Early goal-directed therapy: An evidence-based review

Utilizing Near-Infrared Spectroscopy to Identify Pediatric Trauma Patients Needing Lifesaving Interventions: A Prospective Study

OBJECTIVES

The aim of this study was to prospectively investigate the role of near-infrared spectroscopy (NIRS) in identifying pediatric trauma patients who required lifesaving interventions (LSIs).

METHODS

Prospective cohort study of children age 0 to 18 years who activated the trauma team response between August 15, 2017, and February 12, 2019, at a large, urban pediatric emergency department (ED).The relationship between the lowest somatic NIRS saturation and the need for LSIs (based on published consensus definition) was investigated. Categorical variables were analyzed by χ 2 test, and continuous variables were analyzed by Student t test.

RESULTS

A total of 148 pediatric trauma patients had somatic NIRS monitoring and met the inclusion criteria. Overall, 65.5% were male with a mean ± SD age of 10.9 ± 6.0 years. Injuries included 67.6% blunt trauma and 28.4% penetrating trauma with mortality of 3.4% (n = 5). Overall, the median lowest somatic NIRS value was 72% (interquartile range, 58%-88%; range, 15%-95%), and 43.9% of patients had a somatic NIRS value <70%. The median somatic NIRS duration recorded was 11 minutes (interquartile range, 7-17 minutes; range, 1-105 minutes). Overall, 36.5% of patients required a LSI including 53 who required a lifesaving procedure, 17 required blood products, and 17 required vasopressors. Among procedures, requiring a thoracostomy was significant.Pediatric trauma patients with a somatic NIRS value <70% had a significantly increased odds of requiring a LSI (odds ratio, 2.11; 95% confidence interval, 1.07-4.20). Somatic NIRS values <70% had a sensitivity and specificity of 56% and 63%, respectively.

CONCLUSIONS

Pediatric trauma patients with somatic NIRS values <70% within 30 minutes of ED arrival have an increased odds of requiring LSIs. Among LSIs, pediatric trauma patients requiring thoracostomy was significant. The role of NIRS in incrementally improving the identification of critically injured children in the ED and prehospital setting should be evaluated in larger prospective multicenter studies.

Utilizing Near-Infrared Spectroscopy (NIRS) to Identify Pediatric Trauma Patients Needing Lifesaving Interventions (LSIs): A Retrospective Study

OBJECTIVES

The aim of this study was to investigate the role of near-infrared spectroscopy (NIRS) in identifying pediatric trauma patients who required lifesaving interventions (LSIs).

METHODS

Retrospective chart review of children age 0 to 18 years who activated the trauma team response between January 1, 2015 and August 14, 2017, at a large, urban pediatric emergency department. The lowest somatic NIRS saturation and the need for LSIs (based on published consensus definition) were abstracted from the chart. χ2 and descriptive statistics were used for analysis.

RESULTS

The charts of 84 pediatric trauma patients were reviewed. Overall, 80% were boys with a mean age of 10.4 years (SD, 6.2 years). Injuries included 56% blunt trauma and 36% penetrating trauma with mortality of 10.7% (n = 9). Overall, the median lowest NIRS value was 67% (interquartile range, 51-80%; range, 15%-95%) and 54.8% of the patients had a NIRS value less than 70%. The median somatic NIRS duration recorded was 12 minutes (interquartile range, 6-17 minutes; range, 1-59 minutes). Overall, 50% of patients required a LSI, including 39 who required a lifesaving procedure, 11 required blood products, and 14 required vasopressors. Pediatric trauma patients with NIRS less than 70% had a significantly increased odds of requiring a LSI (odds ratio, 2.67; 95% confidence interval, 1.10-6.47). NIRS less than 70% had a sensitivity and specificity of 67% and 57% respectively.

CONCLUSIONS

Pediatric trauma patients with somatic NIRS less than 70% within 30 minutes of emergency department arrival are associated with the need for LSIs. Continuous NIRS monitoring in the pediatric trauma population should be evaluated prospectively.

Comparison between Pressure Recording Analytical Method and Fick Method to Measure Cardiac Output in Pediatric Cardiac Surgery

Background:

There is an increased interest in methods of objective cardiac output measurement in pediatric cardiac surgery. Several techniques are available, but have limitations, among the new technologies pressure recording analytical method with MostCare (MostCare-PRAM), a minimally invasive hemodynamic monitoring system, represents a novel arterial pulse contour method that does not require calibration. For this reason, we compared the MostCare-PRAM vs the Fick method for estimation of cardiac output.

Methods:

We studied prospectively 13 pediatric patients who underwent cardiac surgery and compared intraoperatively Cardiac Index (CI) measured with the MostCare-PRAM with the CI measured with the Fick method. We also measured Cardiac Cycle Efficiency (CCE) and maximal arterial pressure/time ratio (dp/dt max) and compared with Fick method.

Results:

The data showed good agreement between CI Fick and CI MostCare-PRAM (r = 0.93 and R2= 0.86; p < 0.0001) and also between CCE (r = 0.82 and R2 = 0.67; p < 0.001) and dp/dt (r = 0.84; R2 = 0.81; p < 0.001) with CI measured with Fick method.

Conclusion:

In pediatric patients submitted to cardiac surgery, the MostCare-PRAM seems to estimate CI with a good level of agreement with the Fick method measurements.

Effect of early goal directed therapy in the treatment of severe sepsis and/or septic shock

BACKGROUND

Many investigators have reproduced the mortality reduction shown in the original trial of early goal directed therapy (EGDT) in patients with severe sepsis and/or septic shock. Three large randomized controlled trials (RCTs) found neutral results when compared to usual care and a modified form of EGDT. Some have interpreted these studies as a reason to question the efficacy of EGDT.

OBJECTIVES

The purpose of this study was to comprehensively examine the effect of EGDT in the treatment of severe sepsis and/or septic shock in the literature.

METHODS

A systematic review and meta-analysis of RCTs and prospective studies were performed, which extracted studies from PubMed, Elsevier ScienceDirect, Cochrane, Clinicaltrials.gov, Google Scholar, China Knowledge Resource Integrated Database, and Wanfang Database. The mortality trend in the control group from included studies was analyzed.

RESULTS

Seven RCTs and twelve prospective studies enrolling 3502 EGDT and 3791 usual care participants were included in the analysis. EGDT was found to reduce overall mortality compared to usual care groups. This reduction in mortality was apparent in prospective and randomized control trials conducted before 2010. Over this time period there was a reduction in mortality in patients receiving usual care.

LIMITATIONS

This conclusion was limited by the small size of some selected studies and complicated by the long range of time during the conduction of these studies. These studies were further biased because of the lack of blinding and the crossover of care between the EGDT and usual care groups.

CONCLUSIONS

EGDT significantly reduced mortality in patients with severe sepsis and/or septic shock over 15 years since its publication. Recent studies examining usual care with EGDT have similar mortality benefit because of the diminished treatment effect. This treatment effect is diminished for multiple reasons. With progress in the management of this disease the benefit of EGDT on overall mortality has become comparable with the usual care for sepsis patients. This is because many of the components of EGDT have been incorporated into usual care protocols. As a result, the conclusion that EGDT is ineffective cannot be made. A more rigorous RCT which adjusts for the factors that narrows the treatment effect between groups is required. Given the current state of sepsis care and equipoise that exist, this would be difficult.

Management of septic shock and severe infections in migrants and returning travelers requiring critical care

During the past decade, global human movement created a virtually "borderless world". Consequently, the developed world is facing "forgotten" and now imported infectious diseases. Many infections are observed upon travel and migration, and the clinical spectrum is diverse, ranging from asymptomatic infection to severe septic shock. The severity of infection depends on the etiology and timeliness of diagnosis. While assessing the etiology of severe infection in travelers and migrants, it is important to acquire a detailed clinical history; geography, dates of travel, places visited, type of transportation, lay-overs and intermediate stops, potential exposure to exotic diseases, and activities that were undertaken during travelling and prophylaxis and vaccines either taken or not before travel are all important parameters. Tuberculosis, malaria, pneumonia, visceral leishmaniasis, enteric fever and hemorrhagic fever are the most common etiologies in severely infected travelers and migrants. The management of severe sepsis and septic shock in migrants and returning travelers requires a systematic approach in the evaluation of these patients based on travel history. Early and broad-spectrum therapy is recommended for the management of septic shock comprising broad spectrum antibiotics, source control, fluid therapy and hemodynamic support, corticosteroids, tight glycemic control, and organ support and monitoring. We here review the diagnostic and therapeutic routing of severely ill travelers and migrants, stratified by the nature of the infectious agents most often encountered among them.

[Adequate fluid resuscitation in septic shock with high catecholamine doses]

BACKGROUND

Appropriate fluid resuscitation is a fundamental aspect for the hemodynamic management of septic shock patients and should ideally be achieved before vasopressors and positive inotropic substances are administered. The development of hemodynamic monitoring has revealed that in some cases patients had been improperly treated with high-dose catecholamines for initially insufficient fluid resuscitation. The aim of this study was to show that in some cases it is possible to actively reduce catecholamines by a volume challenge adapted according to the individual patient needs.

MATERIAL AND METHODS

In this retrospective observational study 29 patients with septic shock in a surgical intensive care unit (ICU) at a university hospital (17 male, 12 female, mean age 71 ± 10 years) on high-dose catecholamines (median values norepinephrine 0.204 µg/kg body weight/min, dobutamine 3.876 µg/kg/min and epinephrine 0.025 µg/kg/min, ranging up to 0.810 µg/kg/min, 22.222 µg/kg/min and 0.407 µg/kg/min in 28, 20 and 17 patients, respectively) were analyzed. The extremities of the patients were initially cold with a mottled marbled appearance whereas the mean arterial pressure (MAP) was ≥ 65 mmHg. The median central venous pressure (CVP) was 17 mmHg (range 55-34 mmHg) and the mean lactate concentration was 2.78 mmol/l (range 0.93-10.67 mmol/l). The standard therapy concept consisted of a forced volume challenge combined with active reduction of catecholamines to achieve an adequate fluid loading status, guided by the passive leg raising test (PLR), clinical signs and in 19 cases by hemodynamic monitoring (pulmonary artery catheter Vigilance II(™) n = 10, FloTrac(™), Vigileo(™) n = 9 and PreSep(™) n = 5; Edwards Life Sciences). The forced volume challenge was stopped after clinical improvement with rewarmed extremities, increasing diuresis volumes and lack of improvement by PLR.

RESULTS

Catecholamine doses could be significantly reduced in all patients: norepinephrine to 0 µg/kg/min, dobutamine to 1.852 µg/kg/min and epinephrine to 0 µg/kg/min (up to 0.133 µg/kg/min, 6.289 µg/kg/min and 0.091 µg/kg/min, respectively, p < 0.05 Wilcoxon signed rank test). Volume challenge test: + 4,500 ml Ringer solution (range 0-24,000 ml) and 1,000 ml hydroxyethyl starch (range 0-2,500 ml) and mean fluid balance + 6,465 ml (range + 2,040 ml to + 27,255 ml). The median weaning time from catecholamines was 12 h (range 4-43 h). After treatment all patients showed rewarmed extremities and a decrease in mean lactate levels from 2.78 mmol/l (range 0.93-10.67 mmol/l) to 2.05 mmol/l (range 0.7-5.4 mmol/l). The measured hemodynamic constellations showed clear interindividual differences but no cardiac deterioration occurred. The median oxygenation index (paO2/FiO2) showed a statistically insignificant change from 264 mmHg (range 75-418 mmHg) to 250 mmHg (range 120-467 mmHg). Of the patients 20 survived and 9 died.

CONCLUSION

It is possible to wean a substantial proportion of septic shock patients from high-dose catecholamines in combination with a needs-adapted forced volume challenge test. The importance of appropriate fluid loading prior to the use of high catecholamine doses should be a main subject of discussion in patients with severe septic shock and was confirmed in this study. This should be oriented to clinical and if possible, hemodynamic parameters and should not be underestimated.

Clinical significance of dynamic monitoring of blood lactic acid, oxygenation index and C-reactive protein levels in patients with severe pneumonia

The aim of the present study was to analyze the clinical significance of the dynamic monitoring of blood lactic acid levels, the oxygenation index and C-reactive protein (CRP) levels in patients with severe pneumonia. The clinical data of 34 cases with severe pneumonia were collected. According to the clinical outcome, the patients were divided into a survival group (n=26) and a fatality group (n=8). Various factors, including the blood lactic acid level, oxygenation index, CRP level and acute physiology and chronic health evaluation II (APACHE II) score, were retrospectively analyzed in order to investigate whether these values had clinical significance for the prognosis of the patients. No statistically significant differences with regard to age, gender, initial concentrations of blood lactic acid and CRP, and APACHE II scores were observed between the two groups at admission to the Intensive Care Unit. However, the blood lactic acid levels were found to decrease to a normal level within 12-24 h after treatment in the survival group, while the levels were maintained at a higher concentration in the fatality group, even at 72 h after treatment (P<0.05). Furthermore, the oxygenation index in the survival group was significantly higher when compared with that in the fatality group. The oxygenation index was maintained at a normal level in the survival group, while the oxygenation index levels were below normal and continued to decline in the fatality group. A positive correlation was observed between the blood lactic acid level and the APACHE II scores (r=0.656, P<0.05). Therefore, the present study demonstrated that dynamic monitoring of blood lactic acid, oxygenation index and CRP levels in patients with severe pneumonia can be used to evaluate the therapeutic efficiency, in addition to serving as a prognosis indicator, for patients with severe pneumonia.

Fluid Administration, Vasopressor Use and Patient Outcomes in a Group of High-Risk Cardiac Surgical Patients Receiving Postoperative Goal-Directed Haemodynamic Therapy: A Pilot Study

The role of goal-directed therapy in high-risk cardiac surgical patients has not been determined. This study sought to observe the effect of a postoperative standardised haemodynamic protocol (SHP) on the administration of fluid and vasoactive drugs after high-risk cardiac surgery. This was an interventional pilot study. In 2010 to 2011, the SHP was introduced to the ICU at Wellington Regional Hospital, Wellington, New Zealand, for the perioperative management of patients undergoing high-risk cardiac surgery. A pulmonary artery catheter was inserted in the patients in the study group and fluids and supportive medications were provided in the ICU according to a protocol that targeted a cardiac index ≥2 l/min/m2, mixed venous oxygen saturation ≥60% and a mean arterial pressure of 65 to 75 mmHg. Data from 40 consecutive high-risk cardiac surgical patients assigned to this protocol were compared with a matched cohort of 40 consecutive high-risk cardiac surgical patients receiving ‘usual care’ in 2009. Baseline characteristics were similar in the two groups. There was no significant difference in the duration of noradrenaline infusion in the SHP cohort compared to historical controls (median [IQR] 18.5 hours [31.63] versus 18 hours [18.3]; P=0.35), despite patients receiving more fluid in their first 12 hours in the ICU (mean 4687 ml [SD±2284 ml] versus 1889 ml [SD±1344 ml]; P <0.001). The SHP cohort had a higher rate of reintubation (4 in 37 [10.8%] versus 0 in 40 [0%]; P=0.049). The SHP delivered significantly more fluid, but did not reduce the duration of noradrenaline infusion, compared to usual care.

Blood transfusion practices in sepsis

Sepsis is a clinical syndrome characterised by systemic inflammation due to infection. There is a spectrum with severity ranging from sepsis to severe sepsis and septic shock. Even with optimal treatment, mortality due to severe sepsis or septic shock is significant and poses a challenge to management. Antibiotics, source control, resuscitation with fluids, vasopressor and inotropic agents are the main-stay of treatment for septic shock. These may be supplemented with transfusion of red blood cells and or blood products, in the case of anaemia to sustain sufficient oxygen delivery^[1] or to manage associated haematological issues. Transfusion in sepsis has always been a debatable issue, especially in relation to choice of the fluid and the role of blood or blood product transfusion.

Hydroxyethyl starch: a review of pharmacokinetics, pharmacodynamics, current products, and potential clinical risks, benefits, and use

OBJECTIVE

To review and summarize the pharmacokinetics and pharmacodynamics of hydroxyethyl starch (HES), as well as reported risks and benefits of HES infusion, and to provide administration and monitoring recommendations for HES use in dogs and cats.

DATA SOURCES

Veterinary and human peer-reviewed medical literature, including scientific reviews, clinical and laboratory research articles, and authors' clinical experience.

SUMMARY

HES solutions are the most frequently used synthetic colloid plasma volume expanders in human and veterinary medicine. The majority of research in human medicine has focused on the adverse effects of HES infusion, with emphasis on acute kidney injury and coagulation derangements. The studies often differ in or fail to report factors, such as the type, amount, interval, and concentration of HES administered; the patient population studied; or concurrent fluids administered. Currently, there is no definitive clinical evidence that the reported adverse effects of HES use in human medicine occur in veterinary species. There is little information available on HES administration techniques or simultaneous administration of additional fluids in human and veterinary medicine. The rationale for HES use in small animals has been largely extrapolated from human medical studies and guidelines. A controlled approach to intravenous fluid resuscitation using crystalloid and HES volumes titrated to reach desired resuscitation end point parameters is outlined for small animal practitioners.

CONCLUSION

The extrapolation of data from human studies directly to small animals should be done with the knowledge that there may be species variations and different pharmacokinetics with different HES solutions. Veterinary reports indicate that bolus and continuous rate infusions of 6% hetastarch solutions at moderate doses are well tolerated in feline and canine subjects. Further research in domesticated species is necessary to better define and expand the knowledge regarding use of HES solutions in small animal medicine.

Acute kidney injury: the beginning of the end of the dark ages

There has been enormous progress in the understanding of acute kidney injury (AKI) over the past 5 years. This article reviews some of the salient new findings, the challenges revealed by these findings and new insights into the pathogenesis of ischemic AKI. Clinical studies have demonstrated that even a small, transient rise in serum creatinine increases the risk of mortality in hospitalized patients and that a single event of AKI increases the risk for developing chronic kidney disease. Although the overall mortality rate from AKI has improved over the past 2 decades, it continues to be significant. Current treatment is focused on maintaining renal perfusion and avoiding volume overload. However, new therapeutic targets are emerging for the treatment of AKI as our understanding of the pathogenesis of ischemic injury and inflammation increases. Early diagnosis, however, continues to be challenging as the search continues for sensitive and specific biomarkers.

The admission systemic inflammatory response syndrome predicts outcome in patients undergoing emergency surgery

OBJECTIVE

To investigate the incidence of systemic inflammatory response syndrome (SIRS) on emergency department admission and the prognostic significance of SIRS in patients undergoing emergency surgery.

METHODS

This is a retrospective study of 889 adults who were admitted as emergency cases and were operated on within 24 hours of admission. Data on patient demography, clinical information including comorbidities, categories of surgery, American Society of Anesthesiologists physical status, SIRS score, postoperative outcomes including duration of mechanical ventilation, intensive care unit (ICU) and hospital lengths of stay, and mortality were collected.

RESULTS

SIRS occurred in 43% of the patients and was associated with a significantly worse outcome in terms of duration of ventilator use (10.5 ± 15.4 vs. 3.5 ± 4.4 days, p < 0.001), ICU stay (11.2 ± 13.6 vs. 5.0 ± 5.4 days, p < 0.001), hospital length of stay (19.4 ± 22.4 vs. 7.1 ± 7.6 days, p < 0.001) and mortality (12.7% vs. 0.4%, p < 0.001). After adjusting for covariates (including age, gender, American Society of Anesthesiologists physical status, comorbid conditions, and surgery categories), SIRS was independently associated with higher mortality (adjusted odd ratio, 21.5; 95% confidence interval (CI), 4.9-93.2), longer ventilator duration (adjusted coefficient, 7.8; 95% CI, 3.2-12.5), longer ICU stay (adjusted coefficient, 6.2; 95% CI, 2.6-9.8) and longer hospital stay (adjusted coefficient, 9.7; 95% CI, 7.5-11.9).

CONCLUSION

The presence of SIRS at admission in patients receiving emergency surgery predicted worse outcomes and higher mortality rates.

Human recombinant protein C for severe sepsis and septic shock in adult and paediatric patients

BACKGROUND

Sepsis is a common and frequently fatal condition. Human recombinant activated protein C (APC) has been introduced to reduce the high risk of death associated with severe sepsis or septic shock. This systematic review is an update of a Cochrane review originally published in 2007.

OBJECTIVES

We assessed the benefits and harms of APC for patients with severe sepsis or septic shock.

SEARCH METHODS

We searched CENTRAL (The Cochrane Library 2012, Issue 6); MEDLINE (2010 to June 2012); EMBASE (2010 to June 2012); BIOSIS (1965 to June 2012); CINAHL (1982 to June 2012) and LILACS (1982 to June 2012). There was no language restriction.

SELECTION CRITERIA

We included randomized clinical trials assessing the effects of APC for severe sepsis or septic shock in adults and children. We excluded studies on neonates. We considered all-cause mortality at day 28 and at the end of study follow up, and hospital mortality as the primary outcomes.

DATA COLLECTION AND ANALYSIS

We independently performed trial selection, risk of bias assessment, and data extraction in duplicate. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We used a random-effects model.

MAIN RESULTS

We identified one new randomized clinical trial in this update which includes six randomized clinical trials involving 6781 participants in total, five randomized clinical trials in adult (N = 6307) and one randomized clinical trial in paediatric (N = 474) participants. All trials had high risk of bias and were sponsored by the pharmaceutical industry. APC compared with placebo did not significantly affect all-cause mortality at day 28 compared with placebo (780/3435 (22.7%) versus 767/3346 (22.9%); RR 1.00, 95% confidence interval (CI) 0.86 to 1.16; I(2) = 56%). APC did not significantly affect in-hospital mortality (393/1767 (22.2%) versus 379/1710 (22.1%); RR 1.01, 95% CI 0.87 to 1.16; I(2) = 20%). APC was associated with an increased risk of serious bleeding (113/3424 (3.3%) versus 74/3343 (2.2%); RR 1.45, 95% CI 1.08 to 1.94; I(2) = 0%). APC did not significantly affect serious adverse events (463/3334 (13.9%) versus 439/3302 (13.2%); RR 1.04, 95% CI 0.92 to 1.18; I(2) = 0%). Trial sequential analyses showed that more trials do not seem to be needed for reliable conclusions regarding these outcomes.

AUTHORS' CONCLUSIONS

This updated review found no evidence suggesting that APC should be used for treating patients with severe sepsis or septic shock. APC seems to be associated with a higher risk of bleeding. The drug company behind APC, Eli Lilly, has announced the discontinuation of all ongoing clinical trials using this drug for treating patients with severe sepsis or septic shock. APC should not be used for sepsis or septic shock outside randomized clinical trials.

Human recombinant activated protein C for severe sepsis

BACKGROUND

Sepsis is a common and frequently fatal condition. Human recombinant activated protein C (APC) has been used to reduce the high rate of death by severe sepsis or septic shock. This is an update of a Cochrane review (originally published in 2007 and updated in 2008).

OBJECTIVES

We assessed the clinical effectiveness and safety of APC for the treatment of patients with severe sepsis or septic shock.

SEARCH METHODS

For this updated review we searched CENTRAL (The Cochrane Library 2010, Issue 6); MEDLINE (1966 to June 2010); EMBASE (1980 to July 1, 2010); BIOSIS (1965 to July 1, 2010); CINAHL (1982 to 16 June 2010) and LILACS (1982 to 16 June 2010). There was no language restriction.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing the effects of APC for severe sepsis in adults and children. We excluded studies on neonates. We considered all-cause mortality at day 28, at the end of study follow up, and hospital mortality as the primary outcomes.

DATA COLLECTION AND ANALYSIS

We independently performed study selection, risk of bias assessment and data extraction. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We used a random-effects model.

MAIN RESULTS

We identified one new RCT in this update. We included a total of five RCTs involving 5101 participants. For 28-day mortality, APC did not reduce the risk of death in adult participants with severe sepsis (pooled RR 0.97, 95% confidence interval (CI) 0.78 to 1.22; P = 0.82, I(2) = 68%). APC use was associated with an increased risk of bleeding (RR 1.47, 95% CI 1.09 to 2.00; P = 0.01, I(2) = 0%). In paediatric patients, APC did not reduce the risk of death (RR 0.98, 95% CI 0.66 to 1.46; P = 0.93). Although the included trials had no major limitations most of them modified their original completion or recruitment protocols.

AUTHORS' CONCLUSIONS

This updated review found no evidence suggesting that APC should be used for treating patients with severe sepsis or septic shock. Additionally, APC is associated with a higher risk of bleeding. Unless additional RCTs provide evidence of a treatment effect, policy-makers, clinicians and academics should not promote the use of APC.Warning: On October 25th 2011, the European Medicines Agency issued a press release on the worldwide withdrawal of Xigris (activated protein C / drotrecogin alfa) from the market by Eli Lilly due to lack of beneficial effect on 28-day mortality in the PROWESS-SHOCK study. Furthermore, Eli Lily has announced the discontinuation of all other ongoing clinical trials. The final results of the PROWESS-SHOCK study are expected to be published in 2012. This systematic review will be updated when results of the PROWESS-SHOCK or other trials are published.

Mortality and regional oxygen saturation index in septic shock patients: a pilot study

BACKGROUND

Peripheral muscle tissue oxygenation determined noninvasively using near-infrared spectroscopy may help to identify tissue hypoperfusion in septic patients. The aim of this study was to investigate regional oxygen saturation index (rSO2) in the brachioradialis (forearm) muscle by comparing measurements in healthy subjects and in intensive care unit (ICU) septic shock patients, and determine whether brachioradialis muscle rSO2 is associated with poor outcome in ICU septic shock patients.

METHODS

We conducted a prospective observational study in healthy volunteers (n = 50) and ICU septic shock patients (n=19). Brachioradialis (forearm) rSO2 measurements in healthy volunteers at rest and in ICU septic shock patients were compared. Pulmonary artery catheter monitoring was used in ICU patients.

RESULTS

Significant differences in rSO2 were observed between healthy volunteers and ICU septic shock patients at ICU admission (68.7±4.9 vs. 55.0±13.0; p<0.001). When comparing septic shock survivors and nonsurvivors, significant differences were observed in rSO2 at baseline (64.5±8.9 vs. 47.5±10.7; p<0.01), 12 hours (67.3±9.6 vs. 45.0±14.9; p<0.01), and 24 hours (65.7±7.0 vs. 50.1±10.3; p<0.01). Lactate concentration was lower in survivors than nonsurvivors at 24 hours (12.0±7.5 mmol/L vs. 23.2±12.5 mmol/L; p<0.04). Cardiac index was greater in nonsurvivors than survivors at baseline (4.6+1.9 L/min/m vs. 3.0+0.9 L/min/m; p<0.05) and 12 h (3.9+0.5 L/min/m vs. 3.1+0.3 L/min/m; p<0.05).

CONCLUSIONS

We observed that septic shock patients with forearm skeletal muscle rSO2≤60% throughout first 24 hours after ICU admission had significantly greater mortality rate than patients with forearm skeletal muscle rSO2>60% throughout this critical time.

Near-infrared spectroscopy as a hemodynamic monitor in critical illness

BACKGROUND

Near-infrared spectroscopy has moved from a research tool to a widely used clinical monitor in the critically ill pediatric patient over the last decade. The physiological and clinical evidence supporting this technology in practice is reviewed here.

METHODOLOGY

A search of MEDLINE and PubMed was conducted to find validation studies, controlled trials, and other reports of near-infrared spectroscopy use in children and adults in the clinical setting. Guidelines published by the American Heart Association, the American Academy of Pediatrics, and the International Liaison Committee on Resuscitation were reviewed including further review of references cited.

RESULTS

The biophysical properties of near-infrared spectroscopy devices allow measurement of capillary-venous oxyhemoglobin saturation in tissues a few centimeters beneath the surface sensor with validated accuracy in neonates, infants, and small patients. The biologic basis for the relationship of capillary-venous oxyhemoglobin saturation to cerebral injury has been described in animal and human studies. Normal ranges for cerebral and somatic capillary-venous oxyhemoglobin saturation have been described for normal newborns and infants and children with congenital heart disease and other disease states. The capillary-venous oxyhemoglobin saturation from both cerebral and somatic regions has been used to estimate mixed venous saturation and to predict biochemical shock, multiorgan dysfunction, and mortality in different populations. The relationship of cerebral capillary-venous oxyhemoglobin saturation to neuroimaging and functional assessment of outcome is limited but ongoing. Although there are numerous conflicting reports in small populations, expert opinion would suggest that special use may exist for near-infrared spectroscopy in patients with complex circulatory anatomy, with extremes of physiology, and in whom extended noninvasive monitoring is useful.

CONCLUSIONS

Class II, level B evidence supports the conclusion that near-infrared spectroscopy offers a favorable risk-benefit profile and can be effective and beneficial as a hemodynamic monitor for the care of critically patients.

Human recombinant activated protein C for severe sepsis

BACKGROUND

Sepsis is a common and frequently fatal condition. Human recombinant activated protein C (APC) has been used to reduce the high rate of death by severe sepsis or septic shock. This is an update of a Cochrane review (originally published in 2007 and updated in 2008).

OBJECTIVES

We assessed the clinical effectiveness and safety of APC for the treatment of patients with severe sepsis or septic shock.

SEARCH STRATEGY

For this updated review we searched CENTRAL (The Cochrane Library 2010, Issue 6); MEDLINE (1966 to June 2010); EMBASE (1980 to July 1, 2010); BIOSIS (1965 to July 1, 2010); CINAHL (1982 to 16 June 2010) and LILACS (1982 to 16 June 2010). There was no language restriction.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing the effects of APC for severe sepsis in adults and children. We excluded studies on neonates. We considered all-cause mortality at day 28, at the end of study follow up, and hospital mortality as the primary outcomes.

DATA COLLECTION AND ANALYSIS

We independently performed study selection, risk of bias assessment and data extraction. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using the I(2) statistic. We used a random-effects model.

MAIN RESULTS

We identified one new RCT in this update. We included a total of five RCTs involving 5101 participants. For 28-day mortality, APC did not reduce the risk of death in adult participants with severe sepsis (pooled RR 0.97, 95% confidence interval (CI) 0.78 to 1.22; P = 0.82, I(2) = 68%). APC use was associated with an increased risk of bleeding (RR 1.47, 95% CI 1.09 to 2.00; P = 0.01, I(2) = 0%). In paediatric patients, APC did not reduce the risk of death (RR 0.98, 95% CI 0.66 to 1.46; P = 0.93). Although the included trials had no major limitations most of them modified their original completion or recruitment protocols.

AUTHORS' CONCLUSIONS

This updated review found no evidence suggesting that APC should be used for treating patients with severe sepsis or septic shock. Additionally, APC is associated with a higher risk of bleeding. Unless additional RCTs provide evidence of a treatment effect, policy-makers, clinicians and academics should not promote the use of APC.

Effects of high-volume hemofiltration on alveolar-arterial oxygen exchange in patients with refractory septic shock

BACKGROUND

High-volume hemofiltration (HVHF) is technically possible in severe acute pancreatitis (SAP) patients complicated with multiple organ dysfunction syndrome (MODS). Continuous HVHF is expected to become a beneficial adjunct therapy for SAP complicated with MODS. In this study, we aimed to explore the effects of fluid resuscitation and HVHF on alveolar-arterial oxygen exchange, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score in patients with refractory septic shock.

METHODS

A total of 89 refractory septic shock patients, who were admitted to ICU, the Provincial Hospital affiliated to Shandong University from August 2006 to December 2009, were enrolled in this retrospective study. The patients were randomly divided into two groups: fluid resuscitation (group A, n=41), and fluid resuscitation plus high-volume hemofiltration (group B, n=48). The levels of O2 content of central venous blood (CcvO2), arterial oxygen content (CaO2), alveolar-arterial oxygen pressure difference P(A-a)DO2, ratio of arterial oxygen pressure/alveolar oxygen pressure (PaO2/PaO2), respiratory index (RI) and oxygenation index (OI) were determined. The oxygen exchange levels of the two groups were examined based on the arterial blood gas analysis at different times (0, 24, 72 hours and 7 days of treatment) in the two groups. The APACHE II score was calculated before and after 7-day treatment in the two groups.

RESULTS

The levels of CcvO2, CaO2 on day 7 in group A were significantly lower than those in group B (CcvO2: 0.60±0.24 vs. 0.72±0.28, P<0.05; CaO2: 0.84±0.43 vs. 0.94±0.46, P<0.05). The level of oxygen extraction rate (O2ER) in group A on the 7th day was significantly higher than that in group B (28.7±2.4 vs. 21.7±3.4, P<0.01). The levels of P(A-a)DO2 and RI in group B on the 7th day were significantly lower than those in group A. The levels of PaO2/PaO2 and OI in group B on 7th day were significantly higher than those in group A (P<0.05 or P<0.01). The APACHE II score in the two groups reduced gradually after 7-day treatment, and the APACHE II score on the 7th day in group B was significantly lower than that in group A (8.2±3.8 vs. 17.2±6.8, P<0.01).

CONCLUSION

HVHF combined with fluid resuscitation can improve alveolar-arterial-oxygen exchange, decrease the APACHE II score in patients with refractory septic shock, and thus it increases the survival rate of patients.

Implementing a collaborative protocol in a sepsis intervention program: lessons learned

The objective of this prospective cohort study was to see the effect of the implementation of a Sepsis Intervention Program on the standard processes of patient care using a collaborative approach between the Emergency Department (ED) and Medical Intensive Care Unit (MICU). This was performed in a large urban tertiary-care hospital, with no previous experience utilizing a specific intervention program as routine care for septic shock and which has services and resources commonly available in most hospitals. The study included 106 patients who presented to the ED with severe sepsis or septic shock. Eighty-seven of those patients met the inclusion criteria for complete data analysis. The ED and MICU staff underwent a 3-month training period followed by implementation of a protocol for sepsis intervention program over 6 months. In the first 6 months of the program's implementation, 106 patients were admitted to the ED with severe sepsis and septic shock. During this time, the ED attempted to initiate the sepsis intervention protocol in 76% of the 87 septic patients who met the inclusion criteria. This was assessed by documentation of a central venous catheter insertion for continuous SvO(2) monitoring in a patient with sepsis or septic shock. However, only 48% of the eligible patients completed the early goal-directed therapy (EGDT) protocol. Our data showed that the in-hospital mortality rate was 30.5% for the 87 septic shock patients with a mean APACHE II score of 29. This was very similar to a landmark study of EGDT (30.5% mortality with mean APACHE II of 21.5). Data collected on processes of care showed improvements in time to fluid administration, central venous access insertion, antibiotic administration, vasopressor administration, and time to MICU transfer from ED arrival in our patients enrolled in the protocol versus those who were not. Further review of our performance data showed that processes of care improved steadily the longer the protocol was in effect, although this was not statistically significant. There was no improvement in secondary outcomes, including total length of hospital stay, MICU days, and mortality. Implementation of a sepsis intervention program as a standard of care in a typical hospital protocol leads to improvements in processes of care. However, despite a collaborative approach, the sepsis intervention program was underutilized with only 48% of the patients completing the sepsis intervention protocol.

Cardiac output measurement by arterial pressure waveform analysis during optimization of biventricular pacing after cardiac surgery

Biventricular pacing (BiVP) can optimize cardiac output (CO) in patients after cardiac surgery, so devices that calculate continuous CO from arterial pressure may be a useful tool. We investigated PulseCO for measuring CO during optimization by comparison with aortic flow probe measurement. Seven patients in the Biventricular Pacing After Cardiac Surgery (BiPACS) trial were studied. Before weaning from cardiopulmonary bypass, BiVP was initiated. After bypass, CO was optimized by varying atrioventricular pacing delay, ventricular site, and interventricular pacing delay with a randomized protocol. Continuous CO was measured by PulseCO and aortic flow probe. Reliability was estimated by Fleiss method and agreement assessed by Bland-Altman analysis. Compared with flow probe, PulseCO reliably measured changes in CO (intraclass correlation coefficient = 0.90) but underestimated the change (-4% + or - 17%). In contrast, changes in mean arterial pressure did not reflect changes in CO (intraclass correlation coefficient = 0.02). Thus, PulseCO can measure continuous CO in open-chest patients after cardiac surgery, whereas underestimating changes occurring across 10-second pacemaker changes. Further studies in the closed chest are indicated.

Arginine vasopressin in the treatment of vasodilatory septic shock

Vasodilatory septic shock is characterized by profound vasodilation of the peripheral circulation, relative refractoriness to catecholamines and a relative deficiency of the posterior pituitary hormone, vasopressin. Arginine vasopressin is effective in restoring vascular tone in vasodilatory septic shock and may be associated with decreased mortality in less severe septic shock as well as improved mortality and decreased renal failure in septic shock patients at risk for renal failure.

Highlights from the 2008 Surviving Sepsis Campaign, Part 1

In 2004, the Society of Critical Care Medicine and 10 other health care organizations sponsored the Surviving Sepsis Campaign (SSC) guidelines. 1 The SSC represents the first major international effort to reduce sepsis-related mortality. The campaign has proven to be highly controversial and has been greeted with both high praise and sharp criticism. In 2008, these guidelines were revised. 2 This article is part 1 of a 2-part series, summarizing and providing analysis of key aspects of the 2008 SSC. Part 1 will discuss controversial issues surrounding the campaign and examine the recommendations for initial resuscitation, antibiotic, as well as vasopressor therapy.

The influence of volume management on outcome

PURPOSE OF REVIEW

Fluid (volume) therapy is an integral component in the management of critically ill patients and fluid management may influence outcome. There is much controversy, however, about the type, timing and amount of fluid therapy. Here, we discuss the evidence available to guide such choices.

RECENT FINDINGS

Fluid therapy is widely endorsed for resuscitation of critically ill patients across a range of conditions. Yet, the approach to fluid therapy is subject to substantial variation in clinical practice. Emerging data show that the choice, timing and amount of fluid therapy may affect clinical outcomes. Synthetic colloids may increase the risk of acute kidney injury. Albumin may benefit hypoalbuminemic patients with sepsis and acute lung injury but may worsen outcome in traumatic brain injury. Early administration of fluid therapy in sepsis may improve survival but may be unnecessary in patients with penetrating trauma. Later fluid therapy in acute lung injury patients will increase the duration of ventilator dependence without achieving better survival. A positive cumulative balance likely contributes to increased morbidity and mortality after major surgery.

SUMMARY

Emerging evidence shows that choice, timing and amount of fluid therapy affect outcome. Future studies need to focus on these aspects of fluid therapy by means of larger, more rigorous and blinded controlled trials.

Evidence-based medicine in equine critical care

One of the fundamental skills required for practicing evidence-based medicine is the development of a well-built clinical question, which specifies the patient group or problem, intervention, and outcome of interest. For this purpose, various "levels of evidence" have been developed in the human literature, which rank the validity of evidence. Our established conclusions and advice are thus supported by specific "grades of recommendations," which are intended to give an indication of the "strength" of a clinical recommendation. This article was compiled with these principles in mind.

A 5-year PICU experience of disseminated staphylococcal disease, part 2: management, critical care needs and outcome

Staphylococcus aureus causes an impressive spectrum of disease in tropics and subtropics. Scanty data are available regarding disseminated staphylococcal disease (DSD) in children, especially on their critical care needs. It is important to recognize and prioritize patients who may benefit most from Pediatric Critical Care. The objective of this article is to review the, critical care needs, management and outcome of patients with DSD and to identify clinical indicators for need of critical care. The study setting is a Pediatric Intensive Care Unit of an urban tertiary care teaching hospital in a developing economy. Fifty-three patients (age, 1 month to 12 years) with DSD, admitted to PICU during June 1994 to June 1999, form the subjects for the study. DSD was defined as involvement of at least two distant organs with presence of Gram-positive cocci in clusters and/or growth of S. aureus from at least one normally sterile body fluid. Data regarding demographic and clinical picture, microbiological profile, indication for PICU admission, monitoring needs, medical and surgical management and outcome was retrieved from the case records. Critical care problems included septic shock (28/53), pericardial effusion (21/53, cardiac tamponade in six), raised intracranial pressure (5 patients) and refractory status epilepticus (1 patient). The majority developed septic shock after first few doses of parenteral antimicrobials. They required an impressive amount of fluid [100 (56) ml/kg] during initial 6 h of resuscitation, and 90% had myocardial dysfunction requiring inotropic support. Tracheal intubation was needed in 18 (34%) and ventilatory support in 17 (32%) patients. About 60% patients had metabolic abnormalities. Soft tissue disease was associated with high risk of septic shock (RR, 1.77; P < 0.05). Presence of both septic shock and need for ventilation was associated with high mortality (RR, 20.5; P < 0.001). Patients with suspected DSD need intensive cardio-respiratory monitoring during initial 48-72 h of therapy; and those who develops shock, respiratory failure, pericardial effusion and necrotizing soft tissue disease should be prioritized for PICU admission.

Sepsis in critical care

Sepsis is a syndrome produced by the accelerated activity of the inflammatory immune response, the clotting cascade, and endothelial damage. It is a systematic process that can progress easily into septic shock and MODS. The chemical mediators or cytokines produce a complex self-perpetuating process that impacts all body systems. It is critical for the nurse first to identify patients at risk for developing sepsis and to assess patients who have SIRS and sepsis continually for signs and symptoms of organ involvement and organ dysfunction. Once sepsis has been diagnosed, evidence-based practice indicates initiation of fluid resuscitation. Vasopressor therapy, positive inotropic support, and appropriate antibiotic therapy should be started within the first hour. Within a 6-hour timeframe the goal is stabilization of the CVP, MAP, and UOP to prevent further organ damage. The challenge for nurses caring for septic patients is to support the treatment goals, to prevent added complications including stress ulcers, DVTs, aspiration pneumonia, and the progression to MODS, and to address the patient's and the family's psychosocial needs. As complex as the pathophysiology of sepsis is, the nursing care is equally complex but also rewarding. Patients who previously might have died now recover as vigilant nursing care combines forces with new drug therapies and evidence-based practice guidelines.

Fluid resuscitation and the septic kidney

Acute renal failure is a common complication of sepsis in the critically ill patient. Fluid resuscitation is considered a cornerstone for preservation of function in the septic kidney. This is generally based on the assumption that fluid therapy will restore and maintain adequate renal blood flow. This principle, however, has not yet been formally evaluated in humans. Thus, it remains unclear how fluid therapy may affect renal blood flow in septic acute renal failure. Further, there is new evidence to imply that the choice, timing and amount of fluid used for resuscitation in sepsis may have a direct impact on kidney function. Thus, in this editorial, we consider the relevant literature and more recent insights into the effect of fluid resuscitation on the septic kidney.

[Pulmonary artery catheter in anaesthesiology and intensive care medicine]

The indication for the use of the pulmonary artery catheter (PAC) in high-risk patients is still a matter of discussion. Observational studies suggested that the use of the PAC did not result in decreased mortality but may even lead to increased mortality and morbidity. Therefore, a number of randomized controlled trials have been performed throughout recent years in patients suffering from sepsis/ARDS, congestive heart failure, multi-organ failure and those undergoing high-risk non-cardiac surgery. The majority of recent randomized studies failed to demonstrate any benefit of the PAC with respect to mortality and morbidity. However, the use of the PAC was also regularly not associated with an increase in morbidity and/or mortality. This review gives an overview of measurement parameters obtained by the current generation of PACs, alternatives to the PAC and recent studies on the use of the PAC in clinical practice.

Before–after study of a standardized hospital order set for the management of septic shock*

OBJECTIVE

To evaluate a standardized hospital order set for the management of septic shock in the emergency department.

DESIGN

Before-after study design with prospective consecutive data collection.

SETTING

Emergency department of a 1,200-bed academic medical center.

PATIENTS

A total of 120 patients with septic shock.

INTERVENTIONS

Implementation of a standardized hospital order set for the management of septic shock.

MEASUREMENTS AND MAIN RESULTS

A total of 120 consecutive patients with septic shock were identified. Sixty patients (50.0%) were managed before the implementation of the standardized order set, constituting the before group, and 60 (50.0%) were evaluated after the implementation of the standardized order set, making up the after group. Demographic variables and severity of illness measured by the Acute Physiology and Chronic Health Evaluation II were similar for both groups. Patients in the after group received statistically more intravenous fluids while in the emergency department (2825 +/- 1624 mL vs. 3789 +/- 1730 mL, p = .002), were more likely to receive intravenous fluids of >20 mL/kg body weight before vasopressor administration (58.3% vs. 88.3%, p < .001), and were more likely to be treated with an appropriate initial antimicrobial regimen (71.7% vs. 86.7%, p = .043) compared with patients in the before group. Patients in the after group were less likely to require vasopressor administration at the time of transfer to the intensive care unit (100.0% vs. 71.7%, p < .001), had a shorter hospital length of stay (12.1 +/- 9.2 days vs. 8.9 +/- 7.2 days, p = .038), and a lower risk for 28-day mortality (48.3% vs. 30.0%, p = .040).

CONCLUSIONS

Our study found that the implementation of a standardized order set for the management of septic shock in the emergency department was associated with statistically more rigorous fluid resuscitation of patients, greater administration of appropriate initial antibiotic treatment, and a lower 28-day mortality. These data suggest that the use of standardized order sets for the management of septic shock should be routinely employed.

Arterial pulse wave analysis: An accurate means of determining cardiac output in children

OBJECTIVE

Cardiac output is a useful measure of myocardial performance. Standard methods of determining cardiac output are not without risk and can be problematic in children. Arterial pulse wave analysis (PulseCO), a novel, minimally invasive cardiac output determination technique, offers the advantage of continuous monitoring, convenience, and low risk. This technique has not been validated in children. The purpose of this study was to validate PulseCO as an accurate means of noninvasively determining real-time cardiac output in children.

DESIGN

Prospective, single-center evaluation.

SETTING

Children's hospital.

PATIENTS

Any child with a structurally normal heart, undergoing hemodynamic evaluation in the cardiac catheterization laboratory, was included.

INTERVENTIONS

A prograde right heart catheterization was performed, and cardiac output was determined using the thermodilution technique, via placement of a pulmonary arterial catheter.

MEASUREMENTS AND MAIN RESULTS

Thermodilution results were compared with continuous real-time cardiac output measurements obtained with the PulseCO system, and they were then analyzed by standard correlation techniques and Bland-Altman analysis. Twenty patients were evaluated with a median age of 10.5 yrs and a median weight of 25 kg. The mean thermodilution cardiac index was 3.3 +/- 0.9 L/min/m, whereas the mean PulseCO cardiac index was 3.1 +/- 0.9 L/min/m. Standard Pearson correlation tests revealed a correlation coefficient of .94 (p < .001). Bland-Altman analysis revealed excellent clinical agreement with a mean difference of 0.19 L/min/m and a precision of 0.28 L/min/m at 2 sd.

CONCLUSIONS

Arterial pulse wave analysis by the PulseCO system provides a novel, minimally invasive method of determining real-time cardiac output in children.

Nursing care of the mechanically ventilated patient: what does the evidence say? Part one

The care of the mechanically ventilated patient is at the core of a nurse's clinical practice in the Intensive Care Unit (ICU). Published work relating to the numerous nursing issues of the care of the mechanically ventilated patient in the ICU is growing significantly. Literature focuses on patient assessment and management strategies for patient stressors, pain and sedation. Yet this literature is fragmentary by nature. The purpose of this paper is to provide a single comprehensive examination of the evidence related to the care of the mechanically ventilated patient. In part one of this two-part paper, the evidence on nursing care of the mechanically ventilated patient is explored with specific focus on patient safety: particularly patient and equipment assessment. Part two of the paper examines the evidence related to the mechanically ventilated patient's comfort, the patient/family unit, patient position, hygiene, management of stressors, pain management and sedation.

Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis

BACKGROUND

Mortality in patients with acute pancreatitis is associated with the number of failing organs and the severity and reversibility of organ dysfunction. The aim of this study was to assess the significance of early systemic inflammatory response syndrome (SIRS) in the development of multiorgan dysfunction syndrome (MODS) and death from acute pancreatitis.

METHODS

Data for all patients with a diagnosis of acute pancreatitis between January 2000 and December 2004 were reviewed. Serum C-reactive protein (CRP), Acute Physiology And Chronic Health Evaluation (APACHE) II scores and presence of SIRS were recorded on admission and at 48 h. Marshall organ dysfunction scores were calculated during the first week of presentation. Presence of SIRS and raised serum CRP levels on admission and at 48 h were correlated with the cumulative organ dysfunction scores in the first week.

RESULTS

A total of 759 patients with acute pancreatitis were identified, of whom 45 (5.9 per cent) died during the index admission. SIRS was identified in 162 patients on admission and was persistent in 138 at 48 h. The median (range) cumulative Marshall score in patients with persistent SIRS was significantly higher than that in patients in whom SIRS resolved and in those with no SIRS (4 (0-12), 3 (0-7) and 0 (0-9) respectively; P < 0.001). Thirty-five patients (25.4 per cent) with persistent SIRS died from acute pancreatitis, compared with six patients (8 per cent) with transient SIRS and four (0.7 per cent) without SIRS (P < 0.001). No correlation was observed between CRP level on admission and Marshall score (P = 0.810); however, there was a close correlation between CRP level at 48 h and Marshall score (P < 0.001).

CONCLUSION

Persistent SIRS is associated with MODS and death in patients with acute pancreatitis and is an early indicator of the likely severity of acute pancreatitis.

Severe Sepsis and Septic Shock in Adult Patients: An Approach to Management and Future Trends

Severe sepsis is sepsis associated with acute organ dysfunction. Septic shock in turn, implies severe sepsis that has led to circulatory shock refractory to fluid resuscitation alone. The immediate approach to severe sepsis follows the ABCs of resuscitation: Airway, Breathing, and Circulation. Special emphasis on the circulation involves early goal-directed therapy, adequate fluid resuscitation, and vasopressor/inotropic support. Once the patient's cardiorespiratory status is stabilized, efforts must be directed at uncovering the source and empirically yet accurately treating the infective underpinnings of severe sepsis. Following that, each of the patient's other organ systems at risk needs to be addressed: Renal/metabolic, gastrointestinal, hematological, and endocrine. Novel treatments will target both the proinflammatory and procoagulation cascades of sepsis.

Sepsis: Still Going Strong

Sepsis definitions help to understand and to better define a group of syndromes secondary to an infectious insult. The hierarchical continuum of inflammatory response leads, in absence of counterregulatory forces, to organ damage and death. We have learned first the response to treatment and afterwards the pathophysiology behind it. This lesson has, of course, not always been followed by a reduction of mortality. The definition, natural history, risk factors, diagnoses, and treatment based on emerging evidence will help to improve patient outcomes and mortality. Standardized care seems to improve survival, and validation and further evaluation of this care is necessary to maximize resources and outcomes.

Evaluation of tissue saturation as a noninvasive measure of mixed venous saturation in children

BACKGROUND

Mixed venous saturation (S & OV0456;o2) is an important measurement that helps guide the care of critically ill patients. Invasive S & OV0456;o2 assessment in infants and children is often avoided because of the inherent risks. A noninvasive tissue saturation (S to 2) monitor has recently been developed that uses near-infrared spectroscopy to measure oxyhemoglobin saturation in muscle. In adult and animal studies, S to 2 correlated with oxygen delivery and S & OV0456;o2. There has been no evaluation in pediatric patients.

OBJECTIVE

To evaluate tissue saturation as a noninvasive measure of mixed venous saturation in children.

DESIGN

A prospective observational study.

SETTING

Catheterization laboratory in a tertiary care children's medical center.

PATIENTS

We studied 98 children (49 without intracardiac mixing and 49 with intracardiac mixing) <or=12 yrs of age who underwent cardiac catheterization. Under general anesthesia, we compared S to 2 measured over the deltoid muscle with superior vena cava saturation in both groups and S to 2 with pulmonary artery saturation in patients without intracardiac mixing. Paired measurements were analyzed for bias, precision, and correlation via Bland-Altman plot and linear regression.

RESULTS

No meaningful correlation was found between S to 2 and superior vena cava saturation or pulmonary artery saturation. Bland-Altman analyses of S to 2 with superior vena cava saturation yielded bias values of -6.67 +/- 37.33% in patients with intracardiac mixing and -0.82 +/- 41.31% in patients without mixing. Bland-Altman analysis of S to 2 with pulmonary artery saturation yielded a bias of 3.61 +/- 41.32% in patients without mixing. Differences between noninvasive and invasive measurements were greatest in smaller children.

CONCLUSION

Noninvasive tissue saturation over the deltoid does not correlate with S & OV0456;o2 in children. It is possible that more precise probe spacing, coupled with optimal muscle-mass location, could result in more accurate measures in future investigations.