1
|
Jouffroy R, Négrello F, Limery J, Gilbert B, Travers S, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye P. The prehospital NEW score to assess septic shock in-hospital, 30-day and 90-day mortality. BMC Infect Dis 2024; 24:213. [PMID: 38365608 PMCID: PMC10873999 DOI: 10.1186/s12879-024-09104-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 02/06/2024] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND The early identification of sepsis presenting a high risk of deterioration is a daily challenge to optimise patient pathway. This is all the most crucial in the prehospital setting to optimize triage and admission into the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the prehospital National Early Warning Score 2 (NEWS-2) and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU). METHODS Septic shock (SS) patients cared for by a MICU between 2016, April 6th and 2021 December 31st were included in this retrospective cohort study. The NEWS-2 is based on 6 physiological variables (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation prior oxygen supplementation, and level of consciousness) and ranges from 0 to 20. The Inverse Probability Treatment Weighting (IPTW) propensity method was applied to assess the association with in-hospital, 30 and 90-day mortality. A NEWS-2 ≥ 7 threshold was chosen for increased clinical deterioration risk definition and usefulness in clinical practice based on previous reports. RESULTS Data from 530 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 69 ± 15 years and presumed origin of sepsis was pulmonary (43%), digestive (25%) or urinary (17%) infection. In-hospital mortality rate was 33%, 30 and 90-day mortality were respectively 31% and 35%. A prehospital NEWS-2 ≥ 7 is associated with an increase in-hospital, 30 and 90-day mortality with respective RRa = 2.34 [1.39-3.95], 2.08 [1.33-3.25] and 2.22 [1.38-3.59]. Calibration statistic values for in-hospital mortality, 30-day and 90-day mortality were 0.54; 0.55 and 0.53 respectively. CONCLUSION A prehospital NEWS-2 ≥ 7 is associated with an increase in in-hospital, 30 and 90-day mortality of septic shock patients cared for by a MICU in the prehospital setting. Prospective studies are needed to confirm the usefulness of NEWS-2 to improve the prehospital triage and orientation to the adequate facility of sepsis.
Collapse
Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Ambroise Paré Hospital- Assistance Publique Hôpitaux Paris, 9 avenue Charles De Gaulle, 92100, Boulogne-Billancourt, Paris, France.
- IRMES - Institute for Research in Medicine and Epidemiology of Sport, INSEP, Paris, France.
- INSERM U-1018, Centre de recherche en Epidémiologie et Santé des Populations - U1018 INSERM, Paris Saclay University, Villejuif, France.
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France.
- UR5_3 PC2E, University of the Antilles, French West Indies, France.
| | - Florian Négrello
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- UR5_3 PC2E, University of the Antilles, French West Indies, France
| | - Jean Limery
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- UR5_3 PC2E, University of the Antilles, French West Indies, France
| | - Basile Gilbert
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | | | - Emmanuel Bloch-Laine
- Emergency Department, Cochin Hospital, Paris, France
- Emergency Department, SMUR, Hôtel Dieu Hospital, Paris, France
| | - Patrick Ecollan
- Intensive Care Unit, SMUR, Pitie Salpêtriere Hospital, 47 Boulevard de l'Hôpital, 75013, Paris, France
| | - Josiane Boularan
- Centre Hospitalier Intercommunal Castres-Mazamet, Castres, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Benoit Vivien
- Intensive Care Unit, Anaesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Papa Gueye
- SAMU 972, Centre Hospitalier Universitaire de Martinique, Fort-de-France Martinique, France
- UR5_3 PC2E, University of the Antilles, French West Indies, France
| |
Collapse
|
2
|
Li J, Yang D, Ge S, Liu L, Huo Y, Hu Z. Identifying hub genes of sepsis-associated and hepatic encephalopathies based on bioinformatic analysis-focus on the two common encephalopathies of septic cirrhotic patients in ICU. BMC Med Genomics 2024; 17:19. [PMID: 38212812 PMCID: PMC10785360 DOI: 10.1186/s12920-023-01774-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 12/12/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND In the ICU ward, septic cirrhotic patients are susceptible to suffering from sepsis-associated encephalopathy and/or hepatic encephalopathy, which are two common neurological complications in such patients. However, the mutual pathogenesis between sepsis-associated and hepatic encephalopathies remains unclear. We aimed to identify the mutual hub genes, explore effective diagnostic biomarkers and therapeutic targets for the two common encephalopathies and provide novel, promising insights into the clinical management of such septic cirrhotic patients. METHODS The precious human post-mortem cerebral tissues were deprived of the GSE135838, GSE57193, and GSE41919 datasets, downloaded from the Gene Expression Omnibus database. Furthermore, we identified differentially expressed genes and screened hub genes with weighted gene co-expression network analysis. The hub genes were then subjected to Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway functional enrichment analyses, and protein-protein interaction networks were constructed. Receiver operating characteristic curves and correlation analyses were set up for the hub genes. Finally, we explored principal and common signaling pathways by using Gene Set Enrichment Analysis and the association between the hub genes and immune cell subtype distribution by using CIBERSORT algorithm. RESULTS We identified seven hub genes-GPR4, SOCS3, BAG3, ZFP36, CDKN1A, ADAMTS9, and GADD45B-by using differentially expressed gene analysis and weighted gene co-expression network analysis method. The AUCs of these genes were all greater than 0.7 in the receiver operating characteristic curves analysis. The Gene Set Enrichment Analysis results demonstrated that mutual signaling pathways were mainly enriched in hypoxia and inflammatory response. CIBERSORT indicated that these seven hub genes were closely related to innate and adaptive immune cells. CONCLUSIONS We identified seven hub genes with promising diagnostic value and therapeutic targets in septic cirrhotic patients with sepsis-associated encephalopathy and/or hepatic encephalopathy. Hypoxia, inflammatory, and immunoreaction responses may share the common downstream pathways of the two common encephalopathies, for which earlier recognition and timely intervention are crucial for management of such septic cirrhotic patients in ICU.
Collapse
Affiliation(s)
- Juan Li
- Department of Intensive Care Unit, Hebei Key Laboratory of Critical Disease Mechanism and Intervention, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, Hebei, China
| | - Dong Yang
- Department of Emergency (Xiangjiang Hospital), The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Shengmei Ge
- Department of Intensive Care Unit, Hebei Key Laboratory of Critical Disease Mechanism and Intervention, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, Hebei, China
| | - Lixia Liu
- Department of Intensive Care Unit, Hebei Key Laboratory of Critical Disease Mechanism and Intervention, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, Hebei, China
| | - Yan Huo
- Department of Intensive Care Unit, Hebei Key Laboratory of Critical Disease Mechanism and Intervention, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, Hebei, China
| | - Zhenjie Hu
- Department of Intensive Care Unit, Hebei Key Laboratory of Critical Disease Mechanism and Intervention, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, Hebei, China.
| |
Collapse
|
3
|
Guo S, Guo Z, Ren Q, Wang X, Wang Z, Chai Y, Liao H, Wang Z, Zhu H, Wang Z. A PREDICTION MODEL FOR SEPSIS IN INFECTED PATIENTS: EARLY ASSESSMENT OF SEPSIS ENGAGEMENT. Shock 2023; 60:214-220. [PMID: 37477387 PMCID: PMC10476592 DOI: 10.1097/shk.0000000000002170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 04/24/2023] [Accepted: 06/12/2023] [Indexed: 07/22/2023]
Abstract
ABSTRACT Purpose: To evaluate significant risk variables for sepsis incidence and develop a predictive model for rapid screening and diagnosis of sepsis in patients from the emergency department (ED). Methods: Sepsis-related risk variables were screened based on the PIRO (Predisposition, Insult, Response, Organ dysfunction) system. Training (n = 1,272) and external validation (n = 568) datasets were collected from Peking Union Medical College Hospital (PUMCH) and Beijing Tsinghua Changgung Hospital (BTCH), respectively. Variables were collected at the time of admission. Sepsis incidences were determined within 72 h after ED admissions. A predictive model, Early Assessment of Sepsis Engagement (EASE), was developed, and an EASE-based nomogram was generated for clinical applications. The predictive ability of EASE was evaluated and compared with the National Early Warning Score (NEWS) scoring system. In addition, internal and external validations were performed. Results: A total of 48 characteristics were identified. The EASE model, which consists of alcohol consumption, lung infection, temperature, respiration rate, heart rate, serum urea nitrogen, and white blood cell count, had an excellent predictive performance. The EASE-based nomogram showed a significantly higher area under curve (AUC) value of 86.5% (95% CI, 84.2%-88.8%) compared with the AUC value of 78.2% for the NEWS scoring system. The AUC of EASE in the external validation dataset was 72.2% (95% CI, 66.6%-77.7%). Both calibration curves of EASE in training and external validation datasets were close to the ideal model and were well-calibrated. Conclusions: The EASE model can predict and screen ED-admitted patients with sepsis. It demonstrated superior diagnostic performance and clinical application promise by external validation and in-parallel comparison with the NEWS scoring system.
Collapse
Affiliation(s)
- Siying Guo
- School of Medicine, Tsinghua University, Beijing, China
- Department of Liver Critical Care Medicine, Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Zhe Guo
- Department of Liver Critical Care Medicine, Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Qidong Ren
- School of Medicine, Tsinghua University, Beijing, China
| | - Xuesong Wang
- Department of General Medicine, Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Ziyi Wang
- Department of General Medicine, Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Yan Chai
- Department of General Medicine, Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Haiyan Liao
- Department of General Medicine, Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Ziwen Wang
- Department of General Medicine, Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Huadong Zhu
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Beijing, China
| | - Zhong Wang
- Department of General Medicine, Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| |
Collapse
|
4
|
Assessment of Infection Progression per Host Gene Expression. Crit Care Med 2022; 50:1834-1837. [PMID: 36394402 DOI: 10.1097/ccm.0000000000005677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
5
|
Clustering ICU patients with sepsis based on the patterns of their circulating biomarkers: A secondary analysis of the CAPTAIN prospective multicenter cohort study. PLoS One 2022; 17:e0267517. [PMID: 36301921 PMCID: PMC9612564 DOI: 10.1371/journal.pone.0267517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 10/11/2022] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Although sepsis is a life-threatening condition, its heterogeneous presentation likely explains the negative results of most trials on adjunctive therapy. This study in patients with sepsis aimed to identify subgroups with similar immune profiles and their clinical and outcome correlates. METHODS A secondary analysis used data of a prospective multicenter cohort that included patients with early assessment of sepsis. They were described using Predisposition, Insult, Response, Organ failure sepsis (PIRO) staging system. Thirty-eight circulating biomarkers (27 proteins, 11 mRNAs) were assessed at sepsis diagnosis, and their patterns were determined through principal component analysis (PCA). Hierarchical clustering was used to group the patients and k-means algorithm was applied to assess the internal validity of the clusters. RESULTS Two hundred and three patients were assessed, of median age 64.5 [52.0-77.0] years and SAPS2 score 55 [49-61] points. Five main patterns of biomarkers and six clusters of patients (including 42%, 21%, 17%, 9%, 5% and 5% of the patients) were evidenced. Clusters were distinguished according to the certainty of the causal infection, inflammation, use of organ support, pro- and anti-inflammatory activity, and adaptive profile markers. CONCLUSIONS In this cohort of patients with suspected sepsis, we individualized clusters which may be described with criteria used to stage sepsis. As these clusters are based on the patterns of circulating biomarkers, whether they might help to predict treatment responsiveness should be addressed in further studies. TRIAL REGISTRATION The CAPTAIN study was registered on clinicaltrials.gov on June 22, 2011, # NCT01378169.
Collapse
|
6
|
Dronamraju S, Agrawal S, Kumar S, Acharya S, Gaidhane S, Wanjari A, Jaiswal P, Bawiskar N. Comparison of PIRO, APACHE IV, and SOFA Scores in Predicting Outcome in Patients with Sepsis Admitted to Intensive Care Unit: A Two-year Cross-sectional Study at Rural Teaching Hospital. Indian J Crit Care Med 2022; 26:1099-1105. [PMID: 36876200 PMCID: PMC9983679 DOI: 10.5005/jp-journals-10071-24323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/03/2022] [Indexed: 11/23/2022] Open
Abstract
Introduction Though many scoring systems for prognostication of sepsis are available in the intensive care set-up, predisposition, insult, response, and organ dysfunction (PIRO) score helps to assess each patient and evaluate response to therapy. There are few studies comparing the efficacy of PIRO score with other sepsis scores. Hence, our study was planned to compare PIRO score with acute physiology and chronic health evaluation IV (APACHE IV) score and sequential (sepsis-related) organ failure assessment (SOFA) score in predicting the mortality of intensive care patients with sepsis. Materials and methods This prospective cross-sectional study was done in the medical intensive care unit (MICU) from August 2019 to September 2021 among patients above 18 years of age with the diagnosis of sepsis. Predisposition, insult, response, and organ dysfunction score, SOFA score, and APACHE IV score on admission and at day 3 were calculated and statistically analyzed in the terms of outcome. Results A total of 280 patients fulfilling the inclusion criteria were included in the study, the mean age was 59.38 ± 15.9 years. There was a significant association of PIRO score, SOFA score, and APACHE IV score on admission and at day 3 with mortality (p-value <0.05). Among all three parameters, the PIRO score on admission and at day 3 was the best predictor of mortality at cut-off points of >14 and >16 with 92.50% and 96.50% chances of correctly predicting mortality, respectively. Conclusion Predisposition, insult, response, and organ dysfunction score can be considered as a strong predictor of prognostication of patients with sepsis admitted to the intensive care unit (ICU) and predict mortality. It should be routinely used as it is a simple and comprehensive score. How to cite this article Dronamraju S, Agrawal S, Kumar S, Acharya S, Gaidhane S, Wanjari A, et al. Comparison of PIRO, APACHE IV, and SOFA Scores in Predicting Outcome in Patients with Sepsis Admitted to Intensive Care Unit: A Two-year Cross-sectional Study at Rural Teaching Hospital. Indian J Crit Care Med 2022;26(10):1099-1105.
Collapse
Affiliation(s)
- Sameera Dronamraju
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Sachin Agrawal
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Sourya Acharya
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Shilpa Gaidhane
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Anil Wanjari
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Praraj Jaiswal
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| | - Nipun Bawiskar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
| |
Collapse
|
7
|
The End of “One Size Fits All” Sepsis Therapies: Toward an Individualized Approach. Biomedicines 2022; 10:biomedicines10092260. [PMID: 36140361 PMCID: PMC9496597 DOI: 10.3390/biomedicines10092260] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 08/30/2022] [Accepted: 09/02/2022] [Indexed: 12/20/2022] Open
Abstract
Sepsis, defined as life-threatening organ dysfunction caused by a dysregulated host response to an infection, remains a major challenge for clinicians and trialists. Despite decades of research and multiple randomized clinical trials, a specific therapeutic for sepsis is not available. The evaluation of therapeutics targeting components of host response anomalies in patients with sepsis has been complicated by the inability to identify those in this very heterogeneous population who are more likely to benefit from a specific intervention. Additionally, multiple and diverse host response aberrations often co-exist in sepsis, and knowledge of which dysregulated biological organ system or pathway drives sepsis-induced pathology in an individual patient is limited, further complicating the development of effective therapies. Here, we discuss the drawbacks of previous attempts to develop sepsis therapeutics and delineate a future wherein interventions will be based on the host response profile of a patient.
Collapse
|
8
|
Jouffroy R, Parfait PA, Gilbert B, Tourtier JP, Bloch-Laine E, Ecollan P, Boularan J, Bounes V, Vivien B, Gueye PN. Relationship between prehospital modified Charlson Comorbidity Index and septic shock 30-day mortality. Am J Emerg Med 2022; 60:128-133. [DOI: 10.1016/j.ajem.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 07/31/2022] [Accepted: 08/02/2022] [Indexed: 10/15/2022] Open
|
9
|
Abstract
Research and practice in critical care medicine have long been defined by syndromes, which, despite being clinically recognizable entities, are, in fact, loose amalgams of heterogeneous states that may respond differently to therapy. Mounting translational evidence-supported by research on respiratory failure due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection-suggests that the current syndrome-based framework of critical illness should be reconsidered. Here we discuss recent findings from basic science and clinical research in critical care and explore how these might inform a new conceptual model of critical illness. De-emphasizing syndromes, we focus on the underlying biological changes that underpin critical illness states and that may be amenable to treatment. We hypothesize that such an approach will accelerate critical care research, leading to a richer understanding of the pathobiology of critical illness and of the key determinants of patient outcomes. This, in turn, will support the design of more effective clinical trials and inform a more precise and more effective practice at the bedside.
Collapse
|
10
|
Capan M, Schubel LC, Pradhan I, Catchpole K, Shara N, Arnold R, Schwartz JS, Seagull J, Miller K. Display and perception of risk: Analysis of decision support system display and its impact on perceived clinical risk of sepsis-induced health deterioration. Health Informatics J 2022; 28:14604582211073075. [DOI: 10.1177/14604582211073075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite acknowledging the value of clinical decision support systems (CDSS) in identifying risk for sepsis-induced health deterioration in-hospitalized patients, the relationship between display features, decision maker characteristics, and recognition of risk by the clinical decision maker remains an understudied, yet promising, area. The objective of this study is to explore the relationship between CDSS display design and perceived clinical risk of in-hospital mortality associated with sepsis. The study utilized data collected through in-person experimental sessions with 91 physicians from the general medical and surgical floors who were recruited across 12 teaching hospitals within the United States. Results of descriptive and statistical analyses provided evidence supporting the impact of display configuration and clinical case severity on perceived risk associated with in-hospital mortality. Specifically, findings showed that a high level of information (represented by the Predisposition, Infection, Response and Organ dysfunction (PIRO) score) and Figure display (as opposed to Text or baseline) increased awareness to recognizing the risk for in-hospital mortality of hospitalized sepsis patients. A CDSS display that synthesizes the optimal features associated with information level and design elements has the potential to enhance the quantification and communication of clinical risk in complex health conditions beyond sepsis.
Collapse
Affiliation(s)
- Muge Capan
- LeBow College of Business, Drexel University, Philadelphia, PA, USA
| | - Laura C Schubel
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, DC, USA
| | - Ishika Pradhan
- LeBow College of Business, Drexel University, Philadelphia, PA, USA
| | - Ken Catchpole
- Clinical Practice and Human Factors, Medical University of South Carolina, Charleston, SC, USA
| | - Nawar Shara
- Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Washington, DC, USA
| | - Ryan Arnold
- Emergency Medicine, Santa Ynez Valley Cottage Hospital, Santa Barbara, CA, USA
| | - J Sanford Schwartz
- Department of Health Care Management, University of Pennsylvania, Philadelphia, PA, USA
| | - Jake Seagull
- MedStar Health Research Institute, Hyattsville, MD, USA
| | - Kristen Miller
- National Center for Human Factors in Healthcare, MedStar Health Research Institute, Washington, DC, USA
| |
Collapse
|
11
|
Kumar S, Dronamraju S, Acharya S, Jaiswal P, Hulkoti V, Talwar D, Hepat S, Vs I, Shah D, Bhagawati J. COVID-PIRO (Predisposition, Insult, Response, Organ Dysfunction) Score: A Reliable Predictor of Outcomes in COVID-19 Patients Admitted in Intensive Care Unit. Cureus 2021; 13:e18960. [PMID: 34812327 PMCID: PMC8604422 DOI: 10.7759/cureus.18960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction To measure the severity of sepsis and pneumonia in adult patients with coronavirus disease 2019 (COVID-19), the PIRO model (predisposition, insult, response, organ dysfunction) was adopted as a scoring system. In this study, the PIRO model was modified to classify the severity of pneumonia in adults and predict mortality risk infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), admitted to a tertiary intensive care unit (ICU) in central rural India. Method This prospective, observational study was conducted in the Department of Medicine, in rural medical college at Wardha, Maharashtra, India from May 2020 to May 2021. Patients with reverse transcription-polymerase chain reaction (RT-PCR) positive for COVID-19 and whose age was more than 18 years admitted in the intensive care unit were included in the study. Results A total of 240 patients were included in the analysis having mean age of 60.27 ± 15.3 years. Number of deaths were 115 out of 240 (48.3%). Mean ICU stay was 9.09 ± 6.34 days. PIRO score ≤14.5 had a mortality rate of 1.25% as compared to the group having PIRO>14.5 which had mortality of 27.5%, with a cure rate of 26.25% and 5% respectively in both groups (p = 0.0001). Conclusion COVID-PIRO modified PIRO score was a highly sensitive and specific model in predicting in-hospital mortality but it is moderately sensitive in predicting ICU stay.
Collapse
Affiliation(s)
- Sunil Kumar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Sameera Dronamraju
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Sourya Acharya
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Praraj Jaiswal
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Vidyashree Hulkoti
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Dhruv Talwar
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Sanyukta Hepat
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Irhsad Vs
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Divit Shah
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| | - Jahnabi Bhagawati
- Department of Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Wardha, IND
| |
Collapse
|
12
|
Giang C, Calvert J, Rahmani K, Barnes G, Siefkas A, Green-Saxena A, Hoffman J, Mao Q, Das R. Predicting ventilator-associated pneumonia with machine learning. Medicine (Baltimore) 2021; 100:e26246. [PMID: 34115013 PMCID: PMC8202554 DOI: 10.1097/md.0000000000026246] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 05/02/2021] [Indexed: 01/04/2023] Open
Abstract
Ventilator-associated pneumonia (VAP) is the most common and fatal nosocomial infection in intensive care units (ICUs). Existing methods for identifying VAP display low accuracy, and their use may delay antimicrobial therapy. VAP diagnostics derived from machine learning (ML) methods that utilize electronic health record (EHR) data have not yet been explored. The objective of this study is to compare the performance of a variety of ML models trained to predict whether VAP will be diagnosed during the patient stay.A retrospective study examined data from 6126 adult ICU encounters lasting at least 48 hours following the initiation of mechanical ventilation. The gold standard was the presence of a diagnostic code for VAP. Five different ML models were trained to predict VAP 48 hours after initiation of mechanical ventilation. Model performance was evaluated with regard to the area under the receiver operating characteristic (AUROC) curve on a 20% hold-out test set. Feature importance was measured in terms of Shapley values.The highest performing model achieved an AUROC value of 0.854. The most important features for the best-performing model were the length of time on mechanical ventilation, the presence of antibiotics, sputum test frequency, and the most recent Glasgow Coma Scale assessment.Supervised ML using patient EHR data is promising for VAP diagnosis and warrants further validation. This tool has the potential to aid the timely diagnosis of VAP.
Collapse
|
13
|
The Range of Cardiogenic Shock Survival by Clinical Stage: Data From the Critical Care Cardiology Trials Network Registry. Crit Care Med 2021; 49:1293-1302. [PMID: 33861557 DOI: 10.1097/ccm.0000000000004948] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Cardiogenic shock presents with variable severity. Categorizing cardiogenic shock into clinical stages may improve risk stratification and patient selection for therapies. We sought to determine whether a structured implementation of the 2019 Society for Cardiovascular Angiography and Interventions clinical cardiogenic shock staging criteria that is ascertainable in clinical registries discriminates mortality in a contemporary population with or at-risk for cardiogenic shock. DESIGN We developed a pragmatic application of the Society for Cardiovascular Angiography and Interventions cardiogenic shock staging criteria-A (at-risk), B (beginning), C (classic cardiogenic shock), D (deteriorating), or E (extremis)-and examined outcomes by stage. SETTING The Critical Care Cardiology Trials Network is an investigator-initiated multicenter research collaboration coordinated by the TIMI Study Group (Boston, MA). Consecutive admissions with or at-risk for cardiogenic shock during two annual 2-month collection periods (2017-2019) were analyzed. PATIENTS Patients with or at-risk for cardiogenic shock. MEASUREMENTS AND MAIN RESULTS Of 8,240 CICU admissions reviewed, 1,991 (24%) had or were at-risk for cardiogenic shock. Distributions across the five stages were as follows: A: 33%; B: 7%; C: 16%; D: 23%; and E: 21%. Overall in-hospital mortality among patients with established cardiogenic shock was 39%; however, mortality varied from only 15.8% to 32.1% to 62.5% across stages C, D, and E (Cochran-Armitage ptrend < 0.0001). The Society for Cardiovascular Angiography and Interventions stages improved mortality prediction beyond the Sequential Organ Failure Assessment and Intra-Aortic Balloon Pumpin Cardiogenic Shock II scores. CONCLUSIONS Although overall mortality in cardiogenic shock remains high, it varies considerably based on clinical stage, identifying stage C as relatively lower risk. We demonstrate a pragmatic adaptation of the Society for Cardiovascular Angiography and Interventions cardiogenic shock stages that effectively stratifies mortality risk and could be leveraged for future clinical research.
Collapse
|
14
|
Mendelson AA, Lansdell C, Fox-Robichaud AE, Liaw P, Arora J, Cailhier JF, Cepinskas G, Charbonney E, Dos Santos C, Dwivedi D, Ellis CG, Fergusson D, Fiest K, Gill SE, Hendrick K, Hunniford VT, Kowalewska PM, Krewulak K, Lehmann C, Macala K, Marshall JC, Mawdsley L, McDonald B, McDonald E, Medeiros SK, Muniz VS, Osuchowski M, Presseau J, Sharma N, Sohrabipour S, Sunohara-Neilson J, Vázquez-Grande G, Veldhuizen RAW, Welsh D, Winston BW, Zarychanski R, Zhang H, Zhou J, Lalu MM. National Preclinical Sepsis Platform: developing a framework for accelerating innovation in Canadian sepsis research. Intensive Care Med Exp 2021; 9:14. [PMID: 33738642 PMCID: PMC7973346 DOI: 10.1186/s40635-020-00366-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 12/13/2020] [Indexed: 12/28/2022] Open
Abstract
Despite decades of preclinical research, no experimentally derived therapies for sepsis have been successfully adopted into routine clinical practice. Factors that contribute to this crisis of translation include poor representation by preclinical models of the complex human condition of sepsis, bias in preclinical studies, as well as limitations of single-laboratory methodology. To overcome some of these shortcomings, multicentre preclinical studies—defined as a research experiment conducted in two or more research laboratories with a common protocol and analysis—are expected to maximize transparency, improve reproducibility, and enhance generalizability. The ultimate objective is to increase the efficiency and efficacy of bench-to-bedside translation for preclinical sepsis research and improve outcomes for patients with life-threatening infection. To this end, we organized the first meeting of the National Preclinical Sepsis Platform (NPSP). This multicentre preclinical research collaboration of Canadian sepsis researchers and stakeholders was established to study the pathophysiology of sepsis and accelerate movement of promising therapeutics into early phase clinical trials. Integrated knowledge translation and shared decision-making were emphasized to ensure the goals of the platform align with clinical researchers and patient partners. 29 participants from 10 independent labs attended and discussed four main topics: (1) objectives of the platform; (2) animal models of sepsis; (3) multicentre methodology and (4) outcomes for evaluation. A PIRO model (predisposition, insult, response, organ dysfunction) for experimental design was proposed to strengthen linkages with interdisciplinary researchers and key stakeholders. This platform represents an important resource for maximizing translational impact of preclinical sepsis research.
Collapse
Affiliation(s)
- Asher A Mendelson
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada
| | - Casey Lansdell
- Regenerative Medicine Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Alison E Fox-Robichaud
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Patricia Liaw
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Jaskirat Arora
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.,Department of Medical Sciences, McMaster University, Hamilton, ON, Canada
| | - Jean-François Cailhier
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.,Département de Médecine, Université de Montréal, Montreal, QC, Canada
| | - Gediminas Cepinskas
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada
| | - Emmanuel Charbonney
- Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada.,Département de Médecine, Université de Montréal, Montreal, QC, Canada
| | - Claudia Dos Santos
- Keenan Research Centre for Biomedical Science, Unity Health Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Dhruva Dwivedi
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Christopher G Ellis
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Robarts Research Institute, University of Western Ontario, London, ON, Canada
| | - Dean Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kirsten Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sean E Gill
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada.,Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Kathryn Hendrick
- Department of Communications, Global Sepsis Alliance, Canada Sector, Toronto, ON, Canada
| | - Victoria T Hunniford
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Karla Krewulak
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christian Lehmann
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Kimberly Macala
- Department of Critical Care Medicine, Royal Alexandra Hospital, University of Alberta, Edmonton, AB, Canada
| | - John C Marshall
- Keenan Research Centre for Biomedical Science, Unity Health Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgery, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Laura Mawdsley
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Braedon McDonald
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Ellen McDonald
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Sarah K Medeiros
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.,Department of Medical Sciences, McMaster University, Hamilton, ON, Canada
| | - Valdirene S Muniz
- Department of Medicine, McMaster University, Hamilton, ON, Canada.,Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | - Marcin Osuchowski
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.,School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Neha Sharma
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.,Department of Medical Sciences, McMaster University, Hamilton, ON, Canada
| | - Sahar Sohrabipour
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada.,Department of Medical Sciences, McMaster University, Hamilton, ON, Canada
| | | | - Gloria Vázquez-Grande
- Department of Internal Medicine, Section of Critical Care, University of Manitoba, Winnipeg, MB, Canada.,Department of Medical Microbiology and Infectious Diseases, University of Manitoba, Winnipeg, MB, Canada
| | - Ruud A W Veldhuizen
- Centre for Critical Illness Research, Lawson Health Research Institute, London, ON, Canada.,Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Donald Welsh
- Robarts Research Institute, University of Western Ontario, London, ON, Canada.,Department of Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada.,Department of Physiology and Pharmacology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, Canada
| | - Brent W Winston
- Snyder Institute for Chronic Diseases, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Biochemistry and Molecular Biology, University of Calgary, Calgary, AB, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Section of Critical Care, University of Manitoba, Winnipeg, MB, Canada.,Department of Internal Medicine, Section of Hematology/Medical Oncology, University of Manitoba, Winnipeg, MB, Canada
| | - Haibo Zhang
- Keenan Research Centre for Biomedical Science, Unity Health Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, Department of Anesthesia, University of Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, Department of Physiology, University of Toronto, Toronto, ON, Canada
| | - Juan Zhou
- Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
| | - Manoj M Lalu
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada. .,Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, 501 Smyth Road, PO Box 201B, Ottawa, ON, K1H 8L6, Canada.
| | | |
Collapse
|
15
|
Valentania V, Somasetia DH, Hilmanto D, Setiabudi D, Nataprawira HMN. Modified PIRO (predisposition, insult, response, organ dysfunction) severity score as a predictor for mortality of children with pneumonia in Hasan Sadikin Hospital, Bandung, Indonesia. Multidiscip Respir Med 2021; 16:735. [PMID: 33747506 PMCID: PMC7967494 DOI: 10.4081/mrm.2021.735] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/19/2021] [Indexed: 12/21/2022] Open
Abstract
Background Clinical manifestations for pneumonia vary from mild to severe. The PIRO model (predisposition, insult, response, organ dysfunction) was used as scoring system to determine severity of sepsis and pneumonia in adult patients. The PIRO model was modified for sorting the severity of pneumonia in children and predicting its risk of mortality. Methods An ambispective cohort study of pneumonia patients aged 1 month to ≤ 18 years admitted over the period from May to September 2020. Data were collected from history, physical examination, laboratory examination, and chest radiography. Based on bivariate analysis (p<0.05 and relative risk (RR) with 95% confidence interval), variables of each PIRO component that were significant for mortality were assigned a value of 1. The cut-off score for predictor of mortality was calculated using the receiver operating characteristics (ROC) curve and the scores were stratified into three degrees of risk based on interquartile range, score ≤Q1 was categorized as low risk; Q1-Q3 was categorized as moderate risk; and score >Q3 was categorized as high risk. Results Out of the 80 subjects enrolled, 6 months-5 years was the largest age group (56.3%). The observed mortality was 15/80 (18.8%). The modified PIRO severity score was compiled from significant variables of predisposition (malnutrition), insult (chest radiograph), response (hypoxemia, hypotension, CRP >0.5 mg/dL, PCT >0.5 ng/dL) and organ dysfunction, with range of score 0-7. Score >3 was categorized as a cut-off point score for predictor of mortality with AUC 0.919 (95% CI 0.836–0.968), sensitivity of 80%, and specificity of 84.62%. Subjects with score >3 have RR of 10.544 compared to those with score ≤3. The stratification of score level was low (≤2), moderate (3-4), and high (5-7). The mortality levels were 0%, 46.7%, and 53.3%, respectively. Conclusions Modified PIRO severity score can be used as a sorting tool and predictor of mortality risk in children with pneumonia. This score can also be used to select candidates for intensive care, especially in health facilities with limited intensive care capacity.
Collapse
Affiliation(s)
- Vebri Valentania
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Dadang H Somasetia
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Dany Hilmanto
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Djatnika Setiabudi
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Heda Melinda N Nataprawira
- Department of Child Health, Faculty of Medicine, Universitas Padjadjaran/Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| |
Collapse
|
16
|
Busani S, Roat E, Tosi M, Biagioni E, Coloretti I, Meschiari M, Gelmini R, Brugioni L, De Biasi S, Girardis M. Adjunctive Immunotherapy With Polyclonal Ig-M Enriched Immunoglobulins for Septic Shock: From Bench to Bedside. The Rationale for a Personalized Treatment Protocol. Front Med (Lausanne) 2021; 8:616511. [PMID: 33681248 PMCID: PMC7930614 DOI: 10.3389/fmed.2021.616511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/27/2021] [Indexed: 01/19/2023] Open
Abstract
Septic shock still has a high mortality rate which has not hinted at decreasing in recent years. Unfortunately, randomized trials failed mainly because the septic patient was considered as a homogeneous entity. All this creates a sort of therapeutic impotence in everyday clinical practice in treating patients with septic shock. The need to customize therapy on each patient with sepsis has now become an established necessity. In this scenario, adjuvant therapies can help if interpreted as modulators of the immune system. Indeed, the host's immune response differs from patient to patient based on the virulence of the pathogen, comorbidity, infection site, and prolonged hospitalization. In this review, we summarize the rationale for using immunoglobulins as an adjunctive treatment. Furthermore, we would like to suggest a possible protocol to personalize treatment in the different clinical scenarios of the host's response to serious infectious events.
Collapse
Affiliation(s)
- Stefano Busani
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Erika Roat
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Martina Tosi
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Emanuela Biagioni
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Irene Coloretti
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Marianna Meschiari
- Infectious Diseases Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Roberta Gelmini
- Department of Medical and Surgical Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Lucio Brugioni
- Internal Medicine Department, Azienda Ospedaliero-Universitaria Policlinico of Modena, Modena, Italy
| | - Sara De Biasi
- Department of Medical and Surgical Sciences for Children and Adults, University of Modena and Reggio Emilia School of Medicine, Modena, Italy
| | - Massimo Girardis
- Intensive Care Unit, University Hospital Policlinico di Modena, University of Modena and Reggio Emilia, Modena, Italy
| |
Collapse
|
17
|
The prehospital SIGARC score to assess septic shock in-hospital, 30-day and 90-day mortality. Am J Emerg Med 2020; 46:355-360. [PMID: 34348435 DOI: 10.1016/j.ajem.2020.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/05/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In the pre-hospital setting the early identification of septic shock (SS) patients presenting with a high risk of poor outcome remains a daily challenge. The development of a simple score to quickly identify these patients is essential to optimize triage towards the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the new SIGARC score and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU). METHODS SS patients cared for by a MICU between 2017, April 15th, and 2019, December 1st were included in this retrospective study. The SIGARC score consists of the addition of 5 following items (1 point for each one): shock index≥1, Glasgow coma scale<13, age > 65, respiratory rate > 22 and comorbidity defined by the presence of at least 2 underlying conditions among: hypertension, coronaropathy, chronic cardiac failure, chronic renal failure, chronic obstructive pulmonary disease, diabetes mellitus, history of cancer and human immunodeficiency virus infection. A threshold of SIGARC score ≥ 2 was arbitrarily chosen to define severity for its usefulness in clinical practice. RESULTS Data from 406 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 71 ± 15 years and 268 of the patients (66%) were male. The presumed origin of SS was pulmonary (42%), digestive (25%) or urinary (17%) infection. Overall in-hospital mortality was 31% with, 30 and 90-day mortality was respectively 28% and 33%. A prehospital SIGARC score ≥ 2 is associated with an increase in 30 and 90-day mortality with HR = 1.57 [1.02-2.42] and 1.82 [1.21-2.72], respectively. CONCLUSION A SIGARC score ≥ 2 is associated with an increase in in-hospital, 30 and 90-day mortality of SS patients cared for by a MICU in the prehospital setting. These observational results need to be confirmed by prospective studies.
Collapse
|
18
|
Cox MC, Brakenridge SC, Stortz JA, Hawkins RB, Darden DB, Ghita GL, Mohr AM, Moldawer LL, Efron PA, Moore FA. Abdominal sepsis patients have a high incidence of chronic critical illness with dismal long-term outcomes. Am J Surg 2020; 220:1467-1474. [PMID: 32807383 DOI: 10.1016/j.amjsurg.2020.07.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 05/20/2020] [Accepted: 07/16/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND As hospital sepsis mortality has decreased, more surgical ICU survivors are progressing into chronic critical illness (CCI). This study documents the incidence of CCI and long-term outcomes of patients with abdominal sepsis. We hypothesized that patients developing CCI would have biomarker evidence of immune and metabolic derangement, with a high incidence of poor 1-year outcomes. METHODS Review of abdominal sepsis patients entered in a prospective longitudinal study of surgical ICU sepsis. RESULTS Of the 144 study patients, only 6% died early, 37% developed CCI (defined as ICU days ≥14 with organ dysfunction) and 57% were classified rapid recovery (RAP). Compared to RAP, CCI patients a) were older (66 vs 58), males who were sicker at baseline (Charlson Comorbidity Index 4 vs 2), b) had persistently elevated biomarkers of dysregulated immunity/metabolism (IL-6, IL-8, sPDL-1, GLP1), c) experienced more secondary infections (4.9 vs 2.3) and organ failure (Denver MOF frequency 40 vs 1%), d) were much more likely to have poor dispositions (85 vs 22%) with severe persistent disabilities by Zubrod Score and e) had a notably higher 1-year mortality of 42% (all p < 0.05). CONCLUSION Over 1/3rd surgical ICU patients treated for abdominal sepsis progress into CCI and experience dismal long-term outcomes.
Collapse
Affiliation(s)
- Michael C Cox
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Scott C Brakenridge
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Julie A Stortz
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Russell B Hawkins
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Dijoa B Darden
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Gabriela L Ghita
- Department of Biostatistics, University of Florida, Gainesville, FL, USA
| | - Alicia M Mohr
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Lyle L Moldawer
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Philip A Efron
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Frederick A Moore
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA.
| |
Collapse
|
19
|
Gradel KO, Engberg H, Zampieri FG, Póvoa P, Simonsen SF, Vinholt PJ, Garvik OS, Ljungdalh PS, Frederiksen H. Contributing factors to the plasma albumin level at diagnosis of hematological malignancy. Hosp Pract (1995) 2020; 48:223-229. [PMID: 32484370 DOI: 10.1080/21548331.2020.1770511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Many factors contribute to the plasma albumin (PA) level. We aimed to quantify different factors' relative contribution to the PA level when diagnosing hematological malignancy (HM). METHODS The study was a population-based registry study including patients with HM in a Danish region. We applied multivariate linear regression analyses with C-reactive protein (CRP), WHO performance score (WHO-PS), age, sex, comorbidity, and HM type as exposures and the PA level on the day of the HM diagnosis (DX) as the outcome. The relative contribution of each exposure was determined as a percentage of the models' coefficient of determination (R2). RESULTS In total, 2528 patients with HM had PA measured on DX. In the model comprising all exposures, CRP contributed with 65.8% to the R2 of 0.389 whereas 3 variables (CRP, WHO-PS, HM type) together contributed with 96.1%. When CRP was excluded from the model, R2 declined to 0.215 and the WHO-PS contributed with 96%. Other models, including separate analyses for each HM type, corroborated these results, except in myeloma patients where WHO-PS contributed with 61.1% to the R2 of 0.234. CONCLUSION The inflammation biomarker CRP was the main predictor of the PA level on DX. The WHO-PS also contributed to the PA level on DX whereas the remaining factors (HM type, age, sex, and comorbidity) were of much less importance.
Collapse
Affiliation(s)
- Kim Oren Gradel
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark , Odense C, Denmark.,OPEN - Odense Patient Data Exploratory Network, Odense University Hospital , Odense C, Denmark
| | - Henriette Engberg
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark , Odense C, Denmark.,The Danish Clinical Quality Program and Clinical Registries (RKKP), Odense University Hospital , Odense, Denmark
| | - Fernando G Zampieri
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark , Odense C, Denmark.,HCor-Hospital Do Coração, R. Des. Eliseu Guilherme , São Paulo, Brazil
| | - Pedro Póvoa
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark , Odense C, Denmark.,Polyvalent Intensive Care Unit, Hospital De São Francisco Xavier, and NOVA Medical School, CHRC, New University of Lisbon , Lisbon, Portugal
| | - Simone F Simonsen
- Department of Geriatrics, Odense University Hospital , Svendborg, Denmark
| | - Pernille Just Vinholt
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital , Odense C, Denmark
| | - Olav Sivertsen Garvik
- Center for Clinical Epidemiology, Odense University Hospital, and Research Unit of Clinical Epidemiology, Department of Clinical Research, University of Southern Denmark , Odense C, Denmark
| | - Pernille S Ljungdalh
- Department of Regional Health Research, University of Southern Denmark , Odense C, Denmark
| | - Henrik Frederiksen
- Department of Haematology, Odense University Hospital, and the Research Unit of Haematology, Department of Clinical Research, University of Southern Denmark , Odense C, Denmark
| |
Collapse
|
20
|
Phenotypic heterogeneity by site of infection in surgical sepsis: a prospective longitudinal study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:203. [PMID: 32381107 PMCID: PMC7206740 DOI: 10.1186/s13054-020-02917-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/23/2020] [Indexed: 01/16/2023]
Abstract
Background The role of site of infection in sepsis has been poorly characterized. Additionally, sepsis epidemiology has evolved. Early mortality has decreased, but many survivors now progress into chronic critical illness (CCI). This study sought to determine if there were significant differences in the host response and current epidemiology of surgical sepsis categorized by site of infection. Study design This is a longitudinal study of surgical sepsis patients characterized by baseline predisposition, insult characteristics, serial biomarkers, hospital outcomes, and long-term outcomes. Patients were categorized into five anatomic sites of infection. Results The 316 study patients were predominantly Caucasian; half were male, with a mean age of 62 years, high comorbidity burden, and low 30-day mortality (10%). The primary sites were abdominal (44%), pulmonary (19%), skin/soft tissue (S/ST, 17%), genitourinary (GU, 12%), and vascular (7%). Most abdominal infections were present on admission and required source control. Comparatively, they had more prolonged proinflammation, immunosuppression, and persistent organ dysfunction. Their long-term outcome was poor with 37% CCI (defined as > 14 in ICU with organ dysfunction), 49% poor discharge dispositions, and 30% 1-year mortality. Most pulmonary infections were hospital-acquired pneumonia. They had similar protracted proinflammation and organ dysfunction, but immunosuppression normalized. Long-term outcomes are similarly poor (54% CCI, 47% poor disposition, 32% 1-year mortality). S/ST and GU infections occurred in younger patients with fewer comorbidities, less perturbed immune responses, and faster resolution of organ dysfunction. Comparatively, S/ST had better long-term outcomes (23% CCI, 39% poor disposition, 13% 1-year mortality) and GU had the best (10% CCI, 20% poor disposition, 10% 1-year mortality). Vascular sepsis patients were older males, with more comorbidities. Proinflammation was blunted with baseline immunosuppression and organ dysfunction that persisted. They had the worst long-term outcomes (38% CCI, 67% poor disposition, 57% 1-year mortality). Conclusion There are notable differences in baseline predisposition, host responses, and clinical outcomes by site of infection in surgical sepsis. While previous studies have focused on differences in hospital mortality, this study provides unique insights into the host response and long-term outcomes associated with different sites of infection.
Collapse
|
21
|
Jouffroy R, Tourtier JP, Philippe P, Bloch-Laine E, Bounes V, Gueye-Ngalgou P, Vivien B. Prehospital Shock Precautions on Triage (PSPoT) score to assess in-hospital mortality for septic shock. Am J Emerg Med 2020; 44:230-234. [PMID: 32591305 DOI: 10.1016/j.ajem.2020.03.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 03/15/2020] [Accepted: 03/21/2020] [Indexed: 10/24/2022] Open
Abstract
CONTEXT In the prehospital setting, early identification of septic shock (SS) with high risk of poor outcome is a daily issue. There is a need for a simple tool aiming to early assess outcome in order to decide delivery unit (emergency department (ED) or intensive care unit (ICU)). In France, prehospital emergencies are managed by the Service d'Aide Médicale d'Urgence (SAMU). The SAMU physician decides the destination ward either to the ICU or to the ED after on scene severity assessment. We report the association between The Prehospital Shock Precautions on Triage (PSPoT) score, and in-hospital mortality of SS patients initially cared for in the prehospital setting by a mobile ICU (MICU). METHODS SS patients cared for by MICU were prospectively included between February 2017 and July 2019. The PSPoT score was established by adding shock index>1 and criterion based on past medical history: age >65 years and at least 1 previous comorbidity (chronic cardiac failure, chronic renal failure, chronic obstructive pulmonary disease, previous or actual history of cancer, institutionalization, hospitalisation within previous 3 months. A threshold of ≥2, was arbitrarily chosen for clinical relevance and usefulness in clinical practice. RESULTS One-hundred and sixty-nine with a median age of 72 [20-93] years were analysed. SS origin was mainly pulmonary (54%), abdominal (19%) and urinary (15%). The median PSPoT score was 2 [1-2]. PSPoT score and PSPoT score ≥ 2 were associated with in-hospital mortality: OR = 1.24 [0.77-2.05] and OR = 2.19 [1.09-4.59] respectively. CONCLUSION We report an association between PSPoT score, and in-hospital mortality of SS patients cared for by a MICU. A PSPoT score ≥ 2 early identifies poorer outcome.
Collapse
Affiliation(s)
- Romain Jouffroy
- Intensive Care Unit, Anesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France; Department of Anesthesia, Clinical Epidemiology and Biostatistics, Michael De Groote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, David Braley Cardiac, Vascular and Stroke Research Institute, Perioperative Medicine and Surgical Research Unit, Hamilton, Ontario, Canada; Fire Brigade of Paris, Paris, France.
| | | | - Pascal Philippe
- Intensive Care Unit, Anesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Emmanuel Bloch-Laine
- Emergency department, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Vincent Bounes
- Department of Emergency Medicine, SAMU 31, University Hospital of Toulouse, Toulouse, France
| | - Papa Gueye-Ngalgou
- SAMU 972 CHU de Martinique Pierre Zobda -Quitman Hospital, 97261 Fort-de-France Martinique, France
| | - Benoit Vivien
- Intensive Care Unit, Anesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| |
Collapse
|
22
|
Abstract
Sepsis is one of the oldest and most elusive syndromes in medicine that is still incompletely understood. Biomarkers may help to transform sepsis from a physiologic syndrome to a group of distinct biochemical disorders. This will help to differentiate between systemic inflammation of infectious and noninfectious origin and aid therapeutic decision making, hence improve the prognosis for patients, guide antimicrobial therapy, and foster the development of novel adjunctive sepsis therapies. To reach this goal requires increased systematic investigation that includes twenty-first century scientific approaches and technologies and appropriate clinical evaluation.
Collapse
Affiliation(s)
- Gunnar Lachmann
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, D-10178 Berlin, Germany
| | - Konrad Reinhart
- Department of Anesthesiology and Operative Intensive Care Medicine (CCM, CVK), Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; Berlin Institute of Health, Anna-Louisa-Karsch-Straße 2, D-10178 Berlin, Germany; Jena University Hospital, Carl-Zeiss-Straße 12, D-07743 Jena, Germany.
| |
Collapse
|
23
|
Vafaei A, Heydari K, Hashemi-Nazari SS, Izadi N, Hassan Zadeh H. PIRO, SOFA and MEDS Scores in Predicting One-Month Mortality of Sepsis Patients; a Diagnostic Accuracy Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2019; 7:e59. [PMID: 31875213 PMCID: PMC6905425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Different scoring systems based on clinical and laboratory findings are designed for prediction of short-term mortality of patients with severe sepsis and septic shock. This study aimed to compare the screening performance characteristics of PIRO, SOFA and MEDS Scores in predicting one-month mortality of sepsis patients. METHODS This diagnostic accuracy study was performed on septic shock and severe sepsis patients referring to emergency department of Loghmane Hakim Hospital, Tehran, Iran, from 2017 to 2018. The performance of MEDS, SOFA, and PIRO models in predicting 30-day mortality of patients was evaluated using discrimination and calibration indices. RESULTS 200 patients with the mean age of 71.03±15.59 years were studied (61% male). During the 30 days, 66 patients died (mortality rate=33%). The area under the ROC curve of PIRO, MEDS, and SOFA scores were 0.83 (95% CI=0.78-0.89), 0.94 (95% CI=0.91-0.97) and 0.87 (95% CI=0.81-0.92), respectively. Based on Brier, BrierScaled and Nagelkerke's R2 of the models, the best performance in predicting one-month mortality belonged to MEDS score. C-statistic showed that MEDS score had the highest value in the differentiation between the survived and non-survived cases. CONCLUSION This study showed that MEDS score performs better than PIRO and SOFA scores in predicting one-month mortality of patients with severe sepsis and septic shock.
Collapse
Affiliation(s)
- Ali Vafaei
- Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Kamran Heydari
- Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Skull Base Research Center, Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Seyed-Saeed Hashemi-Nazari
- Prevention of Cardiovascular Disease Research Center, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Neda Izadi
- Student Research Committee, Department of Epidemiology, School of Public Health and Safety, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hassan Hassan Zadeh
- Department of Emergency Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran.,Corresponding Author: Hassan Hassan Zadeh; Loghmane-Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran. E-mail:
| |
Collapse
|
24
|
Should We Manage All Septic Patients Based on a Single Definition? An Alternative Approach. Crit Care Med 2019; 46:177-180. [PMID: 29068856 DOI: 10.1097/ccm.0000000000002778] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
25
|
The immunosuppressive face of sepsis early on intensive care unit-A large-scale microarray meta-analysis. PLoS One 2018; 13:e0198555. [PMID: 29920518 PMCID: PMC6007920 DOI: 10.1371/journal.pone.0198555] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 05/21/2018] [Indexed: 12/15/2022] Open
Abstract
Background Sepsis is defined as a life-threatening condition, resulting from a dysregulated and harmful response of the hosts’ immune system to infection. Apart from this, the (over-)compensating mechanisms counterbalancing the inflammatory response have been proven to render the host susceptible to further infections and increase delayed mortality. Our study aimed to unravel the heterogeneity of immune response in early sepsis and to explain the biology behind it. Methods A systematic search of public repositories yielded 949 microarray samples from patients with sepsis of different infectious origin and early after clinical manifestation. These were merged into a meta-expression set, and after applying sequential conservative bioinformatics filtering, an in-deep analysis of transcriptional heterogeneity, as well as a comparison to samples of healthy controls was performed. Results We can identify two distinct clusters of patients (cluster 1: 655 subjects, cluster 2: 294 subjects) according to their global blood transcriptome. While both clusters exhibit only moderate differences in direct comparison, a comparison of both clusters individually to healthy controls yielded strong expression changes of genes involved in immune responses. Both comparisons found similar regulated genes, with a stronger dysregulation occurring in the larger patient cluster and implicating a loss of monocyte and T cell function, co-occurring with an activation of neutrophil granulocytes. Conclusion We propose a consistent—but in its extent varying—presence of immunosuppression, occurring as early in sepsis as its clinical manifestation and irrespective of the infectious origin. While certain cell types possess contradictory activation states, our finding underlines the urgent need for an early host-directed therapy of sepsis side-by-side with antibiotics.
Collapse
|
26
|
Wong HR, Marshall JC. Leveraging Transcriptomics to Disentangle Sepsis Heterogeneity. Am J Respir Crit Care Med 2017; 196:258-260. [PMID: 28762788 DOI: 10.1164/rccm.201701-0143ed] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Affiliation(s)
- Hector R Wong
- 1 Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati, Ohio Cincinnati Children's Research Foundation Cincinnati, Ohio.,2 Department of Pediatrics University of Cincinnati College of Medicine Cincinnati, Ohio and
| | - John C Marshall
- 3 St. Michael's Hospital University of Toronto Toronto, Ontario, Canada
| |
Collapse
|
27
|
Abstract
The word, sepsis, dates back more than 2 millennia but has, over the past 2 centuries, come to be applied first to the clinical state evoked by invasive infection and, more recently, to describe the syndrome resulting from the host response to infection. Further refinements embodied in the recently published Sepsis-3 definition underline the concept of a dysregulated immune response resulting in potentially modifiable life-threatening organ dysfunction. This review summarizes the evolution and limitations of efforts to characterize a common and complex disorder.
Collapse
Affiliation(s)
- John C Marshall
- Departments of Surgery and Critical Care Medicine, St. Michael's Hospital, 4th Floor Bond Wing, Room 4-007, 30 Bond Street, Toronto, ON M5B 1W8, Canada.
| |
Collapse
|
28
|
Dieleman J, Peelen L, Coulson T, Tran L, Reid C, Smith J, Myles P, Pilcher D. Age and other perioperative risk factors for postoperative systemic inflammatory response syndrome after cardiac surgery. Br J Anaesth 2017; 119:637-644. [DOI: 10.1093/bja/aex239] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2017] [Indexed: 02/05/2023] Open
|
29
|
Exaggerated plasma interleukin 6, interleukin 10, and subsequent development of health care-associated infections in patients with sepsis. Dimens Crit Care Nurs 2016; 34:100-11. [PMID: 25650495 DOI: 10.1097/dcc.0000000000000098] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Health care-associated infections (HAIs) are the target of many well-known preventive measures in the intensive care unit (ICU); however, little is known about post-sepsis-induced immunosuppression. OBJECTIVES This study explores the relationship between baseline plasma levels of inflammatory cytokines interleukin 6 (IL-6), IL-10, and IL-6:IL-10 and subsequent development of HAIs in patients with admitted with sepsis. METHODS Prospective observational study was conducted among veterans admitted to the ICU with sepsis and monitored daily through ICU discharge (up to 28 days) to investigate HAI development. Baseline plasma IL-6 and IL-10 levels were measured with a multiplex bead based assay. Exaggerated systemic inflammation was defined as the fourth quartile (IL-6 and IL-10) compared with other quartiles. RESULTS We recruited 78 patients over 18 months, primarily older (65.5 ± 12.6 years) men (94.9%) with underlying comorbidities (93.9%) and a high severity of illness (Acute Physiologic and Chronic Health Evaluation II score 20.6 ± 6.4). Seventeen patients (21.7%) developed at least 1 HAI, and candidemia was the leading infection. Patients with exaggerated baseline systemic inflammation developed a nonsignificantly higher proportion of HAI as compared with those not developing HAI (IL-6: 31.6% vs 18.6%, P = .55; IL-10: 26.3% vs 20.3%, P = .43). DISCUSSION Patients with exaggerated systemic inflammation had a higher severity of illness, but not a statistically significant higher incidence of HAI. A larger, more adequately powered sample with serial cytokine measures is needed. Routine surveillance cultures are needed. Health care-associated infection may occur in the absence of fever, and the emerging incidence of Candida is a concern. Immune suppression after sepsis should be recognized as a risk for HAI development. Antibiotic therapy should be targeted with prompt de-escalation of empiric therapy per established guidelines to preserve normal flora.
Collapse
|
30
|
Seckel MA, Ahrens T. Challenges in Sepsis Care: New Sepsis Definitions and Fluid Resuscitation Beyond the Central Venous Pressure. Crit Care Nurs Clin North Am 2016; 28:513-532. [PMID: 28236396 DOI: 10.1016/j.cnc.2016.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
There are two important recent changes in sepsis care. The first key change is the 2016 Sepsis-3 definitions from the recent consensus workgroup with new sepsis and septic shock definitions. Useful tools for assessing patients that have a greater risk of mortality include Sequential Organ Failure Assessment (SOFA) in intensive care units and quick SOFA outside intensive care units. The second change involves management of fluid resuscitation and measures of volume responsiveness. Measures such as blood pressure and central venous pressure are not reliable. Fluid challenges and responsiveness should be based on stroke volume change of greater than 10%.
Collapse
Affiliation(s)
- Maureen A Seckel
- Christiana Care Health Services, Affiliated Faculty, College of Nursing, University of Delaware, 4755 Ogletown-Stanton Road, Newark, DE 19711, USA.
| | | |
Collapse
|
31
|
Abstract
Severe sepsis may be underrecognized in older adults. Therefore, the purpose of this article is to review special considerations related to early detection of severe sepsis in older adults. Normal organ changes attributed to aging may delay early detection of sepsis at the time when interventions have the greatest potential to improve patient outcomes. Systems are reviewed for changes. For example, the cardiovascular system may have a limited or absent compensatory response to inflammation after an infectious insult, and the febrile response and recruitment of white blood cells may be blunted because of immunosenescence in aging. Three of the 4 hallmark responses (temperature, heart rate, and white blood cell count) to systemic inflammation may be diminished in older adults as compared with younger adults. It is important to consider that older adults may not always manifest the typical systemic inflammatory response syndrome. Atypical signs such as confusion, decreased appetite, and unsteady gait may occur before sepsis related organ failure. Systemic inflammatory response syndrome criteria and a comparison of organ failure criteria were reviewed. Mortality rates in sepsis and severe sepsis remain high and are often complicated by multiple organ failures. As the numbers of older adults increase, early identification and prompt treatment is crucial in improving patient outcomes.
Collapse
|
32
|
Identification of Predictive Early Biomarkers for Sterile-SIRS after Cardiovascular Surgery. PLoS One 2015; 10:e0135527. [PMID: 26263001 PMCID: PMC4532358 DOI: 10.1371/journal.pone.0135527] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 07/22/2015] [Indexed: 12/21/2022] Open
Abstract
Systemic inflammatory response syndrome (SIRS) is a common complication after cardiovascular surgery that in severe cases can lead to multiple organ dysfunction syndrome and even death. We therefore set out to identify reliable early biomarkers for SIRS in a prospective small patient study for timely intervention. 21 Patients scheduled for planned cardiovascular surgery were recruited in the study, monitored for signs of SIRS and blood samples were taken to investigate biomarkers at pre-assigned time points: day of admission, start of surgery, end of surgery, days 1, 2, 3, 5 and 8 post surgery. Stored plasma and cryopreserved blood samples were analyzed for cytokine expression (IL1β, IL2, IL6, IL8, IL10, TNFα, IFNγ), other pro-inflammatory markers (sCD163, sTREM-1, ESM-1) and response to endotoxin. Acute phase proteins CRP, PCT and pro-inflammatory cytokines IL6 and IL8 were significantly increased (p<0.001) at the end of surgery in all patients but could not distinguish between groups. Normalization of samples revealed significant increases in IL1β changes (p<0.05) and decreased responses to endotoxin (p<0.01) in the SIRS group at the end of surgery. Soluble TREM-1 plasma concentrations were significantly increased in patients with SIRS (p<0.01). This small scale patient study could show that common sepsis markers PCT, CRP, IL6 and TNFα had low predictive value for early diagnosis of SIRS after cardiovascular surgery. A combination of normalized IL1β plasma levels, responses to endotoxin and soluble TREM-1 plasma concentrations at the end of surgery are predictive markers of SIRS development in this small scale study and could act as an indicator for starting early therapeutic interventions.
Collapse
|
33
|
Arendts G, Etherton-Beer C, Jones R, Bullow K, MacDonald E, Dumas S, Parker D, Hutton M, Burrows S, Brown SGA, Almeida OP. Use of a risk nomogram to predict emergency department reattendance in older people after discharge: a validation study. Intern Emerg Med 2015; 10:481-7. [PMID: 25757530 DOI: 10.1007/s11739-015-1219-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 02/15/2015] [Indexed: 01/19/2023]
Abstract
In older people, revisit to the emergency department (ED) in the short period after discharge is not entirely avoidable, but in a proportion of cases is preventable, and should ideally be minimised. We have previously derived a risk probability nomogram to predict the likelihood of revisit. In this study, we sought to validate the nomogram for use as a general risk stratification tool for use in older people being discharged from ED. We conducted a prospective cohort study, applying the nomogram to consecutive community dwelling discharged patients aged 65 and over. Patients were followed up at 28 days post-discharge to determine whether there had been any unplanned ED revisit in that period. We cross tabulated predicted risk versus revisit rates. In 1143 study subjects, we find the odds of revisit increases progressively with increasing strata of predicted risk, culminating in an OR of 9.7 (95% CI 4.7-19.9) in the highest risk group. The 28-day revisit rates across strata range from 16% through 65%, with the difference between strata being statistically highly significant (p < 0.001). The area under the ROC curve is 0.65. We conclude that the risk nomogram can classify older people discharged from ED into risk strata, and has modest overall predictive value.
Collapse
Affiliation(s)
- Glenn Arendts
- University of Western Australia, Crawley, Australia,
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Macdonald SPJ, Arendts G, Fatovich DM, Brown SGA. Comparison of PIRO, SOFA, and MEDS scores for predicting mortality in emergency department patients with severe sepsis and septic shock. Acad Emerg Med 2014; 21:1257-63. [PMID: 25377403 DOI: 10.1111/acem.12515] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 06/18/2014] [Accepted: 07/02/2014] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The Predisposition Insult Response and Organ failure (PIRO) scoring system has been developed for use in the emergency department (ED) to risk stratify sepsis cases, but has not been well studied among high-risk patients with severe sepsis and septic shock. The PIRO score was compared with the Sequential Organ Failure Assessment (SOFA) and Mortality in ED Sepsis (MEDS) scores to predict mortality in ED patients with features suggesting severe sepsis or septic shock in the ED. METHODS This was an analysis of sepsis patients enrolled in a prospective observational ED study of patients presenting with evidence of shock, hypoxemia, or other organ failure. PIRO, MEDS, and SOFA scores were calculated from ED data. Analysis compared areas under the receiver operator characteristic (ROC) curves for 30-day mortality. RESULTS Of 240 enrolled patients, final diagnoses were septic shock in 128 (53%), severe sepsis without shock in 70 (29%), and infection with no organ dysfunction in 42 (18%). Forty-eight (20%) patients died within 30 days of presentation. Area under the ROC curve (AUC) for mortality was 0.86 (95% confidence interval [CI] = 0.80 to 0.92) for PIRO, 0.81 (95% CI = 0.74 to 0.88) for MEDS, and 0.78 (95% CI = 0.71 to 0.87) for SOFA scores. Pairwise comparisons of the AUC were as follows: PIRO versus SOFA, p = 0.01; PIRO versus MEDS, p = 0.064; and MEDS versus SOFA; p = 0.37. Mortality increased with increasing PIRO scores: PIRO < 5, 0%; PIRO 5 to 9, 5%; PIRO 10 to 14, 5%; PIRO 15 to 19, 37%; and PIRO ≥ 20, 80% (p < 0.001). The MEDS score also showed increasing mortality with higher scores: MEDS < 5, 0%; MEDS 5 to 7, 12%; MEDS 8 to 11, 15%; MEDS 12 to 14, 48%; and MEDS > 15, 65% (p < 0.001). CONCLUSIONS The PIRO model, taking into account comorbidities and septic source as well as physiologic status, performed better than the SOFA score and similarly to the MEDS score for predicting mortality in ED patients with severe sepsis and septic shock. These findings have implications for identifying and managing high-risk patients and for the design of clinical trials in sepsis.
Collapse
Affiliation(s)
- Stephen P. J. Macdonald
- The Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth WA
- The Discipline of Emergency Medicine University of Western Australia Perth WA
- The Emergency Department Armadale Health Service Perth WA
| | - Glenn Arendts
- The Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth WA
- The Discipline of Emergency Medicine University of Western Australia Perth WA
- The Emergency Department Royal Perth Hospital Perth WA Australia
| | - Daniel M. Fatovich
- The Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth WA
- The Discipline of Emergency Medicine University of Western Australia Perth WA
- The Emergency Department Royal Perth Hospital Perth WA Australia
| | - Simon G. A. Brown
- The Centre for Clinical Research in Emergency Medicine Harry Perkins Institute of Medical Research Perth WA
- The Discipline of Emergency Medicine University of Western Australia Perth WA
- The Emergency Department Royal Perth Hospital Perth WA Australia
| |
Collapse
|
35
|
Bhagwanjee S, Ugarte S. Sepsis in vulnerable populations. Glob Heart 2014; 9:281-8. [PMID: 25667179 DOI: 10.1016/j.gheart.2014.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/18/2014] [Indexed: 12/29/2022] Open
Abstract
Despite the acquisition of a large body of evidence, there are many unanswered questions about sepsis. The definition of this disease is plagued by the lack of a simple pathophysiological description linking cause to effect and the activation of host immune responses that hinders disease progression at the same time producing multiorgan dysfunction. A plethora of inconsistent clinical features has served to obfuscate rather than illuminate. The Surviving Sepsis Guidelines (SSG) are a major advance because it comprehensively interrogates all aspects of care for the critically ill. For vulnerable populations living in low- and middle-income countries, this guideline is ineffectual because of the lack of region-specific data, differences in etiology of sepsis and burden of disease, limited human capacity and infrastructure, as well as socioeconomic realities. Appropriate care must be guided by common sense guidelines that are sensitive to local realities and adapted as relevant data are acquired.
Collapse
Affiliation(s)
- Satish Bhagwanjee
- Department of Anaesthesiology and Pain Medicine, University of Washington, Seattle, Washington, USA.
| | | |
Collapse
|
36
|
Khilanani A, Mazwi M, Paquette ET. Pediatric Sepsis in the Global Setting. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2014. [DOI: 10.1016/j.cpem.2014.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
|
37
|
Why have clinical trials in sepsis failed? Trends Mol Med 2014; 20:195-203. [PMID: 24581450 DOI: 10.1016/j.molmed.2014.01.007] [Citation(s) in RCA: 485] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2013] [Revised: 01/16/2014] [Accepted: 01/22/2014] [Indexed: 12/17/2022]
Abstract
The systemic inflammatory response is biologically complex, redundant, and activated by both infectious and noninfectious triggers. Its manipulation can cause both benefit and harm. More than 100 randomized clinical trials have tested the hypothesis that modulating the septic response to infection can improve survival. With one short-lived exception, none of these has resulted in new treatments. The current challenge for sepsis research lies in a failure of concept and reluctance to abandon a demonstrably ineffectual research model. Future success will necessitate large studies of clinical and biochemical epidemiology to understand the course of illness, better integration of basic and clinical science, and the creation of stratification systems to target treatment towards those who are most likely to benefit.
Collapse
|
38
|
Affiliation(s)
- Steven M Opal
- Infectious Disease Division; Alpert Medical School of Brown University; Pawtucket, RI USA
| |
Collapse
|