Septic Shock: Phenotypes and Outcomes

INTRODUCTION

Sepsis is a heterogeneous syndrome that results in life-threatening organ dysfunction. Our goal was to determine the relevant variables and patient phenotypes to use in predicting sepsis outcomes.

METHODS

We performed an ancillary study concerning 119 patients with septic shock at intensive care unit (ICU) admittance (T0). We defined clinical worsening as having an increased sequential organ failure assessment (SOFA) score of ≥ 1, 48 h after admission (ΔSOFA ≥ 1). We performed univariate and multivariate analyses based on the 28-day mortality rate and ΔSOFA ≥ 1 and determined three patient phenotypes: safe, intermediate and unsafe. The persistence of the intermediate and unsafe phenotypes after T0 was defined as a poor outcome.

RESULTS

At T0, the multivariate analysis showed two variables associated with 28-day mortality rate: norepinephrine dose and serum lactate concentration. Regarding ΔSOFA ≥ 1, we identified three variables at T0: norepinephrine dose, lactate concentration and venous-to-arterial carbon dioxide difference (P(v-a)CO₂). At T0, the three phenotypes (safe, intermediate and unsafe) were found in 28 (24%), 70 (59%) and 21 (18%) patients, respectively. We thus suggested using an algorithm featuring norepinephrine dose, lactate concentration and P(v-a)CO₂ to predict patient outcomes and obtained an area under the curve (AUC) of 74% (63-85%).

CONCLUSION

Our findings highlight the fact that identifying relevant variables and phenotypes may help physicians predict patient outcomes.

Impact of platelet transfusion on outcomes in trauma patients

Background

Trauma-induced coagulopathy includes thrombocytopenia and platelet dysfunction that impact patient outcome. Nevertheless, the role of platelet transfusion remains poorly defined. The aim of the study was 1/ to evaluate the impact of early platelet transfusion on 24-h all-cause mortality and 2/ to describe platelet count at admission (PCA) and its relationship with trauma severity and outcome.

Methods

Observational study carried out on a multicentre prospective trauma registry. All adult trauma patients directly admitted in participating trauma centres between May 2011 and June 2019 were included. Severe haemorrhage was defined as ≥ 4 red blood cell units within 6 h and/or death from exsanguination. The impact of PCA and early platelet transfusion (i.e. within the first 6 h) on 24-h all-cause mortality was assessed using uni- and multivariate logistic regression.

Results

Among the 19,596 included patients, PCA (229 G/L [189,271]) was associated with coagulopathy, traumatic burden, shock and bleeding severity. In a logistic regression model, 24-h all-cause mortality increased by 37% for every 50 G/L decrease in platelet count (OR 0.63 95% CI 0.57–0.70; p < 0.001). Regarding patients with severe hemorrhage, platelets were transfused early for 36% of patients. Early platelet transfusion was associated with a decrease in 24-h all-cause mortality (versus no or late platelets): OR 0.52 (95% CI 0.34–0.79; p < 0.05).

Conclusions

PCA, although mainly in normal range, was associated with trauma severity and coagulopathy and was predictive of bleeding intensity and outcome. Early platelet transfusion within 6 h was associated with a decrease in mortality in patients with severe hemorrhage. Future studies are needed to determine which doses of platelet transfusion will improve outcomes after major trauma.

OUP accepted manuscript

Background

Physiotherapy is a major cornerstone of enhanced rehabilitation after surgery (ERAS) and reduces the development of atelectasis after thoracic surgery. By initiating physiotherapy in the post-anaesthesia care unit (PACU), the aim was to evaluate whether the ultra-early initiation of rehabilitation (in the first hour following tracheal extubation) would improve the outcomes of patients undergoing elective thoracic surgery.

Methods

A case–control study with a before-and-after design was conducted. From a historical control group, patients were paired at a 3:1 ratio with an intervention group. This group consisted of patients treated with the ultra-early rehabilitation programme after elective thoracic surgery (clear fluids, physiotherapy, and ambulation). The primary outcome was the incidence of postoperative atelectasis and/or pneumonia during the hospital stay.

Results

After pairing, 675 patients were allocated to the historical control group and 225 patients to the intervention group. A significant decrease in the incidence of postoperative atelectasis and/or pneumonia was found in the latter (11.4 versus 6.7 per cent respectively; P = 0.042) and remained significant on multivariate analysis (OR 0.53, 95 per cent c.i. 0.26 to 0.98; P = 0.045). A subgroup analysis of the intervention group showed that early ambulation during the PACU stay was associated with a further significant decrease in the incidence of postoperative atelectasis and/or pneumonia (2.2 versus 9.5 per cent; P = 0.012).

Conclusions

Ultra-early rehabilitation in the PACU was associated with a decrease in the incidence of postoperative atelectasis and/or pneumonia after major elective thoracic surgery.

Management of SARS-CoV-2 pneumonia in intensive care unit: An observational retrospective study comparing two bundles

Purpose

To compare the effects of two therapeutic bundles of management in SARS-CoV2 ICU patients.

Materials and methods

Our retrospective, observational study was performed in a university ICU from March to June 2020 (first wave) and from September 2020 to January 2021 (second wave). In first wave, patients received bundle 1 including early invasive ventilation, hydroxychloroquine, cefotaxime and azithromycin. In second wave, bundle 2 included non-invasive oxygenation support and dexamethasone. The main outcome was in-hospital mortality. Secondary outcomes included ICU and hospital length of stay, ICU supportive therapies, viral clearance and antimicrobial resistance emergence.

Results

129 patients with SARS-CoV-2 pneumonia were admitted to our ICU. Thirty-five were treated according to bundle 1 and 76 to bundle 2. In-hospital mortality was similar in the two groups (23%, p = 1). The hospital (p = 0.003) and ICU (p = 0.01) length of stay and ventilator-free days at 28 days (p = 0.03) were significantly reduced in bundle 2. Increasing age, vasopressor use and PaO₂/FiO₂ ratio < 125 were associated with in-hospital mortality.

Conclusion

Within the limitations of our study, changes in therapeutic bundles for SARS-Cov-2 ICU patients might have no effect on in-hospital mortality but were associated with less exposure to mechanical ventilation and reduced hospital length of stay.

The Mars 2020 Engineering Cameras and Microphone on the Perseverance Rover: A Next-Generation Imaging System for Mars Exploration

The Mars 2020 Perseverance rover is equipped with a next-generation engineering camera imaging system that represents an upgrade over previous Mars rover missions. These upgrades will improve the operational capabilities of the rover with an emphasis on drive planning, robotic arm operation, instrument operations, sample caching activities, and documentation of key events during entry, descent, and landing (EDL). There are a total of 16 cameras in the Perseverance engineering imaging system, including 9 cameras for surface operations and 7 cameras for EDL documentation. There are 3 types of cameras designed for surface operations: Navigation cameras (Navcams, quantity 2), Hazard Avoidance Cameras (Hazcams, quantity 6), and Cachecam (quantity 1). The Navcams will acquire color stereo images of the surface with a 96 ∘ × 73 ∘ field of view at 0.33 mrad/pixel. The Hazcams will acquire color stereo images of the surface with a 136 ∘ × 102 ∘ at 0.46 mrad/pixel. The Cachecam, a new camera type, will acquire images of Martian material inside the sample tubes during caching operations at a spatial scale of 12.5 microns/pixel. There are 5 types of EDL documentation cameras: The Parachute Uplook Cameras (PUCs, quantity 3), the Descent stage Downlook Camera (DDC, quantity 1), the Rover Uplook Camera (RUC, quantity 1), the Rover Descent Camera (RDC, quantity 1), and the Lander Vision System (LVS) Camera (LCAM, quantity 1). The PUCs are mounted on the parachute support structure and will acquire video of the parachute deployment event as part of a system to characterize parachute performance. The DDC is attached to the descent stage and pointed downward, it will characterize vehicle dynamics by capturing video of the rover as it descends from the skycrane. The rover-mounted RUC, attached to the rover and looking upward, will capture similar video of the skycrane from the vantage point of the rover and will also acquire video of the descent stage flyaway event. The RDC, attached to the rover and looking downward, will document plume dynamics by imaging the Martian surface before, during, and after rover touchdown. The LCAM, mounted to the bottom of the rover chassis and pointed downward, will acquire 90 ∘ × 90 ∘ FOV images during the parachute descent phase of EDL as input to an onboard map localization by the Lander Vision System (LVS). The rover also carries a microphone, mounted externally on the rover chassis, to capture acoustic signatures during and after EDL. The Perseverance rover launched from Earth on July 30th, 2020, and touchdown on Mars is scheduled for February 18th, 2021.

Exacerbation of circadian rhythms of core body temperature and sepsis in trauma patients

PURPOSE

This study aimed to describe by mathematical modeling an accurate course of core body temperature (CBT) in severe trauma patients and its relation to sepsis.

METHODS

In a cohort of severe trauma, the CBT measurements were collected for 24 h on day 2 after admission and rhythmicity assessed by Fourier transform and Cosinor analysis to describe circadian features (frequency and amplitude). CBT was compared between patients who developed sepsis or not during the early ICU stay.

RESULTS

33 patients were included in this analysis. 24 patients (73%) had a predominant rhythm of 24 h (period). The main period was lower in the 9 remaining patients (6 of 12 h, 1 of 8 h, and 2 of 6 h). Other significant frequencies of oscillation (second and third frequencies) were found, which showed an association of several well-marked rhythms. Patients with sepsis (n = 12) had a significantly higher level of CBT, but also more intense rhythms and higher amplitudes of CBT.

CONCLUSION

Trauma patients exhibit complex temperature circadian rhythms. Early exacerbation of the temperature rhythmicity (in frequency and amplitude) is associated with the development of sepsis. This observation accentuates the concept of circadian disruption and sepsis in ICU patients.

Circadian disruption of core body temperature in trauma patients: a single-center retrospective observational study

Background

Circadian clock alterations were poorly reported in trauma patients, although they have a critical role in human physiology. Core body temperature is a clinical variable regulated by the circadian clock. Our objective was to identify the circadian temperature disruption in trauma patients and to determine whether these disruptions were associated with the 28-day mortality rate.

Methods

A retrospective and observational single-center cohort study was conducted. All adult severe trauma patients admitted to the intensive care unit of Aix Marseille University, North Hospital, from November 2013 to February 2018, were evaluated. The variations of core body temperature for each patient were analyzed between days 2 and 3 after intensive care unit admission. Core body temperature variations were defined by three parameters: mesor, amplitude, and period. A logistic regression model was used to determine the variables influencing these three parameters. A survival analysis was performed assessing the association between core body temperature rhythm disruption and 28-day mortality rate. A post hoc subgroup analysis focused on the patients with head trauma.

Results

Among the 1584 screened patients, 248 were included in this study. The period differed from 24 h in 177 (71%) patients. The mesor value (°C) was associated with body mass index and ketamine use. Amplitude (°C) was associated with ketamine use only. The 28-day mortality rate was 18%. For all trauma patients, age, body mass index, intracranial hypertension, and amplitude were independent risk factors. The patients with a mesor value < 36.9 °C (p < 0.001) and an amplitude > 0.6 °C (p < 0.001) had a higher 28-day mortality rate. Among the patients with head trauma, mesor and amplitude were identified as independent risk factors (HR = 0.40, 95% CI [0.23–0.70], p = 0.001 and HR = 4.73, 95% CI [1.38–16.22], p = 0.01).

Conclusions

Our results highlight an association between core body temperature circadian alteration and 28-day mortality rate. This association was more pronounced in the head trauma patients than in the non-head trauma patients. Further studies are needed to show a causal link and consider possible interventions.

Circadian Rhythm Disruption and Sepsis in Severe Trauma Patients

BACKGROUND

Circadian rhythms are important regulators of immune functions. Admission to an intensive care unit may impact molecular clock activity and host response. Our objective was to assess and compare the immune circadian rhythms in trauma patients who develop and in those who do not develop sepsis.

METHODS

Blood samples were collected from severe trauma patients within 4 days after admission, with collections taking place every 4 h over a 24-h period. Cortisol and cytokines were measured with immunoassays. Whole-blood expression of 3 clock genes (Bmal1, Per2, and Per3) was studied by reverse transcription quantitative polymerase chain reaction. Neutrophils, monocytes, and lymphocytes were analyzed by flow cytometry. Patients with and without sepsis were compared with the cosinor mixed model to estimate mesors, amplitudes, and acrophases.

RESULTS

Thirty-eight patients were enrolled in the study, and 13 developed at least 1 septic episode. The septic patients had higher levels of cortisol than the nonseptic patients (mesor at 489 nmol/L vs. 405 nmol/L, P < 0.05) and delayed acrophases (22 h vs. 15 h, P < 0.05). They also had lower lymphocyte counts (mesor at 785 vs. 1,012 cells/μL, P < 0.05), higher neutrophil counts (mesor at 7,648 vs. 7,001 cells/μL, P < 0.05), and monocyte counts (mesor at 579 vs. 473 cells/μL, P < 0.05) than the nonseptic patients. Although no amplitude difference was identified, the acrophases were significantly different between the 2 groups for lymphocytes, interleukin 10 and tumor necrosis factor.

CONCLUSION

We demonstrated that all trauma patients had impaired circadian rhythms of cortisol, cytokines, leukocytes, and clock genes. Early circadian disruption was associated with the occurrence of sepsis and might be a marker of sepsis severity.

Characterization of the Mercury pulsed power x-ray source spectrum using multichannel density aerogel Cherenkov detectors

The Aerogel Cherenkov Detector for Cygnus (ACD/C) is a time-dependent, x-ray spectral detector that uses SiO₂ aerogels spanning an index of refraction (n = 1.02-1.07) corresponding to a 1.1-2.3 MeV x-ray energy threshold. The ACD/C was developed for pulsed power x-ray sources like Cygnus located at the Nevada National Site and Mercury located at the Naval Research Laboratory (NRL). Aerogels sit between the measurement capabilities of gas (>2 MeV) and solids such as fused silica (>0.3 MeV). The detector uses an aluminum converter to Compton scatter incoming x-rays and create relativistic electrons, which produce Cherenkov light in an aerogel or a fused silica medium. The ACD/C was fielded at the NRL when Mercury was tuned to produce up to 4.8 MeV endpoint bremsstrahlung. Despite a high radiation and electromagnetic interference background, the ACD/C was able to achieve high signal over noise across five aerogel densities and fused silica, including a signal to noise for a 1.1 MeV aerogel threshold. Previous experiments at Cygnus observed a signal that was comparable to the noise (1×) at the same threshold. The ACD/C observed time-resolved rise and fall times for different energy thresholds of the photon spectrum. Monte Carlo simulations of the ACD/C's aerogel response curves were folded with a simulation of Mercury's photon energy spectrum and agree within the error to the observed result.

Bupropion and sexual function: a placebo-controlled prospective study on diabetic men with erectile dysfunction

Many antidepressant agents interfere with sexual function. The purpose of this single-blind, prospective study was to determine sexual side effects, both positive and negative, of the amino-ketone antidepressant bupropion in a group of nondepressed diabetic men with somatic erectile dysfunction. Fourteen men participated in a 10-week protocol consisting sequentially of 2 weeks of baseline testing, 2 weeks of placebo, and 6 weeks of bupropion. Participants also completed daily and weekly questionnaires concerning sexual functioning, and a team of investigators rated various dimensions of sexual function every 2 weeks. In addition, a variety of physiologic measures, relevant either to erectile function or to neural/vascular systems that underlie sexual response, were assessed during baseline and bupropion treatment. Results indicated that neither subjective nor objective measures of erectile and overall sexual functioning worsened during bupropion. In fact, several measures suggested a trend toward improved sexual functioning. Furthermore, diabetic control was unaffected by bupropion administration. Given the lack of adverse effects on sexual function, along with the potential for improved erectile response, bupropion may provide an attractive choice for the treatment of depression in diabetic men or others for whom sexual dysfunction is a concern.