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Li Y, Dubick MA, Yang Z, Barr JL, Gremmer BJ, Lucas ML, Necsoiu C, Jordan BS, Batchinsky AI, Cancio LC. Distal organ inflammation and injury after resuscitative endovascular balloon occlusion of the aorta in a porcine model of severe hemorrhagic shock. PLoS One 2020; 15:e0242450. [PMID: 33201908 PMCID: PMC7671515 DOI: 10.1371/journal.pone.0242450] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 11/03/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Resuscitative Endovascular Balloon Occlusion of Aorta (REBOA) has emerged as a potential life-saving maneuver for the management of non-compressible torso hemorrhage in trauma patients. Complete REBOA (cREBOA) is inherently associated with the burden of ischemia reperfusion injury (IRI) and organ dysfunction. However, the distal organ inflammation and its association with organ injury have been little investigated. This study was conducted to assess these adverse effects of cREBOA following massive hemorrhage in swine. METHODS Spontaneously breathing and consciously sedated Sinclair pigs were subjected to exponential hemorrhage of 65% total blood volume over 60 minutes. Animals were randomized into 3 groups (n = 7): (1) Positive control (PC) received immediate transfusion of shed blood after hemorrhage, (2) 30min-cREBOA (A30) received Zone 1 cREBOA for 30 minutes, and (3) 60min-cREBOA (A60) given Zone 1 cREBOA for 60 minutes. The A30 and A60 groups were followed by resuscitation with shed blood post-cREBOA and observed for 4h. Metabolic and hemodynamic effects, coagulation parameters, inflammatory and end organ consequences were monitored and assessed. RESULTS Compared with 30min-cREBOA, 60min-cREBOA resulted in (1) increased IL-6, TNF-α, and IL-1β in distal organs (kidney, jejunum, and liver) (p < 0.05) and decreased reduced glutathione in kidney and liver (p < 0.05), (2) leukopenia, neutropenia, and coagulopathy (p < 0.05), (3) blood pressure decline (p < 0.05), (4) metabolic acidosis and hyperkalemia (p < 0.05), and (5) histological injury of kidney and jejunum (p < 0.05) as well as higher levels of creatinine, AST, and ALT (p < 0.05). CONCLUSION 30min-cREBOA seems to be a feasible and effective adjunct in supporting central perfusion during severe hemorrhage. However, prolonged cREBOA (60min) adverse effects such as distal organ inflammation and injury must be taken into serious consideration.
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Affiliation(s)
- Yansong Li
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
- * E-mail:
| | - Michael A. Dubick
- Department of Damage Control Resuscitation, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Zhangsheng Yang
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Johnny L. Barr
- Department of Damage Control Resuscitation, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Brandon J. Gremmer
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Michael L. Lucas
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Corina Necsoiu
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Bryan S. Jordan
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Andriy I. Batchinsky
- Department of Expeditionary Critical Care Research, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
| | - Leopoldo C. Cancio
- U. S. Army Burn Center, US Army Institute of Surgical Research, Fort Sam Houston, Texas, United States of America
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Abstract
Sepsis mortality has improved following advancements in early recognition and standardized management, including emphasis on early administration of appropriate antimicrobials. However, guidance regarding antimicrobial duration in sepsis is surprisingly limited. Decreased antibiotic exposure is associated with lower rates of de novo resistance development, Clostridioides difficile-associated disease, antibiotic-related toxicities, and health care costs. Consequently, data weighing safety versus adequacy of shorter treatment durations in sepsis would be beneficial. We provide a narrative review of evidence to guide antibiotic duration in sepsis. Evidence is significantly limited by noninferiority trial designs and exclusion of critically ill patients in many trials. Potential challenges to shorter antimicrobial duration in sepsis include inadequate source control, treatment of multidrug-resistant organisms, and pharmacokinetic alterations that predispose to inadequate antimicrobial levels. Additional studies specifically targeting patients with clinical indicators of sepsis are needed to guide measures to safely reduce antimicrobial exposure in this high-risk population while preserving clinical effectiveness.
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Affiliation(s)
- Lindsay M Busch
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
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Blouin AG, Hsu M, Fleisher M, Ramanathan LV, Pastores SM. Utility of procalcitonin as a predictor of bloodstream infections and supportive modality requirements in critically ill cancer patients. Clin Chim Acta 2020; 510:181-185. [PMID: 32679129 DOI: 10.1016/j.cca.2020.07.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 07/06/2020] [Accepted: 07/10/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND We evaluated the diagnostic utility of procalcitonin (PCT) in predicting bacterial bloodstream infections (BSI) in critically ill cancer patients with and without neutropenia. We also investigated the role of PCT as a prognostic marker of supportive modalities (vasopressors, invasive mechanical ventilation, and renal replacement therapy (RRT)) in the intensive care unit (ICU). METHODS We retrospectively analyzed 2200 PCT and blood cultures from adult cancer patients with suspected sepsis. Primary outcome was BSI, defined by positive blood culture, collected within 72 h of PCT collection. RESULTS Median PCT values were higher in encounters with BSI (3.2 vs 0.5 ng/ml, p < 0.001). The area under the ROC curve (AUC) was 0.726 (95%CI 0.698, 0.754). PCT > 2.0 ng/ml was significantly associated with greater likelihood of BSI and this effect was significantly stronger for neutropenic (OR 9.09, 95%CI: 4.39, 18.79) compared with non-neutropenic patients (OR 4.00 (95% CI: 3.13, 5.10), interaction p = 0.036). PCT > 2.0 was associated with vasopressor requirement on ICU admission (OR 1.82 (95% CI 1.31, 2.53), p < 0.001) and RRT (OR 2.20 (95% CI 1.24, 3.91), p = 0.007). CONCLUSIONS Procalcitonin is a fair discriminator of BSI in critically ill cancer patients with and without neutropenia and a PCT > 2.0 ng/ml was significantly more likely to require vasopressors and RRT in the ICU.
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Affiliation(s)
- Amanda G Blouin
- Center for Laboratory Medicine, New York, NY, United States.
| | - Meier Hsu
- Department of Epidemiology and Biostatistics, New York, NY, United States
| | | | | | - Stephen M Pastores
- Critical Care Center Memorial Sloan Kettering Cancer Center, New York, NY, United States
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Xu CH, Su Y, Lyu YX, Tian ZY, Sun FJ, Lin QS, Wang C. [Perianal swabs surveillance cultures of Carbapenem-resistant Enterobacteriaceae(CRE) can be hints for CRE bloodstream infection in patients with hematological diseases]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2019; 39:1021-1025. [PMID: 30612405 PMCID: PMC7348228 DOI: 10.3760/cma.j.issn.0253-2727.2018.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
目的 探讨血液病患者肛周皮肤拭子细菌培养检出耐碳青霉烯类肠杆菌(CRE)对CRE血流感染的预警价值,寻找CRE血流感染的危险因素。 方法 对2016年1月至2017年12月进行肛周皮肤拭子细菌培养的血液病患者分离出CRE的耐药率、患者后期CRE血流感染发生情况及危险因素进行回顾性分析。 结果 2 914例血液病患者进行了肛周皮肤拭子细菌培养,74例检出CRE,其中后期发生CRE血流感染者13例(17.6%)。共分离出CRE 87株(相同患者相同部位去重),包括肺炎克雷伯菌31株、大肠埃希菌43株、阴沟肠杆菌8株、其他肠杆菌科细菌6株。分离出CRE菌株对哌拉西林/他唑巴坦、亚胺培南、美罗培南、阿米卡星、左氧氟沙星、替加环素的耐药率分别为91.9%、74.4%、98.8%、17.6%、74.4%和8.0%。13例发生CRE血流感染患者肛周皮肤拭子与血液中分离株对碳青霉烯类、氨基糖苷类、喹诺酮类及替加环素耐药程度一致率较高。粒细胞缺乏(粒缺)、存在消化道症状、肛周感染持续时间为肛周皮肤CRE阳性患者发生CRE血流感染的独立危险因素(OR值分别为1.10、1.13和1.23,P值分别为0.029、0.005、0.016)。 结论 对血液病患者进行肛周皮肤拭子细菌培养可为后期CRE血流感染提供预警,并可为其提供抗菌药物选择参考;粒缺、伴消化道症状以及肛周感染持续时间长可作为CRE血流感染患者早期识别因素。
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Affiliation(s)
- C H Xu
- Institute of Hematology & Blood Diseases Hospital, CAMS & PUMC, Tianjin 300020, China
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Kim SJ, Kim GE, Park JH, Lee SL, Kim CS. Clinical features and prognostic factors of early-onset sepsis: a 7.5-year experience in one neonatal intensive care unit. KOREAN JOURNAL OF PEDIATRICS 2018; 62:36-41. [PMID: 30304900 PMCID: PMC6351802 DOI: 10.3345/kjp.2018.06807] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 09/27/2018] [Indexed: 11/27/2022]
Abstract
Purpose In this study, we investigated the clinical features and prognostic factors of early-onset sepsis (EOS) in neonatal intensive care unit (NICU) patients. Methods A retrospective analysis was conducted on medical records from January 2010 to June 2017 (7.5 years) of a university hospital NICU. Results There were 45 cases of EOS (1.2%) in 3,862 infants. The most common pathogen responsible for EOS was group B Streptococcus (GBS), implicated in 10 cases (22.2%), followed by Escherichia coli, implicated in 9 cases (20%). The frequency of gram-positive sepsis was higher in term than in preterm infants, whereas the rate of gram-negative infection was higher in preterm than in term infants (P<0.05). The overall mortality was 37.8% (17 of 45), and 47% of deaths occurred within the first 3 days of infection. There were significant differences in terms of gestational age (26.8 weeks vs. 35.1 weeks) and birth weight (957 g vs. 2,520 g) between the death and survival groups. After adjustments based on the difference in gestational age and birth weight between the 2 groups, gram-negative pathogens (odds ratio [OR], 42; 95% confidence interval [CI], 1.4–1,281.8) and some clinical findings, such as neutropenia (OR, 46; 95% CI, 1.3–1,628.7) and decreased activity (OR, 34; 95% CI, 1.8–633.4), were found to be associated with fatality. Conclusion The common pathogens found to be responsible for EOS in NICU patients are GBS and E. coli. Gram-negative bacterial infections, decreased activity in the early phase of infection, and neutropenia were associated with poor outcomes.
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Affiliation(s)
- Se Jin Kim
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Ga Eun Kim
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Jae Hyun Park
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Sang Lak Lee
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
| | - Chun Soo Kim
- Department of Pediatrics, Keimyung University School of Medicine, Daegu, Korea
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Schnell D, Azoulay E, Benoit D, Clouzeau B, Demaret P, Ducassou S, Frange P, Lafaurie M, Legrand M, Meert AP, Mokart D, Naudin J, Pene F, Rabbat A, Raffoux E, Ribaud P, Richard JC, Vincent F, Zahar JR, Darmon M. Management of neutropenic patients in the intensive care unit (NEWBORNS EXCLUDED) recommendations from an expert panel from the French Intensive Care Society (SRLF) with the French Group for Pediatric Intensive Care Emergencies (GFRUP), the French Society of Anesthesia and Intensive Care (SFAR), the French Society of Hematology (SFH), the French Society for Hospital Hygiene (SF2H), and the French Infectious Diseases Society (SPILF). Ann Intensive Care 2016; 6:90. [PMID: 27638133 PMCID: PMC5025409 DOI: 10.1186/s13613-016-0189-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Accepted: 08/29/2016] [Indexed: 02/07/2023] Open
Abstract
Neutropenia is defined by either an absolute or functional defect (acute myeloid leukemia or myelodysplastic syndrome) of polymorphonuclear neutrophils and is associated with high risk of specific complications that may require intensive care unit (ICU) admission. Specificities in the management of critically ill neutropenic patients prompted the establishment of guidelines dedicated to intensivists. These recommendations were drawn up by a panel of experts brought together by the French Intensive Care Society in collaboration with the French Group for Pediatric Intensive Care Emergencies, the French Society of Anesthesia and Intensive Care, the French Society of Hematology, the French Society for Hospital Hygiene, and the French Infectious Diseases Society. Literature review and formulation of recommendations were performed using the Grading of Recommendations Assessment, Development and Evaluation system. Each recommendation was then evaluated and rated by each expert using a methodology derived from the RAND/UCLA Appropriateness Method. Six fields are covered by the provided recommendations: (1) ICU admission and prognosis, (2) protective isolation and prophylaxis, (3) management of acute respiratory failure, (4) organ failure and organ support, (5) antibiotic management and source control, and (6) hematological management. Most of the provided recommendations are obtained from low levels of evidence, however, suggesting a need for additional studies. Seven recommendations were, however, associated with high level of evidences and are related to protective isolation, diagnostic workup of acute respiratory failure, medical management, and timing surgery in patients with typhlitis.
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Affiliation(s)
| | | | | | - Benjamin Clouzeau
- Medical Intensive Care Unit, Pellegrin University Hospital, Bordeaux, France
| | - Pierre Demaret
- Paediatric Intensive Care Unit, Centre Hospitalier Chrétien, Liège, Belgium
| | - Stéphane Ducassou
- Pediatric Hematological Unit, Bordeaux University Hospital, Bordeaux, France
| | - Pierre Frange
- Microbiology Laboratory & Pediatric Immunology - Hematology Unit, Necker University Hospital, Paris, France
| | - Matthieu Lafaurie
- Department of Infectious Diseases, Saint-Louis University Hospital, Paris, France
| | - Matthieu Legrand
- Surgical ICU and Burn Unit, Saint-Louis University Hospital, Paris, France
| | - Anne-Pascale Meert
- Thoracic Oncology Department and Oncologic Intensive Care Unit, Institut Jules Bordet, Brussels, Belgium
| | - Djamel Mokart
- Polyvalent Intensive Care Unit, Department of Anesthesiology and Critical Care, Institut Paoli Calmette, Marseille, France
| | - Jérôme Naudin
- Pediatric ICU, Robert Debré University Hospital, Paris, France
| | | | - Antoine Rabbat
- Respiratory Intensive Care Unit, Cochin University Hospital Hospital, Paris, France
| | - Emmanuel Raffoux
- Department of Hematology, Saint-Louis University Hospital, Paris, France
| | - Patricia Ribaud
- Department of Stem Cell Transplantation, Saint-Louis University Hospital, Paris, France
| | | | | | - Jean-Ralph Zahar
- Infection Control Unit, Angers University Hospital, Angers, France
| | - Michael Darmon
- University Hospital, Saint-Etienne, France. .,Medical-Surgical Intensive Care Unit, Saint-Etienne University Hospital, Avenue Albert Raymond, 42270, Saint-Etienne, Saint-Priest-En-Jarez, France.
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