Epidemiology of the Systemic Inflammatory Response Syndrome (SIRS) in the emergency department

Improving Sepsis Outcomes in the Era of Pay-for-Performance and Electronic Quality Measures: A Joint IDSA/ACEP/PIDS/SHEA/SHM/SIDP Position Paper

The Centers for Medicare & Medicaid Services (CMS) introduced the Severe Sepsis/Septic Shock Management Bundle (SEP-1) as a pay-for-reporting measure in 2015 and is now planning to make it a pay-for-performance measure by incorporating it into the Hospital Value-Based Purchasing Program. This joint IDSA/ACEP/PIDS/SHEA/SHM/SIPD position paper highlights concerns with this change. Multiple studies indicate that SEP-1 implementation was associated with increased broad-spectrum antibiotic use, lactate measurements, and aggressive fluid resuscitation for patients with suspected sepsis but not with decreased mortality rates. Increased focus on SEP-1 risks further diverting attention and resources from more effective measures and comprehensive sepsis care. We recommend retiring SEP-1 rather than using it in a payment model and shifting instead to new sepsis metrics that focus on patient outcomes. CMS is developing a community-onset sepsis 30-day mortality electronic clinical quality measure (eCQM) that is an important step in this direction. The eCQM preliminarily identifies sepsis using systemic inflammatory response syndrome (SIRS) criteria, antibiotic administrations or diagnosis codes for infection or sepsis, and clinical indicators of acute organ dysfunction. We support the eCQM but recommend removing SIRS criteria and diagnosis codes to streamline implementation, decrease variability between hospitals, maintain vigilance for patients with sepsis but without SIRS, and avoid promoting antibiotic use in uninfected patients with SIRS. We further advocate for CMS to harmonize the eCQM with the Centers for Disease Control and Prevention's (CDC) Adult Sepsis Event surveillance metric to promote unity in federal measures, decrease reporting burden for hospitals, and facilitate shared prevention initiatives. These steps will result in a more robust measure that will encourage hospitals to pay more attention to the full breadth of sepsis care, stimulate new innovations in diagnosis and treatment, and ultimately bring us closer to our shared goal of improving outcomes for patients.

Therapeutic potential of mesenchymal stromal/stem cells in critical-care patients with systemic inflammatory response syndrome

BACKGROUND

Despite notable advances in the support and treatment of patients admitted to the intensive care unit (ICU), the management of those who develop a systemic inflammatory response syndrome (SIRS) still constitutes an unmet medical need.

MAIN BODY

Both the initial injury (trauma, pancreatitis, infections) and the derived uncontrolled response promote a hyperinflammatory status that leads to systemic hypotension, tissue hypoperfusion and multiple organ failure. Mesenchymal stromal/stem cells (MSCs) are emerging as a potential therapy for severe ICU patients due to their potent immunomodulatory, anti-inflammatory, regenerative and systemic homeostasis-regulating properties. MSCs have demonstrated clinical benefits in several inflammatory-based diseases, but their role in SIRS needs to be further explored.

CONCLUSION

In the current review, after briefly overviewing SIRS physiopathology, we explore the potential mechanisms why MSC therapy could aid in the recovery of this condition and the pre-clinical and early clinical evidence generated to date.

Monocyte distribution width (MDW) as a useful indicator for early screening of sepsis and discriminating false positive blood cultures

BACKGROUND

Severe sepsis and septic shock are the leading cause of in-hospital death. As sepsis progresses, expression and activity of endogenous mediators of inflammation change. Early detection of biomarkers can play a role in sepsis screening and in improvement of patient outcomes. Recent studies suggest that increase in monocyte volume may be helpful in early detection of sepsis. Therefore, we evaluated the utility of monocyte distribution width (MDW) for the early assessment of sepsis compared with the blood culture and other inflammatory biomarkers.

METHODS

Medical records of 1,404 patients (aged ≥19 years) who were admitted to the emergency department owing to clinically suspected infectious disease and requested blood cultures from Oct 2019 to Jan 2021 were reviewed. The patients were grouped based on Sepsis-3 criteria. They had undergone other laboratory tests to evaluate their clinical status. MDW was analyzed using DxH900 hematology analyzer (Beckman Coulter, Brea, California, USA). To determine the diagnostic performance of MDW, C-reactive protein (CRP), and procalcitonin (PCT) for sepsis, the area under the curve (AUC) of receiver operating characteristics curves and their sensitivity and specificity were measured.

RESULTS

Among 1,404 patients, 520 patients were designated the sepsis group based on Sepsis-3 criteria. In the sepsis group, MDW value was 24.1 (median, IQR 21.6-28.1); AUC values for MDW, CRP, and PCT were 0.67 (95% CI, 0.64-0.69), 0.66 (95% CI, 0.63-0.68), and 0.75 (95% CI, 0.72-0.77), respectively. For diagnosis of the sepsis, the cut-off value of MDW was 21.7 (sensitivity 74% and specificity 54%). Measured values of MDW were higher for the blood culture positive group than that of the blood culture contamination group (P<0.001, 95% CI, -5.9 to -3.0) or blood culture negative group (P<0.001, 95% CI = -5.8 to -4.2).

CONCLUSIONS

MDW is a new hematological parameter that is simultaneously calculated during complete blood cell counting by Beckman Coulter hematology analyzer. MDW is expected to serve as a useful indicator for early screening of sepsis in conjunction with CRP and PCT. MDW is especially useful for sepsis assessment in patients with a suspected infection. MDW can also assist in discriminating false positive blood cultures.

Monocyte Distribution Width (MDW) as an Early Investigational Marker for the Diagnosis of Sepsis in an Emergency Department of a Tertiary Care Hospital in North India

Background Sepsis is an emergency state in response to an infectious process ultimately leading to multiorgan dysfunction and death. There is an urgent need for sepsis detection methods, especially in emergency settings. To fill this gap, monocyte distribution width (MDW) was studied as an early indicator of sepsis. Aim To evaluate MDW as an early marker of sepsis. Material and methods This was a prospective observational study including critically ill adult patients who presented to the emergency department. MDW was measured using a DxH 900 Hematology Analyser (Beckman Coulter Inc., Miami, FL). Abnormal MDW (>20.0) was considered a predictor of sepsis. Results A total of 148 patients were included and categorized according to the Sepsis-2 and Sepsis-3 criteria, as having sepsis (25.6%), sepsis with shock (21.6%), and non-sepsis (52.8%). In patients with sepsis with and without shock, MDW was 28.28 ± 9.20 and 28.02 ± 9.01, respectively, significantly higher than in patients without sepsis (p < 0.001). The diagnostic accuracy value of MDW testing for early sepsis detection was highly significant (0.74, p < 0.000). Conclusion MDW can be used as a marker for the early prediction of sepsis.

Varying Estimates of Sepsis among Adults Presenting to US Emergency Departments: Estimates from a National Dataset from 2002-2018

Background

A variety of approaches to defining sepsis using administrative datasets have been previously reported. We aimed to compare estimates, demographics, treatment factors, outcomes and longitudinal trends of patients identified with sepsis in United States emergency departments (EDs) using differing sets of sepsis criteria.

Methods

We performed a cross-sectional study using the National Healthcare Ambulatory Medical Care Survey, a complex survey of nonfederal US ED encounters between 2002 to 2018. We obtained survey-weighted population-adjusted encounters of sepsis using the following criteria: explicit sepsis, severe sepsis, and quick Sequential Organ Failure Assessment (qSOFA) score combined with the presence of infection.

Results

Age-adjusted for US adults, 18.6, 16.1 and 8.9 encounters per 10 000 population were identified when using the explicit, severe sepsis and qSOFA definitions, respectively. A higher proportion of the explicit cohort was hospitalized and had blood cultures performed, compared to cohorts ascertained using severe sepsis and qSOFA criteria, though confidence intervals overlapped. Antibiotic use was highest in encounters meeting qSOFA criteria. When inspecting unweighted encounters meeting each set of criteria, there was minimal overlap, with only 3% meeting all three. Encounters meeting the explicit and severe sepsis criteria were increasing over time.

Conclusion

The explicit, severe sepsis and qSOFA criteria generated similar annual rates of presentation when applied to US ED encounters, with some evidence of the explicit sepsis cohort being higher acuity. There was minimal overlap of cases and instability in estimates when assessed longitudinally. Our findings inform research efforts to accurately identify sepsis among ED encounters using administrative data.

The Knowledge of Nursing Internship Program Students about Early Detection of Sepsis

Background: Sepsis is a life-threatening condition due to the failure of the body’s regulation of infection. Knowledge deficit is one of the barriers to early detection and initiation of sepsis care. Nursing internship program students as future nurses need to have sufficient knowledge about early detection of sepsis to support their behavior. Thus, the purpose of this study was to describe the knowledge of nursing internship program students regarding the early detection of sepsis and the demographic factor related to the knowledge.      Methods: The study design was a quantitative study. Through the proportionate stratified non-random sampling technique, the researcher involved 143 nursing internship program students of Universitas Padjadjaran. Data collection used a questionnaire based on the Sepsis-3 guidelines to measure nursing internship program students’ knowledge about early detection of sepsis. The data was carried out in July-August 2021.   Results: The average knowledge score of the respondents was 70.4 (SD=11.9). More than half of the respondents (56.6%) got a score below the average. Almost all respondents do not know the current definition of sepsis and still use the SIRS definition as clinical criteria for sepsis. However, respondents could identify clinical criteria for sepsis based on qSOFA and analyse sepsis indicators based on case scenarios. Meanwhile, based on its characteristics, the information is a factor that significantly affects the knowledge score (p < 0.05).          Conclusion: In conclusion, there is still a gap in the knowledge of the nursing internship program students regarding the update of the Sepsis-3 guidelines. Besides, information is identified as the factor that influences knowledge. Therefore, it suggested that the institution provide further effective educational methods to update students’ knowledge about the early detection of sepsis.

Diagnostic Accuracy and Prognostic Value of Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Septic Patients outside the Intensive Care Unit

Background and Objectives: The aim of this study was to evaluate the diagnostic accuracy and prognostic value of neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocyte (PLR) ratios and to compare them with other biomarkers and clinical scores of sepsis outside the intensive care unit. Materials and methods: In this retrospective study, 251 patients with sepsis and 126 patients with infection other than sepsis were enrolled. NLR and PLR were calculated as the ratio between absolute values of neutrophils, lymphocytes, and platelets by complete blood counts performed on whole blood by Sysmex XE-9000 (Dasit, Italy) following the manufacturer’s instruction. Results: The best NLR value in diagnosis of sepsis was 7.97 with sensibility, specificity, AUC, PPV, and NPV of 64.26%, 80.16%, 0.74 (p < 0.001), 86.49%, and 53.18%, respectively. The diagnostic role of NLR significantly increases when PLR, C-reactive protein (PCR), procalcitonin (PCT), and mid-regional pro-adrenomedullin (MR-proADM) values, as well as systemic inflammatory re-sponse syndrome (SIRS), sequential organ failure assessment (SOFA), and quick-sequential organ failure assessment (qSOFA) scores, were added to the model. The best value of NLR in predicting 90-day mortality was 9.05 with sensibility, specificity, AUC, PPV, and NPV of 69.57%, 61.44%, 0.66 (p < 0.0001), 28.9%, and 89.9%, respectively. Sensibility, specificity, AUC, PPV, and NPV of NLR increase if PLR, PCR, PCT, MR-proADM, SIRS, qSOFA, and SOFA scores are added to NLR. Conclusions: NLR and PLR represent a widely useful and cheap tool in diagnosis and in predict-ing 90-day mortality in patients with sepsis.

Fetal Growth Restriction and Subsequent Low Grade Fetal Inflammatory Response Are Associated with Early-Onset Neonatal Sepsis in the Context of Early Preterm Sterile Intrauterine Environment

There is no information about whether fetal growth restriction (FGR) is an independent risk factor for low-grade fetal inflammatory response (FIR), and which is more valuable for the prediction of early-onset neonatal sepsis (EONS) between low-grade FIR or fetal inflammatory response syndrome (FIRS) in the context of human early preterm sterile intrauterine environment. We examined FIR (umbilical cord plasma (UCP) CRP concentration at birth) according to the presence or absence of FGR (birth weight < 5th percentile for gestational age (GA)) and EONS in 81 singleton preterm births (GA at delivery: 24.5~33.5 weeks) within 72 h after amniocentesis and with sterile intrauterine environment. A sterile intrauterine environment was defined by the presence of both a sterile amniotic fluid (AF) (AF with both negative culture and MMP-8 < 23 ng/mL) and inflammation-free placenta. Median UCP CRP (ng/mL) was higher in cases with FGR than in those without FGR (63.2 vs. 34.5; p = 0.018), and FGR was an independent risk factor for low-grade FIR (UCP CRP ≥ 52.8 ng/mL) (OR 3.003, 95% CI 1.024-8.812, p = 0.045) after correction for confounders. Notably, low-grade FIR (positive likelihood-ratio (LR) and 95% CI, 2.3969 (1.4141-4.0625); negative-LR and 95% CI, 0.4802 (0.2591-0.8902)), but not FIRS (positive-LR and 95% CI, 2.1071 (0.7526-5.8993); negative-LR and 95% CI, 0.8510 (0.6497-1.1145)), was useful for the identification of EONS. In conclusion, FGR is an independent risk factor for low-grade FIR, and low-grade FIR, but not FIRS, has a value for the identification of EONS in the context of the early preterm sterile intrauterine environment.

Best diagnostic accuracy of sepsis combining SIRS criteria or qSOFA score with Procalcitonin and Mid-Regional pro-Adrenomedullin outside ICU

Early diagnosis and treatment significantly reduce sepsis mortality. Currently, no gold standard has been yet established to diagnose sepsis outside the ICU. The aim of the study was to evaluate the diagnostic accuracy of sepsis defined by SIRS Criteria of 1991, Second Consensus Conference Criteria of 2001, modified Second Consensus Conference Criteria of 2001 (obtaining SIRS Criteria and SOFA score), Third Consensus Conference of 2016, in addition to the dosage of Procalcitonin (PCT) and MR-pro-Adrenomedullin (MR-proADM). In this prospective study, 209 consecutive patients with clinical diagnosis of sepsis were enrolled (May 2014-June 2018) outside intensive care unit (ICU) setting. A diagnostic protocol could include SIRS criteria or qSOFA score evaluation, rapid testing of PCT and MR-proADM, and SOFA score calculation for organ failure definition. Using this approach outside the ICU, a rapid diagnostic and prognostic evaluation could be achieved, also in the case of negative SIRS, qSOFA or SOFA scores with high post-test probability to reduce mortality and improve outcomes.

Association of triage hypothermia with in-hospital mortality among patients in the emergency department with suspected sepsis

PURPOSE

To identify if triage hypothermia (<36.0 °C) among emergency department (ED) encounters with sepsis are independently associated with mortality.

METHODS

We analyzed data from a multi-stage probability sample survey of visits to United States EDs between 2007 and 2015, using two inclusion approaches: an explicit definition based on diagnosis codes for sepsis and a severe sepsis definition, combining evidence of infection with organ dysfunction. We used multivariable regression to determine an association between hypothermia and in-hospital mortality.

RESULTS

Of 1.2 billion ED encounters (95% confidence interval [CI] 1.0-1.3 billion), 3.1 million (95% CI 2.7-3.5 million) met the explicit sepsis definition; 7.4% (95% CI 75.2-9.7%) had triage hypothermia. The adjusted odds ratio (aOR) for hypothermia for in-hospital mortality was 6.82 (95% CI 3.08-15.22). The severe sepsis definition identified 3.5 million (95% 3.1-4.0 million) encounters; 30.3% (95% CI 25.0-34.6%) had triage hypothermia. The aOR for hypothermia with mortality was 4.08 (95% CI 2.09-7.95). Depending on sepsis definition, 78.1-84.4% had other systemic inflammatory response syndrome vital sign abnormalities.

CONCLUSION

Up to one in three patients with sepsis have triage hypothermia, which is independently associated with mortality. 10-20% of patients with hypothermic sepsis do not have other vital sign abnormalities.

Fluid overload in patients with septic shock and lactate clearance as a therapeutic goal: a retrospective cohort study

OBJECTIVE

To assess whether fluid overload in fluid therapy is a prognostic factor for patients with septic shock when adjusted for lactate clearance goals.

METHODS

This was a retrospective cohort study conducted at a level IV care hospital in Bogotá, Colombia. A cohort of patients with septic shock was assembled. Their characteristics and fluid balance were documented. The patients were stratified by exposure levels according to the magnitude of fluid overload by body weight after 24 hours of therapy. Mortality was determined at 30 days, and an unconditional logistic regression model was created, adjusting for confounders. The statistical significance was established at p ≤ 0.05.

RESULTS

There were 213 patients with septic shock, and 60.8% had a lactate clearance ≥ 50% after treatment. Ninety-seven (46%) patients developed fluid overload ≥ 5%, and only 30 (13%) developed overload ≥ 10%. Patients exhibiting fluid overload ≥ 5% received an average of 6227mL of crystalloids (SD ± 5838mL) in 24 hours, compared to 3978mL (SD ± 3728mL) among unexposed patients (p = 0.000). The patients who developed fluid overload were treated with mechanical ventilation (70.7% versus 50.8%) (p = 0.003), albumin (74.7% versus 55.2%) (p = 0.003) and corticosteroids (53.5% versus 35.0%) (p = 0.006) more frequently than those who did not develop fluid overload. In the multivariable analysis, cumulative fluid balance was not associated with mortality (OR 1.03; 95%CI 0.89 - 1.20).

CONCLUSIONS

Adjusting for the severity of the condition and adequate lactate clearance, cumulative fluid balance was not associated with increased mortality in this Latin American cohort of septic patients.

Monocyte distribution width enhances early sepsis detection in the emergency department beyond SIRS and qSOFA

Background

The initial presentation of sepsis in the emergency department (ED) is difficult to distinguish from other acute illnesses based upon similar clinical presentations. A new blood parameter, a measurement of increased monocyte volume distribution width (MDW), may be used in combination with other clinical parameters to improve early sepsis detection. We sought to determine if MDW, when combined with other available clinical parameters at the time of ED presentation, improves the early detection of sepsis.

Methods

A retrospective analysis of prospectively collected clinical data available during the initial ED encounter of 2158 adult patients who were enrolled from emergency departments of three major academic centers, of which 385 fulfilled Sepsis-2 criteria, and 243 fulfilled Sepsis-3 criteria within 12 h of admission. Sepsis probabilities were determined based on MDW values, alone or in combination with components of systemic inflammatory response syndrome (SIRS) or quick sepsis-related organ failure assessment (qSOFA) score obtained during the initial patient presentation (i.e., within 2 h of ED admission).

Results

Abnormal MDW (> 20.0) consistently increased sepsis probability, and normal MDW consistently reduced sepsis probability when used in combination with SIRS criteria (tachycardia, tachypnea, abnormal white blood count, or body temperature) or qSOFA criteria (tachypnea, altered mental status, but not hypotension). Overall, and regardless of other SIRS or qSOFA variables, MDW > 20.0 (vs. MDW ≤ 20.0) at the time of the initial ED encounter was associated with an approximately 6-fold increase in the odds of Sepsis-2, and an approximately 4-fold increase in the odds of Sepsis-3.

Conclusions

MDW improves the early detection of sepsis during the initial ED encounter and is complementary to SIRS and qSOFA parameters that are currently used for this purpose. This study supports the incorporation of MDW with other readily available clinical parameters during the initial ED encounter for the early detection of sepsis.

Trial registration

ClinicalTrials.gov, NCT03145428. First posted May 9, 2017. The first subjects were enrolled June 19, 2017, and the study completion date was January 26, 2018.

Early Systemic Inflammatory Response Syndrome Duration Predicts Infected Pancreatic Necrosis

BACKGROUND AND PURPOSE

Systemic inflammatory response syndrome (SIRS) was considered to play an important role in the progress of acute pancreatitis, but its specific relation with infected pancreatic necrosis remains largely unclear. We aimed to investigate the correlation between SIRS duration and infected pancreatic necrosis, and its application in prediction of infected pancreatic necrosis.

METHODS

A prospective observational cohort study of 2130 patients with acute pancreatitis from 2012 to 2017. The SIRS duration at the first week was registered daily, and demographic, radiology, and all clinical laboratory data were prospectively collected and retrospectively reviewed.

RESULTS

A significant upward tendency of infected pancreatic necrosis incidence was observed with increased SIRS duration. In multivariate logistic regression, SIRS duration (odds ratio, 1.305; 95% CI, 1.161-1.468) was independently associated with infected pancreatic necrosis. ROC analysis demonstrated that the areas under curves of SIRS duration for predicting persistent multi-organ failure, pancreatic infection, and mortality were 0.97 (95% CI, 0.96-0.98), 0.92 (95% CI, 0.91-0.94), and 0.86 (95% CI, 0.83-0.90), respectively, which were comparable to, or even greater than, the area under curves of APACHE II and CT severity index scores.

CONCLUSIONS

Early SIRS duration was strongly associated with infected pancreatic necrosis and could serve as an easy bedside indicator to predict pancreatic infection.

Using sepsis scores in emergency department and ward patients

Sepsis-3, published in 2016, defined sepsis as 'life-threatening organ dysfunction caused by a dysregulated host response to infection'. Instead of systemic inflammatory response syndrome (SIRS), calculating the Sequential Organ Failure Assessment (SOFA) score was recommended. The complexity of SOFA also led to the introduction of quick SOFA (qSOFA) as a bedside tool. The simultaneous removal of SIRS and introduction of qSOFA belies their significant differences, with SIRS having a high sensitivity but very low specificity, and qSOFA being very specific for a poor outcome, but having a lower sensitivity than SIRS. In the UK, the variables within qSOFA are collected on a regular and repeated basis, along with additional variables, as part of the National Early Warning Score (NEWS). A knowledge of SIRS, qSOFA and NEWS is of value in assessing patients with suspected sepsis, as discussed in this article.

SIRS Triggered by Acute Right Ventricular Function, Mimicked Septic Shock

Background

The systemic inflammatory response syndrome (SIRS) is a complex immune response which can be precipitated by non-infectious aetiologies such as trauma, burns or pancreatitis. Addressing the underlying cause is crucial because it can be associated with increased mortality. Although the current literature associates chronic heart failure with SIRS, acute right ventricular dysfunction has not previously been reported to trigger SIRS. This case report describes the presentation of acute right ventricular dysfunction that triggered SIRS and mimicked septic shock.

Case presentation

A 70-year-old male presented to the Intensive Care Unit (ICU) with elevated inflammatory markers and refractory hypotension after a robotic-assisted laparoscopic radical choledochectomy with pancreaticoduodenectomy. Septic shock was misdiagnosed, and he was later found to have a pulmonary embolus. Thrombectomy and antimicrobials had no significant efect on lowering the elevated inflammatory markers or improving the persistent hypotension. Through Point of Care Ultrasound (POCUS), right ventricular dysfunction was diagnosed. Treatment with intravenous milrinone improved blood pressure, normalised inflammatory markers and led to a prompt discharge from the ICU.

Conclusion

Acute right ventricular dysfunction can trigger SIRS, which may mimic septic shock and delay appropriate treatment.

Effects of propolis and melatonin on oxidative stress, inflammation, and clinical status in patients with primary sepsis: Study protocol and review on previous studies

BACKGROUND

Previous studies have explored the anti-inflammatory, anti-infection and oxidative stress reduction effects of propolis and melatonin in experimental studies. However, there are no studies at present exploring the effects of propolis and melatonin in patients with primary sepsis. The present study aims to evaluate the potential effects of propolis and melatonin as a pharmaceutical agent in patients with primary sepsis.

METHODS/DESIGN

The study will be conducted as a randomized controlled clinical trial at the Imamreza hospital. Patients with primary sepsis, in four equal groups, will be recruited for the study. The treatment drugs are propolis and melatonin and the placebo. The following primary and secondary outcome measures will be evaluated: APACHE II Score, SOFA score, NUTRIC score, inflammatory factors, and oxidative stress markers.

DISCUSSION

We describe the protocol for a clinical trial design evaluating the effects of simultaneous administration of propolis and melatonin in patients with primary sepsis. The result of the present study, positive or negative, should provide a step change in the evidence guiding current and future policies regarding the use of propolis and melatonin as an auxiliary treatment in patients with primary sepsis.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials: IRCT20181025041460N1. Registered on 6 November 2018.

The utility of systemic inflammatory response syndrome (SIRS) for diagnosing sepsis in the immediate postpartum period

BACKGROUND

The systemic inflammatory response syndrome (SIRS) and sepsis definitions were developed to improve the ability for early detection of infection and sepsis. We studied the incidence of immediate postpartum SIRS and sepsis. We further studied immediate postpartum SIRS as a potential predictor for immediate postpartum sepsis.

METHODS

This was a retrospective study of 638 immediate postpartum women who delivered either vaginally or by cesarean section. Multivariate logistic regression was used for statistical analysis. Predictor variables included demographic, labor and delivery, and SIRS variables to determine their association with acute immediate postpartum sepsis.

RESULTS

We found that 72.10% of vital signs of immediate postpartum women met SIRS criteria while only 1.25% had sepsis. Both preterm gestational age of <37 weeks (OR:19.09, 95% CI:4.13, 88.36, p < 0.001) and only one of the four SIRS criteria of abnormal temperature (OR:25.90, 95% CI: 3.17, 211.52, p = 0.002) were each significantly associated with increased odds for sepsis.

CONCLUSION

Our findings suggest that immediate postpartum SIRS is not useful for the identification of immediate postpartum sepsis. Furthermore, SIRS does not appear to be a useful screening tool for infection and sepsis in the immediate postpartum period.

Bacteremia complicating urinary tract infection by Pseudomonas aeruginosa: Mortality risk factors

OBJECTIVES

To examine the clinical risk factors for death within 30 days of diagnosis of Pseudomonas aeruginosa-causing bacteremia after a urinary tract infection.

METHODS

A total of 62 patients with Pseudomonas aeruginosa isolated from both urine and blood at the same episode from January 2009 to December 2016 were enrolled in the present study. We retrospectively investigated clinical risk factors for death by comparison between surviving patients and those who died within 30 days after diagnosis of P. aeruginosa bacteremia. The comparison for risk factors for bacteremia-related death included 31 categories, such as age, laboratory data, underlying diseases, clinical history, history of surgery, care in the intensive care unit, P. aeruginosa susceptibility to the antibiotics used at the time of bacteremia diagnosis and consultation with urological department.

RESULTS

The study included 48 men and 14 women aged 71.3 ± 10.4 years. Nine patients (14.5%) died of P. aeruginosa bacteremia. Statistical analysis showed that non-survivors had significantly lower albumin levels than survivors (2.07 ± 0.62 vs 2.62 ± 0.65; P = 0.023). The non-survivors had significantly higher rates of ventilator use, history of heart disease, septic shock and lower rates of consultation with urological departments after diagnosis (P < 0.05).

CONCLUSIONS

Patients with bacteremia complicating urinary infection by P. aeruginosa have a low death rate. Earlier intervention by urologists might improve patients' outcome. Lower albumin levels, ventilator use, history of heart disease and septic shock are factors associated with higher mortality rate.

Derivation of a screen to identify severe sepsis and septic shock in the ED-BOMBARD vs. SIRS and qSOFA

STUDY OBJECTIVE

To predict severe sepsis/septic shock in ED patients.

METHODS

We conducted a retrospective case-control study of patients ≥18 admitted to two urban hospitals with a combined ED census of 162,000. Study cases included patients with severe sepsis/septic shock admitted via the ED. Controls comprised admissions without severe sepsis/septic shock. Using multivariate logistic regression, a prediction rule was constructed. The model's AUROC was internally validated using 1000 bootstrap samples.

RESULTS

143 study and 286 control patients were evaluated. Features predictive of severe sepsis/septic shock included: SBP ≤ 110 mm Hg, shock index/SI ≥ 0.86, abnormal mental status or GCS < 15, respirations ≥ 22, temperature ≥ 38C, assisted living facility residency, disabled immunity. Two points were assigned to SI and temperature with other features assigned one point (mnemonic: BOMBARD). BOMBARD was superior to SIRS criteria (AUROC 0.860 vs. 0.798, 0.062 difference, 95% CI 0.022-0.102) and qSOFA scores (0.860 vs. 0.742, 0.118 difference, 95% CI 0.081-0.155) at predicting severe sepsis/septic shock. A BOMBARD score ≥ 3 was more sensitive than SIRS ≥ 2 (74.8% vs. 49%, 25.9% difference, 95% CI 18.7-33.1) and qSOFA ≥ 2 (74.8% vs. 33.6%, 41.2% difference, 95% CI 33.2-49.3) at predicting severe sepsis/septic shock. A BOMBARD score ≥ 3 was superior to SIRS ≥ 2 (76% vs. 45%, 32% difference, 95% CI 10-50) and qSOFA ≥ 2 (76% vs. 29%, 47% difference, 95% CI 25-63) at predicting sepsis mortality.

CONCLUSION

BOMBARD was more accurate than SIRS and qSOFA at predicting severe sepsis/septic shock and sepsis mortality.

Impact of Fluid Choice in Systemic Inflammatory Response Syndrome Patients on Hospital Cost Savings

BACKGROUND

There is growing evidence of the benefits of intravenous fluid therapy with balanced crystalloids over 0.9% 'normal' saline. This analysis evaluated the economic impact of increasing usage of a calcium-free balanced crystalloid solution (BAL) in patients with systemic inflammatory response syndrome (SIRS) on an annual hospital budget.

METHODS

An Excel^®-based economic model was developed to estimate costs associated with increased BAL usage (i.e., use in a greater proportion of patients), from the US hospital perspective, over a 5-year time horizon. Clinical inputs were based on the results of a retrospective Electronic Health Record (EHR) database analysis identifying significantly fewer complications among SIRS patients receiving predominantly BAL versus saline. Complication-associated costs, adjusted to 2015, were obtained from published reports. Scenario analyses examined cost impacts for hospitals of various sizes, with different BAL adoption levels and rates.

RESULTS

Base-case scenario analysis (300-bed hospital, 80% occupancy, current and year 5 BAL usage in 5 and 75% of SIRS patients, respectively, exponential year-over-year adoption) showed year 1 hospital savings of US$29,232 and cumulative 5-year savings of US$1.16M. Cumulative 5-year pharmacy savings were US$172,641. Scenario analyses demonstrated increasing cumulative 5-year savings with increasing hospital size, year 5 BAL usage in greater proportions of patients, and rapid/early BAL adoption.

CONCLUSIONS

Increased BAL usage represents an opportunity for hospitals and pharmacy departments to reduce complication-related costs associated with managing SIRS patients. The model suggests that savings could be expected across a range of scenarios, likely benefiting hospitals of various sizes and with different adoption capabilities.

[Reality and prospects of sepsis epidemiology research]

Current foreign and Russian literature for sepsis epidemiology is reviewed. There is advanced incidence of sepsis in developing countries among young people as a rule. Absent high-quality epidemiological studies lead to overdiagnosis of sepsis and increased morbidity. National and territorial screening and diagnostic programs for sepsis became possible with introduction of new recommendations 'Sepsis-3'. Thus, there is a possibility to systematize regular epidemiological studies devoted to sepsis.

Antibody-modified conduits for highly selective cytokine elimination from blood

Cytokines play an important role in dysregulated immune responses to infection, pancreatitis, ischemia/reperfusion injury, burns, hemorrhage, cardiopulmonary bypass, trauma, and many other diseases. Moreover, the imbalance between inflammatory and antiinflammatory cytokines can have deleterious effects. Here, we demonstrated highly selective blood-filtering devices - antibody-modified conduits (AMCs) - that selectively eliminate multiple specific deleterious cytokines in vitro. AMCs functionalized with antibodies against human vascular endothelial growth factor A or tumor necrosis factor α (TNF-α) selectively eliminated the target cytokines from human blood in vitro and maintained them in reduced states even in the face of ongoing infusion at supraphysiologic rates. We characterized the variables that determine AMC performance, using anti-human TNF-α AMCs to eliminate recombinant human TNF-α. Finally, we demonstrated selective cytokine elimination in vivo by filtering interleukin 1 β from rats with lipopolysaccharide-induced hypercytokinemia.

Improved Early Detection of Sepsis in the ED With a Novel Monocyte Distribution Width Biomarker

BACKGROUND

Sepsis most often presents to the ED, and delayed detection is harmful. WBC count is often used to detect sepsis, but changes in WBC count size also correspond to sepsis. We sought to determine if volume increases of circulating immune cells add value to the WBC count for early sepsis detection in the ED.

METHODS

A blinded, prospective cohort study was conducted in two different ED populations within a large academic hospital.

RESULTS

Neutrophil and monocyte volume parameters were measured in conjunction with routine CBC testing on a UniCel DxH 800 analyzer at the time of ED admission and were evaluated for the detection of sepsis. There were 1,320 subjects in the ED consecutively enrolled and categorized as control subjects (n = 879) and those with systemic inflammatory response syndrome (SIRS) (n = 203), infection (n = 140), or sepsis (n = 98). Compared with other parameters, monocyte distribution width (MDW) best discriminated sepsis from all other conditions (area under the curve [AUC], 0.79; 95% CI, 0.73-0.84; sensitivity, 0.77; specificity, 0.73; MDW threshold, 20.50), sepsis from SIRS (AUC, 0.74; 95% CI, 0.67-0.84), and severe sepsis from noninfected patients in the ED (AUC, 0.88; 95% CI, 0.75-0.99; negative predictive value, 99%). The added value of MDW to WBC count was statistically significant (AUC, 0.89 for MDW + WBC vs 0.81 for WBC alone; P < .01); a decision curve analysis also showed improved performance compared with WBC count alone.

CONCLUSIONS

The incorporation of MDW with WBC count is shown in this prospective cohort study to improve detection of sepsis compared with WBC count alone at the time of admission in the ED.

TRIAL REGISTRY

ClinicalTrials.gov; No.: NCT02232750; URL: www.clinicaltrials.gov.

Screening cytokine/chemokine profiles in serum and organs from an endotoxic shock mouse model by LiquiChip

Studying the cytokine profiles in animal models or patients with sepsis provides an experimental basis for the identification of diagnostic biomarkers and therapeutic targets. In this study, we used a liquid protein chip (LiquiChip), also known as flexible multi-analyte profiling technology, to perform quantitative analyses of several cytokines and chemokines (e.g., IL-1β, IL-2, IL-4, IL-5, IL-6, IL-10, IL-12, TNF-α, IFN-γ, granulocyte-macrophage colony-stimulating factor, keratinocyte chemoattractant, monocyte chemoattractant protein, monokine induced by gamma interferon, IFN-γ-inducible protein 10, and macrophage inflammatory protein 1 alpha). The levels of these cytokines and chemokines were determined both in the blood and in tissues, including the lung, liver, heart, kidney, spleen, brain, stomach, intestine and muscle, of mice challenged with LPS. Our data showed variable production levels of LPS-induced cytokines in different mouse organs, and the cytokine in the blood did not correlate with those in the organs. We also showed that the levels of most cytokines peaked within 1 to 6 h and decreased rapidly afterward. A variety of inflammatory cytokines might be related to the damage in different organs during septic shock. Our data also suggest that the spleen might be an important target organ in the development of systemic inflammatory response syndrome and sepsis.

Temporal changes in physiological parameters of systemic inflammatory response syndrome during the three days prior to a diagnosis of sepsis: a case-control study

AIMS AND OBJECTIVES

This study was conducted to determine temporal patterns of early changes in physiological parameters of systemic inflammatory response syndrome over three days prior to a diagnosis of sepsis.

BACKGROUND

Early detection and timely management of systemic inflammatory response syndrome are often not implemented due to a failure to recognise or diagnose systemic inflammatory response syndrome.

DESIGN

A retrospective case-control study design was adopted.

METHODS

All 81 study subjects in an intensive care unit were included: 33 case subjects who received a definitive diagnosis of sepsis and 48 control patients who were not diagnosed with systemic inflammatory response syndrome or sepsis. Vital signs (temperatures, heart rates, blood pressures and respiratory rates) and white blood cell count, urine output, serum creatinine concentration, platelet count and serum glucose level data were collected for one, two and three days prior to sepsis diagnosis.

RESULTS

Homogeneity test revealed greater proportions of the aged and subjects with diabetes mellitus, hypertension and wound in the case group. Analysis also showed significant intergroup differences in systemic inflammatory response syndrome criteria score, heart rates, platelet counts and blood glucose levels, but no intergroup differences in body temperatures, blood pressures, respiratory rates, urine outputs or serum creatinine levels. A larger proportion of case subjects were fitted with a central venous or Foley catheter.

CONCLUSIONS

The presence of a wound, hypertension or diabetes mellitus, and the use of an invasive medical device may increase the risk of systemic inflammatory response syndrome. Of the physiological parameters examined, heart rate, platelet counts, and blood glucose levels might serve as significant early signs of systemic inflammatory response syndrome.

RELEVANCE TO CLINICAL PRACTICE

Caution should be observed whenever diabetic or hypertension patients develop sudden and persistent hyperglycaemia or tachycardia, and nurses should also be aware of the potential for systemic inflammatory response syndrome in patients with a central venous or indwelling urinary catheter.

Cost-effectiveness analysis of early point-of-care lactate testing in the emergency department

PURPOSE

To determine the cost-effectiveness of implementing a point-of-care (POC) Lactate Program in the emergency department (ED) for patients with suspected sepsis to identify patients who can benefit from early resuscitation.

MATERIALS AND METHODS

We constructed a cost-effectiveness model to examine an ED with 30 000 patients annually. We evaluated a POC lactate program screening patients with suspected sepsis for an elevated lactate ≥4 mmol/L. Those with elevated lactate levels are resuscitated and their lactate clearance is evaluated by serial POC lactate measurements. The POC Lactate Program was compared with a Usual Care Strategy in which all patients with sepsis and an elevated lactate are admitted to the intensive care unit. Costs were estimated from the 2014 Medicare Inpatient and National Physician Fee schedules, and hospital and industry estimates.

RESULTS

In the base-case, the POC Lactate Program cost $39.53/patient whereas the Usual Care Strategy cost $33.20/patient. The screened patients in the POC arm resulted in 1.07 quality-adjusted life years for an incremental cost-effectiveness ratio of $31 590 per quality-adjusted life year gained, well below accepted willingness-to-pay-thresholds.

CONCLUSIONS

Implementing a POC Lactate Program for screening ED patients with suspected sepsis is a cost-effective intervention to identify patients responsive to early resuscitation.

Paradoxical Roles of the Neutrophil in Sepsis: Protective and Deleterious

Sepsis, an overwhelming inflammatory response syndrome secondary to infection, is one of the costliest and deadliest medical conditions worldwide. Neutrophils are classically considered to be essential players in the host defense against invading pathogens. However, several investigations have shown that impairment of neutrophil migration to the site of infection, also referred to as neutrophil paralysis, occurs during severe sepsis, resulting in an inability of the host to contain and eliminate the infection. On the other hand, the neutrophil antibacterial arsenal contributes to tissue damage and the development of organ dysfunction during sepsis. In this review, we provide an overview of the main events in which neutrophils play a beneficial or deleterious role in the outcome of sepsis.

Systemic inflammatory response syndrome-based severe sepsis screening algorithms in emergency department patients with suspected sepsis

OBJECTIVE

Systemic inflammatory response syndrome (SIRS)-based severe sepsis screening algorithms have been utilised in stratification and initiation of early broad spectrum antibiotics for patients presenting to EDs with suspected sepsis. We aimed to investigate the performance of some of these algorithms on a cohort of suspected sepsis patients.

METHODS

We conducted a retrospective analysis on an ED-based prospective sepsis registry at a tertiary Sydney hospital, Australia. Definitions for sepsis were based on the 2012 Surviving Sepsis Campaign guidelines. Numerical values for SIRS criteria and ED investigation results were recorded at the trigger of sepsis pathway on the registry. Performance of specific SIRS-based screening algorithms at sites from USA, Canada, UK, Australia and Ireland health institutions were investigated.

RESULTS

Severe sepsis screening algorithms' performance was measured on 747 patients presenting with suspected sepsis (401 with severe sepsis, prevalence 53.7%). Sensitivity and specificity of algorithms to flag severe sepsis ranged from 20.2% (95% CI 16.4-24.5%) to 82.3% (95% CI 78.2-85.9%) and 57.8% (95% CI 52.4-63.1%) to 94.8% (95% CI 91.9-96.9%), respectively. Variations in SIRS values between uncomplicated and severe sepsis cohorts were only minor, except a higher mean lactate (>1.6 mmol/L, P < 0.01).

CONCLUSIONS

We found the Ireland and JFK Medical Center sepsis algorithms performed modestly in stratifying suspected sepsis patients into high-risk groups. Algorithms with lactate levels thresholds of >2 mmol/L rather than >4 mmol/L performed better. ED sepsis registry-based characterisation of patients may help further refine sepsis definitions of the future.

Comparison of diagnostic and prognostic utility of lactate and procalcitonin for sepsis in adult cancer patients presenting to emergency department with systemic inflammatory response syndrome

Objectives

Differentiating sepsis from other noninfectious causes of systemic inflammatory response syndrome (SIRS) in cancer patients is often challenging. Although lactate and procalcitonin have been studied extensively regarding sepsis management, little is known about their utility in cancer patients.

This study aimed to compare the diagnostic and prognostic utility of lactate and procalcitonin for sepsis in cancer patients.

Material and methods

This prospective case-control study was conducted with adult cancer patients presenting to emergency department (ED) with at least two SIRS criteria. The infection status of each patient was determined retrospectively.

Main diagnostic variables were calculated for diagnostic and prognostic utilities of lactate and procalcitonin.

Results

Among 86 patients, mean age was 61. Twenty-two (25.6%) were determined in the sepsis group.

In the ROC analysis, a lactate value of 1 mmol/L predicted sepsis with 86.36% (95%CI: 65.1%–97.1%) sensitivity and 28.12% (95%CI: 17.6%–40.76%) specificity. A procalcitonin value of 0.8 ng/mL yielded a sensitivity of 63.64% (95%CI: 40.7%–82.8%) and 76.56% (95%CI: 63.4%–86.2%) specificity for differential diagnosis of sepsis in cancer patients.

Lactate and procalcitonin showed similar abilities in differentiating sepsis from non-infective SIRS in cancer patients [AUROCs of 0.638 (95%CI:0.527–0.739) vs 0.637 (95%CI:0.527–0.738), respectively. p = 0.994].

They were also similar in predicting poor clinical outcome with AUROCs of 0.629 (95%CI:0.518–0.731) and 0.584 (95%CI: 0.473–0.69), respectively (p = 0.577).

Conclusions

The results of this study indicated that, none of the lactate and procalcitonin can be recommended alone to differentiate sepsis from non-infectious SIRS and to predict the poor clinical outcomes in adult cancer patients with SIRS in the ED.

Outcomes and Resource Use of Sepsis-associated Stays by Presence on Admission, Severity, and Hospital Type

OBJECTIVE

To establish a baseline for the incidence of sepsis by severity and presence on admission in acute care hospital settings before implementation of a broad sepsis screening and response initiative.

METHODS

A retrospective cohort study using hospital discharge abstracts of 5672 patients, aged 18 years and above, with sepsis-associated stays between February 2012 and January 2013 at an academic medical center and 5 community hospitals in Texas.

RESULTS

Sepsis was present on admission in almost 85% of cases and acquired in-hospital in the remainder. The overall inpatient death rate was 17.2%, but was higher in hospital-acquired sepsis (38.6%, medical; 29.2%, surgical) and Stages 2 (17.6%) and 3 (36.4%) compared with Stage 1 (5.9%). Patients treated at the academic medical center had a higher death rate (22.5% vs. 15.1%, P<0.001) and were more costly ($68,050±184,541 vs. $19,498±31,506, P<0.001) versus community hospitals.

CONCLUSIONS

Greater emphasis is needed on public awareness of sepsis and the detection of sepsis in the prehospitalization and early hospitalization period. Hospital characteristics and case mix should be accounted for in cross-hospital comparisons of sepsis outcomes and costs.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The prevalence and diagnostic utility of systemic inflammatory response syndrome vital signs in a pediatric emergency department

OBJECTIVES

This study sought to determine the prevalence, test characteristics, and severity of illness of pediatric patients with systemic inflammatory response syndrome (SIRS) vital signs among pediatric emergency department (ED) visits.

METHODS

This was a retrospective descriptive cohort study of all visits to the ED of a tertiary academic free-standing pediatric hospital over 1 year. Visits were included if the patient was <18 years of age and did not leave before full evaluation or against medical advice. Exclusion criteria were trauma diagnoses or missing documentation of vital signs. Data were electronically extracted from the medical record. The primary predictor was presence of vital signs meeting pediatric SIRS definitions. Specific vital sign pairs comprising SIRS were evaluated as predictors (temperature-heart rate, temperature-respiratory rate, and temperature-corrected heart rate, in which a formula was used to correct heart rate for degree of temperature elevation). The primary outcome measure was requirement for critical care (receipt of a vasoactive agent or intubation) within 24 hours of ED arrival.

RESULTS

There were 56,210 visits during the study period; 40,356 met inclusion criteria. Of these, 6,596 (16.3%) visits had fever >38.5°C, and 6,122 (15.2% of included visits) met SIRS vital sign criteria. Among included visits, those with SIRS vital signs accounted for 92.8% of all visits with fever >38.5°C. Among patients with SIRS vital signs, 4993 (81.6%) were discharged from the ED without intravenous (IV) therapy and without 72-hour readmission. Critical care within the first 24 hours was present in 99 (0.25%) patients: 23 patients with and 76 without SIRS vital signs. Intensive care unit (ICU) admission was present in 126 (2.06%) with SIRS vital signs and 487 (1.42%) without SIRS vital signs. SIRS vital signs were associated with increased risk of critical care within 24 hours (relative risk [RR] = 1.69, 95% confidence interval [CI] = 1.06 to 2.70), ICU admission (RR = 1.45, 95% CI = 1.19 to 1.76), ED laboratory tests (RR = 1.41, 95% CI = 1.37 to 1.45), ED IV medication/fluid administration (RR = 2.54, 95% CI = 2.29 to 2.82), hospital admission (RR = 1.52, 95% CI = 1.42 to 1.63), and 72-hour readmission (RR = 1.31, 95% CI = 1.01 to 1.69). SIRS vital signs were not associated with 30-day in-hospital mortality (RR = 0.37, 95% CI = 0.05 to 2.82). SIRS vital signs had a low sensitivity for critical care requirement (23.2%, 95% CI = 15.3% to 32.8%). The pair of SIRS vital signs with the strongest association with critical care requirement was temperature and corrected heart rate (positive likelihood ratio = 2.74, 95% CI = 1.87 to 4.01).

CONCLUSIONS

Systemic inflammatory response syndrome vital signs are common among medical pediatric patients presenting to an ED, and critical illness is rare. The majority of patients with SIRS vital signs were discharged without IV therapy and without readmission. Patients with SIRS vital signs had a statistically significant increased risk of critical care requirement, ED IV treatment, ED laboratory tests, admission, and readmission. However, SIRS vital sign criteria did not identify the majority of patients with mortality or need for critical care. SIRS vital signs had low sensitivity for critical illness, making it poorly suited for use in isolation in this setting as a test to detect children requiring sepsis resuscitation.

Low molecular weight heparin may prevent acute lung injury induced by sepsis in rats

The purpose of this study was to assess the protective effect of low molecular weight heparin (LMWH) on acute lung injury (ALI) in rats induced by sepsis. Rat ALI model was reproduced by cecal ligation and puncture (CLP). All rats were randomly divided into three groups (n=50): control group (A), ALI group (B), and LMWH-treated group (C). Group A received a sham operation and the other groups underwent CLP operation. Groups A and B accepted intraperitoneal injection (i.p.) of normal saline (NS) at a dose of 2.0 ml kg(-1) and ceftriaxone (30 mg kg(-1)), group C was intraperitoneally injected with additional LMWH (150 U kg(-1)) except saline and ceftriaxone. Blood was collected and lung tissue was harvested at the designated time points for analysis. The lung specimens were harvested for morphological studies, immunohistochemistry examination. Lung tissue edema was evaluated by tissue water content. The levels of lung tissue myeloperoxidase (MPO) were determined. Meanwhile, the nuclear factor-kappa B (NF-κB) activation, tumor necrosis factor-α (TNF-α), interleukin-1β (IL-1β) levels, high mobility group box 1 (HMGB1) and intercellular adhesion molecule-1 (ICAM-1) protein levels in the lung were studied. There was a significant difference in each index between groups A and B (P<0.05). Treatment with LMWH significantly decreased the expression of TNF-α, IL-1β, HMGB1 and ICAM-1 in the lungs of ALI rats. Similarly, treatment with LMWH dramatically diminished sepsis-induced neutrophil sequestration and markedly reduced the enhanced lung permeability. In the present study, LMWH administration inhibited the nuclear translocation of NF-κB in the lungs. These data suggest that LMWH attenuates inflammation and ameliorates lung pathology in CLP-induced sepsis in a rat model.