CLINICAL CHARACTERISTICS AND PREDICTORS OF MORTALITY DIFFER BETWEEN PULMONARY AND ABDOMINAL SEPSIS

DEVELOPMENT AND INTERNAL-EXTERNAL VALIDATION OF THE ACCI-SOFA MODEL FOR PREDICTING IN-HOSPITAL MORTALITY OF PATIENTS WITH SEPSIS-3 IN THE ICU: A MULTICENTER RETROSPECTIVE COHORT STUDY

ABSTRACT

Objective: To achieve a better prediction of in-hospital mortality, the Sequential Organ Failure Assessment (SOFA) score needs to be adjusted and combined with comorbidities. This study aims to enhance the prediction of SOFA score for in-hospital mortality in patients with Sepsis-3. Methods: This study adjusted the maximum SOFA score within the first 3 days (Max Day3 SOFA) in relation to in-hospital mortality using logistic regression and incorporated the age-adjusted Charlson Comorbidity Index (aCCI) as a continuous variable to build the age-adjusted Charlson Comorbidity Index-Sequential Organ Failure Assessment (aCCI-SOFA) model. The outcome was in-hospital mortality. We developed, internally validated, and externally validated the aCCI-SOFA model using cohorts of Sepsis-3 patients from the MIMIC-IV, MIMIC-III (CareVue), and the FAHWMU cohort. The predictive performance of the model was assessed through discrimination and calibration, which was assessed using the area under the receiver operating characteristic and calibration curves, respectively. The overall predictive effect was evaluated using the Brier score. Measurements and main results: Compared with the Max Day3 SOFA, the aCCI-SOFA model showed significant improvement in area under the receiver operating characteristic with all cohorts: development cohort (0.81 vs 0.75, P < 0.001), internal validation cohort (0.81 vs 0.76, P < 0.001), MIMIC-III (CareVue) cohort (0.75 vs 0.68, P < 0.001), and FAHWMU cohort (0.72 vs 0.67, P = 0.001). In sensitivity analysis, it was suggested that the application of aCCI-SOFA in early nonseptic shock patients had greater clinical value, with significant differences compared with the original SOFA scores in all cohorts ( P < 0.05). Conclusion: For septic patients in intensive care unit, the aCCI-SOFA model exhibited superior predictive performance. The application of aCCI-SOFA in early nonseptic shock patients had greater clinical value.

PROTECTIVE ROLE OF MELATONIN FOR ACUTE KIDNEY INJURY: A SYSTEMATIC REVIEW AND META-ANALYSIS

ABSTRACT

Introduction : Acute kidney injury (AKI) is an important clinical issue that arouses global concerns, which puzzles clinicians and lacks effective drug treatment for AKI until the present. Melatonin has been well recognized to modulate the sleep-wake cycle and had the renal protective effect. However, there are still few clinical trials investigating the relationship between melatonin and AKI. The conclusions drawn in existing clinical studies are still inconsistent. The study systematically reviewed and assessed the efficacy of melatonin in preventing AKI. Methods : A systematic literature search was conducted in the PubMed, Embase, and Cochranelibrary on May 19, 2023. Eligible records were screened according to the inclusion and exclusion criteria. The risk ratio and the corresponding 95% confidence intervals were selected to evaluate the effects of melatonin on AKI. We pooled extracted data using a fixed- or random effects model based on a heterogeneity test. Results : Six randomized controlled trials regarding the use of melatonin in preventing kidney injury met our inclusion criteria. The pooled results showed that melatonin increased the estimated glomerular filtration rate, and effectively inhibited the occurrence of AKI. Melatonin tended to reduce the serum creatinine and urea nitrogen levels, but there was no statistical significance. Conclusions : Melatonin can increase the estimated glomerular filtration rate and effectively inhibit the occurrence of AKI. More well-designed randomized controlled trials are needed to verify the protective effect of melatonin in the future.

EARLY BLOOD LACTATE AS A BIOMARKER FOR CARDIOVASCULAR COLLAPSE IN EXPERIMENTAL SEPSIS

ABSTRACT

Cecal ligation and puncture (CLP) is the gold standard model for studying septic shock, which is characterized by hypotension and hyporeactivity to vasoconstrictors. However, approximately 30% of CLP animals do not exhibit cardiovascular changes, requiring more replicates because of the high variability of the model. Therefore, biomarkers enabling the early prediction of cardiovascular collapse in sepsis would greatly benefit sepsis nonclinical studies, refining experimental models and improving clinical translation. Thus, this study aimed to test whether the early increase in lactate levels could predict hypotension and hyporesponsiveness to vasoconstrictors in a rat model of sepsis. Male and female Wistar rats were subjected to CLP or sham procedure. Tail blood lactate was measured 6, 12, and 24 h after surgery. Then, inflammatory, biochemical, and hemodynamic parameters were evaluated. Rats subjected to CLP developed hypotension, hyporesponsiveness to vasoconstrictors, an intense inflammatory process, and increased plasma markers of organ dysfunction. By using receiver operating characteristics curve analysis, we have established that a lactate value of 2.45 mmol/L can accurately discriminate between a rat exhibiting a normal vasoconstrictive response and a vasoplegic rat with 84% accuracy (area under the curve: 0.84; confidence interval [CI]: 0.67-1.00). The sensitivity, which is the ability to identify a diseased rat (true positive), was 75% (CI: 41-95), and the true negative rate was 81% (CI: 57-93). Therefore, early measurement of lactate levels in sepsis could serve as a valuable biomarker for distinguishing vasoplegic rats from those exhibiting normal vasoconstrictive responses.

THE ACCURACY OF INFERIOR VENA CAVA DISTENSIBILITY THROUGH THE TRANSHEPATIC APPROACH TO PREDICT FLUID RESPONSIVENESS IN PATIENTS WITH SEPTIC SHOCK AFTER EMERGENCY LAPAROTOMY

ABSTRACT

Background: We aimed to evaluate the ability of inferior vena cava (IVC) distensibility using the transhepatic approach to predict fluid responsiveness in mechanically ventilated patients with septic shock after emergency laparotomy. Methods: This prospective observational study included mechanically ventilated paralyzed adult who had septic shock after emergency laparotomy. The IVC dimensions were measured through the transhepatic and subxiphoid approaches. The fluid responsiveness was confirmed with >15% increase in cardiac output after 500 mL of fluid bolus. The outcomes were the ability of transhepatic (primary outcome) and subxiphoid approach to predict fluid responders using the area under the receiver operating characteristics curve analysis. The gray zone for the two approaches was calculated. Results: Data from 51 patients were analyzed, and the number of fluid responders was 30 of 52 (58%). The transhepatic approach was feasible in all patients, whereas the subxiphoid approach was only feasible in 42 patients. The area under the receiver operating characteristics curve (95% confidence interval) for the transhepatic IVC distensibility was 0.88 (0.76-0.95), and it was comparable with that of the subxiphoid approach (0.81 [0.66-0.92], P = 0.417). The gray zone for the transhepatic IVC distensibility was 17% to 35% including 24 of 51 patients (47%), whereas the gray zone for the subxiphoid IVC distensibility was 13% to 34% including 18 of 42 patients (43%). Conclusion: In conclusion, the transhepatic approach for evaluation of IVC distensibility showed good accuracy in predicting fluid responsiveness in patients with septic shock after emergency laparotomy. The transhepatic approach showed the same accuracy as the subxiphoid approach with the advantage of being feasible in larger number of patients.