Initial emergency department diagnosis and management of adult patients with severe sepsis and septic shock

Prognostic role of albumin, lactate-to-albumin ratio and C-reactive protein-to-albumin ratio in infected patients

INTRODUCTION

The prognostic evaluation of the septic patient has recently been enriched by some predictive indices such as albumin concentration, lactate/albumin ratio (LAR) and C-reactive protein/albumin ratio (CAR). The performance of these indices has been evaluated in septic patients in intensive care, but until now their performance in infected patients in the Emergency Department (ED) has not been evaluated.

AIM

To investigate the potential prognostic role of albumin, LAR and CAR in patients with infection in the ED.

METHODS

Single-centre prospective study performed between 1 January 2021 and 31 December 2021 at the ED of the Merano Hospital (Italy). All patients with infection were enrolled. The study outcome was death within 30 days. The predictive ability of albumin, LAR and CAR was assessed by area under the receiver operating characteristic curves (AUROCs). A multivariate logistic regression model was used to examine the association of the indices with 30-day mortality, with comorbidity, acute urgency and severity of infection as covariates.

RESULTS

The study enrolled 962 patients with an infectious status. The overall 30-day mortality rate was 8.9% (86/962). The AUROC of albumin was 0.831 (95% CI 0.795-868), while for LAR this was 0.773 (CI95% 0.719-0.827) and for CAR 0.718 (CI95% 0.664-0.771). The odds ratio for 30-day mortality for albumin was 3.362 (95% CI 1.904-5.936), for ln(LAR) 2.651 (95% CI 1.646-4.270) and for ln(CAR) 1.739 (95% CI 1.326-2.281).

CONCLUSIONS

All three indices had a good discriminatory ability for the risk of short-term death in patients with infection, indicating their promising use in the ED as well as in the ICU. Further studies are needed to confirm the better performance of albumin compared to LAR and CAR.

Deep learning-based prediction of in-hospital mortality for sepsis

As a serious blood infection disease, sepsis is characterized by a high mortality risk and many complications. Accurate assessment of mortality risk of patients with sepsis can help physicians in Intensive Care Unit make optimal clinical decisions, which in turn can effectively save patients' lives. However, most of the current clinical models used for assessing mortality risk in sepsis patients are based on conventional indicators. Unfortunately, some of the conventional indicators have been shown to be inapplicable in the accurate clinical diagnosis nowadays. Meanwhile, traditional evaluation models only focus on a small amount of personal data, causing misdiagnosis of sepsis patients. We refine the core indicators for mortality risk assessment of sepsis from massive clinical electronic medical records with machine learning, and propose a new mortality risk assessment model, DGFSD, for sepsis patients based on deep learning. The DGFSD model can not only learn individual clinical information about unassessed patients, but also obtain information about the structure of the similarity graph between diagnosed patients and patients to be assessed. Numerous experiments have shown that the accuracy of the DGFSD model is superior to baseline methods, and can significantly improve the efficiency of clinical auxiliary diagnosis.

Novel Hydroxamic Acids Containing Aryl-Substituted 1,2,4- or 1,3,4-Oxadiazole Backbones and an Investigation of Their Antibiotic Potentiation Activity

UDP-3-O-(R-3-hydroxymyristoyl)-N-acetylglucosamine deacetylase (LpxC) is a zinc amidase that catalyzes the second step of the biosynthesis of lipid A, which is an outer membrane essential structural component of Gram-negative bacteria. Inhibitors of this enzyme can be attributed to two main categories, non-hydroxamate and hydroxamate inhibitors, with the latter being the most effective given the chelation of Zn2+ in the active site. Compounds containing diacetylene or acetylene tails and the sulfonic head, as well as oxazoline derivatives of hydroxamic acids, are among the LpxC inhibitors with the most profound antibacterial activity. The present article describes the synthesis of novel functional derivatives of hydroxamic acids-bioisosteric to oxazoline inhibitors-containing 1,2,4- and 1,3,4-oxadiazole cores and studies of their cytotoxicity, antibacterial activity, and antibiotic potentiation. Some of the hydroxamic acids we obtained (9c, 9d, 23a, 23c, 30b, 36) showed significant potentiation in nalidixic acid, rifampicin, and kanamycin against the growth of laboratory-strain Escherichia coli MG1655. Two lead compounds (9c, 9d) significantly reduced Pseudomonas aeruginosa ATCC 27853 growth in the presence of nalidixic acid and rifampicin.

Ciclopirox mitigates inflammatory response in LPS-induced septic shock via inactivation of SORT1-mediated wnt/β-Catenin signaling pathway

OBJECTIVE

Septic shock, the most severe stage of sepsis, is a deadly inflammatory disorder with high mortality. Ciclopirox (CPX) is a broad-spectrum antimycotic agent which also exerts anti-inflammatory effects in human diseases. However, whether CPX can relieve inflammatory response in LPS-induced septic shock remains unclear.

MATERIALS AND METHODS

Male C57BL/6 mice LPS were injected intraperitoneally with LPS to simulate septic shock in vivo. RAW264.7 cells and bone marrow-derived macrophages (BMDMs) were subject to LPS treatment to simulate septic shock in vitro. ELISA was applied to detect the level of pro-inflammatory cytokines. Cell viability was assessed by CCK-8 assay. Protein levels was detected by western blotting.

RESULTS

CPX enhanced the survival rate and attenuated inflammation in mice with LPS-induced septic shock. Similarly, CPX dose-dependently mitigated LPS-induced inflammation in BMDMs. It was also found that Sortilin 1 (SORT1) was upregulated in both in vivo and in vitro models of LPS-induced septic shock. In addition, SORT1 overexpression counteracted the alleviative effects of CPX on the inflammation response of LPS-challenged BMDMs by activating the Wnt/β-Catenin signaling. Furthermore, BML-284 (a Wnt/β-Catenin agonist) treatment also abrogated CPX-mediated moderation of LPS-triggered inflammatory reaction in BMDMs.

CONCLUSIONS

In sum, we found that CPX protected against LPS-induced septic shock by mitigating inflammation via SORT1-mediated Wnt/β-Catenin signaling pathway.

DEVELOPMENT OF SCORE SYSTEM BASED ON POINT-OF-CARE ULTRASOUND TO PREDICT VASOPRESSOR REQUIREMENT FOR EMERGENCY PATIENTS WITH CARDIOPULMONARY SYMPTOMS

ABSTRACT

Objectives : Patients with cardiopulmonary symptoms admitted to the emergency department (ED) have high mortality and intensive care unit admission rates. We developed a new scoring system comprising concise triage information, point-of-care ultrasound, and lactate levels to predict vasopressor requirements. Methods : This retrospective observational study was conducted at a tertiary academic hospital. Patients with cardiopulmonary symptoms who visited the ED and underwent point-of-care ultrasound between January 2018 and December 2021 were enrolled. The influence of demographic and clinical findings on the requirement for vasopressor support within 24 h of ED admission was investigated. A new scoring system was developed using key components after stepwise multivariable logistic regression analysis. Prediction performance was evaluated using the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results : A total of 2,057 patients were analyzed. A stepwise multivariable logistic regression model showed high predictive performance in the validation cohort (AUC, 0.87). Eight key components were selected: hypotension, chief complaint, and fever at ED admission, and way of ED visit, systolic dysfunction, regional wall motion abnormalities, inferior vena cava status, and serum lactate level. The scoring system was developed based on the β coefficients of each component: accuracy, 0.8079; sensitivity, 0.8057; specificity, 0.8214; PPV, 0.9658; and NPV, 0.4035, with a cutoff value according to the Youden index. Conclusions : A new scoring system was developed to predict vasopressor requirements in adult ED patients with cardiopulmonary symptoms. This system can serve as a decision-support tool to guide efficient assignment of emergency medical resources.

Temporal convolution attention model for sepsis clinical assistant diagnosis prediction

Sepsis is an organ failure disease caused by an infection acquired in an intensive care unit (ICU), which leads to a high mortality rate. Developing intelligent monitoring and early warning systems for sepsis is a key research area in the field of smart healthcare. Early and accurate identification of patients at high risk of sepsis can help doctors make the best clinical decisions and reduce the mortality rate of patients with sepsis. However, the scientific understanding of sepsis remains inadequate, leading to slow progress in sepsis research. With the accumulation of electronic medical records (EMRs) in hospitals, data mining technologies that can identify patient risk patterns from the vast amount of sepsis-related EMRs and the development of smart surveillance and early warning models show promise in reducing mortality. Based on the Medical Information Mart for Intensive Care Ⅲ, a massive dataset of ICU EMRs published by MIT and Beth Israel Deaconess Medical Center, we propose a Temporal Convolution Attention Model for Sepsis Clinical Assistant Diagnosis Prediction (TCASP) to predict the incidence of sepsis infection in ICU patients. First, sepsis patient data is extracted from the EMRs. Then, the incidence of sepsis is predicted based on various physiological features of sepsis patients in the ICU. Finally, the TCASP model is utilized to predict the time of the first sepsis infection in ICU patients. The experiments show that the proposed model achieves an area under the receiver operating characteristic curve (AUROC) score of 86.9% (an improvement of 6.4% ) and an area under the precision-recall curve (AUPRC) score of 63.9% (an improvement of 3.9% ) compared to five state-of-the-art models.

Small molecule LpxC inhibitors against gram-negative bacteria: Advances and future perspectives

Uridine diphosphate-3-O-(hydroxymyristoyl)-N-acetylglucosamine deacetylase (LpxC) is a metalloenzyme with zinc ions as cofactors and is a key enzyme in the essential structural outer membrane lipid A synthesis commitment step of gram-negative bacteria. As LpxC is extremely homologous among different Gram-negative bacteria, it is conserved in almost all gram-negative bacteria, which makes LpxC a promising target. LpxC inhibitors have been reported extensively in recent years, such as PF-5081090 and CHIR-090 were found to have broad-spectrum antibiotic activity against P. aeruginosa and E. coli. They are mainly classified into hydroxamate inhibitors and non-hydroxamate inhibitors based on their structure, but no LpxC inhibitors have been marketed due to safety and activity issues. This review, therefore, focuses on small molecule inhibitors of LpxC against gram-negative pathogenic bacteria and covers recent advances in LpxC inhibitors, focusing on their structural optimization process, structure-activity relationships, and future directions, with the aim of providing ideas for the development of LpxC inhibitors and clinical research.

Dual-Enhanced Plasmonic Biosensing for Point-of-Care Sepsis Detection

Rapid, sensitive, simultaneous quantification of multiple biomarkers in point-of-care (POC) settings could improve the diagnosis and management of sepsis, a common, potentially life-threatening condition. Compared to high-end commercial analytical systems, POC systems are often limited by low sensitivity, limited multiplexing capability, or low throughput. Here, we report an ultrasensitive, multiplexed plasmonic sensing technology integrating chemifluorescence signal enhancement with plasmon-enhanced fluorescence detection. Using a portable imaging system, the dual chemical and plasmonic amplification enabled rapid analysis of multiple cytokine biomarkers in 1 h with sub-pg/mL sensitivities. Furthermore, we also developed a plasmonic sensing chip based on nanoparticle-spiked gold nanodimple structures fabricated by wafer-scale batch processes. We used the system to detect six cytokines directly from clinical plasma samples (n = 20) and showed 100% accuracy for sepsis detection. The described technology could be employed in rapid, ultrasensitive, multiplexed plasmonic sensing in POC settings for myriad clinical conditions.

Prediction of sepsis onset in hospital admissions using survival analysis

To determine the efficacy of modern survival analysis methods for predicting sepsis onset in ICU, emergency, medical/surgical, and TCU departments. We performed a retrospective analysis on ICU, med/surg, ED, and TCU cases from multiple Mercy Health hospitals from August 2018 to March 2020. Patients in these departments were monitored by the Mercy Virtual vSepsis team and sepsis cases were determined and documented in the Mercy EHR via a rule-based engine utilizing clinical data. We used survival-based modeling methods to predict sepsis onset in these cases. The three survival methods that were used to predict the onset of severe sepsis and septic shock produced AUC values > 0.85 and each provided a median lead time of > 20 h prior to disease onset. This methodology improves upon previous work by demonstrating excellent model performance when generalizing survival-based prediction methods to both severe sepsis and septic shock as well as non-ICU departments.IRB InformationTrial Registration ID: 1,532,327-1.Trial Effective Date: 12/02/2019.

Adipose‑derived mesenchymal stem cell‑derived HCAR1 regulates immune response in the attenuation of sepsis

Sepsis serves as a leading cause of admission to and death of patients in the intensive care unit (ICU) and is described as a systemic inflammatory response syndrome caused by abnormal host response to infection. Adipose‑derived mesenchymal stem cells (ADSCs) have exhibited reliable and promising clinical application potential in multiple disorders. However, the function and the mechanism of ADSCs in sepsis remain elusive. In the present study, the crucial inhibitory effect of ADSC‑derived hydroxy‑carboxylic acid receptor 1 (HCAR1) on sepsis was identified. Reverse transcription quantitative‑PCR determined that the mRNA expression of HCAR1 was reduced while the mRNA expression of Toll‑like receptor 4 (TLR4), major histocompatibility complex class II (MHC II), NOD‑like receptor family pyrin domain containing 3 (NLRP3), and the levels of interleukin‑1β (IL‑1β), tumor necrosis factor‑α (TNF‑α), interleukin‑10 (IL‑10), and interleukin‑18 (IL‑18) were enhanced in the peripheral blood of patients with sepsis. The expression of HCAR1 was negatively correlated with TLR4 (r=‑0.666), MHC II (r=‑0.587), and NLRP3 (r=‑0.621) expression and the expression of TLR4 was positively correlated with NLRP3 (r=0.641), IL‑1β (r=0.666), TNF‑α (r=0.606), and IL‑18 (r=0.624) levels in the samples. Receiver operating characteristic (ROC) curve analysis revealed that the area under the ROC curve (AUC) of HCAR1, TLR4, MHC II and NLRP3 mRNA expression was 0.830, 0.853, 0.735 and 0.945, respectively, in which NLRP3 exhibited the highest diagnostic value, and the AUC values of IL‑1β, IL‑18, TNF‑α, and IL‑10 were 0.751, 0.841, 0.924 and 0.729, respectively, in which TNF‑α exhibited the highest diagnostic value. A sepsis rat model was established by injecting lipopolysaccharide (LPS) and the rats were randomly divided into 5 groups, including a normal control group (NC group; n=6), a sepsis model group (LPS group; n=6), an ADSC transplantation group (L + M group; n=6), a combined HCAR1 receptor agonist group [L + HCAR1 inducer (Gi) + M group; n=6], and a combined HCAR1 receptor inhibitor group [L + HCAR1 blocker (Gk) + M group; n=6]. Hematoxylin and eosin staining determined that ADSCs attenuated the lung injury of septic rats and ADSC‑derived HCAR1 enhanced the effect of ADSCs. The expression of HCAR1, TLR4, MHC II, NLRP3, IL‑1β, IL‑18 and TNF‑α levels were suppressed by ADSCs and the effect was further induced by ADSC‑derived HCAR1. However, ADSC‑derived HCAR1 induced the levels of anti‑inflammatory factor IL‑10. The negative correlation of HCAR1 expression with TLR4, MHC II, and NLRP3 expression in the peripheral blood and lung tissues of the rats was then identified. It is thus concluded that ADSC‑derived HCAR1 regulates immune response in the attenuation of sepsis. ADSC‑derived HCAR1 may be a promising therapeutic strategy for sepsis.

Pulsed Electromagnetic Field (PEMF) Treatment Reduces Lipopolysaccharide-Induced Septic Shock in Mice

Despite advances in medicine, mortality due to sepsis has not decreased. Pulsed electromagnetic field (PEMF) therapy is emerging as an alternative treatment in many inflammation-related diseases. However, there are few studies on the application of PEMF therapy to sepsis. In the current study, we examined the effect of PEMF therapy on a mouse model of lipopolysaccharide (LPS)-induced septic shock. Mice injected with LPS and treated with PEMF showed higher survival rates compared with the LPS group. The increased survival was correlated with decreased levels of pro-inflammatory cytokine mRNA expression and lower serum nitric oxide levels and nitric oxide synthase 2 mRNA expression in the liver compared with the LPS group. In the PEMF + LPS group, there was less organ damage in the liver, lungs, spleen, and kidneys compared to the LPS group. To identify potential gene targets of PEMF treatment, microarray analysis was performed, and the results showed that 136 genes were up-regulated, and 267 genes were down-regulated in the PEMF + LPS group compared to the LPS group. These results suggest that PEMF treatment can dramatically decrease septic shock through the reduction of pro-inflammatory cytokine gene expression. In a clinical setting, PEMF may provide a beneficial effect for patients with bacteria-induced sepsis and reduce septic shock-induced mortality.

Early warning model for death of sepsis via length insensitive temporal convolutional network

Sepsis is a life-threatening systemic syndrome characterized by various biological, biochemical, and physiological abnormalities. Due to its high mortality, identifying sepsis patients with high risk of in-hospital death early and accurately will help doctors make optimal clinical decisions and reduce the mortality of sepsis patients. In this paper, we propose a length insensitive TCN-based model to predict sepsis patient's death risk in the future k hours, which is the first work for sepsis death risk early warning model only based on vital signs time series to our best knowledge. Furthermore, we design residual connections between temporal residual blocks to improve the prediction performance and stability especially on short input sequences. We validate and evaluate our model on two freely-available datasets, i.e., MIMIC-IV and eICU, from which 16,520 and 29,620 patients are selected respectively. The experiment results show that our model outperforms LSTM and other machine learning methods, as it has the highest sensitivity and Youden index in almost all cases. Meanwhile, the Youden index of the TCN-based model only slightly decreases by 0.0233 and 0.0307 when the time range of the input sequence changes from 24 to 4 h for k equal to 6 and 12, respectively.

Exploring nursing and medical perceptions of sepsis management in a New Zealand emergency department: A qualitative study

OBJECTIVE

Early sepsis recognition and treatment are essential in order to reduce the burden of disease. Initial assessment of patients with infection is often undertaken by ED nurses and resident doctors. This descriptive qualitative study aimed to explore their perceptions and perspectives regarding the factors that impede the identification and management of patients with sepsis.

METHODS

This was a qualitative study conducted between 30 January 2020 and 27 February 2020. Semi-structured focus group interviews were performed to collect data. All participants provided written informed consent and completed a basic demographic and work experience form. Two study investigators facilitated the interviews. Interviews were audio-recorded and later transcribed. Thematic analysis was performed with the aid of NVivo 12 software.

RESULTS

Six focus group interviews were conducted involving 40 ED nurses and doctors. Interview length ranged from 27 to 38 min (mean 33.5 min). Three major themes were identified: (i) clinical management; (ii) challenges and delays; and (iii) communication. Each of these themes was broken down into subthemes, which are presented in more detail.

CONCLUSION

ED nurses and doctors have identified important factors that limit and enhance their capacity to recognise and respond to patients with sepsis. Complex interactions exist between clinical and organisational structures that can affect the care of patients and the ability of clinicians to provide optimal care. The three major themes and specific subthemes provide a useful framework and stimulus for service improvements and research that could help foster future sepsis management improvement strategies.

Identification of the Diagnostic Signature of Sepsis Based on Bioinformatic Analysis of Gene Expression and Machine Learning

BACKGROUND

Sepsis is a life-threatening disease caused by the dysregulated host response to the infection and the major cause of death of patients in the intensive care unit (ICU).

OBJECTIVE

Early diagnosis of sepsis could significantly reduce in-hospital mortality. Though generated from infection, the development of sepsis follows its own psychological process and disciplines, alters with gender, health status and other factors. Hence, the analysis of mass data by bioinformatics tools and machine learning is a promising method for exploring early diagnosis.

METHODS

We collected miRNA and mRNA expression data of sepsis blood samples from Gene Expression Omnibus (GEO) and ArrayExpress databases, screened out differentially expressed genes (DEGs) by R software, predicted miRNA targets on TargetScanHuman and miRTarBase websites, conducted Gene Ontology (GO) term and KEGG pathway enrichment analysis based on overlapping DEGs. The STRING database and Cytoscape were used to build protein-protein interaction (PPI) network and predict hub genes. Then we constructed a Random Forest model by using the hub genes to assess sample type.

RESULTS

Bioinformatic analysis of GEO dataset revealed 46 overlapping DEGs in sepsis. The PPI network analysis identified five hub genes, SOCS3, KBTBD6, FBXL5, FEM1C and WSB1. Random Forest model based on these five hub genes was used to assess GSE95233 and GSE95233 datasets, and the area under the curve (AUC) of ROC was 0.900 and 0.7988, respectively, which confirmed the efficacy of this model.

CONCLUSION

The integrated analysis of gene expression in sepsis and the effective Random Forest model built in this study may provide promising diagnostic methods for sepsis.

Failing the metric but saving lives: The protocolization of sepsis treatment through quality measurement

Quality metrics in the healthcare sector have become a key component of ensuring improved health outcomes and care equity. Alongside the emergence of information technology in healthcare (eg. electronic health records), the primary method utilized to infer "quality" has been the development of measures for healthcare processes and outcomes. Engaging with the specific case of sepsis treatment and sepsis quality metrics, this paper traces how quality is defined, measured, and codified in a 600-bed acute-care hospital in New York City. Sepsis is a severe health condition, primarily managed in the emergency department, that is caused by infection and can result in multi-organ shutdown and mortality. Multiple government agencies have established metrics that regulate New York hospitals based on their compliance with specific sepsis treatment procedures. I draw on data from a 15-month ethnography and in-depth interviews with clinicians and administrators, to show how quality measurement is reshaping the ways healthcare is delivered and organized. I reveal how, at Borough Hospital, efforts to treat sepsis based on quality metrics have constrained clinician expertise, prioritized compliance, and reoriented workflow towards standardized treatment protocols. This reorientation leads to, what I term abstracted surveillance protocols, that increasingly regulate definitions of healthcare quality. I demonstrate that abstracted surveillance protocols enable highly complex clinical processes to be measured based on metric compliance rather than clinical pathways, therefore moving definitions of quality away from the bedside.

Performance of the MEDS score in predicting mortality among emergency department patients with a suspected infection: a meta-analysis

OBJECTIVES

To carry out a meta-analysis to examine the prognostic performance of the Mortality in Emergency Department Sepsis (MEDS) score in predicting mortality among emergency department patients with a suspected infection.

METHODS

Electronic databases-PubMed, Embase, Scopus, EBSCO and the Cochrane Library-were searched for eligible articles from their respective inception through February 2019. Sensitivity, specificity, likelihood ratios and receiver operator characteristic area under the curve were calculated. Subgroup analyses were performed to explore the prognostic performance of MEDS in selected populations.

RESULTS

We identified 24 studies involving 21 246 participants. The pooled sensitivity of MEDS to predict mortality was 79% (95% CI 72% to 84%); specificity was 74% (95% CI 68% to 80%); positive likelihood ratio 3.07 (95% CI 2.47 to 3.82); negative likelihood ratio 0.29 (95% CI 0.22 to 0.37) and area under the curve 0.83 (95% CI 0.80 to 0.86). Significant heterogeneity was seen among included studies. Meta-regression analyses showed that the time at which the MEDS score was measured and the cut-off value used were important sources of heterogeneity.

CONCLUSION

The MEDS score has moderate accuracy in predicting mortality among emergency department patients with a suspected infection. A study comparison MEDS and qSOFA in the same population is needed.

High sPLA2-IIA level is associated with eicosanoid metabolism in patients with bacterial sepsis syndrome

The aim of this study was to determine the association between secretory phospholipase A2 group IIA (sPLA2-IIA) and eicosanoid pathway metabolites in patients with bacterial sepsis syndrome (BSS). Levels of sPLA2-IIA, eicosanoids prostaglandin (PG)E2, PGD synthase were quantified in the sera from patients confirmed to have bacterial sepsis (BS; N = 45), bacterial severe sepsis/septic shock (BSS/SS; N = 35) and healthy subjects (N = 45). Cyclooxygenase (COX)-1 and COX-2 activities were analyzed from cell lysate. Serum levels of sPLA2-IIA, PGE2, and PGDS increased significantly in patients with BS and BSS/SS compared to healthy subjects (p<0.05). COX-2 activity was significantly increased in patients with BS compared to healthy subjects (p<0.05), but not COX-1 activity. Binary logistic regression analysis showed that sPLA2-IIA and PGE2 were independent factors predicting BSS severity. In conclusion, high level of sPLA2-IIA is associated with eicosanoid metabolism in patients with BSS.

Arterial blood pressure correlates with 90-day mortality in sepsis patients: a retrospective multicenter derivation and validation study using high-frequency continuous data

OBJECTIVE

To identify the outcome of patients with sepsis using high-frequency blood pressure data.

MATERIALS AND METHODS

This retrospective observational study was conducted at a university hospital ICU (derivation study) and at two urban hospitals (validation study) with data from adult sepsis patients who visited the centers during the same period. The area under the curve (AUC) of blood pressure falling below threshold was calculated. The predictive 90-day mortality (primary endpoint) area under threshold (AUT) and critical blood pressure were calculated as the maximum area under the curve of the receiver operating characteristic curve (AUCROC) and the threshold minus average AUT (derivation study), respectively. For the validation study, the derived 90-day mortality AUCROC (using critical blood pressure) was compared with Sequential Organ Failure Assessment (SOFA), Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II, and APACHE III.

RESULTS

Derivation cohort (N = 137): the drop area from the mean blood pressure of 70 mmHg at 24-48 hours most accurately predicted 90-day mortality [critical blood pressure, 67.8 mmHg; AUCROC, 0.763; 95% confidence interval (CI), 0.653-0.890]. Validation cohort (N = 141): the 90-day mortality AUCROC (0.776) compared with the AUCROC for SOFA (0.711), SAPSII (0.771), APACHE II (0.745), and APACHE III (0.710) was not significantly different from the critical blood pressure 67.8 mmHg (P = 0.420).

CONCLUSION

High-frequency arterial blood pressure data of the period and extent of blood pressure depression can be useful in predicting the clinical outcomes of patients with sepsis.

Shen fu injection for patients with septic shock: Protocol for an updated systematic review

BACKGROUND

Septic shock is a serious disease with high morbidity, which will lead to organ dysfunction. Shen fu injection (SFI) has been widely used for septic shock as a treatment in China. Many clinical trials have been reported that it could assess the efficacy and safety of SFI to cure septic shock and accelerate resuscitation. Reassessing the efficacy and safety of SFI as a treatment of patients with septic shock is the objective of this updated systematic review.

METHODS

The following electronic databases major in English and Chinese will be conducted a systematic search until September 2018: PubMed, EMBASE, Cochrane Library, Chinese National Knowledge Infrastructure, Chinese Science and Technology Periodical Database, Chinese BioMedical Literature Database, and Wan-fang Database. Randomized controlled trials of SFI will be included. Review Manager 5.2 software will be used for assessment of risk of bias, data synthesis, and subgroup analysis. We will conduct the GRADE system to assess the quality of evidence, if possible.

RESULTS

This study will provide a rational synthesis of current evidences for SFI on septic shock.

CONCLUSION

We hope our research results will provide an objective and reliable evidence to patients, clinicians and healthcare policymakers who are concerning the treatment options of SFI in septic shock.

REGISTRATION

PROSPERO CRD42016049332.

Clinical and Demographic Parameters of Patients Treated Using a Sepsis Protocol

PURPOSE

The purpose of this study was to investigate potential differences by sex in the demographic and clinical characteristics of patients treated utilizing a sepsis electronic bundle order set. Risk factors for in-hospital mortality were also assessed.

METHODS

Data on patients in whom the sepsis order set was initiated in the emergency department over a 16-month period were entered into the hospital database. Data were analyzed for differences by sex in demographic and clinical factors, treatment modalities, and in-hospital mortality. The Bonferroni correction was applied to account for multiple comparisons; α was set at 0.006 for sex differences.

FINDINGS

A total of 2204 patients were included. Male and female cohorts were similar with regard to a variety of demographic and clinical factors, including age, Emergency Severity Index (ESI) levels 1 and 2, time to disposition, appropriateness of antibiotics, and total fluids given by weight. The ESI is an assessment score ranging from 1 to 5 (1 is emergent). There were modest differences in the source of infection (genitourinary was 4% more common in women; P = 0.03) and mode of arrival (men were 4% more likely to arrive by ambulance; P = 0.03). These differences did not achieve our predefined α of 0.006 when the Bonferroni correction was applied. Factors associated with in-hospital mortality were advanced age, arrival by ambulance, and an ESI level of 1 or 2 (all, P < 0.01).

IMPLICATIONS

Women were more likely to have a genitourinary cause of sepsis and less likely to arrive by ambulance. Risk factors of in-hospital mortality were older age, arrival by ambulance, and an ESI level of 1 or 2, but not sex.

Pseudomonas aeruginosa Alters Its Transcriptome Related to Carbon Metabolism and Virulence as a Possible Survival Strategy in Blood from Trauma Patients

While a considerable body of knowledge regarding sepsis in trauma patients is available, the potential influence of trauma-induced changes in the blood of these patients on the pathogenesis of Pseudomonas aeruginosa is basically an unexplored area. Rather than using standard laboratory media, we grew P. aeruginosa in whole blood from either healthy volunteers or trauma patients. The specific changes in the P. aeruginosa transcriptome in response to growth in blood from trauma patients reflect the adaptation of this organism to the bloodstream environment. This knowledge is vital for understanding the strategies this pathogen uses to adapt and survive within the host during systemic infection. Such information will help researchers and clinicians to develop new approaches for treatment of sepsis caused by P. aeruginosa in trauma patients, especially in terms of recognizing the effects of specific therapies (e.g., iron, zinc, or mannitol) on the organism. Further, this information can most likely be extrapolated to all patients with P. aeruginosa septicemia.

Trauma patients (TPs) are highly susceptible to infections, which often lead to sepsis. Among the numerous causative agents, Pseudomonas aeruginosa is especially important, as P. aeruginosa sepsis is often fatal. Understanding the mechanism of its pathogenesis in bloodstream infections is imperative; however, this mechanism has not been previously described. To examine the effect of trauma-induced changes in blood on the expression of P. aeruginosa genes, we grew strain UCBPP-PA14 (PA14) in blood samples from eight TPs and seven healthy volunteers (HVs). Compared with its growth in blood from HVs, the growth of PA14 in blood from TPs significantly altered the expression of 285 genes. Genes whose expression was significantly increased were related to carbon metabolism, especially malonate utilization and mannitol uptake, and efflux of heavy metals. Genes whose expression was significantly reduced included genes of the type VI secretion system, genes related to uptake and metabolism of amino acids, and genes related to biosynthesis and transport of the siderophores pyoverdine and pyochelin. These results suggest that during systemic infection in trauma patients, and to adapt to the trauma-induced changes in blood, P. aeruginosa adjusts positively and negatively the expression of numerous genes related to carbon metabolism and virulence, respectively.

IMPORTANCE While a considerable body of knowledge regarding sepsis in trauma patients is available, the potential influence of trauma-induced changes in the blood of these patients on the pathogenesis of Pseudomonas aeruginosa is basically an unexplored area. Rather than using standard laboratory media, we grew P. aeruginosa in whole blood from either healthy volunteers or trauma patients. The specific changes in the P. aeruginosa transcriptome in response to growth in blood from trauma patients reflect the adaptation of this organism to the bloodstream environment. This knowledge is vital for understanding the strategies this pathogen uses to adapt and survive within the host during systemic infection. Such information will help researchers and clinicians to develop new approaches for treatment of sepsis caused by P. aeruginosa in trauma patients, especially in terms of recognizing the effects of specific therapies (e.g., iron, zinc, or mannitol) on the organism. Further, this information can most likely be extrapolated to all patients with P. aeruginosa septicemia.

Author Video: An author video summary of this article is available.

Sepsis alerts in EMS and the results of pre-hospital ETCO2

BACKGROUND

Field sepsis alerts have the ability to expedite initial ED sepsis treatment. Our hypothesis is that in patients that meet EMS sepsis alert criteria there is a strong relationship between prehospital end-tidal carbon dioxide (ETCO2) readings and the outcome of diagnosed infection.

METHODS

In 2014, our EMS service initiated a protocol requiring hospitals to receive notification of a "sepsis alert" on all suspected sepsis patients. The EMS service transports 70,000 patients/year to a number of urban centers. All patients transported to our major urban teaching hospital by our EMS service in one year in which a sepsis alert was announced were included in this study. The primary outcome variable was diagnosed infection and secondary outcomes were hospital admission, ICU admission and mortality. Positive lactate was defined as >4.0 mmol/L. ROC curve analysis was used to define the best cutoff for ETCO2.

RESULTS

351 patients were announced as EMS sepsis alert patients and transported to our center over a one year period. Positive outcomes were as follows: diagnosed infection in 28% of patients, hospital admission in 63% and ICU admission in 11%. The correlation between lactate and ETCO2 was -0.45. A ROC curve analysis of ETCO2 vs. lactate >4 found that the best cutoff to predict a high lactate was an ETCO2 of 25 or less, which was considered a positive ETCO2 (AUC = 0.73). 27% of patients had a positive ETCO2 and 24% had a positive lactate. A positive ETCO2 predicted a positive lactate with 76% accuracy, 63% sensitivity and 80% specificity. 27% of those with a positive ETCO2 and 44% of those with a positive lactate had a diagnosed infection. 59% of those with a positive ETCO2 and 89% of those with a positive lactate had admission to the hospital. 15% of those with a positive ETCO2 and 18% of those with a positive lactate had admission to the ICU. Neither lactate nor ETCO2 were predictive of an increased risk for diagnosed infection, hospital admission or ICU admission in this patient population.

CONCLUSION

While ETCO2 predicted the initial ED lactate levels it did not predict diagnosed infection, admission to the hospital or ICU admission in our patient population but did predict mortality.

Consideration of Occult Infection and Sepsis Mimics in the Sick Patient Without an Apparent Infectious Source

BACKGROUND

Evaluation and treatment of the acutely ill patient is typically complicated by multiple comorbidities and incomplete medical histories. This is exemplified by patients with sepsis, whose care is complicated by variable presentations, shifting definitions, and a variety of potential sources. Many practitioners fail to consider and recognize less-common sources of infection in a timely manner. Additionally, multiple noninfectious conditions can present with the fever and tachycardia typical of the septic patient. The errors of anchoring and premature closure may lead to delay in, or failure of, diagnosis of these conditions.

OBJECTIVE

This review addresses the evaluation of the acutely ill-appearing patient without an apparent source, focusing on occult sources of infection and conditions that mimic sepsis.

DISCUSSION

Musculoskeletal, cardiac, neuraxial, and abdominal sources of sepsis should be considered in the acutely ill patient. Indwelling devices should be carefully examined for signs of infection. Consideration for sepsis mimics, such as neuroleptic malignant syndrome, malignant hyperthermia, medication toxicity, and thyroid storm, in patients who fail to respond to standard therapies for sepsis, may lead the physician to potentially reversible life-threatening diagnoses and management.

CONCLUSION

In the seemingly septic patient who does not respond to antimicrobials and fluids, the differential should be broadened to include acutely life-threatening conditions that can mimic sepsis. A review of the patient's medical history, medications, and recent exposures can assist in identifying the source of the patient's elevated body temperature and tachycardia. Consideration of potential sources and other mimics of sepsis is needed in the emergency department.

Mortality outcomes based on ED qSOFA score and HIV status in a developing low income country

OBJECTIVE

To evaluate the utility of the quick Sepsis-related Organ Failure Assessment (qSOFA) score to predict risks for emergency department (ED) and hospital mortality among patients in a sub-Saharan Africa (SSA) setting.

METHODS

This retrospective cohort study was carried out at a tertiary-care hospital, in Kigali, Rwanda and included patients ≥15years, presenting for ED care during 2013 with an infectious disease (ID). ED and overall hospital mortality were evaluated using multivariable regression, with qSOFA scores as the primary predictor (reference: qSOFA=0), to yield adjusted relative risks (aRR) with 95% confidence intervals (CI). Analyses were performed for the overall population and stratified by HIV status.

RESULTS

Among 15,748 cases, 760 met inclusion (HIV infected 197). The most common diagnoses were malaria and intra-abdominal infections. Prevalence of ED and hospital mortality were 12.5% and 25.4% respectively. In the overall population, ED mortality aRR was 4.8 (95% CI 1.9-12.0) for qSOFA scores equal to 1 and 7.8 (95% CI 3.1-19.7) for qSOFA scores ≥2. The aRR for hospital mortality in the overall cohort was 2.6 (95% 1.6-4.1) for qSOFA scores equal to 1 and 3.8 (95% 2.4-6.0) for qSOFA scores ≥2. For HIV infected cases, although proportional mortality increased with greater qSOFA score, statistically significant risk differences were not identified.

CONCLUSION

The qSOFA score provided risk stratification for both ED and hospital mortality outcomes in the setting studied, indicating utility in sepsis care in SSA, however, further prospective study in high-burden HIV populations is needed.

The pancreas responds to remote damage and systemic stress by secretion of the pancreatic secretory proteins PSP/regI and PAP/regIII

INTRODUCTION

In patients with infection and sepsis serum levels of Pancreatic Stone protein/regenerating protein I (PSP) are highly elevated. The origin of PSP during these conditions is presumably the pancreas, however, an intestinal origin cannot be excluded. Similarly, pancreatitis-associated protein (PAP) was identified in the pancreas. These proteins were also localized in intestinal organs. Here we aim to elucidate the bio-distribution of PSP and PAP in animal models of sepsis and in healthy humans.

RESULTS

PSP and PAP responded to remote lesions in rats although the pancreatic response was much more pronounced than the intestinal. Tissue distribution of PSP demonstrated a 100-fold higher content in the pancreas compared to any other organ while PAP was most abundant in the small intestine. Both proteins responded to CLP or sham operation in the pancreas. PSP also increased in the intestine during CLP. The distribution of PSP and PAP in human tissue mirrored the distribution in the murine models.

MATERIALS AND METHODS

Distribution of PSP and PAP was visualized by immunohistochemistry. Rats and mice underwent midline laparotomies followed by mobilization of tissue and incision of the pancreatic duct or duodenum. Standard cecum-ligation-puncture (CLP) procedures or sham laparotomies were performed. Human tissue extracts were analyzed for PSP and PAP.

CONCLUSIONS

The pancreas reacts to remote lesions and septic insults in mice and rats with increased PSP synthesis, while PAP is selectively responsive to septic events. Furthermore, our results suggest that serum PSP in septic patients is predominantly derived through an acute phase response of the pancreas.

Serum Lactate Predicts Adverse Outcomes in Emergency Department Patients With and Without Infection

INTRODUCTION

Lactate levels are increasingly used to risk stratify emergency department (ED) patients with and without infection. Whether a serum lactate provides similar prognostic value across diseases is not fully elucidated. This study assesses the prognostic value of serum lactate in ED patients with and without infection to both report and compare relative predictive value across etiologies.

METHODS

We conducted a prospective, observational study of ED patients displaying abnormal vital signs (AVS) (heart rate ≥130 bpm, respiratory rate ≥24 bpm, shock index ≥1, and/or systolic blood pressure <90 mmHg). The primary outcome, deterioration, was a composite of acute renal failure, non-elective intubation, vasopressor administration or in-hospital mortality.

RESULTS

Of the 1,152 patients with AVS who were screened, 488 patients met the current study criteria: 34% deteriorated and 12.5% died. The deterioration rate was 88/342 (26%, 95% CI: 21 - 30%) for lactate < 2.5 mmol/L, 47/90 (52%, 42 - 63%) for lactate 2.5 - 4.0 mmol/L, and 33/46 (72%, 59 - 85%) for lactate >4.0mmol/L. Trended stratified lactate levels were associated with deterioration for both infected (p<0.01) and non-infected (p<0.01) patients. In the logistic regression models, lactate > 4mmol/L was an independent predictor of deterioration for patients with infection (OR 4.8, 95% CI: 1.7 - 14.1) and without infection (OR 4.4, 1.7 - 11.5).

CONCLUSION

Lactate levels can risk stratify patients with AVS who have increased risk of adverse outcomes regardless of infection status.

Escherichia coli Braun Lipoprotein (BLP) exhibits endotoxemia - like pathology in Swiss albino mice

The endotoxin lipopolysaccharide (LPS) promotes sepsis, but bacterial peptides also promote inflammation leading to sepsis. We found, intraperitoneal administration of live or heat inactivated E. coli JE5505 lacking the abundant outer membrane protein, Braun lipoprotein (BLP), was less toxic than E. coli DH5α possessing BLP in Swiss albino mice. Injection of BLP free of LPS purified from E. coli DH5α induced massive infiltration of leukocytes in lungs and liver. BLP activated human polymorphonuclear cells (PMNs) ex vivo to adhere to denatured collagen in serum and polymyxin B independent fashion, a property distinct from LPS. Both LPS and BLP stimulated the synthesis of platelet activating factor (PAF), a potent lipid mediator, in human PMNs. In mouse macrophage cell line, RAW264.7, while both BLP and LPS similarly upregulated TNF-α and IL-1β mRNA; BLP was more potent in inducing cyclooxygenase-2 (COX-2) mRNA and protein expression. Peritoneal macrophages from TLR2^−/− mice significantly reduced the production of TNF-α in response to BLP in contrast to macrophages from wild type mice. We conclude, BLP acting through TLR2, is a potent inducer of inflammation with a response profile both common and distinct from LPS. Hence, BLP mediated pathway may also be considered as an effective target against sepsis.

Prospective study of the clinical performance of three BACTEC media in a modern emergency department: Plus Aerobic/F, Plus Anaerobic/F, and Anaerobic Lytic/F

The performance of 3 blood culture bottles (BACTEC Plus Aerobic/F, Plus Anaerobic/F, and Anaerobic Lytic/F) were analyzed with clinical specimens collected from 688 Emergency Department patients. A total of 270 strains belonging to 33 species were identified, with E. coli and S. aureus as the most frequently detected. Overall recovery rate (RR) of bacteria and yeast was equivalent in the Plus Aerobic/F vials (208 of 270 isolates; 77.0%) and Anaerobic Lytic/F vials (206 isolates; 76.3%) and significantly better than in the Plus Anaerobic/F vials (189 isolates; 70.0%). Median time to detection (TTD) was earliest with the Anaerobic Lytic/F vials (12.0h) compared with the Plus Aerobic/F (14.6h) and Plus Anaerobic/F vials (15.4h). Positivity rate (PR) was similar for Anaerobic Lytic/F vials (76.9%) and Plus Aerobic/F vials (76.5%), but better if compared with Plus Anaerobic/F vials (69.4%). The PR and TTD for the combination of Plus Aerobic/F with Anaerobic Lytic/F (94.5% and 12.3h, respectively) was significantly better than with Plus Aerobic/F with Plus Anaerobic/F (87.8% and 14.1h).

Serum Calprotectin Expression as a Diagnostic Marker for Sepsis in Postoperative Intensive Care Unit Patients

The research was performed to explore the diagnosis value of dynamic serum calprotectin (SC) expression for sepsis in postoperative intensive care unit patients. One hundred sixty-three patients who met the inclusion criteria served as the study group. All cases in the study group were further divided into the sepsis subgroup (51 cases) and the nonsepsis subgroup (112 cases). Fifty healthy volunteers served as the control group. The levels of SC and other laboratory indexes including complete blood counts, leukocytes, the immature-to-total-neutrophil ratio, procalcitonin (PCT), C-reactive protein, and blood lactate were detected, cytokines [interleukin (IL)-2, IL-6, and interferon-γ] released by neutrophils were also determined. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the Sequential Organ Failure Assessment score were calculated. The factors related to prognosis were analyzed with multivariate logistic regression analysis. The diagnostic accuracies of ΔSC [the differences of SC levels between postoperative day (POD) 1 and POD 2, 3, 5, 7] and ΔPCT (the differences of PCT levels between POD 1 and POD 2, 3, 5, 7) on sepsis were compared with other markers for sepsis. The levels of SC and cytokines were markedly increased on POD 1, 2, 3, 5, and 7 in the study group compared with the control group (P < 0.05 or P < 0.01). The same results were found in the sepsis subgroup compared with the nonsepsis subgroup (P < 0.05 or P < 0.01). Significant positive correlations between SC and cytokines were confirmed in patients of the study group (P < 0.05 or P < 0.01). APACHE II scores and the levels of SC and PCT on POD 1 were the variables significantly associated with sepsis. The diagnostic accuracies of ΔSC_1-3 (sensitivity 87%, specificity 89%) and ΔPCT_1-3 (sensitivity 89%, specificity 90%) for sepsis were greater than other ΔSCs and ΔPCTs. It appears that the dynamic changes in SC are of the predictive values for septic patients after major surgeries.

Sepsis: in search of cure

INTRODUCTION

Sepsis is a complex inflammatory disorder believed to originate from an infection by any types of microbes and/or their products. It is the leading cause of death in intensive care units (ICUs) throughout the globe. The mortality rates depend both on the severity of infection and the host's response to infection.

METHODS

Literature survey on pathobiology of sepsis in general and failure of more than hundred clinical trials conducted so far in search of a possible cure for sepsis resulted in the preparation of this manuscript.

FINDINGS

Sepsis lacks a suitable animal model that mimics human sepsis. However, based on the results obtained in animal models of sepsis, clinical trials conducted so far have been disappointing. Although involvement of multiple mediators and pathways in sepsis has been recognized, only few components are being targeted and this could be the major reason behind the failure of clinical trials.

CONCLUSION

Inability to recognize a single critical mediator of sepsis may be the underlying cause for the poor therapeutic intervention of sepsis. Therefore, sepsis is still considered as a disease-in search of cure.

Goal-Directed Resuscitation in Septic Shock: A Critical Analysis

The Early Goal-Directed Therapy versus Standard Care for Sepsis trial by Rivers and colleagues in 2001 suggested that a significant mortality reduction may be realized through goal-directed interventions early in the care of patients with septic shock. However, the recent publication of the Protocol-Based Care for Early Septic Shock (ProCESS), Australasian Resuscitation in Sepsis Evaluation (ARISE), and Protocolised Management in Sepsis (ProMISE) trials did not demonstrate the superiority of early goal-directed therapy over usual care. If usual care includes timely and meticulous care, a protocol may not be needed to realize the continued lowering mortality rates.

Derivation and Validation of Predictive Factors for Clinical Deterioration after Admission in Emergency Department Patients Presenting with Abnormal Vital Signs Without Shock

INTRODUCTION

Strategies to identify high-risk emergency department (ED) patients often use markedly abnormal vital signs and serum lactate levels. Risk stratifying such patients without using the presence of shock is challenging. The objective of the study is to identify independent predictors of in-hospital adverse outcomes in ED patients with abnormal vital signs or lactate levels, but who are not in shock.

METHODS

We performed a prospective observational study of patients with abnormal vital signs or lactate level defined as heart rate ≥130 beats/min, respiratory rate ≥24 breaths/min, shock index ≥1, systolic blood pressure <90 mm/Hg, or lactate ≥4 mmole/L. We excluded patients with isolated atrial tachycardia, seizure, intoxication, psychiatric agitation, or tachycardia due to pain (ie: extremity fracture). The primary outcome was deterioration, defined as development of acute renal failure (creatinine 2× baseline), non-elective intubation, vasopressor requirement, or mortality. Independent predictors of deterioration after hospitalization were determined using logistic regression.

RESULTS

Of 1,152 consecutive patients identified with abnormal vital signs or lactate level, 620 were excluded, leaving 532 for analysis. Of these, 53/532 (9.9±2.5%) deteriorated after hospital admission. Independent predictors of in-hospital deterioration were: lactate >4.0 mmol/L (OR 5.1, 95% CI [2.1-12.2]), age ≥80 yrs (OR 1.9, CI [1.0-3.7]), bicarbonate <21 mEq/L (OR 2.5, CI [1.3-4.9]), and initial HR≥130 (OR 3.1, CI [1.5-6.1]).

CONCLUSION

Patients exhibiting abnormal vital signs or elevated lactate levels without shock had significant rates of deterioration after hospitalization. ED clinical data predicted patients who suffered adverse outcomes with reasonable reliability.

National early warning score at Emergency Department triage may allow earlier identification of patients with severe sepsis and septic shock: a retrospective observational study

INTRODUCTION

Severe sepsis and septic shock (SS) are time-critical medical emergencies that affect millions of people in the world. Earlier administration of antibiotics has been shown to reduce mortality from SS; however, the initiation of early resuscitation requires recognition that a patient may have sepsis. Early warning scores (EWS) are broadly used to detect patient deterioration, but to date have not been evaluated to detect patients at risk for SS. The purpose of our study was to look at the relationship between the initial national EWS (NEWS) in the emergency department (ED) and the diagnosis of SS.

METHODS

We performed a retrospective, single-centre, observational study in the ED of an urban university hospital with an annual attendance of 140,000 patients. We aimed to include 500 consecutive non-trauma adult patients presenting to the ED with Manchester Triage System (MTS) category 1-3. The final diagnosis was taken from either the ED medical records or the hospital discharge summary. For all NEWS, the sensitivity and specificity to detect patients with SS was calculated.

RESULTS

A total of 500 patients were included, 27 patients (5.4%) met the criteria for SS. The area under the curve (AUC) for NEWS to identify patient at risk for SS is 0.89 (95% CI 0.84 to 0.94). A NEWS of 3 or more at ED triage has a sensitivity of 92.6% (95% CI 74.2% to 98.7%) and a specificity of 77% (95% CI 72.8% to 80.6%) to detect patients at risk for SS at ED triage.

CONCLUSIONS

A NEWS of 3 or more at ED triage may be the trigger to systematically screen the patient for SS, which may ultimately lead to early recognition and treatment.

Capillary lactate as a tool for the triage nurse among patients with SIRS at emergency department presentation: a preliminary report

Background

The triage nurse is involved in the early identification of the most severe patients at emergency department (ED) presentation. However, clinical criteria alone may be insufficient to identify them correctly. Measurement of capillary lactate concentration at ED presentation may help to discriminate these patients. The primary objective of this study was to identify the prognostic value of capillary lactate concentration measured by the triage nurse among patients presenting to the ED.

Methods

This was a prospective observational study, performed in the ED of a university hospital. At ED presentation, capillary lactate measurement was performed by the triage nurse among patients presenting with a clinical criteria of systemic inflammatory response syndrome (SIRS). Clinical variables usually used to determine severity were collected at presentation. Twenty-eight-day mortality and MEDS score were recorded.

Results

One hundred seventy-six patients with clinical SIRS presented to the ED. Median age was 72 years, and 28-day mortality was 16%. Capillary lactate at ED presentation was significantly higher among 28-day non-survivors than among survivors (5.7 mmol.L⁻¹ [3.2 to 7.4] vs 2.9 mmol.L⁻¹ [1.9 to 5.2], p = 0.003). A score based on mottling and capillary lactate concentration >3.6 mmol.L⁻¹ was significantly associated with 28-day mortality (area under curve, AUC = 0.75), independently of the MEDS score (AUC = 0.79) for the prediction of 28-day mortality (AUC global model 0.87).

Conclusions

A high capillary lactate concentration measured by the triage nurse among patients presenting to the ED with clinical SIRS is associated with a high risk of death. A score calculated by the triage nurse, based on mottling and capillary lactate concentration, appears to be useful for identifying the most severe patients.

EMS patients and walk-in patients presenting with severe sepsis: differences in management and outcome

OBJECTIVES

Sepsis is a significant problem. The differences between patients with sepsis who walk into the emergency department (ED) and those who are transported via emergency medical services (EMS) have not been clarified. The aim of the study was to determine whether there was a difference in outcome between patients arriving by EMS and those presenting directly to the ED.

METHODS

We prospectively collected and reviewed a cohort of all cases of severe sepsis and septic shock admitted to the medical intensive care unit from the ED from November 2009 to March 2012. Extracted data were basic demographic information (including mode of ED arrival), clinical data, and treatments. We calculated Systemic Inflammatory Response Syndrome criteria, Acute Physiology and Chronic Health Evaluation II scores, and Sequential Organ Failure Assessment (SOFA) scores. The primary outcome was mortality in severely ill patients with sepsis.

RESULTS

A total of 378 subjects (78%) presented by EMS and 107 subjects were walk-in patients (22%). Patients transported via EMS were older (P < 0.01), had fewer lactates >4 (P < 0.02), a more altered mental status (P < 0.01), and higher respiratory rates (P < 0.05) than did walk-in patients. Patients transported by EMS had worse disease severity when measured by an Acute Physiology and Chronic Health Evaluation II score (P < 0.01) but not by SOFA score. EMS patients had a shorter time to receiving antibiotics (P = 0.02) and central line placement (P < 0.01) than did walk-in patients. In a logistic model, mortality was associated with increasing age (adjusted odds ratio 1.3; 95% confidence interval [CI] 1.2-1.4), higher first-measured ED lactates (1.2; 95% CI 1.1-1.2), and increased initial SOFA score (adjusted odds ratio 1.2; 95% CI 1.1-1.3) but not EMS arrival or prehospital fluids.

CONCLUSIONS

Neither arrival by EMS nor fluid administration by EMS is associated with decreased mortality in severe sepsis.

Identification of the severe sepsis patient at triage: a prospective analysis of the Australasian Triage Scale

Objective

This study aims to investigate the accuracy and validity of the Australasian Triage Scale (ATS) as a tool to identify and manage in a timely manner the deteriorating patient with severe sepsis.

Methods

This was a prospective observational study conducted in five sites of adult patients. Keywords and physiological vital signs data from triage documentation were analysed for the ‘identified’ status compared with confirmed diagnosis of severe sepsis after admission to the intensive care unit. The primary outcome is the accuracy and validity of the ATS Triage scale categories to identify a prespecified severe sepsis population at triage. Secondary outcome measures included time compliance, antimicrobial administration and mortality prediction. Statistical analysis included parameters of diagnostic performance. Adjusted multivariate logistic regression analysis was applied to mortality prediction.

Results

Of 1022 patients meeting the criteria for severe sepsis, 995 were triaged through the emergency department, 164 with shock. Only 53% (n=534) were identified at triage. The overall sensitivity of the ATS to identify severe sepsis was 71%. ATS 3 was the most accurate (likelihood ratio positive, 2.45, positive predictive value 0.73) and ATS 2 the most valid (area under the curve 0.567) category. Identified cases were more likely to survive (OR 0.81, 95% CI 0.697 to 0.94, p<0.007). The strongest bias-adjusted predictors of mortality were circulatory compromise variable (1.78, 95% CI 1.34 to 1.41, p<0.001), lactate >4 (OR 1.63, 95% CI 1.10 to 2.89, p<0.001) and ATS 1 category (OR 1.55, 95% CI 1.09 to 2.35, p<0.005).

Conclusions

The ATS and its categories is a sensitive and moderately accurate and valid tool for identifying severe sepsis in a predetermined group, but lacks clinical efficacy and safety without further education or quality improvement strategies targeted to the identification of severe sepsis.

The role of obesity in the immune response during sepsis

Background/Objectives:

Sepsis is one of the most important causes of mortality in the developed world, where almost two-thirds of the population suffer from obesity. Therefore, the coexistence of both conditions has become frequent in clinical practice and a growing number of clinical studies attempts to examine the potential effect of obesity on sepsis with controversial results up to now. The present study investigates how obesity influences the immune response of septic patients, by assessing the number and activation state of adipose tissue macrophages, serum and adipose tissue tumor necrosis factor-alpha (TNFα) levels and plasma oxidative stress markers.

Subjects/methods:

The study included 106 patients, divided into four groups (control n=26, obesity n=27, sepsis n=27 and sepsis and obesity n=26). The number of macrophages in subcutaneous and visceral adipose tissue (SAT and VAT) and their subtypes (M1 and M2) were defined with immunohistochemical staining techniques under light microscopy. TNFα mRNA levels were determined in SAT and VAT using real-time reverse transcription-PCR. Serum levels of TNFα were determined with sandwich enzyme-linked immunosorbent assay. Plasma oxidative stress was evaluated using selective biomarkers (thiobarbituric acid-reactive substances (TBARS), protein carbonyls and total antioxidant capacity (TAC)).

Results:

Sepsis increased the total number of macrophages and their M2 subtype in (VAT), whereas obesity did not seem to affect the concentration of macrophages in fat. Obesity increased TNFα mRNA levels (P<0.05) in VAT as well as the plasma TBARS (P<0.001) and protein carbonyls (P<0.001) in septic patients. The plasma TAC levels were decreased and the serum TNFα levels were increased in sepsis although they were not influenced by obesity.

Conclusions:

Obesity is associated with elevated TNFα adipose tissue production and increased oxidative stress biomarkers, promoting the proinflammatory response in septic patients.

Transforming growth factor β-induced protein promotes severe vascular inflammatory responses

RATIONALE

Sepsis is a systemic inflammatory condition resulting from bacterial infections; it has a high mortality rate and limited therapeutic options. Despite extensive research into the mechanisms driving bacterial sepsis, the target molecules controlling vascular leakage are still largely unknown. Transforming growth factor β-induced protein (TGFBIp) is an extracellular matrix protein expressed in several cell types, which is known to interact with integrins.

OBJECTIVES

The aim of this study was to determine the roles of TGFBIp in vascular proinflammatory responses, and the mechanisms of action driving these responses.

METHODS

Circulating levels of TGFBIp were measured in patients admitted to the hospital with sepsis, severe sepsis, and septic shock and in cecal ligation and puncture (CLP)-induced septic mice. Effects of TGFBIp knockout on CLP-induced septic mortality and effects of TGFBIp on multiple vascular proinflammatory responses were determined.

MEASUREMENTS AND MAIN RESULTS

Circulating levels of TGFBIp were significantly elevated compared with healthy controls, and were strongly correlated with disease severity. High blood TGFBIp levels were also observed in CLP-induced septic mice. The absence of the TGFBIp gene in mice attenuated CLP-induced sepsis. TGFBIp enhanced vascular proinflammatory responses including vascular permeability, adhesion and migration of leukocytes, and disruption of adherence junctions through interacting with integrin αvβ5.

CONCLUSIONS

Collectively, our findings demonstrate that the TGFBIp-αvβ5 axis can elicit severe inflammatory responses, suggesting it to be a potential target for development of diagnostics and therapeutics for sepsis.

Plethysmographic variation index predicts fluid responsiveness in ventilated patients in the early phase of septic shock in the emergency department: a pilot study

PURPOSE

Feasibility study examining whether plethysmographic variability index (PVI) can predict fluid responsiveness in mechanically ventilated patients in the early phase of septic shock in the emergency department.

MATERIALS AND METHODS

Monocentric, prospective, observational study that included 31 mechanically ventilated and sedated patients with septic shock in whom volume expansion was planned. The patients were equipped with a pulse oximeter that automatically calculated and displayed PVI. The intervention consisted in infusing 8 mL/kg of hydroxylethyl starch over a 20-minute period. Before and after intervention, we recorded PVI and measured the aortic velocity-time integral (VTIao) using transthoracic echocardiography. Responders were defined as patients who increased their VTIao by 15% or higher after fluid infusion.

RESULTS

Sixteen patients were classified as responders, and 15 as nonresponders. Mean PVI values before intervention were significantly higher in responders vs nonresponders (30%±9% vs 8%±5%, P<.001). Plethysmographic variability index values before intervention were correlated with percent changes in VTIao induced by intervention (R2=0.67; P<.001). A PVI threshold value of 19% discriminates responders from nonresponders with a sensitivity of 94% and a specificity of 87% (area under the curve, 0.97; P<.001).

CONCLUSION

Our study suggests that PVI is a feasible and interesting method to predict fluid responsiveness in early phase septic shock patients in the emergency department.