Early management of sepsis with emphasis on early goal directed therapy: AME evidence series 002

Infection in ECMO patients: Changes in epidemiology, diagnosis and prevention

Patients with prolonged duration of extracorporeal membrane oxygenation support (ECMO) are a vulnerable population for sepsis, particularly ventilator-associated pneumonia and bloodstream infections. Rates differ between venous-arterial and venous-venous ECMO patients and according to the cannulation technique used. The presence of particular organisms depends on local epidemiology, antibiotic exposure, and the duration of the intervention; patients undergoing ECMO for more than three weeks present a high risk of persistent candidemia. Recognizing predisposing factors, and establishing the best preventive interventions and therapeutic choices are critical to optimizing the management of these complications. Infection control practices, including shortening the period of the indwelling devices, and reducing antibiotic exposure, must be followed meticulously. Innovations in oxygenator membranes require an updated approach. Hand hygiene and avoiding breaking the circuit-oxygenator sterility are cornerstones. ECMO management would benefit from clearer definitions, optimization of infection control strategies, and updated infectious clinical practice guidelines.

Effectiveness of anisodamine for the treatment of critically ill patients with septic shock: a multicentre randomized controlled trial

BACKGROUND

Septic shock is characterized by an uncontrolled inflammatory response and microcirculatory dysfunction. There is currently no specific agent for treating septic shock. Anisodamine is an agent extracted from traditional Chinese medicine with potent anti-inflammatory effects. However, its clinical effectiveness remains largely unknown.

METHODS

In a multicentre, open-label trial, we randomly assigned adults with septic shock to receive either usual care or anisodamine (0.1-0.5 mg per kilogram of body weight per hour), with the anisodamine doses adjusted by clinicians in accordance with the patients' shock status. The primary end point was death on hospital discharge. The secondary end points were ventilator-free days at 28 days, vasopressor-free days at 28 days, serum lactate and sequential organ failure assessment (SOFA) score from days 0 to 6. The differences in the primary and secondary outcomes were compared between the treatment and usual care groups with the χ² test, Student's t test or rank-sum test, as appropriate. The false discovery rate was controlled for multiple testing.

RESULTS

Of the 469 patients screened, 355 were assigned to receive the trial drug and were included in the analyses-181 patients received anisodamine, and 174 were in the usual care group. We found no difference between the usual care and anisodamine groups in hospital mortality (36% vs. 30%; p = 0.348), or ventilator-free days (median [Q1, Q3], 24.4 [5.9, 28] vs. 26.0 [8.5, 28]; p = 0.411). The serum lactate levels were significantly lower in the treated group than in the usual care group after day 3. Patients in the treated group were less likely to receive vasopressors than those in the usual care group (OR [95% CI] 0.84 [0.50, 0.93] for day 5 and 0.66 [0.37, 0.95] for day 6).

CONCLUSIONS

There is no evidence that anisodamine can reduce hospital mortality among critically ill adults with septic shock treated in the intensive care unit. Trial registration ClinicalTrials.gov ( NCT02442440 ; Registered on 13 April 2015).

Study of the diagnostic criteria for hemophagocytic lymphohistiocytosis in neonatal and pediatric patients with severe sepsis or septic shock

Septic shock is a major public health concern. However, the clinical and laboratory criteria for sepsis overlap with those for hemophagocytic lymphohistiocytosis (HLH), and their differentiation can be challenging. The aim of this study was to compare HLH criteria among patients diagnosed with neonatal sepsis and childhood sepsis and to study the outcomes in patients fulfilling the diagnostic criteria for HLH. A cross-sectional study included 50 neonates and children with severe sepsis and/or septic shock. Clinical and laboratory data and HLH diagnostic criteria were studied in relation to patients outcome. Of all patients, 18% fulfilled three of the eight HLH diagnostic criteria, 2% fulfilled four criteria, and 4% fulfilled five criteria. All patients who fulfilled three or more of the criteria died. Mortality was higher in the presence of more positive HLH criteria and in pediatric age groups. However, the distributions of the HLH criteria were comparable for pediatric and neonatal patients with severe sepsis/septic shock, and their mortality rates were not significantly different when based on the criteria.

Analysis of Noninvasive Ventilation in Subjects With Sepsis and Acute Respiratory Failure

BACKGROUND

Acute respiratory failure is among the sequelae of complications that can develop in response to severe sepsis. Research into sepsis-related respiratory failure has focused on ARDS and invasive mechanical ventilation. We studied the factors associated with success and failure of noninvasive ventilation (NIV) in the treatment of sepsis-related acute respiratory failure.

METHODS

This retrospective study included 136 subjects with a diagnosis of acute respiratory failure and intrapulmonary or extrapulmonary sepsis who were placed on NIV. Subjects were divided into 2 groups based on the need for intubation from NIV: NIV failure (n = 70) and NIV success (n = 66). Demographic, clinical, and outcome data were collected and compared between groups, with the development of multivariate models to predict NIV failure and mortality.

RESULTS

The overall NIV failure rate in subjects with a diagnosis of sepsis was 51%. There were no between-group differences in demographic or baseline characteristics. However, there were significant differences in clinical variables, with higher SOFA scores (NIV failure: 6.4 [± 3.0] vs NIV success: 4.9 [± 2.1]; P = .002), 2nd lactate levels (NIV failure: 2.6 [1.7 - 4.3] vs NIV success: 1.9 [1.4 - 2.6] mmol/L; P = .007), and initial NIV [Formula: see text] settings (NIV failure: 0.50 [0.40 - 0.70] vs NIV failure: 0.40 [0.35 - 0.50]; P = .003) in subjects who failed NIV. There were also more subjects in the NIV failure group who had a lactate ≥ 4 mmol/L prior to NIV start compared to those who succeeded on NIV (33% vs 15%, P = .02). At NIV start, subjects in the NIV failure group had lower mean arterial pressure (85 mm Hg [IQR 74-96] vs 91.7 mm Hg [IQR 78-108], P = .042) and Glasgow coma scale scores (14 [IQR 13-15] vs 15 [IQR 14-15], P < .002), while fewer subjects in the NIV failure group received a fluid bolus in the 24 h prior to NIV start (33% vs 53%, P = .02) or had signs of volume overload (36% vs 64%, P < .001). Multivariate analysis indicated that age (odds ratio 1.05 [95% CI 1.01-1.09], P = .02), SOFA score (odds ratio 1.49 [95% CI 1.15-1.94], P = .002), first systolic blood pressure (odds ratio 0.97 [95% CI 0.95-0.99], P = .02), signs of volume overload (odds ratio 0.23 [95% CI 0.07-0.68], P = .008], fluids prior to NIV (odds ratio 0.08 [95% CI 0.02-0.31], P < .001), and initial [Formula: see text] on NIV (odds ratio 1.04 [95% CI 1.01-1.08, P = .002) independently predicted NIV failure with an area under the curve of 0.88. Only NIV failure independently predicted death in multivariate analysis (area under the curve = 0.70).

CONCLUSIONS

NIV failure in sepsis-related acute respiratory failure was independently predicted by patient acuity, first systolic blood pressure after sepsis alert, initial [Formula: see text] settings on NIV, fluid resuscitation, and signs of volume overload. However, only NIV failure independently predicted death in this cohort of subjects.

Screening of hemophagocytic lymphohistiocytosis in children with severe sepsis in pediatric intensive care

BACKGROUND

We sought to screen for clinical and laboratory features of hemophagocytic lymphohistiocytosis among pediatric patients with severe sepsis.

METHODS

We conducted a retrospective study that analyzed the clinical and laboratory data of 70 pediatric patients who died of severe sepsis. Medical records were revised for the presence of fever, splenomegaly, pancytopenia, hyperferritinemia, hypertriglyceridemia, and hypofibrinogenemia. Soluble CD25 was measured in stored samples.

RESULTS

Patients' ages ranged between 0.5 and 11 years with median (interquartile range) 2 (1-5). All patients had fever (≥38.5 °C) and pancytopenia, 58 (82.9%) hepatosplenomegaly, 36 (51.4%) lymphadenopathy, 37 (52.9%) had ferritin >500 ng/ml, 20 (28.6%) had fibrinogen <1.5 mg/ml, 14 (20%) had fasting triglycerides >264 mg/dl while 5 (7.1%) had soluble CD25 >2400 U/ml. Twenty-five (35.7%) patients fulfilled at least 5/6 of the hemophagocytic lymphohistiocytosis-2004 diagnostic criteria. Multivariate backward binary logistic regression analysis revealed lymphadenopathy as an independent predictor for hemophagocytic lymphohistiocytosis criteria fulfilment with odds ratio of 23.9. Fibrinogen had the best performance in discriminating hemophagocytic lymphohistiocytosis fulfilling from non-fulfilling groups (cut-off value: <1.8 mg/ml), followed by ferritin/erythrocyte sedimentation rate ratio (cut-off value: >17).

CONCLUSION

There is a significant clinical and laboratory overlap between hemophagocytic lymphohistiocytosis and severe sepsis, making the syndromes difficult to distinguish. The use of current hemophagocytic lymphohistiocytosis-2004 diagnostic criteria should be applied cautiously in those patients.

Prompt admission to intensive care is associated with improved survival in patients with severe sepsis and/or septic shock

Objective To investigate the association between time from hospital admission to intensive care unit (ICU) admission (door to ICU time) and hospital mortality in patients with sepsis. Methods This retrospective observational study included routinely collected healthcare data from patients with sepsis. The primary endpoint was hospital mortality, defined as the survival status at hospital discharge. Door to ICU time was calculated and included in a multivariable model to investigate its association with mortality. Results Data from 13 115 patients were included for analyses, comprising 10 309 survivors and 2 806 non-survivors. Door to ICU time was significantly longer for non-survivors than survivors (median, 43.0 h [interquartile range, 12.4, 91.3] versus 26.7 h [7.0, 74.2]). In the multivariable regression model, door to ICU time remained significantly associated with mortality (odds ratio [OR] 1.11, 95% confidence interval [CI] 1.006, 1.017) and there was a significant interaction between age and door to ICU time (OR 0.99, 95% CI 0.99, 1.00). Conclusion A shorter time from hospital door to ICU admission was shown to be independently associated with reduced hospital mortality in patients with severe sepsis and/or septic shock.

Ulinastatin is effective in reducing mortality for critically ill patients with sepsis: a causal mediation analysis

Ulinastatin has been found to have anti-inflammatory effect for patients with sepsis. However, its clinical effects were conflicting. The study aimed to investigate the cost-effectiveness of ulinastatin and to perform mediation analysis to explore the proportion of the total effects that can be explained by inflammatory responses. This is a retrospective study involving critically ill patients with sepsis from January 2014 to July 2017. A total of 263 patients were included in the study, involving 179 patients in the ulinastatin group and 84 in the control group. Ulinastatin group showed significantly lower 28-day mortality rate than that in the control group (31% vs. 55%; p < 0.001). Both total (46330 [26000,83500] vs. 19870 [8747,41140] RMB; p < 0.01) and drug cost (18210 [9492,31920] vs. 7230 [2675,19270] RMB; p < 0.01) were significantly higher in the ulinastatin group than the control group. In multivariable model, the adjusted odds ratio for ulinastatin was 0.304 (95% CI: 0.152 to 0.592; p = 0.001). The mediation analysis showed that the use of ulinastatin was able to reduce the probability of death by 23.5%. The average causal mediation effect of delta C-reactive protein (CRP) was 8%, accounting for 35% of the total effect.

Hotspot Analysis of Sepsis Literature

Sepsis is a common life-threatening pathological process. However, the transformation efficiency of studies on the treatment of sepsis is relatively low. Therefore, a hotspot and trend development study was attempted on the treatment area of sepsis in accordance with the literature. We selected 2511 studies most related to the treatment of sepsis within the past 5 years as research samples. Text and co-word matrix were established by analyzing and selecting high-frequency words using BICOMB software. Classifications in hotspot areas were obtained through biclustering and visual analysis of high-frequency words using Ggluto software. Strategy coordinates for hotspot research were conducted using a co-word matrix. A total of 41 high-frequency words, text, and co-word matrix were conducted within the 2511 studies. A peak map was drawn based on biclustering analysis. The density and concentricity of each hotspot were calculated using the result of the co-word matrix and biclustering analysis. The research concluded 4 categories and 9 aspects for the treatment of sepsis. Additionally, calculation results showed that the relationship between the prognosis of sepsis and the hematological prognosis was in the fourth quadrant of the strategic diagram, that means it was the potential hotspot area for the treatment of sepsis. This conclusion provides potential value for future exploratory stages of study.

The top 2,000 cited articles in critical care medicine: a bibliometric analysis

BACKGROUND

The bibliometric analysis has been performed on several topics in critical care medicine (CCM) focusing on top 100 cited articles, but the analysis on CCM literature as a whole is missing. The present study aimed to perform a complete bibliometric analysis in the field of CCM.

METHODS

An electronic search of the Scopus database was performed on Feb 13, 2018. The search strategy involved core terms related to CCM. The top 2,000 most cited articles in the field of CCM were included in the analysis. Descriptive statistics on these top-cited articles, country distributions, and journals are reported. Individual author's productivity was assessed with the Lotka's law. Co-occurrence of keywords was visualized with the Fruchterman-Reingold layout. The Walktrap algorithm was employed for clustering analysis.

RESULTS

A total of 2,000 documents were included in the analysis with median citations of 386 times [interquartile range (IQR): 308-562 times]. The most cited article was the original paper that described the Acute Physiology and Chronic Health Evaluation (APACHE) II score. The included articles were published in 411 journals. The median number of documents published in one journal was 1, and the mean number was 4.9, indicating a skewed distribution. The maximum number of publications was 217 in CCM. Author's productivity profile was significantly different from the Lotka's law (P=0.001), with n and C values of 2.8 and 0.52, respectively. Fruchterman-Reingold network plot showed that studies involving human subject were the most common literature type. Sepsis was a major research topic that co-occurred with keywords such as disease severity, nonhuman, risk assessment and practice guideline.

CONCLUSIONS

The study performed bibliometric analyses of 2,000 top-cited articles in CCM. The most cited article was the one which developed the APACHE II score. Author's productivity was significantly different from the Lotka's law.

Hemophagocytic syndrome masquerading as septic shock: An approach to such dilemma

Introduction:

Hemophagocytic syndrome or hemophagocytic lymphohistiocytosis is a rare condition characterized by excessive inflammation that is thought to be caused by the absence of normal downregulation of activated macrophages and lymphocytes. The treatment of hemophagocytic lymphohistiocytosis can depend on whether it is primary or secondary. In secondary hemophagocytic lymphohistiocytosis, the treatment can be directed according to the cause. In general, protocol HLH-94 (which consists of dexamethasone and etoposide in induction and maintenance) has been widely used as it has good outcomes. Hemophagocytic lymphohistiocytosis and septic shock largely overlap which can lead to refractory septic shock and death if not treated. Unfortunately, there is no clear approach for such dilemma. Thereby, we would like to present our case as it has a valuable approach to hemophagocytic lymphohistiocytosis in the setting of sepsis.

Case description:

A 60-year-old female, with history of hypertension, came with fever, productive cough, and dyspnea; she was admitted for acute exacerbation of chronic obstructive pulmonary disease and was transferred to intensive care unit for septic shock. The patient progressed to refractory septic shock with no focus of infection. After further investigations, detailed history raised the suspicion of hemophagocytic lymphohistiocytosis; a bone marrow biopsy was collected and confirmed the diagnosis. The patient was on methylprednisolone while waiting for other investigation results and improved markedly. After ruling out secondary causes of hemophagocytic lymphohistiocytosis, she was switched to protocol-94 and continued to improve.

Conclusion:

It should be emphasized that septic shock, with or without focus of infection, overlaps with hemophagocytic lymphohistiocytosis and can consequently lead to refractory septic shock and death. Thus, our aim of this case is to encourage further investigations, specifically for hemophagocytic lymphohistiocytosis in the setting of septic shock of unknown origin, to decrease mortality rate. More importantly, early initiation of immunosuppression therapy may be a crucial step before switching to hemophagocytic lymphohistiocytosis–specific treatment.

Why Antibiotic Treatment Is Not Enough for Sepsis Resolution: an Evaluation in an Experimental Animal Model

Sepsis remains a major health problem at the levels of mortality, morbidity, and economic burden to the health care system, a condition that is aggravated by the development of secondary conditions such as septic shock and multiple-organ failure. Our current understanding of the etiology of human sepsis has advanced, at least in part, due to the use of experimental animal models, particularly the model of cecum ligation and puncture (CLP). Antibiotic treatment has been commonly used in this model to closely mirror the treatment of human septic patients. However, whether their use may obscure the elucidation of the cellular and molecular mechanisms involved in the septic response is questionable. The objective of the present study was to determine the effect of antibiotic treatment in the outcome of a fulminant model of CLP. Various dosing strategies were used for the administration of imipenem, which has broad-spectrum coverage of enteric bacteria. No statistically significant differences in the survival of mice were observed between the different antibiotic dosing strategies and no treatment, suggesting that live bacteria may not be the only factor inducing septic shock. To further investigate this hypothesis, mice were challenged with sterilized or unsterilized cecal contents. We found that exposure of mice to sterilized cecal contents also resulted in a high mortality rate. Therefore, it is possible that bacterial debris, apart from bacterial proliferation, triggers a septic response and contributes to mortality in this model, suggesting that additional factors are involved in the development of septic shock.