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Liang C, Pan S, Wu W, Chen F, Zhang C, Zhou C, Gao Y, Ruan X, Quan S, Zhao Q, Pan J. Glucocorticoid therapy for sepsis in the AI era: a survey on current and future approaches. Comput Struct Biotechnol J 2024; 24:292-305. [PMID: 38681133 PMCID: PMC11047203 DOI: 10.1016/j.csbj.2024.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 04/06/2024] [Accepted: 04/07/2024] [Indexed: 05/01/2024] Open
Abstract
Sepsis, a life-threatening medical condition, manifests as new or worsening organ failures due to a dysregulated host response to infection. Many patients with sepsis have manifested a hyperinflammatory phenotype leading to the identification of inflammatory modulation by corticosteroids as a key treatment modality. However, the optimal use of corticosteroids in sepsis treatment remains a contentious subject, necessitating a deeper understanding of their physiological and pharmacological effects. Our study conducts a comprehensive review of randomized controlled trials (RCTs) focusing on traditional corticosteroid treatment in sepsis, alongside an analysis of evolving clinical guidelines. Additionally, we explore the emerging role of artificial intelligence (AI) in medicine, particularly in diagnosing, prognosticating, and treating sepsis. AI's advanced data processing capabilities reveal new avenues for enhancing corticosteroid therapeutic strategies in sepsis. The integration of AI in sepsis treatment has the potential to address existing gaps in knowledge, especially in the application of corticosteroids. Our findings suggest that combining corticosteroid therapy with AI-driven insights could lead to more personalized and effective sepsis treatments. This approach holds promise for improving clinical outcomes and presents a significant advancement in the management of this complex and often fatal condition.
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Affiliation(s)
- Chenglong Liang
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
- Wenzhou Medical University, Wenzhou 325000, China
- School of Nursing, Wenzhou Medical University, Wenzhou 325000, China
| | - Shuo Pan
- Wenzhou Medical University, Wenzhou 325000, China
| | - Wei Wu
- School of Computer Science and Software Engineering, University of Science and Technology Liaoning, Anshan 114051, China
| | - Fanxuan Chen
- Wenzhou Medical University, Wenzhou 325000, China
- School of Biomedical Engineering, School of Ophthalmology and Optometry, Eye Hospital, Wenzhou Medical University, Wenzhou 325000, China
| | - Chengxi Zhang
- School of Materials Science and Engineering, Shandong Jianzhu University, Jinan 250101, China
| | - Chen Zhou
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Yifan Gao
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Xiangyuan Ruan
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Shichao Quan
- Department of Big Data in Health Science, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Qi Zhao
- School of Computer Science and Software Engineering, University of Science and Technology Liaoning, Anshan 114051, China
| | - Jingye Pan
- The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
- Department of Intensive Care Unit, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
- Key Laboratory of Intelligent Treatment and Life Support for Critical Diseases of Zhejiang Province, Wenzhou 325000, China
- Wenzhou Key Laboratory of Critical Care and Artificial Intelligence, Wenzhou 325000, China
- Zhejiang Engineering Research Center for Hospital Emergency and Process Digitization, Wenzhou 325000, China
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Zhan Z, Lian Z, Bai H. Dexamethasone inhibited angiotensin II and its receptors to reduce sepsis-induced lung and kidney injury in rats. PLoS One 2024; 19:e0308557. [PMID: 39178201 PMCID: PMC11343412 DOI: 10.1371/journal.pone.0308557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 07/25/2024] [Indexed: 08/25/2024] Open
Abstract
OBJECTIVES To investigate the effect of dexamethasone (DXM) on acute lung and kidney injury with sepsis and its possible mechanism. METHODS Control (NC), lipopolysaccharide (LPS) and lipopolysaccharide + dexamethasone (LPS+DXM) treated groups were established by random assignment of 72 Wistar rats. The NC rats were injected with physiological saline, while the LPS group was injected with LPS (5 mg/kg) and LPS+DXM group was injected with LPS(5 mg/kg) first and followed by DXM (1 mg/kg). Serum tumor necrosis factor-α (TNF-α) and serum macrophage inflammatory protein 1α (MIP-1α) were measured by ELISA. Lung wet/dry weight ratio, serum creatinine(SCR) and blood urea nitrogen(BUN) were determined at various time points. Hematoxylin Eosin staining (HE) for pathological changes in the lung and kidney. Radioimmunoassay was used to detect the levels of angiotensin II (Ang II) in plasma, lung and kidney tissues. Immunohistochemistry and western blot (WB) were used to detect angiotensin II receptor type 1 (AT1R) protein and angiotensin II receptor type 2 (AT2R) protein in lung and kidney tissues. The level of nitric oxide (NO) in serum, lung and kidney were detected using nitrate reductase method. RESULTS Compared with control group, serum TNF-α, MIP-1α, SCR, BUN, lung W/D, Ang II level in plasma, lung and kidney, lung and kidney AT2R protein, NO level in serum, lung and kidney were significantly elevated(P<0.05) and pathological damage of lung and kidney tissues were showed in LPS group rats (P<0.05), whereas DXM down-regulated the above indexes and alleviate pathological damage of lung and kidney tissues. However, the expression of the lung and kidney AT1R protein was opposite to the above results. CONCLUSIONS Sepsis can cause acute lung and kidney injury and changes RAAS components in circulating, lung and renal. DXM can improve acute lung and kidney injury in septic rats, and the mechanism may be related to the down-regulation of inflammatory factors, AngII, AT2R, NO and up-regulation of AT1R expression by DXM.
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Affiliation(s)
- Zhuqin Zhan
- Department of Nephrology, Children’s Hospital of Fudan University (Xiamen Branch), Xiamen Children’s Hospital, Xiamen, China
| | - Zhulan Lian
- Department of Pediatrics, The First Affiliated Hospital of Xiamen University, Xiamen, China
- Pediatric Key Laboratory of Xiamen, Xiamen, China
- Institute of Pediatrics School of Medicine, Xiamen University, Xiamen, China
| | - Haitao Bai
- Department of Pediatrics, The First Affiliated Hospital of Xiamen University, Xiamen, China
- Pediatric Key Laboratory of Xiamen, Xiamen, China
- Institute of Pediatrics School of Medicine, Xiamen University, Xiamen, China
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Li H, Chen N, Wang W, Ye L, Fan Y, Xu X. Investigating the impact of the inflammatory immune microenvironment and steroids or COX-2 inhibitors usage on immunotherapy in advanced esophageal squamous cell carcinoma (ESCC): a propensity score matched analysis. Clin Transl Oncol 2024:10.1007/s12094-024-03668-1. [PMID: 39177940 DOI: 10.1007/s12094-024-03668-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 08/07/2024] [Indexed: 08/24/2024]
Abstract
PURPOSE The research aimed to evaluate the connection between pre-treatment inflammatory biomarkers and clinical results in advanced esophageal squamous cell carcinoma (ESCC) receiving immune checkpoint inhibitors. MATERIALS AND METHODS Between 2019 and 2022, we analyzed 354 individuals diagnosed with metastatic ESCC who underwent immunotherapy. The study sought to evaluate the impact of specific inflammatory biomarkers (Neutrophil/Lymphocyte Ratio (NLR), C-reactive protein to albumin ratio (CRP/ALB) and Glasgow Prognostic Score (GPS), Cyclooxygenase-2 (COX-2) inhibitors or steroids usage on the effectiveness and survival outcomes of immunotherapy in advanced ESCC. The research utilized Kaplan‒Meier and Cox regression models alongside propensity score matching for analysis. RESULTS The findings revealed that elevated pre-treatment NLR (11.0 vs. 14.6 months, p = 0.021) and CRP/ALB (11.4 vs. 14.6 months, p = 0.022) levels were significantly associated with poorer overall survival (OS) outcomes, while the use of steroids did not show a significant difference in OS (15.5 vs. 15.4 months, p = 0.685) between groups. Similarly, no notable disparity in OS was observed between patients treated withCOX-2 inhibitors and those who were not (13.8 vs. 11.0 months, p = 0.054). CONCLUSION Lower levels of NLR and CRP/ALB prior to treatment were linked to better effectiveness and OS in immunotherapy for advanced ESCC. The study did not identify a significant relationship between OS in patients with esophageal cancer and the use of either steroids or COX-2 inhibitors.
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Affiliation(s)
- Huihui Li
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China
- Postgraduate Training Base Alliance, Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China
| | - Ning Chen
- Department of Medical Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, No. 1 Banshan East Road, Gongshu District, Hangzhou, 310022, Zhejiang, China
- Department of Oncology, The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310053, China
| | - Wenjing Wang
- Department of Medical Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, No. 1 Banshan East Road, Gongshu District, Hangzhou, 310022, Zhejiang, China
- Postgraduate Training Base Alliance, Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China
| | - Lisha Ye
- Department of Medical Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, No. 1 Banshan East Road, Gongshu District, Hangzhou, 310022, Zhejiang, China
- Postgraduate Training Base Alliance, Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China
| | - Yun Fan
- Department of Medical Thoracic Oncology, Zhejiang Cancer Hospital, Hangzhou Institute of Medicine (HIM), Chinese Academy of Sciences, No. 1 Banshan East Road, Gongshu District, Hangzhou, 310022, Zhejiang, China.
- Department of Oncology, The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310053, China.
| | - Xiaoling Xu
- Department of Radiation Oncology, Shanghai Pulmonary Hospital, Tongji University School of Medicine, 507 Zhengmin Road, Yangpu District, Shanghai, 200433, China.
- Postgraduate Training Base Alliance, Wenzhou Medical University, Wenzhou, 325035, Zhejiang, China.
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Lai PC, Lai CH, Lai ECC, Huang YT. Do We Need to Administer Fludrocortisone in Addition to Hydrocortisone in Adult Patients With Septic Shock? An Updated Systematic Review With Bayesian Network Meta-Analysis of Randomized Controlled Trials and an Observational Study With Target Trial Emulation. Crit Care Med 2024; 52:e193-e202. [PMID: 38156911 PMCID: PMC10930378 DOI: 10.1097/ccm.0000000000006161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVES This systematic review and Bayesian network meta-analysis evaluated the efficacy and safety of hydrocortisone combined with fludrocortisone or hydrocortisone alone, compared with placebo in adult patients with septic shock. DATA SOURCES By extending a prior Cochrane review, databases, including PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov , along with other relevant websites, were searched until August 31, 2023. STUDY SELECTION Randomized controlled trials (RCTs) and observational studies using target trial emulation were included. DATA EXTRACTION The primary outcome was short-term mortality with an emphasis on 28- or 30-day mortality as the main measure and in-hospital or ICU mortality as the nearest surrogate of this measure. Three of the most common adverse events, namely, gastroduodenal bleeding, superinfection, and hyperglycemia, were also considered. DATA SYNTHESIS A total of 19 studies involving 95,841 patients were included. Hydrocortisone plus fludrocortisone showed the lowest short-term mortality versus placebo (odds ratio [OR]: 0.79; 95% credible interval [CrI], 0.64-0.99; number needed to treat [NNT]: 21, range: 12-500; low certainty of evidence) in terms of informative priors. The surface under the cumulative ranking curve values for hydrocortisone plus fludrocortisone, hydrocortisone alone, and placebo were 0.9469, 0.4542, and 0.0989, respectively. Consistent results were observed in RCTs alone and those using a daily 200-mg dose of hydrocortisone. Although gastroduodenal bleeding or superinfection showed no clear increase, hyperglycemia risk increased. The ORs were 0.53 for placebo versus hydrocortisone plus fludrocortisone and 0.64 for placebo versus hydrocortisone alone, with very low certainty of evidence. CONCLUSIONS In adults with septic shock, hydrocortisone plus fludrocortisone improved short-term survival with minimal adverse events compared with hydrocortisone alone or placebo. However, these findings are not definitive due to the limited certainty of evidence and wide NNT range. Additional large-scale, placebo-controlled RCTs are needed to provide conclusive evidence.
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Affiliation(s)
- Pei-Chun Lai
- Education Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chao-Han Lai
- Education Center, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Pediatrics, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Biochemistry and Molecular Biology, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Department of Biostatistics, Vanderbilt University Medical Centre, Nashville, TN
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Edward Chia-Cheng Lai
- School of Pharmacy, Institute of Clinical Pharmacy and Pharmaceutical Sciences, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yen-Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
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Qutob RA, Alaryni A, Alghamdi A, Alsolamy EN, Al Harbi K, Alammari Y, Alanazi AM, Ababtain AA, Hakami OA, Aleid ZA, Alhaqbani AS, Alshehri RA, Almoshiqeh BA, Alhejazi AQ. A Cross-Sectional Survey Study on the Diagnosis and Management of Critical Illness-Induced Corticosteroid Insufficiency in Saudi Arabia. Cureus 2023; 15:e49982. [PMID: 38179369 PMCID: PMC10766206 DOI: 10.7759/cureus.49982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 01/06/2024] Open
Abstract
Background The presence of critical illness-induced corticosteroid insufficiency (CIRCI) is correlated with elevated concentrations of circulating biomarkers associated with inflammation and coagulation in multiple domains. The management of adrenal insufficiency remains a topic of ongoing debate and disagreement among endocrinologists and intensivists. This study aimed to assess the extent of understanding regarding CIRCI among endocrinologists and intensivists who are actively practicing in Saudi Arabia. Methods This is an online cross-sectional survey study that was conducted between June and August 2023 to assess knowledge of CIRCI among endocrinologists and intensivists working in Saudi Arabia. The questionnaire tool for this study was constructed based on a previous literature review. Binary logistic regression analysis was used to define factors that affect participants' knowledge of CIRCI. Results A total of 76 physicians were involved in this study. Around 32.9% (n= 25) of the participants described CIRCI correctly as an impairment of the hypothalamic-pituitary axis during critical illness. Around 35.5% (n=27) of the participants identified that widespread use of corticosteroids in critically ill patients prompted the need to revisit the concept, diagnosis, and management of CIRCI, and a similar proportion of the participants (35.5%) (n=27) identified that the role of corticosteroids in the management of CIRCI in critically ill patients may be beneficial in selected cases. Around 42.1% (n=32) of the participants identified that CIRCI is specific to critically ill patients while AI can occur in any individual. Around 17.1% (n=13) of the participants confirmed that there is no task force agreement on whether corticosteroids should be used in adult patients with sepsis but without shock. The mean knowledge score of the study participants was 3.6 (sd: 2.2) out of 10, which demonstrates a weak level of knowledge of CIRCI (36.0%). Binary logistic regression analysis identified that physicians from the southern and western regions were less likely to be knowledgeable of CIRCI compared to physicians from the central region (p< 0.05). Conclusion The study revealed that the level of familiarity with CIRCI among endocrinologists and intensivists in Saudi Arabia fell short of the desired benchmark. Clinicians may opt to utilize delta cortisol levels following cosyntropin administration and random plasma cortisol levels as diagnostic measures for CIRCI, instead of relying on plasma-free cortisol or salivary cortisol levels in conjunction with plasma total cortisol. Adherence to customized treatment protocols is crucial to attain the most favorable results for patients.
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Affiliation(s)
- Rayan Abubakker Qutob
- Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Abdullah Alaryni
- Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Abdullah Alghamdi
- Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Eysa N Alsolamy
- Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Khalid Al Harbi
- Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Yousef Alammari
- Department of Internal Medicine, College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | | | - Abdalmohsen A Ababtain
- Department of Critical Care Medicine, King Abdullah bin Abdulaziz University Hospital at Princess Nourah bint Abdulrahman University, Riyadh, SAU
| | - Osamah Ahmad Hakami
- Department of Internal Medicine, King Abdullah Medical City in Holy Capital (KAMC-HC), Makkah, SAU
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Wildi K, Livingstone S, Ainola C, Colombo SM, Heinsar S, Sato N, Sato K, Bouquet M, Wilson E, Abbate G, Passmore M, Hyslop K, Liu K, Wang X, Palmieri C, See Hoe LE, Jung JS, Ki K, Mueller C, Laffey J, Pelosi P, Li Bassi G, Suen J, Fraser J. Application of anti-inflammatory treatment in two different ovine Acute Respiratory Distress Syndrome injury models: a preclinical randomized intervention study. Sci Rep 2023; 13:17986. [PMID: 37863994 PMCID: PMC10589361 DOI: 10.1038/s41598-023-45081-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/16/2023] [Indexed: 10/22/2023] Open
Abstract
Whilst the presence of 2 subphenotypes among the heterogenous Acute Respiratory Distress Syndrome (ARDS) population is becoming clinically accepted, subphenotype-specific treatment efficacy has yet to be prospectively tested. We investigated anti-inflammatory treatment in different ARDS models in sheep, previously shown similarities to human ARDS subphenotypes, in a preclinical, randomized, blinded study. Thirty anesthetized sheep were studied up to 48 h and randomized into: (a) OA: oleic acid (n = 15) and (b) OA-LPS: oleic acid and subsequent lipopolysaccharide (n = 15) to achieve a PaO2/FiO2 ratio of < 150 mmHg. Then, animals were randomly allocated to receive treatment with methylprednisolone or erythromycin or none. Assessed outcomes were oxygenation, pulmonary mechanics, hemodynamics and survival. All animals reached ARDS. Treatment with methylprednisolone, but not erythromycin, provided the highest therapeutic benefit in Ph2 animals, leading to a significant increase in PaO2/FiO2 ratio by reducing pulmonary edema, dead space ventilation and shunt fraction. Animals treated with methylprednisolone displayed a higher survival up to 48 h than all others. In animals treated with erythromycin, there was no treatment benefit regarding assessed physiological parameters and survival in both phenotypes. Treatment with methylprednisolone improves oxygenation and survival, more so in ovine phenotype 2 which resembles the human hyperinflammatory subphenotype.
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Affiliation(s)
- Karin Wildi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.
- The University of Queensland, Brisbane, Australia.
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland.
| | - Samantha Livingstone
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - Carmen Ainola
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - Sebastiano Maria Colombo
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Department of Anaesthesia and Intensive Care Medicine, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Silver Heinsar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - Noriko Sato
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - Mahé Bouquet
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - Emily Wilson
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - Gabriella Abbate
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - Margaret Passmore
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - Kieran Hyslop
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - Keibun Liu
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
| | - Xiaomeng Wang
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Chiara Palmieri
- The University of Queensland, School of Veterinary Science, Gatton, Australia
| | - Louise E See Hoe
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - Jae-Seung Jung
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- Department of Thoracic and Cardiovascular Surgery, College of Medicine, Korea University, Seoul, Republic of Korea
| | - Katrina Ki
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - Christian Mueller
- Cardiovascular Research Institute Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - John Laffey
- Galway University Hospitals, University of Galway, Galway, Ireland
| | - Paolo Pelosi
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Gianluigi Li Bassi
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
- Queensland University of Technology, Brisbane, Australia
- Uniting Care Hospitals, St Andrews War Memorial and The Wesley Intensive Care Units, Brisbane, Australia
| | - Jacky Suen
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
| | - John Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia
- The University of Queensland, Brisbane, Australia
- Uniting Care Hospitals, St Andrews War Memorial and The Wesley Intensive Care Units, Brisbane, Australia
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Zhang L, Gu WJ, Huang T, Lyu J, Yin H. The Timing of Initiating Hydrocortisone and Long-term Mortality in Septic Shock. Anesth Analg 2023; 137:850-858. [PMID: 37171987 DOI: 10.1213/ane.0000000000006516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
BACKGROUND Previous studies on the association between the timing of corticosteroid administration and mortality in septic shock focused only on short-term mortality and produced conflicting results. We performed a retrospective review of a large administrative database of intensive care unit (ICU) patients to evaluate the association between the timing of hydrocortisone initiation and short- and long-term mortality in septic shock. We hypothesized that a longer duration between the first vasopressor use for sepsis and steroid initiation was associated with increased mortality. METHODS Data were extracted from the Medical Information Mart in the Intensive Care-IV database. We included adults who met Sepsis-3 definition for septic shock and received hydrocortisone. The exposure of interest was the time in hours from vasopressor use to hydrocortisone initiation (>12 as late and ≤12 as early). The primary outcome was 1-year mortality. Secondary outcomes included 28-day mortality, 90-day mortality, in-hospital mortality, and length of hospital stay. Cox proportional hazard models were used to estimate the association between exposure and mortality. Competing risk regression models were used to evaluate the association between exposure and length of hospital stay. RESULTS A total of 844 patients were included in this cohort: 553 in the early group and 291 in the late group. The median time to hydrocortisone initiation was 7 hours (interquartile range, 2.0-19.0 hours). After multivariable Cox proportional hazard analysis, we found that hydrocortisone initiation >12 hours after vasopressor use was associated with increased 1-year mortality when compared with initiation <12 hours (adjusted hazard ratio, 1.39; 95% confidence interval, 1.13-1.71; P = .002, E-value = 2.13). Hydrocortisone initiation >12 hours was also associated with increased 28-day, 90-day, and in-hospital mortality and prolonged length of hospital stay. CONCLUSIONS In patients with septic shock, initiating hydrocortisone >12 hours after vasopressor use was associated with an increased risk of both short-term and long-term mortality, and a prolonged length of hospital stay.
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Affiliation(s)
- Luming Zhang
- From the Departments of Intensive Care Unit
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Wan-Jie Gu
- From the Departments of Intensive Care Unit
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Tao Huang
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jun Lyu
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Haiyan Yin
- Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
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Garduno A, Cusack R, Leone M, Einav S, Martin-Loeches I. Multi-Omics Endotypes in ICU Sepsis-Induced Immunosuppression. Microorganisms 2023; 11:1119. [PMID: 37317092 DOI: 10.3390/microorganisms11051119] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/03/2023] [Accepted: 04/21/2023] [Indexed: 06/16/2023] Open
Abstract
It is evident that the admission of some patients with sepsis and septic shock to hospitals is occurring late in their illness, which has contributed to the increase in poor outcomes and high fatalities worldwide across age groups. The current diagnostic and monitoring procedure relies on an inaccurate and often delayed identification by the clinician, who then decides the treatment upon interaction with the patient. Initiation of sepsis is accompanied by immune system paralysis following "cytokine storm". The unique immunological response of each patient is important to define in terms of subtyping for therapy. The immune system becomes activated in sepsis to produce interleukins, and endothelial cells express higher levels of adhesion molecules. The proportions of circulating immune cells change, reducing regulatory cells and increasing memory cells and killer cells, having long-term effects on the phenotype of CD8 T cells, HLA-DR, and dysregulation of microRNA. The current narrative review seeks to highlight the potential application of multi-omics data integration and immunological profiling at the single-cell level to define endotypes in sepsis and septic shock. The review will consider the parallels and immunoregulatory axis between cancer and immunosuppression, sepsis-induced cardiomyopathy, and endothelial damage. Second, the added value of transcriptomic-driven endotypes will be assessed through inferring regulatory interactions in recent clinical trials and studies reporting gene modular features that inform continuous metrics measuring clinical response in ICU, which can support the use of immunomodulating agents.
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Affiliation(s)
- Alexis Garduno
- Department of Clinical Medicine, Trinity College, University of Dublin, D02 PN40 Dublin, Ireland
| | - Rachael Cusack
- Department of Intensive Care Medicine, St. James's Hospital, James's Street, D08 NHY1 Dublin, Ireland
| | - Marc Leone
- Department of Anesthesia, Intensive Care and Trauma Center, Nord University Hospital, Aix Marseille University, APHM, 13015 Marseille, France
| | - Sharon Einav
- General Intensive Care Unit, Shaare Zedek Medical Center, Jerusalem 23456, Israel
- Faculty of Medicine, Hebrew University, Jerusalem 23456, Israel
| | - Ignacio Martin-Loeches
- Department of Clinical Medicine, Trinity College, University of Dublin, D02 PN40 Dublin, Ireland
- Department of Intensive Care Medicine, St. James's Hospital, James's Street, D08 NHY1 Dublin, Ireland
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9
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Roquilly A, Francois B, Huet O, Launey Y, Lasocki S, Weiss E, Petrier M, Hourmant Y, Bouras M, Lakhal K, Le Bel C, Flattres Duchaussoy D, Fernández-Barat L, Ceccato A, Flet L, Jobert A, Poschmann J, Sebille V, Feuillet F, Koulenti D, Torres A. Interferon gamma-1b for the prevention of hospital-acquired pneumonia in critically ill patients: a phase 2, placebo-controlled randomized clinical trial. Intensive Care Med 2023; 49:530-544. [PMID: 37072597 PMCID: PMC10112824 DOI: 10.1007/s00134-023-07065-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/31/2023] [Indexed: 04/20/2023]
Abstract
PURPOSE We aimed to determine whether interferon gamma-1b prevents hospital-acquired pneumonia in mechanically ventilated patients. METHODS In a multicenter, placebo-controlled, randomized trial conducted in 11 European hospitals, we randomly assigned critically ill adults, with one or more acute organ failures, under mechanical ventilation to receive interferon gamma-1b (100 µg every 48 h from day 1 to 9) or placebo (following the same regimen). The primary outcome was a composite of hospital-acquired pneumonia or all-cause mortality on day 28. The planned sample size was 200 with interim safety analyses after enrolling 50 and 100 patients. RESULTS The study was discontinued after the second safety analysis for potential harm with interferon gamma-1b, and the follow-up was completed in June 2022. Among 109 randomized patients (median age, 57 (41-66) years; 37 (33.9%) women; all included in France), 108 (99%) completed the trial. Twenty-eight days after inclusion, 26 of 55 participants (47.3%) in the interferon-gamma group and 16 of 53 (30.2%) in the placebo group had hospital-acquired pneumonia or died (adjusted hazard ratio (HR) 1.76, 95% confidence interval (CI) 0.94-3.29; P = 0.08). Serious adverse events were reported in 24 of 55 participants (43.6%) in the interferon-gamma group and 17 of 54 (31.5%) in the placebo group (P = 0.19). In an exploratory analysis, we found that hospital-acquired pneumonia developed in a subgroup of patients with decreased CCL17 response to interferon-gamma treatment. CONCLUSIONS Among mechanically ventilated patients with acute organ failure, treatment with interferon gamma-1b compared with placebo did not significantly reduce the incidence of hospital-acquired pneumonia or death on day 28. Furthermore, the trial was discontinued early due to safety concerns about interferon gamma-1b treatment.
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Affiliation(s)
- Antoine Roquilly
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 1413, 44000, Nantes, France.
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44000, Nantes, France.
| | - Bruno Francois
- ICU Department and Inserm CIC 1435 & UMR 1092, University Hospital of Limoges, Limoges, France
| | - Olivier Huet
- Département d'anesthésie réanimation et medecine peri-operatoire, CHRU de Brest, Université de Bretagne Occidentale, 29000, Brest, France
| | - Yoann Launey
- Department of Anaesthesia, Critical Care and Perioperative Medicine, Univ Rennes, CHU Rennes, 35000, Rennes, France
| | - Sigismond Lasocki
- Department of Anesthesiology and Critical Care Medicine, University Hospital of Angers, 49000, Angers, France
| | - Emmanuel Weiss
- Department of Anesthesiology and Critical Care, Université Paris Cité, INSERM UMR_S1149, and AP-HP Nord, Hôpital Beaujon, Clichy, France
| | - Melanie Petrier
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44000, Nantes, France
| | - Yannick Hourmant
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 1413, 44000, Nantes, France
| | - Marwan Bouras
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 1413, 44000, Nantes, France
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44000, Nantes, France
| | - Karim Lakhal
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 1413, 44000, Nantes, France
| | - Cecilia Le Bel
- Nantes Université, CHU Nantes, INSERM, Anesthesie Réanimation, CIC 1413, 44000, Nantes, France
| | | | - Laia Fernández-Barat
- CELLEX research laboratories, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Servei de Pneumologia, Hospital Clinic, Barcelona, Universitat de Barcelona, CIBERES, Icrea, IDIBAPS, Barcelona, Spain
| | - Adrian Ceccato
- Servei de Pneumologia, Hospital Clinic, Barcelona, Universitat de Barcelona, CIBERES, Icrea, IDIBAPS, Barcelona, Spain
| | - Laurent Flet
- Nantes Université, CHU Nantes, Pharmacie, 44000, Nantes, France
| | - Alexandra Jobert
- Nantes Université, CHU Nantes, DRI, Département promotion, cellule vigilances recherche, Nantes, France
- Nantes Université, Université de Tours, CHU Nantes, CHU Tours, INSERM, SPHERE U1246, 44000, Nantes, France
| | - Jeremie Poschmann
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, 44000, Nantes, France
| | - Veronique Sebille
- Nantes Université, CHU Nantes, DRI, Plateforme de Méthodologie et de Biostatistique, 44000, Nantes, France
- Nantes Université, Université de Tours, CHU Nantes, CHU Tours, INSERM, SPHERE U1246, 44000, Nantes, France
| | - Fanny Feuillet
- Nantes Université, CHU Nantes, DRI, Plateforme de Méthodologie et de Biostatistique, 44000, Nantes, France
- Nantes Université, Université de Tours, CHU Nantes, CHU Tours, INSERM, SPHERE U1246, 44000, Nantes, France
| | - Despoina Koulenti
- 2nd Critical Care Department, Attikon University Hospital, Athens, Greece
- Faculty of Medicine, UQ Centre for Clinical Research, The University of Queensland, Brisbane, Australia
| | - Antoni Torres
- CELLEX research laboratories, CibeRes (Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, 06/06/0028), Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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10
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Teja B, Bosch NA, Walkey AJ. How We Escalate Vasopressor and Corticosteroid Therapy in Patients With Septic Shock. Chest 2023; 163:567-574. [PMID: 36162481 DOI: 10.1016/j.chest.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/21/2022] Open
Abstract
Septic shock is defined by the need for vasopressor agents to correct hypotension and lactic acidosis resulting from infection, with 30%-40% case fatality rates. The care of patients with worsening septic shock involves multiple treatment decisions involving vasopressor choices and adjunctive treatments. In this edition of "How I Do It", we provide a case-based discussion of common clinical decisions regarding choice of first-line vasopressor, BP targets, route of vasopressor delivery, use of secondary vasopressors, and adjunctive medications. We also consider diagnostic approaches, treatment, and monitoring strategies for the patient with worsening shock, as well as approaches to difficult weaning of vasopressors.
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Affiliation(s)
- Bijan Teja
- Interdepartmental Division of Critical Care Medicine, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, St. Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
| | - Nicholas A Bosch
- The Pulmonary Center, Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University, Boston, MA
| | - Allan J Walkey
- The Pulmonary Center, Section of Pulmonary, Allergy, Sleep, and Critical Care Medicine, Department of Medicine, Boston University, Boston, MA.
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11
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Lee JH, Meyer EJ, Nenke MA, Falhammar H, Torpy DJ. Corticosteroid-binding globulin (CBG): spatiotemporal distribution of cortisol in sepsis. Trends Endocrinol Metab 2023; 34:181-190. [PMID: 36681594 DOI: 10.1016/j.tem.2023.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 01/02/2023] [Indexed: 01/22/2023]
Abstract
Corticosteroid-binding globulin (CBG) is a 50-60 kDa circulating glycoprotein with high affinity for cortisol. CBG is adapted for sepsis; its cortisol binding is reduced reversibly by pyrexia and acidaemia, and reduced irreversibly by neutrophil elastase (NE) cleavage, converting high cortisol-binding affinity CBG to a low affinity form. These characteristics allow for the targeted delivery of immunomodulatory cortisol to tissues at the time and body site where cortisol is required in sepsis and septic shock. In addition, high titer inflammatory cytokines in sepsis suppress CBG hepatic synthesis, increasing the serum free cortisol fraction. Recent clinical studies have highlighted the importance of CBG in septic shock, with CBG deficiency independently associated with mortality.
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Affiliation(s)
- Jessica H Lee
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Emily J Meyer
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia; Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Department of Endocrine and Diabetes, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Marne A Nenke
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia; Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia; Department of Endocrine and Diabetes, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden.
| | - David J Torpy
- Department of Medicine, University of Adelaide, Adelaide, South Australia, Australia; Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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12
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Bouras M, Asehnoune K, Roquilly A. Immune modulation after traumatic brain injury. Front Med (Lausanne) 2022; 9:995044. [PMID: 36530909 PMCID: PMC9751027 DOI: 10.3389/fmed.2022.995044] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/14/2022] [Indexed: 07/20/2023] Open
Abstract
Traumatic brain injury (TBI) induces instant activation of innate immunity in brain tissue, followed by a systematization of the inflammatory response. The subsequent response, evolved to limit an overwhelming systemic inflammatory response and to induce healing, involves the autonomic nervous system, hormonal systems, and the regulation of immune cells. This physiological response induces an immunosuppression and tolerance state that promotes to the occurrence of secondary infections. This review describes the immunological consequences of TBI and highlights potential novel therapeutic approaches using immune modulation to restore homeostasis between the nervous system and innate immunity.
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Affiliation(s)
- Marwan Bouras
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
- CHU Nantes, INSERM, Nantes Université, Anesthesie Reanimation, CIC 1413, Nantes, France
| | - Karim Asehnoune
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
- CHU Nantes, INSERM, Nantes Université, Anesthesie Reanimation, CIC 1413, Nantes, France
| | - Antoine Roquilly
- Nantes Université, CHU Nantes, INSERM, Center for Research in Transplantation and Translational Immunology, UMR 1064, Nantes, France
- CHU Nantes, INSERM, Nantes Université, Anesthesie Reanimation, CIC 1413, Nantes, France
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13
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Kuo KC, Chen CH, Wang CJ, Wu JC, Chung HP, Chen YT, Tang YH, Chang WK, Lin CY, Wu CL. Clinical benefits of inhaled ciclesonide for hospitalized patients with COVID-19 infection: a retrospective study. BMC Pulm Med 2022; 22:368. [PMID: 36171597 PMCID: PMC9517967 DOI: 10.1186/s12890-022-02168-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 09/20/2022] [Indexed: 01/08/2023] Open
Abstract
Background The successful management of patients infected with coronavirus disease 2019 (COVID-19) with inhaled ciclesonide has been reported, however few studies have investigated its application among hospitalized patients. Methods This retrospective cohort study enrolled all adult patients admitted to our hospital with confirmed COVID-19 infection from May to June 2021. Critical patients who received mechanical ventilation within 24 h after admission and those who started ciclesonide more than 14 days after symptom onset were excluded. The in-hospital mortality rate was compared between those who did and did not receive inhaled ciclesonide. Results A total of 269 patients were enrolled, of whom 184 received inhaled ciclesonide and 85 did not. The use of ciclesonide was associated with lower in-hospital mortality (7.6% vs. 23.5%, p = 0.0003) and a trend of shorter hospital stay (12.0 (10.0–18.0) days vs. 13.0 (10.0–25.3) days, p = 0.0577). In subgroup analysis, the use of inhaled ciclesonide significantly reduced mortality in the patients with severe COVID-19 infection (6.8% vs. 50.0%, p < 0.0001) and in those with a high risk of mortality (16.4% vs. 43.2%, p = 0.0037). The use of inhaled ciclesonide also reduced the likelihood of receiving mechanical ventilation in the patients with severe COVID-19 infection. After multivariate analysis, inhaled ciclesonide remained positively correlated with a lower risk of in-hospital mortality (odds ratio: 0.2724, 95% confidence interval: 0.087–0.8763, p = 0.0291). Conclusions The use of inhaled ciclesonide in hospitalized patients with COVID-19 infection can reduce in-hospital mortality. Further randomized studies in patients with moderate to severe COVID-19 infection are urgently needed. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02168-8.
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Affiliation(s)
- Kuan-Chih Kuo
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, No. 45, Minsheng Rd., Tamshui District, New Taipei City, 25160, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chao-Hsien Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, No. 45, Minsheng Rd., Tamshui District, New Taipei City, 25160, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chieh-Jen Wang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, No. 45, Minsheng Rd., Tamshui District, New Taipei City, 25160, Taiwan. .,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.
| | - Jou-Chun Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, No. 45, Minsheng Rd., Tamshui District, New Taipei City, 25160, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Hsin-Pei Chung
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, No. 45, Minsheng Rd., Tamshui District, New Taipei City, 25160, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Yen-Ting Chen
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, No. 45, Minsheng Rd., Tamshui District, New Taipei City, 25160, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Yen-Hsiang Tang
- Department of Medicine, MacKay Medical College, New Taipei City, Taiwan.,Department of Critical Care Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Wen-Kuei Chang
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, No. 45, Minsheng Rd., Tamshui District, New Taipei City, 25160, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chang-Yi Lin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, No. 45, Minsheng Rd., Tamshui District, New Taipei City, 25160, Taiwan.,Department of Medicine, MacKay Medical College, New Taipei City, Taiwan
| | - Chien-Liang Wu
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MacKay Memorial Hospital, No. 45, Minsheng Rd., Tamshui District, New Taipei City, 25160, Taiwan
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14
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Bagate F, Coppens A, Masi P, de Prost N, Carteaux G, Razazi K, Mekontso Dessap A. Cardiac and vascular effects of low-dose steroids during the early phase of septic shock: An echocardiographic study. Front Cardiovasc Med 2022; 9:948231. [PMID: 36225952 PMCID: PMC9549363 DOI: 10.3389/fcvm.2022.948231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 09/06/2022] [Indexed: 01/25/2023] Open
Abstract
BackgroundLow-dose steroids are known to increase arterial pressure during septic shock through restoration of vasopressor response to norepinephrine. However, their effects on cardiac performance and ventriculo-arterial coupling (VAC) have never been scrutinized during human septic shock. The aim of this study was to perform a comprehensive description of the cardiovascular effects of low-dose steroids using modern echocardiographic tools (including speckle tracking imaging).MethodsThis prospective study was conducted in the intensive care unit (ICU) of a university hospital in France. Consecutive adult patients admitted for septic shock and requiring low-dose steroid therapy were prospectively enrolled within 24 h of septic shock onset. We recorded hemodynamic and echocardiographic data to explore left ventricle (LV) contractility, loading conditions and VAC just before the initiation of low-dose steroids (50 mg intravenous hydrocortisone plus 50 μg enteral fludrocortisone) and 2–4 h after.ResultsFifty patients [65 (55–73) years; 33 men] were enrolled. Arterial pressure, heart rate, almost all LV afterload parameters, and most cardiac contractility parameters significantly improved after steroids. VAC improved with steroid therapy and less patients had uncoupled VAC (> 1.36) after (24%) than before (44%) treatment.ConclusionIn this comprehensive echocardiographic study, we confirmed an improvement of LV afterload after initiation of low-dose steroids. We also observed an increase in LV contractility with improved cardiovascular efficiency (less uncoupling with decreased VAC).
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Affiliation(s)
- François Bagate
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de Recherche Clinique CARMAS, Créteil, France
- *Correspondence: François Bagate,
| | - Alexandre Coppens
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
| | - Paul Masi
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de Recherche Clinique CARMAS, Créteil, France
| | - Nicolas de Prost
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de Recherche Clinique CARMAS, Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Guillaume Carteaux
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de Recherche Clinique CARMAS, Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, Créteil, France
| | - Keyvan Razazi
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de Recherche Clinique CARMAS, Créteil, France
| | - Armand Mekontso Dessap
- AP-HP, CHU Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de Recherche Clinique CARMAS, Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, Créteil, France
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15
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Kamps NN, Banks R, Reeder RW, Berg RA, Newth CJ, Pollack MM, Meert KL, Carcillo JA, Mourani PM, Sorenson S, Varni JW, Cengiz P, Zimmerman JJ. The Association of Early Corticosteroid Therapy With Clinical and Health-Related Quality of Life Outcomes in Children With Septic Shock. Pediatr Crit Care Med 2022; 23:687-697. [PMID: 35695852 PMCID: PMC9444900 DOI: 10.1097/pcc.0000000000003009] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Corticosteroids are commonly used in the treatment of pediatric septic shock without clear evidence of the potential benefits or risks. This study examined the association of early corticosteroid therapy with patient-centered clinically meaningful outcomes. DESIGN Subsequent cohort analysis of data derived from the prospective Life After Pediatric Sepsis Evaluation (LAPSE) investigation. Outcomes among patients receiving hydrocortisone or methylprednisolone on study day 0 or 1 were compared with those who did not use a propensity score-weighted analysis that controlled for age, sex, study site, and measures of first-day illness severity. SETTING Twelve academic PICUs in the United States. PATIENTS Children with community-acquired septic shock 1 month to 18 years old enrolled in LAPSE, 2013-2017. Exclusion criteria included a history of chronic corticosteroid administration. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Among children enrolled in LAPSE, 352 of 392 met analysis inclusion criteria, and 155 of 352 (44%) received early corticosteroid therapy. After weighting corticosteroid therapy administration propensity across potentially confounding baseline characteristics, differences in outcomes associated with treatment were not statistically significant (adjusted effect or odds ratio [95% CI]): vasoactive-inotropic support duration (-0.37 d [-1.47 to 0.72]; p = 0.503), short-term survival without new morbidity (1.37 [0.83-2.28]; p = 0.218), new morbidity among month-1 survivors (0.70 [0.39-1.23]; p = 0.218), and persistent severe deterioration of health-related quality of life or mortality at month 1 (0.70 [0.40-1.23]; p = 0.212). CONCLUSIONS This study examined the association of early corticosteroid therapy with mortality and morbidity among children encountering septic shock. After adjusting for variables with the potential to confound the relationship between early corticosteroid administration and clinically meaningful end points, there was no improvement in outcomes associated with this therapy. Results from this propensity analysis provide additional justification for equipoise regarding corticosteroid therapy for pediatric septic shock and ascertain the need for a well-designed clinical trial to examine benefit/risk for this intervention.
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Affiliation(s)
- Nicole N Kamps
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, American Family Children's Hospital, University of Wisconsin, Madison, WI
| | - Russell Banks
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Ron W Reeder
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Robert A Berg
- Department of Anesthesiology and Critical Care Medicine Children's Hospital of Philadelphia, Philadelphia, PA
| | - Christopher J Newth
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA
| | - Murray M Pollack
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's National Hospital, Washington, DC
| | - Kathleen L Meert
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI
- Department of Pediatrics, Central Michigan University, Mt. Pleasant, MI
| | - Joseph A Carcillo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Peter M Mourani
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Samuel Sorenson
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - James W Varni
- Department of Pediatrics, Texas A&M University, College Station, TX
| | - Pelin Cengiz
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, American Family Children's Hospital, University of Wisconsin, Madison, WI
| | - Jerry J Zimmerman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, Seattle Children's Research Institute, University of Washington School of Medicine, Seattle, WA
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16
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Ishiyama K, Oguma J, Kubo K, Kanematsu K, Fujii Y, Kurita D, Daiko H. Does Preoperative Corticosteroid Administration Improve the Short-Term Outcome of Minimally Invasive Esophagectomy for Esophageal Cancer? A Propensity Score-Matched Analysis. Ann Surg Oncol 2022; 29:6886-6893. [DOI: 10.1245/s10434-022-11821-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 03/23/2022] [Indexed: 11/18/2022]
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17
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Mentzelopoulos SD, Pappa E, Malachias S, Vrettou CS, Giannopoulos A, Karlis G, Adamos G, Pantazopoulos I, Megalou A, Louvaris Z, Karavana V, Aggelopoulos E, Agaliotis G, Papadaki M, Baladima A, Lasithiotaki I, Lagiou F, Temperikidis P, Louka A, Asimakos A, Kougias M, Makris D, Zakynthinos E, Xintara M, Papadonta ME, Koutsothymiou A, Zakynthinos SG, Ischaki E. Physiologic effects of stress dose corticosteroids in in-hospital cardiac arrest (CORTICA): A randomized clinical trial. Resusc Plus 2022; 10:100252. [PMID: 35652112 PMCID: PMC9149191 DOI: 10.1016/j.resplu.2022.100252] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 05/09/2022] [Accepted: 05/11/2022] [Indexed: 01/15/2023] Open
Abstract
Aim Postresuscitation hemodynamics are associated with hospital mortality/functional outcome. We sought to determine whether low-dose steroids started during and continued after cardiopulmonary resuscitation (CPR) affect postresuscitation hemodynamics and other physiological variables in vasopressor-requiring, in-hospital cardiac arrest. Methods We conducted a two-center, randomized, double-blind trial of patients with adrenaline (epinephrine)-requiring cardiac arrest. Patients were randomized to receive either methylprednisolone 40 mg (steroids group) or normal saline-placebo (control group) during the first CPR cycle post-enrollment. Postresuscitation shock was treated with hydrocortisone 240 mg daily for 7 days maximum and gradual taper (steroids group), or saline-placebo (control group). Primary outcomes were arterial pressure and central-venous oxygen saturation (ScvO2) within 72 hours post-ROSC. Results Eighty nine of 98 controls and 80 of 86 steroids group patients with ROSC were treated as randomized. Primary outcome data were collected from 100 patients with ROSC (control, n = 54; steroids, n = 46). In intention-to-treat mixed-model analyses, there was no significant effect of group on arterial pressure, marginal mean (95% confidence interval) for mean arterial pressure, steroids vs. control: 74 (68–80) vs. 72 (66–79) mmHg] and ScvO2 [71 (68–75)% vs. 69 (65–73)%], cardiac index [2.8 (2.5–3.1) vs. 2.9 (2.5–3.2) L/min/m2], and serum cytokine concentrations [e.g. interleukin-6, 89.1 (42.8–133.9) vs. 75.7 (52.1–152.3) pg/mL] determined within 72 hours post-ROSC (P = 0.12–0.86). There was no between-group difference in body temperature, echocardiographic variables, prefrontal blood flow index/cerebral autoregulation, organ failure-free days, and hazard for poor in-hospital/functional outcome, and adverse events (P = 0.08–>0.99). Conclusions Our results do not support the use of low-dose corticosteroids in in-hospital cardiac arrest. Trial Registration:ClinicalTrials.gov number: NCT02790788 (https://www.clinicaltrials.gov).
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Affiliation(s)
- Spyros D. Mentzelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
- Corresponding author at: Department of Intensive Care Medicine, Evaggelismos General Hospital, 45-47 Ipsilandou Street, GR-10675 Athens, Greece.
| | - Evanthia Pappa
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Sotirios Malachias
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Charikleia S. Vrettou
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Achilleas Giannopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - George Karlis
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - George Adamos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Ioannis Pantazopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Aikaterini Megalou
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Zafeiris Louvaris
- Faculty of Movement and Rehabilitation Sciences, Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Belgium
- University Hospitals Leuven, Department of Intensive Care Medicine, Leuven, Belgium
| | - Vassiliki Karavana
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Epameinondas Aggelopoulos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Gerasimos Agaliotis
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Marielen Papadaki
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Aggeliki Baladima
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | | | - Fotini Lagiou
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Prodromos Temperikidis
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Aggeliki Louka
- Department of Anesthesiology, Evaggelismos General Hospital, Athens, Greece
| | - Andreas Asimakos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Marios Kougias
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Demosthenes Makris
- Department of Intensive Care Medicine, University of Thessaly Medical School, Larissa, Greece
| | | | - Maria Xintara
- Department of Intensive Care Medicine, University of Thessaly Medical School, Larissa, Greece
| | | | | | - Spyros G. Zakynthinos
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
| | - Eleni Ischaki
- First Department of Intensive Care Medicine, National and Kapodistrian University of Athens Medical School, Evaggelismos General Hospital, Athens, Greece
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Skirecki T, Adamik B, Frostell C, Pasławska U, Zieliński S, Glatzel-Plucińska N, Olbromski M, Dzięgiel P, Gozdzik W. Compartment-Specific Differences in the Activation of Monocyte Subpopulations Are Not Affected by Nitric Oxide and Glucocorticoid Treatment in a Model of Resuscitated Porcine Endotoxemic Shock. J Clin Med 2022; 11:2641. [PMID: 35566768 PMCID: PMC9100570 DOI: 10.3390/jcm11092641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 11/16/2022] Open
Abstract
Inhaled nitric oxide (iNO) remains one of the treatment modalities in shock, and in addition to its vasoactive properties, iNO exerts immunomodulatory effects. We used a porcine model of endotoxemia with shock resuscitation (control) and additional treatment with iNO and a steroid (treatment group). After 20 h, bone marrow (BM), peripheral blood (PB), and bronchoalveolar lavage fluid (BALF) were collected to analyze the immunophenotype and mitochondrial membrane potential (Δφ) in three subsets of monocytes. In both groups, SLA-DR expression decreased twofold on the circulating CD14+CD163+ and CD14−CD163+ monocytes, while it did not change on the CD14+CD163+. Δφ increased only in the CD14−CD163+ subpopulation (0.8 vs. 2.0, p < 0.001). The analysis of compartment-specific alterations showed that nearly 100% of BALF CD14+CD163+ and CD14−CD163+ monocytes expressed SLA-DR, and it was higher compared to PB (32% and 20%, p < 0.0001) and BM (93% and 67%, p < 0.001, respectively) counterparts. BALF CD14+CD163+ had a threefold higher Δφ than PB and BM monocytes, while the Δφ of the other subsets was highest in PB monocytes. We confirmed the compartmentalization of the monocyte response during endotoxemic shock, which highlights the importance of studying tissue-resident cells in addition to their circulating counterparts. The iNO/steroid treatment did not further impair monocyte fitness.
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Affiliation(s)
- Tomasz Skirecki
- Laboratory of Flow Cytometry, Centre of Postgraduate Medical Education Marymoncka 99/103, 01-813 Warsaw, Poland
| | - Barbara Adamik
- Clinical Department of the Anaesthesiology and Intensive Therapy, Wroclaw Medical University, 50-367 Wroclaw, Poland; (B.A.); (S.Z.); (W.G.)
| | - Claes Frostell
- Department of Anaesthesia and Intensive Care, Karolinska Institutet, Danderyd Hospital, 182 57 Stockholm, Sweden;
| | - Urszula Pasławska
- Institute of Veterinary Medicine, Faculty of Biological and Veterinary Sciences, Nicolaus Copernicus University in Torun, 87-100 Torun, Poland;
- Department of Internal Medicine and Clinic for Horses, Dogs and Cats, Wroclaw University of Environmental and Life Sciences, 50-375 Wroclaw, Poland
| | - Stanisław Zieliński
- Clinical Department of the Anaesthesiology and Intensive Therapy, Wroclaw Medical University, 50-367 Wroclaw, Poland; (B.A.); (S.Z.); (W.G.)
| | - Natalia Glatzel-Plucińska
- Department of Histology and Embryology, Department of Human Morphology and Embryology, Wroclaw Medical University, 50-367 Wroclaw, Poland; (N.G.-P.); (M.O.); (P.D.)
| | - Mateusz Olbromski
- Department of Histology and Embryology, Department of Human Morphology and Embryology, Wroclaw Medical University, 50-367 Wroclaw, Poland; (N.G.-P.); (M.O.); (P.D.)
| | - Piotr Dzięgiel
- Department of Histology and Embryology, Department of Human Morphology and Embryology, Wroclaw Medical University, 50-367 Wroclaw, Poland; (N.G.-P.); (M.O.); (P.D.)
- Department of Physiotherapy, University School of Physical Education, 51-612 Wroclaw, Poland
| | - Waldemar Gozdzik
- Clinical Department of the Anaesthesiology and Intensive Therapy, Wroclaw Medical University, 50-367 Wroclaw, Poland; (B.A.); (S.Z.); (W.G.)
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Cytokine producing ability of peripheral blood cells from COVID-19 patients after unspecific in vitro stimulation. Inflamm Res 2022; 71:331-341. [PMID: 35157090 PMCID: PMC8853300 DOI: 10.1007/s00011-022-01543-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Revised: 12/29/2021] [Accepted: 01/29/2022] [Indexed: 11/05/2022] Open
Abstract
Objective and design Subjects and methods Results Conclusion
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20
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Costa NA, Pereira AG, Sugizaki CSA, Vieira NM, Garcia LR, de Paiva SAR, Zornoff LAM, Azevedo PS, Polegato BF, Minicucci MF. Insights Into Thiamine Supplementation in Patients With Septic Shock. Front Med (Lausanne) 2022; 8:805199. [PMID: 35155482 PMCID: PMC8832096 DOI: 10.3389/fmed.2021.805199] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/31/2021] [Indexed: 11/13/2022] Open
Abstract
Septic shock is associated with unacceptably high mortality rates, mainly in developing countries. New adjunctive therapies have been explored to reduce global mortality related to sepsis. Considering that metabolic changes, mitochondrial dysfunction and increased oxidative stress are specific disorders within the path of septic shock, several micronutrients that could act in cellular homeostasis have been studied in recent decades. Thiamine, also known as vitamin B1, plays critical roles in several biological processes, including the metabolism of glucose, synthesis of nucleic acids and reduction of oxidative stress. Thiamine deficiency could affect up to 70% of critically ill patients, and thiamine supplementation appears to increase lactate clearance and decrease the vasopressor dose. However, there is no evident improvement in the survival of septic patients. Other micronutrients such as vitamin C and D, selenium and zinc have been tested in the same context but have not been shown to improve the outcomes of these patients. Some problems related to the neutrality of these clinical trials are the study design, doses, route, timing, length of intervention and the choice of endpoints. Recently, the concept that multi-micronutrient administration may be better than single-micronutrient administration has gained strength. In general, clinical trials consider the administration of a single micronutrient as a drug. However, the antioxidant defense is a complex system of endogenous agents in which micronutrients act as cofactors, and the physiological interactions between micronutrients are little discussed. In this context, the association of thiamine, vitamin C and corticoids was tested as an adjunctive therapy in septic shock resulting in a significant decrease in mortality. However, after these initial results, no other study conducted with this combination could reproduce those benefits. In addition, the use of low-dose corticosteroids is recommended in patients with septic shock who do not respond to vasopressors, which can affect the action of thiamine. Therefore, given the excellent safety profile, good biologic rationale and promising clinical studies, this review aims to discuss the mechanisms behind and the evidence for single or combined thiamine supplementation improving the prognosis of patients with septic shock.
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Affiliation(s)
- Nara Aline Costa
- Faculty of Nutrition, Universidade Federal de Goiás (UFG), Goiânia, Brazil
| | - Amanda Gomes Pereira
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | | | - Nayane Maria Vieira
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | - Leonardo Rufino Garcia
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | | | | | - Paula Schmidt Azevedo
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | - Bertha Furlan Polegato
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
| | - Marcos Ferreira Minicucci
- Department of Internal Medicine, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, Brazil
- *Correspondence: Marcos Ferreira Minicucci
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21
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Low-dose corticosteroid therapy for cardiogenic shock in adults (COCCA): study protocol for a randomized controlled trial. Trials 2022; 23:4. [PMID: 34980224 PMCID: PMC8722083 DOI: 10.1186/s13063-021-05947-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 12/17/2021] [Indexed: 01/04/2023] Open
Abstract
Background Cardiogenic shock (CS) is a life-threatening condition characterized by circulatory insufficiency caused by an acute dysfunction of the heart pump. The pathophysiological approach to CS has recently been enriched by the tissue consequences of low flow, including inflammation, endothelial dysfunction, and alteration of the hypothalamic-pituitary-adrenal axis. The aim of the present trial is to evaluate the impact of early low-dose corticosteroid therapy on shock reversal in adults with CS. Method/design This is a multicentered randomized, double-blind, placebo-controlled trial with two parallel arms in adult patients with CS recruited from medical, cardiac, and polyvalent intensive care units (ICU) in France. Patients will be randomly allocated into the treatment or control group (1:1 ratio), and we will recruit 380 patients (190 per group). For the treatment group, hydrocortisone (50 mg intravenous bolus every 6 h) and fludrocortisone (50 μg once a day enterally) will be administered for 7 days or until discharge from the ICU. The primary endpoint is catecholamine-free days at day 7. Secondary endpoints include morbidity and all-cause mortality at 28 and 90 days post-randomization. Pre-defined subgroups analyses are planned, including: postcardiotomy, myocardial infarction, etomidate use, vasopressor use, and adrenal profiles according the short corticotropin stimulation test. Each patient will be followed for 90 days. All analyses will be conducted on an intention-to-treat basis. Discussion This trial will provide valuable evidence about the effectiveness of low dose of corticosteroid therapy for CS. If effective, this therapy might improve outcome and become a therapeutic adjunct for patients with CS. Trial registration ClinicalTrials.gov, NCT03773822. Registered on 12 December 2018
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22
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Na W, Shen H, Li Y, Qu D. Hydrocortisone, ascorbic acid, and thiamine (HAT) for sepsis and septic shock: a meta-analysis with sequential trial analysis. J Intensive Care 2021; 9:75. [PMID: 34922637 PMCID: PMC8684090 DOI: 10.1186/s40560-021-00589-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/01/2021] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Sepsis is a primary global health threat and costs a lot, requiring effective and affordable treatments. We performed this meta-analysis to explore the treatment of hydrocortisone, ascorbic acid, and thiamine (HAT) in sepsis and septic shock. METHODS We searched Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials from inception to August 14, 2021. We included randomized controlled trials (RCTs) that evaluated the HAT treatments in sepsis and septic shock. The primary outcome was the change in SOFA score over the 72 h. The second outcomes were the hospital, and 28-/30-day mortality, the duration of vasopressors, PCT clearance, hospital length of stay (LOS), and ICU LOS. We performed a subgroup analysis and a trial sequential analysis (TSA). The Der Simonian-Laird random-effects models were used to report the pooled risk ratios (RR) or mean difference (MD) with confidence intervals (CI). RESULTS Nine RCTs, enrolling 1427 patients of sepsis and septic shock treated with HAT (717) or only standard care (710), were included. There was a significant difference between the two groups in the change in SOFA score over the first 72 h (MD 0.65, 95% CI 0.30 to 1.00), the duration of vasopressors (MD - 18.16, 95% CI - 25.65 to - 10.68) and the PCT clearance (MD 14.54, 95% CI 0.64 to 28.43). In addition, there was no significant difference in the hospital mortality (RR 1.07, 95% CI 0.85 to 1.34), the 28-/30-day mortality (RR 0.96, 95% CI 0.80 to 1.15), the hospital LOS (MD 0.78, 95% CI - 0.30 to 1.86), and ICU LOS (MD 0.12, 95% CI - 0.53 to 0.78). CONCLUSIONS The HAT combination improves the SOFA score in the first 72 h and reduces the duration of vasopressors in patients with sepsis. Given the minor mean difference of the change in SOFA score, the mortality benefit has not been observed. TRIAL REGISTRATION PROSPERO, CRD42020203166.
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Affiliation(s)
- Weilan Na
- Department of Critical Medicine, Children's Hospital Affiliated to the Capital Institute of Pediatrics, NO.2 Ya Bao Road, Chaoyang District, Beijing, 100020, China
| | - Huili Shen
- Pediatric Intensive Care Unit, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, 100020, China
| | - Yichu Li
- Department of Critical Medicine, Children's Hospital Affiliated to the Capital Institute of Pediatrics, NO.2 Ya Bao Road, Chaoyang District, Beijing, 100020, China
| | - Dong Qu
- Department of Critical Medicine, Children's Hospital Affiliated to the Capital Institute of Pediatrics, NO.2 Ya Bao Road, Chaoyang District, Beijing, 100020, China.
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23
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Mohammed HSED, Ramadan HKA, El-Mahdy RI, Ahmed EH, Hosni A, Mokhtar AA. The Prognostic Value of Different Levels of Cortisol and High-sensitivity C-reactive Protein in Early Acute Pancreatitis. Am J Med Sci 2021; 363:435-443. [PMID: 34798139 DOI: 10.1016/j.amjms.2021.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 07/09/2021] [Accepted: 09/24/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Acute pancreatitis (AP) ranges in severity from mild to severe with high mortality. Severe AP, similar to other critical illnesses, is associated with changes in cortisol level. Early increase of high-sensitivity C-reactive protein (hs-CRP) as an inflammatory marker could be an indicator of AP progression. We aimed to assess the level of cortisol and hs-CRP on initial diagnosis of AP and identify their prognostic value. METHODS This case-control study included patients with AP and a control group of healthy subjects. Laboratory tests such as liver profile, kidney functions, blood picture, lactate dehydrogenase, blood glucose, and lipogram were evaluated, the severity of AP was determined, the duration of hospitalization, complications, and outcomes were identified, and the serum levels of cortisol and hs-CRP were assessed. RESULTS There were 90 patients with AP and 60 controls with a higher percent of females in both groups. Serum cortisol and hs-CRP were significantly higher in AP relative to controls and were higher in severe AP relative to mild AP. Significant positive correlation was present between high cortisol and severity of AP (r=0.520 and p<0.001) and negatively with pancreatic necrosis (r= - 0.303 and p= 0.007) and morality (r= - 0.432, p= 0.005) while hs-CRP did not show significant correlation. CONCLUSIONS Different levels of serum cortisol in early AP should be considered on initial diagnosis. High cortisol level was a good prognostic indicator for AP with low mortality. This could have further implications on the appropriate initiation of steroid therapy to prevent necrotizing pancreatitis and lower the mortality. Meanwhile, hs-CRP has a low prognostic value in early AP.
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Affiliation(s)
| | - Haidi Karam-Allah Ramadan
- Department of Tropical Medicine and Gastroenterology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Reham I El-Mahdy
- Department of Medical Biochemistry and Molecular Biology, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Entsar H Ahmed
- Department of Microbiology and Immunology, Faculty of Medicine, Assiut University, Egypt
| | - Amal Hosni
- Department of Clinical Pathology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Abeer A Mokhtar
- Department of Clinical Pathology, Faculty of Medicine, Assiut University, Assiut, Egypt
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24
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Cour M, Simon M, Argaud L, Monneret G, Venet F. Effects of dexamethasone on immune dysfunction and ventilator-associated pneumonia in COVID-19 acute respiratory distress syndrome: an observational study. J Intensive Care 2021; 9:64. [PMID: 34663481 PMCID: PMC8522132 DOI: 10.1186/s40560-021-00580-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 10/13/2021] [Indexed: 12/15/2022] Open
Abstract
Dexamethasone improves survival of patients with COVID-19 acute respiratory distress syndrome, but might shorten the delay between the start of invasive mechanical ventilation and the occurrence of ventilator-associated pneumonia, suggesting possible worsening of COVID-19-induced immune dysfunction with this treatment. In a prospective observational study, we found that mechanically ventilated patients with COVID-19 treated with dexamethasone presented earlier ventilator-associated pneumonia, had significantly lower monocyte Human Leukocyte Antigen-DR expression and number of circulating CD4 + cells after ICU admission, than those not treated with corticoids.
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Affiliation(s)
- Martin Cour
- Hospices Civils de Lyon, Intensive Care Medicine, Service de Médecine Intensive-Réanimation, Hôpital Edouard Herriot, 5, Place d'Arsonval, F-69437, Lyon Cedex 03, France. .,Faculté de médecine Lyon-Est, Université de Lyon, Université Claude Bernard Lyon 1, F-69437, Lyon, France.
| | - Marie Simon
- Hospices Civils de Lyon, Intensive Care Medicine, Service de Médecine Intensive-Réanimation, Hôpital Edouard Herriot, 5, Place d'Arsonval, F-69437, Lyon Cedex 03, France
| | - Laurent Argaud
- Hospices Civils de Lyon, Intensive Care Medicine, Service de Médecine Intensive-Réanimation, Hôpital Edouard Herriot, 5, Place d'Arsonval, F-69437, Lyon Cedex 03, France.,Faculté de médecine Lyon-Est, Université de Lyon, Université Claude Bernard Lyon 1, F-69437, Lyon, France
| | - Guillaume Monneret
- Faculté de médecine Lyon-Est, Université de Lyon, Université Claude Bernard Lyon 1, F-69437, Lyon, France.,Immunology Laboratory, Hospices Civils de Lyon, Edouard Herriot Hospital, 69437, Lyon, France
| | - Fabienne Venet
- Faculté de médecine Lyon-Est, Université de Lyon, Université Claude Bernard Lyon 1, F-69437, Lyon, France.,Immunology Laboratory, Hospices Civils de Lyon, Edouard Herriot Hospital, 69437, Lyon, France.,Centre International de Recherche en Infectiologie (CIRI), Inserm U1111, CNRS, UMR5308, Ecole Normale Supérieure de Lyon, Université Claude, Bernard-Lyon 1, Lyon, France
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25
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Sahebnasagh A, Nejad PS, Salehi-Abargouei A, Dehghani MH, Saghafi F. A characterization of cortisol level and adrenal reservation in human cardiopulmonary arrest: systematic review and meta-analysis. Syst Rev 2021; 10:266. [PMID: 34625103 PMCID: PMC8499554 DOI: 10.1186/s13643-021-01820-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Accepted: 09/25/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cardiopulmonary arrest (CPA) is an urgency, which is associated with high mortality. This systematic review evaluated the relationship between baseline cortisol level and the outcome of resuscitated CPA patients. METHODS We searched the following databases: PubMed, Scopus, ISI Web of Science, and Google Scholar. Relevant observational and controlled trials were explored from inception by April 2020. The quality of the articles was assessed using the Newcastle-Ottawa Scale (NOS). RESULTS Finally, five cohort studies (n = 201 participants in total) were eligible for including in the meta-analysis. The results of this meta-analysis showed that although the baseline serum cortisol levels were higher in survivors of cardiac arrest compared with non-survivors, the differences between groups do not reach a significance level (Hedges' g = 0.371, 95% CI, -0.727, 1.469, P value = 0.508). Between-study heterogeneity was statistically significant (Cochrane Q test: P value < 0.001, I2 = 89.323). CONCLUSIONS The result of the present meta-analysis was suggestive of a higher baseline serum cortisol levels in survivors of CPA. Future randomized controlled studies with a large sample size will determine the exact relationship between adrenal reservation and the eventual outcome of patients with CPA. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42018085468.
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Affiliation(s)
- Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Paria Soltani Nejad
- Pharmaceutical Sciences Research Center, School of Pharmacy, Student Research Committee, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Amin Salehi-Abargouei
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
- Department of Nutrition, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Mohammad Hossein Dehghani
- Department of Anesthesiology and Critical Care, Shahid Rahnemoun Hospital, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Fatemeh Saghafi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Shahid Sadoughi University of Medical Sciences, Professor Hesabi Blvd, Yazd, Iran.
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Nedel W, Lisboa T, Salluh JIF. What Is the Role of Steroids for Septic Shock in 2021? Semin Respir Crit Care Med 2021; 42:726-734. [PMID: 34544190 DOI: 10.1055/s-0041-1733900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Corticosteroids have been used for decades in the adjunctive treatment of severe infections in intensive care. The most frequent scenario in intensive care is in septic shock, where low doses of glucocorticoids appear to restore vascular responsiveness to norepinephrine. There is a strong body of evidence suggesting that hydrocortisone reduces time on vasopressor, and may modulate the immune response. In this review, we explore the current evidence supporting the use of corticosteroids in septic shock, its benefits, and potential harms. In addition to landmark clinical trials, we will also describe new frontiers for the use of corticosteroids in septic shock which should be explored in future studies.
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Affiliation(s)
- Wagner Nedel
- Programa de Pós-Graduação em Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Intensive Care Unit, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | - Thiago Lisboa
- Critical Care Department, Programa de Pós-Graduação em Ciencias Pneumologicas, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
- Programa de Pós-Graduação em Saúde e Desenvolvimento Humano, Universidade Unilasalle, Canoas, Brazil
- Instituto de Pesquisa, HCOR, São Paulo, Brazil
| | - Jorge I F Salluh
- Department of Critical Care and Postgraduate Program in Translational Medicine, D'Or Institute for Research and Education (IDOR), Rio de Janeiro, Brazil
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Liang H, Song H, Zhai R, Song G, Li H, Ding X, Kan Q, Sun T. Corticosteroids for Treating Sepsis in Adult Patients: A Systematic Review and Meta-Analysis. Front Immunol 2021; 12:709155. [PMID: 34484209 PMCID: PMC8415513 DOI: 10.3389/fimmu.2021.709155] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 07/26/2021] [Indexed: 12/27/2022] Open
Abstract
Objective Corticosteroids are a common option used in sepsis treatment. However, the efficacy and potential risk of corticosteroids in septic patients have not been well assessed. This review was performed to assess the efficacy and safety of corticosteroids in patients with sepsis. Methods PubMed, Embase, and Cochrane library databases were searched from inception to March 2021. Randomized controlled trials (RCTs) that evaluated the effect of corticosteroids on patients with sepsis were included. The quality of outcomes in the included articles was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation methodology. The data were pooled by using risk ratio (RR) and mean difference (MD). The random-effects model was used to evaluate the pooled MD or RR and 95% confidence intervals (CIs). Results Fifty RCTs that included 12,304 patients with sepsis were identified. Corticosteroids were not associated with the mortality in 28-day (RR, 0.94; 95% CI, 0.87–1.02; evidence rank, moderate) and long-term mortality (>60 days) (RR, 0.96; 95% CI, 0.88–1.05) in patients with sepsis (evidence rank, low). However, corticosteroids may exert a significant effect on the mortality in the intensive care unit (ICU) (RR, 0.9; 95% CI, 0.83–0.97), in-hospital (RR, 0.9; 95% CI, 0.82–0.99; evidence rank, moderate) in patients with sepsis or septic shock (evidence rank, low). Furthermore, corticosteroids probably achieved a tiny reduction in the length of hospital stay and ICU. Corticosteroids were associated with a higher risk of hypernatremia and hyperglycemia; furthermore, they appear to have no significant effect on superinfection and gastroduodenal bleeding. Conclusions Corticosteroids had no significant effect on the 28-day and long-term mortality; however, they decreased the ICU and hospital mortality. The findings suggest that the clinical corticosteroids may be an effective therapy for patients with sepsis during the short time. Systematic Review Registration https://inplasy.com/wp-content/uploads/2021/05/INPLASY-Protocol-1074-4.pdf
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Affiliation(s)
- Huoyan Liang
- General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Heng Song
- General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Ruiqing Zhai
- College of Bioinformatics Science and Technology, Harbin Medical University, Harbin, China
| | - Gaofei Song
- General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Hongyi Li
- General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
| | - Xianfei Ding
- General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, China
| | - Quancheng Kan
- Department of Pharmacy, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Tongwen Sun
- General ICU, The First Affiliated Hospital of Zhengzhou University, Henan Key Laboratory of Critical Care Medicine, Zhengzhou Key Laboratory of Sepsis, Henan Engineering Research Center for Critical Care Medicine, Zhengzhou, China.,Academy of Medical Sciences, Zhengzhou University, Zhengzhou, China
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Hussein AA, Sabry NA, Abdalla MS, Farid SF. A prospective, randomised clinical study comparing triple therapy regimen to hydrocortisone monotherapy in reducing mortality in septic shock patients. Int J Clin Pract 2021; 75:e14376. [PMID: 34003568 DOI: 10.1111/ijcp.14376] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/09/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES This prospective, comparative and randomised clinical study evaluated the effectiveness of triple therapy regimen (hydrocortisone, thiamine and vitamin C) versus hydrocortisone alone in reducing the mortality rate and preventing progressive organ dysfunction in septic shock patients. METHODS A total of 94 patients were randomly assigned to one of two groups: the first group received hydrocortisone 50 mg/6-h IV for 7 days or till intensive care unit (ICU) discharge, if sooner, followed by tapering. The second group received hydrocortisone 50 mg/6-h IV for 7 days or ICU discharge followed by tapering, vitamin C 1.5 g/6-h IV for 4 days or till ICU discharge and thiamine 200 mg/12-h IV for 4 days or till ICU discharge. RESULTS The triple therapy regimen showed a non-significant reduction in 28-day mortality compared to hydrocortisone alone (17 [36.2%] vs. 21 [44.7%]; P = .4005), but it was significantly lower than the control group regarding shock time and the duration of vasopressor use in days (4.000 [3.000-7.000]; 5.000 [4.000-8.000], [P = .0100]). The patients in the control group were likely to get 0.59 more in SCr level than those in the intervention group by a linear regression model which was significant (P < .05). Also, the number of patients who developed a fever after 216 hours was significantly higher in the control group (P value = .0299). CONCLUSION Vitamin C, thiamine, and hydrocortisone regimen for septic shock management showed non-significant efficacy in decreasing 28-day mortality when compared to hydrocortisone monotherapy. On the other hand, it showed significant efficacy in decreasing the shock time and duration on vasopressors.
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Affiliation(s)
| | - Nirmeen A Sabry
- Clinical pharmacy department, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Maged S Abdalla
- Anaesthesia and Critical Care department, Faculty of Medicine (Kasr-el Ainy), Cairo University, Cairo, Egypt
| | - Samar F Farid
- Department of Clinical Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
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29
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Kooistra EJ, van Berkel M, van Kempen NF, van Latum CRM, Bruse N, Frenzel T, van den Berg MJW, Schouten JA, Kox M, Pickkers P. Dexamethasone and tocilizumab treatment considerably reduces the value of C-reactive protein and procalcitonin to detect secondary bacterial infections in COVID-19 patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:281. [PMID: 34353339 PMCID: PMC8340482 DOI: 10.1186/s13054-021-03717-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 07/29/2021] [Indexed: 02/17/2023]
Abstract
Background Procalcitonin (PCT) and C-reactive protein (CRP) were previously shown to have value for the detection of secondary infections in critically ill COVID-19 patients. However, since the introduction of immunomodulatory therapy, the value of these biomarkers is unclear. We investigated PCT and CRP kinetics in critically ill COVID-19 patients treated with dexamethasone with or without tocilizumab, and assessed the value of these biomarkers to detect secondary bacterial infections. Methods In this prospective study, 190 critically ill COVID-19 patients were divided into three treatment groups: no dexamethasone, no tocilizumab (D−T−), dexamethasone, no tocilizumab (D+T−), and dexamethasone and tocilizumab (D+T+). Serial data of PCT and CRP were aligned on the last day of dexamethasone treatment, and kinetics of these biomarkers were analyzed between 6 days prior to cessation of dexamethasone and 10 days afterwards. Furthermore, the D+T− and D+T+ groups were subdivided into secondary infection and no-secondary infection groups to analyze differences in PCT and CRP kinetics and calculate detection accuracy of these biomarkers for the occurrence of a secondary infection. Results Following cessation of dexamethasone, there was a rebound in PCT and CRP levels, most pronounced in the D+T− group. Upon occurrence of a secondary infection, no significant increase in PCT and CRP levels was observed in the D+T− group (p = 0.052 and p = 0.08, respectively). Although PCT levels increased significantly in patients of the D+T+ group who developed a secondary infection (p = 0.0003), this rise was only apparent from day 2 post-infection onwards. CRP levels remained suppressed in the D+T+ group. Receiver operating curve analysis of PCT and CRP levels yielded area under the curves of 0.52 and 0.55, respectively, which are both markedly lower than those found in the group of COVID-19 patients not treated with immunomodulatory drugs (0.80 and 0.76, respectively, with p values for differences between groups of 0.001 and 0.02, respectively). Conclusions Cessation of dexamethasone in critically ill COVID-19 patients results in a rebound increase in PCT and CRP levels unrelated to the occurrence of secondary bacterial infections. Furthermore, immunomodulatory treatment with dexamethasone and tocilizumab considerably reduces the value of PCT and CRP for detection of secondary infections in COVID-19 patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03717-z.
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Affiliation(s)
- Emma J Kooistra
- Department of Intensive Care Medicine, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Miranda van Berkel
- Department of Laboratory Medicine, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Noortje F van Kempen
- Department of Intensive Care Medicine, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Celine R M van Latum
- Department of Intensive Care Medicine, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Niklas Bruse
- Department of Intensive Care Medicine, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Tim Frenzel
- Department of Intensive Care Medicine, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Maarten J W van den Berg
- Department of Intensive Care Medicine, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Jeroen A Schouten
- Department of Intensive Care Medicine, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Matthijs Kox
- Department of Intensive Care Medicine, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands.,Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Postbus 9101, 6500 HB, Nijmegen, The Netherlands. .,Radboud Center for Infectious Diseases, Radboud University Medical Center, 6500 HB, Nijmegen, The Netherlands.
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Luo MH, Qian YQ, Huang DL, Luo JC, Su Y, Wang H, Yu SJ, Liu K, Tu GW, Luo Z. Tailoring glucocorticoids in patients with severe COVID-19: a narrative review. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1261. [PMID: 34532398 PMCID: PMC8421952 DOI: 10.21037/atm-21-1783] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 06/10/2021] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To discuss the pathogenesis of severe coronavirus disease 2019 (COVID-19) infection and the pharmacological effects of glucocorticoids (GCs) toward this infection. To review randomized controlled trials (RCTs) using GCs to treat patients with severe COVID-19, and investigate whether GC timing, dosage, or duration affect clinical outcomes. Finally. to discuss the use of biological markers, respiratory parameters, and radiological evidence to select patients for improved GC therapeutic precision. BACKGROUND COVID-19 has become an unprecedented global challenge. As GCs have been used as key immunomodulators to treat inflammation-related diseases, they may play key roles in limiting disease progression by modulating immune responses, cytokine production, and endothelial function in patients with severe COVID-19, who often experience excessive cytokine production and endothelial and renin-angiotensin system (RAS) dysfunction. Current clinical trials have partially proven this efficacy, but GC timing, dosage, and duration vary greatly, with no unifying consensus, thereby creating confusion. METHODS Publications through March 2021 were retrieved from the Web of Science and PubMed. Results from cited references in published articles were also included. CONCLUSIONS GCs play key roles in treating severe COVID-19 infections. Pharmacologically, GCs could modulate immune cells, reduce cytokine and chemokine, and improve endothelial functions in patients with severe COVID-19. Benefits of GCs have been observed in multiple clinical trials, but the timing, dosage and duration vary across studies. Tapering as an option is not widely accepted. However, early initiation of treatment, a tailored dosage with appropriate tapering may be of particular importance, but evidence is inconclusive and more investigations are needed. Biological markers, respiratory parameters, and radiological evidence could also help select patients for specific tailored treatments.
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Affiliation(s)
- Ming-Hao Luo
- Shanghai Medical College, Fudan University, Shanghai, China
| | - Yi-Qi Qian
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Dan-Lei Huang
- Shanghai Medical College, Fudan University, Shanghai, China
| | - Jing-Chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ying Su
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Shen-Ji Yu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Kai Liu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
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Abstract
Sepsis is a host immune disorder induced by infection. It can lead to multiple organ dysfunction syndrome (MODS), which has high morbidity and mortality. There has been great progress in the clinical diagnosis and treatment of sepsis, such as improvements in pathogen detection technology, innovations regarding anti-infection drugs, and the development of organ function support. Abnormal immune responses triggered by pathogens, ranging from excessive inflammation to immunosuppression, are recognized to be an important cause of the high mortality rate. However, no drugs have been approved specifically for treating sepsis. Here, we review the recent research progress on immune responses in sepsis to provide a theoretical basis for the treatment of sepsis. Constructing and optimizing a dynamic immune system treatment regimen based on anti-infection treatment, fluid replacement, organ function support, and timely use of immunomodulatory interventions may improve the prognosis of sepsis patients.
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Affiliation(s)
- Jian Chen
- Department of Intensive Care Medicine, The First Affiliated Hospital of, USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei, China
| | - Haiming Wei
- Department of Geriatrics, The First Affiliated Hospital of, USTC, Division of Life Science and Medicine, University of Science and Technology of China, Hefei, China.,Institute of Immunology, University of Science and Technology of China, Hefei, China
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32
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Somagutta MKR, Pormento MKL, Khan MA, Hamdan A, Hange N, Kc M, Pagad S, Jain MS, Lingarajah S, Sharma V, Kaur J, Emuze B, Batti E, Iloeje OJ. The Efficacy of vitamin C, thiamine, and corticosteroid therapy in adult sepsis patients: a systematic review and meta-analysis. Acute Crit Care 2021; 36:185-200. [PMID: 34185986 PMCID: PMC8435446 DOI: 10.4266/acc.2021.00108] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 05/04/2021] [Indexed: 12/11/2022] Open
Abstract
Background Previous studies have suggested favorable outcomes of hydrocortisone, ascorbic acid (vitamin C), and thiamine (HAT) therapy in patients with sepsis. However, similar results have not been duplicated in sequential studies. This meta-analysis aimed to reevaluate the value of HAT treatment in patients with sepsis. Methods Electronic databases were searched up until October 2020 for any studies that compared the effect of HAT versus non-HAT use in patients with sepsis. Results Data from 15 studies (eight randomized controlled trials [RCTs] and seven cohort studies) involving 67,349 patients were included. The results from the RCTs show no significant benefit of triple therapy on hospital mortality (risk ratio [RR], 0.99; P=0.92; I2=0%); intensive care unit (ICU) mortality (RR, 0.77; P=0.20; I2=58%); ICU length of stay (weighted mean difference [WMD], 0.11; P=0.86; I2=37%) or hospital length of stay (WMD: 0.57; P=0.49; I2=17%), and renal replacement therapy (RR, 0.64; P=0.44; I2=39%). The delta Sequential Organ Failure Assessment (SOFA) score favored treatment after a sensitivity analysis (WMD, -0.72; P=0.01; I2=32%). However, a significant effect was noted for the duration of vasopressor use (WMD, -25.49; P<0.001; I2=46%). The results from cohort studies have also shown no significant benefit of HAT therapy on hospital mortality, ICU mortality, ICU length of stay, length of hospital stay, the delta SOFA score, the use of renal replacement therapy, or vasopressor duration. Conclusion HAT therapy significantly reduced the duration of vasopressor use and improved the SOFA score but appeared not to have significant benefits in other outcomes for patients with sepsis. Further RCTs can help understand its benefit exclusively.
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Affiliation(s)
| | | | - Muhammad Adnan Khan
- Department of Clinical and Translational Research, Larkin Community Hospital, South Miami, FL, USA
| | - Alaa Hamdan
- Department of Clinical and Translational Research, Larkin Community Hospital, South Miami, FL, USA
| | - Namrata Hange
- Department of Clinical and Translational Research, Larkin Community Hospital, South Miami, FL, USA
| | - Manish Kc
- Department of Clinical and Translational Research, Larkin Community Hospital, South Miami, FL, USA
| | - Sukrut Pagad
- Department of Clinical and Translational Research, Larkin Community Hospital, South Miami, FL, USA
| | - Molly Sanjay Jain
- Department of Medicine, Saint James School of Medicine, Park Ridge, IL, USA
| | - Sivasthikka Lingarajah
- Department of Medicine, Windsor University School of Medicine, Cayon (St. Kitts and Nevis), USA
| | - Vishal Sharma
- Department of Medicine, Windsor University School of Medicine, Cayon (St. Kitts and Nevis), USA
| | - Jaspreet Kaur
- Department of Medicine, Medical University of Silesia, Katowice, Poland
| | - Bernard Emuze
- Department of Medicine, Saint James School of Medicine, Park Ridge, IL, USA
| | - Erkan Batti
- Department of Medicine, Washington University of Health and Science, San Pedro, Belize
| | - Obumneme Jude Iloeje
- Department of Medicine, University of Health Sciences, Antigua, Antigua and Barbuda
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Asehnoune K, Le Moal C, Lebuffe G, Le Penndu M, Josse NC, Boisson M, Lescot T, Faucher M, Jaber S, Godet T, Leone M, Motamed C, David JS, Cinotti R, El Amine Y, Liutkus D, Garot M, Marc A, Le Corre A, Thomasseau A, Jobert A, Flet L, Feuillet F, Pere M, Futier E, Roquilly A. Effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery: multicentre, double blind, randomised controlled trial. BMJ 2021; 373:n1162. [PMID: 34078591 PMCID: PMC8171383 DOI: 10.1136/bmj.n1162] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE To assess the effect of dexamethasone on complications or all cause mortality after major non-cardiac surgery. DESIGN Phase III, randomised, double blind, placebo controlled trial. SETTING 34 centres in France, December 2017 to March 2019. PARTICIPANTS 1222 adults (>50 years) requiring major non-cardiac surgery with an expected duration of more than 90 minutes. The anticipated time frame for recruitment was 24 months. INTERVENTIONS Participants were randomised to receive either dexamethasone (0.2 mg/kg immediately after the surgical procedure, and on day 1) or placebo. Randomisation was stratified on the two prespecified criteria of cancer and thoracic procedure. MAIN OUTCOMES MEASURES The primary outcome was a composite of postoperative complications or all cause mortality within 14 days after surgery, assessed in the modified intention-to-treat population (at least one treatment administered). RESULTS Of the 1222 participants who underwent randomisation, 1184 (96.9%) were included in the modified intention-to-treat population. 14 days after surgery, 101 of 595 participants (17.0%) in the dexamethasone group and 117 of 589 (19.9%) in the placebo group had complications or died (adjusted odds ratio 0.81, 95% confidence interval 0.60 to 1.08; P=0.15). In the stratum of participants who underwent non-thoracic surgery (n=1038), the primary outcome occurred in 69 of 520 participants (13.3%) in the dexamethasone group and 93 of 518 (18%) in the placebo group (adjusted odds ratio 0.70, 0.50 to 0.99). Adverse events were reported in 288 of 613 participants (47.0%) in the dexamethasone group and 296 of 609 (48.6%) in the placebo group (P=0.46). CONCLUSIONS Dexamethasone was not found to significantly reduce the incidence of complications and death in patients 14 days after major non-cardiac surgery. The 95% confidence interval for the main result was, however, wide and suggests the possibility of important clinical effectiveness. TRIAL REGISTRATION ClinicalTrials.gov NCT03218553.
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Affiliation(s)
- Karim Asehnoune
- CHU Nantes, Université de Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France
| | - Charlene Le Moal
- Service d'Anesthésie, Centre Hospitalier Le Mans, Le Mans, France
| | - Gilles Lebuffe
- Centre Hospitalier Universitaire (CHU) Lille, Pôle Anesthésie Réanimation, Lille, France
| | - Marguerite Le Penndu
- CHU Nantes, Université de Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France
| | | | - Matthieu Boisson
- CHU de Poitiers, Université de Poitiers, Service d'Anesthésie-Réanimation, Poitiers, France
| | - Thomas Lescot
- Hôpital Saint Antoine, Service d'Anesthésie Réanimation Chirurgicale, Assistance publique des hôpitaux de Paris, Paris, France
| | - Marion Faucher
- Institut Paoli Calmette, Service d'Anesthésie, Marseille, France
| | - Samir Jaber
- Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, Centre Hospitalier Universitaire Montpellier, University of Montpellier, INSERM U1046, CNRS UMR 9214, Montpellier, France
| | - Thomas Godet
- Service d'Anesthésie et Réanimation, Hôpital Estaing, CHU Clermont Ferrand, Clermont-Ferrand, France
| | - Marc Leone
- Department of Anesthesiology and Critical Care Medicine, Hôpital Nord, Aix Marseille University, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Cyrus Motamed
- Département d'Anesthésie & VVC, Gustave Roussy Cancer Center, Villejuif, France
| | - Jean Stephane David
- Service d'Anesthésie Réanimation, Groupe Hospitalier Sud, Civils de Lyon, Pierre Benite, France
| | - Raphael Cinotti
- CHU Nantes, Université de Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôpital Guillaume et René Laennec, Saint-Herblain, France
| | | | - Darius Liutkus
- Service d'Anesthésie, Centre Hospitalier Le Mans, Le Mans, France
| | - Matthias Garot
- Centre Hospitalier Universitaire (CHU) Lille, Pôle Anesthésie Réanimation, Lille, France
| | - Antoine Marc
- CHU Nantes, Université de Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France
| | - Anne Le Corre
- Service d'Anesthésie, Hôpital Privé du Confluent, Nantes, France
| | - Alexandre Thomasseau
- CHU de Poitiers, Université de Poitiers, Service d'Anesthésie-Réanimation, Poitiers, France
| | - Alexandra Jobert
- CHU de Nantes, Direction de la Recherche, Plateforme de Méthodologie et Biostatistique, Nantes, France
| | - Laurent Flet
- CHU Nantes, Service Pharmacie, Hôtel Dieu, Nantes, France
| | - Fanny Feuillet
- Université de Nantes, Université de Tours, INSERM, SPHERE U1246, Nantes, France
| | - Morgane Pere
- CHU de Nantes, Direction de la Recherche, Plateforme de Méthodologie et Biostatistique, Nantes, France
| | - Emmanuel Futier
- Service d'Anesthésie et Réanimation, Hôpital Estaing, CHU Clermont Ferrand, Clermont-Ferrand, France
| | - Antoine Roquilly
- CHU Nantes, Université de Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Nantes, France
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Sahebnasagh A, Najmeddin F, Najafi A, Saghafi F, Salehi-Abargouei A, Ahmadi A, Amini S, Mojtahedzadeh M, Sharifnia H. Efficacy of Glucocorticoid Administration in Patients with Cardiac Arrest: A Systematic Review of Clinical Studies. Curr Med Chem 2021; 29:136-151. [PMID: 34060997 DOI: 10.2174/0929867328666210531145617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Revised: 03/31/2021] [Accepted: 04/05/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The pathophysiology of cardiac arrest (CA) involves over-activation of systemic inflammatory responses, relative adrenal insufficiency, and glycocalyx damage. Corticosteroids have beneficial effects in preventing the perturbation of the endothelial glycocalyx. OBJECTIVES The aim of this systematic review was to determine the efficacy of glucocorticoids in patients with cardiac arrest. METHODS We searched PubMed, Scopus, ISI Web of Science, Google Scholar and Cochrane central register for relevant clinical trials and cohort studies until September 2019. RESULTS We retrieved 7 peer-reviewed published studies for the systematic review. Two studies were clinical trials evaluating 147 patients, while five illustrated cohort design, evaluating 196,192 patients. In total, 196,339 patients were assessed. There was limited evidence and conflicting results to establish a correlation between glucocorticoids and the survival of patients suffering from cardiac arrest. However, the link between these medications and survival-to-admission, survival-to discharge, and 1-year survival rates was strong and consistent in observational studies. CONCLUSION The clinical evidence regarding the efficacy and safety of glucocorticoids in CA is limited to observational studies with inconsistent methodology and few clinical trials with small sample size. Nevertheless, it seems that glucocorticoid supplementation during and after cardiopulmonary resuscitation (CPR) may have significant effects in terms of survival-to-admission, survival to discharge, 1-year survival rates and an improved return of spontaneous circulation (ROSC) rate, especially in patients with hemodynamic instability and cardiovascular diseases (i.e., refractory hemodynamic shock). Future studies with high-quality, large-scale, long-term intervention and precise baseline characteristics are needed to evaluate the exact effective dose, duration, and efficacy of glucocorticoids in CA.
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Affiliation(s)
- Adeleh Sahebnasagh
- Clinical Research Center, Department of Internal Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Farhad Najmeddin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Atabak Najafi
- Department of Anesthesiology and Critical Care Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Saghafi
- Department of Clinical Pharmacy, Faculty of Pharmacy and Pharmaceutical Sciences Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Amin Salehi-Abargouei
- Nutrition and Food Security Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Arezoo Ahmadi
- Department of Anesthesiology and Critical Care Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahideh Amini
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tehran University of Medical Sciences, Tehran, Iran
| | - Mojtaba Mojtahedzadeh
- Department of Clinical Pharmacy, Faculty of Pharmacy, The Institute of Pharmaceutical Sciences (TIPS), Tehran University of Medical Sciences, Tehran, Iran
| | - Hamidreza Sharifnia
- Department of Anesthesiology and Critical Care Medicine, Sina Hospital, Tehran University of Medical Sciences, Iran
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Bagate F, Bedet A, Tomberli F, Boissier F, Razazi K, de Prost N, Carteaux G, Mekontso Dessap A. Critical illness-related corticosteroid insufficiency during difficult weaning from mechanical ventilation. Ann Intensive Care 2021; 11:65. [PMID: 33900478 PMCID: PMC8072727 DOI: 10.1186/s13613-021-00852-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/10/2021] [Indexed: 12/19/2022] Open
Abstract
Background Critical illness-related corticosteroid insufficiency (CIRCI) is common during critical illness and is usually associated with poor outcomes, as prolonged duration of mechanical ventilation (MV) and higher mortality. CIRCI may alter cardiac and vascular functions. Weaning-induced pulmonary oedema (WiPO) is a major mechanism of weaning failure. The aim of this study was to evaluate the role of CIRCI in patients with difficult ventilator weaning and its possible relation with WiPO. Methods This is a prospective study conducted in the intensive care of a university hospital in France. Patients under MV for more than 24 h, meeting weaning criteria and having failed the first spontaneous breathing trial (SBT) underwent a corticotropin stimulation test, with assessment of total blood cortisol levels immediately before (T0) 0.25 mg iv of tetracosactrin and 30 and 60 min afterward. Δmax was defined as the difference between the maximal value after the test and T0. CIRCI was defined as T0 < 10 μg/dL (276 nmol/L) and/or Δmax < 9 μg/dL (248 nmol/L) and inadequate adrenal reserve as Δmax < 9 μg/dL. Biomarkers (natriuretic peptide and protidemia) sampling and echocardiograms were performed during the second SBT and were used to diagnose WiPO, which was defined according to two definitions (one liberal and one conservative) derived from recent publications on the topic. Successful extubation was defined as patient alive without reintubation 7 days after extubation. A competing risk analysis was used to assess extubation failure and mortality. Results Seventy-six consecutive patients (63 ± 14 years; 49 men) with difficult weaning were enrolled. CIRCI and inadequate adrenal reserve occurred in 25 (33%) and 17 (22%) patients, respectively. The probability of successful extubation was significantly decreased in patients with CIRCI or inadequate adrenal reserve, as compared to their counterparts, and this association persisted after adjustment on severity (SOFA score at first SBT). WiPO occurred in 44 (58%) and 8 (11%) patients, according to the liberal and conservative definition, respectively. WiPO was not associated with CIRCI nor with inadequate adrenal reserve. Conclusion CIRCI was common during difficult weaning and was associated with its prolongation. We did not find a significant association between CIRCI and WiPO. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00852-2.
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Affiliation(s)
- François Bagate
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France. .,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France.
| | - Alexandre Bedet
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France
| | - Françoise Tomberli
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France
| | - Florence Boissier
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Service de Réanimation Médicale, CHU de Poitiers, Poitiers, France.,INSERM CIC 1402 (ALIVE Group), Université de Poitiers, Poitiers, France
| | - Keyvan Razazi
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France
| | - Nicolas de Prost
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France.,INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| | - Guillaume Carteaux
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France.,INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
| | - Armand Mekontso Dessap
- AP-HP, DHU A-TVB, Service de Médecine Intensive Réanimation, Centre Hospitalo-Universitaire Henri Mondor, 51, avenue du Mal de Lattre de Tassigny, 94010, Créteil Cedex, France.,Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010, Créteil, France.,INSERM U955, Institut Mondor de Recherche Biomédicale, 94010, Créteil, France
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[S3 Guideline Sepsis-prevention, diagnosis, therapy, and aftercare : Long version]. Med Klin Intensivmed Notfmed 2021; 115:37-109. [PMID: 32356041 DOI: 10.1007/s00063-020-00685-0] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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37
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König R, Kolte A, Ahlers O, Oswald M, Krauss V, Roell D, Sommerfeld O, Dimopoulos G, Tsangaris I, Antoniadou E, Jaishankar N, Bogatsch H, Löffler M, Rödel M, Garcia-Moreno M, Tuchscherr L, Sprung CL, Singer M, Brunkhorst F, Oppert M, Gerlach H, Claus RA, Coldewey SM, Briegel J, Giamarellos-Bourboulis EJ, Keh D, Bauer M. Use of IFNγ/IL10 Ratio for Stratification of Hydrocortisone Therapy in Patients With Septic Shock. Front Immunol 2021; 12:607217. [PMID: 33767693 PMCID: PMC7985546 DOI: 10.3389/fimmu.2021.607217] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 02/09/2021] [Indexed: 12/15/2022] Open
Abstract
Large clinical trials testing hydrocortisone therapy in septic shock have produced conflicting results. Subgroups may benefit of hydrocortisone treatment depending on their individual immune response. We performed an exploratory analysis of the database from the international randomized controlled clinical trial Corticosteroid Therapy of Septic Shock (CORTICUS) employing machine learning to a panel of 137 variables collected from the Berlin subcohort comprising 83 patients including demographic and clinical measures, organ failure scores, leukocyte counts and levels of circulating cytokines. The identified theranostic marker was validated against data from a cohort of the Hellenic Sepsis Study Group (HSSG) (n = 246), patients enrolled in the clinical trial of Sodium Selenite and Procalcitonin Guided Antimicrobial Therapy in Severe Sepsis (SISPCT, n = 118), and another, smaller clinical trial (Crossover study, n = 20). In addition, in vitro blood culture experiments and in vivo experiments in mouse models were performed to assess biological plausibility. A low serum IFNγ/IL10 ratio predicted increased survival in the hydrocortisone group whereas a high ratio predicted better survival in the placebo group. Using this marker for a decision rule, we applied it to three validation sets and observed the same trend. Experimental studies in vitro revealed that IFNγ/IL10 was negatively associated with the load of (heat inactivated) pathogens in spiked human blood and in septic mouse models. Accordingly, an in silico analysis of published IFNγ and IL10 values in bacteremic and non-bacteremic patients with the Systemic Inflammatory Response Syndrome supported this association between the ratio and pathogen burden. We propose IFNγ/IL10 as a molecular marker supporting the decision to administer hydrocortisone to patients in septic shock. Prospective clinical studies are necessary and standard operating procedures need to be implemented, particularly to define a generic threshold. If confirmed, IFNγ/IL10 may become a suitable theranostic marker for an urging clinical need.
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Affiliation(s)
- Rainer König
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Amol Kolte
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Olaf Ahlers
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Marcus Oswald
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Veiko Krauss
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Daniela Roell
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
- Institute of Infectious Diseases and Infection Control, Jena University Hospital, Jena, Germany
| | - Oliver Sommerfeld
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - George Dimopoulos
- 2nd Department of Critical Care Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Iraklis Tsangaris
- 2nd Department of Critical Care Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni Antoniadou
- Intensive Care Unit, “George Gennimatas” Thessaloniki General Hospital, Thessaloniki, Greece
| | - Neeraja Jaishankar
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | | | - Markus Löffler
- Institute for Medical Informatics, Statistics and Epidemiology, Leipzig University, Leipzig, Germany
| | - Markus Rödel
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | | | - Lorena Tuchscherr
- Institute of Medical Microbiology, Jena University Hospital, Jena, Germany
| | - Charles L. Sprung
- Department of Anesthesiology and Critical Care Medicine, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Mervyn Singer
- Division of Medicine, Bloomsbury Institute of Intensive Care Medicine, University College London, London, United Kingdom
| | - Frank Brunkhorst
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
| | - Michael Oppert
- Department of Emergency and Intensive Care Medicine, Klinikum Ernst von Bergmann, Potsdam, Germany
| | - Herwig Gerlach
- Department of Anesthesia, Operative Intensive Care Medicine, and Pain Management, Vivantes Neukölln Hospital, Berlin, Germany
| | - Ralf A. Claus
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Sina M. Coldewey
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
- Septomics Research Center, Jena University Hospital, Jena, Germany
| | - Josef Briegel
- Department of Anesthesiology, University Hospital, Ludwig Maximilian University of Munich, Munich, Germany
| | - Evangelos J. Giamarellos-Bourboulis
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
- 4th Department of Internal Medicine, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Didier Keh
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Michael Bauer
- Integrated Research and Treatment Center, Center for Sepsis Control and Care, Jena University Hospital, Jena, Germany
- Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
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Reddy P. Diagnosis and Management of Adrenal Insufficiency in Hospitalized Patients. Am J Ther 2021; 28:e238-e244. [PMID: 31567142 DOI: 10.1097/mjt.0000000000001064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Plasma cortisol is commonly obtained in hospitalized hypotensive patients, and adrenocorticotropic hormone (ACTH) challenge is typically conducted to further workup hypocortisolemia. It is important to recognize that relative adrenal insufficiency (AI) is the most common cause of low cortisol levels and failed ACTH challenge in ill patients. Both cortisol and synthetic ACTH challenge assays are unreliable in critically ill patients. In clinical practice, corticosteroid therapy in septic shock patients results in immediate hemodynamic benefits with less vasopressor and ventilator dependence. AREAS OF UNCERTAINTY There is no consensus about the diagnostic criteria of relative AI, appropriate cortisol level, and the dose used for synthetic ACTH challenge in patients with septic shock. There is controversy about the mortality benefits of supplemental steroid therapy and about the use of adjunctive fludrocortisone. DATA SOURCES PubMed search of randomized control trials and meta-analyses. THERAPEUTIC OPINION Despite all the controversies, hospital physicians frequently use steroids in patients with septic shock with hypocortisolemia. Hydrocortisone should be the choice of steroid for most relative AI patients, and fludrocortisone can be added on a case-by-case basis in refractory shock. Most of the adverse effects induced by a short course of steroids are easily managed in the inpatient setting.
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Affiliation(s)
- Pramod Reddy
- Division of General Internal Medicine, UF Health Jacksonville, Jacksonville, FL
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Huber S, Weinberger J, Pilecky M, Lorenz I, Schildberger A, Weber V, Fuchs S, Posch W, Knabl L, Würzner R, Posch AE, Orth-Höller D. A high leukocyte count and administration of hydrocortisone hamper PCR-based diagnostics for bloodstream infections. Eur J Clin Microbiol Infect Dis 2021; 40:1441-1449. [PMID: 33547522 DOI: 10.1007/s10096-020-04126-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Accepted: 12/13/2020] [Indexed: 12/14/2022]
Abstract
Bloodstream infections (BSIs) require an accurate and fast identification of causative pathogens. Molecular diagnostics, in particular polymerase chain reaction (PCR)-based approaches for BSI diagnostics directly from whole blood, suffer from limitations such as inhibition leading to invalid results. In this retrospective study, we analyzed 23 parameters for their potential interference with LightCycler SeptiFast PCR tests (n = 2167) routinely performed at our institution. The overall inhibition rate was 9.1%. Test date, type of ward, procalcitonin levels, high leukocyte counts, and absolute neutrophil count were significantly associated with inhibition. For a subset (n = 448), cut-off values for leukocyte counts of < 5700 cells/μL and ≥ 26,900 cells/μL were significantly associated with a low (5%) and high (67%) inhibition risk. For patients with a moderate to high leukocyte count (5700-26,900 cells/μL), the additional administration of hydrocortisone significantly increased the inhibition risk. Furthermore, freezing of blood samples prior to DNA extraction and SF testing appeared to neutralize inhibitory factors. It remains to be investigated whether other molecular diagnostic tests are susceptible to similar inhibiting parameters.
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Affiliation(s)
- Silke Huber
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020, Innsbruck, Austria
| | | | - Matthias Pilecky
- Center for Biomedical Technology, Department for Biomedical Research, Danube University Krems, Krems, Austria
| | - Ingo Lorenz
- Department of General and Surgical Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Anita Schildberger
- Center for Biomedical Technology, Department for Biomedical Research, Danube University Krems, Krems, Austria
| | - Viktoria Weber
- Center for Biomedical Technology, Department for Biomedical Research, Danube University Krems, Krems, Austria.,Christian Doppler Laboratory for Innovative Therapy Approaches in Sepsis, Danube University Krems, Krems, Austria
| | - Stefan Fuchs
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020, Innsbruck, Austria
| | - Wilfried Posch
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020, Innsbruck, Austria
| | - Ludwig Knabl
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020, Innsbruck, Austria
| | - Reinhard Würzner
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020, Innsbruck, Austria
| | - Andreas E Posch
- Ares Genetics GmbH, Karl-Farkas-Gasse 18, 1030, Vienna, Austria.
| | - Dorothea Orth-Höller
- Institute of Hygiene and Medical Microbiology, Medical University of Innsbruck, Schöpfstrasse 41, 6020, Innsbruck, Austria.
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Wepler M, Preuss JM, Merz T, McCook O, Radermacher P, Tuckermann JP, Vettorazzi S. Impact of downstream effects of glucocorticoid receptor dysfunction on organ function in critical illness-associated systemic inflammation. Intensive Care Med Exp 2020; 8:37. [PMID: 33336296 PMCID: PMC7746781 DOI: 10.1186/s40635-020-00325-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/14/2020] [Indexed: 12/20/2022] Open
Abstract
Glucocorticoids (GCs) are stress hormones that regulate developmental and physiological processes and are among the most potent anti-inflammatory drugs to suppress chronic and acute inflammation. GCs act through the glucocorticoid receptor (GR), a ubiquitously expressed ligand-activated transcription factor, which translocates into the nucleus and can act via two different modes, as a GR monomer or as a GR dimer. These two modes of action are not clearly differentiated in practice and may lead to completely different therapeutic outcomes. Detailed aspects of GR mechanisms are often not taken into account when GCs are used in different clinical scenarios. Patients, with critical illness-related corticosteroid insufficiency, treated with natural or synthetic GCs are still missing a clearly defined therapeutic strategy. This review discusses the different modes of GR function and its importance on organ function in vivo.
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Affiliation(s)
- Martin Wepler
- Institute for Anesthesiological Pathophysiology and Process Engineering, University Hospital Ulm, Ulm, Germany. .,Department of Anesthesia, University Hospital Ulm, Ulm, Germany.
| | - Jonathan M Preuss
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Ulm, Germany
| | - Tamara Merz
- Institute for Anesthesiological Pathophysiology and Process Engineering, University Hospital Ulm, Ulm, Germany
| | - Oscar McCook
- Institute for Anesthesiological Pathophysiology and Process Engineering, University Hospital Ulm, Ulm, Germany
| | - Peter Radermacher
- Institute for Anesthesiological Pathophysiology and Process Engineering, University Hospital Ulm, Ulm, Germany
| | - Jan P Tuckermann
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Ulm, Germany
| | - Sabine Vettorazzi
- Institute of Comparative Molecular Endocrinology (CME), Ulm University, Ulm, Germany
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Comparison of shock reversal with high or low dose hydrocortisone in intensive care unit patients with septic shock: A retrospective cohort study. J Crit Care 2020; 62:111-116. [PMID: 33338674 DOI: 10.1016/j.jcrc.2020.12.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/14/2020] [Accepted: 12/01/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE This study aims to describe differences in shock reversal between hydrocortisone 200 mg and 300 mg per day dosing regimens in patients with septic shock. METHODS This is a multi-center retrospective study including patients admitted to intensive care units with septic shock receiving vasopressors and hydrocortisone between 2013 and 2018. We compared patients who received low dose hydrocortisone (50 mg every 6 h) versus high dose hydrocortisone (100 mg every 8 h) on the primary outcome of shock reversal. RESULTS 319 patients (low dose group, n = 134 and high dose group, n = 185) were included. In the multivariate regression model, high-dose steroids were associated with shock reversal [OR (95% CI) = 2.278 (1.063-4.880), p = 0.034]. This was not confirmed in the propensity score matched analysis [OR (95% CI) =2.202 (0.892-5.437), p = 0.087]. High dose steroids were associated with a lower need for additional vasopressor therapy (22% vs. 34%, p = 0.012) and lower shock recurrence (6.7% vs. 16%, p = 0.013), which was confirmed with propensity score matching. CONCLUSIONS Low and high dose hydrocortisone have similar rates of shock reversal in septic shock patients. Hydrocortisone 100 mg every 8 h may reduce rates of recurrence of shock and reduce the need for additional vasopressors.
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Meduri GU, Annane D, Confalonieri M, Chrousos GP, Rochwerg B, Busby A, Ruaro B, Meibohm B. Pharmacological principles guiding prolonged glucocorticoid treatment in ARDS. Intensive Care Med 2020; 46:2284-2296. [PMID: 33150472 PMCID: PMC7641258 DOI: 10.1007/s00134-020-06289-8] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/08/2020] [Indexed: 12/15/2022]
Abstract
Current literature addressing the pharmacological principles guiding glucocorticoid (GC) administration in ARDS is scant. This paucity of information may have led to the heterogeneity of treatment protocols and misinterpretation of available findings. GCs are agonist compounds that bind to the GC receptor (GR) producing a pharmacological response. Clinical efficacy depends on the magnitude and duration of exposure to GR. We updated the meta-analysis of randomized trials investigating GC treatment in ARDS, focusing on treatment protocols and response. We synthesized the current literature on the role of the GR in GC therapy including genomic and non-genomic effects, and integrated current clinical pharmacology knowledge of various GCs, including hydrocortisone, methylprednisolone and dexamethasone. This review addresses the role dosage, timing of initiation, mode of administration, duration, and tapering play in achieving optimal response to GC therapy in ARDS. Based on RCTs' findings, GC plasma concentration-time profiles, and pharmacodynamic studies, optimal results are most likely achievable with early intervention, an initial bolus dose to achieve close to maximal GRα saturation, followed by a continuous infusion to maintain high levels of response throughout the treatment period. In addition, patients receiving similar GC doses may experience substantial between-patient variability in plasma concentrations affecting clinical response. GC should be dose-adjusted and administered for a duration targeting clinical and laboratory improvement, followed by dose-tapering to achieve gradual recovery of the suppressed hypothalamic-pituitary-adrenal (HPA) axis. These findings have practical clinical relevance. Future RCTs should consider these pharmacological principles in the study design and interpretation of findings.
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Affiliation(s)
- Gianfranco Umberto Meduri
- Memphis Veterans Affairs Medical Center Research Service, Departments of Medicine, University of Tennessee Health Science Center, Memphis, TN, USA.
- Pulmonary, Critical Care, and Sleep Medicine Service and Research Service, Memphis Veterans Affairs Medical Center, 1030 Jefferson Avenue, Suite room #CW444, Memphis, TN, 38104, USA.
| | - Djillali Annane
- Department of Critical Care, Raymond Poincaré Hospital (AP-HP), Laboratory Infection and Inflammation, U1173, Faculty of Health Science Simone Veil, University of Versailles SQY, University Paris Saclay, INSERM, FHU SEPSIS, RHU RECORDS, Versailles, France
| | - Marco Confalonieri
- Pulmonology Department, University Hospital of Cattinara, University of Trieste, Trieste, Italy
| | - George P Chrousos
- University Research Institute of Maternal and Child Health and Precision Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Amanda Busby
- Health Research Methods Unit, School of Life and Medical Sciences, University of Hertfordshire, Hatfield, UK
| | - Barbara Ruaro
- Pulmonology Department, University Hospital of Cattinara, University of Trieste, Trieste, Italy
| | - Bernd Meibohm
- Department of Pharmaceutical Sciences, University of Tennessee Health Science Center, Memphis, TN, USA
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Yang R, Xiong Y, Ke H, Chen T, Gao S. The role of methylprednisolone on preventing disease progression for hospitalized patients with severe COVID-19. Eur J Clin Invest 2020; 50:e13412. [PMID: 32954492 PMCID: PMC7537029 DOI: 10.1111/eci.13412] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/28/2020] [Accepted: 09/07/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND COVID-19 is a public health emergency that is spreading worldwide and seriously affecting the global economy. Data on the effectiveness and safety of the use of methylprednisolone for patients with severe COVID-19 remain limited. METHODS In this retrospective study, epidemiological, clinical, laboratory, treatment and outcomes data of hospitalized patients with severe COVID-19 in Zhongnan Hospital of Wuhan University from January 1 to 7 March 2020, were collected. Binary logistic regression model was used to analyse risk factors for disease progression from severe COVID-19 illness to critical illness. The effectiveness and safety of the use of methylprednisolone for patients with severe COVID-19 disease were evaluated. RESULTS The results of the multivariate analysis from 175 patients with severe COVID-19 indicate that the use of methylprednisolone was a protective factor against disease progression from severe to critical illness(P < .001; OR: 0.054 95% CI: 0.017-0.173). Among patients with severe COVID-19 aged < 65 years, both the proportion of patients who progressed to critical illness (42.2% vs 90.0%, P = .000) and the mortality(6.7% vs 30.0%, P = .002) were lower for patients in methylprednisolone group, compared with those in the non-methylprednisolone group, whereas no statistical differences between the methylprednisolone group and the non-methylprednisolone group were found among patients with COVID-19 older than 65 years. Moreover, both the levels of CD4+ T lymphocyte counts (646 vs 463/µL, P = .007) and IL-6 (241.9 vs 82.8 pg/mL, P = .025) were higher among patients with severe COVID-19 aged < 65 years, compared with those patients ≥ 65 years old. CONCLUSION Data from the limited sample showed that the early use of low or medium doses of methylprednisolone has a positive effect for patients with severe COVID-19 younger than 65 years old, and excessive immune response and cytokine storm may be some of the reasons for the effectiveness.
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Affiliation(s)
- Rongrong Yang
- Department of Infectious DiseasesZhongnan HospitalWuhan UniversityWuhanChina
| | - Yong Xiong
- Department of Infectious DiseasesZhongnan HospitalWuhan UniversityWuhanChina
| | - Hengning Ke
- Department of Infectious DiseasesZhongnan HospitalWuhan UniversityWuhanChina
| | - Tielong Chen
- Department of Infectious DiseasesZhongnan HospitalWuhan UniversityWuhanChina
| | - Shicheng Gao
- Department of Infectious DiseasesZhongnan HospitalWuhan UniversityWuhanChina
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Abstract
Sepsis care has evolved significantly since the initial early goal-directed therapy (EGDT) trials. Early fluid resuscitation, source control, and antibiotic therapy remain cornerstones of care but overall understanding is more nuanced, particularly regarding fluid selection, vasopressors, and inotropic support. Timely nutrition therapy and ventilatory support tend to receive less attention but also are important. Recent research has explored immunomodulation, β-blockade, and vitamin supplementation. A renewed emphasis on early, aggressive resuscitation reaffirms the importance of emergency medicine providers knowledgeable and skilled in sepsis management.
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Hydrocortisone mitigates ICU-AW by fine-tuning of muscle atrophic and hypertrophic signaling pathways in a sepsis model with limb immobilization. Life Sci 2020; 261:118366. [PMID: 32871182 DOI: 10.1016/j.lfs.2020.118366] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/14/2020] [Accepted: 08/27/2020] [Indexed: 12/29/2022]
Abstract
AIMS Intensive care unit-acquired weakness (ICU-AW) is a complex spectrum of disability that delays recovery of critically ill-immobilized patients with sepsis. Much discrepancy remain on the use of corticosteroids and their impact on muscle regeneration in critical illness management. Therefore, the aim of this study is to investigate whether hydrocortisone (HCT) modulates muscle mass turnover in ICU-AW induced by sepsis with limb immobilization (SI). MAIN METHODS Sepsis by cecal ligation puncture (CLP) with forelimb-immobilization were performed in rats. The study consisted of four groups: Sham (left forelimb-immobilization), Sham HCT (left forelimb-immobilization + HCT), SI (CLP + left forelimb-immobilization) and SI HCT (CLP + left forelimb-immobilization + HCT). Motor force, blood and muscle sampling were assessed. KEY FINDINGS HCT prevented body weight loss associated with SI and attenuated systemic and muscular inflammation. Besides, myosin was restituted in SI HCT group in conjunction to muscle mass and strength restoration. Pro-hypertrophic calcineurin (PP2B-Aβ) and nuclear factor of activated T-cells C3 (NFATc3) but not protein kinase B (Akt) were re-activated by HCT. Finally, pro-atrophic extracellular signal-regulated kinases (ERK1/2) and p38 mitogen-activated protein kinases (p38) but not nuclear factor kappa-light-chain-enhancer of activated B cells (NF-kB) were inhibited in SI HCT group. SIGNIFICANCE This study unravels new molecular events thought to control muscle protein synthesis in ICU-AW induced by sepsis and limb immobilization. HCT has a potential to fine-tune muscle-signaling pathways and to reduce the negative outcomes of ICU-AW.
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46
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Vandewalle J, Libert C. Glucocorticoids in Sepsis: To Be or Not to Be. Front Immunol 2020; 11:1318. [PMID: 32849493 PMCID: PMC7396579 DOI: 10.3389/fimmu.2020.01318] [Citation(s) in RCA: 57] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 05/26/2020] [Indexed: 12/12/2022] Open
Abstract
Sepsis is a highly lethal syndrome resulting from dysregulated immune and metabolic responses to infection, thereby compromising host homeostasis. Activation of the hypothalamic–pituitary–adrenal (HPA) axis and subsequently adrenocortical glucocorticoid (GC) production during sepsis are important regulatory processes to maintain homeostasis. Multiple preclinical studies have proven the pivotal role of endogenous GCs in tolerance against sepsis by counteracting several of the sepsis characteristics, such as excessive inflammation, vascular defects, and hypoglycemia. Sepsis is however often complicated by dysfunction of the HPA axis, resulting from critical-illness-related corticosteroid insufficiency (CIRCI) and GC resistance. Therefore, GCs have been tested as an adjunctive therapy in sepsis and septic shock in different randomized clinical trials (RCTs). Nonetheless, these studies produced conflicting results. Interestingly, adding vitamin C and thiamin to GC therapy enhances the effects of GCs, probably by reducing GC resistance, and this results in an impressive reduction in sepsis mortality as was shown in two recent preliminary retrospective before–after studies. Multiple RCTs are currently underway to validate this new combination therapy in sepsis.
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Affiliation(s)
- Jolien Vandewalle
- Center for Inflammation Research, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
| | - Claude Libert
- Center for Inflammation Research, VIB, Ghent, Belgium.,Department of Biomedical Molecular Biology, Ghent University, Ghent, Belgium
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47
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Perricone C, Triggianese P, Bartoloni E, Cafaro G, Bonifacio AF, Bursi R, Perricone R, Gerli R. The anti-viral facet of anti-rheumatic drugs: Lessons from COVID-19. J Autoimmun 2020; 111:102468. [PMID: 32317220 PMCID: PMC7164894 DOI: 10.1016/j.jaut.2020.102468] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 02/07/2023]
Abstract
The outbreak of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has posed the world at a pandemic risk. Coronavirus-19 disease (COVID-19) is an infectious disease caused by SARS-CoV-2, which causes pneumonia, requires intensive care unit hospitalization in about 10% of cases and can lead to a fatal outcome. Several efforts are currently made to find a treatment for COVID-19 patients. So far, several anti-viral and immunosuppressive or immunomodulating drugs have demonstrated some efficacy on COVID-19 both in vitro and in animal models as well as in cases series. In COVID-19 patients a pro-inflammatory status with high levels of interleukin (IL)-1B, IL-1 receptor (R)A and tumor necrosis factor (TNF)-α has been demonstrated. Moreover, high levels of IL-6 and TNF-α have been observed in patients requiring intensive-care-unit hospitalization. This provided rationale for the use of anti-rheumatic drugs as potential treatments for this severe viral infection. Other agents, such as hydroxychloroquine and chloroquine might have a direct anti-viral effect. The anti-viral aspect of immunosuppressants towards a variety of viruses has been known since long time and it is herein discussed in the view of searching for a potential treatment for SARS-CoV-2 infection.
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Affiliation(s)
- Carlo Perricone
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Paola Triggianese
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", University of Rome Tor Vergata, Via Montpellier 1, 00133, Rome, Italy
| | - Elena Bartoloni
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Giacomo Cafaro
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Angelo F Bonifacio
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Bursi
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy
| | - Roberto Perricone
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", University of Rome Tor Vergata, Via Montpellier 1, 00133, Rome, Italy
| | - Roberto Gerli
- Rheumatology, Department of Medicine, University of Perugia, Piazzale Giorgio Menghini, 1, 06129, Perugia, Italy.
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48
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Rushworth RL, Torpy DJ, Falhammar H. Adrenal crises in older patients. Lancet Diabetes Endocrinol 2020; 8:628-639. [PMID: 32559478 DOI: 10.1016/s2213-8587(20)30122-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 03/29/2020] [Accepted: 04/01/2020] [Indexed: 12/21/2022]
Abstract
Adrenal crises are severe manifestations of adrenal insufficiency that result in hospital admission and incur a risk of cardiovascular events, acute renal injury, and death. Evidence from population-based studies indicate that adults older than 60 years have the highest adrenal insufficiency incidence, contribute to the highest number of adrenal crises, and have the highest age-specific incidence of adrenal crisis, which doubles between the age groups of 60-69 years and 80 years or older. Older patients might be more susceptible to adrenal crises because of a higher prevalence of comorbidities and a consequently higher risk of acute illness. This susceptibility might be compounded by shortfalls in the implementation of prevention strategies for adrenal crisis, because of individual and social factors that increase with age. Although little research has focused on adrenal crisis prevention in older patients, it seems logical that a timely diagnosis of adrenal insufficiency and the use of consensus driven adrenal crisis prevention and attenuation strategies might reduce adrenal crises in patients older than 60 years old.
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Affiliation(s)
- Ruth L Rushworth
- School of Medicine, Sydney, The University of Notre Dame Australia, Darlinghurst, NSW, Australia
| | - David J Torpy
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia; University of Adelaide, Adelaide, SA, Australia
| | - Henrik Falhammar
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
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49
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Angus DC, Berry S, Lewis RJ, Al-Beidh F, Arabi Y, van Bentum-Puijk W, Bhimani Z, Bonten M, Broglio K, Brunkhorst F, Cheng AC, Chiche JD, De Jong M, Detry M, Goossens H, Gordon A, Green C, Higgins AM, Hullegie SJ, Kruger P, Lamontagne F, Litton E, Marshall J, McGlothlin A, McGuinness S, Mouncey P, Murthy S, Nichol A, O’Neill GK, Parke R, Parker J, Rohde G, Rowan K, Turner A, Young P, Derde L, McArthur C, Webb SA. The REMAP-CAP (Randomized Embedded Multifactorial Adaptive Platform for Community-acquired Pneumonia) Study. Rationale and Design. Ann Am Thorac Soc 2020; 17:879-891. [PMID: 32267771 PMCID: PMC7328186 DOI: 10.1513/annalsats.202003-192sd] [Citation(s) in RCA: 229] [Impact Index Per Article: 57.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2020] [Accepted: 04/08/2020] [Indexed: 12/22/2022] Open
Abstract
There is broad interest in improved methods to generate robust evidence regarding best practice, especially in settings where patient conditions are heterogenous and require multiple concomitant therapies. Here, we present the rationale and design of a large, international trial that combines features of adaptive platform trials with pragmatic point-of-care trials to determine best treatment strategies for patients admitted to an intensive care unit with severe community-acquired pneumonia. The trial uses a novel design, entitled "a randomized embedded multifactorial adaptive platform." The design has five key features: 1) randomization, allowing robust causal inference; 2) embedding of study procedures into routine care processes, facilitating enrollment, trial efficiency, and generalizability; 3) a multifactorial statistical model comparing multiple interventions across multiple patient subgroups; 4) response-adaptive randomization with preferential assignment to those interventions that appear most favorable; and 5) a platform structured to permit continuous, potentially perpetual enrollment beyond the evaluation of the initial treatments. The trial randomizes patients to multiple interventions within four treatment domains: antibiotics, antiviral therapy for influenza, host immunomodulation with extended macrolide therapy, and alternative corticosteroid regimens, representing 240 treatment regimens. The trial generates estimates of superiority, inferiority, and equivalence between regimens on the primary outcome of 90-day mortality, stratified by presence or absence of concomitant shock and proven or suspected influenza infection. The trial will also compare ventilatory and oxygenation strategies, and has capacity to address additional questions rapidly during pandemic respiratory infections. As of January 2020, REMAP-CAP (Randomized Embedded Multifactorial Adaptive Platform for Community-acquired Pneumonia) was approved and enrolling patients in 52 intensive care units in 13 countries on 3 continents. In February, it transitioned into pandemic mode with several design adaptations for coronavirus disease 2019. Lessons learned from the design and conduct of this trial should aid in dissemination of similar platform initiatives in other disease areas.Clinical trial registered with www.clinicaltrials.gov (NCT02735707).
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Affiliation(s)
- Derek C. Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Roger J. Lewis
- Berry Consultants, LLC, Austin, Texas
- Department of Emergency Medicine, Harbor–University of California Los Angeles (UCLA) Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care
- Department of Medical Microbiology, and
| | | | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care, Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Allen C. Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jean-Daniel Chiche
- Medical Intensive Care Unit, Hôpital Cochin, Paris Descartes University, Paris, France
| | - Menno De Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Anthony Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare National Health Service Trust, London, United Kingdom
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alisa M. Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | | | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | - John Marshall
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit and
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, British Columbia, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent’s University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Genevieve K. O’Neill
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit and
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Gernot Rohde
- Department of Respiratory Medicine, University Hospital Frankfurt, Frankfurt, Germany
- CAPNETZ Foundation, Hannover, Germany
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Paul Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand; and
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Colin McArthur
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Steven A. Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St. John of God Hospital, Subiaco, Western Australia, Australia
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50
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Abstract
Phagocytosis is a complex process by which cells within most organ systems remove pathogens and cell debris. Phagocytosis is usually followed by inflammatory pathway activation, which promotes pathogen elimination and inhibits pathogen growth. Delayed pathogen elimination is the first step in sepsis development and a key factor in sepsis resolution. Phagocytosis thus has an important role during sepsis and likely contributes to all of its clinical stages. However, only a few studies have specifically explored and characterized phagocytic activity during sepsis. Here, we describe the phagocytic processes that occur as part of the immune response preceding sepsis onset and identify the elements of phagocytosis that might constitute a predictive marker of sepsis outcomes. First, we detail the key features of phagocytosis, including the main receptors and signaling hallmarks associated with different phagocytic processes. We then discuss how the initial events of phagosome formation and cytoskeletal remodeling might be associated with known sepsis features, such as a cytokine-driven hyperinflammatory response and immunosuppression. Finally, we highlight the unresolved mechanisms of sepsis development and progression and the need for cross-disciplinary approaches to link the clinical complexity of the disease with basic cellular and molecular mechanisms.
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