Long-Term Survival Following Sepsis

Urgent call for attention to diabetes-associated hospital infections

In this editorial, we discuss the recent article by Zhao et al published in the World Journal of Diabetes, which highlights the importance of recognizing the risk indicators associated with diabetes mellitus (DM). Given the severe implications of healthcare-associated infections (HAIs) in hospitalized individuals- such as heightened mortality rates, prolonged hospitalizations, and increased costs- we focus on elucidating the connection between DM and nosocomial infections. Diabetic patients are susceptible to pathogenic bacterial invasion and subsequent infection, with some already harboring co-infections upon admission. Notably, DM is an important risk factor for nosocomial urinary tract infections and surgical site infections, which may indirectly affect the occurrence of nosocomial bloodstream infections, especially in patients with DM with poor glycemic control. Although evidence regarding the impact of DM on healthcare-associated pneumonias remains inconclusive, attention to this potential association is warranted. Hospitalized patients with DM should prioritize meticulous blood glucose management, adherence to standard operating procedures, hand hygiene pra-ctices, environmental disinfection, and rational use of drugs during hospitalization. Further studies are imperative to explore the main risk factors of HAIs in patients with DM, enabling the development of preventative measures and mitigating the occurrence of HAIs in these patients.

A dynamic nomogram for predicting 28-day mortality in septic shock: a Chinese retrospective cohort study

Background

Septic shock is a severe life-threatening disease, and the mortality of septic shock in China was approximately 37.3% that lacks prognostic prediction model. This study aimed to develop and validate a prediction model to predict 28-day mortality for Chinese patients with septic shock.

Methods

This retrospective cohort study enrolled patients from Intensive Care Unit (ICU) of the Second Affiliated Hospital, School of Medicine, Zhejiang University between December 2020 and September 2021. We collected patients' clinical data: demographic data and physical condition data on admission, laboratory data on admission and treatment method. Patients were randomly divided into training and testing sets in a ratio of 7:3. Univariate logistic regression was adopted to screen for potential predictors, and stepwise regression was further used to screen for predictors in the training set. Prediction model was constructed based on these predictors. A dynamic nomogram was performed based on the results of prediction model. Using receiver operator characteristic (ROC) curve to assess predicting performance of dynamic nomogram, which were compared with Sepsis Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation II (APACHE II) systems.

Results

A total of 304 patients with septic shock were included, with a 28-day mortality of 25.66%. Systolic blood pressure, cerebrovascular disease, Na, oxygenation index (PaO2/FiO2), prothrombin time, glucocorticoids, and hemodialysis were identified as predictors for 28-day mortality in septic shock patients, which were combined to construct the predictive model. A dynamic nomogram (https://zhijunxu.shinyapps.io/DynNomapp/) was developed. The dynamic nomogram model showed a good discrimination with area under the ROC curve of 0.829 in the training set and 0.825 in the testing set. Additionally, the study suggested that the dynamic nomogram has a good predictive value than SOFA and APACHE II.

Conclusion

The dynamic nomogram for predicting 28-day mortality in Chinese patients with septic shock may help physicians to assess patient survival and optimize personalized treatment strategies for septic shock.

A comprehensive analysis of immune features and construction of an immune gene diagnostic model for sepsis

Sepsis is a life-threatening syndrome resulting from immune system dysfunction that is caused by infection. It is of great importance to analyze the immune characteristics of sepsis, identify the key immune system related genes, and construct diagnostic models for sepsis. In this study, the sepsis transcriptome and expression profiling data were merged into an integrated dataset containing 277 sepsis samples and 117 non-sepsis control samples. Single-sample gene set enrichment analysis (ssGSEA) was used to assess the immune cell infiltration. Two sepsis immune subtypes were identified based on the 22 differential immune cells between the sepsis and the healthy control groups. Weighted gene co-expression network analysis (WCGNA) was used to identify the key module genes. Then, 36 differentially expressed immune-related genes were identified, based on which a robust diagnostic model was constructed with 11 diagnostic genes. The expression of 11 diagnostic genes was finally assessed in the training and validation datasets respectively. In this study, we provide comprehensive insight into the immune features of sepsis and establish a robust diagnostic model for sepsis. These findings may provide new strategies for the early diagnosis of sepsis in the future.

[Preclinical early detection and diagnosis of sepsis - step by step]

Because of very unspecific sepsis symptoms, early recognition of the emergency sepsis is difficult. If the disease is recognized in time it is possible to initiate diagnosis and treatment quickly. Rapid treatment of sepsis leads to lower mortality and less severe long-term consequences. Early detection is therefore of central importance in the diagnostic and therapeutic process, also in the outpatient setting.

[Aftercare of ICU patients: A task for pneumology?]

As the number of patients treated in intensive care medicine increases, so does the number of those who suffer from the long-term consequences of critical illness and the consequences of a stay in an intensive care unit. For this group of patients with a post-intensive care syndrome (PICS), there are currently no specialized outpatient care structures that follow the hospital stay and possible follow-up treatment. A number of studies are researching the effectiveness of intensive care outpatient clinics nationally and internationally.After presenting the PICS and the associated complex need for care, this review article presents various model projects for outpatient follow-up care of critically ill patients. We discuss whether the field of pneumology is particularly suitable for the study of therapy control of complex clinical pictures since it has vast experience in the treatment of intensive care patients and the outpatient care of chronically ill patients.

Effects of evidence-based ICU care on long-term outcomes of patients with sepsis or septic shock (ILOSS): protocol for a multicentre prospective observational cohort study in Japan

INTRODUCTION

Sepsis is not only the leading cause of death in the intensive care unit (ICU) but also a major risk factor for physical and cognitive impairment and mental disorders, known as postintensive care syndrome (PICS), reduced health-related quality of life (HRQoL) and even mental health disorders in patient families (PICS-family; PICS-F). The ABCDEF bundle is strongly recommended to overcome them, while the association between implementing the bundle and the long-term outcomes is also unknown.

METHODS AND ANALYSIS

This is a multicentre prospective observational study at 26 ICUs. All consecutive patients between 1 November 2020 and 30 April 2022, who are 18 years old or older and expected to stay in an ICU for more than 48 hours due to sepsis or septic shock, are enrolled. Follow-up to evaluate survival and PICS/ PICS-F will be performed at 3, 6 and 12 months and additionally every 6 months up to 5 years after hospital discharge. Primary outcomes include survival at 12 months, which is the primary outcome, and the incidence of PICS defined as the presence of any physical impairment, cognitive impairment or mental disorders. PICS assessment scores, HRQoL and employment status are evaluated. The association between the implementation rate for the ABCDEF bundle and for each of the individual elements and long-term outcomes will be evaluated. The PICS-F, defined as the presence of mental disorders, and HRQoL of the family is also assessed. Additional analyses with data up to 5 years follow-up are planned.

ETHICS AND DISSEMINATION

This study received ethics approvals from Saiseikai Utsunomiya Hospital (2020-42) and all other participating institutions and was registered in the University Hospital Medical Information Network Clinical Trials Registry. Informed consent will be obtained from all patients. The findings will be published in peer-reviewed journals and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

UMIN000041433.

Critical Parameters in Dynamic Network Modeling of Sepsis

In this work, we propose a dynamical systems perspective on the modeling of sepsis and its organ-damaging consequences. We develop a functional two-layer network model for sepsis based upon the interaction of parenchymal cells and immune cells via cytokines, and the coevolutionary dynamics of parenchymal, immune cells, and cytokines. By means of the simple paradigmatic model of phase oscillators in a two-layer system, we analyze the emergence of organ threatening interactions between the dysregulated immune system and the parenchyma. We demonstrate that the complex cellular cooperation between parenchyma and stroma (immune layer) either in the physiological or in the pathological case can be related to dynamical patterns of the network. In this way we explain sepsis by the dysregulation of the healthy homeostatic state (frequency synchronized) leading to a pathological state (desynchronized or multifrequency cluster) in the parenchyma. We provide insight into the complex stabilizing and destabilizing interplay of parenchyma and stroma by determining critical interaction parameters. The coupled dynamics of parenchymal cells (metabolism) and nonspecific immune cells (response of the innate immune system) is represented by nodes of a duplex layer. Cytokine interaction is modeled by adaptive coupling weights between nodes representing immune cells (with fast adaptation timescale) and parenchymal cells (slow adaptation timescale), and between pairs of parenchymal and immune cells in the duplex network (fixed bidirectional coupling). The proposed model allows for a functional description of organ dysfunction in sepsis and the recurrence risk in a plausible pathophysiological context.

[Sepsis-associated deaths in Germany: characteristics and regional variation]

Hintergrund

Sepsis ist weltweit jährlich für geschätzt 11 Mio. Todesfälle verantwortlich. Die Epidemiologie sepsisassoziierter Todesfälle ist in Deutschland unzureichend verstanden, da Sepsis bisher nicht über die deutsche unikausale Todesursachenstatistik erfasst werden kann.

Ziel der Arbeit

Epidemiologie und Charakteristika sepsisassoziierter Krankenhaustodesfälle sollen analysiert sowie regionale Unterschiede beschrieben werden.

Material und Methoden

Retrospektive Beobachtungsstudie basierend auf der deutschlandweiten fallpauschalenbezogenen Krankenhausstatistik (DRG-Statistik) 2016. Sepsisassoziierte Krankenhaustodesfälle wurden über explizite und implizite Sepsis-ICD-10-GM(Internationale statistische Klassifikation der Krankheiten und verwandter Gesundheitsprobleme, 10. Revision, German Modification)-Codierungen identifiziert. Verstorbene wurden anhand der klinischen Merkmale und ihres Wohnortes entsprechend Amtlichem Gemeindeschlüssel (AGS-5-Steller) charakterisiert. Basierend auf der Bevölkerungsstatistik wurde der Anteil an den Gesamttodesfällen ermittelt.

Ergebnisse

2016 gab es in Deutschland 58.689 mit explizit codierter Sepsis assoziierte Krankenhaustodesfälle (14,1 % aller Krankenhaustodesfälle). Die Mortalität betrug 73/100.000 Einwohner und variierte 1,8-fach zwischen den Bundesländern und 7,9-fach zwischen den Kreisen. 6,4 % der deutschlandweiten Todesfälle waren sepsisassoziierte Krankenhaustodesfälle. Dieser Anteil war am höchsten in der Altersgruppe der 40- bis 64-Jährigen (9,6 %) und höher bei Männern als bei Frauen (7,7 % vs. 5,2 %). Im Vergleich dazu betrug der Anteil von implizit codierten sepsisassoziierten Krankenhaustodesfällen 47,2 % an allen Krankenhaustodesfällen und 21,6 % an allen Todesfällen.

Diskussion

Auch wenn die direkte Todesursache nicht sicher ableitbar ist, lässt sich aus dem hohen Anteil sepsisassoziierter Todesfälle an den Krankenhaustodesfällen der Bedarf weiterer Forschung und epidemiologischer Surveillance ableiten, zum Beispiel in Kohortenstudien oder auf Basis von multikausalen Todesursachenstatistiken.

Zusatzmaterial online

Zusätzliche Informationen sind in der Online-Version dieses Artikels (10.1007/s00103-021-03427-5) enthalten.

Birkenfeld A, Sponholz C, A. Müller U, von Loeffelholz C. Blood Sugar Targets in Surgical Intensive Care—Management and Special Considerations in Patients With Diabetes

BACKGROUND

30-80% of patients being treated in intensive care units in the perioperative period develop hyperglycemia. This stress hyperglycemia is induced and maintained by inflammatory-endocrine and iatrogenic stimuli and generally requires treatment. There is uncertainty regarding the optimal blood glucose targets for patients with diabetes mellitus.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed and Google Scholar.

RESULTS

Patients in intensive care with pre-existing diabetes do not benefit from blood sugar reduction to the same extent as metabolically healthy individuals, but they, too, are exposed to a clinically relevant risk of hypoglycemia. A therapeutic range from 4.4 to 6.1 mmol/L (79-110 mg/dL) cannot be justified for patients with diabetes mellitus. The primary therapeutic strategy in the perioperative setting should be to strictly avoid hypoglycemia. Neurotoxic effects and the promotion of wound-healing disturbances are among the adverse consequences of hyperglycemia. Meta-analyses have shown that an upper blood sugar limit of 10 mmol/L (180 mg/dL) is associated with better outcomes for diabetic patients than an upper limit of less than this value. The target range of 7.8-10 mmol/L (140-180 mg/dL) proposed by specialty societies for hospitalized patients with diabetes seems to be the best compromise at present for optimizing clinical outcomes while avoiding hypoglycemia. The method of choice for achieving this goal in intensive care medicine is the continuous intravenous administration of insulin, requirng standardized, high-quality monitoring conditions.

CONCLUSION

Optimal blood sugar control for diabetic patients in intensive care meets the dual objectives of avoiding hypoglycemia while keeping the blood glucose concentration under 10 mmol/L (180 mg/dL). Nutrition therapy in accordance with the relevant guidelines is an indispensable pre - requisite.

Long-Term Outcomes after Sepsis

Sepsis is one of the most serious problems in modern medicine. Long-term outcomes in septic shock patients are very discouraging: 75% individuals who survived sepsis and septic shock demonstrate signs of organ failure and experience persistent functional deficit. Acute sepsis and its management in an intensive care unit (ICU) to a great extent determine the pathogenesis of further complications. We believe that the concept of phenoptosis proposed by Prof. Skulachev deserves a special attention from anesthesiologists and ICU doctors. According to this concept, septic shock is a suicidal mechanism of programmed organism death, which protects human population from dangerously infected individuals. The article suggests a potential approach to the sepsis treatment based on the notion that septic shock can be prevented by identification and blockade of receptors involved in the processing of phenoptotic signal induced by lipopolysaccharide and other substances that initiate septic shock. In view of this, the search for agents that can block molecular mechanisms of the phenoptotic signal transmission seems very promising.