The effect of early goal-directed therapy on mortality in patients with severe sepsis and septic shock: a meta-analysis

Sepsis screening protocol implementation: a clinician-validated rapid realist review

INTRODUCTION

The failed or partial implementation of clinical practices negatively impacts patient safety and increases systemic inefficiencies. Implementation of sepsis screening guidelines has been undertaken in many settings with mixed results. Without a theoretical understanding of what leads to successful implementation, improving implementation will continue to be ad hoc or intuitive. This study proposes a programme theory for how and why the successful implementation of sepsis screening guidelines can occur.

METHODS

A rapid realist review was conducted to develop a focused programme theory for the implementation of sepsis screening guidelines. An independent two-reviewer approach was used to iteratively extract and synthesise context and mechanism data. Theoretical context-mechanism-outcome propositions were refined and validated by clinicians using a focus group and individual realist interviews. Implementation resources and clinical reasoning were differentiated in articulating mechanisms.

RESULTS

Eighteen articles were included in the rapid review. The theoretical domains framework was identified as the salient substantive theory informing the programme theory. The theory consisted of five main middle-range propositions. Three promoting mechanisms included positive belief about the benefits of the protocol, belief in the legitimacy of using the protocol and trust within the clinical team. Two inhibiting mechanisms included pessimism about the protocol being beneficial and pessimism about the team. Successful implementation was defined as achieving fidelity and sustained use of the intervention. Two intermediate outcomes, acceptability and feasibility of the intervention, and adoption, were necessary to achieve before successful implementation.

CONCLUSION

This rapid realist review synthesised key information from the literature and clinician feedback to develop a theory-based approach to clinical implementation of sepsis screening. The programme theory presents knowledge users with an outline of how and why clinical interventions lead to successful implementation and could be applied in other clinical areas to improve quality and safety.

Alarmins and MicroRNAs, a New Axis in the Genesis of Respiratory Diseases: Possible Therapeutic Implications

It is well ascertained that airway inflammation has a key role in the genesis of numerous respiratory pathologies, including asthma, chronic obstructive pulmonary disease, and acute respiratory distress syndrome. Pulmonary tissue inflammation and anti-inflammatory responses implicate an intricate relationship between local and infiltrating immune cells and structural pulmonary cells. Alarmins are endogenic proteins discharged after cell injury in the extracellular microenvironment. The purpose of our review is to highlight the alterations in respiratory diseases involving some alarmins, such as high mobility group box 1 (HMGB1) and interleukin (IL)-33, and their inter-relationships and relationships with genetic non-coding material, such as microRNAs. The role played by these alarmins in some pathophysiological processes confirms the existence of an axis composed of HMGB1 and IL-33. These alarmins have been implicated in ferroptosis, the onset of type 2 inflammation and airway alterations. Moreover, both factors can act on non-coding genetic material capable of modifying respiratory function. Finally, we present an outline of alarmins and RNA-based therapeutics that have been proposed to treat respiratory pathologies.

Multilabel hybridization probes for sequence-specific detection of sepsis-related drug resistance genes in plasmids

Emerging antimicrobial drug resistance is increasing the complexity involved in treating critical conditions such as bacterial induced sepsis. Methods for diagnosing specific drug resistance tend to be rapid or sensitive, but not both. Detection methods like sequence-specific single-molecule analysis could address this concern if they could be adapted to work on smaller targets similar to those produced in traditional clinical situations. In this work we demonstrate that a 120 bp double stranded polynucleotide with an overhanging single stranded 25 bp probe sequence can be created by immobilizing DNA with a biotin/streptavidin magnetic bead system, labeling with SYBR Gold, and rinsing the excess away while the probe retains multiple fluorophores. These probes with multiple fluorophores can then be used to label a bacterial plasmid target in a sequence-specific manner. These probes enabled the detection of 1 pM plasmid samples containing a portion of an antibiotic resistance gene sequence. This system shows the possibility of improving capture and fluorescence labeling of small nucleic acid fragments, generating lower limits of detection for clinically relevant samples while maintaining rapid processing times.

Protective effects of glucocorticoid on liver injury in a rat sepsis model

Sepsis is one of the leading causes of death with unsatisfactory current treatments. The present study assessed the liver protective effect of glucocorticoids on different levels of inflammation in septic shock rats. A rat septic shock model was established by lipopolysaccharide (LPS) injection. Rats were divided into control (Control), high-inflammation treated with hydrocortisone (HT), high-inflammation non-treatment (HNT), low-inflammation treated with hydrocortisone (LT) and low-inflammation non-treatment (LNT) groups according to the levels of serum C-reactive protein (CRP), interleukin (IL)-6 and interferon (IFN)-γ. The mean arterial pressure and heart rate changes were continuously monitored and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were measured by an automatic biochemical analyzer. Hematoxylin and eosin (H&E) staining was performed to observe the pathological changes of liver tissue. Western blot analysis was used to detect the expression of p38 mitogen-activated protein kinase (MAPK) and NF-κB protein. The results demonstrated that following 7 days of treatment, there were no obvious differences in the serum CRP, IL-6 and IFN-γ levels between the HT group and the control group, whilst the HNT group, LT group and LNT group were significantly different compared with the HT and control groups. H&E staining demonstrated that the liver cells in the HT group were homogeneous following 7 days of treatment. Western blot analysis determined that the phosphorylation levels of p38MAPK and NF-κB in HT group were reduced significantly compared with the LT group, while there was no obvious difference with the control group after 7 days treatment. The present results indicated that glucocorticoids have better therapeutic effect on septic shock rats with high-inflammation compared with low-inflammation rats. The present study provides a novel approach for glucocorticoid treatment of septic shock.

Septic shock in the ER: diagnostic and management challenges

Sepsis is a common presentation in the emergency department and a common cause of intensive care unit admissions and death. Accurate triage, rapid recognition, early resuscitation, early antibiotics, and eradication of the source of infection are the key components in delivering quality sepsis care. Evaluation of the patient's volume status, optimal hemodynamic resuscitation, and evaluation of patient response is crucial for sepsis management in the emergency department.

Exosomes from endothelial progenitor cells improve outcomes of the lipopolysaccharide-induced acute lung injury

Background

The acute respiratory distress syndrome (ARDS) is characterized by disruption of the alveolar-capillary barrier resulting in accumulation of proteinaceous edema and increased inflammatory cells in the alveolar space. We previously found that endothelial progenitor cell (EPC) exosomes prevent endothelial dysfunction and lung injury in sepsis in part due to their encapsulation of miRNA-126. However, the effects of EPC exosomes in acute lung injury (ALI) remain unknown.

Methods

To determine if EPC exosomes would have beneficial effects in ALI, intratracheal administration of lipopolysaccharide (LPS) was used to induce ALI in mice. Lung permeability, inflammation, and the role of miRNA-126 in the alveolar-epithelial barrier function were examined.

Results

The intratracheal administration of EPC exosomes reduced lung injury following LPS-induced ALI at 24 and 48 h. Compared to placebo, intratracheal administration of EPC exosomes significantly reduced the cell number, protein concentration, and cytokines/chemokines in the bronchoalveolar lavage fluid (BALF), indicating a reduction in permeability and inflammation. Further, EPC exosomes reduced myeloperoxidase (MPO) activity, lung injury score, and pulmonary edema, demonstrating protection against lung injury. Murine fibroblast (NIH3T3) exosomes, which do not contain abundant miRNA-126, did not provide these beneficial effects. In human small airway epithelial cells (SAECs), we found that overexpression of miRNA-126-3p can target phosphoinositide-3-kinase regulatory subunit 2 (PIK3R2), while overexpression of miRNA-126-5p inhibits the inflammatory alarmin HMGB1 and permeability factor VEGFα. Interestingly, both miR-126-3p and 5p increase the expression of tight junction proteins suggesting a potential mechanism by which miRNA-126 may mitigate LPS-induced lung injury.

Conclusions

Our data demonstrated that human EPC exosomes are beneficial in LPS-induced ALI mice, in part through the delivery of miRNA-126 into the injured alveolus.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2339-3) contains supplementary material, which is available to authorized users.

Early goal-directed and lactate-guided therapy in adult patients with severe sepsis and septic shock: a meta-analysis of randomized controlled trials

Background

The ProCESS, ARISE, and ProMISe trials have failed to show that early goal-directed therapy (EGDT) reduces mortality in patients with severe sepsis and septic shock. Although lactate-guided therapy (LGT) has been shown to result in significantly lower mortality, its use remains controversial. Therefore, we performed a meta-analysis to evaluate EGDT vs. LGT or usual care (UC) in adult patients with severe sepsis and septic shock.

Methods

Relevant randomized controlled trials published from January 1, 2001 to March 30, 2017 were identified in PubMed, EMBASE, Web of Science, and the Cochrane Library. The primary outcome was mortality; secondary outcomes included red cell transfusions, dobutamine use, vasopressor infusion, and mechanical ventilation support within the first 6 h and Acute Physiology and Chronic Health Evaluation II (APACHE II) score.

Results

Sixteen studies enrolling 5968 patients with 2956 in EGDT, 2547 in UC, and 465 in LGT were included in this meta-analysis. Compared with UC, EGDT was associated with a lower mortality (10 trials; RR 0.85, 95% CI 0.74–0.97, P = 0.01), and this difference was more pronounced in the subgroup of UC patients with mortality > 30%. In addition, EGDT patients received more red cell transfusions, dobutamine, and vasopressor infusions within the first 6 h. Compared with LGT, EGDT was associated with higher mortality (6 trials; RR 1.42, 95% CI 1.19–1.70, P = 0.0001) with no heterogeneity (P = 0.727, I² = 0%).

Conclusion

EGDT seems to reduce mortality in adult patients with severe sepsis and septic shock, and the benefit may primarily be attributed to red cell transfusions, dobutamine administration, and vasopressor infusions within the first 6 h. However, LGT may result in a greater mortality benefit than EGDT.

Electronic supplementary material

The online version of this article (10.1186/s12967-018-1700-7) contains supplementary material, which is available to authorized users.

Improved Survival of Patients With Extensive Burns: Trends in Patient Characteristics and Mortality Among Burn Patients in a Tertiary Care Burn Facility, 2004-2013

Classic determinants of burn mortality are age, burn size, and the presence of inhalation injury. Our objective was to describe temporal trends in patient and burn characteristics, inpatient mortality, and the relationship between these characteristics and inpatient mortality over time. All patients aged 18 years or older and admitted with burn injury, including inhalation injury only, between 2004 and 2013 were included. Adjusted Cox proportional hazards regression models were used to estimate the relationship between admit year and inpatient mortality. A total of 5540 patients were admitted between 2004 and 2013. Significant differences in sex, race/ethnicity, burn mechanisms, TBSA, inhalation injury, and inpatient mortality were observed across calendar years. Patients admitted between 2011 and 2013 were more likely to be women, non-Hispanic Caucasian, with smaller burn size, and less likely to have an inhalation injury, in comparison with patients admitted from 2004 to 2010. After controlling for patient demographics, burn mechanisms, and differential lengths of stay, no calendar year trends in inpatient mortality were detected. However, a significant decrease in inpatient mortality was observed among patients with extensive burns (≥75% TBSA) in more recent calendar years. This large, tertiary care referral burn center has maintained low inpatient mortality rates among burn patients over the past 10 years. While observed decreases in mortality during this time are largely due to changes in patient and burn characteristics, survival among patients with extensive burns has improved.

Microbial recognition and danger signals in sepsis and trauma

Early host recognition of microbial invasion or damaged host tissues provides an effective warning system by which protective immune and inflammatory processes are initiated. Host tissues responsible for continuous sampling of their local environment employ cell surface and cytosolic pattern recognition receptors (PRRs) that provide redundant and overlapping identification of both microbial and host alarmins. Microbial products containing pathogen-associated molecular patterns (PAMPs), as well as damage-associated molecular patterns (DAMPs) serve as principle ligands for recognition by these PRRs. It is this interaction which plays both an essential survival role in response to infection and injury, as well as the pathologic role in tissue and organ injury associated with severe sepsis and trauma. Elucidating the interaction between ligands and their respective PRRs can provide both a better understanding of the host response, as well as a rational basis for therapeutic intervention. This article is part of a Special Issue entitled: Immune and Metabolic Alterations in Trauma and Sepsis edited by Dr. Raghavan Raju.

Early goal-directed treatment versus standard care in management of early septic shock: Meta-analysis of randomized trials

BACKGROUND

Since the incorporation of the early hemodynamic resuscitation in septic shock according to the early goal-directed therapy (EGDT) protocol among the 6-hour resuscitation bundle of the Surviving Sepsis Campaign guidelines, a great debate has been raised about the issue. The present meta-analysis aims to determine whether the resuscitative phase really takes advantages by being performed with EGDT.

METHODS

A systematic review with meta-analysis of randomized controlled trials (RCTs) of EGDT versus usual care in patients with early septic shock was performed.

RESULTS

Four high-quality RCTs have been included with 4,464 patients (1990 in EGDT and 2013 in usual care arm). ICU admission and cardiovascular support necessity increased in the EGDT group (OR = 2.00, 95% CI 1.55-2.57 and OR = 1.33, 95% CI 1.08-1.64, respectively). EGDT has no significant effect on mortality (90 days, 60 days, 28 days, and mortality by the time of hospital discharge). EGDT has no significant effect in reducing the length of hospital stay, the necessity of respiratory and renal function support, and the duration of respiratory and cardiocirculatory support.

CONCLUSIONS

EGDT seems to increase the resource demand in terms of ICU admissions and cardiocirculatory support necessity without reducing mortality, renal and respiratory organ support necessity, respiratory and cardiocirculatory support duration, and length of hospital stay.

LEVEL OF EVIDENCE

Systematic review, level I.

The effect of early goal-directed therapy for treatment of severe sepsis or septic shock: A systemic review and meta-analysis

PURPOSE

To assess the effects of early goal-directed therapy (EGDT) on reducing mortality compared with conventional management of severe sepsis or septic shock.

MATERIALS AND METHODS

We included a systemic review, using the Medline and EMBASE. Seventeen randomized trials with 5765 patients comparing EGDT with usual care were included.

RESULTS

There were no significant differences in mortality between EGDT and control groups (relative risk [RR], 0.89; 95% confidence interval [CI], 0.79-1.00), with moderate heterogeneity (I2=56%). The EGDT was associated with lower mortality rates when the mortality rate of the usual care group was greater than 30% (12 trials; RR, 0.83; 95% CI, 0.72-0.96), but not when the mortality rate in the usual care group was less than 30% (5 trials; RR, 1.03; 95% CI, 0.92-1.16). The mortality benefit was seen only in subgroup of population analyzed between publication of the 2004 and 2012 Surviving Sepsis Campaign guidelines, but not before and after these publications.

CONCLUSION

This meta-analysis was heavily influenced by the recent addition of the trio of trials published after 2014. The results of the recent trio of trials may be biased due to methodological issues. This includes lack of blinding by incorporating similar diagnostic and therapeutic interventions as the original EGDT trial.