Sepsis. What it is and how to recognize it

Application Prospect of the SOFA Score and Related Modification Research Progress in Sepsis

In 2016, the SOFA score was proposed as the main evaluation system for diagnosis in the definition of sepsis 3.0, and the SOFA score has become a new research focus in sepsis. Some people are skeptical about diagnosing sepsis using the SOFA score. Experts and scholars from different regions have proposed different, modified versions of SOFA score to make up for the related problems with the use of the SOFA score in the diagnosis of sepsis. While synthesizing the different improved versions of SOFA proposed by experts and scholars in various regions, this paper also summarizes the relevant definitions of sepsis put forward in recent years to build a clear, improved application framework of SOFA score. In addition, the comparison between machine learning and SOFA scores related to sepsis is described and discussed in the article. Taken together, by summarizing the application of the improved SOFA score proposed in recent years in the related definition of sepsis, we believe that the SOFA score is still an effective means of diagnosing sepsis, but in the process of the continuous refinement and development of sepsis in the future, the SOFA score needs to be further refined and improved to provide more accurate coping strategies for different patient populations or application directions regarding sepsis. Against the big data background, machine learning has immeasurable value and significance, but its future applications should add more humanistic references and assistance.

A prospective, double-blind study on the efficacy of the bioline surface-heparinized extracorporeal perfusion circuit

BACKGROUND

We evaluated the newly introduced Bioline heparin coating and tested the hypothesis that surface heparinization limited to the oxygenator and the arterial filter will ameliorate systemic inflammation and preserve platelets during cardiopulmonary bypass (CPB).

METHODS

In a prospective double-blind study, 159 patients underwent coronary revascularization using closed-system CPB with systemic heparinization, mild hypothermia (33 degrees C), a hollow-fiber oxygenator, and an arterial filter. The patients were randomly divided in three groups. In group A (controls, n = 51), surface heparinization was not used. In group B (n = 52), the extracorporeal circuits were totally surface-heparinized with Bioline coating. In group C (n = 56), surface heparinization was limited to oxygenator and arterial filter.

RESULTS

No significant difference was noted in patient characteristics and operative data between groups. Operative (30-day) mortality was zero. Platelet counts dropped by 12.3% of pre-CPB value among controls at 15 minutes of CPB, but were preserved in groups B and C throughout perfusion (p = 0.0127). Platelet factor 4, plasmin-antiplasmin levels, and tumor necrosis factor-alpha increased more in controls during CPB than in groups B or C (p = 0.0443, p = 0.0238 and p = 0.0154 respectively). Beta-thromboglobulin, fibrinopeptide-A, prothrombin fragments 1 + 2, factor XIIa levels, bleeding times, blood loss, and transfusion requirements were similar between groups. Intensive care unit stay was shorter in groups B and C than in controls (p = 0.037).

CONCLUSIONS

Surface heparinization with Bioline coating preserves platelets, ameliorates the inflammatory response and is associated with a reduced fibrinolytic activity during CPB. Surface heparinization limited to the oxygenator and the arterial filter had similar results as totally surface-heparinized circuits.

Protective capacity of a IgM/IgA-enriched polyclonal immunoglobulin-G preparation in endotoxemia

Animal experiments were carried out to investigate whether a protective effect can be achieved in endotoxemia by intravenous (i.v.) application of a polyclonal immunoglobulin preparation (IVIG-IgG/A/M) enriched with 12% IgM and 12% IgA. Following administration of IVIG-IgG/A/M (500 mg/kg), endotoxemia was induced by intraperitoneal inoculation of a sublethal dose (5x10(8) CFU/kg) of Escherichia coli (E. coli) and subsequent i.v. administration of an antimicrobial agent (Imipenem). Plasma endotoxin activity, IL-6 activity, mean arterial pressure, and skeletal muscle oxygen pressure (tpO2) were measured at regular intervals over a total observation period of 7 h. Prophylactic administration of IVIG-IgG/A/M was found to significantly attenuate (P<0.01) the antibiotic-induced increase in endotoxin activity as compared to the albumin control group. Limited endotoxemia in the IgG/A/M group was associated with reduced levels of circulating IL-6 (P<0.01). Both lipopolysaccharide-induced hypotension and depression of tissue oxygenation were attenuated (P<0.01) by pre-treatment with IVIG-IgG/A/M. The experimental results suggest that in endotoxemia the polyclonal immunoglobulin preparation has a prophylactic protective effect on the acute phase responses and reduces the cardiodepressant effects of E. coli septicaemia.

Effects of naloxone on beta-endorphin and cortisol release in sepsis

We investigated the effects of the opiate antagonist naloxone on the release of beta-endorphin and cortisol in rats subjected to sepsis. Sepsis was induced in weanling male Wistar albino rats (3-4 weeks old, 75-90 g) by cecal ligation and double perforation (CLP). Forty animals were randomly allocated to four groups. Group 1 was given naloxone hydrochloride 0.5 mg/kg subcutaneously after CLP and this treatment was repeated at 2-h intervals until the rats were killed. Group 2 rats underwent a sham operation. Group 3 (control group) rats had CLP. Group 4 consisted of nonoperated animals used to establish normal reference values. Eighteen hours after CLP or sham operation, the rats were killed by cervical dislocation and a blood sample was drawn via cardiac puncture to determine the beta-endorphin and cortisol levels. The beta-endorphin levels were significantly higher in the control group than in the sham-operated, naloxone-treated (NT), and nonoperated rats (P < 0.05). However, there were no significant differences in plasma beta-endorphin levels between sham-operated, NT and nonoperated rats (P > 0.05). Plasma cortisol levels were significantly higher in the control group compared with the other three groups and this difference was more significant in sham-operated and nonoperated rats (P < 0.01). However, no difference existed between sham-operated, NT, and nonoperated rats (P > 0.05). This study demonstrates that the endogenous opioid system may play a role in the activation of the pituitary-adrenal axis following sepsis, and shows that the increase in beta-endorphin and cortisol could be blocked by naloxone.

Sepsis and septic shock. II. Treatment

Mortality from septic shock is considerable despite the advantages of cardiovascular support and antibiotic therapy. This article reviews current therapy of septic shock including immunotherapy and further possibilities of septic shock treatment. The role of cytokines, their inhibitors and antibodies to endotoxin is mentioned. Although these treatments hold much promise for the future, careful evaluation of both the benefits and complications of therapy is needed before widespread clinical use can be recommended.

Continuous arteriovenous hemofiltration in the treatment of amniotic fluid embolism

Continuous arteriovenous hemofiltration (CAVH) was successfully used in a 35-year-old woman, who had developed amniotic fluid embolism in the course of a premature labor and cesarean delivery. With CAVH, the pulmonary artery pressure decreased, the cardiac index rose, and the arterial oxygenation improved dramatically. This technique seems to be an important contribution to the management of amniotic fluid embolism.

Diagnosis and management of pericardial abscess in trauma patients

Pericardial infection is an uncommon clinical entity after traumatic injury. Although invasive intervention is rarely necessary for mild pericardial inflammation, pericardial abscess can be life-threatening. The charts of 27 patients with pericarditis requiring management in the intensive care unit and/or invasive intervention at Harborview Medical Center during a 10-year period were reviewed. Six cases of trauma-related pericarditis were identified, including three cases of pericardial abscess following torso trauma without initial cardiac or pericardial injury. Pericardial abscess following trauma was associated with the sepsis syndrome and multiple system organ failure (MSOF) in all patients. Computed tomography and pericardiocentesis were useful diagnostic adjuncts. All patients required thoracotomy for pericardial drainage and pericardiectomy. Successful surgical management of pericardial abscess contributed to the resolution of sepsis, multiple end-organ dysfunction and, ultimately, patient survival in all cases. We conclude that pericardial abscess, although rare, should be considered a potential occult site of sepsis capable of driving MSOF in trauma patients. Expedient diagnosis and surgical drainage are essential for successful patient outcome.