In-Hospital Death after Septic Shock Reversal: A Retrospective Analysis of In-Hospital Death among Septic Shock Survivors at Thailand's Largest National Tertiary Referral Center

Hemolytic Activity and Cytotoxicity of Synthetic Nanoclays with Montmorillonite Structure for Medical Applications

The factors influencing the appearance of toxicity in samples of synthetic montmorillonite with a systematically changing chemical composition Na_x(Al, Mg)_2-3Si₄O₁₀(OH)₂ nH₂O, which are potentially important for their use in medicine as drug carriers, targeted drug delivery systems, entero- and hemosorbents have been studied. Samples synthesized under hydrothermal conditions had the morphology of nanolayers self-organized into the nanosponge structures. The effect of the aluminum content, particle sizes, porosity, and ζ-potential of the samples on their toxicity was studied. The cytotoxic effect of the samples on eukaryotic cells Ea. hy 926 was determined using the MTT assay. The hemolytic activity of the samples in the wide concentration range in relation to human erythrocytes was also estimated. It has been established that the toxicity of aluminosilicate nanoparticles can be significantly reduced by correctly selecting their synthesis conditions and chemical composition, which opens up the opportunities for their use in medicine.

Serum Lactate-Albumin Ratio: Soothsayer for Outcome in Sepsis

AIM

The aim of this study is to assess the efficacy of the serum lactate/albumin (L/A) ratio as a prognostic marker of sepsis syndrome.

MATERIALS AND METHODS

This study was conducted in the Internal Medicine Department at Acharya Vinoba Bhave Rural Hospital with a sample size of 160 cases of sepsis. The serum L/A ratio was calculated on admission and correlated with deaths and morbidity. Statistical analysis was significant if the P-value was less than 0.05.

RESULTS

The mean age of patients was 52.83 ± 16.80 years with a male predominance (64.4% vs. 35.6%). The mean L/A ratio was 0.95 ± 0.46. The proportion of discharged subjects and mortality were 58.8% and 41.2%, respectively. The study found that a higher mean L/A ratio (1.1-1.44) was significantly linked to the various variables in the study. Furthermore, a significantly higher median L/A ratio of 1.23 was found in subjects with vasopressor use. The median L/A ratio in the Discharge group and Death group was 0.64 and 1.27, respectively. The area under the receiver operating characteristic (AUROC) curve indicated that accurate diagnostic performance was 0.976 in predicting Death versus Discharge for the L/A ratio.

CONCLUSION

This study found that, compared to lactate and albumin alone, the predictor value of the L/A ratio was outstanding in predicting death and hospital stay (discharge) among sepsis participants, with a sensitivity of 100% and a specificity of 88%.

Comprehensive Investigations of Multiple Factors That Are Related to Refractory Outcome in Urosepsis Patients

Background

Urosepsis is an acute life-threating disease, and some cases show refractory outcome to therapy. In an aging society of developed countries, characteristics of urosepsis are becoming complicated. We performed a comprehensive investigation regarding the clinical and social aspects that are related to refractory outcomes in urosepsis patients.

Methods

The patient cohort consisted of 66 patients with urosepsis. Multiple factors from clinical and social aspects were reviewed retrospectively. Two categories of refractory outcomes were defined. One was afebrile resistance (AR); fever continued more than 7 days from the initiation of therapy. Another was discharge resistance (DR); hospitalization continued for more than 30 days. Logistic regression analyses were performed to identify significant factors that are related to the AR or DR.

Results

Univariate analysis demonstrated that high score of Eastern Cooperative Oncology Group Performance Status (ECOG PS) (≥ 2) and Age-adjusted Charlson comorbidity index (CCI) (≥ 4), high serum C-reactive protein (CRP) level (≥ 14.9 mg/dL), and low serum albumin level (≤ 2.26 g/dL) were significantly related to AR. Univariate analysis results also revealed that high score of ECOG PS (≥ 2), high serum creatinine level (≥ 1.54 mg/dL) and vasopressor administration were significantly related to DR. Multivariate analyses demonstrated that low serum albumin level (≤ 2.26g/dL) was the only significant factor that was related to AR. In contrast, high score of ECOG PS (≥ 2) and high serum creatinine level (≥ 1.54 mg/dL) were significant factors that were related to DR.

Conclusion

It is suggested that evaluating serum albumin levels is essential for the therapeutic first step because hypoalbuminemia was the significant factor that was related to obstruction to antipyresis. It is also suggested that the deterioration of patients' activities of daily living and renal dysfunction might be the refractory factors for discharge from the hospital, which was the ultimate therapeutic goal.

Epidemiology and Burden of Sepsis at Thailand's Largest University-Based National Tertiary Referral Center during 2019

Data specific to the epidemiology and burden of sepsis in low- and middle-income countries are limited. This study aimed to determine the epidemiology and burden of adult patients with sepsis at Siriraj Hospital during 2019. Randomly selected adult patients who had blood cultures performed at our center during January−December 2019 were enrolled. A Quick Sepsis-related Organ Failure Assessment (qSOFA) score was used to determine the presence of sepsis. Demographic data and clinical outcome data were collected, and the annual incidence of sepsis or septic shock and death was estimated. Of the 987 subjects who had blood cultures performed, 798 had infections, 341 had sepsis, and 104 had septic shock. The prevalence of sepsis or septic shock was 34.9% among blood cultured patients, and 42.7% among those with infections. The prevalence of septic shock was 30.5% among subjects with sepsis. Approximately 63% of sepsis subjects were hospital-acquired infections. The factors independently associated with 28-day mortality in sepsis were receiving an immunosuppressive agent (adjusted odds ratio [aOR]: 2.37, 95% confidence interval [CI]: 1.27−4.45; p = 0.007), septic shock (aOR: 2.88, 95% CI: 1.71−4.87; p < 0.001), and proven infection (aOR: 2.88, 95% CI: 1.55−5.36; p = 0.001). Receiving appropriate, definitive antibiotic therapy (ABT) was independently associated with lower mortality in sepsis (aOR: 0.50, 95% CI: 0.27−0.93; p = 0.028) and septic shock subjects (aOR: 0.21, 95% CI: 0.06−0.72; p = 0.013). Achievement of mean arterial pressure (MAP) ≥ 65 mmHg (aOR: 0.09, 95% CI: 0.01−0.77; p = 0.028) and urine output ≥ 0.5 mL/kg/h (aOR: 0.15, 95% CI: 0.04−0.51; p = 0.006) were independently associated with lower mortality in septic shock patients. The incidence and mortality of sepsis remains high. Appropriate choice of definitive ABT and achievement of MAP and urine output goals may lower mortality in patients with sepsis or septic shock.

High-flow nasal oxygen cannula vs. noninvasive mechanical ventilation to prevent reintubation in sepsis: a randomized controlled trial

BACKGROUND

High-flow nasal oxygen cannula (HFNC) and noninvasive mechanical ventilation (NIV) can prevent reintubation in critically ill patients. However, their efficacy in post-extubated sepsis patients remains unclear. The objective of this study was to compare the efficacy of HFNC vs. NIV to prevent reintubation in post-extubated sepsis patients.

METHODS

We conducted a single-centre, prospective, open-labelled, randomised controlled trial at the medical intensive care unit of Siriraj Hospital, Mahidol University, Bangkok, Thailand. Sepsis patients who had been intubated, recovered, and passed the spontaneous breathing trial were enrolled and randomly assigned in a 1:1 ratio to receive either HFNC or NIV support immediately after extubation. The primary outcome was rate of reintubation at 72 h after extubation.

RESULTS

Between 1st October 2017 and 31st October 2019, 222 patients were enrolled and 112 were assigned to the HFNC group and 110 to the NIV group. Both groups were well matched in baseline characteristics. The median [IQR] age of the HFNC group was 66 [50-77] vs. 65.5 [54-77] years in the NIV group. The most common causes of intubation at admission were shock-related respiratory failure (57.1% vs. 55.5%) and acute hypoxic respiratory failure (34.8% vs. 40.9%) in the HFNC and NIV groups, respectively. The duration of mechanical ventilation before extubation was 5 [3-8] days in the HFNC group vs. 5 [3-9] days in the NIV group. There was no statistically significant difference in the primary outcome: 20/112 (17.9%) in the HFNC group required reintubation at 72 h compared to 20/110 (18.2%) in the NIV group [relative risk (RR) 0.99: 95% confidence interval (CI) (0.70-1.39); P = 0.95]. The 28-day mortality was not different: 8/112 (7.1%) with HFNC vs. 10/110 (9.1%) with NIV (RR 0.88: 95% CI (0.57-1.37); P = 0.59).

CONCLUSIONS

Among sepsis patients, there was no difference between HFNC and NIV in the prevention of reintubation at 72 h after extubation. Clinical Trial Registration ClinicalTrials.gov Identifier: NCT03246893; Registered 11 August 2017; https://clinicaltrials.gov/ct2/show/NCT03246893?term=surat+tongyoo&draw=2&rank=3.

Hypoalbuminemia as Surrogate and Culprit of Infections

Hypoalbuminemia is associated with the acquisition and severity of infectious diseases, and intact innate and adaptive immune responses depend on albumin. Albumin oxidation and breakdown affect interactions with bioactive lipid mediators that play important roles in antimicrobial defense and repair. There is bio-mechanistic plausibility for a causal link between hypoalbuminemia and increased risks of primary and secondary infections. Serum albumin levels have prognostic value for complications in viral, bacterial and fungal infections, and for infectious complications of non-infective chronic conditions. Hypoalbuminemia predicts the development of healthcare-associated infections, particularly with Clostridium difficile. In coronavirus disease 2019, hypoalbuminemia correlates with viral load and degree of acute lung injury and organ dysfunction. Non-oncotic properties of albumin affect the pharmacokinetics and pharmacodynamics of antimicrobials. Low serum albumin is associated with inadequate antimicrobial treatment. Infusion of human albumin solution (HAS) supplements endogenous albumin in patients with cirrhosis of the liver and effectively supported antimicrobial therapy in randomized controlled trials (RCTs). Evidence of the beneficial effects of HAS on infections in hypoalbuminemic patients without cirrhosis is largely observational. Prospective RCTs are underway and, if hypotheses are confirmed, could lead to changes in clinical practice for the management of hypoalbuminemic patients with infections or at risk of infectious complications.