Septic shock

Strong correlation between doppler snuffbox resistive index and systemic vascular resistance in septic patients

PURPOSE

To compare systemic vascular resistance index (SVRI) as measured by invasive transpulmonary indicator dilution (TPID) and non-invasive Doppler-derived resistive index in septic patients.

METHODS

We measured the snuffbox resistive index (SBRI) in both hands of septic patients who received hemodynamic monitoring by TPID prospectively.

RESULTS

Thirty-six patients with septic shock were enrolled (median acute physiology and chronic health evaluation II score: 23; median age: 64 years). Four SBRI values were measured in each patient, for a total of 96 patient days and 951 ultrasound measurements. The correlation coefficients between SVRI and the four SBRI values were all higher than 0.87 (p < .001). A higher SVRI was associated with sharp waveforms and reversed diastolic flow. A resistive index (RI) of 0.97 was the lower limit of normal SVRI (1700 dyn*s*cm^-5*m²), and an RI of 1.1 was the upper limit of normal SVRI (2400 dyn*s*cm^-5*m²).

CONCLUSIONS

Using ultrasound to measure RI is a noninvasive, inexpensive, reliable method to evaluate peripheral vascular resistance in septic patients, and it is highly correlated with SVRI. In addition, SBRI can be used to evaluate peripheral circulatory disturbances in septic patients.

Resuscitation With Balanced Fluids Is Associated With Improved Survival in Pediatric Severe Sepsis

OBJECTIVE

To evaluate outcomes in patients receiving balanced fluids for resuscitation in pediatric severe sepsis.

DESIGN

Observational cohort review of prospectively collected data from a large administrative database.

SETTING

PICUs from 43 children's hospitals.

PATIENTS

PICU patients diagnosed with severe sepsis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We reviewed data from the Pediatric Health Information System database from 2004 to 2012. Children with pediatric severe sepsis receiving balanced fluids for resuscitation in the first 24 and 72 hours of treatment were compared to those receiving unbalanced fluids. Thirty-six thousand nine hundred eight patients met entry criteria for analysis. Two thousand three hundred ninety-eight patients received exclusively balanced fluids at 24 hours and 1,641 at 72 hours. After propensity matching, the 72-hour balanced fluids group had lower mortality (12.5% vs 15.9%; p = 0.007; odds ratio, 0.76; 95% CI, 0.62-0.93), lower prevalence of acute kidney injury (16.0% vs 19.2%; p = 0.028; odds ratio, 0.82; 95% CI, 0.68-0.98), and fewer vasoactive infusion days (3.0 vs 3.3 d; p < 0.001) when compared with the unbalanced fluids group.

CONCLUSIONS

In this retrospective analysis carried out by propensity matching, exclusive use of balanced fluids in pediatric severe sepsis patients for the first 72 hours of resuscitation was associated with improved survival, decreased prevalence of acute kidney injury, and shorter duration of vasoactive infusions when compared with exclusive use of unbalanced fluids.

Procalcitonin to Detect Suspected Bacterial Infections in the PICU

OBJECTIVES

Nonspecific clinical symptoms frequently lead to suspicion of bacterial infection in critically ill children. Clinicians send bacterial cultures for suspected infection and begin an empiric course of antibiotics while microbiology results are pending. We investigated whether the biomarker procalcitonin could be useful to predict confirmed bacterial infection in critically ill children in the PICU, before culture results are available.

DESIGN

Prospective, blinded single-center study.

SETTING

Tertiary PICU and cardiothoracic ICU.

PATIENTS

There were one hundred forty-four patients with suspected bacterial infections that had bacterial cultures sent by clinicians.

INTERVENTIONS

Procalcitonin samples were obtained at three time intervals: as close to the time of the initial culture as possible (up to 12 hr after) and 24 and 72 hours after the initial culture. Patients were stratified into clinical outcome groups based on microbiology results and clinical symptoms using Centers for Disease Control and Prevention criteria. These assignments were blinded to procalcitonin levels. Primary outcome was the presence of culture-proven bacterial infection.

MEASUREMENTS AND MAIN RESULTS

There was a statistically significant difference in initial and subsequent median procalcitonin values between patients with confirmed bacterial infections and patients with low suspicion of bacterial infection (p < 0.02). However, there was extremely high variability in procalcitonin values among all groups. Procalcitonin had only a fair ability to predict bacterial infection, with area under the curve of receiver operating characteristic plots ranging between 0.63 and 0.71. When using serial procalcitonin values to predict bacterial infection, positive likelihood ratios were near 1 and negative likelihood ratios were between 0.3 and 0.4.

CONCLUSIONS

Procalcitonin levels were higher in children with documented confirmed bacterial infection as compared with those with low suspicion of infection. However, neither single nor serial procalcitonin measurements were able to predict the presence or absence of confirmed bacterial infection with enough certainty to be clinically useful as to recommend initiating or withholding antibiotics.

Bacterial sepsis in Brazilian children: a trend analysis from 1992 to 2006

Background

The objective of this study was to determine the epidemiology of hospitalized pediatric sepsis in Brazil (1992–2006) and to compare mortality caused by sepsis to that caused by other major childhood diseases.

Methods and Findings

We performed a retrospective descriptive study of hospital admissions using a government database of all hospital affiliated with the Brazilian health system. We studied all hospitalizations in children from 28 days through 19 years with diagnosis of bacterial sepsis defined by the criteria of the International Classification of Diseases (ICD), (Appendix S1). Based on the data studied from 1992 through 2006, the pediatric hospital mortality rate was 1.23% and there were 556,073 pediatric admissions with bacterial sepsis with a mean mortality rate of 19.9%. There was a case reduction of 67% over.1992–2006 (p<0.001); however, the mortality rate remained unchanged (from 1992–1996, 20.5%; and from 2002–2006, 19.7%). Sepsis-hospital mortality rate was substantially higher than pneumonia (0.5%), HIV (3.3%), diarrhea (0.3%), undernutrition (2.3%), malaria (0.2%) and measles (0.7%). The human development index (HDI) and mortality rates (MR) by region were: North region 0.76 and 21.7%; Northeast region 0.72 and 27.1%; Central-West 0.81 and 23.5%; South region 0.83 and 12.2% and Southeast region 0.82 and 14.8%, respectively.

Conclusions

We concluded that sepsis remains an important health problem in children in Brazil. The institution of universal primary care programs has been associated with substantially reduced sepsis incidence and therefore deaths; however, hospital mortality rates in children with sepsis remain unchanged. Implementation of additional health initiatives to reduce sepsis mortality in hospitalized patients could have great impact on childhood mortality rates in Brazil.

Ketamine inhibits tumor necrosis factor secretion by RAW264.7 murine macrophages stimulated with antibiotic-exposed strains of community-associated, methicillin-resistant Staphylococcus aureus

Background

Infections caused by community-associated strains of methicillin-resistant Staphylococcus aureus (CA-MRSA) are associated with a marked and prolonged host inflammatory response. In a sepsis simulation model, we tested whether the anesthetic ketamine inhibits the macrophage TNF response to antibiotic-exposed CA-MRSA bacteria via its antagonism of N-methyl-D-aspartate (NMDA) receptors. RAW264.7 cells were stimulated for 18 hrs with 10⁵ to 10⁷ CFU/mL inocula of either of two prototypical CA-MRSA isolates, USA300 strain LAC and USA400 strain MW2, in the presence of either vancomycin or daptomycin. One hour before bacterial stimulation, ketamine was added with or without MK-801 (dizocilpine, a chemically unrelated non-competitive NMDA receptor antagonist), APV (D-2-amino-5-phosphono-valerate, a competitive NMDA receptor antagonist), NMDA, or combinations of these agents. Supernatants were collected and assayed for TNF concentration by ELISA.

Results

RAW264.7 cells exposed to either LAC or MW2 in the presence of daptomycin secreted less TNF than in the presence of vancomycin. The addition of ketamine inhibited macrophage TNF secretion after stimulation with either of the CA-MRSA isolates (LAC, MW2) in the presence of either antibiotic. The NMDA inhibitors, MK-801 and APV, also suppressed macrophage TNF secretion after stimulation with either of the antibiotic-exposed CA-MRSA isolates, and the effect was not additive or synergistic with ketamine. The addition of NMDA substrate augmented TNF secretion in response to the CA-MRSA bacteria, and the addition of APV suppressed the effect of NMDA in a dose-dependent fashion.

Conclusions

Ketamine inhibits TNF secretion by MRSA-stimulated RAW264.7 macrophages and the mechanism likely involves NMDA receptor antagonism. These findings may have therapeutic significance in MRSA sepsis.

Probing structure-activity relationships in bactericidal peptide betapep-25

Cationic peptides, known to disrupt bacterial membranes, are being developed as promising agents for therapeutic intervention against infectious disease. In the present study, we investigate structure-activity relationships in the bacterial membrane disruptor betapep-25, a peptide 33-mer. For insight into which amino acid residues are functionally important, we synthesized alanine-scanning variants of betapep-25 and assessed their ability to kill bacteria (Escherichia coli, Pseudomonas aeruginosa and Staphylococcus aureus) and to neutralize LPS (lipopolysaccharide). Activity profiles were found to vary with the bacterial strain examined. Specific cationic and smaller hydrophobic alkyl residues were crucial to optimal bactericidal activity against the Gram-negative bacteria, whereas larger hydrophobic and cationic residues mediated optimal activity against Gram-positive Staph. aureus. Lysine-substituted norleucine (n-butyl group) variants demonstrated that both charge and alkyl chain length mediate optimal activity. In terms of LPS neutralization, activity profiles were essentially the same against four species of LPS (E. coli 055 and 0111, Salmonella enterica serotype Typhimurium and Klebsiella pneumoniae), and different for two others (Ps. aeruginosa and Serratia marcescens), with specific hydrophobic, cationic and, surprisingly, anionic residues being functionally important. Furthermore, disulfide-bridged analogues demonstrated that an anti parallel beta-sheet structure is the bioactive conformation of betapep-25 in terms of its bactericidal, but not LPS endotoxin neutralizing, activity. Moreover, betapep-25 variants, like the parent peptide, do not lyse eukaryotic cells. This research contributes to the development and design of novel antibiotics.

Adrenal insufficiency in pediatric critical illness: controversies regarding its prevalence, pathogenesis, definition and management

Proper functioning of the hypothalamic–pituitary–adrenal axis is necessary for normal homeostasis in children and especially under conditions of stress, such as critical illness. Disturbances of this axis have been classified collectively under the heading of adrenal insufficiency. Although the majority of literature has focused on children with septic shock, more recent evidence suggests that adrenal insufficiency occurs in a much broader group of critically ill children. Its etiology in pediatric critical illness remains unclear but is most likely multifactorial. Several studies have suggested possible diagnostic criteria for adrenal insufficiency in pediatric critical illness; however, to date none of these biochemical definitions have been validated. Similarly, current management of this condition in children remains based primarily on an empiric, best-practice approach. Future large-scale studies are needed to elucidate the prevalence, pathogenesis, definition, diagnosis and management of this condition.

Capacitive biosensor for detection of endotoxin

A capacitive biosensor for the detection of bacterial endotoxin has been developed. Endotoxin-neutralizing protein derived from American horseshoe crab was immobilized to a self-assembled thiol layer on a biosensor transducer (Au). Upon injection of a sample containing endotoxin, a decrease in the observed capacitive signal was registered. Endotoxin could be determined under optimum conditions with a detection limit of 1.0 x 10(-13) M and linearity ranging from 1.0 x 10(-13) to 1.0 x 10(-10) M. Good agreement was achieved when applying endotoxin preparations purified from an Escherichia coli cultivation to the capacitive biosensor system, utilizing the conventional method for quantitative endotoxin determination, the Limulus amebocyte lysate test as a reference. The capacitive biosensor method was statistically tested with the Wilcoxon signed rank test, which proved the system is acceptable for the quantitative analysis of bacterial endotoxin (P<0.05).

Topomimetics of amphipathic beta-sheet and helix-forming bactericidal peptides neutralize lipopolysaccharide endotoxins

Release of lipopolysaccharide (LPS) endotoxin from Gram negative bacterial membranes triggers macrophages to produce large quantities of cytokines that can lead to septic shock and eventual death. Agents that bind to and neutralize LPS may provide a means to clinically prevent septic shock upon bacterial infection. Previously, we reported the design of antibacterial helix peptide SC4 and beta-sheet-forming betapep peptides that neutralize LPS in vitro. We hypothesized that the ability of these and other such peptides to neutralize LPS rested in the common denominator of positively charged amphipathic structure. Here, we describe the design and synthesis of nonpeptide, calixarene-based helix/sheet topomimetics that mimic the folded conformations of these peptides in their molecular dimensions, amphipathic surface topology, and compositional properties. From a small library of topomimetics, we identified several compounds that neutralize LPS in the 10-8 M range, making them as effective as bactericidal/permeability increasing protein and polymyxin B. In an endotoxemia mouse model, three of the most in vitro effective topomimetics are shown to be at least partially protective against challenges of LPS from different bacterial species. NMR studies provide mechanistic insight by suggesting the site of molecular interaction between topomimetics and the lipid A component of LPS, with binding being mediated by electrostatic and hydrophobic interactions. This research contributes to the development of pharmaceutical agents against endotoxemia and septic shock.

Procalcitonin does discriminate between sepsis and systemic inflammatory response syndrome

AIMS

To evaluate whether procalcitonin (PCT) and C reactive protein (CRP) are able to discriminate between sepsis and systemic inflammatory response syndrome (SIRS) in critically ill children.

METHODS

Prospective, observational study in a paediatric intensive care unit. Kinetics of PCT and CRP were studied in patients undergoing open heart surgery with cardiopulmonary bypass (CPB) (SIRS model; group I1) and patients with confirmed bacterial sepsis (group II).

RESULTS

In group I, PCT median concentration was 0.24 ng/ml (reference value <2.0 ng/ml). There was an increment of PCT concentrations which peaked immediately after CPB (median 0.58 ng/ml), then decreased to 0.47 ng/ml at 24 h; 0.33 ng/ml at 48 h, and 0.22 ng/ml at 72 h. CRP median concentrations remained high on POD1 (36.6 mg/l) and POD2 (13.0 mg/l). In group II, PCT concentrations were high at admission (median 9.15 ng/ml) and subsequently decreased in 11/14 patients who progressed favourably (median 0.31 ng/ml). CRP levels were high in only 11/14 patients at admission. CRP remained high in 13/14 patients at 24 h; in 12/14 at 48 h; and in 10/14 patients at 72 h. Median values were 95.0, 50.9, 86.0, and 20.3 mg/l, respectively. The area under the ROC curve was 0.99 for PCT and 0.54 for CRP. Cut off concentrations to differentiate SIRS from sepsis were >2 ng/ml for PCT and >79 mg/l for CRP.

CONCLUSION

PCT is able to differentiate between SIRS and sepsis while CRP is not. Moreover, unlike CRP, PCT concentrations varied with the evolution of sepsis.

Linking the sepsis triad of inflammation, coagulation, and suppressed fibrinolysis to infants

Sepsis continues to be a significant cause of morbidity and mortality in hospitalized newborns and premature infants. The pathophysiology and disease state of sepsis appear to be similar between adults and children. Both groups display symptoms that indicate a systemic inflammatory response leading to coagulopathy, hypotension, inadequate perfusion of peripheral tissues and organs, and, ultimately, organ failure and death. By presenting a comparison of adult and neonatal pathophysiology, as well as a supporting literature review and clinical evidence, this article links the pathways of inflammation, activation of coagulation, and impaired fibrinolysis, known as the sepsis cascade, to neonatal sepsis. Knowledge of the pathophysiology has important clinical and research implications. Unlike traditional antimicrobial therapy, new potential therapies, currently under investigation for the treatment of sepsis, target the cellular response rather than the invading organism. A more complete understanding of the pathophysiology of sepsis may also lead to diagnostic tools with improved sensitivity and specificity for early recognition and treatment.

Vital organ blood flow during hyperdynamic sepsis

OBJECTIVES

To develop a nonlethal model of hyperdynamic sepsis, and to measure vital organ blood flows in this setting.

DESIGN

Randomized crossover animal study.

SETTING

Animal laboratory of university-affiliated physiology institute.

SUBJECTS

Seven Merino cross sheep.

INTERVENTIONS

Surgical implantation of transit-time flow probes around sagittal sinus and circumflex coronary, superior mesenteric, and left renal arteries, and of an electromagnetic flow probe around the ascending aorta. After recovery, randomization to either 6 h of observation under normal conditions (control) or 6 h of observation after the induction of hyperdynamic nonlethal sepsis (sepsis), with each animal crossing over to the other treatment after a 2-week interval.

MEASUREMENTS AND MAIN RESULTS

Injection of Escherichia coli induced nonlethal hyperdynamic sepsis within 5 to 6 h with hypotension (mean arterial pressure [+/- SD], 85 +/- 7 mm Hg vs 69 +/- 8 mm Hg), increased cardiac output (4.0 +/- 0.9 L/min vs 7.2 +/- 1.2 L/min), tachycardia (60 +/- 10 beats/min vs 160 +/- 15 beats/min), fever, oliguria, and tachypnea. Compared to control animals, hyperdynamic sepsis increased renal (330 +/- 101 mL/min vs 214 +/- 75 mL/min), mesenteric (773 +/- 370 mL/min vs 516 +/- 221 mL/min), and coronary (54 +/- 24 mL/min vs 23 +/- 10 mL/min) blood flow (p < 0.05). There was no significant change in sagittal sinus flow. Despite increased coronary flow, myocardial contractility decreased (800 +/- 150 L/min/s vs 990 +/- 150 L/min/s). Despite increased mesenteric and renal blood flow, there was hyperlactatemia (0.5 +/- 0.1 mmol/L vs 1.9 +/- 0.3 mmol/L); despite increased renal blood flow, all experimental animals acquired oliguria (160 +/- 75.3 mL/2 h vs 50.2 +/- 13.1 mL/2 h) and increased serum creatinine levels (0.07 +/- 0.02 mmol/L vs 0.11 +/- 0.02 mmol/L).

CONCLUSIONS

Injection of E coli induced hyperdynamic nonlethal sepsis. During such hyperdynamic sepsis, blood flow to heart, gut, and kidney was markedly increased; however, organ dysfunction developed. We speculate that global ischemia may not be the principal mechanism of vital organ dysfunction in hyperdynamic sepsis.

Coagulation dysfunction in sepsis and multiple organ system failure

In patients diagnosed with sepsis, severe sepsis or septic shock, cytokine-mediated endothelial injury, and TF activation initiate a cascade of events that culminate in the development of coagulation dysfunction characterized as procoagulant and antifibrinolytic. This abnormal state predisposes the patient to develop microvascular thrombosis, tissue ischemia, and organ hypoperfusion. Multiple organ dysfunction syndrome may be a product of this pertubation in coagulation regulation. Treatments aimed at correcting this coagulation dysfunction have met with mixed success. Current data suggest that AT III replacement therapy has limited efficacy in adults with severe sepsis. In contrast, adult patients diagnosed with severe sepsis and organ failure and treated with aPC (drotrecogin alfa activate) have a significantly reduced risk of death when compared with placebo-treated patients. A phase III trial examining the efficacy of protein C replacement therapy in pediatric patients with severe sepsis and organ failure is underway.

Pediatric septic shock and multiple organ failure

In the last 5 years, the understanding of the epidemiology and pathogenesis of pediatric sepsis, septic shock, and multiple organ failure has expanded greatly. There has also been a substantial increase in the number of successful randomized trials in which success has been measured as reduction in mortality in adults, children, and newborns. This article discusses these advances, updating the 1997 article on septic shock written by the author and by Dr. Robert E. Cunnion and following the format of the 1997 article.

Arginine and nitric oxide metabolism in critically ill septic pediatric patients

OBJECTIVE

To investigate whole body, arginine metabolism and nitric oxide synthesis rates in septic, critically ill pediatric patients.

DESIGN

Prospective study.

SETTING

Pediatric intensive care unit at a general hospital.

PATIENTS

Ten consecutive septic patients age 6-16 yrs.

INTERVENTIONS

Septic patients received an 8-hr primed, constant intravenous tracer infusion of L-[guanidino-15N2]arginine, L-[1-13C]leucine, and [13C]urea. A 24-hr urine collection was obtained for determination of [15N]nitrate enrichment (15NO3(-)) and urinary nitrogen. The next day they received an infusion of L-[5-13C]arginine and L-[5-13C-ureido, 5,5, 2H2]citrulline. Blood samples were obtained for determination of plasma isotopic enrichment of the tracers given and of derived [15N]citrulline (nitric oxide synthesis), L-[13C-guanidino 5,5, 2H2]arginine (M+3 arg) (arginine synthesis), and [15N]urea (urea formation). Data are compared with historic controls from studies in healthy young adults.

MEASUREMENTS AND MAIN RESULTS

Plasma arginine fluxes were 67 +/- 21 and 72 +/- 17 micromol x kg(-1) x hr(-1), respectively, for the [15N2 guanidino] and the [13C] arginine labels, which were not different from reported adult values. The rates of arginine oxidation were 22.9 +/- 10.8 micromol x kg(-1) x hr(-1) and were higher than arginine synthesis rates of 9.6 +/- 4.2 micromol x kg(-1) x hr(-1) (p <.01); therefore, these patients were in a negative arginine balance. The rates of nitric oxide synthesis as estimated by the [15N]citrulline method were 1.58 +/- 0.69 micromol x kg(-1) x hr(-1) for septic patients and higher (p <.05) than values of 0.96 +/- 0.1 micromol x kg(-1) x hr(-1) in healthy adults. Septic patients were in a negative protein (leucine) balance of about -1.00 +/- 0.40 g x kg(-1) x day(-1).

CONCLUSIONS

Homeostasis of plasma arginine in septic patients was impaired compared with reported adult values. The rates of arginine oxidation were increased whereas net arginine synthesis was unchanged, leading to a negative arginine balance. The rates of nitric oxide synthesis and the fraction of plasma arginine used for nitric oxide and urea formation were increased. These findings suggest that under condition of sepsis, arginine becomes essential in critically ill children.

Heart failure in pediatric septic shock: utilizing inotropic support

Septic shock presents a unique challenge in the pediatric patient. Sepsis stimulates the release of inflammatory mediators that can compromise cardiac function. Oxygen extraction abnormalities, diminished responses to adrenergic agonists, and impaired ventricular function often result. After fluid resuscitation and antibiotic therapy, careful cardiovascular assessment is needed to administer appropriate inotropic and vasoactive drugs.

Cysteine metabolism and whole blood glutathione synthesis in septic pediatric patients

OBJECTIVE

To investigate whole body in vivo cysteine kinetics and its relationship to whole blood glutathione (GSH) synthesis rates in septic, critically ill pediatric patients and controls.

DESIGN

Prospective cohort study.

SETTING

Multidisciplinary intensive care unit and pediatric inpatient units at a children's hospital.

PATIENTS

Ten septic pediatric patients and ten controls (children admitted to the hospital for elective surgery).

INTERVENTIONS

Septic patients (age, 31 months to 17 yrs) and controls (age, 24 months to 21 yrs) received a 6-hr primed, constant, intravenous tracer infusion of l-[1-13C]cysteine. Blood samples were obtained to determine isotopic enrichment of plasma cysteine and whole blood [1-13C]cysteinyl-glutathione by gas-chromatography mass spectrometric techniques. The plasma flux and oxidation rate of cysteine and the fractional and absolute synthesis rates of GSH were determined. Septic patients received variable protein and energy intake, as per routine clinical management, and controls were studied in the early postabsorptive state.

MEASUREMENTS AND MAIN RESULTS

Plasma cysteine fluxes were increased in the septic patients when compared with the controls (68.2 +/- 17.5 [sd] vs. 48.7 +/- 8.8 micromol x kg(-1) x hr(-1); p <.01), and the fraction of plasma cysteine flux associated with oxidative disposal was similar among the groups. The absolute rates of GSH synthesis in whole blood were decreased (p <.01) in the septic patients (368 +/- 156 vs. 909 +/- 272 micromol x L(-1) x day(-1)). The concentration of whole blood GSH also was decreased in the septic group (665.4 +/- 194 vs. 1059 +/- 334 microM; p <.01)

CONCLUSIONS

Whole blood glutathione synthesis rates are decreased, by about 60%, in critically ill septic children receiving limited nutritional support. Plasma cysteine fluxes and concentration of cysteine were increased in the septic patients, suggesting a hypermetabolic state with increased protein breakdown. The mechanisms whereby GSH synthesis rates are decreased in these patients are probably multifactorial, presumably involving an inflammatory response in the presence of limited nutritional support. The role of nutritional modulation and the use of cysteine prodrugs in maintaining GSH concentration and synthesis remain to be established.

Severe group A streptococcal infection and streptococcal toxic shock syndrome

PURPOSE

To review the literature on group A streptococcal toxic shock syndrome, (STSS).

DATA SOURCE

Medline and EMBASE searches were conducted using the key words group A streptococcal toxic shock syndrome, alone and in combination with anesthesia; and septic shock, combined with anesthesia. Medline was also searched using key words intravenous immunoglobulin, (IVIG) and group A streptococcus, (GAS); and group A streptococcus and antibiotic therapy. Other references were included in this review if they addressed the history, microbiology, pathophysiology, incidence, mortality, presentation and management of invasive GAS infections. Relevant references from the papers reviewed were also considered. Articles on the foregoing topics were included regardless of study design. Non-English language studies were excluded. Literature on the efficacy of IVIG and optimal antibiotic therapy was specifically searched.

PRINCIPAL FINDINGS

Reports of invasive GAS infections have recently increased. Invasive GAS infection is associated with a toxic shock syndrome, (STSS), in 8-14% of cases. The STSS characteristically results in shock and multi-organ failure soon after the onset of symptoms, and is associated with a mortality of 33-81%. Many of these patients will require extensive soft tissue debridement or amputation in the operating room, on an emergency basis. The extent of tissue debridement required is often underestimated before skin incision.

CONCLUSIONS

Management of STSS requires volume resuscitation, vasopressor/inotrope infusion, antibiotic therapy and supportive care in an intensive care unit, usually including mechanical ventilation. Intravenous immunoglobulin infusion has been recommended. Further studies are needed to define the role of IVIG in STSS management and to determine optimal anesthetic management of patients with septic shock.

High adenosine plasma concentration as a prognostic index for outcome in patients with septic shock

OBJECTIVE

Sepsis and septic shock are a common cause of mortality in critically ill patients. Many substances have been implicated in the pathophysiology of these syndromes. We postulated that adenosine may be implicated in the sepsis- or septic shock-induced blood pressure failure. Indeed, this nucleoside is a strong endogenous vasodilating agent released by endothelial cells and myocytes under circumstances of metabolic stress, such as during critical illness.

DESIGN

A prospective, comparative observational study.

SETTING

The adult intensive care unit of a tertiary care university hospital.

PATIENTS

We measured adenosine plasma concentration (APC) in patients with severe sepsis (n = 11), in patients with septic shock (n = 14), in patients with hemorrhagic traumatic shock (n = 14), and in 12 healthy volunteers. APC was evaluated every 12 hrs over 3 days.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

At study entry, we found that APC was higher in patients with septic shock (mean +/- so = 8.4 +/-3.5 micromol/L) than in patients with hemorrhagic traumatic shock (1.1 +/- 0.6 micromol/L) and controls (0.8 +/- 0.3 micromol/L). Intermediate values (3.9 +/- 1.9 micromol/L) were found in patients with severe sepsis. APC in patients with traumatic shock did not differ from controls. In the course of the hospitalization, for both sepsis and septic shock patients, APC decreased significantly but remained higher than controls 72 hrs after entry into the study. In the septic shock group, APC was significantly higher in the nonsurvivor group (n = 6) than in the survivor group (n = 8), whatever the time of sample collection and assay.

CONCLUSIONS

High adenosine plasma concentrations are found in patients with septic shock but not during traumatic shock, or in healthy volunteers. Intermediate values of circulating adenosine are found in patients with severe sepsis. APC may be a prognostic index for outcome in septic patients, with much higher values being found in nonsurvivors.

Improving the outcome of septic shock in children

Sepsis is an important cause of pediatric morbidity and mortality. Improving the outcome of pediatric sepsis requires diverse efforts, including prevention, early recognition, improvements in early management and transport, and physiology-directed care. Awareness that septic shock represents a pathophysiologic host response to infection has prompted investigation of immune mediators and coagulation factors as potential targets for anti-sepsis therapies. Advancements thus far include: the potential prevention of neonatal sepsis with granulocyte colony-stimulating factor; recognition of clindamycin as a potential inhibitor of endotoxin release; improved outcome from meningococcal disease in children treated with bactericidal/permeability-increasing protein (rBPI21); and improved outcome from sepsis in premature infants treated with pentoxifylline. Further randomized controlled studies of immunomodulatory agents are indicated and a few are in progress. Current studies on genetic propensities in cytokine and coagulation protein expression may explain variability in patient outcomes and eventually lead to genomics-based therapeutics.

Pharmacologic issues in the management of septic shock

Despite our increased understanding of the biochemistry and physiology of sepsis, the treatment of septic shock remains a challenge. Initial management of septic shock entails urgent and emergent stabilization of the patient followed by broad-spectrum, empiric antibiotic therapy. After volume resuscitation, vasopressors or inotropic therapy or both may be necessary to restore perfusion. Adjunctive therapies and monitoring strategies may be helpful in preventing complications in the intensive care setting. Additional research and clinical trials are needed to identify supportive interventions that may affect the outcome of the septic patient.

Neonatal oxidative liver metabolism: effects of hydrogen peroxide, a putative mediator of septic damage

BACKGROUND/PURPOSE

Surgical neonates are at risk for sepsis and liver dysfunction. These complications are more common in preterm neonates and in those who receive total parenteral nutrition. Elevated levels of reactive oxygen species (eg, hydrogen peroxide) have been reported in these "at-risk" patients and may be the mediators of liver impairment via their effect on oxidative energy metabolism. The aim of this study was to test the hypothesis that elevated levels of hydrogen peroxide (H2O2) impair neonatal liver oxidative energy metabolism.

METHODS

An in vitro model to test this hypothesis was developed in hepatocytes isolated from neonatal (11-day to 15-day) rats. The cells, respiring on palmitate (0.5 mmol/L in 2% bovine serum albumin), were exposed to H2O2. Oxygen consumption was measured polarographically. In experiment A, H2O2 was added to the cell preparation at different concentrations (0.5 mmol/L, 1 mmol/L, 1.5 mmol/L, 2 mmol/L) to assess the effect on oxygen consumption. In experiment B, H2O2 (2 mmol/L) was added to hepatocytes in the presence of inhibitors of mitochondrial respiration to define the site of action of H2O2. In experiment C, electron microscopy was performed on hepatocytes after incubation with 1 mmol/L and 2 mmol/L of H2O2.

RESULTS

In experiment A, H2O2 significantly reduced hepatocyte oxygen consumption at 1.5 and 2 mmol/L. In experiment B, in the presence of inhibitors of mitochondrial respiration, myxothiazol (inhibitor of substrate oxidation), and oligomycin (inhibitor of adenosine triphosphate (ATP) synthase), no further inhibition by H2O2 occurred, indicating that the effect of H2O2 was intramitochondrial and affecting the synthesis of ATP. In experiment C, microscopic alterations of mitochondria were noticed exclusively in hepatocytes incubated with 2 mmol/L H2O2.

CONCLUSIONS

Results of this study demonstrate that H2O2 impairs neonatal liver oxidative metabolism. H2O2 probably directly inhibits ATP synthase. The authors hypothesize that H2O2 may play a role in the biochemical pathogenesis of liver dysfunction associated with sepsis. Identification of the precise target site of H2O2 may be valuable in directing therapy in septic neonates.

Metabolic response to neonatal surgery

The energy and protein metabolism of newborn infants differs from that of older individuals. Although energy expenditure and protein turnover are higher in newborn infants than in adults, the metabolic response to surgery in neonates has not been fully characterized. Preliminary studies indicate that metabolic response to operative stress is different in infants and adults: infants have an increased metabolic rate postoperatively for only 6 to 12 hours and do not have increased protein catabolism. More studies are needed in "stressed" newborn infants to further characterize substrate use and the metabolism of single organs.

Hemodynamic support in fluid-refractory pediatric septic shock

OBJECTIVE

Assess outcome in children treated with inotrope, vasopressor, and/or vasodilator therapy for reversal of fluid-refractory and persistent septic shock.

DESIGN

Survey; case series.

SETTING

Three pediatric hospitals.

PATIENTS

Fifty consecutive patients with fluid-refractory septic shock with a pulmonary artery catheter within 6 hours of resuscitation.

INTERVENTIONS

Patients were categorized according to hemodynamic state and use of inotrope, vasopressor, and/or vasodilator therapy to maintain cardiac index (CI) >3.3 L/min/m2 and systemic vascular resistance >800 dyne-sec/cm/m to reverse shock.

OUTCOME MEASURES

Hemodynamic state, response to class of cardiovascular therapy, and mortality.

RESULTS

After fluid resuscitation, 58% of the children had a low CI and responded to inotropic therapy with or without a vasodilator (group I), 20% had a high CI and low systemic vascular resistance and responded to vasopressor therapy alone (group II), and 22% had both vascular and cardiac dysfunction and responded to combined vasopressor and inotropic therapy (group III). Shock persisted in 36% of the children. Of the children in group I, 50% needed the addition of a vasodilator, and in group II, 50% of children needed the addition of an inotrope for evolving myocardial dysfunction. Four children showed a complete change in hemodynamic state and responded to a switch from inotrope to vasopressor therapy or vice versa. The overall 28-day survival rate was 80% (group I, 72%; group II, 90%; group III, 91%).

CONCLUSIONS

Unlike adults, children with fluid-refractory shock are frequently hypodynamic and respond to inotrope and vasodilator therapy. Because hemodynamic states are heterogeneous and change with time, an incorrect cardiovascular therapeutic regimen should be suspected in any child with persistent shock. Outcome can be improved compared with historical literature.