World Sepsis Day: a global agenda to target a leading cause of morbidity and mortality

Molecular basis of sepsis: A New insight into the role of mitochondrial DNA as a damage-associated molecular pattern

Sepsis remains a critical challenge in the field of medicine, claiming countless lives each year. Despite significant advances in medical science, the molecular mechanisms underlying sepsis pathogenesis remain elusive. Understanding molecular sequelae is gaining deeper insights into the roles played by various damage-associated molecular patterns (DAMPs) and pathogen-associated molecular patterns (PAMPs) in disease pathogenesis. Among the known DAMPs, circulating cell-free mitochondrial DNA (mtDNA) garners increasing attention as a key player in the immune response during sepsis and other diseases. Mounting evidence highlights numerous connections between circulating cell-free mtDNA and inflammation, a pivotal state of sepsis, characterized by heightened inflammatory activity. In this review, we aim to provide an overview of the molecular basis of sepsis, particularly emphasizing the role of circulating cell-free mtDNA as a DAMP. We discuss the mechanisms of mtDNA release, its interaction with pattern recognition receptors (PRRs), and the subsequent immunological responses that contribute to sepsis progression. Furthermore, we discuss the forms of cell-free mtDNA; detection techniques of circulating cell-free mtDNA in various biological fluids; and the diagnostic, prognostic, and therapeutic implications offering insights into the potential for innovative interventions in sepsis management.

Advances and Challenges in Sepsis Management: Modern Tools and Future Directions

Sepsis, a critical condition marked by systemic inflammation, profoundly impacts both innate and adaptive immunity, often resulting in lymphopenia. This immune alteration can spare regulatory T cells (Tregs) but significantly affects other lymphocyte subsets, leading to diminished effector functions, altered cytokine profiles, and metabolic changes. The complexity of sepsis stems not only from its pathophysiology but also from the heterogeneity of patient responses, posing significant challenges in developing universally effective therapies. This review emphasizes the importance of phenotyping in sepsis to enhance patient-specific diagnostic and therapeutic strategies. Phenotyping immune cells, which categorizes patients based on clinical and immunological characteristics, is pivotal for tailoring treatment approaches. Flow cytometry emerges as a crucial tool in this endeavor, offering rapid, low cost and detailed analysis of immune cell populations and their functional states. Indeed, this technology facilitates the understanding of immune dysfunctions in sepsis and contributes to the identification of novel biomarkers. Our review underscores the potential of integrating flow cytometry with omics data, machine learning and clinical observations to refine sepsis management, highlighting the shift towards personalized medicine in critical care. This approach could lead to more precise interventions, improving outcomes in this heterogeneously affected patient population.

The Role of New Morphological Parameters Provided by the BC 6800 Plus Analyzer in the Early Diagnosis of Sepsis

BACKGROUND

Late diagnosis of sepsis is associated with adverse consequences and high mortality rate. The aim of this study was to evaluate the diagnostic value of hematologic research parameters, that reflect the cell morphology of blood cells, available on the BC 6800 plus automated analyzer (Mindray) for the early detection of sepsis.

MATERIALS AND METHODS

A complete blood count (CBC) was performed by Mindray BC 6800 Plus Analyzer in 327 patients (223 with a confirmed diagnosis of sepsis following sepsis-3 criteria, 104 without sepsis), admitted at the Intensive Care Unit of the Novara's Hospital (Italy) and in 56 patients with localized infection.

RESULTS

In univariate logistic regression, age, Hb, RDW, MO#, NMR, NeuX, NeuY, NeuZ, LymX, MonX, MonY, MonZ were associated with sepsis (p < 0.005). In multivariate analysis, only RDW, NeuX, NeuY, NeuZ, MonX and MonZ were found to be independent predictors of sepsis (p < 0.005). Morphological research parameters are confirmed to be predictors of sepsis even when analyzing the group with localized infection.

CONCLUSIONS

In addition to already established biomarkers and basic CBC parameters, new morphological cell parameters can be a valuable aid in the early diagnosis of sepsis at no additional cost.

Association between reduced muscle mass and poor prognosis of biliary sepsis

Sepsis is a life-threatening disease, contributing to significant morbidity and mortality. This study aimed to investigate the association between low muscle mass and the prognosis of patients with biliary sepsis, focusing on outcomes such as length of hospital stay (LOS), intensive care unit (ICU) admission, and in-hospital mortality. This retrospective, single-center, observational study included adult patients with biliary sepsis who visited the emergency department between January 2016 and December 2021. Low muscle mass was assessed using the psoas muscle index (PMI). Using computed tomography imaging, the area of both sides of the psoas muscle at the L3 level was measured, and the PMI, corrected by the patient's height was calculated. The primary outcome was in-hospital mortality, and the secondary outcomes were intensive care unit (ICU) admission, LOS, and 14-day mortality. A total of 745 patients were included in this study. Low muscle mass was defined as a PMI < 421 mm2/m2 for males and < 268 mm2/m2 for females with the lower quartile of PMI according to sex. The cohort was classified into sarcopenic (n = 189) and non-sarcopenic (n = 556) groups. There was a significant association between low muscle mass and in-hospital mortality (odds ratio, 3.81; 95% confidence interval, 1.08-13.47; p < 0.001), while there was no significant association between low muscle mass and ICU admission. In addition, the median LOS in the sarcopenic group (10 [7-14] days) was significantly longer than the median (8 [6-11] days) in the non-sarcopenic group. Low muscle mass was significantly associated with clinical outcomes, particularly in-hospital mortality and LOS, in patients with biliary sepsis.

Understanding Post-Sepsis Syndrome: How Can Clinicians Help?

Sepsis is a global health challenge, with over 49 million cases annually. Recent medical advancements have increased in-hospital survival rates to approximately 80%, but the escalating incidence of sepsis, owing to an ageing population, rise in chronic diseases, and antibiotic resistance, have also increased the number of sepsis survivors. Subsequently, there is a growing prevalence of "post-sepsis syndrome" (PSS). This syndrome includes long-term physical, medical, cognitive, and psychological issues after recovering from sepsis. PSS puts survivors at risk for hospital readmission and is associated with a reduction in health- and life span, both at short and long term, after hospital discharge. Comprehensive understanding of PSS symptoms and causative factors is vital for developing optimal care for sepsis survivors, a task of prime importance for clinicians. This review aims to elucidate our current knowledge of PSS and its relevance in enhancing post-sepsis care provided by clinicians.

Exploring Albumin Functionality Assays: A Pilot Study on Sepsis Evaluation in Intensive Care Medicine

Human serum albumin (HSA) as the most abundant plasma protein carries multifunctional properties. A major determinant of the efficacy of albumin relies on its potent binding capacity for toxins and pharmaceutical agents. Albumin binding is impaired in pathological conditions, affecting its function as a molecular scavenger. Limited knowledge is available on the functional properties of albumin in critically ill patients with sepsis or septic shock. A prospective, non-interventional clinical trial assessed blood samples from 26 intensive care patients. Albumin-binding capacity (ABiC) was determined by quantifying the unbound fraction of the fluorescent marker, dansyl sarcosine. Electron paramagnetic resonance fatty acid spin-probe evaluated albumin's binding and detoxification efficiencies. Binding efficiency (BE) reflects the strength and amount of bound fatty acids, and detoxification efficiency (DTE) indicates the molecular flexibility of patient albumin. ABiC, BE, and DTE effectively differentiated control patients from those with sepsis or septic shock (AUROC > 0.8). The diagnostic performance of BE showed similarities to procalcitonin. Albumin functionality correlates with parameters for inflammation, hepatic, or renal insufficiency. Albumin-binding function was significantly reduced in critically ill patients with sepsis or septic shock. These findings may help develop patient-specific algorithms for new diagnostic and therapeutic approaches.

Artificial Intelligence Versus Human-Controlled Doctor in Virtual Reality Simulation for Sepsis Team Training: Randomized Controlled Study

BACKGROUND

Interprofessional communication is needed to enhance the early recognition and management of patients with sepsis. Preparing medical and nursing students using virtual reality simulation has been shown to be an effective learning approach for sepsis team training. However, its scalability is constrained by unequal cohort sizes between medical and nursing students. An artificial intelligence (AI) medical team member can be implemented in a virtual reality simulation to engage nursing students in sepsis team training.

OBJECTIVE

This study aimed to evaluate the effectiveness of an AI-powered doctor versus a human-controlled doctor in training nursing students for sepsis care and interprofessional communication.

METHODS

A randomized controlled trial study was conducted with 64 nursing students who were randomly assigned to undertake sepsis team training with an AI-powered doctor (AI-powered group) or with medical students using virtual reality simulation (human-controlled group). Participants from both groups were tested on their sepsis and communication performance through simulation-based assessments (posttest). Participants' sepsis knowledge and self-efficacy in interprofessional communication were also evaluated before and after the study interventions.

RESULTS

A total of 32 nursing students from each group completed the simulation-based assessment, sepsis and communication knowledge test, and self-efficacy questionnaire. Compared with the baseline scores, both the AI-powered and human-controlled groups demonstrated significant improvements in communication knowledge (P=.001) and self-efficacy in interprofessional communication (P<.001) in posttest scores. For sepsis care knowledge, a significant improvement in sepsis care knowledge from the baseline was observed in the AI-powered group (P<.001) but not in the human-controlled group (P=.16). Although no significant differences were found in sepsis care performance between the groups (AI-powered group: mean 13.63, SD 4.23, vs human-controlled group: mean 12.75, SD 3.85, P=.39), the AI-powered group (mean 9.06, SD 1.78) had statistically significantly higher sepsis posttest knowledge scores (P=.009) than the human-controlled group (mean 7.75, SD 2.08). No significant differences were found in interprofessional communication performance between the 2 groups (AI-powered group: mean 29.34, SD 8.37, vs human-controlled group: mean 27.06, SD 5.69, P=.21). However, the human-controlled group (mean 69.6, SD 14.4) reported a significantly higher level of self-efficacy in interprofessional communication (P=.008) than the AI-powered group (mean 60.1, SD 13.3).

CONCLUSIONS

Our study suggested that AI-powered doctors are not inferior to human-controlled virtual reality simulations with respect to sepsis care and interprofessional communication performance, which supports the viability of implementing AI-powered doctors to achieve scalability in sepsis team training. Our findings also suggested that future innovations should focus on the sociability of AI-powered doctors to enhance users' interprofessional communication training. Perhaps in the nearer term, future studies should examine how to best blend AI-powered training with human-controlled virtual reality simulation to optimize clinical performance in sepsis care and interprofessional communication.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05953441; https://clinicaltrials.gov/study/NCT05953441.

2023 Update on Sepsis and Septic Shock in Adult Patients: Management in the Emergency Department

BACKGROUND

Sepsis/septic shock is a life-threatening and time-dependent condition that requires timely management to reduce mortality. This review aims to update physicians with regard to the main pillars of treatment for this insidious condition.

METHODS

PubMed, Scopus, and EMBASE were searched from inception with special attention paid to November 2021-January 2023.

RESULTS

The management of sepsis/septic shock is challenging and involves different pathophysiological aspects, encompassing empirical antimicrobial treatment (which is promptly administered after microbial tests), fluid (crystalloids) replacement (to be established according to fluid tolerance and fluid responsiveness), and vasoactive agents (e.g., norepinephrine (NE)), which are employed to maintain mean arterial pressure above 65 mmHg and reduce the risk of fluid overload. In cases of refractory shock, vasopressin (rather than epinephrine) should be combined with NE to reach an acceptable level of pressure control. If mechanical ventilation is indicated, the tidal volume should be reduced from 10 to 6 mL/kg. Heparin is administered to prevent venous thromboembolism, and glycemic control is recommended. The efficacy of other treatments (e.g., proton-pump inhibitors, sodium bicarbonate, etc.) is largely debated, and such treatments might be used on a case-to-case basis.

CONCLUSIONS

The management of sepsis/septic shock has significantly progressed in the last few years. Improving knowledge of the main therapeutic cornerstones of this challenging condition is crucial to achieve better patient outcomes.

xPM: Enhancing exogenous data visibility

Process mining is a well-established discipline with applications in many industry sectors, including healthcare. To date, few publications have considered the context in which processes execute. Little consideration has been given as to how contextual data (exogenous data) can be practically included for process mining analysis, beyond including case or event attributes in a typical event log. We show that the combination of process data (endogenous) and exogenous data can generate insights not possible with standard process mining techniques. Our contributions are a framework for process mining with exogenous data and new analyses, where exogenous data and process behaviour are linked to process outcomes. Our new analyses visualise exogenous data, highlighting the trends and variations, to show where overlaps or distinctions exist between outcomes. We applied our analyses in a healthcare setting and show that clinicians could extract insights about differences in patients' vital signs (exogenous data) relevant to clinical outcomes. We present two evaluations, using a publicly available data set, MIMIC-III, to demonstrate the applicability of our analysis. These evaluations show that process mining can integrate large amounts of physiologic data and interventions, with resulting discrimination and conversion to clinically interpretable information.

Sepsis affects kidney graft function and one-year mortality of the recipients in contrast with systemic inflammatory response

Background

Infections remain a major cause of morbidity and mortality after kidney transplantation. The aim of our study was to determine the effect of sepsis on kidney graft function and recipient mortality.

Methods

A prospective, observational, single-center study was performed. Selected clinical and biochemical parameters were recorded and compared between an experimental group (with sepsis, n = 34) and a control group (with systemic inflammatory response syndrome, n = 31) comprising kidney allograft recipients.

Results

Sepsis worsened both patient (HR = 14.77, p = 0.007) and graft survival (HR = 15.07, p = 0.007). Overall one-year mortality was associated with age (HR = 1.08, p = 0.048), APACHE II score (HR = 1.13, p = 0.035), and combination immunosuppression therapy (HR = 0.1, p = 0.006), while graft survival was associated with APACHE II (HR = 1.25, p = 0.004) and immunosuppression. In sepsis patients, mortality correlated with the maximal dose of noradrenalin (HR = 100.96, p = 0.008), fungal infection (HR = 5.64, p = 0.024), SAPS II score (HR = 1.06, p = 0.033), and mechanical ventilation (HR = 5.97, p = 0.033), while graft survival was influenced by renal replacement therapy (HR = 21.16, p = 0.005), APACHE II (HR = 1.19, p = 0.035), and duration of mechanical ventilation (HR = 1.01, p = 0.015).

Conclusion

In contrast with systemic inflammatory response syndrome, septic kidney allograft injury is associated with early graft loss and may represent a significant risk of mortality.

Anticardiolipin Autoantibodies as Useful Biomarkers for the Prediction of Mortality in Septic Patients

Background. The detection of antiphospholipid antibodies (aPL) is of interest because of their importance in the pathogenesis of arterial or venous thrombosis. They could be a “second hit” of an inflammatory event such as infection. The aim of our study was to assess the performance of antiphospholipid antibody biomarker to predict in-hospital mortality in intensive care unit (ICU) septic patients. Methods. We conducted a prospective single-center observational study including consecutive critically ill septic adults admitted to the intensive care unit. Clinical and laboratory data including enzyme-linked immunosorbent assay for antiphospholipid antibodies (anticardiolipin (aCL), antiphosphatidylserine (aPS)) were obtained. Blood samples were collected on days 1, 3, 5, 8, and 10 of hospitalization. The primary study endpoint was ICU mortality defined as death before ICU discharge. Secondary end points included correlation between SOFA score and biological parameters. Results. A total of 53 patients were enrolled. 18.8% of patients were aPL positive. In-hospital mortality rate was 60%. Multivariate analysis showed that age and aCL at days 3 and 5 along with SOFA at day 3 were independent outcome predictors. A significant positive correlation existed between SOFA at days 3, 5, and 8 and antiphospholipid antibody concentrations. Conclusions. Our data showed that antiphospholipid was useful biomarkers for the prediction of mortality in critically ill septic patients. We found a positive correlation between SOFA score and antiphospholipid antibodies.

The Effect of a Sepsis Interprofessional Education Using Virtual Patient Telesimulation on Sepsis Team Care in Clinical Practice: Mixed Methods Study

BACKGROUND

Improving interprofessional communication and collaboration is necessary to facilitate the early identification and treatment of patients with sepsis. Preparing undergraduate medical and nursing students for the knowledge and skills required to assess, escalate, and manage patients with sepsis is crucial for their entry into clinical practice. However, the COVID-19 pandemic and social distancing measures have created the need for interactive distance learning to support collaborative learning.

OBJECTIVE

This study aimed to evaluate the effect of sepsis interprofessional education on medical and nursing students' sepsis knowledge, team communication skills, and skill use in clinical practice.

METHODS

A mixed methods design using a 1-group pretest-posttest design and focus group discussions was used. This study involved 415 undergraduate medical and nursing students from a university in Singapore. After a baseline evaluation of the participants' sepsis knowledge and team communication skills, they underwent didactic e-learning followed by virtual telesimulation on early recognition and management of sepsis and team communication strategies. The participants' sepsis knowledge and team communication skills were evaluated immediately and 2 months after the telesimulation. In total, 4 focus group discussions were conducted using a purposive sample of 18 medical and nursing students to explore their transfer of learning to clinical practice.

RESULTS

Compared with the baseline scores, both the medical and nursing students demonstrated a significant improvement in sepsis knowledge (P<.001) and team communication skills (P<.001) in immediate posttest scores. At the 2-month follow-up, the nursing students continued to have statistically significantly higher sepsis knowledge (P<.001) and communication scores (P<.001) than the pretest scores, whereas the medical students had no significant changes in test scores between the 2-month follow-up and pretest time points (P=.99). A total of three themes emerged from the qualitative findings: greater understanding of each other's roles, application of mental models in clinical practice, and theory-practice gaps. The sepsis interprofessional education-particularly the use of virtual telesimulation-fostered participants' understanding and appreciation of each other's interprofessional roles when caring for patients with sepsis. Despite noting some incongruities with the real-world clinical practice and not encountering many sepsis scenarios in clinical settings, participants shared the application of mental models using interprofessional communication strategies and the patient assessment framework in their daily clinical practice.

CONCLUSIONS

Although the study did not show long-term knowledge retention, the use of virtual telesimulation played a critical role in facilitating the application of mental models for learning transfer and therefore could serve as a promising education modality for sepsis training. For a greater clinical effect, future studies could complement virtual telesimulation with a mannequin-based simulation and provide more evidence on the long-term retention of sepsis knowledge and clinical skills performance.

Oxygen therapy for sepsis and prevention of complications

Patients with sepsis have a wide range of respiratory disorders that can be treated with oxygen therapy. Experimental data in animal sepsis models show that oxygen therapy significantly increases survival, while clinical data on the use of different oxygen therapy protocols are ambiguous. Oxygen therapy, especially hyperbaric oxygenation, in patients with sepsis can aggravate existing oxidative stress and contribute to the development of disseminated intravascular coagulation. The purpose of this article is to compare experimental and clinical data on oxygen therapy in animals and humans, to discuss factors that can influence the results of oxygen therapy for sepsis treatment in humans, and to provide some recommendations for reducing oxidative stress and preventing disseminated intravascular coagulation during oxygen therapy.

A 2-year retrospective analysis of the prognostic value of MqSOFA compared to lactate, NEWS and qSOFA in patients with sepsis

Purpose

Sepsis is a life-threating organ dysfunction caused by a dysregulated host response to infection. Being a time-dependent condition, the present study aims to compare a recently established score, i.e., modified quick SOFA (MqSOFA), with other existing tools commonly applied to predict in-hospital mortality.

Methods

All cases of sepsis and septic shock consecutively observed at St. Anna University Hospital of Ferrara, Italy, from January 2017 to December 2018 were included in this study. Each patient was evaluated with MqSOFA, lactate assay, NEWS and qSOFA. Accurate statistical and logistic regression analyses were applied to our database.

Results

A total of 1001 consecutive patients with sepsis/septic shock were retrieved. Among them, 444 were excluded for incomplete details about vital parameters; thus, 556 patients were eligible for the study. Data analysis showed that MqSOFA, NEWS and lactate assay provided a better predictive ability than qSOFA in terms of in-hospital mortality (p < 0.001). Aetiology-based stratification in 5 subgroups demonstrated the superiority of NEWS vs. other tools in predicting fatal outcomes (p = 0.030 respiratory, p = 0.036 urinary, p = 0.044 abdominal, p = 0.047 miscellaneous and p = 0.041 for indeterminate causes). After Bonferroni’s correction, MqSOFA was superior to qSOFA over respiratory (p < 0.001) and urinary (p < 0.001) aetiologies. Age was an independent factor for negative outcomes (p < 0.001).

Conclusions

MqSOFA, NEWS and lactate assay better predicted in-hospital mortality compared to qSOFA. Since sepsis needs a time-dependent assessment, an easier and non-invasive score, i.e., MqSOFA, could be used to establish patients’ outcome in the emergency setting.

Impact of sepsis education for healthcare professionals and students on learner and patient outcomes: A systematic review

BACKGROUND

Sepsis is an important global healthcare problem that is a key challenge faced by healthcare professionals face worldwide. One key effort aimed at reducing the global burden of sepsis is educating healthcare professionals about early identification and management of sepsis.

AIM

To provide a comprehensive evaluation of sepsis education among healthcare professionals and students.

METHODS

Six databases (PubMed, CINAHL, Embase, MEDLINE, Cochrane Central Register of Controlled Trials, and Scopus) were searched. We included studies that described and evaluated any form of education or training on sepsis delivered to healthcare professionals and students. Study outcomes were summarised according to the adapted Kirkpatrick model of training evaluation.

RESULTS

Thirty-two studies were included in the review. The learning contents were reported to be in accordance with the Surviving Sepsis Campaign guidelines. Seven studies included the topic of interprofessional teamwork and communication in their sepsis education content. Most educational programs were effective and reported positive effects on immediate knowledge outcomes. Interventions that were delivered through an active learning approach such as simulation and game-based learning generally produced greater gains than didactic teaching. Improvements in patient care processes and patient outcomes were associated with the concomitant existence or implementation of a hospital sepsis care bundle.

CONCLUSION

Incorporating active learning strategies into sepsis education interventions has the potential to improve learners' long-term outcomes. In addition, sepsis education and protocol-based sepsis care bundle act in synergy to augment greater improvements in care processes and patient benefits.

Knowledge translation following the implementation of a state-wide Paediatric Sepsis Pathway in the emergency department- a multi-centre survey study

Background

Several health care systems internationally have implemented protocolised sepsis recognition and treatment bundles for children to improve outcomes, as recommended by the Surviving Sepsis Campaign. Successful implementation of clinical pathways is challenging and dependent on nurse engagement. There is limited data on knowledge translation during implementation of sepsis quality improvement programs.

Methods

This cross-sectional, multicentre observational survey study evaluated knowledge and perceptions of Emergency Department nurses in relation to the recognition, escalation and management of paediatric sepsis following implementation of a sepsis pathway. The study was conducted between September 2019 and March 2020 across 14 Emergency Departments in Queensland, Australia. The primary outcome was a sepsis knowledge score. An exploratory factor analysis was conducted to identify factors impacting nurses’ perceptions of recognition, escalation and management of paediatric sepsis and their association with knowledge. Using a logistic mixed effects model we explored associations between knowledge, identified factors and other clinical, demographic and hospital site variables.

Results

In total, 676 nurses responded to the survey and 534 were included in the analysis. The median knowledge score was 57.1% (IQR = 46.7–66.7), with considerable variation observed between sites. The exploratory factor analysis identified five factors contributing to paediatric sepsis recognition, escalation and management, categorised as 1) knowledge and beliefs, 2) social influences, 3) beliefs about capability and skills delivering treatment, 4) beliefs about capability and behaviour and 5) environmental context. Nurses reported strong agreement with statements measuring four of the five factors, responding lowest to the factor pertaining to capability and skills delivering treatment for paediatric sepsis. The factors knowledge and beliefs, capability and skills, and environmental context were positively associated with a higher knowledge score. Years of paediatric experience and dedicated nurse funding for the sepsis quality improvement initiative were also associated with a higher knowledge score.

Conclusion

Translation of evidence to practice such as successful implementation of a sepsis care bundle, relies on effective education of staff and sustained uptake of protocols in daily practice. Our survey findings identify key elements associated with enhanced knowledge including dedicated funding for hospitals to target paediatric sepsis quality improvement projects.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07128-2.

Metabolic resuscitation in pediatric sepsis: a narrative review

Sepsis, defined as infection with associated organ dysfunction, accounts for most childhood deaths due to infection globally. Evidence for the optimal support of children with septic shock refractory to the initial sepsis management bundle remains minimal. There is an urgent need for more effective interventions. Administration of hydrocortisone in children with septic shock might fasten shock resolution, and has been shown to dampen the systemic host immune response, augment adrenergic effects, and support the stress response. Ascorbic acid (vitamin C) is one of the most powerful naturally occurring antioxidants and has beneficial effects on multiple pathways which are severely deranged during septic shock. A regimen combining hydrocortisone, ascorbic acid, and thiamine termed "metabolic resuscitation" or "HAT therapy" has been tested in large trials in critically ill adults with sepsis with conflicting results. Available information on intravenous ascorbic acid indicates an excellent safety profile even at very high doses both in adults and children. Given the pharmacological properties and beneficial effects shown both in vitro and in animal studies, and its safety profile, ascorbic acid either as a single therapy or as part of HAT treatment represents a promising candidate for future pediatric sepsis treatments. While pediatric age groups may be more susceptible to ascorbic acid deficiency during sepsis, there is a lack of high-quality trial data on HAT therapy in this age group. A single centre retrospective study identified potential for mortality benefit in children with septic shock, and the results from a randomized controlled pilot trial are being awaited. It is imperative for pediatric research on ascorbic acid and HAT in children with sepsis to critically investigate key questions related to pharmacology, dosing, timing, feasibility, safety, effects on short- and long-term outcomes, and generalisability in view of the global burden of sepsis.

Long-Term Functional Outcomes After Sepsis for Adult and Pediatric Critical Care Patients-Protocol for a Systematic Review

Objective: Sepsis is responsible for a massive burden of disease, with a global estimate of 48.9 million cases resulting in approximately 11 million deaths annually. Survivors of sepsis may also experience long-term impairments that can persist for years after hospital discharge. These cognitive, physical and/or psychosocial deficits may contribute to a lower health related quality of life and represent a significant ongoing burden to the individual, the community and the health care system. We aim to systematically review the available evidence on long-term functional and quality of life outcomes after sepsis in children and adults. Data Sources: Medline, EMBASE, and CINAHL will be searched for eligible studies. Study Selection: Studies of adult and pediatric survivors of sepsis who had required admission to intensive care will be included. A minimum 6 month prospective follow up will be required. Accepted outcomes will be any validated measure of health-related quality of life (HRQoL) or functional deficits, using the Post-Intensive Care Syndrome (PICS) framework of cognitive, physical or psychosocial outcomes. Data Extraction: Data extraction will include information related to study characteristics, population characteristics, clinical criteria and outcomes. Data Synthesis: Studies meeting the inclusion criteria will be presented descriptively separated for pediatric and adult age groups. Meta-analysis will be attempted if sufficient primary data from several studies applying the same tests and outcomes are available. The primary outcome is HRQoL after sepsis; secondary outcomes include the functional status at follow-up. Conclusions: This systematic review will define the long-term impact of sepsis survivorship. The data will contribute to informing patient, clinician and stakeholder decisions and guide further research and resource management.

Early Resuscitation in Paediatric Sepsis Using Inotropes - A Randomised Controlled Pilot Study in the Emergency Department (RESPOND ED): Study Protocol and Analysis Plan

Introduction: Septic shock in children still carries substantial mortality and morbidity. While resuscitation with 40-60 mL/kg intravenous fluid boluses remains a cornerstone of initial resuscitation, an increasing body of evidence indicates potential for harm related to high volume fluid administration. We hypothesize that a protocol on early use of inotropes in children with septic shock is feasible and will lead to less fluid bolus use compared to standard fluid resuscitation. Here, we describe the protocol of the Early Resuscitation in Paediatric Sepsis Using Inotropes - A Randomised Controlled Pilot Study in the Emergency Department (RESPOND ED). Methods and analysis: The RESPOND ED study is an open label randomised controlled, two arm, multicentre pilot study conducted at four specialised paediatric Emergency Departments. Forty children aged between 28 days and 18 years treated for presumed septic shock will be randomized in a 1:1 ratio to early inotropes vs. standard fluid resuscitation. Early inotrope treatment is defined as the commencement of a continuous intravenous adrenaline infusion after 20 mL/kg fluid bolus resuscitation. Standard fluid resuscitation is defined as delivery of 40 to 60 mL/kg fluid bolus resuscitation prior to commencement of inotropes. In addition to feasibility outcomes, survival free of organ dysfunction censored at 28 days will be assessed as the main clinical outcome. The study cohort will be followed up at 28 days, and at 6 months post enrolment to assess quality of life and functional status. Biobanking nested in the study cohort will be performed to enable ancillary biomarker studies. Ethics and dissemination: The trial has ethical clearance (Children's Health Queensland, Brisbane, HREC/18/QCHQ/49168) and is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12619000828123). Enrolment commenced on July 21st, 2019. The primary manuscript will be submitted for publication in a peer-reviewed journal. Trial Registration: Australian and New Zealand Clinical Trials Registry, ACTRN12619000828123.