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Zhao B, Si M, Hu Z, Jiang J. Alveolar-arterial oxygen gradient: An early marker to predict the severity of community-acquired pneumonia in children. Medicine (Baltimore) 2024; 103:e37670. [PMID: 38579093 PMCID: PMC10994442 DOI: 10.1097/md.0000000000037670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 02/29/2024] [Indexed: 04/07/2024] Open
Abstract
To study the clinical significance of alveolar-arterial oxygen gradient (PA-aO2) for children with community-acquired pneumonia (CAP). A prospective study was carried out from January 2020 to June 2023, Overall, 100 patients were included in the study, 35 had severe pneumonia, whereas, 65 had non-severe pneumonia. Clinical and laboratory data were retrospectively collected at the time of hospital admission and during hospitalization. Patients were divided into severe and non-severe groups. PA-aO2 was significantly higher among children with severe pneumonia, as determined by WHO, PRESS (P < .001). PA-aO2 was significantly higher among children with mechanical ventilation, shock, sepsis, and mortality. Receiver operating characteristic curve (ROC) analysis for PA-aO2 showed that the area under the curve was 0.76 (P value < .05), with a sensitivity of 84.3% and a specificity of 67.9%. Our study suggests that PA-aO2 level has a predictive value for detecting community-acquired pneumonia severity in children.
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Affiliation(s)
- Baoxi Zhao
- Department of Pediatrics, The First People’s Hospital of Linping District, Hangzhou, China
| | - Mingqiang Si
- Department of Pediatrics, The First People’s Hospital of Linping District, Hangzhou, China
| | - Zhonghua Hu
- Department of Pediatrics, The First People’s Hospital of Linping District, Hangzhou, China
| | - Junsheng Jiang
- Department of Pediatrics, The First People’s Hospital of Linping District, Hangzhou, China
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Palalıoğlu B, Erdoğan S, Atay G, Tugrul HC, Özer ÖF. Diagnostic and Prognostic Value of Pentraxin 3, Interleukin-6, CRP, and Procalcitonin Levels in Patients with Sepsis and Septic Shock. Niger J Clin Pract 2024; 27:317-324. [PMID: 38528351 DOI: 10.4103/njcp.njcp_615_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 12/16/2023] [Indexed: 03/27/2024]
Abstract
INTRODUCTION AND PURPOSE In this prospective study, we aim to evaluate the effects of antibiotherapy on pentraxin-3 (PTX3), C-reactive protein (CRP), and interleukin-6 (IL-6) levels in patients with sepsis and septic shock. MATERIALS AND METHODS In our study, CRP, procalcitonin, IL-6, and PTX3 levels at initial and 48 hours of the antibiotherapy of patients who were admitted to the pediatric intensive care unit (PICU) with the diagnosis of sepsis and septic shock between June 2020 and March 2021 were compared. Patients were compared with the age-appropriate case-control group formed from the patients who received pre-operative routines to investigate the diagnostic value. RESULTS CRP, IL-6, and PTX3 levels of the patients were significantly higher compared to controls (P < 0.05). After the 48th hour of treatment compared to initial CRP, lactate and PCT levels were significantly lower (P < 0.05). The IL-6 and PCT levels were significantly higher in patients with mortality than in surviving patients. Surviving patients showed a significant decrease in CRP level at the 48th hour. IL-6 levels of patients with septic shock were significantly higher than those with sepsis (P = 0.010; P < 0.05). In the diagnosis of septic shock, the area under curve was 0.785 for IL-6 and the standard deviation was 0.09 (P = 0.002, cut-off value, >32 pg/mL, 88.9% sensitivity, 65.6% specifity). CONCLUSION The results of this study indicated that IL-6 level is an appropriate biomarker with high specificity in the diagnosis of sepsis and septic shock and in evaluating the response to treatment and determining the prognosis.
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Affiliation(s)
- B Palalıoğlu
- Department of Pediatrics, University of Health Sciences Zeynep Kamil Training and Research Hospital, Uskudar Opr. Dr. Burhanettin Ustunel Cad. No:10, Istanbul, Turkey
| | - S Erdoğan
- Department of Pediatric Intensive Care, University of Health Sciences Umraniye Training and Research Hospital, Elmalıkent, Adem Yavuz Cd., Istanbul, Turkey
| | - G Atay
- Department of Pediatric Intensive Care, University of Health Sciences Umraniye Training and Research Hospital, Elmalıkent, Adem Yavuz Cd., Istanbul, Turkey
| | - H C Tugrul
- Department of Pediatric Intensive Care, University of Health Sciences Umraniye Training and Research Hospital, Elmalıkent, Adem Yavuz Cd., Istanbul, Turkey
| | - Ö F Özer
- Bezmialem Vakif University, Department of Biochemistry Adnan Menderes Bulvarı (Vatan Cad.) P.K. 34093 Fatih/Istanbul, Turkey
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Almutairi A, Alenezi F, Tamim H, Sadat M, Humaid FB, AlMatrood A, Syed Y, Arabi Y. The prevalence of acute kidney injury in patients with community-acquired pneumonia who required mechanical ventilation. Ann Saudi Med 2024; 44:104-110. [PMID: 38615183 PMCID: PMC11016152 DOI: 10.5144/0256-4947.2024.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 12/08/2023] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is a common reason for intensive care unit (ICU) admission and sepsis. Acute kidney injury (AKI) is a frequent complication of community-acquired pneumonia and is associated with increased short- and long-term morbidity and mortality and healthcare costs. OBJECTIVE Describe the prevalence of AKI in patients with CAP requiring mechanical ventilation and evaluate its association with inhospital mortality. DESIGN Retrospective cohort. SETTING Intensive care unit. PATIENTS AND METHODS We included patients with CAP on mechanical ventilation. Patients were categorized according to the development of AKI in the first 24 hours of ICU admission using the Kidney Disease Improving Global Outcomes (KDIGO) classification from no AKI, stage 1 AKI, stage 2 AKI, and stage 3 AKI. MAIN OUTCOME MEASURES The primary outcome was hospital mortality. Secondary outcomes were ICU mortality, hospital and ICU length of stay, ventilation duration, tracheostomy, and renal replacement therapy requirement. RESULTS Of 1536 patients included in the study, 829 patients (54%) had no AKI while 707 (46%) developed AKI. In-hospital mortality was 288/829 (34.8%) for patients with no AKI, 43/111 (38.7%) for stage 1 AKI, 86/216 (40%) for stage 2 AKI, and 196/380 (51.7%) for stage 3 AKI (P<.0001). Multivariate analysis revealed that stages 1, 2, or 3 AKI compared to no AKI were not independently associated with in-hospital mortality. Older age, vasopressor use; decreased Glasgow coma scale, PaO2/Fio2 ratio and platelet count, increased bilirubin, lactic acid and INR were associated with increased mortality while female sex was associated with reduced mortality. CONCLUSION Among mechanically ventilated patients with CAP, AKI was common and was associated with higher crude mortality. The higher mortality could not be attributed alone to AKI, but rather appeared to be related to multi-organ dysfunction. LIMITATIONS Single-center retrospective study with no data on baseline serum creatinine and the use of estimated baseline creatinine distributions based on the MDRD (Modification of Diet in Renal Disease)equation which may lead to an overestimation of AKI. Second, we did not have data on the microbiology of pneumonia, appropriateness of antibiotic therapy or the administration of other medications that have been demonstrated to be associated with AKI.
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Affiliation(s)
- Abdulmajed Almutairi
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Farhan Alenezi
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Hani Tamim
- Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
| | - Musharaf Sadat
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Felwa Bin Humaid
- Intensive Care Unit, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Amal AlMatrood
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yadullah Syed
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yaseen Arabi
- From the Intensive Care Department, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
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Gong S, Lian H, Ding X, Wang X. High Respiratory and Cardiac Drive Exacerbate Secondary Lung Injury in Patients With Critical Illness. J Intensive Care Med 2024:8850666231222220. [PMID: 38173252 DOI: 10.1177/08850666231222220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
The high respiratory and cardiac drive is essential to the host-organ unregulated response. When a primary disease and an unregulated secondary response are uncontrolled, the patient may present in a high respiratory and cardiac drive state. High respiratory drive can cause damage to the lungs, pulmonary circulation, and diaphragm, while high cardiac drive can lead to fluid leakage and infiltration as well as pulmonary interstitial edema. A "respiratory and cardiac dual high drive" state may be a sign of an unregulated response and can lead to secondary lung injury through the increase of transvascular pressure and pulmonary microcirculation injury. Ultrasound examination of the lung, heart, and diaphragm is important when evaluating the phenotype of high respiratory drive in critically ill patients. Ultrasound assessment can guide sedation, analgesia, and antistress treatment and reduce the risk of high respiratory and cardiac drive-induced lung injury in these patients.
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Affiliation(s)
- Shiyi Gong
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Lian
- Department of Health Care, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xin Ding
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
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Kim TW, Lee SU, Park B, Jeon K, Park S, Suh GY, Oh DK, Lee SY, Park MH, Lee H, Lim CM, Ko RE. Clinical effects of bacteremia in sepsis patients with community-acquired pneumonia. BMC Infect Dis 2023; 23:887. [PMID: 38114902 PMCID: PMC10729397 DOI: 10.1186/s12879-023-08887-5] [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] [Received: 03/25/2023] [Accepted: 12/09/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Data regarding the clinical effects of bacteremia on severe community-acquired pneumonia (CAP) are limited. Thus, we investigated clinical characteristics and outcomes of severe CAP patients with bacteremia compared with those of subjects without bacteremia. In addition, we evaluated clinical factors associated with bacteremia at the time of sepsis awareness. METHODS We enrolled sepsis patients diagnosed with CAP at emergency departments (EDs) from an ongoing nationwide multicenter observational registry, the Korean Sepsis Alliance, between September 2019 and December 2020. For evaluation of clinical factors associated with bacteremia, we divided eligible patients into bacteremia and non-bacteremia groups, and logistic regression analysis was performed using the clinical characteristics at the time of sepsis awareness. RESULT During the study period, 1,510 (47.9%) sepsis patients were caused by CAP, and bacteremia was identified in 212 (14.0%) patients. Septic shock occurred more frequently in the bacteremia group than in the non-bacteremia group (27.4% vs. 14.8%; p < 0.001). In multivariable analysis, hematologic malignancies and septic shock were associated with an increased risk of bacteremia. However, chronic lung disease was associated with a decreased risk of bacteremia. Hospital mortality was significantly higher in the bacteremia group than in the non-bacteremia group (27.3% vs. 40.6%, p < 0.001). The most prevalent pathogen in blood culture was Klebsiella pneumoniae followed by Escherichia coli in gram-negative pathogens. CONCLUSION The incidence of bacteremia in severe CAP was low at 14.0%, but the occurrence of bacteremia was associated with increased hospital mortality. In severe CAP, hematologic malignancies and septic shock were associated with an increased risk of bacteremia.
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Affiliation(s)
- Tae Wan Kim
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, South Korea
| | - Se-Uk Lee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Boram Park
- Biomedical Statistics Center, Research Institute for Future Medicine, Samsung Medical Center, Seoul, South Korea
| | - Kyeongman Jeon
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Gee Young Suh
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, South Korea
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Dong Kyu Oh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Soo Yeon Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Mi Hyeon Park
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Haein Lee
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ryoung-Eun Ko
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-Ro, Gangnam-Gu, Seoul, 06351, South Korea.
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Rosenstrom E, Meshkinfam S, Ivy JS, Goodarzi SH, Capan M, Huddleston J, Romero-Brufau S. Optimizing the First Response to Sepsis: An Electronic Health Record-Based Markov Decision Process Model. DECISION ANALYSIS 2022. [DOI: 10.1287/deca.2022.0455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Sepsis is considered a medical emergency where delays in initial treatment are associated with increased morbidity and mortality, yet there is no gold standard for identifying sepsis onset and thus treatment timing. We leverage electronic health record (EHR) data with clinical expertise to develop a continuous-time Markov decision process (MDP) optimal stopping model that identifies the optimal first intervention action (anti-infective, fluid, or wait). To study the impact of initial treatment of patients at risk for developing sepsis, we define the delayed treatment population who received delayed treatment upon admission or during hospitalization and serves as an approximation of the natural history of sepsis. We apply the optimal first treatment policy to sample patient visits from the nondelayed treatment population. This analysis indicates the average risk of death could be reduced by approximately 2.2%, the average time until treatment could be reduced by 106 minutes, and the average severity of the treatment state could be reduced by 15.5% compared with the treatment they received in the hospital. We study the properties of the optimal policy to define an easily interpretable initial treatment heuristic that considers a patient’s organ dysfunction, location, and septic shock status. This generalizable framework can inform personalized treatment of patients at risk for sepsis.
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Affiliation(s)
- Erik Rosenstrom
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, North Carolina 27606
| | - Sareh Meshkinfam
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, North Carolina 27606
- Dynamic Ideas LLC, Waltham, Massachusetts 02452
| | - Julie Simmons Ivy
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, North Carolina 27606
| | - Shadi Hassani Goodarzi
- Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, North Carolina 27606
| | - Muge Capan
- Department of Mechanical and Industrial Engineering, University of Massachusetts Amherst, Amherst, Massachusetts 01003
| | - Jeanne Huddleston
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota 55902
| | - Santiago Romero-Brufau
- Department of Otolaryngology (ENT) / Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota 55902
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts 02115
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7
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Chotalia M, Ali M, Hebballi R, Singh H, Parekh D, Bangash MN, Patel JM. Hyperdynamic Left Ventricular Ejection Fraction in ICU Patients With Sepsis. Crit Care Med 2022; 50:770-779. [PMID: 34605779 DOI: 10.1097/ccm.0000000000005315] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the cause and prognosis of hyperdynamic left ventricular ejection fraction in critically ill patients with sepsis. DESIGN Retrospective, single-center cohort study. SETTING University Hospital ICU, Birmingham, United Kingdom. PATIENTS ICU patients who received a transthoracic echocardiogram within 7 days of sepsis between April 2016 and December 2019. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The 90-day mortality rates of normal (55-70%), depressed (< 55%), and hyperdynamic left ventricular ejection fraction (> 70%) were compared. Multivariate logistic regression analysis was performed to determine the association of left ventricular ejection fraction phenotypes with mortality and the association of clinical variables with left ventricular ejection fraction phenotypes. One thousand fourteen patients met inclusion criteria and were 62 years old (interquartile range, 47-72), with mostly respiratory infections (n = 557; 54.9%). Ninety-day mortality was 32.1% (n = 325). Patients with hyperdynamic left ventricular ejection fraction had a higher mortality than depressed and normal left ventricular ejection fraction cohorts (58.9% [n = 103] vs 34.0% [n = 55] vs 24.7% [n = 167]; p < 0.0001, respectively). After multivariate logistic regression, hyperdynamic left ventricular ejection fraction was independently associated with mortality (odds ratio, 3.90 [2.09-7.40]), whereas depressed left ventricular ejection fraction did not (odds ratio, 0.62 [0.28-1.37]). Systemic vascular resistance was inversely associated with hyperdynamic left ventricular ejection fraction (odds ratio, 0.79 [0.58-0.95]), and age, frailty, and ischemic heart disease were associated with depressed left ventricular ejection fraction. CONCLUSIONS Hyperdynamic left ventricular ejection fraction was associated with mortality in septic ICU patients and may reflect unmitigated vasoplegia from sepsis. Depressed left ventricular ejection fraction was not associated with mortality but was associated with cardiovascular disease.
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Affiliation(s)
- Minesh Chotalia
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Muzzammil Ali
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
| | - Ravi Hebballi
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
| | - Harjot Singh
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
| | - Dhruv Parekh
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Mansoor N Bangash
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Jaimin M Patel
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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Surfactant protein D: a predictor for severity of community-acquired pneumonia in children. Pediatr Res 2022; 91:665-671. [PMID: 33790414 PMCID: PMC8010482 DOI: 10.1038/s41390-021-01492-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 01/29/2021] [Accepted: 03/04/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surfactant protein D (SP-D) is a promising biomarker proposed for the prediction of community-acquired pneumonia (CAP) severity. Therefore, we aimed to assess the role of SP-D in the prediction of CAP severity in pediatric patients. METHODS A prospective cohort study was carried out at the Pediatric Intensive Care Unit (PICU) and wards of Menoufia University Hospital. We recruited 112 children admitted into wards with pneumonia (simple pneumonia) and 68 children admitted into PICU with severe pneumonia (PICU admitted). World Health Organization (WHO) classification and mortality predictive scores were calculated to determine the severity of pneumonia for the two groups, including the Pediatric Respiratory Severity Score (PRESS) and the Predisposition, Insult, Response, and Organ dysfunction modified Score (PIROm). SP-D was measured at admission. RESULTS The SP-D level was significantly lower in patients with simple pneumonia than in patients with severe pneumonia (P < 0.001). SP-D was significantly higher among children with severe pneumonia, as determined by WHO, PRESS, and PIROm (P = 0.001). SP-D was significantly higher among children with mechanical ventilation, shock, hypoxia, sepsis, and mortality. Receiver operating characteristic curve analysis for SP-D showed that the area under the curve was 0.741 (P value < 0.001), with a sensitivity of 85.3% and a specificity of 44.6%. CONCLUSIONS Serum SP-D level has a predictive value for the detection of community-acquired pneumonia severity in children. IMPACT SP-D is a good predictor for the detection of CAP severity in hospitalized children. SP-D was correlated with severity scores and was associated with indicators of CAP severity, including mechanical ventilation, shock, hypoxia, sepsis, and mortality.
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Gebretekle GB, Mariam DH, Mac S, Abebe W, Alemayehu T, Degu WA, Libman M, Yansouni CP, Fenta TG, Semret M, Sander B. Cost-utility analysis of antimicrobial stewardship programme at a tertiary teaching hospital in Ethiopia. BMJ Open 2021; 11:e047515. [PMID: 34921071 PMCID: PMC8685939 DOI: 10.1136/bmjopen-2020-047515] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Antimicrobial stewardship (AMS) significantly reduces inappropriate antibiotic use and improves patient outcomes. In low-resource settings, AMS implementation may require concurrent strengthening of clinical microbiology capacity therefore additional investments. We assessed the cost-effectiveness of implementing AMS at Tikur Anbessa Specialised Hospital (TASH), a tertiary care hospital in Ethiopia. DESIGN We developed a Markov cohort model to assess the cost-utility of pharmacist-led AMS with concurrent strengthening of laboratory capacity compared with usual care from a 'restricted societal' perspective. We used a lifetime time horizon and discounted health outcomes and cost at 3% annually. Data were extracted from a prospective study of bloodstream infections among patients hospitalised at TASH, supplemented by published literature. We assessed parameter uncertainty using deterministic and probabilistic sensitivity analyses. SETTING Tertiary care hospital in Ethiopia, with 800 beds and serves over half a million patients per year. POPULATION Cohort of adults and children inpatient population aged 19.8 years at baseline. INTERVENTION Laboratory-supported pharmacist-led AMS compared with usual care. Usual care is defined as empirical initiation of antibiotic therapy in the absence of strong laboratory and AMS. OUTCOME MEASURES Expected life-years, quality-adjusted life-years (QALYs), costs (US$2018) and incremental cost-effectiveness ratio. RESULTS Laboratory-supported AMS strategy dominated usual care, that is, AMS was associated with an expected incremental gain of 38.8 QALYs at lower expected cost (incremental cost savings:US$82 370) per 1000 patients compared with usual care. Findings were sensitive to medication cost, infection-associated mortality and AMS-associated mortality reduction. Probabilistic sensitivity analysis demonstrated that AMS programme was likely to be cost-effective at 100% of the simulation compared with usual care at 1%-51% of gross domestic product/capita. CONCLUSION Our study indicates that laboratory-supported pharmacist-led AMS can result in improved health outcomes and substantial healthcare cost savings, demonstrating its economic advantage in a tertiary care hospital despite greater upfront investments in a low-resource setting.
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Affiliation(s)
- Gebremedhin Beedemariam Gebretekle
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Damen Haile Mariam
- School of Public Health, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Stephen Mac
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
| | - Workeabeba Abebe
- Pediatrics and Child Health, Pediatric Cardiology Unit, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tinsae Alemayehu
- St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
- American Medical Center, Specialty Center for Infectious Diseases and Travel Medicine, Addis Ababa, Ethiopia
| | - Wondwossen Amogne Degu
- School of Medicine, Addis Ababa University College of Health Sciences, Addis Ababa, Ethiopia
| | - Michael Libman
- J.D. MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Québec, Canada
| | - Cedric P Yansouni
- J.D. MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Québec, Canada
- Divisions of Infectious Diseases and Medical Microbiology, McGill University Health Centre, Montreal, Québec, Canada
| | - Teferi Gedif Fenta
- School of Pharmacy, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | - Makeda Semret
- J.D. MacLean Centre for Tropical Diseases, McGill University Health Centre, Montreal, Québec, Canada
| | - Beate Sander
- Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Toronto Health Economics and Technology Assessment (THETA) Collaborative, University Health Network, Toronto, Ontario, Canada
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10
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Cennamo F, Masetti R, Largo P, Argentiero A, Pession A, Esposito S. Update on Febrile Neutropenia in Pediatric Oncological Patients Undergoing Chemotherapy. CHILDREN 2021; 8:children8121086. [PMID: 34943282 PMCID: PMC8700030 DOI: 10.3390/children8121086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/12/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022]
Abstract
Febrile neutropenia (FN) is a common complication of chemotherapy in oncological children and one of the most important causes of morbidity and mortality in these patients. The early detection of a bacteremia and the rapid therapeutic intervention are crucial to improve the outcome. We analyzed the literature in order to clarify the epidemiology of FN in children undergoing chemotherapy, the specific factors associated with a negative outcome, the most common etiology, and the value of biological markers as a tool to make an early diagnosis or to monitor the evolution of the infection. Several studies have tried to identify specific factors that could help the clinician in the detection of an infection and in its microbiological identification. However, due to the heterogenicity of the available studies, sufficient evidence is lacking to establish the role of these risk factors in clinical practice and future research on this topic appear mandatory. Determinations of risk factors, etiology, and markers of febrile episodes in these patients are complicated by the characteristics of the underlying illness and the effects of treatments received. Although some studies have tried to develop an evidence-based guideline for the empiric management of FN in pediatrics, validated predictive scores and algorithms are still lacking and urgently needed.
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Affiliation(s)
- Federica Cennamo
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Riccardo Masetti
- Pediatric Oncology and Hematology Unit “Lalla Seragnoli”, Pediatric Unit-IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.M.); (A.P.)
| | - Prisca Largo
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Alberto Argentiero
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
| | - Andrea Pession
- Pediatric Oncology and Hematology Unit “Lalla Seragnoli”, Pediatric Unit-IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (R.M.); (A.P.)
| | - Susanna Esposito
- Pediatric Clinic, Pietro Barilla Children’s Hospital, Department of Medicine and Surgery, University of Parma, Via Gramsci 14, 43126 Parma, Italy; (F.C.); (P.L.); (A.A.)
- Correspondence: ; Tel.: +39-0521-704-790
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Factors associated with severe sepsis in diarrheal adults and their outcome at an urban hospital, Bangladesh: A retrospective analysis. PLoS One 2021; 16:e0257596. [PMID: 34543323 PMCID: PMC8452033 DOI: 10.1371/journal.pone.0257596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 09/06/2021] [Indexed: 12/29/2022] Open
Abstract
Background To describe factors associated with severe sepsis in diarrheal adults and their outcomes and offender in blood and stool to understand their interplay as clinical features of sepsis and severe diarrhea often overlap. Methods and results We used this retrospective chart analysis employing an unmatched case-control design to study critically ill diarrheal adults aged ≥18 years treated in ICU of Dhaka hospital, icddr,b between January 2011 to December 2015. Of 8,863 in-patient diarrheal adults, 350 having severe sepsis were cases and an equal number of randomly selected non-septic patients were the controls. Cases died significantly more (14.9% vs 4.6%, p = <0.001) than controls. 69% of the cases progressed to septic shock. In logistic regression analysis, steroid intake, ileus, acute kidney injury (AKI), metabolic acidosis, and hypocalcemia were significantly associated with severe sepsis in diarrheal adults (all, p<0.05). 12% of cases (40/335) had bacteremia. Streptococcus pneumoniae [9 (22.5%)] was the single most common pathogen and gram-negatives [27 (67.5%)] were prevailing as a group. Conclusion Diarrheal adults who had ileus, AKI, metabolic acidosis, hypocalcemia, and also took steroids were found to have an association with severe sepsis. Strikingly, gram-negative were the predominant bacteria among the diarrheal adults having severe sepsis.
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Fernández S, Palomo M, Molina P, Díaz-Ricart M, Escolar G, Téllez A, Seguí F, Ventosa H, Torramade-Moix S, Rovira M, Carreras E, Nicolás JM, Castro P. Progressive endothelial cell damage in correlation with sepsis severity. Defibrotide as a contender. J Thromb Haemost 2021; 19:1948-1958. [PMID: 33872468 DOI: 10.1111/jth.15343] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 04/03/2021] [Accepted: 04/13/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND The vascular endothelium plays a key role in sepsis pathophysiology and the associated organ dysfunction. METHODS We evaluated endothelial function in an experimental in vitro model of sepsis, using endothelial cells grown in the presence of serum from patients with septic syndromes (sepsis, severe sepsis, and septic shock), noninfectious systemic inflammatory response syndrome (NI-SIRS) and healthy volunteers. Experiments were performed in the absence and presence of defibrotide (DF) (100 µg/ml) to evaluate its potential protective effect. RESULTS After exposure to patients' sera, there was a progressive endothelial cell activation in correlation with sepsis severity, with a proinflammatory and prothrombotic phenotype, exhibiting significantly increased expression of adhesion receptors at the surface (intercellular adhesion molecule-1, p < .05 and vascular cell adhesion molecule-1, p < .05); higher production and release to the extracellular matrix (ECM) of von Willebrand factor (p < .001); augmented thrombogenicity of the ECM toward platelets (p < .001); and increased phosphorylation of intracellular p38MAPK. DF prevented these changes in all groups. CONCLUSIONS Markers of endothelial damage increased progressively in association with the severity of septic syndromes. The endothelium is therefore an important therapeutic target to prevent complications of sepsis. DF shows promising potential to modulate the endothelial damage associated with sepsis and may constitute a pharmacological tool to decrease its sequelae including multiorgan failure.
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Affiliation(s)
- Sara Fernández
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
| | - Marta Palomo
- Josep Carreras Leukaemia Research Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Patricia Molina
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
| | - Maribel Díaz-Ricart
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Ginés Escolar
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Adrián Téllez
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
| | - Ferran Seguí
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
| | - Helena Ventosa
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
| | - Sergi Torramade-Moix
- Hematopathology, Pathology Department, CDB, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
| | - Montserrat Rovira
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
- Stem Cell Transplantation Unit, Department of Haematology, Institute of Haematology and Oncology, Hospital Clinic, Barcelona, Spain
| | - Enric Carreras
- Josep Carreras Leukaemia Research Institute, Hospital Clínic, University of Barcelona, Barcelona, Spain
- Barcelona Endothelium Team, Barcelona, Spain
| | - Josep M Nicolás
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
| | - Pedro Castro
- Medical Intensive Care Unit, Hospital Clinic, Barcelona, Spain
- IDIBAPS, Barcelona, Spain
- School of Medicine, University of Barcelona, Barcelona, Spain
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Kaddoura R, Elmoheen A, Badawy E, Eltawagny MF, Seif MA, Bashir K, Salam AM. Vasoactive pharmacologic therapy in cardiogenic shock: a critical review. J Drug Assess 2021; 10:68-85. [PMID: 34350058 PMCID: PMC8293961 DOI: 10.1080/21556660.2021.1930548] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/12/2021] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Cardiogenic shock (CS) is an acute complex condition leading to morbidity and mortality. Vasoactive medications, such as vasopressors and inotropes are considered the cornerstone of pharmacological treatment of CS to improve end-organ perfusion by increasing cardiac output (CO) and blood pressure (BP), thus preventing multiorgan failure. OBJECTIVE A critical review was conducted to analyze the currently available randomized studies of vasoactive agents in CS to determine the indications of each agent and to critically appraise the methodological quality of the studies. METHODS PubMed database search was conducted to identify randomized controlled trials (RCTs) on vasoactive therapy in CS. After study selection, the internal validity of the selected studies was critically appraised using the three-item Jadad scale. RESULTS Nine studies randomized 2388 patients with a mean age ranged between 62 and 69 years, were identified. Seven of studies investigated CS in the setting of acute myocardial infarction (AMI). The studies evaluated the comparisons of norepinephrine (NE) vs. dopamine, epinephrine vs. NE, levosimendan vs. dobutamine, enoximone or placebo, and nitric oxide synthase inhibitors (NOSi) vs. placebo. The mean Jadad score of the nine studies was 3.33, with only three studies of a score of 5. CONCLUSIONS The evidence from the studies of vasoactive agents in CS carries uncertainties. The methodological quality between the studies is variable due to the inherent difficulties to conduct a study in CS. Vasopressors and inotropes continue to have a fundamental role given the lack of pharmacological alternatives.
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Affiliation(s)
- Rasha Kaddoura
- Heart Hospital Pharmacy, Hamad Medical Corporation, Doha, Qatar
| | - Amr Elmoheen
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Ehab Badawy
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | | | - Mohamed A. Seif
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Khalid Bashir
- Emergency Department, Hamad Medical Corporation, Doha, Qatar
| | - Amar M. Salam
- College of Medicine, QU Health, Qatar University, Doha, Qatar
- Adult Cardiology, Hamad Medical Corporation, Doha, Qatar
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A Locally Optimized Data-Driven Tool to Predict Sepsis-Associated Vasopressor Use in the ICU. Crit Care Med 2021; 49:e1196-e1205. [PMID: 34259450 PMCID: PMC8602707 DOI: 10.1097/ccm.0000000000005175] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To train a model to predict vasopressor use in ICU patients with sepsis and optimize external performance across hospital systems using domain adaptation, a transfer learning approach. DESIGN Observational cohort study. SETTING Two academic medical centers from January 2014 to June 2017. PATIENTS Data were analyzed from 14,512 patients (9,423 at the development site and 5,089 at the validation site) who were admitted to an ICU and met Center for Medicare and Medicaid Services definition of severe sepsis either before or during the ICU stay. Patients were excluded if they never developed sepsis, if the ICU length of stay was less than 8 hours or more than 20 days or if they developed shock up to the first 4 hours of ICU admission. MEASUREMENTS AND MAIN RESULTS Forty retrospectively collected features from the electronic medical records of adult ICU patients at the development site (four hospitals) were used as inputs for a neural network Weibull-Cox survival model to derive a prediction tool for future need of vasopressors. Domain adaptation updated parameters to optimize model performance in the validation site (two hospitals), a different healthcare system over 2,000 miles away. The cohorts at both sites were randomly split into training and testing sets (80% and 20%, respectively). When applied to the test set in the development site, the model predicted vasopressor use 4-24 hours in advance with an area under the receiver operator characteristic curve, specificity, and positive predictive value ranging from 0.80 to 0.81, 56.2% to 61.8%, and 5.6% to 12.1%, respectively. Domain adaptation improved performance of the model to predict vasopressor use within 4 hours at the validation site (area under the receiver operator characteristic curve 0.81 [CI, 0.80-0.81] from 0.77 [CI, 0.76-0.77], p < 0.01; specificity 59.7% [CI, 58.9-62.5%] from 49.9% [CI, 49.5-50.7%], p < 0.01; positive predictive value 8.9% [CI, 8.5-9.4%] from 7.3 [7.1-7.4%], p < 0.01). CONCLUSIONS Domain adaptation improved performance of a model predicting sepsis-associated vasopressor use during external validation.
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Coronavirus Disease 2019 Calls for Predictive Analytics Monitoring-A New Kind of Illness Scoring System. Crit Care Explor 2020; 2:e0294. [PMID: 33364604 PMCID: PMC7752690 DOI: 10.1097/cce.0000000000000294] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Coronavirus disease 2019 can lead to sudden and severe respiratory failure that mandates endotracheal intubation, a procedure much more safely performed under elective rather than emergency conditions. Early warning of rising risk of this event could benefit both patients and healthcare providers by reducing the high risk of emergency intubation. Current illness severity scoring systems, which usually update only when clinicians measure vital signs or laboratory values, are poorly suited for early detection of this kind of rapid clinical deterioration. We propose that continuous predictive analytics monitoring, a new approach to bedside management, is more useful. The principles of this new practice anchor in analysis of continuous bedside monitoring data, training models on diagnosis-specific paths of deterioration using clinician-identified events, and continuous display of trends in risks rather than alerts when arbitrary thresholds are exceeded.
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Korang SK, Safi S, Feinberg J, Gluud C, Perner A, Jakobsen JC. Higher versus lower blood pressure targets in adults with shock. Hippokratia 2019. [DOI: 10.1002/14651858.cd013470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Steven Kwasi Korang
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Sanam Safi
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Joshua Feinberg
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Copenhagen Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Anders Perner
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
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Precision Medicine and its Role in the Treatment of Sepsis: A Personalised View. ACTA ACUST UNITED AC 2019; 5:90-96. [PMID: 31431921 PMCID: PMC6698074 DOI: 10.2478/jccm-2019-0017] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 07/29/2019] [Indexed: 02/08/2023]
Abstract
In recent years, a new form of medicine has become increasingly significant, namely, personalised medicine (PM). PM is a form of care in which treatment is tailored for an individual patient. PM is about using multiple data sets to create a digital human mapping. A person’s biological traits are determined by the interactions of hundreds of genes and gene networks, as well as external factors such as diet and exercise. Combining and then investigating these multiple databases with powerful statistical tools, allows a new understanding of how genetic intricacy drives health and disease and so leads to a closer personalised medical approach that targets each individual’s unique genetic make-up. Sepsis is a systemic inflammatory response to infection, ranging from systemic inflammatory response syndrome (SIRS) to septic shock and multiple organ dysfunction syndromes (MODS). Sepsis is the most common cause of death in intensive care patients. Treatments in an ICU may need to be adapted to the continuous and rapid changes of the disease, making it challenging to identify a single target. PM is thus seen as the future of sepsis treatment in the ICU. The fact that individual patients respond differently to treatment should be regarded as a starting point in the approach to providing treatment. The disease itself comes secondary to this concept.
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Mathematical modeling of septic shock: an innovative tool for assessing therapeutic hypotheses. SN APPLIED SCIENCES 2019. [DOI: 10.1007/s42452-019-0747-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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Grudzinska FS, Aldridge K, Hughes S, Nightingale P, Parekh D, Bangash M, Dancer R, Patel J, Sapey E, Thickett DR, Dosanjh DP. Early identification of severe community-acquired pneumonia: a retrospective observational study. BMJ Open Respir Res 2019; 6:e000438. [PMID: 31258921 PMCID: PMC6561385 DOI: 10.1136/bmjresp-2019-000438] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/16/2019] [Accepted: 05/16/2019] [Indexed: 01/27/2023] Open
Abstract
Background Community-acquired pneumonia (CAP) is a leading cause of sepsis worldwide. Prompt identification of those at high risk of adverse outcomes improves survival by enabling early escalation of care. There are multiple severity assessment tools recommended for risk stratification; however, there is no consensus as to which tool should be used for those with CAP. We sought to assess whether pneumonia-specific, generic sepsis or early warning scores were most accurate at predicting adverse outcomes. Methods We performed a retrospective analysis of all cases of CAP admitted to a large, adult tertiary hospital in the UK between October 2014 and January 2016. All cases of CAP were eligible for inclusion and were reviewed by a senior respiratory physician to confirm the diagnosis. The association between the CURB65, Lac-CURB-65, quick Sequential (Sepsis-related) Organ Failure Assessment tool (qSOFA) score and National Early Warning Score (NEWS) at the time of admission and outcome measures including intensive care admission, length of hospital stay, in-hospital, 30-day, 90-day and 365-day all-cause mortality was assessed. Results 1545 cases were included with 30-day mortality of 19%. Increasing score was significantly associated with increased risk of poor outcomes for all four tools. Overall accuracy assessed by receiver operating characteristic curve analysis was significantly greater for the CURB65 and Lac-CURB-65 scores than qSOFA. At admission, a CURB65 ≥2, Lac-CURB-65 ≥moderate, qSOFA ≥2 and NEWS ≥medium identified 85.0%, 96.4%, 40.3% and 79.0% of those who died within 30 days, respectively. A Lac-CURB-65 ≥moderate had the highest negative predictive value: 95.6%. Conclusion All four scoring systems can stratify according to increasing risk in CAP; however, when a confident diagnosis of pneumonia can be made, these data support the use of pneumonia-specific tools rather than generic sepsis or early warning scores.
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Affiliation(s)
- Frances S Grudzinska
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Kerrie Aldridge
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Sian Hughes
- Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | | | - Dhruv Parekh
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | | | - Rachel Dancer
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Jaimin Patel
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - David R Thickett
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Davinder P Dosanjh
- Institute of Inflammation and Ageing, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
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Evaluation of systemic inflammatory response syndrome-negative sepsis from a Chinese regional pediatric network. BMC Pediatr 2019; 19:11. [PMID: 30621637 PMCID: PMC6325779 DOI: 10.1186/s12887-018-1364-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 12/04/2018] [Indexed: 12/30/2022] Open
Abstract
Background The identification of sepsis in children varies depending on the definition used. Our purpose was to compare clinical data and outcome of atypical sepsis, manifested as having sepsis but not fulfilling the criteria of systemic inflammatory response syndrome (SIRS-negative sepsis, SNS), in children based on the modified Angus criteria with those of sepsis (S) and severe sepsis (SS) based on the international consensus criteria. Methods Pediatric departments in 11 regional city and county referral hospitals with emergency and intensive care settings in Huai’an serving for 843,000 children participated in a parallel multicenter prospective survey. Clinical data registry was used to recruit those who fulfilled the diagnostic criteria for pediatric sepsis from all admissions (n = 27,836) from 28 days to 15 years old, from September 1, 2010 to August 31, 2011. Results A total of 1606 children met the criteria for pediatric sepsis and were divided into three groups: S, (n = 1377), SS (n = 153, including 32 septic shock), based on the consensus definition criteria, and SNS (n = 76) based on the modified Angus criteria. Most deaths (38/54, 70.3%) occurred within three days of admission. The SNS mainly occurred in infants and was associated with cardiopulmonary and neurologic dysfunction without satisfying the SIRS criteria. Conclusions SNS differed from SS in that it predominantly affected infants and manifested with cardiopulmonary and neurologic dysfunction. There were no laboratory variables which were useful in identification of SNS, or predicting response to therapy or outcome.
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Jiang J, Yang J, Jin Y, Cao J, Lu Y. Role of qSOFA in predicting mortality of pneumonia: A systematic review and meta-analysis. Medicine (Baltimore) 2018; 97:e12634. [PMID: 30290639 PMCID: PMC6200542 DOI: 10.1097/md.0000000000012634] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 09/10/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND The concept of sepsis was redefined recently, and a new screening system termed the quick Sequential Organ Failure Assessment (qSOFA) was recommended for identifying infected patients at high risk for death. However, the predictive value of qSOFA for mortality in patients with pneumonia remains unclear. Thus, we performed a meta-analysis with the aim of determining the prognostic value of qSOFA in predicting mortality in patients with pneumonia. METHODS Embase, Google Scholar, and PubMed (up to March 2018) were searched for related articles. We constructed a 2 × 2 contingency table according to mortality and qSOFA scores (<2 and ≥2) in patients with pneumonia. Two investigators independently extracted data and assessed study eligibility. A bivariate meta-analysis model was used to determine the prognostic value of qSOFA in predicting mortality. I index and Q-test were used to assess heterogeneity. RESULTS Six studies with 17,868 patients were included. A qSOFA score ≥2 was related to a higher risk for death in patients with pneumonia, with a pooled risk ratio (RR) was 3.35 (95% CI, 2.24-5.01) using a random-effects model (I = 89.4%). The pooled sensitivity and specificity of a qSOFA score ≥2 to predict mortality in patients with pneumonia were 0.43 (95% CI, 0.33-0.53) and 0.86 (95% CI, 0.76-0.92), respectively. The diagnostic OR was 4 (95% CI, 3-6). The area under the summary receiver operator characteristic (SROC) curve was 0.67 (95% CI, 0.63-0.71). When we calculated the community-acquired pneumonia (CAP) subgroup, the pooled sensitivity and specificity were 0.36 (95% CI, 0.26-0.48) and 0.91 (95% CI, 0.84-0.95), respectively. The area under the SROC curve was 0.70 (95% CI, 0.66-0.74). CONCLUSIONS A qSOFA score ≥2 is strongly associated with mortality in patients with pneumonia, but the poor sensitivity of qSOFA may have limitations in the early identification of mortality in patients with pneumonia.
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Affiliation(s)
- Jianjun Jiang
- Department of Respiratory Medicine, The Second Affiliated Hospital of Anhui Medical University
| | - Jin Yang
- Department of Respiratory Medicine, The Second Affiliated Hospital of Anhui Medical University
| | - Yongmei Jin
- Department of Respiratory Medicine, The Second Affiliated Hospital of Anhui Medical University
| | - Jiyu Cao
- The Teaching Center for Preventive Medicine, School of Public Health, Anhui Medical University, Hefei, China
| | - Youjin Lu
- Department of Respiratory Medicine, The Second Affiliated Hospital of Anhui Medical University
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Viaggi B, Poole D, Tujjar O, Marchiani S, Ognibene A, Finazzi S. Mid regional pro-adrenomedullin for the prediction of organ failure in infection. Results from a single centre study. PLoS One 2018; 13:e0201491. [PMID: 30102716 PMCID: PMC6089425 DOI: 10.1371/journal.pone.0201491] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/15/2018] [Indexed: 01/21/2023] Open
Abstract
Biomarkers are widely used to confirm the presence of infection. However, it would be of the greatest importance to predict in advance the occurrence or worsening of organ dysfunction in infected patients allowing timely antibiotic escalation. This study investigates the ability of procalcitonin (PCT) and MR-proADM to predict the transition to sepsis in infected patients. The study was conducted in a neurointensive care unit over a three-month period. We included both patients with and without infection to investigate the specificity of organ dysfunction prediction in infected patients. Daily measurement of PCT and MR-proADM, SOFA, Pitt, and CPIS were performed. To measure the correlation between each biomarker and each severity score, linear mixed-effects models were developed. For each biomarker-score combination we tested the correlation of the score with the biomarker measured one and two days before, the same day, and the day after. Sixty-four critically ill patients, 31 with infection, were enrolled. The statistically significant biomarker-score combinations were PCT-SOFA, MR-proADM-SOFA, MR-proADM-Pitt, and MR-proADM-CPIS. The MR-proADM models predicting Pitt and CPIS variations with 24-hour anticipation showed the best fit. The scores increased by 0.6 ± 0.3 and 0.4 ± 0.2 for each unitary biomarker increase, respectively. The MR-proADM-SOFA combinations were equivalent when the biomarker was measured the day before or the same day (score increases were 1.5 ± 0.4 and 1.9 ± 0.4, respectively). The PCT-SOFA model had the best fit when PCT was measured the same day of the score. There was no difference in the predictive ability of the biomarker in infected and non-infected patients. This was a pivotal study conducted in a single neurointensive centre on a limited number of patients, and as such it does not provide definitive conclusions. PR-proADM predicted occurrence and worsening of organ failure in critically ill patients with and without infection. The combination with infection diagnostic biomarkers such as PCT would allow predicting evolution to sepsis in infected patients.
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Affiliation(s)
- Bruno Viaggi
- Dept of Anesthesia, NeuroIntensive Care Unit, Careggi University Hospital, Florence, Italy
| | - Daniele Poole
- Anesthesia and intensive care operative Unit, S. Martino Hospital, Belluno, Italy
- * E-mail:
| | - Omar Tujjar
- Dept of Anesthesia, Salt University Healthcare Group, Sligo University Hospital, Sligo, Ireland
| | - Silvia Marchiani
- Dept of Anesthesia, NeuroIntensive Care Unit, Careggi University Hospital, Florence, Italy
| | | | - Stefano Finazzi
- GiViTI coordinating center, IRCCS, Istituto di Ricerche Farmacologiche “Mario Negri”, Ranica, Bergamo, Italy
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Imani S, Buscher H, Marriott D, Gentili S, Sandaradura I. Too much of a good thing: a retrospective study of β-lactam concentration-toxicity relationships. J Antimicrob Chemother 2018; 72:2891-2897. [PMID: 29091190 DOI: 10.1093/jac/dkx209] [Citation(s) in RCA: 160] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 05/31/2017] [Indexed: 01/08/2023] Open
Abstract
Objectives To determine the existence of concentration-toxicity relationships for common β-lactam antibiotic adverse effects and define thresholds above which toxicity is more likely. Patients and methods Retrospective review of consecutive patients treated with piperacillin, meropenem or flucloxacillin who underwent therapeutic drug monitoring (TDM) at St Vincent's Hospital (Sydney, Australia) between January 2013 and December 2015. Adverse events investigated included neurotoxicity, nephrotoxicity, hepatotoxicity and opportunistic Clostridium difficile infection. Toxicity was measured using observational grading criteria, clinical assessment and relevant serum biomarkers. These findings were correlated with trough TDM measurements at the time of toxicity presentation. Results TDM results from 378 patients (piperacillin = 223, meropenem = 94 and flucloxacillin = 61) were investigated. There was no difference in baseline patient characteristics across antibiotic groups. A statistically significant elevation in mean serum trough concentrations (Cmin) was found in patients diagnosed with neurotoxicity (piperacillin, P < 0.01; meropenem, P = 0.04; flucloxacillin, P = 0.01) and those who developed nephrotoxicity whilst being treated with piperacillin (P < 0.01) or meropenem (P < 0.01). Incidence of hepatotoxicity and C. difficile was not related to Cmin. Threshold concentrations for which there is 50% risk of developing a neurotoxicity event (piperacillin, Cmin >361.4 mg/L; meropenem, Cmin >64.2 mg/L; flucloxacillin, Cmin >125.1 mg/L) or nephrotoxicity (piperacillin, Cmin >452.65 mg/L; meropenem, Cmin >44.45 mg/L) varied across antibiotics. Conclusions Our data reveal an association between toxic concentrations for a number of β-lactam agents and neurotoxic/nephrotoxic effects. We have defined threshold concentrations above which these toxicities become more likely. Clinicians should balance concerns for therapeutic efficacy with potential toxicity when considering aggressive therapy.
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Affiliation(s)
- Sahand Imani
- School of Medicine, University of Notre Dame Australia, Sydney, NSW, Australia.,Department of Clinical Microbiology, St Vincent's Hospital, Sydney, NSW, Australia
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, NSW, Australia.,School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Debbie Marriott
- Department of Clinical Microbiology, St Vincent's Hospital, Sydney, NSW, Australia.,School of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Sheridan Gentili
- School of Pharmacy and Medical Sciences, Sansom Institute for Health Research, University of South Australia, Adelaide, SA, Australia
| | - Indy Sandaradura
- School of Medicine, University of New South Wales, Sydney, NSW, Australia.,Centre for Infectious Diseases and Microbiology, Westmead Hospital, Sydney, NSW, Australia
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Bonelli F, Meucci V, Divers TJ, Boccardo A, Pravettoni D, Meylan M, Belloli AG, Sgorbini M. Plasma procalcitonin concentration in healthy calves and those with septic systemic inflammatory response syndrome. Vet J 2018; 234:61-65. [PMID: 29680395 DOI: 10.1016/j.tvjl.2018.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 02/06/2018] [Accepted: 02/09/2018] [Indexed: 10/18/2022]
Abstract
The diagnosis of sepsis in calves is challenging. Blood culture and clinical signs combined with a complete blood count have been used for the diagnosis of sepsis. Recent literature in humans and animal species has been focused on sepsis-specific biomarkers, such as procalcitonin (PCT), that may more accurately and efficiently diagnose sepsis. The aim of this study was to evaluate plasma PCT concentrations in healthy and septic calves. Twenty healthy control calves and 58 sick calves with septic systemic inflammatory response syndrome (SIRS) based on SIRS score and clinical findings were included. Calves with septic SIRS were further divided in septic SIRS survivors (SSS) and non-survivors (SSNS). Plasma PCT concentrations were measured with a commercial ELISA assay for cattle. A receiver operating characteristic curve was used to determine cut-off values and corresponding sensitivity and specificity for the diagnosis of sepsis. Differences in plasma PCT concentration between groups (control vs. SSS vs. SSNS) were evaluated. Plasma PCT concentrations in healthy calves and those with septic SIRS were 33.3pg/mL (0-44.3pg/mL) and 166.5pg/mL (85.9-233.0pg/mL), respectively (P<0.001). The optimal cut-off value to predict septic SIRS was 67.39pg/mL (81.0% sensitivity, 95.0% specificity). Plasma PCT concentrations were 127.4pg/mL (72.2-216.0pg/mL) and 234.3pg/mL (204.5-309.4pg/mL) in the SSS and SSNS subgroups, respectively. Statistically significant differences were found among groups (control vs. SSS and SSNS, P<0.0001; SSS vs. SSNS, P>0.05). These results confirmed an increase in plasma PCT concentrations in calves with septic SIRS, as previously reported in humans and other species.
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Affiliation(s)
- F Bonelli
- Department of Veterinary Sciences, via Livornese snc, 56122, San Piero a Grado (PI), Italy.
| | - V Meucci
- Department of Veterinary Sciences, via Livornese snc, 56122, San Piero a Grado (PI), Italy
| | - T J Divers
- College of Veterinary Medicine, Cornell University, Vet Box 25, Ithaca, NY 14853, USA
| | - A Boccardo
- Department of Veterinary Medicine, via dell'Università 6, 26900, Lodi, Italy
| | - D Pravettoni
- Department of Veterinary Medicine, via dell'Università 6, 26900, Lodi, Italy
| | - M Meylan
- Clinic for Ruminants, Vetsuisse-Faculty, University of Bern, Bremgartenstrasse 109a, 3012 Bern, Switzerland
| | - A G Belloli
- Department of Veterinary Medicine, via dell'Università 6, 26900, Lodi, Italy
| | - M Sgorbini
- Department of Veterinary Sciences, via Livornese snc, 56122, San Piero a Grado (PI), Italy
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25
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Ranzani OT, Prina E, Menéndez R, Ceccato A, Cilloniz C, Méndez R, Gabarrus A, Barbeta E, Bassi GL, Ferrer M, Torres A. New Sepsis Definition (Sepsis-3) and Community-acquired Pneumonia Mortality. A Validation and Clinical Decision-Making Study. Am J Respir Crit Care Med 2017; 196:1287-1297. [DOI: 10.1164/rccm.201611-2262oc] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Otavio T. Ranzani
- Department of Pulmonology, Hospital Clinic of Barcelona, University of Barcelona, Institut D’investigacions August Pi i Sunyer, Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Barcelona, Spain
- Respiratory Intensive Care Unit, Pulmonary Division, Heart Institute, Hospital das Clínicas, University of Sao Paulo, Sao Paulo, Brazil
| | - Elena Prina
- Department of Pulmonology, Hospital Clinic of Barcelona, University of Barcelona, Institut D’investigacions August Pi i Sunyer, Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Barcelona, Spain
| | - Rosario Menéndez
- Pneumology Department, Instituto de Investigación Sanitaria/Hospital Universitario y Politecnico La Fe, Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Valencia, Spain; and
| | - Adrian Ceccato
- Department of Pulmonology, Hospital Clinic of Barcelona, University of Barcelona, Institut D’investigacions August Pi i Sunyer, Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Barcelona, Spain
- Seccion Neumologia, Hospital Nacional Prof. Alejandro Posadas, Palomar, Argentina
| | - Catia Cilloniz
- Department of Pulmonology, Hospital Clinic of Barcelona, University of Barcelona, Institut D’investigacions August Pi i Sunyer, Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Barcelona, Spain
| | - Raul Méndez
- Pneumology Department, Instituto de Investigación Sanitaria/Hospital Universitario y Politecnico La Fe, Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Valencia, Spain; and
| | - Albert Gabarrus
- Department of Pulmonology, Hospital Clinic of Barcelona, University of Barcelona, Institut D’investigacions August Pi i Sunyer, Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Barcelona, Spain
| | - Enric Barbeta
- Department of Pulmonology, Hospital Clinic of Barcelona, University of Barcelona, Institut D’investigacions August Pi i Sunyer, Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Barcelona, Spain
| | - Gianluigi Li Bassi
- Department of Pulmonology, Hospital Clinic of Barcelona, University of Barcelona, Institut D’investigacions August Pi i Sunyer, Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Barcelona, Spain
| | - Miquel Ferrer
- Department of Pulmonology, Hospital Clinic of Barcelona, University of Barcelona, Institut D’investigacions August Pi i Sunyer, Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Barcelona, Spain
| | - Antoni Torres
- Department of Pulmonology, Hospital Clinic of Barcelona, University of Barcelona, Institut D’investigacions August Pi i Sunyer, Centro de Investigación Biomedica En Red-Enfermedades Respiratorias, Barcelona, Spain
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Taniguchi LU, Pires EMC, Vieira JM, Azevedo LCPD. Systemic inflammatory response syndrome criteria and the prediction of hospital mortality in critically ill patients: a retrospective cohort study. Rev Bras Ter Intensiva 2017; 29:317-324. [PMID: 28977100 PMCID: PMC5632974 DOI: 10.5935/0103-507x.20170047] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 04/18/2017] [Indexed: 01/20/2023] Open
Abstract
OBJECTIVE This study intended to determine whether the systemic inflammatory response syndrome criteria can predict hospital mortality in a Brazilian cohort of critically ill patients. METHODS We performed a retrospective cohort study at a private tertiary hospital in São Paulo (SP), Brazil. We extracted information from the adult intensive care unit database (Sistema EpimedTM). We compared the SAPS 3 and the systemic inflammatory response syndrome model as dichotomous (≥ 2 criteria: systemic inflammatory response syndrome -positive versus 0 - 1 criterion: systemic inflammatory response syndrome -negative) and ordinal variables from 0 to 4 (according to the number of systemic inflammatory response syndrome criteria met) in the prediction of hospital mortality at intensive care unit admission. Model discrimination was compared using the area under the receiver operating characteristics (AUROC) curve. RESULTS From January to December 2012, we studied 932 patients (60.4% were systemic inflammatory response syndrome -positive). systemic inflammatory response syndrome -positive patients were more critically ill than systemic inflammatory response syndrome -negative patients and had higher hospital mortality (16.9% versus 8.1%, p < 0.001). In the adjusted analysis, being systemic inflammatory response syndrome -positive independently increased the risk of death by 82% (odds ratio 1.82; 95% confidence interval [CI] 1.12 - 2.96, p = 0.016). However, the AUROC curve for the SAPS 3 model was higher (0.81, 95%CI 0.78 - 0.85) compared to the systemic inflammatory response syndrome model with the systemic inflammatory response syndrome criteria as a dichotomous variable (0.60, 95%CI 0.55 - 0.65) and as an ordinal variable (0.62, 95%CI 0.57 - 0.68; p < 0.001) for hospital mortality. CONCLUSION Although systemic inflammatory response syndrome is associated with hospital mortality, the systemic inflammatory response syndrome criteria show low accuracy in the prediction of mortality compared with the SAPS 3.
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Affiliation(s)
- Leandro Utino Taniguchi
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Disciplina de Emergências Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - José Mauro Vieira
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | - Luciano Cesar Pontes de Azevedo
- Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês - São Paulo (SP), Brasil.,Disciplina de Emergências Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
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27
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Chen M, Lu X, Hu L, Liu P, Zhao W, Yan H, Tang L, Zhu Y, Xiao Z, Chen L, Tan H. Development and validation of a mortality risk model for pediatric sepsis. Medicine (Baltimore) 2017; 96:e6923. [PMID: 28514310 PMCID: PMC5440147 DOI: 10.1097/md.0000000000006923] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Pediatric sepsis is a burdensome public health problem. Assessing the mortality risk of pediatric sepsis patients, offering effective treatment guidance, and improving prognosis to reduce mortality rates, are crucial.We extracted data derived from electronic medical records of pediatric sepsis patients that were collected during the first 24 hours after admission to the pediatric intensive care unit (PICU) of the Hunan Children's hospital from January 2012 to June 2014. A total of 788 children were randomly divided into a training (592, 75%) and validation group (196, 25%). The risk factors for mortality among these patients were identified by conducting multivariate logistic regression in the training group. Based on the established logistic regression equation, the logit probabilities for all patients (in both groups) were calculated to verify the model's internal and external validities.According to the training group, 6 variables (brain natriuretic peptide, albumin, total bilirubin, D-dimer, lactate levels, and mechanical ventilation in 24 hours) were included in the final logistic regression model. The areas under the curves of the model were 0.854 (0.826, 0.881) and 0.844 (0.816, 0.873) in the training and validation groups, respectively.The Mortality Risk Model for Pediatric Sepsis we established in this study showed acceptable accuracy to predict the mortality risk in pediatric sepsis patients.
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Affiliation(s)
- Mengshi Chen
- Hunan Children's Hospital, Ziyuan RD
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, Hunan
| | - Xiulan Lu
- Hunan Children's Hospital, Ziyuan RD
| | - Li Hu
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, Hunan
- Beijing Center for Diseases Prevention and Control, Beijing, P. R. China
| | | | | | | | | | - Yimin Zhu
- Hunan Children's Hospital, Ziyuan RD
| | | | - Lizhang Chen
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, Hunan
| | - Hongzhuan Tan
- Department of Epidemiology and Health Statistics, School of Public Health, Central South University, Changsha, Hunan
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28
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Whiles BB, Deis AS, Simpson SQ. Increased Time to Initial Antimicrobial Administration Is Associated With Progression to Septic Shock in Severe Sepsis Patients. Crit Care Med 2017; 45:623-629. [PMID: 28169944 PMCID: PMC5374449 DOI: 10.1097/ccm.0000000000002262] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES To determine if time to initial antimicrobial is associated with progression of severe sepsis to septic shock. DESIGN Retrospective cohort. SETTING Six hundred fifty-six bed urban academic medical center. PATIENTS Emergency department patients greater than or equal to 18 years old with severe sepsis and/or septic shock and antimicrobial administration within 24 hours. Patients with shock on presentation were excluded. INTERVENTIONS Not available. MEASUREMENTS AND MAIN RESULTS We identified 3,929 severe sepsis patients, with overall mortality 12.8%. Nine hundred eighty-four patients (25.0%) progressed to septic shock. The median time to antimicrobial was 3.77 hours (interquartile range = 1.96-6.42) in those who progressed versus 2.76 hours (interquartile range = 1.60-4.82) in those who did not (p < 0.001). Multivariate logistic regression demonstrated that male sex (odds ratio = 1.18; 95% CI, 1.01-1.36), Charlson Comorbidity Index (odds ratio = 1.18; 95% CI, 1.11-1.27), number of infections (odds ratio = 1.05; 95% CI, 1.02-1.08), and time to first antimicrobial (odds ratio = 1.08; 95% CI, 1.06-1.10) were associated with progression. Each hour until initial antimicrobial administration was associated with a 8.0% increase in progression to septic shock. Additionally, time to broad-spectrum antimicrobial was associated with progression (odds ratio = 1.06; 95% CI, 1.05-1.08). Time to initial antimicrobial was also associated with in-hospital mortality (odds ratio = 1.05; 95% CI, 1.03-1.07). CONCLUSIONS This study emphasizes the importance of early, broad-spectrum antimicrobial administration in severe sepsis patients admitted through the emergency department, as longer time to initial antimicrobial administration is associated with increased progression of severe sepsis to septic shock and increased mortality.
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Affiliation(s)
- Bristol B Whiles
- 1University of Kansas School of Medicine, Kansas City, Kansas.2Division of Pulmonary and Critical Care, Department of Internal Medicine, University of Kansas, Kansas City, Kansas
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29
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Rothman M, Levy M, Dellinger RP, Jones SL, Fogerty RL, Voelker KG, Gross B, Marchetti A, Beals J. Sepsis as 2 problems: Identifying sepsis at admission and predicting onset in the hospital using an electronic medical record–based acuity score. J Crit Care 2017; 38:237-244. [DOI: 10.1016/j.jcrc.2016.11.037] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 11/08/2016] [Accepted: 11/23/2016] [Indexed: 12/14/2022]
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30
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Mousavi S, Ghannadi A, Meidani M. New horizon in the treatment of sepsis: a systematic review of alternative medicine. JOURNAL OF COMPLEMENTARY & INTEGRATIVE MEDICINE 2016; 13:317-332. [PMID: 27394050 DOI: 10.1515/jcim-2016-0003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 06/01/2016] [Indexed: 01/30/2023]
Abstract
BackgroundDespite great advancement in treatment of sepsis, mortality of sepsis remains unacceptably high, even with the modern antibiotic and intensive care technologies. Considering the key role of immune dysfunction in sepsis pathophysiology, different treatments were evaluated, but failed to improve survival of patients. Natural remedies have been tested in various studies to overcome sepsis. In this study, we aim to review some of the evidence from clinical, in vitro and in vivo studies about the effect of alternative medicine on sepsis management. MethodsThe following databases were searched up to March 2014: PubMed, Scopus, Web of Science, Ovid and Google Scholar using combination of Mesh term. All in vitro and in vivo studies, also clinical trials, published in English, which evaluated alternative medicine in management of sepsis were included. Results Out of 95 relevant studies, the inclusion criteria were met for 79 cases. Among them, 18 studies were performed on humans. The most herbal medicine, including Xubijing (n=10) and then Rhubarb (n=3). Most of the reviewed botanical medicines modulate the immune system. Reduction of mortality was also reported in studies. ConclusionsModulation of immune system, anti-inflammatory activities and improvement of survival were the action of herbal medicine. A monovalent approach is not enough for treatment of sepsis, we recommend further studies to identify active component of herbal and use them in combination. Also an animal model of sepsis does not exactly mimic human sepsis, so more clinical studies should be performed. With no new drug on the horizon, herbal medicine will be promising for treatment of sepsis.
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31
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Moraes RB, Guillén JAV, Zabaleta WJC, Borges FK. De-escalation, adequacy of antibiotic therapy and culture positivity in septic patients: an observational study. Rev Bras Ter Intensiva 2016; 28:315-322. [PMID: 27626951 PMCID: PMC5051191 DOI: 10.5935/0103-507x.20160044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Accepted: 05/17/2016] [Indexed: 12/29/2022] Open
Abstract
Objective To evaluate the prevalence of antibiotic de-escalation in patients diagnosed
with severe sepsis or septic shock at a public academic tertiary hospital
and to evaluate antibiotic adequacy and culture positivity. Methods The prevalence of antibiotic de-escalation, the adequacy of antibiotic
treatment and the rates of culture positivity were analyzed in patients with
severe sepsis and septic shock between April and December 2013 at an
intensive care unit in a tertiary university hospital. Results Among the 224 patients included in the study, de-escalation was appropriate
in 66 patients (29.4%) but was implemented in 44 patients (19.6%). Among the
patients who underwent de-escalation, half experienced narrowing of the
antimicrobial spectrum. The mortality rate was 56.3%, with no differences
between the patients with or without de-escalation (56.8% versus 56.1%; p =
0.999) nor in the length of hospital stay. Empirical antibiotic therapy was
appropriate in 89% of cases. Microorganisms were isolated from total
cultures in 30% of cases and from blood cultures in 26.3% of cases. Conclusion The adequacy rate of empirical antibiotic therapy was high, reflecting an
active institutional policy of monitoring epidemiological profiles and
institutional protocols on antimicrobial use. However, antibiotic
de-escalation could have been implemented in a greater number of patients.
De-escalation did not affect mortality rates.
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Affiliation(s)
- Rafael Barberena Moraes
- Serviço de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Julián Alberto Viteri Guillén
- Serviço de Medicina Interna, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - William Javier Castillo Zabaleta
- Serviço de Medicina Interna, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
| | - Flavia Kessler Borges
- Serviço de Medicina Interna, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil
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Fernández RAR, Soriano RN, Francescato HDC, Sabino JP, Coimbra TM, Branco LGS. Cryogenic role of central endogenous hydrogen sulfide in the rat model of endotoxic shock. Brain Res 2016; 1650:218-223. [PMID: 27592137 DOI: 10.1016/j.brainres.2016.08.047] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 07/13/2016] [Accepted: 08/30/2016] [Indexed: 01/25/2023]
Abstract
Thermoregulatory responses to lipopolysaccharide (LPS) are affected by modulators that increase (propyretic) or decrease (cryogenic) body temperature (Tb). We tested the hypothesis that central hydrogen sulfide (H2S) acts as a thermoregulatory modulator and that H2S production in the anteroventral preoptic region of the hypothalamus (AVPO) is increased during hypothermia and decreased during fever induced by bacterial lipopolysaccharide (LPS, 2.5mg/kg i.p.) in rats kept at an ambient temperature of 25°C. Deep Tb was recorded before and after pharmacological inhibition of the enzyme cystathionine β-synthase (CBS - responsible for H2S endogenous production in the brain) combined or not with LPS administration. To further investigate the mechanisms responsible for these thermoregulatory adjustments, we also measured prostaglandin D2 (PGD2) production in the AVPO. LPS caused typical hypothermia followed by fever. Levels of AVPO H2S were significantly increased during hypothermia when compared to both euthermic and febrile rats. Intracerebroventricular (icv) microinjection of aminooxyacetate (AOA, a CBS inhibitor; 100 pmol) neither affected Tb nor basal PGD2 production during euthermia. In LPS-treated rats, AOA caused increased Tb values during hypothermia, along with enhanced PGD2 production. We conclude that the gaseous messenger H2S modulates hypothermia during endotoxic shock, acting as a cryogenic molecule.
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Affiliation(s)
- Rodrigo A R Fernández
- Medical School of Ribeirão Preto, University of São Paulo, 14049-900 Ribeirão Preto, São Paulo, Brazil
| | - Renato N Soriano
- Division of Physiology and Biophysics, Department of Basic Life Sciences, Federal University of Juiz de Fora, 35020-220 Governador Valadares, MG, Brazil
| | - Heloísa D C Francescato
- Medical School of Ribeirão Preto, University of São Paulo, 14049-900 Ribeirão Preto, São Paulo, Brazil
| | - João P Sabino
- Dental School of Ribeirão Preto, University of São Paulo, 14040-904 Ribeirão Preto, São Paulo, Brazil
| | - Terezila M Coimbra
- Medical School of Ribeirão Preto, University of São Paulo, 14049-900 Ribeirão Preto, São Paulo, Brazil
| | - Luiz G S Branco
- Dental School of Ribeirão Preto, University of São Paulo, 14040-904 Ribeirão Preto, São Paulo, Brazil.
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Morozowich ST, Ramakrishna H. Pharmacologic agents for acute hemodynamic instability: recent advances in the management of perioperative shock- a systematic review. Ann Card Anaesth 2016; 18:543-54. [PMID: 26440241 PMCID: PMC4881674 DOI: 10.4103/0971-9784.166464] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Despite the growing body of evidence evaluating the efficacy of vasoactive agents in the management of hemodynamic instability and circulatory shock, it appears no agent is superior. This is becoming increasingly accepted as current guidelines are moving away from detailed algorithms for the management of shock, and instead succinctly state that vasoactive agents should be individualized and guided by invasive hemodynamic monitoring. This extends to the perioperative period, where vasoactive agent selection and use may still be left to the discretion of the treating physician with a goal-directed approach, consisting of close hemodynamic monitoring and administration of the lowest effective dose to achieve the hemodynamic goals. Successful therapy depends on the ability to rapidly diagnose the etiology of circulatory shock and thoroughly understand its pathophysiology as well as the pharmacology of vasoactive agents. This review focuses on the physiology and resuscitation goals in perioperative shock, as well as the pharmacology and recent advances in vasoactive agent use in its management.
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Affiliation(s)
| | - Harish Ramakrishna
- Department of Anesthesiology, Mayo Clinic, College of Medicine; Department of Anesthesiology, Division of Cardiovascular and Thoracic Anesthesiology, Mayo Clinic, Phoenix, Arizona, USA
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34
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Holder AL, Gupta N, Lulaj E, Furgiuele M, Hidalgo I, Jones MP, Jolly T, Gennis P, Birnbaum A. Predictors of early progression to severe sepsis or shock among emergency department patients with nonsevere sepsis. Int J Emerg Med 2016; 9:10. [PMID: 26908009 PMCID: PMC4764600 DOI: 10.1186/s12245-016-0106-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 02/11/2016] [Indexed: 01/20/2023] Open
Abstract
Background Progression from nonsevere sepsis—i.e., sepsis without organ failure or shock—to severe sepsis or shock among emergency department (ED) patients has been associated with significant mortality. Early recognition in the ED of those who progress to severe sepsis or shock during their hospital course may improve patient outcomes. We sought to identify clinical, demographic, and laboratory parameters that predict progression to severe sepsis, septic shock, or death within 96 h of ED triage among patients with initial presentation of nonsevere sepsis. Methods This is a retrospective cohort of patients presenting to a single urban academic ED from November 2008 to October 2010. Patients aged 18 years or older who met criteria for sepsis and had a lactate level measured in the ED were included. Patients were excluded if they had any combination of the following: a systolic blood pressure <90 mmHg upon triage, an initial whole blood lactate level ≥4 mmol/L, or one or more of a set of predefined signs of organ dysfunction upon initial assessment. Disease progression was defined as the development of any combination of the aforementioned conditions, initiation of vasopressors, or death within 96 h of ED presentation. Data on predefined potential predictors of disease progression and outcome measures of disease progression were collected by a query of the electronic medical record and via chart review. Logistic regression was used to assess associations of potential predictor variables with a composite outcome measure of sepsis progression to organ failure, hypotension, or death. Results In this cohort of 582 ED patients with nonsevere sepsis, 108 (18.6 %) experienced disease progression. Initial serum albumin <3.5 mg/dL (OR 4.82; 95 % CI 2.40–9.69; p < 0.01) and a diastolic blood pressure <52 mmHg at ED triage (OR 4.59; 95 % CI 1.57–13.39; p < 0.01) were independently associated with disease progression to severe sepsis or shock within 96 h of ED presentation. There were no deaths within 96 h of ED presentation. Conclusions In our patient cohort, serum albumin <3.5 g/dL and an ED triage diastolic blood pressure <52 mmHg independently predict early progression to severe sepsis or shock among ED patients with presumed sepsis.
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Affiliation(s)
- Andre L Holder
- Department of Medicine, Emory University School of Medicine, 1648 Pierce Dr NE, Atlanta, GA, 30307, USA. .,Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Grady Memorial Hospital, 80 Jesse Hill Jr. Drive SE, Rm 2D012, Atlanta, GA, 30303, USA.
| | - Namita Gupta
- Beacon Health System, Elkhart General Hospital, 600 East Blvd, Elkhart, IN, 46514, USA.
| | - Elizabeth Lulaj
- Department of Radiology, Emory University School of Medicine, 1648 Pierce Dr NE, Atlanta, GA, 30307, USA.
| | - Miriam Furgiuele
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Rosenthal Red Zone, Room 2nd Floor, Bronx, NY, 10467, USA.
| | - Idaly Hidalgo
- Department of Emergency Medicine, Kingston Hospital, 396 Broadway, Kingston, NY, 12401, USA.
| | - Michael P Jones
- Department of Emergency Medicine, Albert Einstein College of Medicine, Jacobi Medical Center, 1400 Pelham Parkway South, 1B-25, Bronx, NY, 10461, USA.
| | - Tiphany Jolly
- Department of Emergency Medicine, Saint Francis Hospital and Medical Center, 114 Woodland Street, Hartford, CT, 06105, USA.
| | - Paul Gennis
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Rosenthal Red Zone, Room 2nd Floor, Bronx, NY, 10467, USA.
| | - Adrienne Birnbaum
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, 111 East 210th Street, Rosenthal Red Zone, Room 2nd Floor, Bronx, NY, 10467, USA.
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Abstract
BACKGROUND Initial goal-directed resuscitation for hypotensive shock usually includes administration of intravenous fluids, followed by initiation of vasopressors. Despite obvious immediate effects of vasopressors on haemodynamics, their effect on patient-relevant outcomes remains controversial. This review was published originally in 2004 and was updated in 2011 and again in 2016. OBJECTIVES Our objective was to compare the effect of one vasopressor regimen (vasopressor alone, or in combination) versus another vasopressor regimen on mortality in critically ill participants with shock. We further aimed to investigate effects on other patient-relevant outcomes and to assess the influence of bias on the robustness of our effect estimates. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015 Issue 6), MEDLINE, EMBASE, PASCAL BioMed, CINAHL, BIOSIS and PsycINFO (from inception to June 2015). We performed the original search in November 2003. We also asked experts in the field and searched meta-registries to identify ongoing trials. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing various vasopressor regimens for hypotensive shock. DATA COLLECTION AND ANALYSIS Two review authors abstracted data independently. They discussed disagreements between them and resolved differences by consulting with a third review author. We used a random-effects model to combine quantitative data. MAIN RESULTS We identified 28 RCTs (3497 participants) with 1773 mortality outcomes. Six different vasopressors, given alone or in combination, were studied in 12 different comparisons.All 28 studies reported mortality outcomes; 12 studies reported length of stay. Investigators reported other morbidity outcomes in a variable and heterogeneous way. No data were available on quality of life nor on anxiety and depression outcomes. We classified 11 studies as having low risk of bias for the primary outcome of mortality; only four studies fulfilled all trial quality criteria.In summary, researchers reported no differences in total mortality in any comparisons of different vasopressors or combinations in any of the pre-defined analyses (evidence quality ranging from high to very low). More arrhythmias were observed in participants treated with dopamine than in those treated with norepinephrine (high-quality evidence). These findings were consistent among the few large studies and among studies with different levels of within-study bias risk. AUTHORS' CONCLUSIONS We found no evidence of substantial differences in total mortality between several vasopressors. Dopamine increases the risk of arrhythmia compared with norepinephrine and might increase mortality. Otherwise, evidence of any other differences between any of the six vasopressors examined is insufficient. We identified low risk of bias and high-quality evidence for the comparison of norepinephrine versus dopamine and moderate to very low-quality evidence for all other comparisons, mainly because single comparisons occasionally were based on only a few participants. Increasing evidence indicates that the treatment goals most often employed are of limited clinical value. Our findings suggest that major changes in clinical practice are not needed, but that selection of vasopressors could be better individualised and could be based on clinical variables reflecting hypoperfusion.
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Affiliation(s)
- Gunnar Gamper
- Universitätsklinikum Sankt PöltenDepartment of CardiologySankt PöltenAustria
| | - Christof Havel
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20 / 6DViennaAustriaA‐1090
| | - Jasmin Arrich
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20 / 6DViennaAustriaA‐1090
| | - Heidrun Losert
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20 / 6DViennaAustriaA‐1090
| | - Nathan L Pace
- University of UtahDepartment of Anesthesiology3C444 SOM30 North 1900 EastSalt Lake CityUTUSA84132‐2304
| | - Marcus Müllner
- Internistisches Zentrum BrigittenauTreustrasse 43ViennaAustria1200
| | - Harald Herkner
- Medical University of ViennaDepartment of Emergency MedicineWähringer Gürtel 18‐20 / 6DViennaAustriaA‐1090
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Paonessa JR, Brennan T, Pimentel M, Steinhaus D, Feng M, Celi LA. Hyperdynamic left ventricular ejection fraction in the intensive care unit. Crit Care 2015; 19:288. [PMID: 26250903 PMCID: PMC4528812 DOI: 10.1186/s13054-015-1012-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Accepted: 07/12/2015] [Indexed: 12/02/2022] Open
Abstract
Introduction Limited information exists on the etiology, prevalence, and significance of hyperdynamic left ventricular ejection fraction (HDLVEF) in the intensive care unit (ICU). Our aim in the present study was to compare characteristics and outcomes of patients with HDLVEF with those of patients with normal left ventricular ejection fraction in the ICU using a large, public, deidentified critical care database. Methods We conducted a longitudinal, single-center, retrospective cohort study of adult patients who underwent echocardiography during a medical or surgical ICU admission at the Beth Israel Deaconess Medical Center using the Multiparameter Intelligent Monitoring in Intensive Care II database. The final cohort had 2867 patients, of whom 324 had HDLVEF, defined as an ejection fraction >70 %. Patients with an ejection fraction <55 % were excluded. Results Compared with critically ill patients with normal left ventricular ejection fraction, the finding of HDLVEF in critically ill patients was associated with female sex, increased age, and the diagnoses of hypertension and cancer. Patients with HDLVEF had increased 28-day mortality compared with those with normal ejection fraction in multivariate logistic regression analysis adjusted for age, sex, Sequential Organ Failure Assessment score, Elixhauser score for comorbidities, vasopressor use, and mechanical ventilation use (odds ratio 1.38, 95 % confidence interval 1.039–1.842, p =0.02). Conclusions The presence of HDLVEF portended increased 28-day mortality, and may be helpful as a gravity marker for prognosis in patients admitted to the ICU. Further research is warranted to gain a better understanding of how these patients respond to common interventions in the ICU and to determine if pharmacologic modulation of HDLVEF improves outcomes.
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Affiliation(s)
- Joseph R Paonessa
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA. .,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA. .,, Present address: 1122 N. Clark Street, Apt. 3709, Chicago, IL, 60610, USA.
| | - Thomas Brennan
- Massachusetts Institute of Technology, 32 Vassar Street, Cambridge, MA, 02139, USA.
| | - Marco Pimentel
- Institute of Biomedical Engineering, Oxford University, Headington, Oxford, OX3 7DQ, UK.
| | - Daniel Steinhaus
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA. .,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA.
| | - Mengling Feng
- Massachusetts Institute of Technology, 32 Vassar Street, Cambridge, MA, 02139, USA.
| | - Leo Anthony Celi
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA, 02215, USA. .,Harvard Medical School, 25 Shattuck Street, Boston, MA, 02115, USA. .,Massachusetts Institute of Technology, 32 Vassar Street, Cambridge, MA, 02139, USA.
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Bonelli F, Meucci V, Divers T, Radcliffe R, Jose-Cunilleras E, Corazza M, Guidi G, Tognetti R, Castagnetti C, Intorre L, Sgorbini M. Evaluation of Plasma Procalcitonin Concentrations in Healthy Foals and Foals Affected by Septic Systemic Inflammatory Response Syndrome. J Equine Vet Sci 2015. [DOI: 10.1016/j.jevs.2015.06.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R. Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med 2015; 372:1629-38. [PMID: 25776936 DOI: 10.1056/nejmoa1415236] [Citation(s) in RCA: 713] [Impact Index Per Article: 79.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The consensus definition of severe sepsis requires suspected or proven infection, organ failure, and signs that meet two or more criteria for the systemic inflammatory response syndrome (SIRS). We aimed to test the sensitivity, face validity, and construct validity of this approach. METHODS We studied data from patients from 172 intensive care units in Australia and New Zealand from 2000 through 2013. We identified patients with infection and organ failure and categorized them according to whether they had signs meeting two or more SIRS criteria (SIRS-positive severe sepsis) or less than two SIRS criteria (SIRS-negative severe sepsis). We compared their characteristics and outcomes and assessed them for the presence of a step increase in the risk of death at a threshold of two SIRS criteria. RESULTS Of 1,171,797 patients, a total of 109,663 had infection and organ failure. Among these, 96,385 patients (87.9%) had SIRS-positive severe sepsis and 13,278 (12.1%) had SIRS-negative severe sepsis. Over a period of 14 years, these groups had similar characteristics and changes in mortality (SIRS-positive group: from 36.1% [829 of 2296 patients] to 18.3% [2037 of 11,119], P<0.001; SIRS-negative group: from 27.7% [100 of 361] to 9.3% [122 of 1315], P<0.001). Moreover, this pattern remained similar after adjustment for baseline characteristics (odds ratio in the SIRS-positive group, 0.96; 95% confidence interval [CI], 0.96 to 0.97; odds ratio in the SIRS-negative group, 0.96; 95% CI, 0.94 to 0.98; P=0.12 for between-group difference). In the adjusted analysis, mortality increased linearly with each additional SIRS criterion (odds ratio for each additional criterion, 1.13; 95% CI, 1.11 to 1.15; P<0.001) without any transitional increase in risk at a threshold of two SIRS criteria. CONCLUSIONS The need for two or more SIRS criteria to define severe sepsis excluded one in eight otherwise similar patients with infection, organ failure, and substantial mortality and failed to define a transition point in the risk of death. (Funded by the Australian and New Zealand Intensive Care Research Centre.).
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Affiliation(s)
- Kirsi-Maija Kaukonen
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (K.-M.K., M.B., D.P., D.J.C., R.B.), the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation (D.P.), and the Department of Intensive Care, Alfred Hospital (D.P.), Melbourne, VIC, and the Intensive Care Unit, Austin Health, Heidelberg, VIC (R.B.) - all in Australia; and the Neurosurgical Unit, Department of Anesthesiology, Intensive Care and Pain Medicine, Helsinki University Central Hospital, Helsinki (K.-M.K.)
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Tsai MJ, Ou SM, Shih CJ, Chao PW, Wang LF, Shih YN, Li SY, Kuo SC, Hsu YT, Chen YT. Association of prior antiplatelet agents with mortality in sepsis patients: a nationwide population-based cohort study. Intensive Care Med 2015; 41:806-13. [PMID: 25829229 DOI: 10.1007/s00134-015-3760-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Accepted: 03/16/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND Antiplatelet agents are widely used for cardiovascular disea ses, but their pleiotropic effects in sepsis are controversial. OBJECTIVE To investigate the association between antiplatelet agents and the survival benefit for sepsis patients. DESIGN A nationwide population-based cohort and nested case-control study. SETTING Taiwan National Health Insurance database. PARTICIPANTS All patients (age ≥18 years) who were hospitalized for sepsis between January 2000 and December 2010. MEASUREMENTS Conditional logistic regression was used to adjust for confounding. Adjusted odd ratios (ORs) were used to compare the mortality rate due to sepsis in antiplatelet drug users and nonusers. RESULTS Of 683,421 included patients, 229,792 (33.6 %) patients died during hospitalization for sepsis, and the rest (64.4 %) survived to discharge. Use of antiplatelet agents before admission was associated with a lower risk of mortality in sepsis patients (aOR 0.82, 95 % confidence interval [CI] 0.81-0.83, P < 0.001). By using another case-control study design, the beneficial effect was more significant in current users (aOR 0.78, 95 % CI 0.76-0.79) than in recent users (aOR 0.88, 95 % CI 0.85-0.91), but was not significant in past users (aOR 1.00, 95 % CI 0.98-1.02). LIMITATIONS Observational study. CONCLUSIONS Prior use of antiplatelet agents was associated with a survival benefit in sepsis patients.
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Affiliation(s)
- Min-Juei Tsai
- Department of Internal Medicine, Taipei Veterans General Hospital, Suao Branch, Yilan, Taiwan
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Anantha RV, Mazzuca DM, Xu SX, Porcelli SA, Fraser DD, Martin CM, Welch I, Mele T, Haeryfar SMM, McCormick JK. T helper type 2-polarized invariant natural killer T cells reduce disease severity in acute intra-abdominal sepsis. Clin Exp Immunol 2014; 178:292-309. [PMID: 24965554 DOI: 10.1111/cei.12404] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2014] [Indexed: 01/09/2023] Open
Abstract
Sepsis is characterized by a severe systemic inflammatory response to infection that is associated with high morbidity and mortality despite optimal care. Invariant natural killer T (iNK T) cells are potent regulatory lymphocytes that can produce pro- and/or anti-inflammatory cytokines, thus shaping the course and nature of immune responses; however, little is known about their role in sepsis. We demonstrate here that patients with sepsis/severe sepsis have significantly elevated proportions of iNK T cells in their peripheral blood (as a percentage of their circulating T cells) compared to non-septic patients. We therefore investigated the role of iNK T cells in a mouse model of intra-abdominal sepsis (IAS). Our data show that iNK T cells are pathogenic in IAS, and that T helper type 2 (Th2) polarization of iNK T cells using the synthetic glycolipid OCH significantly reduces mortality from IAS. This reduction in mortality is associated with the systemic elevation of the anti-inflammatory cytokine interleukin (IL)-13 and reduction of several proinflammatory cytokines within the spleen, notably interleukin (IL)-17. Finally, we show that treatment of sepsis with OCH in mice is accompanied by significantly reduced apoptosis of splenic T and B lymphocytes and macrophages, but not natural killer cells. We propose that modulation of iNK T cell responses towards a Th2 phenotype may be an effective therapeutic strategy in early sepsis.
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Affiliation(s)
- R V Anantha
- Division of General Surgery, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada; Department of Microbiology and Immunology, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
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Shankar-Hari M, Donnelly A, Pinto R, Salih Z, McKenzie C, Terblanche M, Adhikari NKJ. The influence of statin exposure on inflammatory markers in patients with early bacterial infection: pilot prospective cohort study. BMC Anesthesiol 2014; 14:106. [PMID: 25484622 PMCID: PMC4256798 DOI: 10.1186/1471-2253-14-106] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Accepted: 09/25/2014] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND In the context of infection, progressive illness resulting in acute organ dysfunction is thought to be secondary to inflammatory response. Our aims were to determine risk factors for progressive illness following infection in a low-risk hospitalised cohort, including the impact of prior stain therapy. METHODS We performed a prospective observational cohort study on two adult acute medical wards of a single tertiary academic hospital. We screened drug prescription charts of all adult acute medical admissions for inclusion criteria of inpatient administration of antibiotics for more than 24 hours for a microbiologically confirmed or clinically suspected infection. Patients were followed until admission to a high dependency unit (HDU) or intensive care unit (ICU), discharge from hospital, or to a maximum of 10 days. Outcomes were evolution of systemic inflammatory response syndrome (SIRS) criteria, white cell count and C-reactive protein measurements, and adverse clinical outcomes. We constructed multivariable models accounting for repeated within-patient measurements to determine associations between a priori selected predictors (days since admission, age, gender, Charlson score, prior statin exposure) and selected outcomes. RESULTS We enrolled 209 patients; 27.8% were statin users and the commonest infection was pneumonia (51.0%). Most (88.0%) had at least 1 SIRS criterion on admission, and 76 (37.3%) manifested additional SIRS criteria over time. Risks of admission to HDU/ICU (3.3%) and of 30-day mortality (5.7%) were low. The proportion of patients with at least 1 SIRS criterion, mean CRP, and mean WBC all decreased over time. Multivariable regression models identified days since hospital admission as the only variable associated with daily presence of SIRS criteria, WCC, or CRP (adjusted OR <1 and p < 0.0001 in all analyses). Statin exposure was not a significant predictor. CONCLUSIONS This cohort of ward patients treated for infection had a low risk of clinical deterioration, inflammatory markers improved over time, and statin exposure was not associated with any outcome. Future larger studies may identify risk factors for progression of illness in this population and plausible surrogate endpoints for evaluation in clinical trials.
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Affiliation(s)
- Manu Shankar-Hari
- Division of Asthma, Allergy and Lung Biology, King's College London, Department of Critical Care Medicine, St. Thomas' Hospital, 1st Floor, East Wing, Westminster Bridge Road, London, SE1 7EH UK
| | - Antonia Donnelly
- Emergency Department, University Hospital Southampton NHS Foundation Trust, Tremona Road, Southampton, SO16 6YD UK
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, M4N 3M5 Canada
| | - Zaid Salih
- School of Pharmacy, University College London, London, UK ; Department of Pharmacy and Critical Care, Guys and St Thomas NHS Foundation Trust, St Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH UK
| | - Cathrine McKenzie
- Department of Pharmacy and Critical Care, Guys and St Thomas NHS Foundation Trust, St Thomas' Hospital, Lambeth Palace Road, London, SE1 7EH UK ; Institute of Pharmaceutical Sciences, Kings College London, London, UK
| | - Marius Terblanche
- Centre for Critical Illness Data Sciences Research, Division of Health & Social Care Research, King's College London, Department of Critical Care Medicine, 1st Floor, East Wing, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH UK
| | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Sunnybrook Research Institute and University of Toronto, 2075 Bayview Avenue, Toronto, M4N 3M5 Canada
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Abstract
OBJECTIVE The objective of this study was to compare vasopressor requirements between African American (AA) patients and white patients in septic shock. METHODS This was a retrospective cohort review conducted over a 2-year period measuring total and mean dosage of various vasopressors used between two racial groups during the treatment of patients admitted with septic shock. The study included patients admitted to the intensive care unit with septic shock at an 805-bed tertiary, academic center. All septic shock patients were managed with vasopressors. Vasopressor selection, dosage, and duration were at the discretion of the treating physician. Total, mean, and duration of vasopressor dosing requirements were obtained for study participants. Comorbidities, prehospitalization antihypertensive medication requirements, intravenous fluids given during the septic shock phase, and source of infection were analyzed. RESULTS One hundred fifty-nine patients with septic shock were analyzed, of which 96 (60.4%) were AAs (P < 0.059). African Americans had higher rates of end-stage renal disease and hypertension compared with whites, 85.7% vs. 14.3% (P < 0.011; odds ratio [OR], 15.684) and 68.3% vs. 31.7% (P < 0.007; OR, 3.357), respectively. Norepinephrine (NE) was administered to 150 patients, 57.2% of which were AAs (P < 0.509). Thirteen patients received dopamine (5% AAs, P < 0.588), 40 patients received phenylephrine (15.7% AAs, P < 0.451), and five patients received epinephrine (1.9% AAs, P < 0.660). Comparing vasopressors between races, only NE showed statistical significance via logistic regression modeling for the AA race in terms of total dosage (AAs 736.8 [SD, 897.3] μg vs. whites 370 [SD, 554.2] μg, P < 0.003), duration of vasopressor used (AAs 38.38 [SD, 34.75] h vs. whites 29.09 [SD, 27.11] h, P < 0.037), and mean dosage (AAs 21.08 [SD, 22.23] μg/h vs. whites 12.37 [SD, 13.86] μg/h, P < 0.01). Mortality between groups was not significant. Logistic regression identified discrepancy of the mean dose NE in AAs compared with whites, with OR of 1.043 (P = 0.01). CONCLUSIONS African American patients with septic shock were treated with higher doses of NE and required longer duration of NE administration compared with white patients.
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Mekontso Dessap A, Katsahian S, Roche-Campo F, Varet H, Kouatchet A, Tomicic V, Beduneau G, Sonneville R, Jaber S, Darmon M, Castanares-Zapatero D, Brochard L, Brun-Buisson C. Ventilator-associated pneumonia during weaning from mechanical ventilation: role of fluid management. Chest 2014; 146:58-65. [PMID: 24652410 DOI: 10.1378/chest.13-2564] [Citation(s) in RCA: 54] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Pulmonary edema may alter alveolar bacterial clearance and infectivity. Manipulation of fluid balance aimed at reducing fluid overload may, therefore, influence ventilator-associated pneumonia (VAP) occurrence in intubated patients. The objective of the present study was to assess the impact of a depletive fluid-management strategy on ventilator-associated complication (VAC) and VAP occurrence during weaning from mechanical ventilation. METHODS We used data from the B-type Natriuretic Peptide for the Fluid Management of Weaning (BMW) randomized controlled trial performed in nine ICUs across Europe and America. We compared the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid-management group and the usual-care group during the 14 days following randomization, using specific competing-risk methods (the Fine and Gray model). RESULTS Among the 304 patients analyzed, 41 experienced VAP, including 27 (17.8%) in the usual-care group vs 14 (9.2%) in the interventional group (P = .03). From the Fine and Gray model, the probabilities of VAC and VAP occurrence were both significantly reduced with the interventional strategy while adjusting for weaning outcome as a competing event (subhazard ratios [25th-75th percentiles], 0.44 [0.22-0.87], P = .02 and 0.50 [0.25-0.96], P = .03, respectively). CONCLUSIONS Using proper competing risk analyses, we found that a depletive fluid-management strategy, when initiating the weaning process, has the potential for lowering VAP risk in patients who are mechanically ventilated. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00473148; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Armand Mekontso Dessap
- Service de Réanimation Médicale, AP-HP, CHU Henri Mondor, Créteil, F-94010, France; Faculté de Médecine, Université Paris Est Créteil, Créteil, F-94010, France; INSERM, Unité U955, Créteil, F-94010, France.
| | - Sandrine Katsahian
- Unité de Recherche Clinique, AP-HP, CHU Henri Mondor, Créteil, F-94010, France
| | - Ferran Roche-Campo
- Service de Réanimation Médicale, AP-HP, CHU Henri Mondor, Créteil, F-94010, France; Servei de Medicina Intensiva, Hospital de Sant Pau, Barcelona, Spain
| | - Hugo Varet
- Unité de Recherche Clinique, AP-HP, CHU Henri Mondor, Créteil, F-94010, France
| | | | - Vinko Tomicic
- Departamento de Paciente Crítico, Clinica Alemana, Santiago de Chile, Chile
| | - Gaetan Beduneau
- Service de Réanimation Médicale and UPRES-EA 3830, CHU de Rouen, Rouen, France
| | - Romain Sonneville
- Service de Réanimation Médicale et des Maladies Infectieuses, AP-HP, CHU Bichat-Claude Bernard, Univ Paris Diderot, Sorbonne Paris Cité, Paris, France
| | - Samir Jaber
- Réanimation DAR B, CHU Saint Eloi, INSERM U1046, Montpellier, France
| | - Michael Darmon
- Service de Réanimation Médicale, AP-HP, CHU Saint Louis, Paris, France
| | | | - Laurent Brochard
- Critical Care Department, St. Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Christian Brun-Buisson
- Service de Réanimation Médicale, AP-HP, CHU Henri Mondor, Créteil, F-94010, France; Faculté de Médecine, Université Paris Est Créteil, Créteil, F-94010, France; INSERM, Unité U955, Créteil, F-94010, France
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Capelastegui A, Zalacain R, Bilbao A, Egurrola M, Iturriaga LAR, Quintana JM, Gomez A, Esteban C, España PP. Pneumococcal pneumonia: differences according to blood culture results. BMC Pulm Med 2014; 14:128. [PMID: 25096919 PMCID: PMC4127038 DOI: 10.1186/1471-2466-14-128] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 07/24/2014] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Bacteremia by Streptococcus pneumoniae has been traditionally associated with poor outcomes in patients with pneumonia; however, data on its impact on outcomes are limited and are sometimes contradictory. METHODS We performed a prospective study in two hospitals in northern Spain in which cases diagnosed with pneumococcal pneumonia were selected from a cohort of hospitalized patients with pneumonia between January 2001 and July 2009. We compared patients with pneumococcal bacteremic pneumonia with those with pneumococcal non-bacteremic pneumonia. RESULTS We compared 492 patients with negative blood culture and 399 with positive culture results. Host related factors were very similar in both groups. Severity of illness on admission measured by CURB-65 score was similar in both groups. Adjusted analysis showed a greater likelihood of septic shock during in-hospital course among patients with pneumococcal bacteremia (OR, 2.1; 95% CI, 1.2-3.5; P=0.006). Likewise, patients with positive blood culture had greater in-hospital mortality (OR 2.1; 95% CI, 1.1- -3.9; P=0.02), 15-day mortality (OR 3.6; 95% CI, 1.7-7.4; P=0.0006), and 30-day mortality (OR, 2.7; 95% CI, 1.5-5; P=0.002). CONCLUSIONS Although host related factors and severity on admission were very similar in the two groups, bacteremic patients had worse in-hospital course and outcomes. Bacteraemia in pneumococcal pneumonia is of prognostic significance.
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Affiliation(s)
- Alberto Capelastegui
- Service of Pneumology, Hospital de Galdakao-Usansolo, Galdakao, Bizkaia E-48960, Spain
| | - Rafael Zalacain
- From the Pneumology Service, Hospital Universitario Cruces, Barakaldo, Bizkaia, Spain
| | - Amaia Bilbao
- From the Research Unit, Hospital Universitario Basurto - Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Bilbao, Bizkaia, Spain
| | - Mikel Egurrola
- Service of Pneumology, Hospital de Galdakao-Usansolo, Galdakao, Bizkaia E-48960, Spain
| | | | - Jose M Quintana
- From the Research Unit - Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Hospital Galdakao-Usansolo, Galdakao, Bizkaia, Spain
| | - Ainhoa Gomez
- From the Pneumology Service, Hospital Universitario Cruces, Barakaldo, Bizkaia, Spain
| | - Cristobal Esteban
- Service of Pneumology, Hospital de Galdakao-Usansolo, Galdakao, Bizkaia E-48960, Spain
| | - Pedro P España
- Service of Pneumology, Hospital de Galdakao-Usansolo, Galdakao, Bizkaia E-48960, Spain
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Computer versus paper system for recognition and management of sepsis in surgical intensive care. J Trauma Acute Care Surg 2014; 76:311-7; discussion 318-9. [PMID: 24458039 DOI: 10.1097/ta.0000000000000121] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND A system to provide surveillance, diagnosis, and protocolized management of surgical intensive care unit (SICU) sepsis was undertaken as a performance improvement project. A system for sepsis management was implemented for SICU patients using paper followed by a computerized system. The hypothesis was that the computerized system would be associated with improved process and outcomes. METHODS A system was designed to provide early recognition and guide patient-specific management of sepsis including (1) modified early warning signs-sepsis recognition score (MEWS-SRS; summative point score of ranges of vital signs, mental status, white blood cell count; after every 4 hours) by bedside nurse; (2) suspected site assessment (vascular access, lung, abdomen, urinary tract, soft tissue, other) at bedside by physician or extender; (3) sepsis management protocol (replicable, point-of-care decisions) at bedside by nurse, physician, and extender. The system was implemented first using paper and then a computerized system. Sepsis severity was defined using standard criteria. RESULTS In January to May 2012, a paper system was used to manage 77 consecutive sepsis encounters (3.9 ± 0.5 cases per week) in 65 patients (77% male; age, 53 ± 2 years). In June to December 2012, a computerized system was used to manage 132 consecutive sepsis encounters (4.4 ± 0.4 cases per week) in 119 patients (63% male; age, 58 ± 2 years). MEWS-SRS elicited 683 site assessments, and 201 had sepsis diagnosis and protocol management. The predominant site of infection was abdomen (paper, 58%; computer, 53%). Recognition of early sepsis tended to occur more using the computerized system (paper, 23%; computer, 35%). Hospital mortality rate for surgical ICU sepsis (paper, 20%; computer, 14%) was less with the computerized system. CONCLUSION A computerized sepsis management system improves care process and outcome. Early sepsis is recognized and managed with greater frequency compared with severe sepsis or septic shock. The system has a beneficial effect as a clinical standard of care for SICU patients. LEVEL OF EVIDENCE Therapeutic study, level III.
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Use of antiplatelet agents in sepsis: A glimpse into the future. Thromb Res 2014; 133:131-8. [DOI: 10.1016/j.thromres.2013.07.002] [Citation(s) in RCA: 91] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 07/04/2013] [Accepted: 07/08/2013] [Indexed: 11/21/2022]
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Marwick CA, Guthrie B, Pringle JE, McLeod SR, Evans JM, Davey PG. Identifying which septic patients have increased mortality risk using severity scores: a cohort study. BMC Anesthesiol 2014; 14:1. [PMID: 24383430 PMCID: PMC3918178 DOI: 10.1186/1471-2253-14-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 12/18/2013] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Early aggressive therapy can reduce the mortality associated with severe sepsis but this relies on prompt recognition, which is hindered by variation among published severity criteria. Our aim was to test the performance of different severity scores in predicting mortality among a cohort of hospital inpatients with sepsis. METHODS We anonymously linked routine outcome data to a cohort of prospectively identified adult hospital inpatients with sepsis, and used logistic regression to identify associations between mortality and demographic variables, clinical factors including blood culture results, and six sets of severity criteria. We calculated performance characteristics, including area under receiver operating characteristic curves (AUROC), of each set of severity criteria in predicting mortality. RESULTS Overall mortality was 19.4% (124/640) at 30 days after sepsis onset. In adjusted analysis, older age (odds ratio 5.79 (95% CI 2.87-11.70) for ≥80y versus <60y), having been admitted as an emergency (OR 3.91 (1.31-11.70) versus electively), and longer inpatient stay prior to sepsis onset (OR 2.90 (1.41-5.94) for >21d versus <4d), were associated with increased 30 day mortality. Being in a surgical or orthopaedic, versus medical, ward was associated with lower mortality (OR 0.47 (0.27-0.81) and 0.26 (0.11-0.63), respectively). Blood culture results (positive vs. negative) were not significantly association with mortality. All severity scores predicted mortality but performance varied. The CURB65 community-acquired pneumonia severity score had the best performance characteristics (sensitivity 81%, specificity 52%, positive predictive value 29%, negative predictive value 92%, for 30 day mortality), including having the largest AUROC curve (0.72, 95% CI 0.67-0.77). CONCLUSIONS The CURB65 pneumonia severity score outperformed five other severity scores in predicting risk of death among a cohort of hospital inpatients with sepsis. The utility of the CURB65 score for risk-stratifying patients with sepsis in clinical practice will depend on replicating these findings in a validation cohort including patients with sepsis on admission to hospital.
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Affiliation(s)
- Charis A Marwick
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Mackenzie Building, Kirsty Semple Way, Dundee DD2 4BF, UK.
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Jeddi R, Achour M, Amor RB, Aissaoui L, Bouterâa W, Kacem K, Lakhal RB, Abid HB, BelHadjAli Z, Turki A, Meddeb B. Factors associated with severe sepsis: prospective study of 94 neutropenic febrile episodes. Hematology 2013; 15:28-32. [DOI: 10.1179/102453310x12583347009577] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
- Ramzi Jeddi
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Mériem Achour
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Ramzi Ben Amor
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Lamia Aissaoui
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Walid Bouterâa
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Karima Kacem
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Raihane Ben Lakhal
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Héla Ben Abid
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Zaher BelHadjAli
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
| | - Amel Turki
- Department of Microbiology and Biochemical AnalysisAziza Othmana University Hospital, Tunis, Tunisia
| | - Balkis Meddeb
- Department of HematologyAziza Othmana University Hospital, Tunis, Tunisia
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POUKKANEN M, VAARA ST, PETTILÄ V, KAUKONEN KM, KORHONEN AM, HOVILEHTO S, INKINEN O, LARU-SOMPA R, KAMINSKI T, REINIKAINEN M, LUND V, KARLSSON S. Acute kidney injury in patients with severe sepsis in Finnish Intensive Care Units. Acta Anaesthesiol Scand 2013; 57:863-72. [PMID: 23713703 DOI: 10.1111/aas.12133] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2013] [Indexed: 12/27/2022]
Abstract
BACKGROUND Severe sepsis is one of the leading causes of acute kidney injury (AKI). Patients with sepsis-associated AKI demonstrate high-hospital mortality. We evaluated the incidence of severe sepsis-associated AKI and its association with outcome in intensive care units (ICUs) in Finland. METHODS This was a predetermined sub-study of the prospective, observational, multicentre FINNAKI study conducted in 17 ICUs during 1 September 2011 and 1 February 2012. All emergency ICU admissions and elective admissions exceeding 24 hours in the ICU were screened for presence of severe sepsis and AKI up to 5 days in ICU. AKI was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria and severe sepsis according to the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) criteria. RESULTS Of the 2901 included patients, severe sepsis was diagnosed in 918 (31.6%, 95% confidence interval [CI] 29.9-33.4%) patients. Of these 918 patients, 488 (53.2% [95% CI 49.9-56.5%]) had AKI. The 90-day mortality rate was 38.1% (95% CI 33.7-42.5%) for severe sepsis patients with AKI and 24.7% (95% CI 20.5-28.8%) for those without AKI. After adjusting for covariates, KDIGO stage 3 AKI was associated with an increased risk for 90-day mortality with an adjusted odds ratio (OR) of 1.94 (95% CI 1.28-2.94), but stages 1 and 2 were not. CONCLUSIONS More than half of the patients with severe sepsis had AKI according to the KDIGO classification, and AKI stage 3 was independently associated with 90-day mortality.
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Affiliation(s)
- M. POUKKANEN
- Department of Anaesthesia and Intensive Care Medicine; Lapland Central Hospital; Rovaniemi; Finland
| | - S. T. VAARA
- Intensive Care Units, Division of Anaesthesia and Intensive Care Medicine; Helsinki University Central Hospital; Helsinki; Finland
| | | | - K.-M. KAUKONEN
- ANZIC-RC; Department of Epidemiology and Preventive Medicine; Monash University; Melbourne; Australia
| | - A.-M. KORHONEN
- Intensive Care Units, Division of Anaesthesia and Intensive Care Medicine; Helsinki University Central Hospital; Helsinki; Finland
| | - S. HOVILEHTO
- Department of Anaesthesia and Intensive Care Medicine; South Karelia Central Hospital; Lappeenranta; Finland
| | - O. INKINEN
- Department of Anaesthesia and Intensive Care Medicine; Turku University Hospital; Turku; Finland
| | - R. LARU-SOMPA
- Department of Anaesthesia and Intensive Care Medicine; Central Finland Central Hospital; Jyväskylä; Finland
| | - T. KAMINSKI
- Department of Anaesthesia and Intensive Care Medicine; Middle Ostrobothnia Central Hospital; Kokkola; Finland
| | - M. REINIKAINEN
- Department of Intensive Care; North Karelia Central Hospital; Joensuu; Finland
| | - V. LUND
- Department of Anaesthesia and Intensive Care Medicine; Satakunta Central Hospital; Pori; Finland
| | - S. KARLSSON
- Department of Intensive Care Medicine; Tampere University Hospital; Tampere; Finland
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