K, Nishida T, Sumita H, Taito S, Takaki S, Tsuboi N, Unoki T, Yoshino Y, Nishida O. Post-intensive care syndrome: Recent advances and future directions. Acute Med Surg 2024; 11:e929. [PMID: 38385144 PMCID: PMC10879727 DOI: 10.1002/ams2.929] [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: 02/10/2023] [Revised: 12/23/2023] [Accepted: 02/02/2024] [Indexed: 02/23/2024] Open
Abstract
Post-intensive care syndrome comprises physical, cognitive, and mental impairments in patients treated in an intensive care unit (ICU). It occurs either during the ICU stay or following ICU discharge and is related to the patients' long-term prognosis. The same concept also applies to pediatric patients, and it can greatly affect the mental status of family members. In the 10 years since post-intensive care syndrome was first proposed, research has greatly expanded. Here, we summarize the recent evidence on post-intensive care syndrome regarding its pathophysiology, epidemiology, assessment, risk factors, prevention, and treatments. We highlight new topics, future directions, and strategies to overcome post-intensive care syndrome among people treated in an ICU. Clinical and basic research are still needed to elucidate the mechanistic insights and to discover therapeutic targets and new interventions for post-intensive care syndrome.
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Affiliation(s)
- Shigeaki Inoue
- Department of Emergency and Critical Care MedicineWakayama Medical UniversityWakayamaJapan
| | - Nobuto Nakanishi
- Division of Disaster and Emergency Medicine, Department of SurgeryKobe University Graduate School of MedicineKobeJapan
| | - Fumimasa Amaya
- Department of Pain Management and Palliative Care MedicineKyoto Prefectural University of MedicineKyotoJapan
| | - Yoshihisa Fujinami
- Department of Emergency MedicineKakogawa Central City HospitalKakogawaJapan
| | - Junji Hatakeyama
- Department of Emergency and Critical Care MedicineOsaka Medical and Pharmaceutical UniversityTakatsukiJapan
| | - Toru Hifumi
- Department of Emergency and Critical Care MedicineSt. Luke's International HospitalTokyoJapan
| | - Yuki Iida
- Faculty of Physical Therapy, School of Health SciencesToyohashi Sozo UniversityToyohashiJapan
| | - Daisuke Kawakami
- Department of Intensive Care MedicineAso Iizuka HospitalFukuokaJapan
| | - Yusuke Kawai
- Department of NursingFujita Health University HospitalToyoakeJapan
| | - Yutaka Kondo
- Department of Emergency and Critical Care MedicineJuntendo University Urayasu HospitalUrayasuJapan
| | - Keibun Liu
- Critical Care Research GroupThe Prince Charles HospitalChermsideQueenslandAustralia
- Faculty of MedicineThe University of Queensland, Mayne Medical SchoolHerstonQueenslandAustralia
- Non‐Profit Organization ICU Collaboration Network (ICON)TokyoJapan
| | - Kensuke Nakamura
- Department of Critical Care MedicineYokohama City University School of MedicineYokohamaJapan
| | - Takeshi Nishida
- Division of Trauma and Surgical Critical CareOsaka General Medical CenterOsakaJapan
| | | | - Shunsuke Taito
- Division of Rehabilitation, Department of Clinical Practice and SupportHiroshima University HospitalHiroshimaJapan
| | - Shunsuke Takaki
- Department of Critical Care MedicineYokohama City University School of MedicineYokohamaJapan
| | - Norihiko Tsuboi
- Division of Critical Care Medicine, Department of Critical Care and AnesthesiaNational Center for Child Health and DevelopmentSetagayaJapan
| | - Takeshi Unoki
- Department of Acute and Critical Care Nursing, School of NursingSapporo City UniversitySapporoJapan
- Teine Keijinkai HospitalSapporoJapan
| | - Yasuyo Yoshino
- Department of Nursing, Faculty of NursingKomazawa Women's UniversityTokyoJapan
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care MedicineFujita Health University School of MedicineToyoakeJapan
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10
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Kumar A, Hammond N, Abbenbroek B, Thompson K, Taylor C, Venkatesh B, Delaney A, Finfer S. Sepsis-coded hospitalisations and associated costs in Australia: a retrospective analysis. BMC Health Serv Res 2023; 23:1319. [PMID: 38031109 PMCID: PMC10688047 DOI: 10.1186/s12913-023-10223-1] [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: 04/18/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
OBJECTIVE To report trends in Australian hospitalisations coded for sepsis and their associated costs. DESIGN Retrospective analysis of Australian national hospitalisation data from 2002 to 2021. METHODS Sepsis-coded hospitalisations were identified using the Global Burden of Disease study sepsis-specific ICD-10 codes modified for Australia. Costs were calculated using Australian-Refined Diagnosis Related Group codes and National Hospital Cost Data Collection. RESULTS Sepsis-coded hospitalisations increased from 36,628 in 2002-03 to 131,826 in 2020-21, an annual rate of 7.8%. Principal admission diagnosis codes contributed 13,843 (37.8%) in 2002-03 and 44,186 (33.5%) in 2020-21; secondary diagnosis codes contributed 22,785 (62.2%) in 2002-03 and 87,640 (66.5%) in 2020-21. Unspecified sepsis was the most common sepsis code, increasing from 15,178 hospitalisations in 2002-03 to 68,910 in 2020-21. The population-based incidence of sepsis-coded hospitalisations increased from 18.6 to 10,000 population (2002-03) to 51.3 per 10,000 (2021-21); representing an increase from 55.1 to 10,000 hospitalisations in 2002-03 to 111.4 in 2020-21. Sepsis-coded hospitalisations occurred more commonly in the elderly; those aged 65 years or above accounting for 20,573 (55.6%) sepsis-coded hospitalisations in 2002-03 and 86,135 (65.3%) in 2020-21. The cost of sepsis-coded hospitalisations increased at an annual rate of 20.6%, from AUD199M (€127 M) in financial year 2012 to AUD711M (€455 M) in 2019. CONCLUSION Hospitalisations coded for sepsis and associated costs increased significantly from 2002 to 2021 and from 2012 to 2019, respectively.
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Affiliation(s)
- Ashwani Kumar
- Critical Care Program, The George Institute for Global Health, Sydney, NSW, Australia.
- University of New South Wales, Sydney, Australia.
| | - Naomi Hammond
- Critical Care Program, The George Institute for Global Health, Sydney, NSW, Australia
- Royal North Shore Hospital, Sydney, NSW, Australia
- University of New South Wales, Sydney, Australia
| | - Brett Abbenbroek
- Critical Care Program, The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, Australia
| | - Kelly Thompson
- Critical Care Program, The George Institute for Global Health, Sydney, NSW, Australia
- Nepean Blue Mountains LHD, Sydney, NSW, Australia
- University of New South Wales, Sydney, Australia
| | - Colman Taylor
- Critical Care Program, The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, Australia
| | - Bala Venkatesh
- Critical Care Program, The George Institute for Global Health, Sydney, NSW, Australia
- Princess Alexandra Hospital, Brisbane, QLD, Australia
- University of New South Wales, Sydney, Australia
| | - Anthony Delaney
- Critical Care Program, The George Institute for Global Health, Sydney, NSW, Australia
- Royal North Shore Hospital, Sydney, NSW, Australia
- University of New South Wales, Sydney, Australia
| | - Simon Finfer
- Critical Care Program, The George Institute for Global Health, Sydney, NSW, Australia
- School of Public Health, Imperial College London, London, UK
- University of New South Wales, Sydney, Australia
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11
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Sacha GL, Bauer SR. Optimizing Vasopressin Use and Initiation Timing in Septic Shock: A Narrative Review. Chest 2023; 164:1216-1227. [PMID: 37479058 PMCID: PMC10635838 DOI: 10.1016/j.chest.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/23/2023] Open
Abstract
TOPIC IMPORTANCE This review discusses the rationale for vasopressin use, summarizes the results of clinical trials evaluating vasopressin, and focuses on the timing of vasopressin initiation to provide clinicians guidance for optimal adjunctive vasopressin initiation in patients with septic shock. REVIEW FINDINGS Patients with septic shock require vasoactive agents to restore adequate tissue perfusion. After norepinephrine, vasopressin is the suggested second-line adjunctive agent in patients with persistent inadequate mean arterial pressure. Vasopressin use in practice is heterogeneous likely because of inconsistent clinical trial findings, the lack of specific recommendations for when it should be used, and the high drug acquisition cost. Despite these limitations, vasopressin has demonstrated price inelastic demand, and its use in the United States has continued to increase. However, questions remain regarding optimal vasopressin use in patients with septic shock, particularly regarding patient selection and the timing of vasopressin initiation. SUMMARY Experimental studies evaluating the initiation timing of vasopressin in patients with septic shock are limited, and recent observational studies have revealed an association between vasopressin initiation at lower norepinephrine-equivalent doses or lower lactate concentrations and lower mortality.
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Affiliation(s)
- Gretchen L Sacha
- Department of Pharmacy, Cleveland Clinic, Case Western Reserve University, Cleveland, OH.
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Case Western Reserve University, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, Cleveland, OH
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12
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Zhao J, Pan X, Hao D, Zhao Y, Chen Y, Zhou S, Peng H, Zhuang Y. Causal associations of gut microbiota and metabolites on sepsis: a two-sample Mendelian randomization study. Front Immunol 2023; 14:1190230. [PMID: 37781358 PMCID: PMC10537222 DOI: 10.3389/fimmu.2023.1190230] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Background Sepsis stands as a dire medical condition, arising when the body's immune response to infection spirals into overdrive, paving the way for potential organ damage and potential mortality. With intestinal flora's known impact on sepsis but a dearth of comprehensive data, our study embarked on a two-sample Mendelian randomization analysis to probe the causal link between gut microbiota and their metabolites with severe sepsis patients who succumbed within a 28-day span. Methods Leveraging data from Genome-wide association study (GWAS) and combining it with data from 2,076 European descendants in the Framingham Heart Study, single-nucleotide polymorphisms (SNPs) were employed as Instrumental Variables (IVs) to discern gene loci affiliated with metabolites. GWAS summary statistics for sepsis were extracted from the UK Biobank consortium. Results In this extensive exploration, 93 distinct genome-wide significant SNPs correlated with gut microbial metabolites and specific bacterial traits were identified for IVs construction. Notably, a substantial link between Coprococcus2 and both the incidence (OR of 0.80, 95% CI: 0.68-0.94, P=0.007) and the 28-day mortality rate (OR 0.48, 95% CI: 0.27-0.85, P=0.013) of sepsis was observed. The metabolite α-hydroxybutyrate displayed a marked association with sepsis onset (OR=1.08, 95% CI: 1.02-1.15, P=0.006) and its 28-day mortality rate (OR=1.17, 95% CI: 1.01-1.36, P=0.029). Conclusion This research unveils the intricate interplay between the gut microbial consortium, especially the genus Coprococcus, and the metabolite α-hydroxybutyrate in the milieu of sepsis. The findings illuminate the pivotal role of intestinal microbiota and their metabolites in sepsis' pathogenesis, offering fresh insights for future research and hinting at novel strategies for sepsis' diagnosis, therapeutic interventions, and prognostic assessments.
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Affiliation(s)
- Jian Zhao
- Department of Emergency, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xin Pan
- Department of Gerontology, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Di Hao
- Department of Emergency, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yi Zhao
- Department of Emergency, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuanzhuo Chen
- Department of Emergency, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shuqin Zhou
- Department of Emergency, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hu Peng
- Department of Emergency, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yugang Zhuang
- Department of Emergency, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
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13
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Holler JG, Jensen JUS, Engsig FN, Bestle MH, Lindegaard B, Rasmussen JH, Bundgaard H, Nielsen FE, Iversen KK, Larsen JJ, Holzknecht BJ, Boel J, Sivapalan P, Itenov TS. Existing Data Sources in Clinical Epidemiology: Database of Community Acquired Infections Requiring Hospital Referral in Eastern Denmark (DCAIED) 2018-2021. Clin Epidemiol 2023; 15:939-955. [PMID: 37700929 PMCID: PMC10493095 DOI: 10.2147/clep.s413403] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 07/21/2023] [Indexed: 09/14/2023] Open
Abstract
Infectious diseases are major health care challenges globally and a prevalent cause of admission to emergency departments. Epidemiologic characteristics and outcomes based on population level data are limited. The Database of Community Acquired Infections in Eastern Denmark (DCAIED) 2018-2021 was established with the aim to explore and estimate the population characteristics, and outcomes of patients suffering from community acquired infections at the emergency departments in the Capital Region and the Zealand Region of Denmark using data from electronic medical records. Adult patients (≥18 years) presenting to the emergency department with suspected or confirmed infection are included in the cohort. Presence of sepsis and organ failure are assessed using modified criteria from the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). During the inclusion period from January 2018 to January 2022, 2,241,652 adult emergency department visits have been registered. Of these, 451,825 were unique encounters of which 60,316 fulfilled criteria of suspected infection and 28,472 fulfilled sepsis criteria and 8,027 were defined as septic shock. The database covers the entire Capital and Zealand Region of Denmark with an uptake area of 2.6 million inhabitants and includes demographic, laboratory and outcome indicators, with complete follow-up. The database is well-suited for epidemiological research for future national and international collaborations.
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Affiliation(s)
- Jon Gitz Holler
- Department of Pulmonary and Infectious Diseases, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Jens Ulrik Stæhr Jensen
- Department of Medicine, Section of Respiratory Medicine, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- PERSIMUNE & CHIP: Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Frederik Neess Engsig
- Department of Emergency Medicine, Copenhagen University Hospital – Amager and Hvidovre, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthesia and Intensive Care Medicine, Copenhagen University Hospital – North Zealand, Hilleroed, Denmark
| | - Birgitte Lindegaard
- Department of Pulmonary and Infectious Diseases, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Centre for Physical Activity, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Jens Henning Rasmussen
- Department of Emergency Medicine, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Henning Bundgaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, The Capital Region’s Unit of Inherited Cardiac Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Finn Erland Nielsen
- Department of Emergency Medicine, Copenhagen University Hospital – Bispebjerg and Frederiksberg, Copenhagen, Denmark
| | - Kasper Karmark Iversen
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Emergency Medicine, Copenhagen University Hospital – Herlev and Gentofte, Copenhagen, Denmark
| | - Jesper Juul Larsen
- Department of Emergency Medicine, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Barbara Juliane Holzknecht
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
| | - Jonas Boel
- Department of Clinical Microbiology, Copenhagen University Hospital - Herlev and Gentofte, Copenhagen, Denmark
- Copenhagen University Hospital - Capital Region Pharmacy, Copenhagen, Denmark
| | - Pradeesh Sivapalan
- Department of Medicine, Section of Respiratory Medicine, Copenhagen University Hospital - Herlev and Gentofte Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Theis Skovsgaard Itenov
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anesthesiology and Intensive Care Medicine, Copenhagen University Hospital - Bispebjerg and Frederiksberg, Copenhagen, Denmark
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14
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Soubani AO, Sharma A, Soubani O, Mishra T. Septic Shock Short-Term Outcomes in Patients With Psychiatric Disorders: Analysis From the National Inpatient Sample Database. J Acad Consult Liaison Psychiatry 2023; 64:436-443. [PMID: 36972754 DOI: 10.1016/j.jaclp.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 03/20/2023] [Accepted: 03/22/2023] [Indexed: 03/29/2023]
Abstract
BACKGROUND Major psychiatric disorders are associated with lower life expectancy primarily due to comorbid illnesses and suboptimal access to health care. Large-scale contemporary data in the United States on in-hospital mortality of patients with major psychiatric disorder and sepsis are lacking. OBJECTIVE To describe the short-term outcomes of hospitalized patients with major psychiatric disorders and septic shock. METHODS We performed a retrospective cohort study using the National Inpatient Sample database from 2016 to 2019 to identify septic shock hospitalizations in patients with versus without major psychiatric disorder (defined as schizophrenia and affective disorders). Baseline variables and in-hospital mortality trends were compared between the 2 groups. RESULTS Out of 1,653,255 hospitalizations with septic shock identified between 2016 and 2019, 16.2% had a diagnosis of major psychiatric disorder as defined above. After adjusting for various patient-level and hospital-level demographics and coexisting clinical conditions in a multivariable logistic regression, the odds of in-hospital mortality in patients with any major psychiatric disorder were 0.71 times that of those without a diagnosis of psychiatric illness (95% confidence interval [CI], 0.69-0.73; P < 0.001). Similarly, when the disorders were divided into 2 categories for subanalysis, those with schizophrenia had 38% lower odds of dying compared to those without schizophrenia (adjusted odds ratio, 0.62; 95% CI, 0.58-0.66; P < 0.001). Those with affective disorders had 25% lower odds of in-hospital mortality than those without a diagnosis of an affective disorder (adjusted odds ratio, 0.75; 95% CI, 0.73-0.77; P < 0.001). The adjusted mean length of stay for those diagnosed with major psychiatric disorder was 0.38 days longer than those without significant psychiatric illness (95% CI, 0.28-0.49; P < 0.001). On the other hand, the mean hospitalization charges were $10,516 less for patients with a major psychiatric disorder compared to those without (95% CI, -$11,830 to -$9,201; P < 0.001). CONCLUSIONS Hospitalized patients with major psychiatric disorder and septic shock had lower risk of short-term mortality. Further studies are needed to examine the reasons behind this lower in-hospital mortality risk.
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Affiliation(s)
- Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, MI.
| | - Aditi Sharma
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI
| | - Omar Soubani
- Department of Psychiatry and Behavioral Neurosciences, Wayne State University School of Medicine, Detroit, MI
| | - Tushar Mishra
- Department of Internal Medicine, Wayne State University School of Medicine, Detroit, MI
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15
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Wiss AL, Doepker BA, Hoyte B, Olson LM, Disney KA, McLaughlin EM, Esguerra V, Elefritz JL. Impact of initial fluid resuscitation volume on clinical outcomes in patients with heart failure and septic shock. JOURNAL OF INTENSIVE MEDICINE 2023; 3:254-260. [PMID: 37533810 PMCID: PMC10391556 DOI: 10.1016/j.jointm.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 04/13/2023] [Accepted: 05/08/2023] [Indexed: 08/04/2023]
Abstract
Background Fluid resuscitation is a key treatment for sepsis, but limited data exists in patients with existing heart failure (HF) and septic shock. The objective of this study was to determine the impact of initial fluid resuscitation volume on outcomes in HF patients with reduced or mildly reduced left ventricular ejection fraction (LVEF) with septic shock. Methods This multicenter, retrospective, cohort study included patients with known HF (LVEF ≤50%) presenting with septic shock. Patients were divided into two groups based on the volume of fluid resuscitation in the first 6 h; <30 mL/kg or ≥30 mL/kg. The primary outcome was a composite of in-hospital mortality or renal replacement therapy (RRT) within 7 days. Secondary outcomes included acute kidney injury (AKI), initiation of mechanical ventilation, and length of stay (LOS). All related data were collected and compared between the two groups. A generalized logistic mixed model was used to assess the association between fluid groups and the primary outcome while adjusting for baseline LVEF, Acute Physiology and Chronic Health Evaluation (APACHE) II score, inappropriate empiric antibiotics, and receipt of corticosteroids. Results One hundred and fifty-four patients were included (93 patients in <30 mL/kg group and 61 patients in ≥30 mL/kg group). The median weight-based volume in the first 6 h was 17.7 (12.2-23.0) mL/kg in the <30 mL/kg group vs. 40.5 (34.2-53.1) mL/kg in the ≥30 mL/kg group (P <0.01). No statistical difference was detected in the composite of in-hospital mortality or RRT between the <30 mL/kg group compared to the ≥30 mL/kg group (55.9% vs. 45.9%, P=0.25), respectively. The <30 mL/kg group had a higher incidence of AKI, mechanical ventilation, and longer hospital LOS. Conclusions In patients with known reduced or mildly reduced LVEF presenting with septic shock, no difference was detected for in-hospital mortality or RRT in patients who received ≥30 mL/kg of resuscitation fluid compared to less fluid, although this study was underpowered to detect a difference. Importantly, ≥30 mL/kg fluid did not result in a higher need for mechanical ventilation.
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Affiliation(s)
- Adam L. Wiss
- Department of Pharmacy, Ascension Saint Thomas Hospital West, Nashville, TN 37205, USA
| | - Bruce A. Doepker
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Brittany Hoyte
- Department of Pharmacy, Corewell Health, Grand Rapids, MI 49503, USA
| | - Logan M. Olson
- Department of Pharmacy, Nebraska Medicine, Omaha, NE 68105, USA
| | - Kathryn A. Disney
- Department of Pharmacy, Huntsman Cancer Institute at the University of Utah, Salt Lake City, UT 84112, USA
| | - Eric M. McLaughlin
- Center for Biostatistics, The Ohio State University, Columbus, OH 43210, USA
| | - Vincent Esguerra
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine. The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Jessica L. Elefritz
- Department of Pharmacy, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
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16
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Cull J, Brevetta R, Gerac J, Kothari S, Blackhurst D. Epic Sepsis Model Inpatient Predictive Analytic Tool: A Validation Study. Crit Care Explor 2023; 5:e0941. [PMID: 37405252 PMCID: PMC10317482 DOI: 10.1097/cce.0000000000000941] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2023] Open
Abstract
Earlier treatment of sepsis leads to decreased mortality. Epic is an electronic medical record providing a predictive alert system for sepsis, the Epic Sepsis Model (ESM) Inpatient Predictive Analytic Tool. External validation of this system is lacking. This study aims to evaluate the ESM as a sepsis screening tool and determine whether an association exists between ESM alert system implementation and subsequent sepsis-related mortality. DESIGN Before-and-after study comparing baseline and intervention period. SETTING Urban 746-bed academic level 1 trauma center. PATIENTS Adult acute care inpatients discharged between January 12, 2018, and July 31, 2019. INTERVENTIONS During the before period, ESM was turned on in the background, but nurses and providers were not alerted of results. The system was then activated to alert providers of scores greater than or equal to 5, a set point determined using receiver operating characteristic curve analysis (area under the curve, 0.834; p < 0.001). MEASUREMENTS AND MAIN RESULTS Primary outcome was mortality during hospitalization; secondary outcomes were sepsis order set utilization, length of stay, and timing of administration of sepsis-appropriate antibiotics. Of the 11,512 inpatient encounters assessed by ESM, 10.2% (1,171) had sepsis based on diagnosis codes. As a screening test, the ESM had sensitivity, specificity, positive predictive value, and negative predictive value rates of 86.0%, 80.8%, 33.8%, and 98.11%, respectively. After ESM implementation, unadjusted mortality rates in patients with ESM score greater than or equal to 5 and who had not yet received sepsis-appropriate antibiotics declined from 24.3% to 15.9%; multivariable analysis yielded an odds ratio of sepsis-related mortality (95% CI) of 0.56 (0.39-0.80). CONCLUSIONS In this single-center before-and-after study, utilization of the ESM score as a screening test was associated with a 44% reduction in the odds of sepsis-related mortality. Due to wide utilization of Epic, this is a potentially promising tool to improve sepsis mortality in the United States. This study is hypothesis generating, and further work with more rigorous study design is needed.
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Affiliation(s)
- John Cull
- All authors: Prisma Health, Greenville, SC
| | | | - Jeff Gerac
- All authors: Prisma Health, Greenville, SC
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17
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Kadri SS, Warner S, Rhee C, Klompas M, Follmann D, Swihart BJ, Laxminarayan R, Klein E. Early Discontinuation of Antibiotics in Patients Admitted With Clinically Suspected Serious Infection but Negative Cultures: Retrospective Cohort Study of Practice Patterns and Outcomes at 111 US Hospitals. Open Forum Infect Dis 2023; 10:ofad286. [PMID: 37449298 PMCID: PMC10336666 DOI: 10.1093/ofid/ofad286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 05/19/2023] [Indexed: 07/18/2023] Open
Abstract
Background The optimal duration for antibiotics in patients hospitalized with culture-negative serious infection (CNSI) is unknown. We compared outcomes in patients with CNSI treated with 3 or 4 vs ≥5 days of antibiotics. Methods CNSI was identified among adults admitted to 111 US hospitals between 2009 and 2014 via electronic health record data, defined as suspected serious infection (blood cultures drawn and ≥3 days of antibiotics) and negative culture- and nonculture-based tests for infection. Patients treated with antibiotics on their last hospital day and patients with diagnosis codes for sepsis-mimicking conditions were excluded. Among patients without fevers/hypothermia or vasopressors by day 3, we calculated odds ratios for in-hospital mortality or discharge to hospice associated with 3 or 4 vs ≥5 days of antibiotics, adjusting for confounders. Results Antibiotics were discontinued in 3 or 4 days in 1862 (9%) of 20 714 patients with CNSI. Early discontinuation was not associated with higher mortality odds overall (adjusted odds ratio [aOR], 1.27; 95% CI, .98-1.65), in patients presenting with (1.39; .88-2.22) and without sepsis (1.17; .81-1.69), and in those with pulmonary (1.23; .65-2.34) and nonpulmonary CNSI (1.30; .99-1.72). Early discontinuation appeared detrimental with propensity score weighting (aOR, 1.36; 95% CI, 1.03-1.80) and when retaining patients with sepsis mimics (1.38; 1.16-1.65), but it was protective (0.48; .37-.64]) when retaining patients who received antibiotics on their last hospital day. Conclusions Early discontinuation of antibiotics in CNSI was not associated with significant harm in our primary analysis, but different conclusions based on alternative analytic decisions, as well as risk of residual confounding, indicate that randomized controlled trials are needed.
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Affiliation(s)
- Sameer S Kadri
- Clinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Sarah Warner
- Clinical Epidemiology Section, Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
- Critical Care Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD
| | - Chanu Rhee
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Dean Follmann
- Department of Biostatistics, National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | - Bruce J Swihart
- Department of Biostatistics, National Institute of Allergy and Infectious Diseases, Bethesda, MD
| | | | - Eili Klein
- One Health Trust, Washington, DC
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD
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18
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Wahab A, Smith RJ, Lal A, Flurin L, Malinchoc M, Dong Y, Gajic O. CHARACTERISTICS AND PREDICTORS OF PATIENTS WITH SEPSIS WHO ARE CANDIDATES FOR MINIMALLY INVASIVE APPROACH OUTSIDE OF INTENSIVE CARE UNIT. Shock 2023; 59:702-707. [PMID: 36870069 PMCID: PMC10125105 DOI: 10.1097/shk.0000000000002112] [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: 12/23/2022] [Accepted: 02/22/2023] [Indexed: 03/06/2023]
Abstract
ABSTRACT Objective: To identify and describe characteristics of patients with sepsis who could be treated with minimally invasive sepsis (MIS) approach without intensive care unit (ICU) admission and to develop a prediction model to select candidates for MIS approach. Methods: A secondary analysis of the electronic database of patients with sepsis at Mayo Clinic, Rochester, MN. Candidates for the MIS approach were adults with septic shock and less than 48 hours of ICU stay, who did not require advanced respiratory support and were alive at hospital discharge. Comparison group consisted of septic shock patients with an ICU stay of more than 48 hours without advanced respiratory support at the time of ICU admission. Results: Of 1795 medical ICU admissions, 106 patients (6%) met MIS approach criteria. Predictive variables (age >65 years, oxygen flow >4 L/min, temperature <37°C, creatinine >1.6 mg/dL, lactate >3 mmol/L, white blood cells >15 × 10 9 /L, heart rate >100 beats/min, and respiration rate >25 breaths/min) selected through logistic regression were translated into an 8-point score. Model discrimination yielded the area under the receiver operating characteristic curve of 79% and was well fitted (Hosmer-Lemeshow P = 0.94) and calibrated. The MIS score cutoff of 3 resulted in a model odds ratio of 0.15 (95% confidence interval, 0.08-0.28) and a negative predictive value of 91% (95% confidence interval, 88.69-92.92). Conclusions: This study identifies a subset of low-risk septic shock patients who can potentially be managed outside the ICU. Once validated in an independent, prospective sample our prediction model can be used to identify candidates for MIS approach.
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Affiliation(s)
- Abdul Wahab
- Department of Hospital Medicine, Mayo Clinic Health System, Mankato, Minnesota
| | - Ryan J. Smith
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Amos Lal
- Department of Medicine, Division of Pulmonary and Critical Care Medicine. Mayo Clinic, Rochester, Minnesota
| | - Laure Flurin
- Division of Clinical Microbiology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
- Department of Intensive Care, University Hospital of Guadeloupe, Pointe-à-Pitre, France
| | | | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Ognjen Gajic
- Department of Medicine, Division of Pulmonary and Critical Care Medicine. Mayo Clinic, Rochester, Minnesota
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Wang J, Jiang L, Ding S, He SY, Liu SB, Lu ZJ, Liu YZ, Hou LW, Wang BS, Zhang JB. Early Enteral Nutrition and Sepsis-Associated Acute Kidney Injury: A Propensity Score Matched Cohort Study Based on the MIMIC-III Database. Yonsei Med J 2023; 64:259-268. [PMID: 36996897 PMCID: PMC10067798 DOI: 10.3349/ymj.2022.0276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 12/31/2022] [Accepted: 02/01/2023] [Indexed: 04/01/2023] Open
Abstract
PURPOSE We aimed to analyze the optimal timing of enteral nutrition (EN) in the treatment of sepsis and its effect on sepsis-associated acute kidney injury (SA-AKI.). MATERIALS AND METHODS The MIMIC-III database was employed to identify patients with sepsis who had received EN. With AKI as the primary outcome variable, receiver operating characteristic (ROC) curves were utilized to calculate the optimal cut-off time of early EN (EEN). Propensity score matching (PSM) was employed to control confounding effects. Logistic regressions and propensity score-based inverse probability of treatment weighting were utilized to assess the robustness of our findings. Comparisons within the EEN group were performed. RESULTS 2364 patients were included in our study. With 53 hours after intensive care units (ICU) admission as the cut-off time of EEN according to the ROC curve, 1212 patients were assigned to the EEN group and the other 1152 to the delayed EN group. The risk of SA-AKI was reduced in the EEN group (odds ratio 0.319, 95% confidence interval 0.245-0.413, p<0.001). The EEN patients received fewer volumes (mL) of intravenous fluid (IVF) during their ICU stay (3750 mL vs. 5513.23 mL, p<0.001). The mediating effect of IVF was significant (p<0.001 for the average causal mediation effect). No significant differences were found within the EEN group (0-48 hours vs. 48-53 hours), except that patients initiating EN within 48 hours spent fewer days in ICU and hospital. CONCLUSION EEN is associated with decreased risk of SA-AKI, and this beneficial effect may be proportionally mediated by IVF volume.
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Affiliation(s)
- Jun Wang
- Department of Cardiovascular Surgery, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Li Jiang
- Department of Cardiovascular Surgery, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Sheng Ding
- Department of Cardiovascular Surgery, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Si-Yi He
- Department of Cardiovascular Surgery, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Shun-Bi Liu
- Department of Cardiovascular Surgery, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Zhong-Jie Lu
- Department of Cardiovascular Surgery, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Yuan-Zhang Liu
- Department of Cardiovascular Surgery, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Li-Wen Hou
- Department of Cardiovascular Surgery, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Bin-Su Wang
- Department of Cardiovascular Surgery, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China
| | - Jin-Bao Zhang
- Department of Cardiovascular Surgery, People's Liberation Army The General Hospital of Western Theater Command, Chengdu, Sichuan, China.
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Is venoarterial extracorporeal membrane oxygenation an option for managing septic shock. Curr Opin Anaesthesiol 2023; 36:45-49. [PMID: 36550604 DOI: 10.1097/aco.0000000000001206] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW To describe sepsis-induced cardiomyopathy. Discuss indications and current evidence of using venoarterial extracorporeal membrane oxygenation (VA-ECMO) in setting of sepsis-induced cardiomyopathy. RECENT FINDINGS Recent data suggests a survival benefit with the use of VA-ECMO in patients with septic shock complicated by septic-induced cardiomyopathy with severe left ventricular systolic dysfunction. VA-ECMO was associated with poor outcomes in adults with septic shock without severe systolic dysfunction. The evidence is generated from retrospective and meta-analysis of observational studies. SUMMARY Sepsis-induced cardiomyopathy is an increasingly recognized entity characterized by reversible ventricular dysfunction in the setting of sepsis. When hypotension persists despite standard management of septic shock (e.g. adequate fluid resuscitation, vasopressors, inotropes) and there is evidence of severe cardiac systolic dysfunction and end-organ hypoperfusion, VA-ECMO should be considered as a bridge therapy to recovery. VA-ECMO should not be used for isolated vasodilatory septic shock without significant myocardial dysfunction.
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Luo M, He Q. Development of a prognostic nomogram for sepsis associated-acute respiratory failure patients on 30-day mortality in intensive care units: a retrospective cohort study. BMC Pulm Med 2023; 23:43. [PMID: 36717800 PMCID: PMC9885567 DOI: 10.1186/s12890-022-02302-6] [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: 11/18/2021] [Accepted: 05/23/2022] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Acute respiratory failure is a type of sepsis complicated by severe organ failure. We have developed a new nomogram for predicting the 30-day risk of death in patients through a retrospective study. METHOD Data was collected and extracted from MIMICIV, with 768 eligible cases randomly assigned to the primary cohort (540) and the validation cohort (228). The final six factors were included by Cox regression analysis to create the Nomogram, the accuracy of the Nomogram was assessed using the C-index and calibration curve, and finally, the clinical usefulness of the Nomogram was evaluated using DCA in. RESULTS Multivariate Cox regression analysis showed that age, DBP, lactate, PaO2, platelet, mechanical ventilation were independent factors for 30-day mortality of SA-ARF. The nomogram established based on the six factors. The C-index of nomogram in the primary cohort is 0.731 (95% CI 0.657-0.724) and 0.722 (95%CI 0.622-0.759) in the validation cohort. Besides, the decision curve analysis (DCA) confirmed the clinical usefulness of the nomogram. CONCLUSION The study developed and validated a risk prediction model for SA-ARF patients that can help clinicians reasonably determine disease risk and further confirm its clinical utility using internal validation.
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Affiliation(s)
- Mengdi Luo
- grid.263901.f0000 0004 1791 7667Southwest Jiaotong University of Medicine/Southwest Jiaotong University Affiliated Chengdu Third People’s Hospital, Chengdu, 610031 Sichuan China
| | - Qing He
- grid.263901.f0000 0004 1791 7667Southwest Jiaotong University of Medicine/Southwest Jiaotong University Affiliated Chengdu Third People’s Hospital, Chengdu, 610031 Sichuan China
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Quispe-Cornejo AA, Crippa IA, Bakos P, Dominguez-Faure A, Creteur J, Taccone FS. Correlation between heart rate variability and cerebral autoregulation in septic patients. Auton Neurosci 2023; 244:103051. [PMID: 36493585 DOI: 10.1016/j.autneu.2022.103051] [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: 11/28/2021] [Revised: 10/20/2022] [Accepted: 11/09/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Heart rate variability (HRV) may provide an estimation of the autonomous nervous system (ANS) integrity in critically ill patients. Disturbances of cerebral autoregulation (CAR) may share common pathways of ANS dysfunction. AIM To explore whether changes in HRV and CAR index correlate in critically ill septic patients. METHODS Prospectively collected data on septic adult (> 18 years) patients admitted into a mixed Intensive Care between February 2016 and August 2019 with a recorded transcranial doppler CAR assessment. CAR was assessed calculating the Pearson's correlation coefficient (i.e. mean flow index, Mxa) between the left middle cerebral artery flow velocity (FV), insonated with a 2-MHz probe, and invasive blood pressure (BP) signal, both recorded simultaneously through a Doppler Box (DWL, Germany). MATLAB software was used for CAR assessment using a validated script; a Mxa >0.3 was considered as impaired CAR. HRV was assessed during the same time period using a specific software (Kubios HRV 3.2.0) and analyzed in both time-domain and frequency domain methods. Correlation between HRV-derived variables and Mxa were assessed using the Spearman's coefficient. RESULTS A total of 141 septic patients was studied; median Mxa was 0.35 [0.13-0.60], with 77 (54.6 %) patients having an impaired CAR. Mxa had a significant although weak correlation with HRV time domain (SDNN, r = 0.17, p = 0.04; RMSSD, r = 0.18, p = 0.03; NN50, r = 0.23, p = 0.006; pNN50, r = 0.23, p = 0.007), frequency domain (FFT-HF, r = 0.21; p = 0.01; AR-HF, r = 0.19; p = 0.02), and non-linear domain (SD1, r = 0.18, p = 0.03) parameters. Impaired CAR patients had also all of these HRV-derived parameters higher than those with intact CAR. CONCLUSIONS In this exploratory study, a potential association of ANS dysfunction and impaired CAR during sepsis was observed.
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Affiliation(s)
- Armin Alvaro Quispe-Cornejo
- Department of Intensive Care, Erasme University Hospital, Brussels, Belgium; Instituto Académico Científico Quispe-Cornejo, INAAQC, La Paz, Bolivia.
| | | | - Péter Bakos
- Department of Intensive Care, Erasme University Hospital, Brussels, Belgium; Instituto Académico Científico Quispe-Cornejo, INAAQC, La Paz, Bolivia
| | | | - Jacques Creteur
- Department of Intensive Care, Erasme University Hospital, Brussels, Belgium
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Defining Exposure Predictors of Meropenem That Are Associated with Improved Survival for Severe Bacterial Infection: A Preclinical PK/PD Study in Sepsis Rat Model. Antibiotics (Basel) 2022; 11:antibiotics11111660. [PMID: 36421304 PMCID: PMC9686672 DOI: 10.3390/antibiotics11111660] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/08/2022] [Accepted: 11/17/2022] [Indexed: 11/22/2022] Open
Abstract
Background: The pharmacokinetic/pharmacodynamic (PK/PD) index of carbapenems that best correlates with in vivo antimicrobial activity is percent time of dosing interval in which free drug concentration remains above MIC (%fT > MIC), while the magnitudes of the PK/PD index of carbapenems remains undefined in critically ill sepsis patients. Methods: A sepsis rat model was first developed by comparing the survival outcomes after intraperitoneal injection of different inoculum size (1−10 × 107 CFU) of Pseudomonas aeruginosa ATCC9027 (MIC = 0.125 mg/L) in neutropenic rats. The PK characteristics of the model drug meropenem in the developed sepsis rat model was then evaluated, and PK modeling and simulation was applied to design meropenem dosing regimens attaining various PD targets (40%fT > MIC, 100%fT > MIC, and 100%fT > 4 × MIC). The microbiological response and survival outcomes for different meropenem treatment regimens were investigated in the rat sepsis model (n = 12 for each group). Results: The optimal inoculum for the rat sepsis model was 1 × 107 CFU of Pseudomonas aeruginosa ATCC9027. A one-compartment model with first-order absorption best described the PK of meropenem in sepsis rats. Pronounced survival prolongation and lower hazard risk were observed in the treatment groups of 50 or 75 mg/kg/q2.4h (100%fT > MIC) and 75 mg/kg/q2h (100%fT > 4 × MIC) compared to the 75 mg/kg/q6h (40%fT > MIC) group, while meropenem groups with PD targets of 100%fT > MIC and 100%fT > 4 × MIC showed comparable survival curves. Microbiological response for different PD targets is inconclusive due to irregular bacterial counts in blood samples. Conclusions: The PD target of 40%fT > MIC is suboptimal for sepsis rats, and the aggressive 100%fT > 4 × MIC target does not provide a survival benefit against the target of 100%fT > MIC.
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Accuracy of International Classification of Diseases, 10th Revision Codes for Identifying Sepsis: A Systematic Review and Meta-Analysis. Crit Care Explor 2022; 4:e0788. [PMID: 36382338 PMCID: PMC9649267 DOI: 10.1097/cce.0000000000000788] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
UNLABELLED Administrative databases are increasingly used in research studies to capture clinical outcomes such as sepsis. This systematic review and meta-analysis examines the accuracy of International Classification of Diseases, 10th revision (ICD-10), codes for identifying sepsis in adult and pediatric patients. DATA SOURCES We searched MEDLINE, EMBASE, Web of Science, CENTRAL, Epistemonikos, and McMaster Superfilters from inception to September 7, 2021. STUDY SELECTION We included studies that validated the accuracy of sepsis ICD-10 codes against any reference standard. DATA EXTRACTION Three authors, working in duplicate, independently extracted data. We conducted meta-analysis using a random effects model to pool sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). We evaluated individual study risk of bias using the Quality Assessment of Diagnostic Accuracy Studies tool and assessed certainty in pooled diagnostic effect measures using the Grading of Recommendations Assessment, Development, and Evaluation framework. DATA SYNTHESIS Thirteen eligible studies were included in the qualitative synthesis and the meta-analysis. Eleven studies used manual chart review as the reference standard, and four studies used registry databases. Only one study evaluated pediatric patients exclusively. Compared with the reference standard of detailed chart review and/or registry databases, the pooled sensitivity for sepsis ICD-10 codes was 35% (95% CI, 22-48, low certainty), whereas the pooled specificity was 98% (95% CI: 98-99, low certainty). The PPV for ICD-10 codes ranged from 9.8% to 100% (median, 72.0%; interquartile range [IQR], 50.0-84.7%). NPV ranged from 54.7% to 99.1% (median, 95.9%; interquartile range, 85.5-98.3%). CONCLUSIONS Sepsis is undercoded in administrative databases. Future research is needed to explore if greater consistency in ICD-10 code definitions and enhanced quality measures for ICD-10 coders can improve the coding accuracy of sepsis in large databases.
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Han S, Zheng H, Han F, Zhang X, Zhang G, Ma S, Liu K, Qin W, Wu G. Lactobacillus johnsonii 6084 alleviated sepsis-induced organ injury by modulating gut microbiota. Food Sci Nutr 2022; 10:3931-3941. [PMID: 36348793 PMCID: PMC9632218 DOI: 10.1002/fsn3.2989] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Revised: 06/18/2022] [Accepted: 07/01/2022] [Indexed: 11/30/2022] Open
Abstract
Sepsis is a public cause of death in intensive care unit patients. Probiotics were widely used to increase the survival rate of sepsis by a series of clinical research. The purpose of this research was to investigate the therapeutic effects of Lactobacillus johnsonii 6084 in septic mice. Sepsis mouse model was induced by LPS treatment. The influence of L. johnsonii 6084 on the protection of organ injury induced by sepsis was explored. Moreover, the composition of gut microbiota was studied to clarify the mechanism of L. johnsonii 6084 therapeutic effect on sepsis. L. johnsonii 6084 treatment could conspicuously decrease the mortality and organ injury of sepsis. The reduction of gut microbial diversity and richness in septic mice were moderated by the administration of 6084. The abundance of Bacteroidetes and Proteobacteria were change by LPS treatment while restored by L. johnsonii 6084. To conclude, probiotic 6084 may has optimistic result on reducing mortality of sepsis through rebalancing gut microbiota.
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Affiliation(s)
- Shichao Han
- Department of Urology, Xijing HospitalFourth Military Medical UniversityXi'anChina
| | - Haotian Zheng
- BGI Education CenterUniversity of Chinese Academy of SciencesShenzhenChina
| | - Fu Han
- Department of Burns and Cutaneous Surgery, Xijing HospitalFourth Military Medical UniversityXi'anChina
| | - Xiaowei Zhang
- Department of Obstetrics and GynecologyPeking University Shenzhen HospitalShenzhenChina
| | - Geng Zhang
- Department of Urology, Xijing HospitalFourth Military Medical UniversityXi'anChina
| | - Shuaijun Ma
- Department of Urology, Xijing HospitalFourth Military Medical UniversityXi'anChina
| | - Kepu Liu
- Department of Urology, Xijing HospitalFourth Military Medical UniversityXi'anChina
| | - Weijun Qin
- Department of Urology, Xijing HospitalFourth Military Medical UniversityXi'anChina
| | - Gaofeng Wu
- Department of Burns and Cutaneous Surgery, Xijing HospitalFourth Military Medical UniversityXi'anChina
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Lee CC, Kuo G, Chan MJ, Fan PC, Chen JJ, Yen CL, Tsai TY, Chen YC, Tian YC, Chang CH. Characteristics of and Outcomes After Dialysis-Treated Acute Kidney Injury, 2009-2018: A Taiwanese Multicenter Study. Am J Kidney Dis 2022; 81:665-674.e1. [PMID: 36252882 DOI: 10.1053/j.ajkd.2022.08.022] [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: 03/12/2022] [Accepted: 08/17/2022] [Indexed: 11/06/2022]
Abstract
RATIONALE & OBJECTIVE Dialysis-treated acute kidney injury (AKI) is increasingly common in intensive care units (ICUs) and is associated with poor outcomes. Few studies have explored the temporal trends in severity of acute illness at dialysis initiation, indications for dialysis, and their association with patient outcomes. STUDY DESIGN Multicenter retrospective cohort study. SETTING & PARTICIPANTS 9,535 adult patients admitted to the ICU who received their first dialysis treatment from Chang Gung Memorial Hospital system in Taiwan from 2009 through 2018. EXPOSURE Calendar year. OUTCOMES ICU mortality and dialysis treatment at discharge among hospital survivors. ANALYTICAL APPROACH The temporal trends during the study period were investigated using test statistics suited for continuous or categorical data. The association between the study year and the risk of mortality was analyzed using multivariable Cox regression with adjustment for relevant clinical variables, including the severity of acute illness, defined by Sequential Organ Failure Assessment (SOFA) score. RESULTS The mean SOFA score at dialysis initiation decreased slightly from 14.0 in 2009 to 13.6 in 2018. There was no significant trend in the number of indications for dialysis initiation that were fulfilled over time. Observed ICU mortality decreased over time, and the curve appeared to be reverse J-shaped, with a substantial decrease from 56.1% in 2009 to 46.3% in 2015 and a slight increase afterward. The risk of mortality was significantly reduced from 2013 to 2018 compared with 2009 in adjusted models. The decreasing trend in ICU mortality over time remained significant. There was an increase in dialysis treatment at discharge among survivors, mainly in patients with estimated glomerular filtration rate<60mL/min/1.73m2, from 36.8% in 2009 to 43.9% in 2018. LIMITATIONS Residual confounding from unmeasured factors over time such as severity of comorbidities, detailed medication interventions, and delivered dialysis dose. CONCLUSIONS We observed reductions in mortality among ICU patients with dialysis-treated acute kidney injury between 2009 and 2018, even after adjusting for dialysis indication and severity of illness at dialysis initiation. However, dialysis treatment at discharge among survivors has increased over time, mainly in patients with preexisting kidney disease.
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Affiliation(s)
- Cheng-Chia Lee
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - George Kuo
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ming-Jen Chan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Chun Fan
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jia-Jin Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chieh-Li Yen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Tsung-Yu Tsai
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yung-Chang Chen
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ya-Chung Tian
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Kidney Research Center, Department of Nephrology, Chang Gung Memorial Hospital, Taoyuan, Taiwan; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Mao Y, Xu N, Yan M, Pang M, Zhang X, Wang H, Du J, Wu D, Wang H. Factors associated with the decision to administer β-lactams via prolonged infusion in patients with sepsis: a prospective observational cohort study. Int J Infect Dis 2022; 124:113-117. [PMID: 36152955 DOI: 10.1016/j.ijid.2022.09.027] [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: 05/11/2022] [Revised: 09/15/2022] [Accepted: 09/17/2022] [Indexed: 10/31/2022] Open
Abstract
OBJECTIVE β-lactams are the most widely used antibiotics in sepsis. We aimed to explore the factors that drive physicians to choose prolonged infusion (PI) of β-lactams in septic patients. METHODS This prospective observational national cohort study was conducted in 40 ICUs at the teaching hospitals of 31 provinces in China between August 20, 2021 and September 20, 2021. RESULTS Of the 441 enrolled patients, 265 (60.09%) received PI therapy. Multivariate analysis showed that multidrug-resistant bacterial infection and septic shock were independent factors associated with PI. However, our data showed that the survival benefit of PI use was evident in subgroups with less severe sepsis, including those with lower Charlson comorbidity index values (<2), those without septic shock, and those with lower acute physiology and chronic health evaluation II scores (<15). Univariate and multivariate Cox regression indicated that PI was an independent protective factor of 28d mortality, even after adjusting the variables associated with disease severity. CONCLUSIONS PI for administering β-lactams was not a commonly applied strategy in sepsis and was more likely to be used in severely ill patients. However, PI had a survival benefit independent of disease severity.
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Affiliation(s)
- Yang Mao
- Department of Critical Care Medicine, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, Shandong 250012, China
| | - Nana Xu
- Cardiosurgery Care Unit, Department of Cardiosurgery, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, Shandong, 250012, China
| | - Meichen Yan
- Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, Shandong, 250012, China
| | - Mingmin Pang
- Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, Shandong, 250012, China
| | - Xinyue Zhang
- Department of Pharmacy, The Fourth People's Hospital of Jinan, 50 Shifan Road, Jinan, Shandong, 250031, China
| | - Haigang Wang
- Department of Pharmacy, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, Shandong, 250012, China
| | - Juan Du
- Department of Critical Care Medicine, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, Shandong 250012, China
| | - Dawei Wu
- Department of Critical Care Medicine, Qilu Hospital of Shandong University (Qingdao Branch), 758 Hefei Road, Qingdao, Shandong, 266034, China
| | - Hao Wang
- Department of Critical Care Medicine, Qilu Hospital of Shandong University, 107 Wenhuaxi Road, Jinan, Shandong 250012, China.
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Uckun FM, Saeed M, Awili M, Ozercan IH, Qazi S, Lee C, Shibli A, Skolnick AW, Prusmack A, Varon J, Barrera CI, Orhan C, Volk M, Sahin K. Evaluation of the potential of Rejuveinix plus dexamethasone against sepsis. Future Microbiol 2022; 17:1217-1229. [PMID: 36052743 PMCID: PMC9443789 DOI: 10.2217/fmb-2022-0044] [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] [Indexed: 12/15/2022] Open
Abstract
Aim: Our main objectives were to compare the effects of Rejuveinix (RJX), dexamethasone (DEX) and their combination on the severity of sepsis and survival outcome in an animal model of fatal sepsis. Methods: We used the LPS plus D-galactosamine mouse model of sepsis to compare the anti-inflammatory activities of RJX, dexamethasone and a combination of RJX plus DEX. Additionally, we examined the clinical feasibility and tolerability of combining RJX with DEX in COVID-19 patients in a clinical phase I study. Data were analyzed using standard methods. Results & conclusion: RJX exhibited potent anti-inflammatory activity in the murine sepsis model. The combination of RJX plus DEX was more effective than either agent alone, decreased the inflammatory cytokine responses and associated organ damage, and improved the survival outcome in mice. In the phase I clinical study, RJX plus DEX was well tolerated by COVID-19 patients.
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Affiliation(s)
- Fatih M Uckun
- Drug Discovery Program, Reven Pharmaceuticals, Westminster, CO 80234, USA.,Department of Developmental Therapeutics, Immunology & Integrative Medicine, Ares Pharmaceuticals, St Paul, MN 55110, USA
| | - Muhammad Saeed
- PRX Research & Dallas Regional Medical Center, Dallas, TX 75149, USA
| | - Mustafa Awili
- PRX Research & Dallas Regional Medical Center, Dallas, TX 75149, USA
| | - Ibrahim H Ozercan
- Department of Pathology Faculty of Medicine, Firat University, Elazig, 23119, Turkey
| | - Sanjive Qazi
- Department of Developmental Therapeutics, Immunology & Integrative Medicine, Ares Pharmaceuticals, St Paul, MN 55110, USA
| | - Cynthia Lee
- Drug Discovery Program, Reven Pharmaceuticals, Westminster, CO 80234, USA
| | - Adeel Shibli
- PRX Research & Dallas Regional Medical Center, Dallas, TX 75149, USA
| | - Alan W Skolnick
- Memorial Hermann Memorial City Medical Center, Houston, TX 77024, USA; HD Research, Bellaire, TX 77401, USA
| | | | - Joseph Varon
- United Memorial Medical Center, Houston, TX 77091, USA
| | | | - Cemal Orhan
- Department of Animal Nutrition, Faculty of Veterinary, Firat University, Elazig, 23119, Turkey
| | - Michael Volk
- Drug Discovery Program, Reven Pharmaceuticals, Westminster, CO 80234, USA
| | - Kazim Sahin
- Department of Animal Nutrition, Faculty of Veterinary, Firat University, Elazig, 23119, Turkey
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The 2021 Dutch Working Party on Antibiotic Policy (SWAB) guidelines for empirical antibacterial therapy of sepsis in adults. BMC Infect Dis 2022; 22:687. [PMID: 35953772 PMCID: PMC9373543 DOI: 10.1186/s12879-022-07653-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 07/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The Dutch Working Party on Antibiotic Policy (SWAB) in collaboration with relevant professional societies, has updated their evidence-based guidelines on empiric antibacterial therapy of sepsis in adults. METHODS Our multidisciplinary guideline committee generated ten population, intervention, comparison, and outcome (PICO) questions relevant for adult patients with sepsis. For each question, a literature search was performed to obtain the best available evidence and assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The quality of evidence for clinically relevant outcomes was graded from high to very low. In structured consensus meetings, the committee formulated recommendations as strong or weak. When evidence could not be obtained, recommendations were provided based on expert opinion and experience (good practice statements). RESULTS Fifty-five recommendations on the antibacterial therapy of sepsis were generated. Recommendations on empiric antibacterial therapy choices were differentiated for sepsis according to the source of infection, the potential causative pathogen and its resistance pattern. One important revision was the distinction between low, increased and high risk of infection with Enterobacterales resistant to third generation cephalosporins (3GRC-E) to guide the choice of empirical therapy. Other new topics included empirical antibacterial therapy in patients with a reported penicillin allergy and the role of pharmacokinetics and pharmacodynamics to guide dosing in sepsis. We also established recommendations on timing and duration of antibacterial treatment. CONCLUSIONS Our multidisciplinary committee formulated evidence-based recommendations for the empiric antibacterial therapy of adults with sepsis in The Netherlands.
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Prognostic Impact of Neutropenia in Cancer Patients with Septic Shock: A 2009–2017 Nationwide Cohort Study. Cancers (Basel) 2022; 14:cancers14153601. [PMID: 35892860 PMCID: PMC9332608 DOI: 10.3390/cancers14153601] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022] Open
Abstract
Simple Summary The prognostic impact of neutropenia on mortality in cancer patients with septic shock remains controversial despite recent advances in cancer and sepsis management. This study aimed to determine whether neutropenia could be related to an increase in short-term and long-term mortality. This population-based, case–control study used data from the National Health Insurance Service of Korea. Adult cancer patients who presented to the emergency department with septic shock from 2009 to 2017 were analyzed. The 30-day and 1-year mortality rates were evaluated as short-term and long-term outcomes. After adjustment for confounders, neutropenia was independently associated with decreased 30-day and 1-year mortality rates. Neutropenia did not increase mortality in cancer patients with septic shock, suggesting that neutropenia may not be used as a single triage criterion for withholding intensive care in cancer patients presenting to the emergency department with septic shock. Abstract (1) Background: Neutropenia’s prognostic impact on mortality in cancer patients with septic shock remains controversial despite recent advances in cancer and sepsis management. This population-based, case–control study aimed to determine whether neutropenia could be related to an increase in short-term and long-term mortality. (2) Methods: This population-based, case–control study used data from the National Health Insurance Service of Korea. Adult cancer patients who presented to the emergency department with septic shock from 2009 to 2017 were included. The 30-day and 1-year mortality rates were evaluated as short-term and long-term outcomes. Cox proportional hazard regression was performed after adjusting for age, sex, Charlson comorbidity index, and neutropenia. (3) Results: In 43,466 adult cancer patients with septic shock, the 30-day and 1-year mortality rates were 52.1% and 81.3%, respectively. In total, 6391 patients had neutropenic septic shock, and the prevalent cancer type was lung cancer, followed by leukemia, non-Hodgkin’s lymphoma, stomach cancer, and colon cancer. Furthermore, 30-day and 1-year mortality was lower in patients with neutropenia than in those without neutropenia. After adjustment for confounders, neutropenia was independently associated with decreased 30-day and 1-year mortality rates. (4) Conclusions: In cancer patients presenting to the emergency department with septic shock, the presence of neutropenia did not increase mortality. This suggests that neutropenia may not be used as a single triage criterion for withholding intensive care in cancer patients presenting to the emergency department with septic shock.
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Vesteinsdottir E, Sigurdsson MI, Gottfredsson M, Blondal A, Karason S. A nationwide study on characteristics and outcome of cancer patients with sepsis requiring intensive care. Acta Oncol 2022; 61:946-954. [PMID: 35758282 DOI: 10.1080/0284186x.2022.2090276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Sepsis is the leading cause of admission to the intensive care unit (ICU) for cancer patients and survival rates have historically been low. The aims of this nationwide cohort study were to describe the characteristics and outcomes of cancer patients admitted to the ICU with sepsis compared with other sepsis patients requiring ICU admission. MATERIAL AND METHODS This was a retrospective, observational study. All adult admissions to Icelandic ICUs during years 2006, 2008, 2010, 2012, 2014 and 2016 were screened for severe sepsis or septic shock by ACCP/SCCM criteria. Clinical characteristics and outcomes of sepsis patients with cancer were compared to those without cancer. RESULTS In the study period, 235 of 971 (24%) patients admitted to Icelandic ICUs because of sepsis had cancer, most often a solid tumour (100), followed by metastatic tumours (69) and haematological malignancies (66). Infections were more often hospital-acquired in cancer patients (52%) than other sepsis patients (18%, p < 0.001) and sites of infections differed, with abdominal infections being most common in patients with solid and metastatic tumours but lungs and bloodstream infections in haematological malignancies. The length of stay in the ICU was shorter for sepsis patients with metastatic disease than other sepsis patients (2 vs. 4 days, p < 0.001) and they were more likely to have treatment limitations (52 vs. 19%, p < 0.05). Median survival of patients with metastatic disease was 19 days from ICU admission. The 28-day mortality (25%) of solid tumour patients was comparable to that of sepsis patients without cancer (20%, p < 0.001). CONCLUSIONS Cancer is a common comorbidity in patients admitted to the ICU with sepsis. The clinical presentation and outcome differs between cancer types. Individuals with metastatic cancer were unlikely to receive prolonged invasive ICU care treatment. Comparable short-term outcome was found for patients with solid tumours and no cancer.
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Affiliation(s)
- Edda Vesteinsdottir
- Department of Anaesthesia and Intensive Care, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Martin Ingi Sigurdsson
- Department of Anaesthesia and Intensive Care, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Magnus Gottfredsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,Department of Infectious Diseases, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
| | - Asbjorn Blondal
- Department of Anaesthesia and Intensive Care, Akureyri Hospital, Akureyri, Iceland
| | - Sigurbergur Karason
- Department of Anaesthesia and Intensive Care, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Iceland
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Chen Y, Ma XD, Kang XH, Gao SF, Peng JM, Li S, Liu DW, Zhou X, Weng L, Du B. Association of annual hospital septic shock case volume and hospital mortality. Crit Care 2022; 26:161. [PMID: 35659338 PMCID: PMC9166431 DOI: 10.1186/s13054-022-04035-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/26/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The burden of sepsis remains high in China. The relationship between case volume and hospital mortality among patients with septic shock, the most severe complication of sepsis, is unknown in China. METHODS In this retrospective cohort study, we analyzed surveillance data from a national quality improvement program in intensive care units (ICUs) in China in 2020. Association between septic shock case volume and hospital mortality was analyzed using multivariate linear regression and restricted cubic splines. RESULTS We enrolled a total of 134,046 septic shock cases in ICUs from 1902 hospitals in China during 2020. In this septic shock cohort, the median septic shock volume per hospital was 33 cases (interquartile range 14-76 cases), 41.4% were female, and more than half of the patients were over 61 years old, with average hospital mortality of 21.2%. An increase in case volume was associated with improved survival among septic shock cases. In the linear regression model, the highest quartile of septic shock volume was associated with lower hospital mortality compared with the lowest quartile (β - 0.86; 95% CI - 0.98, - 0.74; p < 0.001). Similar differences were found in hospitals of respective geographic locations and hospital levels. With case volume modeled as a continuous variable in a restricted cubic spline, a lower volume threshold of 40 cases before which a substantial reduction of the hospital mortality rate was observed. CONCLUSIONS The findings suggest that hospitals with higher septic shock case volume have lower hospital mortality in China. Further research is needed to explain the mechanism of this volume-outcome relationship.
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Affiliation(s)
- Yan Chen
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xu-Dong Ma
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing, 100044, China
| | - Xiao-Hui Kang
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Si-Fa Gao
- Department of Medical Administration, National Health Commission of the People's Republic of China, Beijing, 100044, China
| | - Jin-Min Peng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Shan Li
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Department of Information Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Xiang Zhou
- Department of Critical Care Medicine, Department of Information Center, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Li Weng
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100730, China.
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Cimiotti JP, Becker ER, Li Y, Sloane DM, Fridkin SK, West AB, Aiken LH. Association of Registered Nurse Staffing With Mortality Risk of Medicare Beneficiaries Hospitalized With Sepsis. JAMA HEALTH FORUM 2022; 3:e221173. [PMID: 35977257 PMCID: PMC9142874 DOI: 10.1001/jamahealthforum.2022.1173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/03/2022] [Indexed: 11/17/2022] Open
Abstract
Question Is registered nurse workload associated with mortality among Medicare beneficiaries who are admitted to an acute care hospital with a diagnosis of sepsis? Findings In this cross-sectional study of 1958 acute care hospitals and 702 140 Medicare beneficiaries with a diagnosis of sepsis, an increase in registered nurse hours per patient day was associated with a 3% decrease in 60-day mortality in these older adults, a finding that was statistically significant. Meaning The study results suggest that the hours of care provided by registered nurses is likely associated with the outcomes of patients with a diagnosis of sepsis. Importance Sepsis is a major physiologic response to infection that if not managed properly can lead to multiorgan failure and death. The US Centers for Medicare & Medicaid Services (CMS) requires that hospitals collect data on core sepsis measure Severe Sepsis and Septic Shock Management Bundle (SEP-1) in an effort to promote the early recognition and treatment of sepsis. Despite implementation of the SEP-1 measure, sepsis-related mortality continues to challenge acute care hospitals nationwide. Objective To determine if registered nurse workload was associated with mortality in Medicare beneficiaries admitted to an acute care hospital with sepsis. Design, Setting, and Participants This cross-sectional study used 2018 data from the American Hospital Association Annual Survey, CMS Hospital Compare, and Medicare claims on Medicare beneficiaries age 65 to 99 years with a primary diagnosis of sepsis that was present on admission to 1 of 1958 nonfederal, general acute care hospitals that had data on CMS SEP-1 scores and registered nurse workload (indicated by registered nurse hours per patient day [HPPD]). Patients with sepsis were identified based on 29 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. Data were analyzed throughout 2021. Exposures SEP-1 score and registered nurse staffing. Main Outcomes and Measures The patient outcome of interest was mortality within 60 days of admission. Hospital characteristics included number of beds, ownership, teaching status, technology status, rurality, and region. Patient characteristics included age, sex, transfer status, intensive care unit admission, palliative care, do-not-resuscitate order, and a series of 29 comorbid diseases based on the Elixhauser Comorbidity Index. Results In total, 702 140 Medicare beneficiaries (mean [SD] age, 78.2 [8.7] years; 360 804 women [51%]) had a diagnosis of sepsis. The mean SEP-1 score was 56.1, and registered nurse HPPD was 6.2. In a multivariable regression model, each additional registered nurse HPPD was associated with a 3% decrease in the odds of 60-day mortality (odds ratio, 0.97; 95% CI 0.96-0.99) controlling for SEP-1 score and hospital and patient characteristics. Conclusions and Relevance The results of this cross-sectional study suggest that hospitals that provide more registered nurse hours of care could likely improve SEP-1 bundle compliance and decrease the likelihood of mortality in Medicare beneficiaries with sepsis.
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Affiliation(s)
- Jeannie P. Cimiotti
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Edmund R. Becker
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Yin Li
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia
| | | | - Scott K. Fridkin
- Rollins School of Public Health, Emory University, Atlanta, Georgia
- School of Medicine, Emory University, Atlanta, Georgia
| | - Anna Beth West
- School of Medicine, Emory University, Atlanta, Georgia
- VA Quality Scholars Program, Atlanta VA Health Care System, Atlanta, Georgia
| | - Linda H. Aiken
- School of Nursing, University of Pennsylvania, Philadelphia
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Ni SQ, Teng WB, Fu YH, Su W, Yang Z, Cai J, Xu JN, Deng XY, Liu XF, Fu SN, Zeng J, Zhang C. The effect of a loading dose of meropenem on outcomes of patients with sepsis treated by continuous renal replacement: study protocol for a randomized controlled trial. Trials 2022; 23:294. [PMID: 35413886 PMCID: PMC9006454 DOI: 10.1186/s13063-022-06264-2] [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: 11/19/2020] [Accepted: 03/31/2022] [Indexed: 08/30/2023] Open
Abstract
Background Sepsis and continuous renal replacement therapy (CRRT) are both responsible for the alterations of the pharmacokinetics of antibiotics. For patients with sepsis receiving CRRT, the serum concentrations of meropenem in the early phase (< 48 h) was significantly lower than that in the late phase (> 48 h). This current trial aimed to investigate whether administration of a loading dose of meropenem results in a more likely achievement of the pharmacokinetic (PK)/pharmacodynamics (PD) target (100% fT > 4 × MIC) and better therapeutic results in the patients with sepsis receiving CRRT. Methods This is a single-blinded, single-center, randomized, controlled, two-arm, and parallel-group trial. This trial will be carried out in Guangzhou First People’s Hospital, School of Medicine, South China University of Technology Guangdong, China. Adult patients (age ≥ 18 years) with critical sepsis or sepsis-related shock receiving CRRT will be included in the study. The subjects will be assigned to the control group and the intervention group (LD group) randomly at a 1:1 ratio, the estimated sample size should be 120 subjects in each group. In the LD group, the patient will receive a loading dose of 1.5-g meropenem resolved in 30-ml saline which is given via central line for 30 min. Afterward, 0.75-g meropenem will be given immediately for 30 min every 8 h. In the control group, the patient will receive 0.75-g meropenem for 30 min every 8 h. The primary objective is the probabilities of PK/PD target (100% fT > 4 × MIC) achieved in the septic patients who receive CRRT in the first 48 h. Secondary objectives include clinical cure rate, bacterial clearance rate, sepsis-related mortality and all-cause mortality, the total dose of meropenem, duration of meropenem treatment, duration of CRRT, Sequential Organ Failure Assessment (SOFA), C-reactive protein levels, procalcitonin levels, white blood cell count, and safety. Discussion This trial will assess for the first time whether administration of a loading dose of meropenem results in a more likely achievement of the PK/PD target and better therapeutic results in the patients with sepsis receiving CRRT. Since CRRT is an important therapeutic strategy for sepsis patients with hemodynamic instability, the results from this trial may help to provide evidence-based therapy for septic patients receiving CRRT. Trial registration Chinese Clinical Trials Registry, ChiCTR2000032865. Registered on 13 May 2020, http://www.chictr.org.cn/showproj.aspx?proj=53616. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06264-2.
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Affiliation(s)
- Sui-Qing Ni
- Department of Pharmacy, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Wen-Bing Teng
- Department of Pharmacy, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Yong-Hong Fu
- Department of Critical Care Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, China
| | - Wei Su
- Department of Critical Care Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, China
| | - Zhi Yang
- Department of Critical Care Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, China
| | - Jie Cai
- Department of Pharmacy, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Jin-Nuo Xu
- Department of Pharmacy, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Xiao-Ying Deng
- Department of Pharmacy, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Xiang-Fang Liu
- Department of Pharmacy, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Sheng-Nan Fu
- Department of Pharmacy, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, Guangdong, China
| | - Jun Zeng
- Department of Critical Care Medicine, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, China
| | - Chen Zhang
- Department of Pharmacy, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Guangzhou, 510180, Guangdong, China.
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Brant EB, Kennedy JN, King AJ, Gerstley LD, Mishra P, Schlessinger D, Shalaby J, Escobar GJ, Angus DC, Seymour CW, Liu VX. Developing a shared sepsis data infrastructure: a systematic review and concept map to FHIR. NPJ Digit Med 2022; 5:44. [PMID: 35379946 PMCID: PMC8979949 DOI: 10.1038/s41746-022-00580-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 02/24/2022] [Indexed: 12/26/2022] Open
Abstract
The development of a shared data infrastructure across health systems could improve research, clinical care, and health policy across a spectrum of diseases, including sepsis. Awareness of the potential value of such infrastructure has been heightened by COVID-19, as the lack of a real-time, interoperable data network impaired disease identification, mitigation, and eradication. The Sepsis on FHIR collaboration establishes a dynamic, federated, and interoperable system of sepsis data from 55 hospitals using 2 distinct inpatient electronic health record systems. Here we report on phase 1, a systematic review to identify clinical variables required to define sepsis and its subtypes to produce a concept mapping of elements onto Fast Healthcare Interoperability Resources (FHIR). Relevant papers described consensus sepsis definitions, provided criteria for sepsis, severe sepsis, septic shock, or detailed sepsis subtypes. Studies not written in English, published prior to 1970, or "grey" literature were prospectively excluded. We analyzed 55 manuscripts yielding 151 unique clinical variables. We then mapped variables to their corresponding US Core FHIR resources and specific code values. This work establishes the framework to develop a flexible infrastructure for sharing sepsis data, highlighting how FHIR could enable the extension of this approach to other important conditions relevant to public health.
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Affiliation(s)
- Emily B Brant
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA.
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Assistant Professor of Critical Care and Emergency Medicine, University of Pittsburgh School of Medicine,, 200 Lothrop Street, #607, Pittsburgh, PA, 15261, USA.
| | - Jason N Kennedy
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
| | - Andrew J King
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Pranita Mishra
- Kaiser Permanente Division of Research, Oakland, CA, USA
| | | | | | | | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
| | - Christopher W Seymour
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Clinical Research, Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Pittsburgh, PA, USA
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Vincent X Liu
- Kaiser Permanente Division of Research, Oakland, CA, USA
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Reitz KM, Kennedy J, Rieser C, Hlavin C, Gershengorn HB, Neal MD, Bensen N, Linstrum K, Prescott HC, Rosengart MR, Talisa V, Hall DE, Tzeng E, Wunsch H, Yende S, Angus DC, Seymour CW. The Epidemiology of Extremity Threat and Amputation after Vasopressor-Dependent Sepsis. Ann Am Thorac Soc 2022; 19:625-632. [PMID: 34644242 PMCID: PMC8996267 DOI: 10.1513/annalsats.202105-547oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 10/12/2021] [Indexed: 11/20/2022] Open
Abstract
Rationale: Extremity threat and amputation after sepsis is a well-publicized and devastating event. However, there is a paucity of data about the epidemiology of extremity threat after sepsis onset. Objectives: To estimate the incidence of extremity threat with or without surgical amputation in community sepsis. Methods: Retrospective cohort study of adults with Sepsis-3 hospitalized at 14 academic and community sites from 2013 to 2017. Vasopressor-dependent sepsis was identified by administration of epinephrine, norepinephrine, phenylephrine, vasopressin, or dopamine for more than 1 hour during the 48 hours before to 24 hours after sepsis onset. Outcomes included the incidence of extremity threat, defined as acute onset ischemia, with or without amputation, in the 90 days after sepsis onset. The association between extremity threat, demographics, comorbid conditions, and time-varying sepsis treatments was evaluated using a Cox proportional hazards model. Results: Among 24,365 adults with sepsis, 12,060 (54%) were vasopressor dependent (mean ± standard deviation age, 64 ± 16 years; male, 6,548 [54%]; sequential organ failure assessment [SOFA], 10 ± 4). Of these, 231 (2%) patients had a threatened extremity with 26 undergoing 37 amputations, a risk of 2.2 (95% confidence interval [CI], 1.4-3.2) per 1,000, and 205 not undergoing amputation, a risk of 17.0 (95% CI, 14.8-19.5) per 1,000. Most amputations occurred in lower extremities (95%), a median (interquartile range) of 16 (6-40) days after sepsis onset. Compared with patients with no extremity threat, patients with threat had a higher SOFA score (11 ± 4 vs. 10 ± 4; P < 0.001), serum lactate (4.6 mmol/L [2.4-8.7] vs. 3.1 [1.7-6.0]; P < 0.001), and more bacteremia (n = 37 [37%] vs. n = 2,087 [26%]; P < 0.001) at sepsis onset. Peripheral vascular disease, congestive heart failure, SOFA score, and norepinephrine equivalents were significantly associated with extremity threat. Conclusions: The evaluation of a threatened extremity resulting in surgical amputation occurred in 2 per 1,000 patients with vasopressor-dependent sepsis.
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Affiliation(s)
- Katherine M. Reitz
- Department of Surgery
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, and
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason Kennedy
- Department of Critical Care Medicine, and
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, and
| | | | | | - Hayley B. Gershengorn
- Division of Pulmonary, Critical Care, and Sleep Medicine, Miller School of Medicine, University of Miami, Miami, Florida
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Bronx, New York
| | - Matthew D. Neal
- Department of Surgery
- Department of Critical Care Medicine, and
| | - Nicole Bensen
- Department of Critical Care Medicine, and
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, and
| | - Kelsey Linstrum
- Department of Critical Care Medicine, and
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, and
| | - Hallie C. Prescott
- Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Victor Talisa
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, Pennsylvania
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, and
| | - Daniel E. Hall
- Department of Surgery
- Veterans Affairs Pittsburgh Healthcare System, and
- Center for Health Equity Research and Promotion, Veterans Affairs, Pittsburgh, Pennsylvania
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Edith Tzeng
- Department of Surgery
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
- Veterans Affairs Pittsburgh Healthcare System, and
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Science Centre, Toronto, Ontario, Canada; and
- Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sachin Yende
- Department of Critical Care Medicine, and
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, and
- Wolff Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Derek C. Angus
- Department of Critical Care Medicine, and
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, and
| | - Christopher W. Seymour
- Department of Critical Care Medicine, and
- Clinical Research, Investigation, and Systems Modeling of Acute Illness Center, and
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Vesteinsdottir E, Sigurdsson MI, Gottfredsson M, Blondal A, Karason S. Temporal trends in the epidemiology, management, and outcome of sepsis-A nationwide observational study. Acta Anaesthesiol Scand 2022; 66:497-506. [PMID: 35014035 DOI: 10.1111/aas.14026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 12/14/2021] [Accepted: 12/20/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Registry-based studies have shown increasing incidence of sepsis and declining mortality rates in recent years, but are inherently at risk of bias. The objectives of this study were to describe 11-year trends in the incidence, treatment and outcome of sepsis using clinical criteria with chart review. METHODS This was a retrospective, observational study. All adult admissions to Icelandic ICUs during years 2006, 2008, 2010, 2012, 2014, and 2016 were screened for severe sepsis or septic shock by ACCP/SCCM criteria (sepsis-2). Incidence, patient characteristics, treatment and outcome were compared across the study years. RESULTS During the six study years, 9166 patients were admitted to Icelandic ICUs, 971 (10.6%) because of severe sepsis or septic shock. The crude incidence of sepsis requiring admission to ICU remained stable between 0.55 and 0.75 per 1000 inhabitants. No statistically significant trends were observed over time in median patient age (67 years), APACHE II score (21), SOFA score (8) or Charlson Comorbidity Index (4). The time to antibiotic administration (median 1.8 h) in the emergency departments was stable over the study period but the time to lactate measurements decreased from 4.1 h in 2006 to 1.2 h in 2016, p < .001. The 28-day mortality was 25% and 1-year mortality 41%, both with no observed change with time. CONCLUSIONS In a nationwide cohort, diagnosed with clinical criteria, the incidence of sepsis requiring intensive care did not change over an 11-year period. Mortality remained stable and only minimal changes were observed in initial resuscitation in the emergency departments.
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Affiliation(s)
- Edda Vesteinsdottir
- Department of Anaesthesia and Intensive Care Landspitali—The National University Hospital of Iceland Reykjavik Iceland
- Faculty of Medicine University of Iceland Reykjavik Iceland
| | - Martin Ingi Sigurdsson
- Department of Anaesthesia and Intensive Care Landspitali—The National University Hospital of Iceland Reykjavik Iceland
- Faculty of Medicine University of Iceland Reykjavik Iceland
| | - Magnus Gottfredsson
- Faculty of Medicine University of Iceland Reykjavik Iceland
- Department of Infectious Diseases Landspitali—The National University Hospital of Iceland Reykjavik Iceland
| | - Asbjorn Blondal
- Department of Anaesthesia and Intensive Care Akureyri Hospital Akureyri Iceland
| | - Sigurbergur Karason
- Department of Anaesthesia and Intensive Care Landspitali—The National University Hospital of Iceland Reykjavik Iceland
- Faculty of Medicine University of Iceland Reykjavik Iceland
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Gray CC, Biron-Girard B, Wakeley ME, Chung CS, Chen Y, Quiles-Ramirez Y, Tolbert JD, Ayala A. Negative Immune Checkpoint Protein, VISTA, Regulates the CD4 + T reg Population During Sepsis Progression to Promote Acute Sepsis Recovery and Survival. Front Immunol 2022; 13:861670. [PMID: 35401514 PMCID: PMC8988198 DOI: 10.3389/fimmu.2022.861670] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 02/25/2022] [Indexed: 02/04/2023] Open
Abstract
Sepsis is a systemic immune response to infection that is responsible for ~35% of in-hospital deaths and over 24 billion dollars in annual treatment costs. Strategic targeting of non-redundant negative immune checkpoint protein pathways can cater therapeutics to the individual septic patient and improve prognosis. B7-CD28 superfamily member V-domain Immunoglobulin Suppressor of T cell Activation (VISTA) is an ideal candidate for strategic targeting in sepsis. We hypothesized that immune checkpoint regulator, VISTA, controls T-regulatory cells (Treg), in response to septic challenge, thus playing a protective role/reducing septic morbidity/mortality. Further, we investigated if changes in morbidity/mortality are due to a Treg-mediated effect during the acute response to septic challenge. To test this, we used the cecal ligation and puncture model as a proxy for polymicrobial sepsis and assessed the phenotype of CD4+ Tregs in VISTA-gene deficient (VISTA-/-) and wild-type mice. We also measured changes in survival, soluble indices of tissue injury, and circulating cytokines in the VISTA-/- and wild-type mice. We found that in wild-type mice, CD4+ Tregs exhibit a significant upregulation of VISTA which correlates with higher Treg abundance in the spleen and small intestine following septic insult. However, VISTA-/- mice have reduced Treg abundance in these compartments met with a higher expression of Foxp3, CTLA4, and CD25 compared to wild-type mice. VISTA-/- mice also have a significant survival deficit, higher levels of soluble indicators of liver injury (i.e., ALT, AST, bilirubin), and increased circulating proinflammatory cytokines (i.e., IL-6, IL-10, TNFα, IL-17F, IL-23, and MCP-1) following septic challenge. To elucidate the role of Tregs in VISTA-/- sepsis mortality, we adoptively transferred VISTA-expressing Tregs into VISTA-/- mice. This adoptive transfer rescued VISTA-/- survival to wild-type levels. Taken together, we propose a protective Treg-mediated role for VISTA by which inflammation-induced tissue injury is suppressed and improves survival in early-stage murine sepsis. Thus, enhancing VISTA expression or adoptively transferring VISTA+ Tregs in early-stage sepsis may provide a novel therapeutic approach to ameliorate inflammation-induced death.
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Affiliation(s)
- Chyna C. Gray
- Department of Molecular Biology, Cell Biology, and Biochemistry, Brown University, Providence, RI, United States
- Division of Surgical Research, Department of Surgery, Brown University, Providence, RI, United States
| | - Bethany Biron-Girard
- Division of Surgical Research, Department of Surgery, Brown University, Providence, RI, United States
| | - Michelle E. Wakeley
- Division of Surgical Research, Department of Surgery, Brown University, Providence, RI, United States
| | - Chun-Shiang Chung
- Division of Surgical Research, Department of Surgery, Brown University, Providence, RI, United States
| | - Yaping Chen
- Division of Surgical Research, Department of Surgery, Brown University, Providence, RI, United States
| | - Yael Quiles-Ramirez
- Division of Surgical Research, Department of Surgery, Brown University, Providence, RI, United States
| | - Jessica D. Tolbert
- Division of Surgical Research, Department of Surgery, Brown University, Providence, RI, United States
| | - Alfred Ayala
- Department of Molecular Biology, Cell Biology, and Biochemistry, Brown University, Providence, RI, United States
- Division of Surgical Research, Department of Surgery, Brown University, Providence, RI, United States
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Gao Y, Wang HL, Zhang ZJ, Pan CK, Wang Y, Zhu YC, Xie FJ, Han QY, Zheng JB, Dai QQ, Ji YY, Du X, Chen PF, Yue CS, Wu JH, Kang K, Yu KJ. A Standardized Step-by-Step Approach for the Diagnosis and Treatment of Sepsis. J Intensive Care Med 2022; 37:1281-1287. [PMID: 35285730 DOI: 10.1177/08850666221085181] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Sepsis is the major culprit of death among critically ill patients who are hospitalized in intensive care units (ICUs). Although sepsis-related mortality is steadily declining year-by-year due to the continuous understanding of the pathophysiological mechanism on sepsis and improvement of the bundle treatment, sepsis-associated hospitalization is rising worldwide. Surviving Sepsis Campaign (SSC) guidelines are continuously updating, while their content is extremely complex and comprehensive for a precisely implementation in clinical practice. As a consequence, a standardized step-by-step approach for the diagnosis and treatment of sepsis is particularly important. In the present study, we proposed a standardized step-by-step approach for the diagnosis and treatment of sepsis using our daily clinical experience and the latest researches, which is close to clinical practice and is easy to implement. The proposed approach may assist clinicians to more effectively diagnose and treat septic patients and avoid the emergence of adverse clinical outcomes.
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Affiliation(s)
- Yang Gao
- Department of Critical Care Medicine, The Sixth Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hong Liang Wang
- Department of Critical Care Medicine, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Zhao Jin Zhang
- Department of Critical Care Medicine, The Yichun Forestry Administration Central Hospital, Yichun, China
| | - Chang Kun Pan
- Department of Critical Care Medicine, The Jiamusi Cancer Hospital, Jiamusi, China
| | - Ying Wang
- Department of Critical Care Medicine, The First People Hospital of Mudanjiang city, Mudanjiang, China
| | - Yu Cheng Zhu
- Department of Critical Care Medicine, The Hongxinglong Hospital of Beidahuang Group, Shuangyashan, China
| | - Feng Jie Xie
- Department of Critical Care Medicine, The Hongqi Hospital Affiliated to Mudanjiang Medical University, Mudanjiang, China
| | - Qiu Yuan Han
- Department of Critical Care Medicine, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Jun Bo Zheng
- Department of Critical Care Medicine, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Qing Qing Dai
- Department of Critical Care Medicine, 105821The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Yuan Yuan Ji
- Department of Critical Care Medicine, 74559The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Xue Du
- Department of Critical Care Medicine, 74559The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Peng Fei Chen
- Department of Critical Care Medicine, 74559The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Chuang Shi Yue
- Department of Critical Care Medicine, 74559The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ji Han Wu
- Department of Critical Care Medicine, 74559The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Kai Kang
- Department of Critical Care Medicine, 74559The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Kai Jiang Yu
- Department of Critical Care Medicine, 74559The First Affiliated Hospital of Harbin Medical University, Harbin, China
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40
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Falk GE, Rogers J, Lu L, Ablah E, Okut H, Vindhyal MR. Sepsis, Septic Shock, and Differences in Cardiovascular Event Occurrence. J Intensive Care Med 2022; 37:1528-1534. [PMID: 35236176 DOI: 10.1177/08850666221083644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: Mortality estimates from sepsis and septic shock ranged from 18% to 35% and 40% to 60%, respectively, prior to 2014. Sepsis patients who experience subsequent cardiovascular events have increased mortality; however, data are limited among septic shock patients. This study reports in-hospital mortality, incident cardiovascular events, and cardiovascular procedures among sepsis patients with and without subsequent septic shock. Methods: Patients with a primary diagnosis of sepsis with and without a secondary diagnosis of septic shock were identified from the 2016 and 2017 National Readmissions Database. These patients were then evaluated for the occurrence of cardiovascular events and procedures. Results: A total of 2,127,137 patients were included in the study, with a mean age of 66 years. Twenty percent of patients (n = 420,135) developed subsequent septic shock. In-hospital mortality among patients with a primary diagnosis of sepsis was 5.3%, and it was 31.2% for those with subsequent septic shock. Notable cardiovascular events occurring among sepsis patients with and without subsequent septic shock, respectively, included: acute kidney injury (65.1% vs. 32.8%, P < .0001), acute systolic heart failure (9.8% vs. 5.1%, P < .0001), NSTEMI (8.8% vs. 3.2%, P < .0001), and ischemic stroke (2.3% vs. 0.9%, P < .0001). Similarly, the most common cardiovascular procedures between the two groups were: percutaneous coronary intervention (0.37% vs. 0.20%, P < .0001), intra-aortic balloon pump (0.19% vs. 0.02%, P < .0001), and extracorporeal membrane oxygenation (0.18% vs. 0.01%, P < .0001). Conclusions: Sepsis with subsequent septic shock is associated with an increased frequency of in-hospital cardiovascular events and procedures.
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Affiliation(s)
- Grace E Falk
- Medical Students, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Jerad Rogers
- Medical Students, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Liuqiang Lu
- Department of Population Health, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Elizabeth Ablah
- Department of Population Health, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Hayrettin Okut
- Department of Population Health, 8586University of Kansas School of Medicine-Wichita, Wichita, KS, USA
| | - Mohinder R Vindhyal
- Department of Cardiovascular Disease, 21638Kansas University Medical Center, Kansas City, KS, USA
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Wan J, Yu X, Niu JQ, Qiu L, Wang F, Chen XL. Inhibition of Bruton's Tyrosine Kinase Protects Against Burn Sepsis-Induced Intestinal Injury. Front Med (Lausanne) 2022; 9:809289. [PMID: 35280898 PMCID: PMC8907476 DOI: 10.3389/fmed.2022.809289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/31/2022] [Indexed: 11/18/2022] Open
Abstract
This study aimed to investigate the role and molecular mechanisms of Bruton's tyrosine kinase (BTK), a member of the Tec family in burn sepsis-induced intestinal injury. Eighty C57BL/6 mice were randomly divided into four groups: the sham group, the burn group, the burn + sepsis group, and the burn + sepsis + LFM-A13 (a selective BTK inhibitor) group. The dynamic expression profiles of BTK and p-BTK in the intestine were measured by Western blot analysis. Intestinal histopathological changes and cellular apoptosis were determined. Inflammatory cytokines in serum and intestinal tissue were examined through enzyme-linked immunosorbent assay. Myeloperoxidase (MPO) activity was determined via a colorimetric assay. Intestinal p-BTK expression in the burn+sepsis group was significantly increased compared with that in the sham and burn groups. In the burn + sepsis group, the p-BTK expression level increased over time, peaked at 12, and then decreased at 24 h. LFM-A13 administration significantly inhibited p-BTK expression in the intestine. In contrast to the sham and burn groups, the burn + sepsis group exhibited obvious histopathological changes, which gradually aggravated over time. LFM-A13 also reduced the histopathological changes and cellular apoptosis in intestinal tissues, inhibited the inflammatory cytokines IL-4, IL-6, and TNF-α in serum and intestinal tissues, and significantly inhibited the increase in intestinal MPO activity induced by burn sepsis. BTK activation is one important aspect of the signaling event that may mediate the release of the anti-inflammatory cytokine IL-4 and the pro-inflammatory cytokines IL-6 and TNF-α; oxidative stress; and intestinal cell apoptosis. Thus, it contributes to burn sepsis-induced intestinal injury.
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Yu D, Unger D, Unge C, Parke Å, Sundén-Cullberg J, Strålin K, Özenci V. Correlation of clinical sepsis definitions with microbiological characteristics in patients admitted through a sepsis alert system; a prospective cohort study. Ann Clin Microbiol Antimicrob 2022; 21:7. [PMID: 35193588 PMCID: PMC8864844 DOI: 10.1186/s12941-022-00498-3] [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: 10/14/2021] [Accepted: 01/28/2022] [Indexed: 11/29/2022] Open
Abstract
Background Sepsis was recently redefined as a life-threatening organ dysfunction caused by a dysregulated host response to infection. With this redefinition (Sepsis-3), clinical and microbiological characteristics of patients with sepsis may differ from the patients fulfilling the previous definition (Sepsis-2). Purpose To describe differences in clinical and microbiological characteristics of sepsis episodes between Sepsis-3 and Sepsis-2. The secondary aim was to compare blood culture outcomes between episodes fulfilling Sepsis-3 and Sepsis-2 criteria, respectively. Methods A prospective study design was used to include patients presenting with clinically suspected sepsis in the emergency department. Six blood culture bottles were collected from each patient. Blood cultures were described as having clinically relevant growth, contaminant growth, or no growth. Clinical and laboratory data were collected from medical records and the laboratory information system. Results The analysis included 514 episodes. There were 357/514 (79.5%) Sepsis-3 and 411/514 (80.0%) Sepsis-2 episodes. In total, 341/514 (66.3%) episodes fulfilled both Sepsis-3 and Sepsis-2 criteria. Blood cultures were positive for clinically relevant growth in 130/357 (36.1%) and 145/411 (35.3%) episodes in Sepsis-3 and Sepsis-2, respectively. Other clinical and microbiological characteristics did not differ between Sepsis-3 and Sepsis-2. Conclusions A high proportion of patients included through a sepsis alert system fulfilled both Sepsis-3 and Sepsis-2 criteria. The performance of blood cultures in detection of microorganisms was poor and were similar in Sepsis-3 and Sepsis-2 patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12941-022-00498-3.
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Affiliation(s)
- David Yu
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.,Trauma & Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | | | - Christian Unge
- Trauma & Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Åsa Parke
- Trauma & Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Jonas Sundén-Cullberg
- Trauma & Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Kristoffer Strålin
- Trauma & Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden.,Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Volkan Özenci
- Division of Clinical Microbiology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden. .,Department of Clinical Microbiology, Karolinska University Hospital Stockholm, Stockholm, Sweden.
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Parra-Rodriguez L, Guillamet MCV. Antibiotic Decision-Making in the ICU. Semin Respir Crit Care Med 2022; 43:141-149. [PMID: 35172364 DOI: 10.1055/s-0041-1741014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
It is well established that Intensive Care Units (ICUs) are a focal point in antimicrobial consumption with a major influence on the ecological consequences of antibiotic use. With the high prevalence and mortality of infections in critically ill patients, and the clinical challenges of treating patients with septic shock, the impact of real life clinical decisions made by intensivists becomes more significant. Both under- and over-treatment with unnecessarily broad spectrum antibiotics can lead to detrimental outcomes. Even though substantial progress has been made in developing rapid diagnostic tests that can help guide antibiotic use, there is still a time window when clinicians must decide the empiric antibiotic treatment with insufficient clinical data. The continuous streams of data available in the ICU environment make antimicrobial optimization an ongoing challenge for clinicians but at the same time can serve as the input for sophisticated models. In this review, we summarize the evidence to help guide antibiotic decision-making in the ICU. We focus on 1) deciding IF: to start antibiotics, 2) choosing the spectrum of the empiric agents to use, and 3) de-escalating the chosen empiric antibiotics. We provide a perspective on the role of machine learning and artificial intelligence models for clinical decision support systems that can be incorporated seamlessly into clinical practice in order to improve the antibiotic selection process and, more importantly, current and future patients' outcomes.
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Affiliation(s)
- Luis Parra-Rodriguez
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - M Cristina Vazquez Guillamet
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
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Xu Z, Lin X, Zhu J, Zhu Z. Long noncoding RNAs Colorectal Neoplasia Differentially Expressed and taurine-upregulated gene 1 are downregulated in sepsis and positively regulate each other to suppress the apoptosis of cardiomyocytes. Bioengineered 2021; 12:11369-11375. [PMID: 34872438 PMCID: PMC8810183 DOI: 10.1080/21655979.2021.2008658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Long noncoding RNAs (lncRNAs) Colorectal Neoplasia Differentially Expressed (CRNDE) and taurine-upregulated gene 1 (TUG1) play similar roles in sepsis, indicating the existence of the crosstalk between them. Sepsis is a major cause of injuries in heart, which are related to high mortality rates. This study was therefore carried out to analyze the potential crosstalk between CRNDE and TUG1 in sepsis, with a focus on sepsis-induced cell apoptosis in heart. Expression of CRNDE and TUG1 was analyzed with RT-qPCR. Correlations between them were analyzed by Pearson’s correlation coefficient. CRNDE and TUG1 were overexpressed in cardiomyocytes to determine the relationship between them. The roles of CRNDE and TUG1 in regulating the apoptosis of cardiomyocytes were explored by cell apoptosis assay. We found that both CRNDE and TUG1 were downregulated in sepsis. In cardiomyocytes, LPS treatment resulted in the downregulation of CRNDE and TUG1. Overexpression of CRNDE and TUG1 in cardiomyocytes increased the expression levels of each other. Under lipopolysaccharide (LPS) treatment, decreased apoptosis rates of cardiomyocytes were observed after CRNDE and TUG1 overexpression. CRNDE and TUG1 co-overexpression showed a stronger effect. In conclusion, CRNDE and TUG1 are downregulated in sepsis and they positively regulate each other to suppress the apoptosis of cardiomyocytes.
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Affiliation(s)
- Zhenwei Xu
- Department of Emergency, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou City, Fujian Province, PR. China
| | - Xingyu Lin
- Department of Emergency, Fujian Medical University Union Hospital, Fuzhou City, Fujian Province, PR China
| | - Jingfa Zhu
- Department of Emergency, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou City, Fujian Province, PR. China
| | - Zhixia Zhu
- Department of Emergency, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou City, Fujian Province, PR. China
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Song Z, Meng L, He Z, Huang J, Li F, Feng J, Jia Z, Huang Y, Liu W, Liu A, Fang H. LBP Protects Hepatocyte Mitochondrial Function Via the PPAR-CYP4A2 Signaling Pathway in a Rat Sepsis Model. Shock 2021; 56:1066-1079. [PMID: 33988537 DOI: 10.1097/shk.0000000000001808] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To explore the role of LPS binding protein (LBP) in metabolism and optimize sepsis treatment. DESIGN A sepsis model was established by injecting LPS into LBP-/- rats and WT rats and observing changes in the liver over time (0, 1, 6, and 24 h). SETTING Detecting liver inflammation and injury. Optimizing the treatment of sepsis. SUBJECTS WT rats and LBP-/- rats. INTERVENTIONS We established a sepsis model by injecting LPS intravenously. MEASUREMENTS AND MAIN RESULTS First, we induced sepsis in WT and LBP-/- rats with LPS. The rats were sacrificed, and serum and liver samples were collected at 1, 6, and 24 h after LPS injection. We found that the deletion of LBP reduced LPS-induced liver inflammation and injury at 1 and 6 h. Ballooning degeneration was clearly present in LBP-/- rat livers at 24 h after LPS injection. We found that mitochondrial damage and reactive oxygen species (ROS) levels were higher in LBP-/- rat livers than in WT rat livers at 24 h after LPS injection. According to the transcriptomic results, the peroxisome proliferator-activated receptor (PPAR) pathway may be the reason for lesions in LBP-/- rats. To further investigate the function of PPARα in sepsis, we inhibited mTOR with rapamycin and examined mitochondrial injury and ROS levels. The levels of mitochondrial damage and ROS were reduced after LBP-/- rats were pretreated with rapamycin in the context of LPS-induced sepsis. Inhibiting CYP4a2, one of the PPARα-target gene products, reduced the level of LPS-induced ROS in LBP-/- rats. CONCLUSION LBP protects hepatic mitochondria against LPS-induced damage via the LBP-PPARα-CYP4a2 signaling pathway.
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Affiliation(s)
- Zichen Song
- Department of Pathophysiology, Anhui Medical University, Hefei, China
| | - Leilei Meng
- Department of Pathophysiology, Anhui Medical University, Hefei, China
| | - Zhixiang He
- The First Clinical Medical College, Anhui Medical University, Hefei, China
| | - Jing Huang
- Department of Pathophysiology, Anhui Medical University, Hefei, China
| | - Fang Li
- The First Clinical Medical College, Anhui Medical University, Hefei, China
| | - Jingjing Feng
- The First Clinical Medical College, Anhui Medical University, Hefei, China
| | - Zhuoran Jia
- The First Clinical Medical College, Anhui Medical University, Hefei, China
| | - Yue Huang
- The First Clinical Medical College, Anhui Medical University, Hefei, China
| | - Wei Liu
- Department of Clinical Laboratory, Binhu Hospital, Anhui Medical University, Hefei, China
| | - Anding Liu
- Experimental Medicine Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Haoshu Fang
- Department of Pathophysiology, Anhui Medical University, Hefei, China
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Rhee C, Yu T, Wang R, Kadri SS, Fram D, Chen HC, Klompas M. Association Between Implementation of the Severe Sepsis and Septic Shock Early Management Bundle Performance Measure and Outcomes in Patients With Suspected Sepsis in US Hospitals. JAMA Netw Open 2021; 4:e2138596. [PMID: 34928358 PMCID: PMC8689388 DOI: 10.1001/jamanetworkopen.2021.38596] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE In October 2015, the Centers for Medicare & Medicaid Services began requiring US hospitals to report adherence to the Severe Sepsis and Septic Shock Early Management Bundle (SEP-1). OBJECTIVE To evaluate the association of SEP-1 implementation with sepsis treatment patterns and outcomes in diverse hospitals. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study with interrupted time-series analysis and logistic regression models was conducted among adults admitted to 114 hospitals from October 2013 to December 2017 with suspected sepsis (blood culture orders, ≥2 systemic inflammatory response syndrome criteria, and acute organ dysfunction) within 24 hours of hospital arrival. Data analysis was conducted from September 2020 to September 2021. EXPOSURES SEP-1 implementation in the fourth quarter (Q4) of 2015. MAIN OUTCOMES AND MEASURES The primary outcome was quarterly rates of risk-adjusted short-term mortality (in-hospital death or discharge to hospice). Secondary outcomes included lactate testing and administration of anti-methicillin-resistant Staphylococcus aureus (MRSA) or antipseudomonal β-lactam antibiotics within 24 hours of hospital arrival. Generalized estimating equations with robust sandwich variances were used to fit logistic regression models to assess for changes in level or trends in these outcomes, adjusting for baseline characteristics and severity of illness. RESULTS The cohort included 117 510 patients (median [IQR] age, 67 years [55-78] years; 60 530 [51.5%] men and 56 980 [48.5%] women) with suspected sepsis. Lactate testing rates increased from 55.1% (95% CI, 53.9%-56.2%) in Q4 of 2013 to 76.7% (95% CI, 75.4%-78.0%) in Q4 of 2017, with a significant level change following SEP-1 implementation (odds ratio [OR], 1.34; 95% CI, 1.04-1.74). There were increases in use of anti-MRSA antibiotics (19.8% [95% CI, 18.9%-20.7%] in Q4 of 2013 to 26.3% [95% CI, 24.9%-27.7%] in Q4 of 2017) and antipseudomonal antibiotics (27.7% [95% CI, 26.7%-28.8%] in Q4 of 2013 to 40.5% [95% CI, 38.9%-42.0%] in Q4 of 2017), but these trends preceded SEP-1 and did not change with SEP-1 implementation. Unadjusted short-term mortality rates were similar in the pre-SEP-1 period (Q4 of 2013 through Q3 of 2015) vs the post-SEP-1 period (Q1 of 2016 through Q4 of 2017) (20.3% [95% CI, 20.0%-20.6%] vs 20.4% [95% CI, 20.1%-20.7%]), and SEP-1 implementation was not associated with changes in level (OR, 0.94; 95% CI, 0.68-1.29) or trend (OR, 1.00; 95% CI, 0.97-1.04) for risk-adjusted short-term mortality rates. CONCLUSIONS AND RELEVANCE In this cohort study, SEP-1 implementation was associated with an immediate increase in lactate testing rates, no change in already-increasing rates of broad-spectrum antibiotic use, and no change in short-term mortality rates for patients with suspected sepsis. Other approaches to decrease sepsis mortality may be warranted.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Tingting Yu
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Rui Wang
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Sameer S. Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - David Fram
- Commonwealth Informatics, Waltham, Massachusetts
| | | | - Michael Klompas
- Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, Massachusetts
- Division of Infectious Diseases, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Vallés J, Diaz E, Carles Oliva J, Martínez M, Navas A, Mesquida J, Gruartmoner G, de Haro C, Mestre J, Guía C, Rodriguez A, Ochagavía A. Clinical risk factors for early mortality in patients with community-acquired septic shock. The importance of adequate source control. Med Intensiva 2021; 45:541-551. [PMID: 34839885 DOI: 10.1016/j.medine.2020.05.013] [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: 03/02/2020] [Accepted: 05/16/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the incidence and risk factors for early mortality (EM) in the ICU in patients with community-acquired septic shock (CASS). DESIGN A retrospective cohort study of patients with CASS admitted to the ICU (2003-2016). SETTING ICU at a University Hospital in Spain. PATIENTS All consecutive patients admitted to the ICU with CASS. INTERVENTIONS None. MAIN VARIABLES OF INTEREST CASS was defined according to the Sepsis-3 definitions. EM were defined as occurring within of 72h following ICU admission. A multinomial logistic regression analysis was performed to identify the risk factors associated with early deaths. RESULTS During the study period, 625 patients met the Sepsis-3 criteria and admitted with CASS. 14.4% of all patients died within the first 72h. Of 161 patients who died in the ICU, 90 (55.9%) died within the first 72h. The percentage of early and late mortality did not vary significantly during the study period. The need and adequacy of source control were significantly lower in patients with EM. In the multivariate analysis, ARDS, non-respiratory infections, bacteremia and severity at admission were variables independently associated with EM. The only factor that decreased EM was adequate source control in patients with infections amenable to source control. CONCLUSIONS The incidence of EM has remained stable over time, which means that more than half of the patients who die from CASS do so within the first 72h. Infections where adequate source control can be performed have lower EM.
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Affiliation(s)
- J Vallés
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain.
| | - E Diaz
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - J Carles Oliva
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - M Martínez
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - A Navas
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - J Mesquida
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - G Gruartmoner
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - C de Haro
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - J Mestre
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - C Guía
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - A Rodriguez
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
| | - A Ochagavía
- Critical Care Department, Fundació Parc Taulí, Hospital Universitari Parc Taulí, Sabadell, Spain
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48
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Tsou PY, Yo CH, Hsein YC, Yungtum G, Hsu WT, Chung JY, Su KY, Chang A, Chang IJ, Lee CC. Temporal Trends in the Microbiological Characteristics of Sepsis in the United States: A Population Based Study. J Intensive Care Med 2021; 37:936-945. [PMID: 34787474 DOI: 10.1177/08850666211053778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Epidemiologic studies are needed for monitoring population-level trends in sepsis. This study examines sepsis-causing microorganisms from 2006 to 2014 in the United States using data from the Nationwide Inpatient Sample database. METHODS 7 860 686 adults hospitalized with sepsis were identified using a validated ICD-9 coding approach. Associated microorganisms were identified by ICD-9 code and classified by major groups (Gram-positive, Gram-negative, fungi, anaerobes) and specific species for analysis of their incidence and mortality. RESULTS The rate of sepsis incidence has increased for all four major categories of pathogens, while the mortality rate decreased. In 2014, Gram-negative pathogens had a higher incidence than Gram-positives. Anaerobes increased the fastest with an average annual increase of 20.17% (p < 0.001). Fungi had the highest mortality (19.28%) and the slowest annual decrease of mortality (-2.31%, p = 0.006) in 2013, while anaerobic sepsis had the highest hazard of mortality (adjusted HR 1.60, 95% CI 1.53-1.66). CONCLUSIONS Gram-negative pathogens have replaced Gram-positives as the leading cause of sepsis in the United States in 2014 during the study period (2006-2014). The incidence of anaerobic sepsis has an annual increase of 20%, while the mortality of fungal sepsis has not decreased at the same rate as other microorganisms. These findings should inform the diagnosis and management of septic patients, as well as the implementation of public health programs.
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Affiliation(s)
| | - Chia-Hung Yo
- 46608FarEastern Memorial Hospital, New Taipei City, Taiwan
| | - Yenh-Chen Hsein
- 37999National Taiwan University Yunlin Branch, Douliou, Taiwan
| | - Gregory Yungtum
- 12321Warren Alpert Medical School of Brown University, RI, USA
| | - Wan-Ting Hsu
- 1857Harvard Chan School of Public Health, Boston, MA, USA
| | | | - Ke-Ying Su
- 38006National Taiwan University Hospital, Taipei, Taiwan
| | | | - I-Jing Chang
- 63474Taipei Medical University Hospital, Taipei, Taiwan
| | - Chien-Chang Lee
- 38006National Taiwan University Hospital, Taipei, Taiwan.,Stanford University, Palo Alto, CA, USA.,38006National Taiwan University Hospital, Taiwan
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49
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Yang T, Shen Y, Park JG, Schulte PJ, Hanson AC, Herasevich V, Dong Y, Bauer PR. Outcome after intubation for septic shock with respiratory distress and hemodynamic compromise: an observational study. BMC Anesthesiol 2021; 21:253. [PMID: 34696738 PMCID: PMC8543776 DOI: 10.1186/s12871-021-01471-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 10/07/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Acute respiratory failure in septic patients contributes to higher in-hospital mortality. Intubation may improve outcome but there are no specific criteria for intubation. Intubation of septic patients with respiratory distress and hemodynamic compromise may result in clinical deterioration and precipitate cardiovascular failure. The decision to intubate is complex and multifactorial. The purpose of this study was to evaluate the impact of intubation in patients with respiratory distress and predominant hemodynamic instability within 24 h after ICU admission for septic shock. METHODS We conducted a retrospective analysis of a prospective registry of adult patients with septic shock admitted to the medical ICU at Mayo Clinic, between April 30, 2014 and December 31, 2017. Septic shock was defined by persistent lactate > 4 mmol/L, mean arterial pressure < 65 mmHg, or vasopressor use after 30 mL/kg fluid boluses and suspected or confirmed infection. Patients who remained hospitalized in the ICU at 24 h were separated into intubated while in the ICU and non-intubated groups. The primary outcome was hospital mortality. The first analysis used linear regression models and the second analysis used time-dependent propensity score matching to match intubated to non-intubated patients. RESULTS Overall, 358 (33%) ICU patients were eventually intubated after their ICU admission and 738 (67%) were not. Intubated patients were younger, transferred more often from an outside facility, more critically ill, had more lung infection, and achieved blood pressure goals more often, but lactate normalization within 6 h occurred less often. Among those who remained hospitalized in the ICU 24 h after sepsis diagnosis, the crude in-hospital mortality was higher in intubated than non-intubated patients, 89 (26%) vs. 82 (12%), p < 0.001, as was the ICU mortality and ICU and hospital length of stay. After adjustment, intubation showed no effect on hospital mortality but resulted in fewer hospital-free days through day 28. One-to-one propensity resulted in similar conclusion. CONCLUSIONS Intubation within 24 h of sepsis was not associated with hospital mortality but resulted in fewer 28-day hospital-free days. Although intubation remains a high-risk procedure, we did not identify an increased risk in mortality among septic shock patients with predominant hemodynamic compromise.
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Affiliation(s)
- Ting Yang
- Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Yongchun Shen
- Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - John G Park
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Phillip J Schulte
- Health Science Research - Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, 55905, USA
| | - Andrew C Hanson
- Health Science Research - Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, 55905, USA
| | | | - Yue Dong
- Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA
| | - Philippe R Bauer
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, 55905, USA.
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50
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Dellinger RP, Levy MM, Schorr CA, Townsend SR. 50 Years of Sepsis Investigation/Enlightenment Among Adults-The Long and Winding Road. Crit Care Med 2021; 49:1606-1625. [PMID: 34342304 DOI: 10.1097/ccm.0000000000005203] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- R Phillip Dellinger
- Cooper Medical School of Rowan University and Cooper University Health, Camden, NJ
| | | | - Christa A Schorr
- Cooper Medical School of Rowan University and Cooper University Health, Camden, NJ
| | - Sean R Townsend
- University of California Pacific Medical Center, (Sutter Health), San Francisco, CA
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