Late recognition and illness severity are determinants of early death in severe septic patients

Emergency critical care: closing the gap between onset of critical illness and intensive care unit admission

Critical illness is an exquisitely time-sensitive condition and follows a disease continuum, which always starts before admission to the intensive care unit (ICU), in the majority of cases even before hospital admission. Reflecting the common practice in many healthcare systems that critical care is mainly provided in the confined areas of an ICU, any delay in ICU admission of critically ill patients is associated with increased morbidity and mortality. However, if appropriate critical care interventions are provided before ICU admission, this association is not observed. Emergency critical care refers to critical care provided outside of the ICU. It encompasses the delivery of critical care interventions to and monitoring of patients at the place and time closest to the onset of critical illness as well as during transfer to the ICU. Thus, emergency critical care covers the most time-sensitive phase of critical illness and constitutes one missing link in the chain of survival of the critically ill patient. Emergency critical care is delivered whenever and wherever critical illness occurs such as in the pre-hospital setting, before and during inter-hospital transfers of critically ill patients, in the emergency department, in the operating theatres, and on hospital wards. By closing the management gap between onset of critical illness and ICU admission, emergency critical care improves patient safety and can avoid early deaths, reverse mild-to-moderate critical illness, avoid ICU admission, attenuate the severity of organ dysfunction, shorten ICU length of stay, and reduce short- and long-term mortality of critically ill patients. Future research is needed to identify effective models to implement emergency critical care systems in different healthcare systems.

Evaluation of time to death after admission to an intensive care unit and factors associated with mortality: A retrospective longitudinal study

Background

Among nonsurvivors admitted to the intensive care unit (ICU), some present early mortality while other patients, despite having a favorable evolution regarding the initial disease, die later due to complications related to hospitalization. This study aims to identify factors associated with the time until death after admission to an ICU of a university hospital.

Methods

Retrospective longitudinal study that included adult patients admitted to the ICU between January 1, 2008, and December 31, 2017. Nonsurviving patients were divided into groups according to the length of time from admission to the ICU until death: Early (0-5 days), intermediate (6-28 days), and late (>28 days). Patients were considered septic if they had this diagnosis on admission to the ICU. Simple linear regression analysis was performed to evaluate the association between time to death over the years of the study. Multivariate cox regression was used to assess risk factors for the outcome in the ICU.

Results

In total, 6596 patients were analyzed. Mortality rate was 32.9% in the ICU. Most deaths occurred in the early (42.8%) and intermediate periods (47.9%). Patients with three or more dysfunctions on admission were more likely to die early (P < 0.001). The diagnosis of sepsis was associated with a higher mortality rate. The multivariate analysis identified age >60 years (hazard ratio [HR] 1.009), male (HR 1.192), mechanical ventilation (HR 1.476), dialysis (HR 2.297), and sequential organ failure assessment >6 (HR 1.319) as risk factors for mortality.

Conclusion

We found a higher proportion of early and intermediate deaths in the study period. The presence of three or more organ dysfunctions at ICU admission was associated with early death. The diagnosis of sepsis evident on ICU admission was associated with higher mortality.

[Clinical features of very preterm small-for-gestational-age infants born due to severe preeclampsia]

OBJECTIVE

To study the clinical features of very preterm small-for-gestational-age infants born by cesarean section due to severe preeclampsia.

METHODS

Forty-two small-for-gestational-age infants who were admitted from August 2017 to July 2018 and were born due to severe preeclampsia were enrolled as the observation group. Forty very preterm infants who were born to healthy mothers since uterine contractions could not be suppressed were enrolled as the control group. Perinatal features, clinical manifestations of infection, complications, and clinical outcomes were analyzed for the two groups.

RESULTS

Within 6 hours and 2-3 days after birth, the observation group had significantly lower white blood cell count (WBC), absolute neutrophil count (ANC), and platelet count (PLT) than the control group (P < 0.05). At 5-7 days after birth, there was no significant difference in WBC between the two groups (P > 0.05), while the observation group still had significantly lower ANC and PLT than the control group (P < 0.05). The observation group had a significantly higher C-reactive protein (CRP) level than the control group at 2-3 days and 5-7 days after birth (P < 0.05). The observation group had a significantly higher proportion of infants with severe infections than the control group (P < 0.05). The observation group had a significantly higher hemoglobin level than the control group within 6 hours after birth (P < 0.05). The observation group had a significantly higher incidence rate of bronchopulmonary dysplasia than the control group (P < 0.05). There was no significant difference between the two groups in the rate of pulmonary hemorrhage, intracranial hemorrhage, neonatal necrotizing enterocolitis, retinopathy of prematurity, and the rate of use of invasive ventilation, and clinical outcomes (P > 0.05).

CONCLUSIONS

Very preterm small-for-gestational-age infants born due to severe preeclampsia have a high incidence rate of infection and severe conditions. Early manifestations include reductions in the infection indicators WBC, ANC, and PLT, and CRP does not increase significantly in the early stage and gradually increases at 2-3 days after birth. Most of these infants require invasive ventilation after birth, with bronchopulmonary dysplasia as the main complication. Clinical changes should be closely observed and inflammatory indicators should be monitored for early identification of infection, timely diagnosis, and timely adjustment of antibiotic treatment, so as to improve the outcome.

Considerations for Empiric Antimicrobial Therapy in Sepsis and Septic Shock in an Era of Antimicrobial Resistance

Patients with sepsis present across a spectrum of infection sites and severity of illnesses requiring complex decision making at the bedside as to when prompt antibiotics are indicated and which regimen is warranted. Many hemodynamically stable patients with sepsis and low acuity of illness may benefit from further work up before initiating therapy, whereas patients with septic shock warrant emergent broad-spectrum antibiotics. The precise empiric regimen is determined by assessing patient and epidemiological risk factors, likely source of infection based on presenting signs and symptoms, and severity of illness. Hospitals should implement quality improvement measures to aid in the rapid and accurate diagnosis of septic patients and to ensure antibiotics are given to patients in an expedited fashion after antibiotic order.

T helper type cytokines in sepsis: time-shared variance and correlation with organ dysfunction and hospital mortality

Objective

We evaluated the kinetics of cytokines belonging to the T helper1 (Th1), Th2, and Th17 profiles in septic patients, and their correlations with organ dysfunction and hospital mortality.

Methods

This was a prospective observational study in a cohort of septic patients admitted to the intensive care units (ICU) of three Brazilian general hospitals. A total of 104 septic patients and 53 health volunteers (controls) were included. Plasma samples were collected within the first 48 h of organ dysfunction or septic shock (0D), after seven (D7) and 14 days (D14) of follow-up. The following cytokines were measured by flow cytometry: Interleukin-1β (IL-1β), IL-2, IL-6, IL-8, IL-10, IL-12/23p40, IL-17, IL-21, tumor necrosis factor-α (TNF-α), granulocyte-macrophage colony stimulating factor (GM-CSF), granulocyte colony-stimulating factor (G-CSF).

Results

IL-6, IL-8, G-CSF and IL-10 concentrations were higher in septic patients than in controls (p < 0.001), while IL-12/23p40 presented higher levels in the controls (p = 0.003). IL-6, IL-8 and IL-17 correlated with Sequential [Sepsis-related] Organ Failure Assessment (SOFA) D0, D1 and D3 (except for IL-6 at D0). IL-8 was associated with renal and cardiovascular dysfunction. In a mixed model analysis, IL-10 estimated means were lower in survivors than in deceased (p = 0.014), while IL-21 had an estimated mean of 195.8 pg/mL for survivors and 98.5 for deceased (p = 0.03). Cytokines were grouped in four factors according to their kinetics over the three dosages (D0, D7, D14). Group 1 encompassed IL-6, IL-8, IL-10, IL-1β, and G-CSF while Group 3 encompassed IL-17 and IL-12/23p40. Both correlated with SOFA (D0) (p = 0.039 and p = 0.003, respectively). IL-21 (Group 4) was higher in those who survived. IL-2, TNF-α and GM-CSF (Group 2) showed no correlation with outcomes.

Conclusion

Inflammatory and anti-inflammatory cytokines shared co-variance in septic patients and were related to organ dysfunctions and hospital mortality.

Diagnostic and predictive performance of biomarkers in patients with sepsis in an intensive care unit

Objective

This study was performed to compare the predictive performance of serum procalcitonin (PCT), N-terminal brain natriuretic propeptide (NT-proBNP), interleukin-6 (IL-6), prothrombin time (PT), thrombin time (TT), and Sequential Organ Failure Assessment (SOFA) score in the intensive care unit (ICU).

Methods

This retrospective cohort study enrolled 150 patients with sepsis and septic shock and 30 control patients without sepsis. Each patient was followed until death or 28 days. Correlations between variables were assessed with Spearman’s rho test. The Kruskal–Wallis and Mann–Whitney U tests were used for between-group comparisons.

Results

Receiver operating characteristic curve analysis of the SOFA score, PCT, NT-proBNP, IL-6, PT, and TT showed an area under the curve of 0.872, 0.732, 0.711, 0.706, 0.806, and 0.691, respectively, for diagnosing sepsis. Binary logistic regression demonstrated that the SOFA score was an independent predictor of 28-day mortality and septic shock. The correlation coefficient (r) between SOFA and PCT, NT-proBNP and SOFA, IL-6 and SOFA, PT and SOFA, and TT and SOFA was 0.79, 0.52, 0.57, 0.56, and 0.58, respectively.

Conclusion

While the SOFA score is the gold standard, analysis of multiple biomarkers could increase the performance capacity for diagnosis and prognosis in patients with sepsis in the ICU.

Are Early Antibiotics Important for Everyone?

Since the first edition of Surviving Sepsis Campaign Guidelines, the administration of intravenous antibiotics in the first hours of sepsis is recommend. However, in the last ten years, several studies around importance of early antibiotics in emergency room or in intensive care unit produced disparate results. Therefore, is early administration of antibiotics a life-salver? In this article, we explore studies around this theme and some questions about what does "early antibiotics" mean are addressed.

Proteomic study revealed cellular assembly and lipid metabolism dysregulation in sepsis secondary to community-acquired pneumonia

Sepsis is a life-threatening disorder characterized by organ dysfunction and a major cause of mortality worldwide. The major challenge in studying sepsis is its diversity in such factors as age, source of infection and etiology. Recently, genomic and proteomic approaches have improved our understanding of its complex pathogenesis. In the present study, we use quantitative proteomics to evaluate the host proteome response in septic patients secondary to community-acquired pneumonia (CAP). Samples obtained at admission and after 7 days of follow-up were analyzed according to the outcomes of septic patients. The patients' proteome profiles were compared with age- and gender-matched healthy volunteers. Bioinformatic analyses of differentially expressed proteins showed alteration in the cytoskeleton, cellular assembly, movement, lipid metabolism and immune responses in septic patients. Actin and gelsolin changes were assessed in mononuclear cells using immunofluorescence, and a higher expression of gelsolin and depletion of actin were observed in survivor patients. Regarding lipid metabolism, changes in cholesterol, HDL and apolipoproteins were confirmed using enzymatic colorimetric methods in plasma. Transcriptomic studies revealed a massive change in gene expression in sepsis. Our proteomic results stressed important changes in cellular structure and metabolism, which are possible targets for future interventions of sepsis.

Inflammasome gene profile is modulated in septic patients, with a greater magnitude in non-survivors

Inflammasome signalling induces the processing and secretion of interleukin (IL)-1β and IL-18 which, coupled with pyroptosis, activate further the inflammatory response. In the present study we evaluated the expression of genes involved in inflammasome signalling pathways in septic patients, their interaction networks and the predicted functions modulated in survivors and non-survivors. Twenty-seven patients with sepsis secondary to community-acquired pneumonia admitted to intensive care units from three general hospitals in São Paulo were included into the study. We performed a polymerase chain reaction (PCR) array encompassing 35 genes related to the nucleotide-binding oligomerization domain and leucine-rich repeat-containing (NLR)-inflammasome in peripheral blood mononuclear cells obtained at admission and after 7 days of follow-up. Eleven healthy volunteers were used as the reference group. Increased NLRC4 and NLRP3 and decreased nucleotide-binding oligomerization domain (NOD1), and NLRP1 expression was observed in septic patients compared to healthy individuals; the IL-1β and IL-18 expression levels were also high in the patients. The gene expression changes followed the same patterns in surviving and non-surviving patients, with higher magnitudes observed in non-survivors. Functional analyses revealed, however, that activation and inhibition intensity for representing functions were different in survivors and non-survivors, as for production of reactive oxygen species, synthesis of nitric oxide and for the control of bacterial infections. Our results showed that the genes involved in the activation of the NLR-inflammasome cascades were altered substantially in septic patients, with a higher number of altered genes and a higher intensity in the disturbance of gene expression found among patients dying of sepsis.

Expression of genes belonging to the interacting TLR cascades, NADPH-oxidase and mitochondrial oxidative phosphorylation in septic patients

Background and objectives

Sepsis is a complex disease that is characterized by activation and inhibition of different cell signaling pathways according to the disease stage. Here, we evaluated genes involved in the TLR signaling pathway, oxidative phosphorylation and oxidative metabolism, aiming to assess their interactions and resulting cell functions and pathways that are disturbed in septic patients.

Materials and methods

Blood samples were obtained from 16 patients with sepsis secondary to community acquired pneumonia at admission (D0), and after 7 days (D7, N = 10) of therapy. Samples were also collected from 8 healthy volunteers who were matched according to age and gender. Gene expression of 84 genes was performed by real-time polymerase chain reactions. Their expression was considered up- or down-regulated when the fold change was greater than 1.5 compared to the healthy volunteers. A p-value of ≤ 0.05 was considered significant.

Results

Twenty-two genes were differently expressed in D0 samples; most of them were down-regulated. When gene expression was analyzed according to the outcomes, higher number of altered genes and a higher intensity in the disturbance was observed in non-survivor than in survivor patients. The canonical pathways altered in D0 samples included interferon and iNOS signaling; the role of JAK1, JAK2 and TYK2 in interferon signaling; mitochondrial dysfunction; and superoxide radical degradation pathways. When analyzed according to outcomes, different pathways were disturbed in surviving and non-surviving patients. Mitochondrial dysfunction, oxidative phosphorylation and superoxide radical degradation pathway were among the most altered in non-surviving patients.

Conclusion

Our data show changes in the expression of genes belonging to the interacting TLR cascades, NADPH-oxidase and oxidative phosphorylation. Importantly, distinct patterns are clearly observed in surviving and non-surviving patients. Interferon signaling, marked by changes in JAK-STAT modulation, had prominent changes in both survivors and non-survivors, whereas the redox imbalance (iNOS signaling, oxidative phosphorylation and superoxide radical degradation) affecting mitochondrial functions was prominent in non-surviving patients.

Effectiveness and safety of procalcitonin evaluation for reducing mortality in adults with sepsis, severe sepsis or septic shock

BACKGROUND

Serum procalcitonin (PCT) evaluation has been proposed for early diagnosis and accurate staging and to guide decisions regarding patients with sepsis, severe sepsis and septic shock, with possible reduction in mortality.

OBJECTIVES

To assess the effectiveness and safety of serum PCT evaluation for reducing mortality and duration of antimicrobial therapy in adults with sepsis, severe sepsis or septic shock.

SEARCH METHODS

We searched the Central Register of Controlled Trials (CENTRAL; 2015, Issue 7); MEDLINE (1950 to July 2015); Embase (Ovid SP, 1980 to July 2015); Latin American Caribbean Health Sciences Literature (LILACS via BIREME, 1982 to July 2015); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; EBSCO host, 1982 to July 2015), and trial registers (ISRCTN registry, ClinicalTrials.gov and CenterWatch, to July 2015). We reran the search in October 2016. We added three studies of interest to a list of 'Studies awaiting classification' and will incorporate these into formal review findings during the review update.

SELECTION CRITERIA

We included only randomized controlled trials (RCTs) testing PCT-guided decisions in at least one of the comparison arms for adults (≥ 18 years old) with sepsis, severe sepsis or septic shock, according to international definitions and irrespective of the setting.

DATA COLLECTION AND ANALYSIS

Two review authors extracted study data and assessed the methodological quality of included studies. We conducted meta-analysis with random-effects models for the following primary outcomes: mortality and time spent receiving antimicrobial therapy in hospital and in the intensive care unit (ICU), as well as time spent on mechanical ventilation and change in antimicrobial regimen from a broad to a narrower spectrum.

MAIN RESULTS

We included 10 trials with 1215 participants. Low-quality evidence showed no significant differences in mortality at longest follow-up (risk ratio (RR) 0.81, 95% confidence interval (CI) 0.65 to 1.01; I2 = 10%; 10 trials; N = 1156), at 28 days (RR 0.89, 95% CI 0.61 to 1.31; I2 = 0%; four trials; N = 316), at ICU discharge (RR 1.03, 95% CI 0.50 to 2.11; I2 = 49%; three trials; N = 506) and at hospital discharge (RR 0.98, 95% CI 0.75 to 1.27; I2 = 0%; seven trials; N = 805; moderate-quality evidence). However, mean time receiving antimicrobial therapy in the intervention groups was -1.28 days (95% CI to -1.95 to -0.61; I2 = 86%; four trials; N = 313; very low-quality evidence). No primary study has analysed the change in antimicrobial regimen from a broad to a narrower spectrum.

AUTHORS' CONCLUSIONS

Up-to-date evidence of very low to moderate quality, with insufficient sample power per outcome, does not clearly support the use of procalcitonin-guided antimicrobial therapy to minimize mortality, mechanical ventilation, clinical severity, reinfection or duration of antimicrobial therapy of patients with septic conditions.

Validity of the Manchester Triage System in patients with sepsis presenting at the ED: a first assessment

BACKGROUND

The Manchester Triage System (MTS) does not have a specific presentational flow chart for sepsis. The goal of this investigation was to determine adequacy of acuity assignment for patients with sepsis presenting at the ED and triaged using the MTS.

MATERIALS AND METHODS

This retrospective analysis included patients >16 presenting to an ED in Bonn, Germany, on the first 12 days of each month between June 2012 and March 2014. Patients were classified into one of three septic groups, or no sepsis. For those with sepsis, adequacy of acuity assignment was based on the criteria of the first consensus conference of the American College of Chest Physicians and Society of Critical Care Medicine, first published in 1992. Adequacy of prioritisation is expressed as sensitivity and likelihood ratio (LR-).

RESULTS

Among 20 836 patients evaluated, 801 (3.8%) were septic; of these, 581 (72.5%) had sepsis, 194 (24.2%) had severe sepsis and 26 (3.2%) had severe sepsis with circulation dysfunction. Patients who met the criteria for sepsis were correctly prioritised with a sensitivity of 70.4% (95% CI 66.5 to 74.0). The LR- was 0.628 (95% CI 0.564 to 0.698). Patients with severe sepsis were appropriately prioritised with a sensitivity of 84.5% (95% CI 78.1 to 89.4), and LR- was 0.330 (95% CI 0.243 to 0.450). In the group with severe sepsis and circulation dysfunction, sensitivity of MTS was 61.5% (95% CI 39.3 to 79.8), and LR- was 0.466 (95% CI 0.286 to 0.757).

CONCLUSIONS

The MTS has some weaknesses regarding priority levels in emergency patients with septic illness. Overall, target key symptoms (discriminators) which aim at identifying systemic infection and ascertaining vital parameters are insufficiently considered.

Does Infection Site Matter? A Systematic Review of Infection Site Mortality in Sepsis

PURPOSE

Sepsis treatment protocols emphasize source control with empiric antibiotics and fluid resuscitation. Previous reviews have examined the impact of infection site and specific pathogens on mortality from sepsis; however, no recent review has addressed the infection site. This review focuses on the impact of infection site on hospital mortality among patients with sepsis.

METHODS

The PubMed database was searched for articles from 2001 to 2014. Studies were eligible if they included (1) one or more statistical models with hospital mortality as the outcome and considered infection site for inclusion in the model and (2) adult patients with sepsis, severe sepsis, or septic shock. Data abstracted included stage of sepsis, infection site, and raw and adjusted effect estimates. Nineteen studies were included. Infection sites most studied included respiratory (n = 19), abdominal (n = 19), genitourinary (n = 18), and skin and soft tissue infections (n = 11). Several studies found a statistically significant lower mortality risk for genitourinary infections on hospital mortality when compared to respiratory infections.

CONCLUSION

Based on studies included in this review, the impact of infection site in patients with sepsis on hospital mortality could not be reliably estimated. Misclassification among infections and disease states remains a serious possibility in studies on this topic.

Reclassifying the spectrum of septic patients using lactate: severe sepsis, cryptic shock, vasoplegic shock and dysoxic shock

Objective

The current definition of severe sepsis and septic shock includes a heterogeneous profile of patients. Although the prognostic value of hyperlactatemia is well established, hyperlactatemia is observed in patients with and without shock. The present study aimed to compare the prognosis of septic patients by stratifying them according to two factors: hyperlactatemia and persistent hypotension.

Methods

The present study is a secondary analysis of an observational study conducted in ten hospitals in Brazil (Rede Amil - SP). Septic patients with initial lactate measurements in the first 6 hours of diagnosis were included and divided into 4 groups according to hyperlactatemia (lactate >4mmol/L) and persistent hypotension: (1) severe sepsis (without both criteria); (2) cryptic shock (hyperlactatemia without persistent hypotension); (3) vasoplegic shock (persistent hypotension without hyperlactatemia); and (4) dysoxic shock (both criteria).

Results

In total, 1,948 patients were analyzed, and the sepsis group represented 52% of the patients, followed by 28% with vasoplegic shock, 12% with dysoxic shock and 8% with cryptic shock. Survival at 28 days differed among the groups (p<0.001). Survival was highest among the severe sepsis group (69%, p<0.001 versus others), similar in the cryptic and vasoplegic shock groups (53%, p=0.39), and lowest in the dysoxic shock group (38%, p<0.001 versus others). In the adjusted analysis, the survival at 28 days remained different among the groups (p<0.001) and the dysoxic shock group exhibited the highest hazard ratio (HR=2.99, 95%CI 2.21-4.05).

Conclusion

The definition of sepsis includes four different profiles if we consider the presence of hyperlactatemia. Further studies are needed to better characterize septic patients, to understand the etiology and to design adequate targeted treatments.

[First-line anti-infective treatment in sepsis]

BACKGROUND

The Surviving Sepsis Campaign strongly recommends that intravenous antibiotic therapy should be started as early as possible, ideally within the first hour of recognition of severe sepsis or septic shock. There is ample evidence that failure to initiate early antimicrobial treatment correlates with increased morbidity and mortality.

OBJECTIVES

The purpose of this work was to review the recent literature regarding optimal initial antimicrobial treatment in patients with severe sepsis and sepsis shock.

MATERIALS AND METHODS

A literature review was performed.

RESULTS

The most frequently quoted papers claiming the overriding prognostic importance of early administered antibiotics are retrospective data analyses. However, an equivalent number of studies report that a group of septic patients do not benefit from early administration of antibiotics, but can also be harmed. In these patients, watchful waiting with administration of a targeted antibiotic can be used, thus, avoiding the possible collateral damage from excessive treatment with antibiotics. Treatment with monotherapy is adequate in most cases.

CONCLUSION

The administration of antibiotics based on the local epidemiology should be initiated quickly in critically ill patients with severe sepsis and septic shock. In patients who are not in septic shock, treatment can be withheld, while awaiting further studies or clinical assessment to confirm the suspicion of infection.

Positive fluid balance as a prognostic factor for mortality and acute kidney injury in severe sepsis and septic shock

PURPOSE

The purpose of this study is to assess whether late positive fluid balances are associated with acute kidney injury and mortality in severe sepsis and septic shock.

METHODS

In this retrospective study, fluid balances were calculated at 3 different time points: the onset of organ dysfunction attributed to sepsis, sepsis diagnosis, and vasopressors initiation. Data were analyzed in logistic regression models for mortality and acute kidney injury as outcomes.

RESULTS

We included 116 patients. A RIFLE score F, diuresis less than 0.9 L from the second day after the first organ dysfunction, and fluid balance more than 3 L between the 24th and the 48th hour after diagnosis were independently associated with higher mortality, whereas in the subgroup with shock, only the latter parameter and diuresis less than 0.85 L on the first day of shock were independent risk factors. After adjusting for age, creatinine more than 1.2 mg/dL, a nonrenal Sequential Organ Failure Assessment greater than or equal to 7.5 on the first day and urine output less than 1.3 L on the first day after organ dysfunction were independent risk factors for RIFLE F. No relationship was found between fluid balance and acute kidney injury.

CONCLUSION

Late positive fluid balance is an independent risk factor for mortality in severe sepsis. Positive fluid balances are not associated with either protection against or risk for acute kidney injury.