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Sample records for preventing septic shock

  1. Gastrointestinal perfusion in septic shock.

    NARCIS (Netherlands)

    Haren, E.M. van; Sleight, J.W.; Pickkers, P.; Hoeven, J.G. van der

    2007-01-01

    Septic shock is characterised by vasodilation, myocardial depression and impaired microcirculatory blood flow, resulting in redistribution of regional blood flow. Animal and human studies have shown that gastrointestinal mucosal blood flow is impaired in septic shock. This is consistent with

  2. Neutrophil Activation During Septic Shock.

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    Stiel, Laure; Meziani, Ferhat; Helms, Julie

    2018-04-01

    In addition to their well-known role as the cellular mediators of immunity, key other roles have been identified for neutrophils during septic shock. Importantly, neutrophils indeed play a critical role in the recently described immunothrombosis concept and in septic shock-induced coagulopathy. Septic shock is one of the most severe forms of infection, characterized by an inadequate host response to the pathogenic organism. This host response involves numerous defense mechanisms with an intense cellular activation, including neutrophil activation. Neutrophils are key cells of innate immunity through complex interactions with vascular cells and their activation may participate in systemic tissue damages. Their activation also leads to the emission of neutrophil extracellular traps, which take part in both pathogen circumscription and phagocytosis, but also in coagulation activation. Neutrophils thus stand at the interface between hemostasis and immunity, called immunothrombosis.The present review will develop a cellular approach of septic shock pathophysiology focusing on neutrophils as key players of septic shock-induced vascular cell dysfunction and of the host response, associating immunity and hemostasis. We will therefore first develop the role of neutrophils in the interplay between innate and adaptive immunity, and will then highlight recent advances in our understanding of immunothrombosis septic shock-induced coagulopathy.

  3. Sepsis and septic shock

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    Hotchkiss, Richard S.; Moldawer, Lyle L.; Opal, Steven M.; Reinhart, Konrad; Turnbull, Isaiah R.; Vincent, Jean-Louis

    2017-01-01

    For more than two decades, sepsis was defined as a microbial infection that produces fever (or hypothermia), tachycardia, tachypnoea and blood leukocyte changes. Sepsis is now increasingly being considered a dysregulated systemic inflammatory and immune response to microbial invasion that produces organ injury for which mortality rates are declining to 15–25%. Septic shock remains defined as sepsis with hyperlactataemia and concurrent hypotension requiring vasopressor therapy, with in-hospital mortality rates approaching 30–50%. With earlier recognition and more compliance to best practices, sepsis has become less of an immediate life-threatening disorder and more of a long-term chronic critical illness, often associated with prolonged inflammation, immune suppression, organ injury and lean tissue wasting. Furthermore, patients who survive sepsis have continuing risk of mortality after discharge, as well as long-term cognitive and functional deficits. Earlier recognition and improved implementation of best practices have reduced in-hospital mortality, but results from the use of immunomodulatory agents to date have been disappointing. Similarly, no biomarker can definitely diagnose sepsis or predict its clinical outcome. Because of its complexity, improvements in sepsis outcomes are likely to continue to be slow and incremental. PMID:28117397

  4. Sepsis and Septic Shock Strategies.

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    Armstrong, Bracken A; Betzold, Richard D; May, Addison K

    2017-12-01

    Three therapeutic principles most substantially improve organ dysfunction and survival in sepsis: early, appropriate antimicrobial therapy; restoration of adequate cellular perfusion; timely source control. The new definitions of sepsis and septic shock reflect the inadequate sensitivity, specify, and lack of prognostication of systemic inflammatory response syndrome criteria. Sequential (sepsis-related) organ failure assessment more effectively prognosticates in sepsis and critical illness. Inadequate cellular perfusion accelerates injury and reestablishing perfusion limits injury. Multiple organ systems are affected by sepsis and septic shock and an evidence-based multipronged approach to systems-based therapy in critical illness results in improve outcomes. Copyright © 2017 Elsevier Inc. All rights reserved.

  5. Chemically modified tetracycline prevents the development of septic shock and acute respiratory distress syndrome in a clinically applicable porcine model.

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    Steinberg, Jay; Halter, Jeffrey; Schiller, Henry; Gatto, Louis; Carney, David; Lee, Hsi-Ming; Golub, Lorne; Nieman, Gary

    2005-10-01

    Sepsis causes more than with 215,000 deaths per year in the United States alone. Death can be caused by multiple system organ failure, with the lung, in the form of the acute respiratory distress syndrome (ARDS), often being the first organ to fail. We developed a chronic porcine model of septic shock and ARDS and hypothesized that blocking the proteases neutrophil elastase (NE) and matrix metalloproteinases (MMP-2 and MMP-9) with the modified tetracycline, COL-3, would significantly improve morbidity in this model. Pigs were anesthetized and instrumented for hemodynamic monitoring and were then randomized to one of three groups: control (n = 3), laparotomy only; superior mesenteric artery occlusion (SMA) + fecal blood clot (FC; n = 7), with intraperitoneal placement of a FC; and SMA + FC + COL (n = 5), ingestion of COL-3 12 h before injury. Animals emerged from anesthesia and were monitored and treated with fluids and antibiotics in an animal intensive care unit continuously for 48 h. Serum and bronchoalveolar lavage fluid (BALF) were sampled and bacterial cultures, MMP-2, MMP-9, NE, and multiple cytokine concentrations were measured. Pigs were reanesthetized and placed on a ventilator when significant lung impairment occurred (PaO2/FiO2 < 250). At necropsy, lung water and histology were assessed. All animals in the SMA + FC group developed septic shock evidenced by a significant fall in arterial blood pressure that was not responsive to fluids. Lung injury typical of ARDS (i.e., a fall in lung compliance and PaO2/FiO2 ratio and a significant increase in lung water) developed in this group. Additionally, there was a significant increase in plasma IL-1 and IL-6 and in BALF IL-6, IL-8, IL-10, NE, and protein concentration in the SMA + FC group. COL-3 treatment prevented septic shock and ARDS and significantly decreased cytokine levels in plasma and BALF. COL-3 treatment also significantly reduced NE activity (P < 0.05) and reduced MMP-2 and MMP-9 activity in BALF by

  6. Severe Sepsis and Septic Shock: Timing of Septic Shock Onset Matters.

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    Huang, Chun-Ta; Tsai, Yi-Ju; Tsai, Pi-Ru; Yu, Chong-Jen; Ko, Wen-Je

    2016-05-01

    Timing of septic shock onset may play a prognostic role in severe sepsis; however, clinical evidence provides contradictory results. This study aimed to investigate possible associations between timing of onset of septic shock and patient outcome. In a university-affiliated hospital, all patients admitted to the intensive care unit (ICU) for severe sepsis or septic shock from November 2007 to March 2011 were included. The primary outcome of interest was the impact of timing of septic shock onset on in-hospital mortality. We also sought to identify potential factors predicting development of septic shock after ICU admission. In total, 772 patients were identified to have severe sepsis; approximately two-thirds (487/772) of them experienced septic shock and overall in-hospital mortality was 57%. Timing of onset of septic shock was an independent predictor of in-hospital outcome, and there was an increasing trend of in-hospital mortality with later onset of septic shock. In addition, timing of septic shock onset provided further mortality risk stratification in patients with APACHE II scores of less than 20 and 20 to 25. We also found that patients who underwent cardiovascular surgery were more likely to experience septic shock after admission and those receiving neurosurgery were at lower risk of developing septic shock. This study showed the significance of timing of septic shock onset in prognosis among ICU patients with severe sepsis. Timing of shock onset further stratified patients with similar disease severity into different mortality risk groups. These findings deliver useful information regarding risk stratification of septic patients.

  7. Long-term physical outcome in patients with septic shock

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    Poulsen, J. B.; Møller, Kirsten; Kehlet, H

    2009-01-01

    Limited information is available on physical function after septic shock. The aim of the present study was to assess the physical outcome in survivors 1 year after septic shock.......Limited information is available on physical function after septic shock. The aim of the present study was to assess the physical outcome in survivors 1 year after septic shock....

  8. Red blood cell transfusion in septic shock

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    Rosland, Ragnhild G; Hagen, Marte U; Haase, Nicolai

    2014-01-01

    BACKGROUND: Treating anaemia with red blood cell (RBC) transfusion is frequent, but controversial, in patients with septic shock. Therefore we assessed characteristics and outcome associated with RBC transfusion in this group of high risk patients. METHODS: We did a prospective cohort study at 7...... general intensive care units (ICUs) including all adult patients with septic shock in a 5-month period. RESULTS: Ninety-five of the 213 included patients (45%) received median 3 (interquartile range 2-5) RBC units during shock. The median pre-transfusion haemoglobin level was 8.1 (7.4-8.9) g...... and SAPS II and SOFA-score on day 1. CONCLUSIONS: The decision to transfuse patients with septic shock was likely affected by disease severity and bleeding, but haemoglobin level was the only measure that consistently differed between transfused and non-transfused patients....

  9. Cathelicidin peptide sheep myeloid antimicrobial peptide-29 prevents endotoxin-induced mortality in rat models of septic shock.

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    Giacometti, Andrea; Cirioni, Oscar; Ghiselli, Roberto; Mocchegiani, Federico; D'Amato, Giuseppina; Circo, Raffaella; Orlando, Fiorenza; Skerlavaj, Barbara; Silvestri, Carmela; Saba, Vittorio; Zanetti, Margherita; Scalise, Giorgio

    2004-01-15

    The present study was designed to investigate the antiendotoxin activity and therapeutic efficacy of sheep myeloid antimicrobial peptide (SMAP)-29, a cathelicidin-derived peptide. The in vitro ability of SMAP-29 to bind LPS from Escherichia coli 0111:B4 was determined using a sensitive limulus chromogenic assay. Two rat models of septic shock were performed: (1) rats were injected intraperitoneally with 1 mg E. coli 0111:B4 LPS and (2) intraabdominal sepsis was induced via cecal ligation and single puncture. All animals were randomized to receive parenterally isotonic sodium chloride solution, 1 mg/kg SMAP-29, 1 mg/kg polymyxin B or 20 mg/kg imipenem. The main outcome measures were: abdominal exudate and plasma bacterial growth, plasma endotoxin and tumor necrosis factor-alpha concentrations, and lethality. The in vitro study showed that SMAP-29 completely inhibited the LPS procoagulant activity at approximately 10 microM peptide concentration. The in vivo experiments showed that all compounds reduced the lethality when compared with control animals. SMAP-29 achieved a substantial decrease in endotoxin and tumor necrosis factor-alpha plasma concentrations when compared with imipenem and saline treatment and exhibited a slightly lower antimicrobial activity than imipenem. No statistically significant differences were noted between SMAP-29 and polymyxin B. SMAP-29, because of its double antiendotoxin and antimicrobial activities, could be an interesting compound for septic shock treatment.

  10. The Septic Shock 3.0 Definition and Trials: A Vasopressin and Septic Shock Trial Experience.

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    Russell, James A; Lee, Terry; Singer, Joel; Boyd, John H; Walley, Keith R

    2017-06-01

    The Septic Shock 3.0 definition could alter treatment comparisons in randomized controlled trials in septic shock. Our first hypothesis was that the vasopressin versus norepinephrine comparison and 28-day mortality of patients with Septic Shock 3.0 definition (lactate > 2 mmol/L) differ from vasopressin versus norepinephrine and mortality in Vasopressin and Septic Shock Trial. Our second hypothesis was that there are differences in plasma cytokine levels in Vasopressin and Septic Shock Trial for lactate less than or equal to 2 versus greater than 2 mmol/L. Retrospective analysis of randomized controlled trial. Multicenter ICUs. We compared vasopressin-to-norepinephrine group 28- and 90-day mortality in Vasopressin and Septic Shock Trial in lactate subgroups. We measured 39 cytokines to compare patients with lactate less than or equal to 2 versus greater than 2 mmol/L. Patients with septic shock with lactate greater than 2 mmol/L or less than or equal to 2 mmol/L, randomized to vasopressin or norepinephrine. Concealed vasopressin (0.03 U/min.) or norepinephrine infusions. The Septic Shock 3.0 definition would have decreased sample size by about half. The 28- and 90-day mortality rates were 10-12 % higher than the original Vasopressin and Septic Shock Trial mortality. There was a significantly (p = 0.028) lower mortality with vasopressin versus norepinephrine in lactate less than or equal to 2 mmol/L but no difference between treatment groups in lactate greater than 2 mmol/L. Nearly all cytokine levels were significantly higher in patients with lactate greater than 2 versus less than or equal to 2 mmol/L. The Septic Shock 3.0 definition decreased sample size by half and increased 28-day mortality rates by about 10%. Vasopressin lowered mortality versus norepinephrine if lactate was less than or equal to 2 mmol/L. Patients had higher plasma cytokines in lactate greater than 2 versus less than or equal to 2 mmol/L, a brisker cytokine response to infection. The Septic

  11. Red blood cell transfusion in septic shock

    DEFF Research Database (Denmark)

    Rosland, Ragnhild G; Hagen, Marte U; Haase, Nicolai

    2014-01-01

    BACKGROUND: Treating anaemia with red blood cell (RBC) transfusion is frequent, but controversial, in patients with septic shock. Therefore we assessed characteristics and outcome associated with RBC transfusion in this group of high risk patients. METHODS: We did a prospective cohort study at 7...... general intensive care units (ICUs) including all adult patients with septic shock in a 5-month period. RESULTS: Ninety-five of the 213 included patients (45%) received median 3 (interquartile range 2-5) RBC units during shock. The median pre-transfusion haemoglobin level was 8.1 (7.4-8.9) g....../dl and independent of shock day and bleeding. Patients with cardiovascular disease were transfused at higher haemoglobin levels. Transfused patients had higher Simplified Acute Physiology Score (SAPS) II (56 (45-69) vs. 48 (37-61), p = 0.0005), more bleeding episodes, lower haemoglobin levels days 1 to 5, higher...

  12. Control groups in recent septic shock trials

    DEFF Research Database (Denmark)

    Pettilä, Ville; Hjortrup, Peter B; Jakob, Stephan M

    2016-01-01

    % the proportion of patients with elevated lactate values. Five studies (21 %) provided data to estimate the proportion of septic shock patients fulfilling the Sepsis-3 definition. The mean data completeness score was 19 out of 36 (range 8-32). Of 18 predefined control group characteristics, a mean of 8 (range 2...

  13. Severe sepsis and septic shock [author's reply

    NARCIS (Netherlands)

    Angus, Derek C.; van der Poll, Tom

    2013-01-01

    To the Editor: We would like to address two potentially confusing issues concerning venous oxygen saturation (Svo(2)) as presented in Table 1 of the review by Angus and van der Poll (Aug. 29 issue).(1) First, Table 1 suggests that Svo(2) is raised in sepsis, severe sepsis, and septic shock.

  14. Varying Presentations and Outcomes of Septic Shock: Should Septic Shock Be Stratified?

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    Zhu, Youfeng; Yin, Haiyan; Zhang, Rui; Ye, Xiaoling; Wei, Jianrui

    2017-11-01

    Recent studies have revealed there are three presentations of septic shock in patients: refractory hypotension without hyperlactatemia, hyperlactatemia without refractory hypotension, and both refractory hypotension and hyperlactatemia. In this study, we sought to identify differences in the outcomes of septic shock patients with these three presentations. We performed a secondary analysis of a large-scale, multicenter, controlled trial. The septic shock patients were categorized into the following three groups according to the presence or absence of refractory hypotension and hyperlactatemia: a hypotension group (refractory hypotension without hyperlactatemia), a hyperlactatemia group (hyperlactatemia without refractory hypotension), and a typical group (both refractory hypotension and hyperlactatemia). The 90-day all-cause mortality was compared among these three groups. A total of 1588 septic shock patients were enrolled in the present study, including 854 (53.8%) in the hypotension group, 477 (30.0%) in the hyperlactatemia group, and 257 (16.2%) in the typical group. The 90-day all-cause mortality were 12.3 per cent for the patients in the hypotension group, 23.1 per cent for those in the hyperlactatemia group, and 31.9 per cent for those in the typical group, these differences among the three groups were significant (Pearson's χ2 = 58.49, P septic shock resulted in significantly different outcomes, suggesting that septic shock should be stratified.

  15. Dopamine versus noradrenaline in septic shock

    Directory of Open Access Journals (Sweden)

    Bo Xu

    2011-10-01

    Full Text Available BackgroundThe ‘Surviving Sepsis’ Campaign guidelines recommend theuse of dopamine or noradrenaline as the first vasopressor inseptic shock. However, information that guides clinicians inchoosing between dopamine and noradrenaline as the firstvasopressor in patients with septic shock is limited.ObjectiveThis article presents a review of the literature regarding theuse of dopamine versus noradrenaline in patients with septicshock.ResultsTwo randomised controlled trials (RCT and two largeprospective cohort studies were analysed. RCT data showeddopamine was associated with increased arrhythmic events.One cohort study found dopamine was associated with higher30-day mortality. The other cohort study found noradrenalinewas associated with higher 28-day mortality.DiscussionData on the use of dopamine versus noradrenaline in patientswith septic shock is limited. Following the recent SOAP IIstudy, there is now strong evidence that the use of dopaminein septic shock is associated with significantly morecardiovascular adverse events, compared tonoradrenaline.ConclusionNoradrenaline should be used as the initial vasopressor inseptic shock to avoid the arrhythmic events associatedwith dopamine.

  16. Cytochrome C in Patients with Septic Shock.

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    Andersen, Lars W; Liu, Xiaowen; Montissol, Sophia; Holmberg, Mathias J; Sulmonte, Christopher; Balkema, Julia L; Cocchi, Michael N; Gazmuri, Raúl J; Berg, Kathrine M; Chase, Maureen; Donnino, Michael W

    2016-05-01

    Cytochrome c is an essential component of the electron transport chain, and circulating cytochrome c might be an indicator of mitochondrial injury. The objective of this study was to determine whether cytochrome c levels are elevated in septic patients, whether there is an association between cytochrome c levels and lactate/inflammatory markers, and whether elevated levels of cytochrome c are associated with poor outcomes. This was a single-center, prospective, observational, pilot study within a randomized, placebo-controlled trial. We enrolled adult patients in septic shock and with an elevated lactate (>3 mmol/L). Blood was collected at enrollment and at 12 and 24  h thereafter. Cytochrome c was measured in plasma using an electrochemiluminescence immunoassay. We included 77 patients. Plasma cytochrome c levels were significantly higher in septic patients than in healthy controls (0.70  ng/mL [quartiles: 0.06, 1.99] vs. 0.19  ng/mL [quartiles: 0.03, 1.32], P = 0.008). Cytochrome c levels at enrollment were positively correlated with lactate levels (r(s) = 0.40, P septic patients than in controls. In unadjusted analysis, septic nonsurvivors had higher cytochrome c levels than survivors.

  17. The Impact of the Sepsis-3 Septic Shock Definition on Previously Defined Septic Shock Patients.

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    Sterling, Sarah A; Puskarich, Michael A; Glass, Andrew F; Guirgis, Faheem; Jones, Alan E

    2017-09-01

    The Third International Consensus Definitions Task Force (Sepsis-3) recently recommended changes to the definitions of sepsis. The impact of these changes remains unclear. Our objective was to determine the outcomes of patients meeting Sepsis-3 septic shock criteria versus patients meeting the "old" (1991) criteria of septic shock only. Secondary analysis of two clinical trials of early septic shock resuscitation. Large academic emergency departments in the United States. Patients with suspected infection, more than or equal to two systemic inflammatory response syndrome criteria, and systolic blood pressure less than 90 mm Hg after fluid resuscitation. Patients were further categorized as Sepsis-3 septic shock if they demonstrated hypotension, received vasopressors, and exhibited a lactate greater than 2 mmol/L. We compared in-hospital mortality in patients who met the old definition only with those who met the Sepsis-3 criteria. Four hundred seventy patients were included in the present analysis. Two hundred (42.5%) met Sepsis-3 criteria, whereas 270 (57.4%) met only the old definition. Patients meeting Sepsis-3 criteria demonstrated higher severity of illness by Sequential Organ Failure Assessment score (9 vs 5; p septic shock did not meet Sepsis-3 criteria. Although Sepsis-3 criteria identified a group of patients with increased organ failure and higher mortality, those patients who met the old criteria and not Sepsis-3 criteria still demonstrated significant organ failure and 14% mortality rate.

  18. Angiotensin II in Refractory Septic Shock.

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    Antonucci, Elio; Gleeson, Patrick J; Annoni, Filippo; Agosta, Sara; Orlando, Sergio; Taccone, Fabio Silvio; Velissaris, Dimitrios; Scolletta, Sabino

    2017-05-01

    Refractory septic shock is defined as persistently low mean arterial blood pressure despite volume resuscitation and titrated vasopressors/inotropes in patients with a proven or suspected infection and concomitant organ dysfunction. Its management typically requires high doses of catecholamines, which can induce significant adverse effects such as ischemia and arrhythmias. Angiotensin II (Ang II), a key product of the renin-angiotensin-aldosterone system, is a vasopressor agent that could be used in conjunction with other vasopressors to stabilize critically ill patients during refractory septic shock, and reduce catecholamine requirements. However, very few clinical data are available to support Ang II administration in this setting. Here, we review the current literature on this topic to better understand the role of Ang II administration during refractory septic shock, differentiating experimental from clinical studies. We also consider the potential role of exogenous Ang II administration in specific organ dysfunction and possible pitfalls with Ang II in sepsis. Various issues remain unresolved and future studies should investigate important topics such as: the optimal dose and timing of Ang II administration, a comparison between Ang II and the other vasopressors (epinephrine; vasopressin), and Ang II effects on microcirculation.

  19. Role of echocardiography in reducing shock reversal time in pediatric septic shock: a randomized controlled trial

    Directory of Open Access Journals (Sweden)

    Ahmed A. EL‐Nawawy

    2018-01-01

    Conclusion: Serial echocardiography provided crucial data for early recognition of septic myocardial dysfunction and hypovolemia that was not apparent on clinical assessment, allowing a timely management and resulting in shock reversal time reduction among children with septic shock.

  20. Predictors of septic shock in obstructive acute pyelonephritis.

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    Tambo, Mitsuhiro; Okegawa, Takatsugu; Shishido, Toshihide; Higashihara, Eiji; Nutahara, Kikuo

    2014-06-01

    Acute pyelonephritis (APN) with obstructive uropathy is not uncommon and often causes serious conditions including sepsis and septic shock. We assessed the risk factors for septic shock in patients with obstructive APN associated with upper urinary tract calculi. We retrospectively studied 69 patients with obstructive APN associated with upper urinary tract calculi who were admitted to our hospital. Emergency drainage for decompression of the renal collecting system was performed for empirical treatment in cases of failure of initial treatment and for severe cases. We assessed the risk factors for septic shock by multivariate logistic regression analysis. Overall, 45 patients (65.2 %) underwent emergency drainage and 23 (33.3 %) patients showed septic shock. Poor performance status and the presence of diabetes mellitus (DM) in the septic shock group were more common than in the non-septic shock group (p = 0.012 and p = 0.011, respectively). The platelet count and serum albumin level in the septic shock group were significantly lower than in the non-septic shock group (p = 0.002 and p = 0.003, respectively). Positive rates of midstream urine culture and blood culture in the septic shock group were significantly higher than in the non-septic shock group (p = 0.022 and p = 0.001, respectively). Multivariate analysis showed that decreases in the platelet count (OR 5.43, p = 0.014) and serum albumin level (OR 5.88, p = 0.023) were independent risk factors for septic shock. Patients with obstructive APN associated with upper urinary tract calculi who have decreases in platelet count and serum albumin level should be treated with caution against the development of septic shock.

  1. The Role of Complement System in Septic Shock

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    Jean Charchaflieh

    2012-01-01

    Full Text Available Septic shock is a critical clinical condition with a high mortality rate. A better understanding of the underlying mechanisms is important to develop effective therapies. Basic and clinical studies suggest that activation of complements in the common cascade, for example, complement component 3 (C3 and C5, is involved in the development of septic shock. The involvement of three upstream complement pathways in septic shock is more complicated. Both the classical and alternative pathways appear to be activated in septic shock, but the alternative pathway may be activated earlier than the classical pathway. Activation of these two pathways is essential to clear endotoxin. Recent investigations have shed light on the role of lectin complement pathway in septic shock. Published reports suggest a protective role of mannose-binding lectin (MBL against sepsis. Our preliminary study of MBL-associated serine protease-2 (MASP-2 in septic shock patients indicated that acute decrease of MASP-2 in the early phase of septic shock might correlate with in-hospital mortality. It is unknown whether excessive activation of these three upstream complement pathways may contribute to the detrimental effects in septic shock. This paper also discusses additional complement-related pathogenic mechanisms and intervention strategies for septic shock.

  2. Red blood cell transfusion during septic shock in the ICU

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    Perner, A; Smith, S H; Carlsen, S

    2012-01-01

    Transfusion of red blood cells (RBCs) remains controversial in patients with septic shock, but current practice is unknown. Our aim was to evaluate RBC transfusion practice in septic shock in the intensive care unit (ICU), and patient characteristics and outcome associated with RBC transfusion....

  3. Current Opinions in Pediatric Septic Shock

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    José Irazuzta

    2009-11-01

    Full Text Available Objectives: Our aim is to describe the current clinical practice related to the management of septic shock (SS. Methods: Review of medical literature using the MEDLINE database. Articles were selected according to their relevancy to the objective and according to the author’s opinion. Summary of the findings: The outcome from SS is dependent on an early recognition and a sequential implementation of time-sensitive goal-directed therapies. The goals of the resuscitation are rapid restoration of micro circulation and improved organ tissue perfusion. Clinical and laboratory markers are needed to assess the adequacy of the treatments. Initial resuscitation involves the use of isotonic solutions (>60ml/kg either crystalloid (normal saline or colloid infusion often followed by vasoactive medications. Altered pharmacokinetics and pharmacodynamics responses dictate that vasoactive agents should be adjusted to achieve predetermined goals. An assessment of central venous pressure complements clinical and serological findings to tailor therapies. Elective airway instrumentation and mechanical ventilation as well as adjunctive therapy with stress dose of corticosteroid are indicated in selected populations. In neonates, a special attention to the presence of electrolyte imbalance and increase pulmonary vascular resistance needs to be considered early. Conclusions: Septic shock hemodynamic is a changing process that requires frequent assessment and therapeutic adjustments.

  4. Higher vs. lower fluid volume for septic shock

    DEFF Research Database (Denmark)

    Smith, Søren H; Perner, Anders

    2012-01-01

    ABSTRACT: INTRODUCTION: Patients with septic shock require fluid, but the optimum amount is unknown. Therefore we assessed patient characteristics and outcome associated with fluid volume in unselected patients with septic shock including those with three days of shock. METHODS: We conducted...... volumes. Characteristics between these groups were compared using non-parametric and Chi-square statistics. RESULTS: The 164 included patients received median 4.0 l (IQR 2.3-6.3) of fluid during the first day of septic shock. Patients receiving higher volumes (> 4.0 l) on day 1 had higher p-lactate (3...... a prospective, multicenter, observational study of all adult patients with septic shock during a 3-month study period at six general ICUs: three in university hospitals and three in regional hospitals. After day 1 and 3 of shock, patients were divided into two groups according to the overall median fluid...

  5. [Septic Shock in Pyogenic Liver Abscess: Clinical Considerations].

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    Cho, A Reum; Lee, Tae Hee; Park, Min Ji; Oh, Sun Hee; Lee, Joo Ah; Park, Joo Ho; Ryu, Ki Hyun; Koo, Hoon Sup; Song, Kyung Ho; Kim, Sun Moon; Huh, Kyu Chan; Choi, Young Woo; Kang, Young Woo

    2016-05-25

    Pyogenic liver abscess (PLA) is a life-threatening condition, despite advances in diagnostic technology and strategies for treatment. A strong predictor of mortality in this condition is septic shock. This study describes clinical, biochemical, and radiologic features in patients with PLA with or without septic shock, with the intent of describing risk factors for septic shock. Of 358 patients with PLA enrolled, 30 suffered septic shock and the remaining 328 did not. We reviewed the medical records including etiologies, underlying diseases, laboratory, radiologic and microbiologic findings, methods of treatment and treatment outcomes. The case fatality rate was 6.1%. In univariate analysis, the presence of general weakness, mental change, low platelet level, prolonged PT, high BUN level, high creatinine level, low albumin level, high AST level, high CRP level, abscess size >6 cm, the presence of gas-forming abscess, APACHE II score ≥ 20, and the presence of Klebsiella pneumoniae infection were significantly associated with septic shock. Multivariate analysis showed the presence of mental change (p=0.004), gas-form -ing abscess (p=0.012), and K. pneumoniae infection (p=0.027) were independent predictors for septic shock. The presence of mental change, gas-forming abscess, and K. pneumoniae infection were independent predictors for septic shock in patients with PLA.

  6. Racial differences in vasopressor requirements for septic shock.

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    Bauman, Zachary M; Killu, Keith F; Rech, Megan A; Bernabei-Combs, Jenna L; Gassner, Marika Y; Coba, Victor E; Tovbin, Alina; Kunkel, Patti L; Mlynarek, Mark E

    2014-03-01

    The objective of this study was to compare vasopressor requirements between African American (AA) patients and white patients in septic shock. This was a retrospective cohort review conducted over a 2-year period measuring total and mean dosage of various vasopressors used between two racial groups during the treatment of patients admitted with septic shock. The study included patients admitted to the intensive care unit with septic shock at an 805-bed tertiary, academic center. All septic shock patients were managed with vasopressors. Vasopressor selection, dosage, and duration were at the discretion of the treating physician. Total, mean, and duration of vasopressor dosing requirements were obtained for study participants. Comorbidities, prehospitalization antihypertensive medication requirements, intravenous fluids given during the septic shock phase, and source of infection were analyzed. One hundred fifty-nine patients with septic shock were analyzed, of which 96 (60.4%) were AAs (P septic shock were treated with higher doses of NE and required longer duration of NE administration compared with white patients.

  7. IL-15 Enables Septic Shock by Maintaining NK Cell Integrity and Function.

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    Guo, Yin; Luan, Liming; Patil, Naeem K; Wang, Jingbin; Bohannon, Julia K; Rabacal, Whitney; Fensterheim, Benjamin A; Hernandez, Antonio; Sherwood, Edward R

    2017-02-01

    Interleukin 15 is essential for the development and differentiation of NK and memory CD8 + (mCD8 + ) T cells. Our laboratory previously showed that NK and CD8 + T lymphocytes facilitate the pathobiology of septic shock. However, factors that regulate NK and CD8 + T lymphocyte functions during sepsis are not well characterized. We hypothesized that IL-15 promotes the pathogenesis of sepsis by maintaining NK and mCD8 + T cell integrity. To test our hypothesis, the pathogenesis of sepsis was assessed in IL-15-deficient (IL-15 knockout, KO) mice. IL-15 KO mice showed improved survival, attenuated hypothermia, and less proinflammatory cytokine production during septic shock caused by cecal ligation and puncture or endotoxin-induced shock. Treatment with IL-15 superagonist (IL-15 SA, IL-15/IL-15Rα complex) regenerated NK and mCD8 + T cells and re-established mortality of IL-15 KO mice during septic shock. Preventing NK cell regeneration attenuated the restoration of mortality caused by IL-15 SA. If given immediately prior to septic challenge, IL-15-neutralizing IgG M96 failed to protect against septic shock. However, M96 caused NK cell depletion if given 4 d prior to septic challenge and conferred protection. IL-15 SA treatment amplified endotoxin shock, which was prevented by NK cell or IFN-γ depletion. IL-15 SA treatment also exacerbated septic shock caused by cecal ligation and puncture when given after the onset of sepsis. In conclusion, endogenous IL-15 does not directly augment the pathogenesis of sepsis but enables the development of septic shock by maintaining NK cell numbers and integrity. Exogenous IL-15 exacerbates the severity of sepsis by activating NK cells and facilitating IFN-γ production. Copyright © 2017 by The American Association of Immunologists, Inc.

  8. Thiamine in septic shock patients with alcohol use disorders

    DEFF Research Database (Denmark)

    Holmberg, Mathias Johan; Moskowitz, Ari; Patel, Parth Vijay

    2018-01-01

    PURPOSE: Alcohol-use disorders (AUDs) have been associated with increased sepsis-related mortality. As patients with AUDs are often thiamine deficient, we investigated practice patterns relating to thiamine administration in patients with AUDs presenting with septic shock and explored...... the association between receipt of thiamine and mortality. MATERIALS: We performed a retrospective cohort study of patients presenting with septic shock between 2008 and 2014 at a single tertiary care center. We identified patients with an AUD diagnosis, orders for microbial cultures and use of antibiotics...... with AUDs admitted for septic shock do not receive thiamine. Thiamine administration in this patient population was associated with decreased mortality....

  9. An alternate pathophysiologic paradigm of sepsis and septic shock

    Science.gov (United States)

    Kumar, Anand

    2014-01-01

    The advent of modern antimicrobial therapy following the discovery of penicillin during the 1940s yielded remarkable improvements in case fatality rate of serious infections including septic shock. Since then, pathogens have continuously evolved under selective antimicrobial pressure resulting in a lack of significant improvement in clinical effectiveness in the antimicrobial therapy of septic shock despite ever more broad-spectrum and potent drugs. In addition, although substantial effort and money has been expended on the development novel non-antimicrobial therapies of sepsis in the past 30 years, clinical progress in this regard has been limited. This review explores the possibility that the current pathophysiologic paradigm of septic shock fails to appropriately consider the primacy of the microbial burden of infection as the primary driver of septic organ dysfunction. An alternate paradigm is offered that suggests that has substantial implications for optimizing antimicrobial therapy in septic shock. This model of disease progression suggests the key to significant improvement in the outcome of septic shock may lie, in great part, with improvements in delivery of existing antimicrobials and other anti-infectious strategies. Recognition of the role of delays in administration of antimicrobial therapy in the poor outcomes of septic shock is central to this effort. However, therapeutic strategies that improve the degree of antimicrobial cidality likely also have a crucial role. PMID:24184742

  10. Advanced Hemodynamic Management in Patients with Septic Shock.

    Science.gov (United States)

    Saugel, Bernd; Huber, Wolfgang; Nierhaus, Axel; Kluge, Stefan; Reuter, Daniel A; Wagner, Julia Y

    2016-01-01

    In patients with sepsis and septic shock, the hemodynamic management in both early and later phases of these "organ dysfunction syndromes" is a key therapeutic component. It needs, however, to be differentiated between "early goal-directed therapy" (EGDT) as proposed for the first 6 hours of emergency department treatment by Rivers et al. in 2001 and "hemodynamic management" using advanced hemodynamic monitoring in the intensive care unit (ICU). Recent large trials demonstrated that nowadays protocolized EGDT does not seem to be superior to "usual care" in terms of a reduction in mortality in emergency department patients with early identified septic shock who promptly receive antibiotic therapy and fluid resuscitation. "Hemodynamic management" comprises (a) making the diagnosis of septic shock as one differential diagnosis of circulatory shock, (b) assessing the hemodynamic status including the identification of therapeutic conflicts, and (c) guiding therapeutic interventions. We propose two algorithms for hemodynamic management using transpulmonary thermodilution-derived variables aiming to optimize the cardiocirculatory and pulmonary status in adult ICU patients with septic shock. The complexity and heterogeneity of patients with septic shock implies that individualized approaches for hemodynamic management are mandatory. Defining individual hemodynamic target values for patients with septic shock in different phases of the disease must be the focus of future studies.

  11. Vasodilators in Septic Shock Resuscitation: A Clinical Perspective

    NARCIS (Netherlands)

    Corrêa, T.D. (Thiago Domingos); Filho, R.R. (Roberto Rabello); Assunção, M.S.C. (Murillo Santucci Cesar); Silva, E. (Eliézer); A.A.P. Lima (Alexandre )

    2017-01-01

    textabstractABSTRACT: Microcirculatory abnormalities have been shown to be frequent in patients with septic shock despite “normalization” of systemic hemodynamics. Several studies have explored the impact of vasodilator therapy (prostacyclin, inhaled nitric oxide, topic acetylcholine and

  12. Coupled plasma filtration adsorption improves hemodynamics in septic shock.

    Science.gov (United States)

    Franchi, Matteo; Giacalone, Marilù; Traupe, Ippolito; Rago, Rocco; Baldi, Giacomo; Giunta, Francesco; Forfori, Francesco

    2016-06-01

    Septic shock involves a dysregulation of the immune response to an infection. This may lead to hemodynamic dysfunction and multiple-organ failure. The main aim of this study was to evaluate the effect of coupled plasma filtration adsorption (CPFA) on the hemodynamic profile in patients with septic shock. We retrospectively analyzed data from 21 adult patients admitted to the intensive care unit with a diagnosis of septic shock, comparing data between pre-CPFA and post-CPFA treatment. They received a maximum of 5 cycles of treatment. Coupled plasma filtration adsorption treatment was associated with a significant increase of mean arterial pressure (P septic shock patients, ameliorating organ failure. Copyright © 2016 Elsevier Inc. All rights reserved.

  13. Higher vs. lower haemoglobin threshold for transfusion in septic shock

    DEFF Research Database (Denmark)

    Rygård, S L; Holst, L B; Wetterslev, J

    2017-01-01

    . a lower haemoglobin threshold. METHODS: In post-hoc analyses of the full trial population of 998 patients from the Transfusion Requirements in Septic Shock (TRISS) trial, we investigated the intervention effect on 90-day mortality in patients with severe comorbidity (chronic lung disease, haematological......BACKGROUND: Using a restrictive transfusion strategy appears to be safe in sepsis, but there may be subgroups of patients who benefit from transfusion at a higher haemoglobin level. We explored if subgroups of patients with septic shock and anaemia had better outcome when transfused at a higher vs.......51), in those who had undergone surgery (P = 0.99) or in patients with septic shock by the new definition (P = 0.20). CONCLUSION: In exploratory analyses of a randomized trial in patients with septic shock and anaemia, we observed no survival benefit in any subgroups of transfusion at a haemoglobin threshold...

  14. [Current concepts on hemodynamic support and therapy in septic shock].

    Science.gov (United States)

    Rocha, Leonardo Lima; Pessoa, Camila Menezes Souza; Corrêa, Thiago Domingos; Pereira, Adriano José; de Assunção, Murillo Santucci Cesar; Silva, Eliézer

    2015-01-01

    Severe sepsis and septic shock represent a major healthcare challenge. Much of the improvement in mortality associated with septic shock is related to early recognition combined with timely fluid resuscitation and adequate antibiotics administration. The main goals of septic shock resuscitation include intravascular replenishment, maintenance of adequate perfusion pressure and oxygen delivery to tissues. To achieve those goals, fluid responsiveness evaluation and complementary interventions - i.e. vasopressors, inotropes and blood transfusion - may be necessary. This article is a literature review of the available evidence on the initial hemodynamic support of the septic shock patients presenting to the emergency room or to the intensive care unit and the main interventions available to reach those targets, focusing on fluid and vasopressor therapy, blood transfusion and inotrope administration. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

  15. Current concepts on hemodynamic support and therapy in septic shock.

    Science.gov (United States)

    Rocha, Leonardo Lima; Pessoa, Camila Menezes Souza; Corrêa, Thiago Domingos; Pereira, Adriano José; de Assunção, Murillo Santucci Cesar; Silva, Eliézer

    2015-01-01

    Severe sepsis and septic shock represent a major healthcare challenge. Much of the improvement in mortality associated with septic shock is related to early recognition combined with timely fluid resuscitation and adequate antibiotics administration. The main goals of septic shock resuscitation include intravascular replenishment, maintenance of adequate perfusion pressure and oxygen delivery to tissues. To achieve those goals, fluid responsiveness evaluation and complementary interventions - i.e. vasopressors, inotropes and blood transfusion - may be necessary. This article is a literature review of the available evidence on the initial hemodynamic support of the septic shock patients presenting to the emergency room or to the intensive care unit and the main interventions available to reach those targets, focusing on fluid and vasopressor therapy, blood transfusion and inotrope administration. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Published by Elsevier Editora Ltda. All rights reserved.

  16. Current concepts on hemodynamic support and therapy in septic shock

    Directory of Open Access Journals (Sweden)

    Leonardo Lima Rocha

    2015-10-01

    Full Text Available ABSTRACTSevere sepsis and septic shock represent a major healthcare challenge. Much of the improvement in mortality associated with septic shock is related to early recognition combined with timely fluid resuscitation and adequate antibiotics administration. The main goals of septic shock resuscitation include intravascular replenishment, maintenance of adequate perfusion pressure and oxygen delivery to tissues. To achieve those goals, fluid responsiveness evaluation and complementary interventions - i.e. vasopressors, inotropes and blood transfusion - may be necessary. This article is a literature review of the available evidence on the initial hemodynamic support of the septic shock patients presenting to the emergency room or to the intensive care unit and the main interventions available to reach those targets, focusing on fluid and vasopressor therapy, blood transfusion and inotrope administration.

  17. Early recognition and management of septic shock in children

    Directory of Open Access Journals (Sweden)

    Paolo Biban

    2012-03-01

    Full Text Available Septic shock remains a major cause of morbidity and mortality among children, mainly due to acute haemodynamic compromise and multiple organ failures. In the last decade, international guidelines for the management of septic shock, as well as clinical practice parameters for hemodynamic support of pediatric patients, have been published. Early recognition and aggressive therapy of septic shock, by means of abundant fluid resuscitation, use of catecholamines and other adjuvant drugs, are widely considered of pivotal importance to improve the short and long-term outcome of these patients. The aim of this paper is to summarize the modern approach to septic shock in children, particularly in its very initial phase, when pediatric healthcare providers may be required to intervene in the pre-intensive care unit setting or just on admission in the pediatric intensive care unit.

  18. The intensive care medicine research agenda on septic shock

    DEFF Research Database (Denmark)

    Perner, Anders; Gordon, Anthony C; Angus, Derek C

    2017-01-01

    Septic shock remains a global health challenge with millions of cases every year, high rates of mortality and morbidity, impaired quality of life among survivors and relatives, and high resource use both in developed and developing nations. Care and outcomes are improving through organisational i...... and translational work. In this review, international experts summarize the current position of clinical research in septic shock and propose a research agenda to advance this field....

  19. Predictors of septic shock in obstructive acute pyelonephritis

    OpenAIRE

    Tambo, Mitsuhiro; Okegawa, Takatsugu; Shishido, Toshihide; Higashihara, Eiji; Nutahara, Kikuo

    2013-01-01

    Purpose Acute pyelonephritis (APN) with obstructive uropathy is not uncommon and often causes serious conditions including sepsis and septic shock. We assessed the risk factors for septic shock in patients with obstructive APN associated with upper urinary tract calculi. Methods We retrospectively studied 69 patients with obstructive APN associated with upper urinary tract calculi who were admitted to our hospital. Emergency drainage for decompression of the renal collecting system was perfor...

  20. Similar change in platelets and leucocytes 24 h after injury is associated with septic shock a week later.

    Science.gov (United States)

    Jol, Saskia; Hietbrink, Falco; Leenen, Luke P H; Koenderman, Leo; van Wessem, Karlijn J P

    2017-03-01

    Septic shock is a severe complication in polytrauma patients. Early identification of patients at risk can guide future prevention strategies. Platelets (PLTs) and leucocytes presumably play an important role in the post-injury inflammatory response. The role of early changes in PLT and leucocyte counts was investigated in search for the aetiology of the development of septic complications. Polytrauma patients (aged 16-80 years) admitted to the intensive care unit with an expected stay of at least 3 days were included. PLT and leucocyte counts were measured on a daily basis for 14 days. A total of 41 patients were included, of whom nine (22%) developed septic shock. There was no difference in (New) Injury Severity Score or Acute Physiology and Chronic Health Evaluation II scores between patients who developed septic shock and patients who did not. Three patients died, one of them in septic shock. Patients who developed septic shock during hospital stay had lower PLTs and a slower recovery to normal PLT counts than patients without septic shock. Patients who developed either a decrease in both PLTs and leucocytes or an increase in PLTs and leucocytes in the first 24 h after trauma were more likely to develop septic shock. This correlation was not found in patients who did not develop septic shock. A similar change in PLT and leucocyte counts in the first 24 h after trauma is associated with the development of septic shock after a week. This indicates an early interaction between PLTs and leucocytes, which needs further investigation to gain more insight in the aetiology of post-injury septic complications. © 2017 Royal Australasian College of Surgeons.

  1. Epidemiology of Vasopressin Use for Adults with Septic Shock.

    Science.gov (United States)

    Vail, Emily A; Gershengorn, Hayley B; Hua, May; Walkey, Allan J; Wunsch, Hannah

    2016-10-01

    Vasopressin may be used to treat vasodilatory hypotension in septic shock, but it is not recommended by guidelines as a first- or second-line agent. Little is known about how often the drug is used currently in septic shock. We conducted this study to describe patterns of vasopressin use in a large cohort of U.S. adults with septic shock and to identify patient and hospital characteristics associated with vasopressin use. This was a retrospective cohort study of adults admitted to U.S. hospitals with septic shock in the Premier healthcare database (July 2008 to June 2013). We performed multilevel mixed-effects logistic regression with hospitals as a random effect to identify factors associated with use of vasopressin alone or in combination with other vasopressors on at least 1 day of hospital admission. We calculated quotients of Akaike Information Criteria (AIC) to determine relative contributions of patient and hospital characteristics to observed variation. Among 584,421 patients with septic shock in 532 hospitals, 100,923 (17.2%) received vasopressin. A total of 6.1% of patients receiving vasopressin received vasopressin alone, and 93.9% received vasopressin in combination with other vasopressors (up to five vasopressors in 15 different combinations). The mean monthly rate of vasopressin use increased from 14.5 to 19.6% over the study period, representing an average annual relative increase of 8% (P septic shock was 11.7% (range, 0-69.7%). Patient demographic and clinical characteristics, including patient age (adjusted odds ratio, 0.71 for age > 85 yr compared with the reference group of age septic shock received vasopressin, but rarely as a single vasopressor. The use of vasopressin has increased over time. The likelihood of receiving vasopressin was strongly associated with the specific hospital to which each patient was admitted.

  2. Hemodynamic Analysis of Pediatric Septic Shock and Cardiogenic Shock Using Transpulmonary Thermodilution.

    Science.gov (United States)

    Lee, En-Pei; Hsia, Shao-Hsuan; Lin, Jainn-Jim; Chan, Oi-Wa; Lee, Jung; Lin, Chia-Ying; Wu, Han-Ping

    2017-01-01

    Septic shock and cardiogenic shock are the two most common types of shock in children admitted to pediatric intensive care units (PICUs). The aim of the study was to investigate which hemodynamic variables were associated with mortality in children with shock. We retrospectively analyzed 50 children with shock (37 septic shock cases and 13 cardiogenic shock cases) in the PICU and monitored their hemodynamics using transpulmonary thermodilution from 2003 to 2016. Clinical factors were analyzed between the patients with septic and cardiogenic shock. In addition, hemodynamic parameters associated with mortality were analyzed. The 28-day mortality was significantly higher in the septic group than in the cardiogenic group ( p = 0.016). Initially, the parameters of cardiac output and cardiac contractility were higher in the septic group ( p shock at the time of initial admission and after the first 24 hours (both p septic shock ( p < 0.001). Therefore, during the first 24 hours after intensive care, SVRI and cardiac index are the most important hemodynamic parameters associated with mortality.

  3. Involvement of Aromatic Metabolites in the Pathogenesis of Septic Shock.

    Science.gov (United States)

    Beloborodova, Natalia V; Sarshor, Yulia N; Bedova, Aleksandra Yu; Chernevskaya, Ekaterina A; Pautova, Alisa K

    2017-11-15

    We hypothesized that aromatic microbial metabolites (AMM), such as phenyllactic (PhLA), p-hydroxyphenylacetic (p-HPhAA), and p-hydroxyphenyllactic (p-HPhLA) acids, contribute to the pathogenesis of septic shock. Clinical and laboratory data of patients with community-acquired pneumonia were obtained on intensive care unit admission and the next day. Patients were divided into two groups based on septic shock presence or absence. The levels of AMM (PhLA, p-HPhAA, p-HPhLA, and their sum, ∑3AMM), catecholamine metabolites (3,4-dihydroxymandelic [DHMA], 3,4-dihydroxyphenylacetic [DOPAC], and homovanillic [HVA] acids), lactate, N-terminal pro-brain natriuretic peptide (NT-proBNP), inducible nitric oxide synthase (iNOS), and procalcitonin (PCT) were compared. Correlations between AMM and clinical and laboratory data were calculated. There were 20 patients in the septic shock group and 21 in the non-septic shock group. On admission, the septic shock patients demonstrated significantly higher levels of PhLA (2.3 vs. 0.8 μmol/L), p-HPhAA (4.6 vs. 1.4 μmol/L), p-HPhLA (7.4 vs. 2.6 μmol/L), HVA, lactate, and significantly lower levels of iNOS. The next day, the two groups also showed significant differences in the levels of PCT and NT-proBNP. The correlation between ∑3AMM and presence of shock, levels of lactate, HVA, and NT-proBNP on admission was 0.44, 0.67, 0.57, and 0.38, respectively, and the correlation on the next day was 0.59, 0.73, 0.76, and 0.6, respectively (p septic shock.

  4. Shock Prevention

    Science.gov (United States)

    1978-01-01

    The electrician pictured is installing a General Electric Ground Fault Interrupter (GFI), a device which provides protection against electrical shock in the home or in industrial facilities. Shocks due to defective wiring in home appliances or other electrical equipment can cause severe burns, even death. As a result, the National Electrical Code now requires GFIs in all new homes constructed. This particular type of GFI employs a sensing element which derives from technology acquired in space projects by SCI Systems, Inc., Huntsville, Alabama, producer of sensors for GE and other manufacturers of GFI equipment. The sensor is based on the company's experience in developing miniaturized circuitry for space telemetry and other spacecraft electrical systems; this experience enabled SCI to package interruptor circuitry in the extremely limited space available and to produce sensory devices at practicable cost. The tiny sensor measures the strength of the electrical current and detects current differentials that indicate a fault in the functioning of an electrical system. The sensing element then triggers a signal to a disconnect mechanism in the GFI, which cuts off the current in the faulty circuit.

  5. Hyperkalemia induced pseudo-myocardial infarction in septic shock

    Directory of Open Access Journals (Sweden)

    S E Pothiawala

    2014-01-01

    Full Text Available Hyperkalemia is an acute life-threatening disorder presenting to the emergency department. Patients with hyperkalemia may manifest characteristic electrocardiographic changes including tented T waves, widening of the QRS complex and loss of P waves, sine wave pattern and eventually asystole. There have been only few reports of hyperkalemia causing ST segment elevation on electrocardiogram simulating an acute myocardial infarction. This case describes pseudo-myocardial infarction due to hyperkalemia and septic shock. Rapid determination of serum potassium levels by bedside blood gas analyzers serves to be a useful guide. ST segment elevation related to hyperkalemia will resolve with successful reduction of the serum potassium levels by appropriate therapy. It is important for physicians to be aware of this condition as this will aid in initiating correct therapy and prevent the patient from unnecessary interventions and the associated risk of complications.

  6. Is Thrombocytopenia an Early Prognostic Marker in Septic Shock?

    Science.gov (United States)

    Thiery-Antier, Nadiejda; Binquet, Christine; Vinault, Sandrine; Meziani, Ferhat; Boisramé-Helms, Julie; Quenot, Jean-Pierre

    2016-04-01

    To assess whether early thrombocytopenia during septic shock is associated with an increased risk of death at day 28 and to identify risk factors associated with a low platelet count. Prospective, multicenter, observational cohort study. Fourteen ICUs from 10 French university teaching and nonacademic hospitals. Consecutive adult patients with septic shock admitted between November 2009 and September 2011 were eligible. None. Of the 1,495 eligible patients, 1,486 (99.4%) were included. Simplified Acute Physiology Score II score of greater than or equal to 56, immunosuppression, age of more than 65 years, cirrhosis, bacteremia (p ≤ 0.001 for each), and urinary sepsis (p = 0.005) were globally associated with an increased risk of thrombocytopenia within the first 24 hours following the onset of septic shock. Survival at day 28 estimated by the Kaplan-Meier method was lower in patients with thrombocytopenia and decreased with thrombocytopenia severity. By multivariate Cox regression, a platelet count of less than or equal to 100,000/mm3 was independently associated with a significantly increased risk of death within the 28 days following septic shock onset. The risk of death increased with the severity of thrombocytopenia (hazard ratio, 1.65; 95% CI, 1.31-2.08 for a platelet count below 50,000/mm3 vs > 150,000/mm3; p septic shock onset as a prognostic marker of survival at day 28 in a large cohort of ICU patients. Measuring platelet count is inexpensive and easily feasible for the physician in routine practice, and thus, it could represent an easy "alert system" among patients in septic shock.

  7. Control groups in recent septic shock trials: a systematic review.

    Science.gov (United States)

    Pettilä, Ville; Hjortrup, Peter Buhl; Jakob, Stephan M; Wilkman, Erika; Perner, Anders; Takala, Jukka

    2016-12-01

    The interpretation of septic shock trial data is profoundly affected by patients, control intervention, co-interventions and selected outcome measures. We evaluated the reporting of control groups in recent septic shock trials. We searched for original articles presenting randomized clinical trials (RCTs) in adult septic shock patients from 2006 to 2016. We included RCTs focusing on septic shock patients with at least two parallel groups and at least 50 patients in the control group. We selected and evaluated data items regarding patients, control group characteristics, and mortality outcomes, and calculated a data completeness score to provide an overall view of quality of reporting. A total of 24 RCTs were included (mean n = 287 patients and 71 % of eligible patients were randomized). Of the 24 studies, 14 (58 %) presented baseline data on vasopressors and 58 % the proportion of patients with elevated lactate values. Five studies (21 %) provided data to estimate the proportion of septic shock patients fulfilling the Sepsis-3 definition. The mean data completeness score was 19 out of 36 (range 8-32). Of 18 predefined control group characteristics, a mean of 8 (range 2-17) were reported. Only 2 (8 %) trials provided adequate data to confirm that their control group treatment represented usual care. Recent trials in septic shock provide inadequate data on the control group treatment and hemodynamic values. We propose a standardized trial dataset to be created and validated, comprising characteristics of patient population, interventions administered, hemodynamic values achieved, surrogate organ dysfunction, and mortality outcomes, to allow better analysis and interpretation of future trial results.

  8. Similar Microcirculatory Alterations in Patients with Normodynamic and Hyperdynamic Septic Shock

    NARCIS (Netherlands)

    Edul, Vanina S. Kanoore; Ince, Can; Vazquez, Alejandro Risso; Rubatto, Paolo N.; Espinoza, Emilio D. Valenzuela; Welsh, Sebastián; Enrico, Carolina; Dubin, Arnaldo

    2016-01-01

    Rationale: In normodynamic septic shock, the quantitative assessment of sublingual microcirculation has shown decreases in perfused vascular density and red blood cell velocity. However, no studies have been performed in hyperdynamic septic shock. Objectives: To characterize the microcirculatory

  9. The majority of patients in septic shock are transfused with fresh-frozen plasma

    DEFF Research Database (Denmark)

    Reiter, Nanna; Wesche, Nikolaj; Perner, Anders

    2013-01-01

    Fresh-frozen plasma (FFP) transfusion may be widely used in patients in septic shock, but the use is not well-described. Our aim was to describe the current use of FFP transfusion in medical patients with septic shock.......Fresh-frozen plasma (FFP) transfusion may be widely used in patients in septic shock, but the use is not well-described. Our aim was to describe the current use of FFP transfusion in medical patients with septic shock....

  10. Bioinformatic analysis of pivotal genes associated with septic shock.

    Science.gov (United States)

    Liu, S Y; Zhang, L; Zhang, Y; Zhen, Y; Wu, Y F

    2017-01-01

    We aimed to identify important genes associated with septic shock and then explore the possibly significant mechanisms of this disease. We downloaded GSE26440 expression data of samples from 98 children with septic shock and 32 normal controls from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) in samples from patients with septic shock were analyzed in comparison with those in samples from normal controls using a limma package. Functional enrichment analysis for DEGs was performed using DAVID, and a protein–protein interaction (PPI) network was constructed. Upstream transcription factors for DEGs were predicted using the CHIPBase database, and a transcriptional regulation network was constructed. A total of 383 significantly DEGs, including 141 downregulated and 242 upregulated genes, were obtained in the sepsis shock group compared with the normal group. The top five nodes in the PPI network were lysine (K)-specific demethylase 6B (KDM6B), histone deacetylase 2 (HDAC2), V-Myc avian myelocytomatosis viral oncogene homolog (MYC), heat-shock protein 90 kDa alpha (cytosolic), class B member 1 (HSP90AB1), and poly (A)-binding protein, cytoplasmic 1 (PABPC1). Nuclear factor kappa-light-chain-enhancer of activated B cells (NFkB) was the transcription factor targeted by most genes, and it regulated the expression of KDM6B, HDAC2, MYC, HSP90AB1, and PABPC1. In conclusion, KDM6B, HDAC2, MYC, HSP90AB1, and PABPC1 may play important roles in the development of septic shock. Furthermore, NFκB may be involved in septic shock by regulating the expression of KDM6B, HDAC2, MYC, HSP90AB1, and PABPC1.

  11. Pseudomonas aeruginosa septic shock secondary to "gripe water" ingestion.

    Science.gov (United States)

    Sas, David; Enrione, Maria A; Schwartz, Richard H

    2004-02-01

    We report the case of a 9-month-old girl who presented in septic shock after ingestion of a contaminated herbal supplement commonly used to treat colic. Herbal supplements are widely used by well-meaning parents for many common conditions. Pediatricians should be aware that the variable manufacturing and packaging conditions of herbal supplements can lead to contamination with infectious agents.

  12. Norepinephrine in septic shock : when and how much?

    NARCIS (Netherlands)

    Hamzaoui, Olfa; Scheeren, Thomas W L; Teboul, Jean-Louis

    Purpose of reviewNorepinephrine is the first-line agent recommended during resuscitation of septic shock to correct hypotension due to depressed vascular tone. Important clinical issues are the best timing to start norepinephrine, the optimal blood pressure target, and the best therapeutic options

  13. Role of peroxynitrite in the cardiovascular dysfunction of septic shock.

    Science.gov (United States)

    Liaudet, Lucas; Rosenblatt-Velin, Nathalie; Pacher, Pal

    2013-03-01

    The intense systemic inflammatory response characterizing septic shock is associated with an increased generation of free radicals by multiple cell types in cardiovascular and non cardiovascular tissues. The oxygen-centered radical superoxide anion (O2 .-) rapidly reacts with the nitrogen-centered radical nitric oxide (NO.) to form the potent oxidant species peroxynitrite. Peroxynitrite oxidizes multiple targets molecules, either directly or via the secondary generation of highly reactive radicals, resulting in significant alterations in lipids, proteins and nucleic acids, with significant cytotoxic consequences. The formation of peroxynitrite is a key pathophysiological mechanism contributing to the cardiovascular collapse of septic shock, promoting vascular contractile failure, endothelial and myocardial dysfunction, and is also implicated in the occurrence of multiple organ dysfunction in this setting. The recent development of various porphyrin-based pharmacological compounds accelerating the degradation of peroxynitrite has allowed to specifically address these pathophysiological roles of peroxynitrite in experimental septic shock. Such agents, including 5,10,15,20-tetrakis(4- sulfonatophenyl)porphyrinato iron III chloride (FeTTPs), manganese tetrakis(4-N-methylpyridyl)porphyrin (MnTMPyP), Fe(III) tetrakis-2-(N-triethylene glycol monomethyl ether)pyridyl porphyrin) (FP-15) and WW-85, have been shown to improve the cardiovascular and multiple organ failure in small and large animal models of septic shock. Therefore, these findings support the development of peroxynitrite decomposition catalysts as potentially useful novel therapeutic agents to restore cardiovascular function in sepsis.

  14. Evolution of Blood Lactate and 90-Day Mortality in Septic Shock. A Post Hoc Analysis of the FINNAKI Study

    DEFF Research Database (Denmark)

    Varis, Elina; Pettilä, Ville; Poukkanen, Meri

    2017-01-01

    Hyperlactatemia predicts mortality in patients with sepsis and septic shock, and its normalization is a potential treatment goal. We investigated the association of blood lactate and its changes over time with 90-day mortality in septic shock. We performed a post hoc analysis of 513 septic shock...... surrogate endpoints for mortality in septic shock patients....

  15. N-terminal-pro-brain natriuretic peptide elevations in the course of septic and non-septic shock reflect systolic left ventricular dysfunction assessed by transpulmonary thermodilution

    NARCIS (Netherlands)

    A.J. Groeneveld; R.J. Trof (R.)

    2016-01-01

    textabstractBackground: The cardiac correlates, if any, of N-terminal probrain natriuretic peptide (NT-proBNP) levels in septic and non-septic shock patients remain controversial. Methods: In the 38 septic and 22 non-septic shock patients in the transpulmonary thermodilution arm of a previous

  16. Quantitative assessment of the microcirculation in healthy volunteers and in patients with septic shock

    NARCIS (Netherlands)

    Edul, Vanina S. Kanoore; Enrico, Carolina; Laviolle, Bruno; Vazquez, Alejandro Risso; Ince, Can; Dubin, Arnaldo

    2012-01-01

    The microcirculation of septic patients has been characterized only semiquantitatively. Our goal was to characterize the sublingual microcirculation in healthy volunteers and patients with septic shock quantitatively. Our hypotheses were that 1) hyperdynamic blood flow is absent in septic shock; 2)

  17. Effects of Chronic Antihypertensives on Vasopressor Dosing in Septic Shock.

    Science.gov (United States)

    DeMott, Joshua M; Patel, Gourang; Lat, Ishaq

    2018-01-01

    In septic shock, chronic antihypertensive medications are held acutely. Vasopressors are often required to maintain blood pressure. The effect of chronic exposure to antihypertensive therapies on vasopressor dosing in septic shock is not known. To determine the effects of chronic exposure to antihypertensive therapies, specifically β-blockers and angiotensin-converting enzyme (ACE) inhibitors, on cumulative vasopressor dosing in septic shock. This was a retrospective cohort review, with data collected from routine care. Patients admitted to the medical intensive care unit with septic shock and vasopressor use were included and divided into 4 groups based on chronic medication use: (1) no β-blocker or ACE inhibitor, (2) β-blocker only, (3) ACE inhibitor only, and (4) β-blocker and ACE inhibitor. Cumulative vasopressor dose at 48 hours was assessed. Demographics, comorbid conditions, suspected site of infection, disease severity, mortality, and concomitant therapies were evaluated between groups. A total of 133 patients with septic shock treated with vasopressors were included. No difference in cumulative vasopressor dose at 48 hours was detected between the 4 groups, respectively (median norepinephrine milligram equivalents [interquartile range (IQR)]: no β-blocker or ACE inhibitor, 13.7 mg [6.0-35.7]; β-blocker only, 13.1 mg [5.4-23.9]; ACE inhibitor only, 13.2 mg [1.2-36.7]; β-blocker and ACE inhibitor, 11.3 mg [4.7-42.9]; P = 0.669). Total time on vasopressors differed between groups (median hours [IQR]: no β-blocker or ACE inhibitor, 30h [17-60]; β-blocker only, 24h [10-69]; ACE inhibitor only, 19h [6-25]; β-blocker and ACE inhibitor, 30h [15-58]; P = 0.031). Comorbid conditions, suspected infection sites, disease severity, mortality, and concomitant therapies were similar. Chronic β-blocker, ACE inhibitor use, or the combination of both did not affect cumulative vasopressor dose at 48 hours in septic shock. However, prior-to-admission medications may

  18. Lower versus higher hemoglobin threshold for transfusion in septic shock

    DEFF Research Database (Denmark)

    Holst, Lars B; Haase, Nicolai; Wetterslev, Jørn

    2014-01-01

    BACKGROUND: Blood transfusions are frequently given to patients with septic shock. However, the benefits and harms of different hemoglobin thresholds for transfusion have not been established. METHODS: In this multicenter, parallel-group trial, we randomly assigned patients in the intensive care...... were similar in the two intervention groups. CONCLUSIONS: Among patients with septic shock, mortality at 90 days and rates of ischemic events and use of life support were similar among those assigned to blood transfusion at a higher hemoglobin threshold and those assigned to blood transfusion....... The primary outcome measure was death by 90 days after randomization. RESULTS: We analyzed data from 998 of 1005 patients (99.3%) who underwent randomization. The two intervention groups had similar baseline characteristics. In the ICU, the lower-threshold group received a median of 1 unit of blood...

  19. Shigellosis with resultant septic shock and renal failure.

    Science.gov (United States)

    Moralez, Elba Iris; Lofland, Denene

    2011-01-01

    Septic shock is a rare, potentially life-threatening complication of bacterial dysentery. The clinical presentation of septic shock includes hypotension, bleeding, hypoxia, acidosis, and jaundice. Historically gram-negative organisms were the most frequent cause of nosocomial bloodstream infections. However isolation of gram-positive organisms has become increasingly frequent with Staphylococcus species accounting for over one half of all nosocomial bloodstream pathogens. Bacterial dysentery is an acute diarrheal illness characterized by abdominal cramping, fever, and the production of mucoid, bloody stools. Laboratory findings include positive stool culture and increased leukocytes in direct fecal exam. Chemistry and hematology values may be abnormal. The disease is usually self-limiting but administration of antibiotics and rehydration therapy may be warranted in severe cases. This case study describes a 53 year old male who presented with diarrhea and diabetic acidosis and subsequently developed respiratory distress and renal failure due to shigellosis. Discussion of disease pathogenesis and treatment are provided.

  20. Septic shock after posterior spinal arthrodesis on a patient with Scheuermann kyphosis and multiple body piercings.

    Science.gov (United States)

    Tsirikos, Athanasios I; Subramanian, Ashok Sridhara

    2011-10-15

    A case report. We report septic shock as postoperative complication following an instrumented posterior spinal arthrodesis on a patient with multiple body piercings. The management of this potentially catastrophic complication and outcome of treatment is been discussed. Body piercing has become increasingly more common because of change in culture or as a fashion statement. This has been associated with local or generalized ill effects including tissue injury, skin and systemic infections, and septic shock. There is no clear guideline pathway regarding removal and reinsertion of body piercings in patients who undergo major surgery. Complications following orthopedic or spinal procedures associated with body piercing have not been reported. We reviewed the medical notes and radiographs of an adolescent patient with Scheuermann kyphosis and multiple body piercings who underwent a posterior spinal arthrodesis and developed septic shock. Septic shock developed on postoperative day 2 after reinsertion of all piercings following the patient's request. The patient became systemically very unwell and required intensive medical management, as well as a total course of antibiotics of 3 months. The piercings remained in situ. She did not develop a wound infection despite the presence of bacteremia and spinal instrumentation. The patient had no new piercings subsequent to her deformity procedure. Two and a half years after spinal surgery she reported no medical problems, had a balanced spine with no loss of kyphosis correction and no evidence of nonunion or recurrence of deformity. The development of septic shock as a result of piercing reinsertion in the postoperative period has not been previously reported. This is an important consideration to prevent potentially life-threatening complications following major spinal surgery.

  1. [Fluid balance and acute kidney injury in septic shock].

    Science.gov (United States)

    Martínez-García, Jesús Javier; León-Sicairos, Nidia Maribel; Canizalez-Román, Adrián; García-Arellano, Bianca Azucena

    In patients with septic shock, excessive fluid administration can lead to increased morbidity and mortality. The aim of this study was to evaluate the association between fluid balance, acute kidney injury and mortality in patients with septic shock. A study of cases and controls was conducted in a Pediatric Intensive Care Unit. The fluid balance in the first 72h and the presence of acute kidney injury was compared in patients diagnosed with septic shock who died against patients who survived the same condition. Univariate and multivariate analyses were performed. Forty-five cases and forty-five controls were included in the analysis. Mortality was associated with Pediatric Risk of Mortality (PRISM III) ≥ 26 points (OR 7.5, 95% CI 2.8-18.7; p=0.000), Pediatric Logistic Organ Dysfunction (PELOD) ≥ 24 points (OR 11.0, 95% CI 4.1-29.4; p=0.000), creatinine ≥ 0.65mg/dl (OR 5.6, 95% CI 2.2-13.9; p=0.000), lactate ≥ 2.5 mmol/l (OR 2.5, 95% CI 1.1-5.9; p=0.033), SvO2 9% in 72h (OR 4.3, 95% CI 1.6-11.7; p=0.003), acute kidney injury (OR 5.7, 95% CI: 2.2-15.1; p=0.000). In the multivariate model, the values of PRISM ≥26 and PELOD ≥24 points were significant. In patients who died due to septic shock, the multivariate model showed an association with PRISM ≥26 and PELOD ≥24 and a trend toward association with SvO2 9%. Copyright © 2017 Hospital Infantil de México Federico Gómez. Publicado por Masson Doyma México S.A. All rights reserved.

  2. Systemic inflammatory response syndrome: a case of septic shock

    Directory of Open Access Journals (Sweden)

    Nicolò Gentiloni Silveri

    2008-09-01

    Full Text Available An elderly, diabetic male, with severe sepsis, swiftly treated with antibiotics that were efficacious in vitro against the E. Coli isolated in his blood, rapidly slides into multiple organ dysfunction syndrome and dies of septic shock after a month in intensive care, despite receiving appropriate pain relief and aetiopathogenetic therapy. This event provides us with the opportunity to take a new look at systemic inflammatory response syndrome and a critical review of the relative therapy

  3. Continuation of Statin Therapy and Vasopressor Use in Septic Shock.

    Science.gov (United States)

    Zechmeister, Carrie; Hurren, Jeff; McNorton, Kelly

    2015-07-01

    Studies have evaluated the use of statins in sepsis; however, no human studies have explored their effect on vasopressor requirements in septic shock. The primary objective was to determine the effect of prehospital statin continuation on duration of vasopressor therapy in patients with septic shock. Secondary objectives included maximum and average vasopressor dose and in-hospital mortality. This was a retrospective, institutional board-approved, observational cohort study in a community teaching hospital; 119 adult intensive care unit (ICU) patients with an ICD-9 code for septic shock and prehospital statin therapy were evaluated. Multivariate analyses were performed to address confounders. Of the 1229 patients screened, 119 (10%) met inclusion criteria; 73 patients (61%) had a statin continued within 24 hours of ICU admission. Crude analysis demonstrated no difference in vasopressor duration in the statin versus no statin group (3.3 vs 4.8 days; P = 0.21). There was no difference in either maximum (17.9 ± 16.1 vs 23.8 ± 21.7 µg/min norepinephrine equivalents [NEQs]; P = 0.1) or average vasopressor dose (9.5 ± 8.4 vs 12.1 ± 11.5 µg/min NEQ; P = 0.17). There was a decrease in mortality in the statin patients (43% vs 67 %; P = 0.05). On adjustment for potential confounders, there was no difference in any outcome, with a persistent trend toward lower mortality in the statin group. Continuation of prehospital statin therapy decreased neither duration nor dose of vasopressors in patients with septic shock but yielded a trend toward decreased mortality. © The Author(s) 2015.

  4. Molecular mechanisms involved in the pathogenesis of septic shock.

    Science.gov (United States)

    López-Bojórquez, Lucia Nikolaia; Dehesa, Alejandro Zentella; Reyes-Terán, Gustavo

    2004-01-01

    Pathogenesis of the development of sepsis is highly complex and has been the object of study for many years. The inflammatory phenomena underlying septic shock are described in this review, as well as the enzymes and genes involved in the cellular activation that precedes this condition. The most important molecular aspects are discussed, ranging from the cytokines involved and their respective transduction pathways to the cellular mechanisms related to accelerated catabolism and multi-organic failure.

  5. [Our experience in Fournier's gangrene with severe septic shock].

    Science.gov (United States)

    Lukász, Péter; Ecsedy, Gábor; Lovay, Zoltán; Nagy, István; Kári, Dániel; Vörös, Attila; Ender, Ferenc

    2014-06-01

    Fournier's gangrene is a rare, rapidly progressing necrotizing fasciitis, which involves the genital area and perineum, progresses towards the thighs and abdominal wall through fascial plains. In our surgical department we treated seven patients with Fournier's gangrene between 2007 and 2011. Early diagnosis, immediate radical surgical debridement, necrosectomy, appropriate antibiotics and intensive care are all required and necessary for the successful treatment. Despite appropriate therapy, two patients were lost in septic shock.

  6. How Do I Integrate Hemodynamic Variables When Managing Septic Shock?

    Directory of Open Access Journals (Sweden)

    Olfa Hamzaoui

    2016-11-01

    Full Text Available Hemodynamic management of sepsis-induced circulatory failure is complex since this pathological state includes multiple cardiovascular derangements that can vary from patient to patient according to the degree of hypovolemia, of vascular tone depression, of myocardial depression and of microvascular dysfunction. The treatment of the sepsis-induced circulatory failure is thus not univocal and should be adapted on an individual basis. As physical examination is insufficient to obtain a comprehensive picture of the hemodynamic status, numerous hemodynamic variables more or less invasively collected, have been proposed to well assess the severity of each component of the circulatory failure and to monitor the response to therapy. In this article, we first describe the hemodynamic variables, which are the most relevant to be used, emphasizing on their physiological meaning, their validation and their limitations in patients with septic shock. We then proposed a general approach for managing patients with septic shock by describing the logical steps that need to be followed in order to select and deliver the most appropriate therapies. This therapeutic approach is essentially based on knowledge of physiology, of pathophysiology of sepsis, and of published data from clinical studies that addressed the issue of hemodynamic management of septic shock.

  7. Tension pneumocephalus mimicking septic shock: a case report

    Directory of Open Access Journals (Sweden)

    Caroline Miranda, MD

    2018-02-01

    Full Text Available Tension pneumocephalus can lead to rapid neurologic deterioration. We report for the first time its association with aseptic systemic inflammatory response syndrome mimicking septic shock and the efficacy of prompt neurosurgical intervention and critical care support in treating this condition. A 64-year-old man underwent 2-stage olfactory groove meningioma resection. The patient developed altered mental status and gait instability on postoperative day 6. Imaging showed significant pneumocephalus. The patient subsequently developed worsening mental status, respiratory failure, and profound shock requiring multiple vasopressors. Bedside needle decompression, identification and repair of the cranial fossa defect, and critical care support led to improved mental status and reversal of shock and multiorgan dysfunction. Thorough evaluation revealed no evidence of an underlying infection. In this case, tension pneumocephalus incited an aseptic systemic inflammatory response syndrome mimicking septic shock. Prompt neurosurgical correction of pneumocephalus and critical care support not only improved neurologic status, but also reversed shock. Such a complication indicates the importance of close monitoring of patients with progressive pneumocephalus.

  8. Comparison of Hydroxocobalamin Versus Norepinephrine Versus Saline in a Swine Model of Servere Septic Shock

    Science.gov (United States)

    2016-05-20

    Versus Saline in a Swine Model of Severe Septic Shock presented at/published to SURF Conference, San Antonio, TX 20 May 2016 with MDWJ 41-108, and has...PRESENTED: Comparison of hydroxocobalamin versus norepinephrine versus saline in a Swine model of severe septic shock 7. FUNDING RECEIVED FOR THIS...Comparison of hydroxocbalamin versus norepinephrine versus saline in a swine model of severe septic shock . Background: Sepsis is associated with a mortality

  9. Comparison of Hydroxocobalamin Versus Norepinephrine Versus Saline in a Swine Model of Severe Septic Shock

    Science.gov (United States)

    2016-05-18

    Versus Saline in a Swine Model of Severe Septic Shock presented at/published to the Lightning Oral, SAEM Conference, New Orleans, LA 10-13 May 2016 with...PRESENTED: Comparison of hydroxocobalamin versus norepinephrine versus sal ine in a Swine model of severe septic shock 7. FUNDING RECEIVED FOR THIS...saline in a swine model of severe septic shock . Background: Sepsis is associated with a mortality of nearly 30%. Mortality is due, in part, to an

  10. Pneumococcal penumonia presenting with septic shock: host-ant pathogen-related factors and outcomes

    OpenAIRE

    García Vidal, Carolina; Ardanuy Tisaire, María Carmen; Tubau, Fe; Viasus, Diego; Dorca i Sargatal, Jordi; Liñares Louzao, Josefina; Gudiol i Munté, Francesc; Carratalà, Jordi

    2009-01-01

    BACKGROUND: Host- and pathogen-related factors associated with septic shock in pneumococcal pneumonia are not well defined. The aim of this study was to identify risk factors for septic shock and to ascertain patient outcomes. Serotypes, genotypes and antibiotic resistance of isolated strains were also analysed. METHODS: Observational analysis of a prospective cohort of non-severely immunosuppressed hospitalised adults with pneumococcal pneumonia. Septic shock was defined as a systolic blood ...

  11. DIAGNOSTICS AND TREATMENT OF THE SEPSIS AND SEPTIC SHOCK IN CHILDREN

    OpenAIRE

    R.F. Tepaev

    2010-01-01

    Sepsis is one of the leading causes of mortality in children. Timely diagnosis is the most important condition of successful therapy for sepsis. The work provides modern recommendations for diagnosis of the systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock, sets out key guidelines for administering and treating severe sepsis and septic shock in children. Key words: systemic inflammatory response syndrome, sepsis, septic shock, children. (Pediatric Pharmacology. – 20...

  12. DIAGNOSTICS AND TREATMENT OF THE SEPSIS AND SEPTIC SHOCK IN CHILDREN

    Directory of Open Access Journals (Sweden)

    R.F. Tepaev

    2010-01-01

    Full Text Available Sepsis is one of the leading causes of mortality in children. Timely diagnosis is the most important condition of successful therapy for sepsis. The work provides modern recommendations for diagnosis of the systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock, sets out key guidelines for administering and treating severe sepsis and septic shock in children. Key words: systemic inflammatory response syndrome, sepsis, septic shock, children. (Pediatric Pharmacology. – 2010; 7(5:24-29

  13. Adjunctive Glucocorticoid Therapy in Patients with Septic Shock.

    Science.gov (United States)

    Venkatesh, Balasubramanian; Finfer, Simon; Cohen, Jeremy; Rajbhandari, Dorrilyn; Arabi, Yaseen; Bellomo, Rinaldo; Billot, Laurent; Correa, Maryam; Glass, Parisa; Harward, Meg; Joyce, Christopher; Li, Qiang; McArthur, Colin; Perner, Anders; Rhodes, Andrew; Thompson, Kelly; Webb, Steve; Myburgh, John

    2018-03-01

    Whether hydrocortisone reduces mortality among patients with septic shock is unclear. We randomly assigned patients with septic shock who were undergoing mechanical ventilation to receive hydrocortisone (at a dose of 200 mg per day) or placebo for 7 days or until death or discharge from the intensive care unit (ICU), whichever came first. The primary outcome was death from any cause at 90 days. From March 2013 through April 2017, a total of 3800 patients underwent randomization. Status with respect to the primary outcome was ascertained in 3658 patients (1832 of whom had been assigned to the hydrocortisone group and 1826 to the placebo group). At 90 days, 511 patients (27.9%) in the hydrocortisone group and 526 (28.8%) in the placebo group had died (odds ratio, 0.95; 95% confidence interval [CI], 0.82 to 1.10; P=0.50). The effect of the trial regimen was similar in six prespecified subgroups. Patients who had been assigned to receive hydrocortisone had faster resolution of shock than those assigned to the placebo group (median duration, 3 days [interquartile range, 2 to 5] vs. 4 days [interquartile range, 2 to 9]; hazard ratio, 1.32; 95% CI, 1.23 to 1.41; Pshock, the number of days alive and out of the ICU, the number of days alive and out of the hospital, the recurrence of mechanical ventilation, the rate of renal-replacement therapy, and the incidence of new-onset bacteremia or fungemia. Among patients with septic shock undergoing mechanical ventilation, a continuous infusion of hydrocortisone did not result in lower 90-day mortality than placebo. (Funded by the National Health and Medical Research Council of Australia and others; ADRENAL ClinicalTrials.gov number, NCT01448109 .).

  14. Early Trophic Enteral Nutrition Is Associated With Improved Outcomes in Mechanically Ventilated Patients With Septic Shock: A Retrospective Review.

    Science.gov (United States)

    Patel, Jayshil J; Kozeniecki, Michelle; Biesboer, Annie; Peppard, William; Ray, Ananda S; Thomas, Seth; Jacobs, Elizabeth R; Nanchal, Rahul; Kumar, Gagan

    2016-08-01

    Current guidelines provide weak recommendations for starting enteral nutrition (EN) in patients with septic shock (on vasopressor support). Outcomes of patients receiving EN in septic shock on vasopressor support have not been well studied. We hypothesize that early trophic EN in mechanically ventilated patients with septic shock is associated with improved outcomes. Single-center retrospective study of mechanically ventilated patients admitted with septic shock to identify patients receiving (1) no EN, (2) septic shock, those receiving septic shock. © The Author(s) 2014.

  15. Septic shock prediction for ICU patients via coupled HMM walking on sequential contrast patterns.

    Science.gov (United States)

    Ghosh, Shameek; Li, Jinyan; Cao, Longbing; Ramamohanarao, Kotagiri

    2017-02-01

    Critical care patient events like sepsis or septic shock in intensive care units (ICUs) are dangerous complications which can cause multiple organ failures and eventual death. Preventive prediction of such events will allow clinicians to stage effective interventions for averting these critical complications. It is widely understood that physiological conditions of patients on variables such as blood pressure and heart rate are suggestive to gradual changes over a certain period of time, prior to the occurrence of a septic shock. This work investigates the performance of a novel machine learning approach for the early prediction of septic shock. The approach combines highly informative sequential patterns extracted from multiple physiological variables and captures the interactions among these patterns via coupled hidden Markov models (CHMM). In particular, the patterns are extracted from three non-invasive waveform measurements: the mean arterial pressure levels, the heart rates and respiratory rates of septic shock patients from a large clinical ICU dataset called MIMIC-II. For baseline estimations, SVM and HMM models on the continuous time series data for the given patients, using MAP (mean arterial pressure), HR (heart rate), and RR (respiratory rate) are employed. Single channel patterns based HMM (SCP-HMM) and multi-channel patterns based coupled HMM (MCP-HMM) are compared against baseline models using 5-fold cross validation accuracies over multiple rounds. Particularly, the results of MCP-HMM are statistically significant having a p-value of 0.0014, in comparison to baseline models. Our experiments demonstrate a strong competitive accuracy in the prediction of septic shock, especially when the interactions between the multiple variables are coupled by the learning model. It can be concluded that the novelty of the approach, stems from the integration of sequence-based physiological pattern markers with the sequential CHMM model to learn dynamic

  16. Septic Shock after Intracervical Laminaria Insertion

    Directory of Open Access Journals (Sweden)

    Shin-Yu Lin

    2006-03-01

    Conclusion: The use of laminaria still places patients at risk for infection because there is a certain risk of ascending colonization with potentially pathogenic microorganisms from the vaginal and cervical microflora, as in our patient. Surgical disinfection, prophylactic antibiotics, and shortened duration of laminaria placement are helpful to prevent infectious insult. Once signs of infection are noted, physicians should take action as soon as possible, such as initiating broad-spectrum antibiotics and intensive care.

  17. Lower versus higher hemoglobin threshold for transfusion in septic shock.

    Science.gov (United States)

    Holst, Lars B; Haase, Nicolai; Wetterslev, Jørn; Wernerman, Jan; Guttormsen, Anne B; Karlsson, Sari; Johansson, Pär I; Aneman, Anders; Vang, Marianne L; Winding, Robert; Nebrich, Lars; Nibro, Helle L; Rasmussen, Bodil S; Lauridsen, Johnny R M; Nielsen, Jane S; Oldner, Anders; Pettilä, Ville; Cronhjort, Maria B; Andersen, Lasse H; Pedersen, Ulf G; Reiter, Nanna; Wiis, Jørgen; White, Jonathan O; Russell, Lene; Thornberg, Klaus J; Hjortrup, Peter B; Müller, Rasmus G; Møller, Morten H; Steensen, Morten; Tjäder, Inga; Kilsand, Kristina; Odeberg-Wernerman, Suzanne; Sjøbø, Brit; Bundgaard, Helle; Thyø, Maria A; Lodahl, David; Mærkedahl, Rikke; Albeck, Carsten; Illum, Dorte; Kruse, Mary; Winkel, Per; Perner, Anders

    2014-10-09

    Blood transfusions are frequently given to patients with septic shock. However, the benefits and harms of different hemoglobin thresholds for transfusion have not been established. In this multicenter, parallel-group trial, we randomly assigned patients in the intensive care unit (ICU) who had septic shock and a hemoglobin concentration of 9 g per deciliter or less to receive 1 unit of leukoreduced red cells when the hemoglobin level was 7 g per deciliter or less (lower threshold) or when the level was 9 g per deciliter or less (higher threshold) during the ICU stay. The primary outcome measure was death by 90 days after randomization. We analyzed data from 998 of 1005 patients (99.3%) who underwent randomization. The two intervention groups had similar baseline characteristics. In the ICU, the lower-threshold group received a median of 1 unit of blood (interquartile range, 0 to 3) and the higher-threshold group received a median of 4 units (interquartile range, 2 to 7). At 90 days after randomization, 216 of 502 patients (43.0%) assigned to the lower-threshold group, as compared with 223 of 496 (45.0%) assigned to the higher-threshold group, had died (relative risk, 0.94; 95% confidence interval, 0.78 to 1.09; P=0.44). The results were similar in analyses adjusted for risk factors at baseline and in analyses of the per-protocol populations. The numbers of patients who had ischemic events, who had severe adverse reactions, and who required life support were similar in the two intervention groups. Among patients with septic shock, mortality at 90 days and rates of ischemic events and use of life support were similar among those assigned to blood transfusion at a higher hemoglobin threshold and those assigned to blood transfusion at a lower threshold; the latter group received fewer transfusions. (Funded by the Danish Strategic Research Council and others; TRISS ClinicalTrials.gov number, NCT01485315.).

  18. Plasma cytokine levels predict response to corticosteroids in septic shock.

    Science.gov (United States)

    Bentzer, Peter; Fjell, Chris; Walley, Keith R; Boyd, John; Russell, James A

    2016-12-01

    To investigate if plasma cytokine concentrations predict a beneficial response to corticosteroid treatment in septic shock patients. A cohort of septic shock patients in whom a panel of 39 cytokines had been measured at baseline (n = 363) was included. Patients who received corticosteroids were propensity score matched to non-corticosteroid-treated patients. An optimal threshold to identify responders to corticosteroid treatment for each cytokine was defined as the concentration above which the odds ratio for 28-day survival between corticosteroid- and non-corticosteroid-treated patients was highest. Propensity score matching partitioned 165 patients into 61 sets; each set contained matched corticosteroid- and non-corticosteroid-treated patients. For 13 plasma cytokines threshold concentrations were found where the odds ratio for survival between corticosteroid- and non-corticosteroid-treated patients was significant (P highest odds ratio and identified 21 % of the patients in the propensity score matched cohort as responders to corticosteroid treatment. Combinations of triplets of cytokines with a significant odds ratio, using the thresholds identified above, were tested to find a higher proportion of responders. IL3, IL6, and CCL4 identified 50 % of the patients in the propensity score matched cohort as responders to corticosteroid treatment. The odds ratio for 28-day survival was 19 (95 % CI 3.5-140, P = 0.02) with a concentration above threshold for a least one of these cytokines. Plasma concentration of selected cytokines is a potential predictive biomarker to identify septic shock patients that may benefit from treatment with corticosteroids.

  19. Septic shock after intracervical laminaria insertion.

    Science.gov (United States)

    Lin, Shin-Yu; Cheng, Wen-Fang; Su, Yi-Ning; Chen, Chi-An; Lee, Chien-Nan

    2006-03-01

    Laminaria placement is seldom thought to be associated with postabortal sepsis. A nulliparous woman presented with high fever, low blood pressure, and signs of infection during artificial legal abortion with laminaria placement for cervical dilatation. Broad-spectrum antibiotics were given. Cultures of blood, placenta, and arterial line all yielded Enterobacter cloacae. The patient responded to antibiotics and supportive care. The use of laminaria still places patients at risk for infection because there is a certain risk of ascending colonization with potentially pathogenic microorganisms from the vaginal and cervical microflora, as in our patient. Surgical disinfection, prophylactic antibiotics, and shortened duration of laminaria placement are helpful to prevent infectious insult. Once signs of infection are noted, physicians should take action as soon as possible, such as initiating broad-spectrum antibiotics and intensive care.

  20. Experimental models of sepsis and septic shock: an overview

    Directory of Open Access Journals (Sweden)

    Garrido Alejandra G.

    2004-01-01

    Full Text Available Sepsis remains a major cause of morbidity and mortality in surgical patients and trauma victims, mainly due to sepsis-induced multiple organ dysfunction. In contrast to preclinical studies, most clinical trials of promising new treatment strategies for sepsis have fails to demonstrate efficacy. Although many reasons could account for this discrepancy, the misinterpretation of preclinical data obtained from experimental studies, and especially the use of animal models that do not adequately mimic human sepsis may have been contributing factors. In this review, the benefits and limitations of various animal models of sepsis are discussed to clarify the extend to which findings are relevant to human sepsis, particularly with respect to the subsequent design and execution of clinical trials. Such models include intravascular infusion of endotoxin or live bacteria, bacterial peritonitis, cecal ligation and perforation, soft tissue infection, pneumonia or meningitis models, using different animal species including rats, mice, rabbits, dogs, pigs, sheep and nonhuman primates. Despite several limitations, animal models remain essential in the development of all new therapies for sepsis and septic shock, because they provide fundamental information about the pharmacokinetics, toxicity, and mechanism of drug action that cannot be duplicated by other methods. New therapeutic agents should be studies in infection models, even after the initiation of the septic process. Furthermore, debility conditions need to be reproduced to avoid the exclusive use of healthy animals, which often do not represent the human septic patient.

  1. Developing a New Definition and Assessing New Clinical Criteria for Septic Shock For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

    NARCIS (Netherlands)

    Shankar-Hari, Manu; Phillips, Gary S.; Levy, Mitchell L.; Seymour, Christopher W.; Liu, Vincent X.; Deutschman, Clifford S.; Angus, Derek C.; Rubenfeld, Gordon D.; Singer, Mervyn; Angus, Derek; Annane, Djilalli; Bauer, Michael; Bellomo, Rinaldo; Bernard, Gordon; Chiche, Jean-Daniel; Coopersmith, Craig; Deutschman, Cliff; Hotchkiss, Richard; Levy, Mitchell; Marshall, John; Martin, Greg; Opal, Steve; Rubenfeld, Gordon; Seymour, Christopher; van der Poll, Tom; Vincent, Jean-Louis

    2016-01-01

    IMPORTANCE Septic shock currently refers to a state of acute circulatory failure associated with infection. Emerging biological insights and reported variation in epidemiology challenge the validity of this definition. OBJECTIVE To develop a new definition and clinical criteria for identifying

  2. Metabolomics as a novel approach for early diagnosis of pediatric septic shock and its mortality.

    Science.gov (United States)

    Mickiewicz, Beata; Vogel, Hans J; Wong, Hector R; Winston, Brent W

    2013-05-01

    Septic shock is a significant cause of morbidity and mortality in the pediatric population. Early recognition of septic shock and appropriate treatment increase survival rate; thus, developing new diagnostic tools may improve patients' outcomes. To determine whether a metabolomics approach could be useful in the diagnosis and prognosis of septic shock in pediatric intensive care unit (PICUs). Serum samples were collected from 60 patients with septic shock, 40 PICU patients with systemic inflammatory response syndrome (not suspected of having an infection), and 40 healthy children. Proton nuclear magnetic resonance spectroscopy spectra were analyzed and quantified using targeted profiling methodology. Multivariate statistical analysis was applied to detect specific patterns in metabolic profiles and to highlight differences between patient samples. Supervised analysis afforded good predictive models and managed to separate patient populations. Some of the metabolite concentrations identified in serum samples changed markedly, indicating their influence on the separation between patient groups. These metabolites represent a composite biopattern of the pediatric metabolic response to septic shock and might be considered as the basis for a biomarker panel for the diagnosis of septic shock and its mortality in PICU. Our results indicate that nuclear magnetic resonance metabolite profiling might serve as a promising approach for the diagnosis and prediction of mortality in septic shock in a pediatric population and that quantitative metabolomics methods can be applied in the clinical evaluations of pediatric septic shock.

  3. Restricting volumes of resuscitation fluid in adults with septic shock after initial management

    DEFF Research Database (Denmark)

    Hjortrup, Peter B; Haase, Nicolai; Bundgaard, Helle

    2016-01-01

    PURPOSE: We assessed the effects of a protocol restricting resuscitation fluid vs. a standard care protocol after initial resuscitation in intensive care unit (ICU) patients with septic shock. METHODS: We randomised 151 adult patients with septic shock who had received initial fluid resuscitation...

  4. Initial fluid resuscitation of patients with septic shock in the intensive care unit

    DEFF Research Database (Denmark)

    Carlsen, Sarah; Perner, A

    2011-01-01

    Fluid is the mainstay of resuscitation of patients with septic shock, but the optimal composition and volume are unknown. Our aim was to evaluate the current initial fluid resuscitation practice in patients with septic shock in the intensive care unit (ICU) and patient characteristics and outcome...... associated with fluid volume....

  5. Initial fluid resuscitation of patients with septic shock in the intensive care unit

    DEFF Research Database (Denmark)

    Carlsen, Sarah; Perner, A

    2011-01-01

    Fluid is the mainstay of resuscitation of patients with septic shock, but the optimal composition and volume are unknown. Our aim was to evaluate the current initial fluid resuscitation practice in patients with septic shock in the intensive care unit (ICU) and patient characteristics and outcome...

  6. Consecutive daily measurements of luminal concentrations of lactate in the rectum in septic shock patients

    DEFF Research Database (Denmark)

    Ibsen, Michael; Wiis, Jørgen; Waldau, Tina

    2012-01-01

    In a recent study we found no difference in the concentrations of luminal lactate in the rectum between nonsurvivors and survivors in early septic shock (......In a recent study we found no difference in the concentrations of luminal lactate in the rectum between nonsurvivors and survivors in early septic shock (...

  7. Lactate concentrations in the rectal lumen in patients in early septic shock

    DEFF Research Database (Denmark)

    Ibsen, Michael; Tenhunen, J.; Wiis, J.

    2010-01-01

    Previously, we observed that rectal luminal lactate was higher in non-survivors compared with survivors of severe sepsis or septic shock persisting >24 h. The present study was initiated to further investigate this tentative association between rectal luminal lactate and mortality in a larger...... population of patients in early septic shock....

  8. Early hemodynamic resuscitation in septic shock : understanding and modifying oxygen delivery

    NARCIS (Netherlands)

    van Beest, Paul A.; Spronk, Peter E.

    2014-01-01

    In a previous issue of Critical Care, researchers have focused on the venous-to-arterial carbon dioxide difference (Pv-aCO(2)) as a surrogate marker for systemic perfusion in patients with septic shock. Although the complex mechanisms responsible for an increased Pv-aCO(2) in septic shock need to be

  9. A holistic approach for perfusion assessment in septic shock: Basic foundations and clinical applications

    NARCIS (Netherlands)

    Hernández Poblete, G.W.

    2013-01-01

    A fundamental challenge in septic shock resuscitation is to evaluate tissue perfusion. In this thesis, we review the basic foundations for the development of a comprehensive and holistic model for perfusion assessment in septic shock, and outline its application to evaluate the impact of

  10. Factors associated with severe sepsis or septic shock in complicated pyelonephritis.

    Science.gov (United States)

    Ruiz-Mesa, Juan D; Marquez-Gomez, Ignacio; Sena, Gabriel; Buonaiuto, Veronica A; Ordoñez, Juan Mora; Salido, Manuel; Ciézar, Antonio Plata; Santis, Lucía Valiente-De; Mediavilla, Concepción; Colmenero, Juan D

    2017-10-01

    Severe sepsis or septic shock are the main factors influencing the prognosis of acute pyelonephritis (APN). Our aim was to analyze factors associated with the development of severe sepsis or septic shock in a large sample of patients with acute complicated pyelonephritis (ACPN).This prospective observational study comprised 1507 consecutive patients aged 14 years or older who were admitted to a tertiary care hospital because of ACPN between 1997 and 2015. Covariates associated in univariate analysis with severe sepsis or septic shock were then analyzed by multivariate logistic regression.Of the 1507 patients, 423 (28.1%) fulfilled the criteria for severe sepsis or septic shock at the time of admission. Crude and attributable mortality at 30 days were 17.7% and 11.7% in patients with severe sepsis or septic shock versus 1.7% and 0.6% in patients without severe sepsis or septic shock, P  65 years, urinary instrumentation in the previous 2 weeks, the lack of mictional syndrome or costovertebral tenderness, an ectasia ≥ grade II, and bacteremia were independent risk factors associated with severe sepsis or septic shock.The prevalence of severe sepsis and septic shock in patients with ACPN is high. Some factors associated with severe sepsis are easy to identify in any emergency department. The information provided here could be useful when deciding which patients should be admitted to receive immediate treatment.

  11. Survivors of septic shock caused by Neisseria meningitidis in childhood : Psychosocial outcomes in young adulthood

    NARCIS (Netherlands)

    Vermunt, Lindy C.; Buysse, Corinne M.; Joosten, Koen F.; Duivenvoorden, Hugo J.; Hazelzet, Jan A.; Verhulst, Frank C.; Utens, Elisabeth M.

    2011-01-01

    Objective: To investigate long-term psychosocial outcomes in young adults who survived septic shock caused by Neisseria meningitidis (meningococcal septic shock) during childhood. Design: A cross-sectional study. Setting: The psychological investigation took place in the department of Child and

  12. Refractory septic shock in children : a European Society of Paediatric and Neonatal Intensive Care definition

    NARCIS (Netherlands)

    Morin, Luc; Ray, Samiran; Wilson, Clare; Remy, Solenn; Benissa, Mohamed Rida; Jansen, Nicolaas J. G.; Javouhey, Etienne; Peters, Mark J.; Kneyber, Martin; De Luca, Daniele; Nadel, Simon; Schlapbach, Luregn Jan; Maclaren, Graeme; Tissieres, Pierre

    2016-01-01

    Although overall paediatric septic shock mortality is decreasing, refractory septic shock (RSS) is still associated with high mortality. A definition for RSS is urgently needed to facilitate earlier identification and treatment. We aim to establish a European society of paediatric and neonatal

  13. Survivors of septic shock caused by Neisseria meningitidis in childhood: psychosocial outcomes in young adulthood

    NARCIS (Netherlands)

    Vermunt, Lindy C.; Buysse, Corinne M.; Joosten, Koen F.; Duivenvoorden, Hugo J.; Hazelzet, Jan A.; Verhulst, Frank C.; Utens, Elisabeth M.

    2011-01-01

    To investigate long-term psychosocial outcomes in young adults who survived septic shock caused by Neisseria meningitidis (meningococcal septic shock) during childhood. A cross-sectional study. The psychological investigation took place in the department of Child and Adolescent Psychiatry of the

  14. A survey of corticosteroid use for the management of septic shock

    African Journals Online (AJOL)

    2012-02-12

    Feb 12, 2012 ... fields in which there is little support for its efficacy, e.g. extended durations of administration, use in sepsis without hypotension, and use in non-septic shock. Unfortunately, the literature has not demonstrated a clear benefit regarding steroid administration for septic shock. A high-quality meta-analysis of 17 ...

  15. Similar change in platelets and leucocytes 24 h after injury is associated with septic shock a week later

    NARCIS (Netherlands)

    Jol, Saskia; Hietbrink, Falco|info:eu-repo/dai/nl/304821713; Leenen, Luke P.H.|info:eu-repo/dai/nl/071390596; Koenderman, Leo|info:eu-repo/dai/nl/074929798; van Wessem, Karlijn J.P.|info:eu-repo/dai/nl/337932077

    2017-01-01

    Background: Septic shock is a severe complication in polytrauma patients. Early identification of patients at risk can guide future prevention strategies. Platelets (PLTs) and leucocytes presumably play an important role in the post-injury inflammatory response. The role of early changes in PLT and

  16. Septic shock with no diagnosis at 24 hours: a pragmatic multicenter prospective cohort study.

    Science.gov (United States)

    Contou, Damien; Roux, Damien; Jochmans, Sébastien; Coudroy, Rémi; Guérot, Emmanuel; Grimaldi, David; Ricome, Sylvie; Maury, Eric; Plantefève, Gaëtan; Mayaux, Julien; Mekontso Dessap, Armand; Brun-Buisson, Christian; de Prost, Nicolas

    2016-11-06

    The lack of a patent source of infection after 24 hours of management of shock considered septic is a common and disturbing scenario. We aimed to determine the prevalence and the causes of shock with no diagnosis 24 hours after its onset, and to compare the outcomes of patients with early-confirmed septic shock to those of others. We conducted a pragmatic, prospective, multicenter observational cohort study in ten intensive care units (ICU) in France. We included all consecutive patients admitted to the ICU with suspected septic shock defined by clinical suspicion of infection leading to antibiotic prescription plus acute circulatory failure requiring vasopressor support. A total of 508 patients were admitted with suspected septic shock. Among them, 374 (74 %) had early-confirmed septic shock, while the 134 others (26 %) had no source of infection identified nor microbiological documentation retrieved 24 hours after shock onset. Among these, 37/134 (28 %) had late-confirmed septic shock diagnosed after 24 hours, 59/134 (44 %) had a condition mimicking septic (septic shock mimicker, mainly related to adverse drug reactions, acute mesenteric ischemia and malignancies) and 38/134 (28 %) had shock of unknown origin by the end of the ICU stay. There were no differences between patients with early-confirmed septic shock and the remainder in ICU mortality and the median duration of ICU stay, of tracheal intubation and of vasopressor support. The multivariable Cox model showed that the risk of day-60 mortality did not differ between patients with or without early-confirmed septic shock. A sensitivity analysis was performed in the subgroup (n = 369/508) of patients meeting the Sepsis-3 definition criteria and displayed consistent results. One quarter of the patients admitted in the ICU with suspected septic shock had no infection identified 24 hours after its onset and almost half of them were eventually diagnosed with a septic shock mimicker. Outcome did not differ

  17. Value of Serum Cholinesterase Activity in the Diagnosis of Septic Shock Due to Bacterial Infections.

    Science.gov (United States)

    Bahloul, Mabrouk; Baccouch, Najeh; Chtara, Kamilia; Turki, Mouna; Turki, Olfa; Hamida, Chokri Ben; Chelly, Hedi; Ayedi, Fatma; Chaari, Anis; Bouaziz, Mounir

    2017-06-01

    We aimed to investigate whether serum cholinesterase (SChE) activity can be helpful for the diagnosis of septic shock and to evaluate its usefulness in comparison with procalcitonin (PCT) and C-reactive protein (CRP). A prospective single-blinded study conducted in an intensive care unit of university hospital. Patients were classified as having cardiogenic shock, septic shock, or hemorrhagic shock. We also included a control group without neither hemodynamic instability nor sepsis. For all included patients, SChE, PCT, and CRP were simultaneously sampled. The comparison of sepsis markers between all groups showed that the mean values of PCT and CRP were significantly higher in patients with septic shock. However, SChE activity was significantly lower in this group. The SChE activity was found to be more accurate than PCT and CRP for the diagnosis of septic shock. In fact, an SChE activity ≤ 4000 UI/L predicted the diagnosis of septic shock with a sensitivity of 78%, a specificity of 89%, a predictive negative value of 97%, and a predictive positive value of 65%. However, the prognostic value of SChE activity was poor in multivariate analysis. The SChE activity level was significantly decreased in patients with septic shock. However, its prognostic value is poor. Our results suggest that SChE activity is useful for the diagnosis of septic shock. Further studies are warranted to confirm our findings.

  18. Incidence and pattern of brain lesions in paediatric septic shock patients.

    Science.gov (United States)

    Sanz, Debora; D'Arco, Felice; Robles, Carlos Andres; Brierley, Joe

    2018-04-01

    Brain injury is frequently observed during septic shock and may be primarily related to the direct effects of the septic insult on the brain or to secondary/indirect injuries (e.g. hypotension, hypoxaemia and hyperglycaemia). We sought to assess incidence and pattern of brain lesions diagnosed by neuroimaging in paediatric septic shock patients. Retrospective descriptive hospital-based study included paediatric patients with a single episode of septic shock admitted to our tertiary paediatric intensive care unit from January 2010 to December 2013. 49 of 193 septic shock patients had a neuroimaging examination [CT only 22 (45%), MRI only 14 (29%) and both 13 (27%)]. Neuroimaging was normal in 16 patients (33%) and showed acute lesions in 20 patients (40%). The most frequent findings were: cerebral infarcts/hypoxic ischaemic injury in 8 (16%) and cerebritis in 7 (14%). The incidence of acute brain lesion in our septic shock cohort was 10% (20 of 193). The diagnosis of brain dysfunction in septic shock patients relies essentially on neurological examination and neurological tests, such as electroencephalography and neuroimaging. Neuroimaging can reveal acute intracerebral structural lesions and their reversibility, helping with management and prognosis. Advances in knowledge: Ischaemic lesions and cerebritis are the most common brain anomalies complicating paediatric septic shock.

  19. Is shock index associated with outcome in children with sepsis/septic shock?*.

    Science.gov (United States)

    Yasaka, Yuki; Khemani, Robinder G; Markovitz, Barry P

    2013-10-01

    To investigate the association between PICU shock index (the ratio of heart rate to systolic blood pressure) and PICU mortality in children with sepsis/septic shock. To explore cutoff values for shock index for ICU mortality, how change in shock index over the first 6 hours of ICU admission is associated with outcome, and how the use of vasoactive therapy may affect shock index and its association with outcome. Retrospective cohort. Single-center tertiary PICU. Five hundred forty-four children with the diagnosis of sepsis/septic shock. None. From January 2003 to December 2009, 544 children met International Pediatric Sepsis Consensus Conference of 2005 criteria for sepsis/septic shock. Overall mortality was 23.7%. Among all patients, hourly shock index was associated with mortality: odds ratio of ICU mortality at 0 hour, 1.08, 95% CI (1.04-1.12); odds ratio at 1 hour, 1.09 (1.04-1.13); odds ratio at 2 hours, 1.09 (1.05-1.13); and odds ratio at 6 hours, 1.11 (1.06-1.15). When stratified by age, early shock index was associated with mortality only in children 1-3 and more than or equal to 12 years old. Area under the receiver operating characteristic curve in age 1-3 and more than or equal to 12 years old for shock index at admission was 0.69 (95% CI, 0.58-0.80) and 0.62 (95% CI, 0.52-0.72) respectively, indicating a fair predictive marker. Although higher shock index was associated with increased risk of mortality, there was no particular cutoff value with adequate positive or negative likelihood ratios to identify mortality in any age group of children. The improvement of shock index in the first 6 hours of ICU admission was not associated with outcome when analyzed in all patients. However, among patients whose shock index were above the 50th percentile at ICU admission for each age group, improvement of shock index was associated with lower ICU mortality in children between 1-3 and more than or equal to 12 years old (p = 0.02 and p = 0.03, respectively). When

  20. Bench-to-bedside review: Vasopressin in the management of septic shock

    Science.gov (United States)

    2011-01-01

    This review of vasopressin in septic shock differs from previous reviews by providing more information on the physiology and pathophysiology of vasopressin and vasopressin receptors, particularly because of recent interest in more specific AVPR1a agonists and new information from the Vasopressin and Septic Shock Trial (VASST), a randomized trial of vasopressin versus norepinephrine in septic shock. Relevant literature regarding vasopressin and other AVPR1a agonists was reviewed and synthesized. Vasopressin, a key stress hormone in response to hypotension, stimulates a family of receptors: AVPR1a, AVPR1b, AVPR2, oxytocin receptors and purinergic receptors. Rationales for use of vasopressin in septic shock are as follows: first, a deficiency of vasopressin in septic shock; second, low-dose vasopressin infusion improves blood pressure, decreases requirements for norepinephrine and improves renal function; and third, a recent randomized, controlled, concealed trial of vasopressin versus norepinephrine (VASST) suggests low-dose vasopressin may decrease mortality of less severe septic shock. Previous clinical studies of vasopressin in septic shock were small or not controlled. There was no difference in 28-day mortality between vasopressin-treated versus norepinephrine-treated patients (35% versus 39%, respectively) in VASST. There was potential benefit in the prospectively defined stratum of patients with less severe septic shock (5 to 14 μg/minute norepinephrine at randomization): vasopressin may have lowered mortality compared with norepinephrine (26% versus 36%, respectively, P = 0.04 within stratum). The result was robust: vasopressin also decreased mortality (compared with norepinephrine) if less severe septic shock was defined by the lowest quartile of arterial lactate or by use of one (versus more than one) vasopressor at baseline. Other investigators found greater hemodynamic effects of higher dose of vasopressin (0.06 units/minute) but also unique adverse

  1. Characteristics and outcomes of patients with vasoplegic versus tissue dysoxic septic shock.

    Science.gov (United States)

    Sterling, Sarah A; Puskarich, Michael A; Shapiro, Nathan I; Trzeciak, Stephen; Kline, Jeffrey A; Summers, Richard L; Jones, Alan E

    2013-07-01

    The current consensus definition of septic shock requires hypotension after adequate fluid challenge or vasopressor requirement. Some patients with septic shock present with hypotension and hyperlactatemia greater than 2 mmol/L (tissue dysoxic shock), whereas others have hypotension alone with normal lactate (vasoplegic shock). The objective of this study was to determine differences in outcomes of patients with tissue dysoxic versus vasoplegic septic shock. This was a secondary analysis of a large, multicenter randomized controlled trial. Inclusion criteria were suspected infection, two or more systemic inflammatory response criteria, and systolic blood pressure less than 90 mmHg after a fluid bolus. Patients were categorized by presence of vasoplegic or tissue dysoxic shock. Demographics and Sequential Organ Failure Assessment scores were evaluated between the groups. The primary outcome was in-hospital mortality. A total of 247 patients were included, 90 patients with vasoplegic shock and 157 with tissue dysoxic shock. There were no significant differences in age, race, or sex between the vasoplegic and tissue dysoxic shock groups. The group with vasoplegic shock had a lower initial Sequential Organ Failure Assessment score than did the group with tissue dysoxic shock (5.5 vs. 7.0 points; P = 0.0002). The primary outcome of in-hospital mortality occurred in 8 (9%) of 90 patients with vasoplegic shock compared with 41 (26%) of 157 in the group with tissue dysoxic shock (proportion difference, 17%; 95% confidence interval, 7%-26%; P shock remained an independent predictor of in-hospital mortality. In this analysis of patients with septic shock, we found a significant difference in in-hospital mortality between patients with vasoplegic versus tissue dysoxic septic shock. These findings suggest a need to consider these differences when designing future studies of septic shock therapies.

  2. Group A Streptococcus Septic Shock after Surgical Abortion: A Case Report and Review of the Literature

    OpenAIRE

    Tardieu, Stephanie C.; Schmidt, Elizabeth

    2017-01-01

    Group A Streptococcus (GAS) causing puerperal sepsis is a leading cause of maternal mortality worldwide. Although rare, GAS infection is a relatively significant public health concern because of its propensity to evolve rapidly into septic shock, streptococcal toxic shock syndrome, and death. We report the case of a 27-year-old patient who presented with GAS septic shock after undergoing a surgical termination of pregnancy and was treated successfully and recovered without sequelae. GAS septi...

  3. Necrotizing Fasciitis Secondary to Aeromonas Infection Presenting with Septic Shock

    Directory of Open Access Journals (Sweden)

    Nikhil Bhatia

    2017-01-01

    Full Text Available This report describes a case of necrotizing fasciitis presenting with septic shock due to an Aeromonas infection. The patient cut his foot while mowing the lawn and then spent time in a pool with black mold. He began feeling ill and developed swelling and a quarter-sized black area on his right lower extremity. Despite being hemodynamically unstable with systolic blood pressure in the low 70s, the patient was transferred to our facility from outside hospital 100 miles away. Upon arriving to facility, the patient appeared to be septic and the infected area of skin had grown. Irrigation and debridement were performed and appropriate antibiotic therapy was given; however, the patient subsequently died on hospital day 8. On review of the literature, cases of necrotizing fasciitis due to Aeromonas infection have been treated successfully with the aforementioned therapy; however, there is high mortality associated with these infections, many times related to a delayed diagnosis. Our patient also had multiple poor prognostic factors including hepatic dysfunction and immunosuppression.

  4. Predictors of septic shock in initially stable patients with pyogenic liver abscess.

    Science.gov (United States)

    Cho, Hyunyoung; Lee, Eu Sun; Lee, Yoon-Seon; Kim, Youn-Jung; Sohn, Chang Hwan; Ahn, Shin; Seo, Dong-Woo; Lee, Jae Ho; Kim, Won Young; Lim, Kyung Soo

    2017-05-01

    The incidence of pyogenic liver abscess (PLA), a life-threatening condition, is increasing worldwide. This study was designed to evaluate clinical features and outcomes in initially stable patients with PLA and to determine the predictors of septic shock. The medical records of all adult patients who were hemodynamically stable and diagnosed with PLA in the emergency department from January 2010 to December 2014, inclusive, were reviewed. The primary outcome was septic shock. A review of medical records identified 453 patients (66.7% male), of mean age 61.4 years, diagnosed with PLA. Of these patients, 73 (16.1%) had septic shock and 10 (2.2%) died in-hospital. Of the 73 patients with septic shock, nine (12.3%) died in-hospital. The most common symptom was fever (79.5%), and the most common infectious agent was Klebsiella pneumoniae. Septic shock was significantly associated with age ≥60 years [odds ratio (OR): 2.99, 95% confidence interval (CI): 1.38-6.48], malignancy (OR: 2.11, 95% CI: 1.08-4.09), systolic blood pressure Septic shock also tended to be associated with procalcitonin concentration, but this was not statistically significant (OR: 3.42, 95% CI: 0.96-12.18). Septic shock was frequent in initially stable patients with PLA and was associated with older age, malignancy, low blood pressure, tachypnea and elevated lactate concentration.

  5. Group A Streptococcus Septic Shock after Surgical Abortion: A Case Report and Review of the Literature

    Directory of Open Access Journals (Sweden)

    Stephanie C. Tardieu

    2017-01-01

    Full Text Available Group A Streptococcus (GAS causing puerperal sepsis is a leading cause of maternal mortality worldwide. Although rare, GAS infection is a relatively significant public health concern because of its propensity to evolve rapidly into septic shock, streptococcal toxic shock syndrome, and death. We report the case of a 27-year-old patient who presented with GAS septic shock after undergoing a surgical termination of pregnancy and was treated successfully and recovered without sequelae. GAS septic shock should always be included in the differential diagnosis of any patient who develops sepsis after a surgical abortion. Patients with GAS septic shock have a rapid clinical decline and need aggressive fluid management, early initiation of broad-spectrum antibiotics, and rapid surgical intervention.

  6. Immediate effects of chest physiotherapy on hemodynamic, metabolic, and oxidative stress parameters in subjects with septic shock.

    Science.gov (United States)

    dos Santos, Rafael S; Donadio, Márcio V F; da Silva, Gabriela V; Blattner, Clarissa N; Melo, Denizar A S; Nunes, Fernanda B; Dias, Fernando S; Squizani, Eamim D; Pedrazza, Leonardo; Gadegast, Isabella; de Oliveira, Jarbas R

    2014-09-01

    Septic shock presents as a continuum of infectious events, generating tissue hypoxia and hypovolemia, and increased oxidative stress. Chest physiotherapy helps reduce secretion, improving dynamic and static compliance, as well as improving secretion clearance and preventing pulmonary complications. The purpose of this study was to evaluate the immediate effect of chest physiotherapy on hemodynamic, metabolic, inflammatory, and oxidative stress parameters in subjects in septic shock. We conducted a quasi-experimental study in 30 subjects in septic shock, who underwent chest physiotherapy, without associated heart diseases and with vasopressors physiotherapy. Thirty subjects with a mean age of 61.8 ± 15.9 y and Sequential Organ Failure Assessment of 8 (range 6-10) were included. Chest physiotherapy caused a normalization of pH (P = .046) and P(aCO2) (P = .008); reduction of lactate (P = .001); and an increase in P(aO2) (P = .03), arterial oxygen saturation (P = .02), and P(aO2)/F(IO2) (P = .034), 15 min after it was applied. The results indicate that chest physiotherapy has immediate effects, improving oxygenation and reducing lactate and oxidative damage in subjects in septic shock. However, it does not cause alterations in the inflammatory and hemodynamic parameters. Copyright © 2014 by Daedalus Enterprises.

  7. Hydrocortisone plus Fludrocortisone for Adults with Septic Shock.

    Science.gov (United States)

    Annane, Djillali; Renault, Alain; Brun-Buisson, Christian; Megarbane, Bruno; Quenot, Jean-Pierre; Siami, Shidasp; Cariou, Alain; Forceville, Xavier; Schwebel, Carole; Martin, Claude; Timsit, Jean-François; Misset, Benoît; Ali Benali, Mohamed; Colin, Gwenhael; Souweine, Bertrand; Asehnoune, Karim; Mercier, Emmanuelle; Chimot, Loïc; Charpentier, Claire; François, Bruno; Boulain, Thierry; Petitpas, Franck; Constantin, Jean-Michel; Dhonneur, Gilles; Baudin, François; Combes, Alain; Bohé, Julien; Loriferne, Jean-François; Amathieu, Roland; Cook, Fabrice; Slama, Michel; Leroy, Olivier; Capellier, Gilles; Dargent, Auguste; Hissem, Tarik; Maxime, Virginie; Bellissant, Eric

    2018-03-01

    Septic shock is characterized by dysregulation of the host response to infection, with circulatory, cellular, and metabolic abnormalities. We hypothesized that therapy with hydrocortisone plus fludrocortisone or with drotrecogin alfa (activated), which can modulate the host response, would improve the clinical outcomes of patients with septic shock. In this multicenter, double-blind, randomized trial with a 2-by-2 factorial design, we evaluated the effect of hydrocortisone-plus-fludrocortisone therapy, drotrecogin alfa (activated), the combination of the three drugs, or their respective placebos. The primary outcome was 90-day all-cause mortality. Secondary outcomes included mortality at intensive care unit (ICU) discharge and hospital discharge and at day 28 and day 180 and the number of days alive and free of vasopressors, mechanical ventilation, or organ failure. After drotrecogin alfa (activated) was withdrawn from the market, the trial continued with a two-group parallel design. The analysis compared patients who received hydrocortisone plus fludrocortisone with those who did not (placebo group). Among the 1241 patients included in the trial, the 90-day mortality was 43.0% (264 of 614 patients) in the hydrocortisone-plus-fludrocortisone group and 49.1% (308 of 627 patients) in the placebo group (P=0.03). The relative risk of death in the hydrocortisone-plus-fludrocortisone group was 0.88 (95% confidence interval, 0.78 to 0.99). Mortality was significantly lower in the hydrocortisone-plus-fludrocortisone group than in the placebo group at ICU discharge (35.4% vs. 41.0%, P=0.04), hospital discharge (39.0% vs. 45.3%, P=0.02), and day 180 (46.6% vs. 52.5%, P=0.04) but not at day 28 (33.7% and 38.9%, respectively; P=0.06). The number of vasopressor-free days to day 28 was significantly higher in the hydrocortisone-plus-fludrocortisone group than in the placebo group (17 vs. 15 days, Pseptic shock, 90-day all-cause mortality was lower among those who received

  8. Pneumococcal pneumonia presenting with septic shock: host- and pathogen-related factors and outcomes.

    Science.gov (United States)

    Garcia-Vidal, C; Ardanuy, C; Tubau, F; Viasus, D; Dorca, J; Liñares, J; Gudiol, F; Carratalà, J

    2010-01-01

    Host- and pathogen-related factors associated with septic shock in pneumococcal pneumonia are not well defined. The aim of this study was to identify risk factors for septic shock and to ascertain patient outcomes. Serotypes, genotypes and antibiotic resistance of isolated strains were also analysed. Observational analysis of a prospective cohort of non-severely immunosuppressed hospitalised adults with pneumococcal pneumonia. Septic shock was defined as a systolic blood pressure of 4 h after fluid replacement. 1041 patients with pneumococcal pneumonia diagnosed by Gram stain and culture of appropriate samples and/or urine antigen test were documented, of whom 114 (10.9%) had septic shock at admission. After adjustment, independent risk factors for shock were current tobacco smoking (OR, 2.11; 95% CI, 1.02 to 4.34; p = 0.044), chronic corticosteroid treatment (OR, 4.45; 95% CI, 1.75 to 11.32; p = 0.002) and serotype 3 (OR, 2.24; 95% CI, 1.12 to 4.475; p = 0.022). No significant differences were found in genotypes and rates of antibiotic resistance. Compared with the remaining patients, patients with septic shock required mechanical ventilation more frequently (37% vs 4%; pshock. Septic shock is a frequent complication of pneumococcal pneumonia and causes high morbidity and mortality. Current tobacco smoking, chronic corticosteroid treatment and infection caused by serotype 3 are independent risk factors for this complication.

  9. Depressed left ventricular performance. Response to volume infusion in patients with sepsis and septic shock

    International Nuclear Information System (INIS)

    Ognibene, F.P.; Parker, M.M.; Natanson, C.; Shelhamer, J.H.; Parrillo, J.E.

    1988-01-01

    Volume infusion, to increase preload and to enhance ventricular performance, is accepted as initial management of septic shock. Recent evidence has demonstrated depressed myocardial function in human septic shock. We analyzed left ventricular performance during volume infusion using serial data from simultaneously obtained pulmonary artery catheter hemodynamic measurements and radionuclide cineangiography. Critically ill control subjects (n = 14), patients with sepsis but without shock (n = 21), and patients with septic shock (n = 21) had prevolume infusion hemodynamic measurements determined and received statistically similar volumes of fluid resulting in similar increases in pulmonary capillary wedge pressure. There was a strong trend (p = 0.004) toward less of a change in left ventricular stroke work index (LVSWI) after volume infusion in patients with sepsis and septic shock compared with control subjects. The LVSWI response after volume infusion was significantly less in patients with septic shock when compared with critically ill control subjects (p less than 0.05). These data demonstrate significantly altered ventricular performance, as measured by LVSWI, in response to volume infusion in patients with septic shock

  10. Plasma Nuclear and Mitochondrial DNA Levels, and Markers of Inflammation, Shock, and Organ Damage in Patients with Septic Shock.

    Science.gov (United States)

    Timmermans, Kim; Kox, Matthijs; Scheffer, Gert Jan; Pickkers, Peter

    2016-06-01

    Plasma levels of the danger-associated molecular patterns (DAMPs) nuclear DNA (nDNA) and mitochondrial DNA (mtDNA) have been shown to be related to sepsis mortality. However, the intermediate factors and/or mechanisms contributing to this relation are largely unknown. Our aim was to determine whether plasma levels of nDNA and mtDNA are related to the markers of inflammation, severity of shock, and organ damage in septic shock patients. Moreover, we investigated the relationship between plasma levels of nDNA/mtDNA and inflammatory cytokines during experimental human endotoxemia, a model of systemic inflammation in humans in vivo mimicking some of the hallmarks of early sepsis. Blood was sampled from the onset of septic shock until day 28 in 121 septic shock patients and from 1 h before endotoxin administration until 8 h afterward in 12 healthy volunteers. Plasma concentrations of five cytokines and circulating levels of nDNA and mtDNA were measured, and correlations with shock-related parameters and markers of organ damage were investigated. In septic shock patients plasma cytokine concentrations, as well as nDNA and mtDNA levels, were increased at the onset of septic shock and remained elevated. During the first 5 days of septic shock, nDNA levels consistently correlated with plasma cytokine concentrations as well as with the shock-related parameter norepinephrine infusion rate and markers of organ damage (total bilirubin and creatinine). Experimental human endotoxemia also resulted in increased levels of plasma nDNA and mtDNA, but to a lesser extent than in septic shock patients. Furthermore, nDNA levels correlated with pro-inflammatory cytokines during endotoxemia. Our findings indicate a relationship between plasma nDNA levels and the inflammatory response. Furthermore, nDNA levels are associated with markers of shock and organ damage in septic shock patients. Nevertheless, the correlations found are relatively weak and it remains to be determined whether n

  11. Transfusion requirements in septic shock (TRISS) trial - comparing the effects and safety of liberal versus restrictive red blood cell transfusion in septic shock patients in the ICU

    DEFF Research Database (Denmark)

    Holst, Lars B; Haase, Nicolai; Wetterslev, Jørn

    2013-01-01

    BACKGROUND: Transfusion of red blood cells (RBC) is recommended in septic shock and the majority of these patients receive RBC transfusion in the intensive care unit (ICU). However, benefit and harm of RBCs have not been established in this group of high-risk patients. METHODS: The Transfusion...... Requirements in Septic Shock (TRISS) trial is a multicenter trial with assessor-blinded outcome assessment, randomising 1,000 patients with septic shock in 30 Scandinavian ICUs to receive transfusion with pre-storage leuko-depleted RBC suspended in saline-adenine-glucose and mannitol (SAGM) at haemoglobin...... and transfusion-related circulatory overload, and acute lung injury) and mortality at 28 days, 6 months and 1 year.The sample size will enable us to detect a 9% absolute difference in 90-day mortality assuming a 45% event rate with a type 1 error rate of 5% and power of 80%. An interim analysis will be performed...

  12. High-performance detection and early prediction of septic shock for alcohol-use disorder patients

    Directory of Open Access Journals (Sweden)

    Jacob Calvert

    2016-06-01

    Conclusions: Analysis of the higher order correlations and trends between relevant clinical measurements using the InSight algorithm leads to more accurate detection and prediction of septic shock, even in cases where diagnosis may be confounded by AUD.

  13. STRUCTURAL CHANGES OF THE HEART DURING SEVERE SEPSIS OR SEPTIC SHOCK

    NARCIS (Netherlands)

    Smeding, Lonneke; Plotz, Frans B.; Groeneveld, A. B. Johan; Kneyber, Martin C. J.

    Cardiovascular dysfunction is common in severe sepsis or septic shock. Although functional alterations are often described, the elevated serum levels of cardiac proteins and autopsy findings of myocardial immune cell infiltration, edema, and damaged mitochondria suggest that structural changes to

  14. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

    NARCIS (Netherlands)

    Rhodes, Andrew; Evans, Laura E.; Alhazzani, Waleed; Levy, Mitchell M.; Antonelli, Massimo; Ferrer, Ricard; Kumar, Anand; Sevransky, Jonathan E.; Sprung, Charles L.; Nunnally, Mark E.; Rochwerg, Bram; Rubenfeld, Gordon D.; Angus, Derek C.; Annane, Djillali; Beale, Richard J.; Bellinghan, Geoffrey J.; Bernard, Gordon R.; Chiche, Jean-Daniel; Coopersmith, Craig; de Backer, Daniel P.; French, Craig J.; Fujishima, Seitaro; Gerlach, Herwig; Hidalgo, Jorge Luis; Hollenberg, Steven M.; Jones, Alan E.; Karnad, Dilip R.; Kleinpell, Ruth M.; Koh, Younsuck; Lisboa, Thiago Costa; Machado, Flavia R.; Marini, John J.; Marshall, John C.; Mazuski, John E.; McIntyre, Lauralyn A.; McLean, Anthony S.; Mehta, Sangeeta; Moreno, Rui P.; Myburgh, John; Navalesi, Paolo; Nishida, Osamu; Osborn, Tiffany M.; Perner, Anders; Plunkett, Colleen M.; Ranieri, Marco; Schorr, Christa A.; Seckel, Maureen A.; Seymour, Christopher W.; Shieh, Lisa; Shukri, Khalid A.; Simpson, Steven Q.; Singer, Mervyn; Thompson, B. Taylor; Townsend, Sean R.; van der Poll, Thomas; Vincent, Jean-Louis; Wiersinga, W. Joost; Zimmerman, Janice L.; Dellinger, R. Phillip

    2017-01-01

    Objective: To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012!' Design: A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings

  15. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

    NARCIS (Netherlands)

    Singer, Mervyn; Deutschman, Clifford S.; Seymour, Christopher Warren; Shankar-Hari, Manu; Annane, Djillali; Bauer, Michael; Bellomo, Rinaldo; Bernard, Gordon R.; Chiche, Jean-Daniel; Coopersmith, Craig M.; Hotchkiss, Richard S.; Levy, Mitchell M.; Marshall, John C.; Martin, Greg S.; Opal, Steven M.; Rubenfeld, Gordon D.; van der Poll, Tom; Vincent, Jean-Louis; Angus, Derek C.

    2016-01-01

    IMPORTANCE Definitions of sepsis and septic shock were last revised in 2001. Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management, and epidemiology of sepsis, suggesting the need

  16. Multicenter Implementation of a Severe Sepsis and Septic Shock Treatment Bundle

    OpenAIRE

    Miller, Russell R.; Dong, Li; Nelson, Nancy C.; Brown, Samuel M.; Kuttler, Kathryn G.; Probst, Daniel R.; Allen, Todd L.; Clemmer, Terry P.

    2013-01-01

    Rationale: Severe sepsis and septic shock are leading causes of intensive care unit (ICU) admission, morbidity, and mortality. The effect of compliance with sepsis management guidelines on outcomes is unclear.

  17. Pylephlebitis and Crohn’s disease: A rare case of septic shock

    Directory of Open Access Journals (Sweden)

    Stefano Scaringi

    2017-01-01

    Conclusion: This case highlights the importance of promptly considerate and treat mesenteric pylephlebitis in presence of a septic shock in a Crohn’s disease patient who is not showing clinical signs of peritonitis.

  18. Evolution of peripheral vs metabolic perfusion parameters during septic shock resuscitation. A clinical-physiologic study

    NARCIS (Netherlands)

    Hernandez, Glenn; Pedreros, Cesar; Veas, Enrique; Bruhn, Alejandro; Romero, Carlos; Rovegno, Maximiliano; Neira, Rodolfo; Bravo, Sebastian; Castro, Ricardo; Kattan, Eduardo; Ince, Can

    2012-01-01

    Purpose: Perfusion assessment during septic shock resuscitation is difficult and usually complex determinations. Capillary refill time (CRT) and central-to-toe temperature difference (Tc-toe) have been proposed as objective reproducible parameters to evaluate peripheral perfusion. The comparative

  19. N-terminal-pro-brain natriuretic peptide elevations in the course of septic and non-septic shock reflect systolic left ventricular dysfunction assessed by transpulmonary thermodilution

    Directory of Open Access Journals (Sweden)

    A.B. Johan Groeneveld

    2016-03-01

    Conclusions: In septic and non-septic shock, NT-proBNP elevations reflect systolic left ventricular dysfunction and are associated with a poor outcome. They may help recognition of cardiac dysfunction in shock and its management when invasive hemodynamic monitoring is not yet instituted.

  20. Management of septic shock: a protocol-less approach.

    Science.gov (United States)

    Cabrera, Jorge L; Pinsky, Michael R

    2015-06-19

    In a single-center study published more than a decade ago involving patients presenting to the emergency department with severe sepsis and septic shock, mortality was markedly lower among those who were treated according to a 6-h protocol of early goal-directed therapy (EGDT), in which intravenous fluids, vasopressors, inotropes, and blood transfusions were adjusted to reach central hemodynamic targets including central venous pressure, central venous oxygen saturation, and indirect estimates of cardiac output, than among those receiving usual care. The objective was to determine whether these EGDT findings were generalizable and whether all aspects of the EGDT protocol were necessary to achieve those outcomes. A multicenter randomized three-arm controlled trial. Thirty-one academic emergency departments in the United States. Patients older than 18 years of age presenting to the emergency department with septic shock. Patients were assigned to one of three groups for 6 h of resuscitation: protocol-based EGDT as defined by River and colleagues; protocol-based standard therapy that did not require the placement of a central venous catheter, administration of inotropes, or blood transfusions; and usual care which mandated no specific monitoring or management approaches. The primary end point was 60-day in-hospital mortality. Also tested sequentially was whether protocol-based care (EGDT and standard therapy groups combined) was superior to usual care and whether protocol-based EGDT was superior to protocol-based standard therapy. Secondary outcomes included longer-term mortality and the need for organ support. A total of 1,351 patients were enrolled, of whom 1,341 were evaluable due to patient/family request: 439 were randomly assigned to protocol-based EGDT, 446 to protocol-based standard therapy, and 456 to usual care. Resuscitation strategies differed significantly with respect to the monitoring of central venous pressure and central venous oxygen and the use of

  1. Timing, method and discontinuation of hydrocortisone administration for septic shock patients

    OpenAIRE

    Ibarra-Estrada, Miguel A; Ch?vez-Pe?a, Quetzalc?atl; Reynoso-Estrella, Claudia I; Rios-Zerme?o, Jorge; Aguilera-Gonz?lez, P?vel E; Garc?a-Soto, Miguel A; Aguirre-Avalos, Guadalupe

    2017-01-01

    AIM To characterize the prescribing patterns for hydrocortisone for patients with septic shock and perform an exploratory analysis in order to identify the variables associated with better outcomes. METHODS This prospective cohort study included 59 patients with septic shock who received stress-dose hydrocortisone. It was performed at 2 critical care units in academic hospitals from June 1st, 2015, to July 31st, 2016. Demographic data, comorbidities, medical management details, adverse effect...

  2. Mortality Prediction Model of Septic Shock Patients Based on Routinely Recorded Data

    OpenAIRE

    Carrara, Marta; Baselli, Giuseppe; Ferrario, Manuela

    2015-01-01

    We studied the problem of mortality prediction in two datasets, the first composed of 23 septic shock patients and the second composed of 73 septic subjects selected from the public database MIMIC-II. For each patient we derived hemodynamic variables, laboratory results, and clinical information of the first 48 hours after shock onset and we performed univariate and multivariate analyses to predict mortality in the following 7 days. The results show interesting features that individually iden...

  3. Septic Shock due to Vibrio alginolyticus in a Cirrhotic Patient: The First Case in Korea

    OpenAIRE

    Lee, Dong-Young; Moon, Soo-Youn; Lee, Sang-Oh; Yang, Hee-Young; Lee, Hee-Joo; Lee, Mi Suk

    2008-01-01

    We describe a case of septic shock due to Vibrio alginolyticus presenting with fever and bilateral leg pain. Despite intensive management with antibiotics and inotropic agents, the patient died from septic shock 1 day after hospitalization. V. alginolyticus was isolated from both leg wounds and a blood culture. To the best of our knowledge, this is the first reported case of V. alginolyticus bacteremia in Korea.

  4. Fluid therapy for septic shock resuscitation: which fluid should be used?

    OpenAIRE

    Corrêa, Thiago Domingos; Rocha, Leonardo Lima; Pessoa, Camila Menezes Souza; Silva, Eliézer; Assuncao, Murillo Santucci Cesar de

    2015-01-01

    Early resuscitation of septic shock patients reduces the sepsis-related morbidity and mortality. The main goals of septic shock resuscitation include volemic expansion, maintenance of adequate tissue perfusion and oxygen delivery, guided by central venous pressure, mean arterial pressure, mixed or central venous oxygen saturation and arterial lactate levels. An aggressive fluid resuscitation, possibly in association with vasopressors, inotropes and red blood cell concentrate transfusion may b...

  5. Severe Sepsis and Septic Shock Associated with Chikungunya Fever in an Adolescent.

    Science.gov (United States)

    Sharma, Pradeep Kumar; Kumar, Maneesh; Bhandari, Neha; Kushwaha, Anand

    2018-01-06

    Chikungunya is usually a benign disease, and little is known on the occurrence of severe clinical complications. We describe a 12-year-old boy with rapid onset septic shock and multi-organ failure associated with chikungunya fever. Severe sepsis and septic shock can be associated with chikungunya. © The Author(s) [2018]. Published by Oxford University Press. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

  6. Septic shock in chronic dialysis patients: clinical characteristics, antimicrobial therapy and mortality.

    Science.gov (United States)

    Clark, Edward; Kumar, Anand; Langote, Amit; Lapinsky, Stephen; Dodek, Peter; Kramer, Andreas; Wood, Gordon; Bagshaw, Sean M; Wood, Ken; Gurka, Dave; Sood, Manish M

    2016-02-01

    To describe the clinical characteristics and in-hospital mortality of chronic dialysis-dependent end-stage kidney disease patients with septic shock in comparison to septic shock patients not receiving chronic dialysis. Using an international, multicenter database, we conducted a retrospective analysis of data collected from 10,414 patients admitted to the intensive care unit (ICU) with septic shock from 1989 to 2013, of which 800 (7.7 %) were chronic dialysis patients. Data on demographic characteristics, sites of infection, microbial pathogens, antimicrobial usage patterns, and in-hospital mortality were aggregated and compared for chronic dialysis and non-dialysis patients. Multivariate time-varying Cox models with and without propensity score matching were constructed to determine the association between dialysis and in-hospital death. Septic shock secondary to central venous catheter infection, peritonitis, ischemic bowel, and cellulitis was more frequent in chronic dialysis patients. The isolation of resistant organisms (10.7 vs. 7.1 %; p = 0.005) and delays in receiving antimicrobials (6.0 vs. 5.0 h) were more common in chronic dialysis patients than in non-dialysis patients. Delayed appropriate antimicrobial therapy was associated with an increased risk of death in chronic dialysis patients (p septic shock differ from those of similar non-dialysis patients. However, there was no significant difference in mortality between the chronic dialysis and non-dialysis patients with septic shock enrolled in this analysis.

  7. Asymmetric dimethylarginine and L-arginine levels in neonatal sepsis and septic shock.

    Science.gov (United States)

    Aydemir, Ozge; Ozcan, Beyza; Yucel, Husniye; Bas, Ahmet Yagmur; Demirel, Nihal

    2015-05-01

    Nitric oxide (NO) formed by the enzyme NO synthase (NOS) from L-arginine, is an important mediator for pathogen elimination. Being a potent vasodilator NO is implicated in hypotension and decreased organ perfusion in sepsis. Asymmetric dimethylarginine (ADMA) is an endogenous NOS inhibitor. We investigated ADMA and L-arginine levels in neonatal sepsis and their relation to disease severity. A prospective controlled study was conducted including 31 neonates with sepsis and 20 controls. Serum ADMA and L-arginine levels were measured within 24 h of sepsis diagnosis. Clinical and laboratory data including clinical risk index for babies (CRIB) score, presence of septic shock, organ dysfunction and death were recorded. L-arginine and ADMA levels were higher in neonates with sepsis compared to controls (p = 0.029 and p = 0.001, respectively). Neonates with septic shock had higher ADMA levels compared to septic neonates without shock (p = 0.026) and controls (p L-arginine levels were higher in neonates with septic shock compared to septic neonates without shock (p = 0.012) and controls (p L-arginine and ADMA levels. ADMA levels were correlated with CRIB score (rho = 0.320, p = 0.025). L-arginine and ADMA levels are elevated in neonatal sepsis and even higher levels are observed in septic shock.

  8. Evaluating the Impact of Classroom Education on the Management of Septic Shock Using Human Patient Simulation.

    Science.gov (United States)

    Lighthall, Geoffrey K; Bahmani, Dona; Gaba, David

    2016-02-01

    Classroom lectures are the mainstay of imparting knowledge in a structured manner and have the additional goals of stimulating critical thinking, lifelong learning, and improvements in patient care. The impact of lectures on patient care is difficult to examine in critical care because of the heterogeneity in patient conditions and personnel as well as confounders such as time pressure, interruptions, fatigue, and nonstandardized observation methods. The critical care environment was recreated in a simulation laboratory using a high-fidelity mannequin simulator, where a mannequin simulator with a standardized script for septic shock was presented to trainees. The reproducibility of this patient and associated conditions allowed the evaluation of "clinical performance" in the management of septic shock. In a previous study, we developed and validated tools for the quantitative analysis of house staff managing septic shock simulations. In the present analysis, we examined whether measures of clinical performance were improved in those cases where a lecture on the management of shock preceded a simulated exercise on the management of septic shock. The administration of the septic shock simulations allowed for performance measurements to be calculated for both medical interns and for subsequent management by a larger resident-led team. The analysis revealed that receiving a lecture on shock before managing a simulated patient with septic shock did not produce scores higher than for those who did not receive the previous lecture. This result was similar for both interns managing the patient and for subsequent management by a resident-led team. We failed to find an immediate impact on clinical performance in simulations of septic shock after a lecture on the management of this syndrome. Lectures are likely not a reliable sole method for improving clinical performance in the management of complex disease processes.

  9. Endocarditis lenta-patient survived septic shock: a case report

    Directory of Open Access Journals (Sweden)

    Amra Macić Džanković

    2012-09-01

    Full Text Available Infective endocarditis is defi ned as an infection of the endocardial surface of the heart. Its intracardiac effects include severe valvular insuffi ciency, which may lead to intractable congestive heart failure and myocardialabscesses. This disease still carries a poor prognosis and a high mortality.A severe case of infective endocarditis with its complications is presented. A man with aortic prosthetic valve due to earlier aortic stenosis and corrected aortal coarctation and implanted pacemaker presentedwith prolonged unexplained fever, malaise, sweating, weight loss (15 kg/4 months and lumbar pain. He was treated with broad-spectrum antibiotics prior IE diagnosis was considered. Echocardiogram showedaortic vegetations and possible periaortal abscess formation. Nonspecifi c infl ammation parameters were high positive. Cultures were constantly negative. His condition had deteriorated suddenly, and he had presentedwith worsening of cutaneous vasculitis, subacute glomerulonephritis and subsequent acute respiratory distress syndrome and septic shock. This patient survived with residual bilateral necrosis of the feet andtoxic peroneal paresis. At the end transthoracic echocardiogram showed enlarged heart chambers, LV mild dilated and concentric hypertrophy with ejection fraction about 40%, degenerative postinfl ammatory mitralvalve changes, mild mitral regurgitation and tricuspid regurgitation, postinfl ammatory aortic root fi brosis and moderate aortic valve stenosis (AVPG max 50,9 mmHg, AVPG mean 24 mmHg with no pericardial effusion. Initial suspicion of Q fever was defi nitely excluded by serological testing showing nonspecifi c IgM positivity,probably rheumatoid factor related.

  10. Sjögren's syndrome and acquired splenic atrophy with septic shock: a case report.

    Science.gov (United States)

    Santos, Natacha; Silva, Rui; Rodrigues, Joana; Torres-Costa, José

    2014-01-06

    The most frequent causes of adult-onset recurrent infections are human immunodeficiency virus infection, malignancy, and autoimmune diseases, while acquired non-surgical hyposplenism is rare. Although acquired asplenia/hyposplenism have been described in association with celiac disease and, less frequently, with autoimmune diseases such as Sjögren's syndrome, the manifestations in this context are usually only detectable in the laboratory setting, with Howell-Jolly bodies or thrombocytosis. To the best of our knowledge, no previous case of pneumococcal septic shock in a patient with acquired hyposplenism and co-morbid Sjögren's syndrome has been reported. We report a case of a 45-year-old Caucasian woman who developed pneumococcal pneumonia at age 42 years, pneumococcal meningitis at age 44 years and septic shock with Streptococcus agalactiae bacteremia at age 45 years and was subsequently diagnosed with radiological splenic atrophy and functional asplenia, as well as primary Sjögren's syndrome. After appropriate immunizations, the patient has been free from clinically important infections. Hyposplenism should be suspected in patients with adult-onset infections caused by encapsulated bacteria, especially if autoantibodies are present. Early diagnosis can help prevent potentially life-threatening infections. Possible associations between splenic atrophy and Sjögren's syndrome are discussed.

  11. Sjögren’s syndrome and acquired splenic atrophy with septic shock: a case report

    Science.gov (United States)

    2014-01-01

    Introduction The most frequent causes of adult-onset recurrent infections are human immunodeficiency virus infection, malignancy, and autoimmune diseases, while acquired non-surgical hyposplenism is rare. Although acquired asplenia/hyposplenism have been described in association with celiac disease and, less frequently, with autoimmune diseases such as Sjögren’s syndrome, the manifestations in this context are usually only detectable in the laboratory setting, with Howell-Jolly bodies or thrombocytosis. To the best of our knowledge, no previous case of pneumococcal septic shock in a patient with acquired hyposplenism and co-morbid Sjögren’s syndrome has been reported. Case presentation We report a case of a 45-year-old Caucasian woman who developed pneumococcal pneumonia at age 42 years, pneumococcal meningitis at age 44 years and septic shock with Streptococcus agalactiae bacteremia at age 45 years and was subsequently diagnosed with radiological splenic atrophy and functional asplenia, as well as primary Sjögren’s syndrome. After appropriate immunizations, the patient has been free from clinically important infections. Conclusion Hyposplenism should be suspected in patients with adult-onset infections caused by encapsulated bacteria, especially if autoantibodies are present. Early diagnosis can help prevent potentially life-threatening infections. Possible associations between splenic atrophy and Sjögren’s syndrome are discussed. PMID:24393211

  12. Olfactomedin-4 Is a Candidate Marker for a Pathogenic Neutrophil Subset in Septic Shock.

    Science.gov (United States)

    Alder, Matthew N; Opoka, Amy M; Lahni, Patrick; Hildeman, David A; Wong, Hector R

    2017-04-01

    Heterogeneity in sepsis-related pathobiology presents a significant challenge. Resolving this heterogeneity presents an opportunity to understand pathobiology and improve patient care. Olfactomedin-4 is a neutrophil subset marker and may contribute to sepsis heterogeneity. Our objective was to evaluate the expression of olfactomedin-4 and characterize neutrophil heterogeneity in children with septic shock. Single-center, prospective cohort, as well as secondary analysis of existing transcriptomic and proteomic databases. Tertiary care PICU. Patients from 5 days to 18 years old with septic shock were enrolled. Data collected included the expression of olfactomedin-4 messenger RNA, serum protein concentrations, and percentage of neutrophils that express olfactomedin-4. None. Secondary analysis of existing transcriptomic data demonstrated that olfactomedin-4 is the most highly expressed gene in nonsurvivors of pediatric septic shock, compared with survivors. Secondary analysis of an existing proteomic database corroborated these observations. In a prospectively enrolled cohort, we quantified the percentage of olfactomedin-4+ neutrophils in patients with septic shock. Patients with a complicated course, defined as greater than or equal to two organ failures at day 7 of septic shock or 28-day mortality, had a higher percentage of olfactomedin-4+ neutrophils, compared with those without a complicated course. By logistic regression, the percentage of olfactomedin-4+ neutrophils was independently associated with increased risk of a complicated course (odds ratio, 1.09; 95% CI, 1.01-1.17; p = 0.024). Olfactomedin-4 identifies a subpopulation of neutrophils in patients with septic shock, and those with a high percentage of olfactomedin-4+ neutrophils are at higher risk for greater organ failure burden and death. Olfactomedin-4 might serve as a marker of a pathogenic neutrophil subset in patients with septic shock.

  13. A survey of corticosteroid use for the management of septic shock ...

    African Journals Online (AJOL)

    Background: Critical illness is associated with pituitary-adrenal axis dysfunction, and may cause adrenal insufficiency that manifests as septic shock that is poorly responsive to fluid or inotropic therapy. Administering a low-dose corticosteroid to these patients results in faster shock resolution, but there is controversy ...

  14. Mortality Prediction Model of Septic Shock Patients Based on Routinely Recorded Data

    Directory of Open Access Journals (Sweden)

    Marta Carrara

    2015-01-01

    Full Text Available We studied the problem of mortality prediction in two datasets, the first composed of 23 septic shock patients and the second composed of 73 septic subjects selected from the public database MIMIC-II. For each patient we derived hemodynamic variables, laboratory results, and clinical information of the first 48 hours after shock onset and we performed univariate and multivariate analyses to predict mortality in the following 7 days. The results show interesting features that individually identify significant differences between survivors and nonsurvivors and features which gain importance only when considered together with the others in a multivariate regression model. This preliminary study on two small septic shock populations represents a novel contribution towards new personalized models for an integration of multiparameter patient information to improve critical care management of shock patients.

  15. IL-1B rs16944 polymorphism is related to septic shock and death.

    Science.gov (United States)

    Jiménez-Sousa, María Ángeles; Medrano, Luz M; Liu, Pilar; Almansa, Raquel; Fernández-Rodríguez, Amanda; Gómez-Sánchez, Esther; Rico, Lucía; Heredia-Rodríguez, María; Gómez-Pesquera, Estefanía; Tamayo, Eduardo; Resino, Salvador

    2017-01-01

    IL-1β is a primary mediator of systemic inflammatory response syndrome (SIRS) and it may lead to shock septic. Our aim was to analyse whether IL-1B rs16944 polymorphism is associated with the onset of septic shock and death after major surgery. We performed a case-control study on 467 patients who underwent major cardiac or abdominal surgery. Of them, 205 patients developed septic shock (cases, SS group) and 262 patients developed SIRS (controls, SIRS group). The primary outcome variables were the development of septic shock and death within 90 days after diagnosis of septic shock. The IL-1B rs16944 polymorphism was genotyped by Sequenom's MassARRAY platform. The association analysis was performed under a recessive genetic model (AA vs. GG/GC). The frequency of septic shock was higher in patients with IL-1B rs16944 AA genotype than in patients with IL-1B rs16944 GG/AG genotype when all patients were taken into account (63·6% vs. 41·8%; P = 0·006), cardiac surgery (52·2% vs. 33·3%; P = 0·072) and abdominal surgery (76·2% vs. 50·2%; P = 0·023). However, the IL-1B rs16944 AA genotype was only associated with higher likelihood of septic shock in the analysis of all population [adjusted odds ratio (aOR) = 2·26 (95%CI = 1·03; 4·97; P = 0·042], but not when it was stratified by cardiac surgery (P = 0·175) or abdominal surgery (P = 0·467). Similarly, IL-1B rs16944 AA genotype was also associated with higher likelihood of septic shock-related death in all population [aOR = 2·67 (95%CI = 1·07; 4·97); P = 0·035]. IL-1B rs16944 AA genotype seems to be related to the onset of septic shock and death in patients who underwent major surgery. © 2016 Stichting European Society for Clinical Investigation Journal Foundation.

  16. Pentraxin 3, a Predicator for 28-Day Mortality in Patients With Septic Shock.

    Science.gov (United States)

    Jie, Hongying; Li, Yunxiang; Pu, Xuehua; Ye, Jilu

    2017-03-01

    Useful biomarkers that can serve as prognostic predictors are of great value in clinical practice because of the complex individual response to sepsis. Pentraxin 3 (PTX3), as a multifunctional pattern-recognition molecule, has been reported to be closely associated with the severity of infectious diseases in intensive care units (ICU). The aim of this study was to investigate whether PTX3 could serve as a potential prognostic biomarker in patients with septic shock. This single-center prospective observational study was conducted during May 2012-May 2015 in the ICU of Taizhou People׳s Hospital. We compared the clinical data and laboratory tests in surviving and deceased patients with septic shock within 28 days from admission. Potential independent prognostic factors for septic shock were analyzed by using univariate and multiple Cox proportional hazards regression analyses. A total of 112 patients admitted to the ICU with septic shock were enrolled in our study with an overall 28-day mortality of 25.9% (29 of 112 patients). PTX3 level was the only independent risk factor for the 28-day mortality by univariate and multivariate Cox analysis (hazard ratio = 3.87; 95% CI: 1.66-8.81, P = 0.004). The deceased patients had significant higher levels of PTX3 at the 4 different points (baseline, day 1, day 2 and day 3) versus the survivors (P septic shock. Copyright © 2017 Southern Society for Clinical Investigation. Published by Elsevier Inc. All rights reserved.

  17. Use of high-dose nandrolone aggravates septic shock in a mouse model

    Directory of Open Access Journals (Sweden)

    Che Lin

    2011-06-01

    Full Text Available Nandrolone, an anabolic-androgenic steroid, is widely misused by athletes who wish to rapidly increase muscle mass and performance. An increasing number of reports have indicated that nandrolone may affect and modulate the immune system. This study aimed to investigate the effects of nandrolone on septic shock-caused immune responses and the cellular mechanism of action using a sepsis murine model. Before septic shock induction, BALB/c mice were given a high dose of nandrolone or peanut oil only. After septic shock induction, mice were sacrificed at different time points. Their blood and tissue specimens were analyzed. It was found that the high-dose nandrolone group had significantly increased mortality compared with the control group (p<0.001. The serum malondialdehyde level was significantly increased in the high-dose group compared with the control group. Animals administered a high dose of nandrolone had significantly increased hepatic tumor necrosis factor-α or splenic interferon-γ at 0 and 6 hours. In lung tissue, insulin-like growth factor-1, insulin-like growth factor binding proteins (IGFBPs and insulin-like growth factor-1 receptor, and IGFBP1 and IGFBP2 mRNA expression were increased in the high-dose nandrolone group at 6 hours. Nandrolone abuse may hasten the death of patients with septic shock and may aggravate septic shock in mice.

  18. Pathogens and outcomes in pediatric septic shock patients supported by extracorporeal membrane oxygenation.

    Science.gov (United States)

    Chang, Tu-Hsuan; Wu, En-Ting; Lu, Chun-Yi; Huang, Shu-Chien; Yang, Tzu-I; Wang, Ching-Chia; Chen, Jong-Min; Lee, Ping-Ing; Huang, Li-Min; Chang, Luan-Yin

    2017-08-04

    Refractory septic shock is the leading cause of mortality in children. There is limited evidence to support extracorporeal membrane oxygenation (ECMO) use in pediatric septic shock. We described the etiology and outcomes of septic patients in our institution and attempted to find predictive factors. We retrospectively reviewed 55 pediatric patients with septic shock who required ECMO support in a tertiary medical center from 2008 to 2015. Septic shock was defined as culture proved or clinical suspected sepsis with hypotension or end-organ hypoperfusion. ECMO would be applied when pediatric advanced life support steps were performed thoroughly without clinical response. Patient's demographics, laboratory parameters before and after ECMO, and outcomes were analyzed. Among 55 children with ECMO support, 31% of them survived on discharge. For 25 immunocompromised patients, causal pathogens were found in 17 patients: 7 due to bacteremia, 9 with preexisting virus infections and one with invasive fungal infection. Among 30 previously healthy patients, causal pathogens were found in 18 patients: 10 due to bacteremia (the most common was pneumococcus), 7 with preexisting virus infections including influenza (n = 4), adenovirus (n = 2), RSV, and 1 patient had mixed virus and bacterial infections. Predictive factors associated with death were arterial blood gas pH, CO 2 and Glasgow Coma Scale (p shock had high mortality rate and ECMO could be used as a rescue modality, and SOFA score could be applied to predict outcomes. Copyright © 2017. Published by Elsevier B.V.

  19. Diagnostic and prognostic value of procalcitonin in patients with septic shock.

    Science.gov (United States)

    Clec'h, Christophe; Ferriere, Françoise; Karoubi, Philippe; Fosse, Jean P; Cupa, Michel; Hoang, Philippe; Cohen, Yves

    2004-05-01

    To determine whether procalcitonin is a reliable diagnostic and prognostic marker in septic shock compared with nonseptic shock. Prospective controlled trial. Intensive care unit of the Avicenne Teaching Hospital, Bobigny, France. All patients admitted to our intensive care unit over a 12-month period with clinical evidence of shock. None. Echocardiography or pulmonary artery flotation catheter measurements were used to assess hemodynamics, and multiple specimens were obtained for microbiological studies. Standard criteria were used to diagnose septic shock. Serum concentrations of procalcitonin, C-reactive protein, and lactate were determined on the day of shock onset (day 1) and on days 3, 7, and 10. Seventy-five patients were included, 62 in the septic shock group and 13 in the cardiogenic shock group. Serum procalcitonin on day 1 was significantly higher in patients with than without septic shock (median, 14 [0.3-767] ng/mL vs. 1 [0.5-36] ng/mL, p < .01). A cutoff value of 1 ng/mL had 95% sensitivity and 54% specificity for separating patients with and without sepsis. C-reactive protein failed to discriminate between these two groups. Among patients with sepsis, procalcitonin concentrations were significantly higher in those who died than in the survivors, at all four measurement time points (median, 16 [0.15-767] ng/mL vs. 6 [0.2-123] ng/mL, p = .045 on day 1; 6.5 [0.3-135] ng/mL vs. 1.05 [0.11-53] ng/mL, p = .02 on day 10). A cutoff value of 6 ng/mL on day 1 separated patients who died from those who survived with 87.5% sensitivity and 45% specificity. C-reactive protein was not helpful for predicting mortality. Serum lactate was a nonspecific prognostic marker. These data indicate that procalcitonin may be a valuable early diagnostic and prognostic marker in patients with septic shock.

  20. Central venous oxygen saturation for the diagnosis of low cardiac output in septic shock patients

    DEFF Research Database (Denmark)

    Perner, A; Haase, N; Wiis, J

    2010-01-01

    Simple diagnostic tests are needed to screen septic patients for low cardiac output because intervention is recommended in these patients. We assessed the diagnostic value of central venous oxygen saturation in the superior vena cava (ScvO(2)) for detecting low cardiac output in patients with sep...... with septic shock.......Simple diagnostic tests are needed to screen septic patients for low cardiac output because intervention is recommended in these patients. We assessed the diagnostic value of central venous oxygen saturation in the superior vena cava (ScvO(2)) for detecting low cardiac output in patients...

  1. Changes in Insulin-like Growth Factor-1 Level in Patients with Sepsis and Septic Shock

    Directory of Open Access Journals (Sweden)

    Sang Hoon Lee

    2016-11-01

    Full Text Available Background Despite many ongoing, prospective studies on the topic, sepsis still remains one of the main causes of death in hospital. The hormone insulin-like growth factor 1 (IGF-1 has a similar molecular structure to that of insulin. IGF-1 exerts anabolic effects and plays important roles in both normal physiology and pathologic processes. Previous studies have observed low serum IGF-1 level in patients with critical illnesses. Here, we evaluated changes in IGF-1 level based on survival of septic patients. Methods We evaluated 140 patients with sepsis and septic shock (21 with sepsis and 119 with septic shock admitted to the intensive care unit of a university-affiliated hospital in Korea. Serum IGF-1 level was measured on days 0, 1, 3, and 7. Patients with liver disease were excluded from this study. All data were analyzed using SPSS version 20 (SPSS Inc., Chicago, IL, USA. Results Patients with septic shock had significantly lower serum IGF-1 level on days 1 and 3 than patients without septic shock (p = 0.002 and p = 0.007, respectively. Generally, there was a negative relationship between IGF-1 and serum cortisol levels; however, this relationship was only significant on day 3 (p = 0.029. Furthermore, renin showed significantly negative correlation with IGF-1 on day 3 (p = 0.038. IGF-1 level did not show significant difference between survivors and non-survivors. Conclusions Our results showed that IGF-1 was associated with septic shock, and that the IGF-1 axis is severely disrupted in septic patients. Additionally, serum cortisol and renin levels were associated with IGF-1 level.

  2. Higher frequency of septic shock in septic patients with the 47C allele (rs4880) of the SOD2 gene.

    Science.gov (United States)

    Paludo, Francis Jackson de Oliveira; Picanço, Juliane Bentes; Fallavena, Paulo Roberto Vargas; Fraga, Lucas da Rosa; Graebin, Pietra; Nóbrega, Otávio de Toledo; Dias, Fernando Suparregui; Alho, Clarice Sampaio

    2013-03-15

    To analyze the effect of the two different versions of the manganese superoxide dismutase gene (SOD2) on sepsis. The SOD2 gene presents the 47C>T single nucleotide polymorphism (SNP; ID: rs4880) which produces MnSOD with different activities. The -9Val MnSOD (47T allele) is less efficient than the -9Ala version (47C allele). During sepsis there are abundance of ROS, high SOD2 expression and excess of H(2)O(2) synthesis. High concentrations of H(2)O(2) could affect the sepsis scenario and/or the sepsis outcome. We determined the 47C>T single nucleotide polymorphism (SNP) frequencies in 529 critically ill patients with or without sepsis, facing outcome. To collect information on population frequencies, we obtained a pilot 47C>T genotypic and allelic frequencies in a random group of 139 healthy subjects. We compared the 47C allele carriers (47CC+47CT genotypes) with 47TT homozygotes and noticed a significant association between 47C allele carriers and septic shock in septic patients (P=0.025). With an adjusted binary multivariate logistic regression, incorporating 47C>T SNP and the main clinical predictors, we showed high SOFA scores [P<0.001, OR=9.107 (95% CI=5.319-15.592)] and 47C allele [P=0.011, OR=2.125 (95% CI=1.190-3.794)] were significantly associated with septic shock outcome. With this information we presented a hypothesis suggesting that this negative outcome from sepsis is possibly explained by effects on cellular stress caused by 47C allele. In our population there was a significant higher frequency of septic shock in septic patients with the 47C allele of the SOD2 gene. This higher 47C allele frequency in septic patients with negative outcome could be explained by effects of higher activity MnSOD on cellular stress during the sepsis. Copyright © 2012 Elsevier B.V. All rights reserved.

  3. Effects of fluid restriction on measures of circulatory efficacy in adults with septic shock

    DEFF Research Database (Denmark)

    Hjortrup, P. B.; Haase, N.; Wetterslev, J.

    2017-01-01

    BACKGROUND: The haemodynamic consequences of fluid resuscitation in septic shock have not been fully elucidated. Therefore, we assessed circulatory effects in the first 24 h of restriction of resuscitation fluid as compared to standard care in intensive care unit (ICU) patients with septic shock....... METHODS: This was a post-hoc analysis of the multicentre CLASSIC randomised trial in which patients with septic shock, who had received the initial fluid resuscitation, were randomised to a protocol restricting resuscitation fluid or a standard care protocol in nine ICUs. The highest plasma lactate......, highest dose of noradrenaline, and the urinary output were recorded in five time frames in the first 24 h after randomisation. We used multiple linear mixed effects models to compare the two groups. RESULTS: We included all 151 randomised patients; the cumulated fluid resuscitation volume in the first 24...

  4. Refractory Septic Shock Treated with Nephrectomy under the Support of Extracorporeal Membrane Oxygenation

    Directory of Open Access Journals (Sweden)

    Young Kun Lee

    2015-08-01

    Full Text Available Conventional medical therapies have not been very successful in treating adults with refractory septic shock. The effects of direct hemoperfusion using polymyxin B and veno-arterial extracorporeal membrane oxygenation (ECMO for refractory septic shock remain uncertain. A 66-year-old man was admitted to the emergency department and suffered from sepsis-induced hemodynamic collapse. For hemodynamic improvement, we performed direct hemoperfusion using polymyxin B. Computed tomography scan of this patient revealed emphysematous pyelonephritis (EPN, for which he underwent emergent nephrectomy with veno-arterial ECMO support. To the best of our knowledge, this is the first report of successful treatment of EPN with refractory septic shock using polymyxin B hemoperfusion and nephrectomy under the support of ECMO.

  5. Decompressive Abdominal Laparotomy for Abdominal Compartment Syndrome in an Unengrafted Bone Marrow Recipient with Septic Shock

    Directory of Open Access Journals (Sweden)

    Derrick J. N. Dauplaise

    2010-01-01

    Full Text Available Objective. To describe a profoundly immunocompromised (panleukopenia child with septic shock who developed abdominal compartment syndrome (ACS and was successfully treated with surgical decompression. Design. Individual case report. Setting. Pediatric intensive care unit of a tertiary children's hospital. Patient. A 32-month-old male with Fanconi anemia who underwent bone marrow transplantation (BMT 5 days prior to developing septic shock secondary to Streptococcus viridans and Escherichia coli ACS developed after massive fluid resuscitation, leading to cardiopulmonary instability. Interventions. Emergent surgical bedside laparotomy and silo placement. Measurements and Main Results. The patient's cardiopulmonary status stabilized after decompressive laparotomy. The abdomen was closed and the patient survived to hospital discharge without cardiac, respiratory, or renal dysfunction. Conclusions. The use of laparotomy and silo placement in an unengrafted BMT patient with ACS and septic shock did not result in additional complications. Surgical intervention for ACS is a reasonable option for high risk, profoundly immunocompromised patients.

  6. Association between fluid balance and mortality in patients with septic shock

    DEFF Research Database (Denmark)

    Cronhjort, M; Hjortrup, P B; Holst, L B

    2016-01-01

    BACKGROUND: Several studies have shown an association between a positive fluid balance and increased mortality in patients with septic shock. This may have led to a more restrictive use of intravenous fluids. The association between fluid accumulation and mortality in the setting of a more...... restrictive use of intravenous fluids, however, is uncertain. We therefore aimed to investigate the association between a cumulative fluid balance 3 days after randomization and 90-day mortality in a recent Nordic multicentre cohort of patients with septic shock. METHODS: A post hoc analysis of patients from...... the Transfusion Requirements in Septic Shock (TRISS) trial treated for 3 days or more in the ICU after randomization. The patients were categorized into four groups depending on their weight-adjusted cumulative fluid balance after 3 days. We performed multivariable Cox regression analysis, adjusting for important...

  7. Statistical analysis plan for the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock (ADRENAL) trial

    DEFF Research Database (Denmark)

    Billot, Laurent; Venkatesh, Balasubramanian; Myburgh, John

    2017-01-01

    BACKGROUND: The Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock (ADRENAL) trial, a 3800-patient, multicentre, randomised controlled trial, will be the largest study to date of corticosteroid therapy in patients with septic shock. OBJECTIVE: To describe a statistic...

  8. A Novel Porcine Model of Septic Shock Induced by Acute Respiratory Distress Syndrome due to Methicillin-resistant Staphylococcus aureus

    Directory of Open Access Journals (Sweden)

    Shuo Wang

    2017-01-01

    Conclusions: In the present study, we developed a novel porcine model of septic shock induced by ARDS due to severe MRSA pneumonia with characteristic hyperdynamic and hypodynamic phases in 24 h, which mimicked the hemodynamic changing of septic shock in human.

  9. Overcoming the Odds: Long-term psychosocial outcomes in survivors of meningococcal septic shock in childhood, and in their parents

    NARCIS (Netherlands)

    L.C.A.C. Vermunt (Lindy)

    2008-01-01

    textabstractSeptic shock, caused by Neisseria meningitidis with petechiae and/or purpura, also called Meningococcal Septic Shock (MSS), is the most serious form of meningococcal infection in early childhood. MSS is a life-threatening illness in mostly previously healthy children, with an unexpected

  10. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012.

    Science.gov (United States)

    Dellinger, R P; Levy, Mitchell M; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; Opal, Steven M; Sevransky, Jonathan E; Sprung, Charles L; Douglas, Ivor S; Jaeschke, Roman; Osborn, Tiffany M; Nunnally, Mark E; Townsend, Sean R; Reinhart, Konrad; Kleinpell, Ruth M; Angus, Derek C; Deutschman, Clifford S; Machado, Flavia R; Rubenfeld, Gordon D; Webb, Steven; Beale, Richard J; Vincent, Jean-Louis; Moreno, Rui

    2013-02-01

    positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO (2)/FiO (2) ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a PaO (2)/FI O (2) management commencing insulin dosing when two consecutive blood glucose levels are >180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical

  11. Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012.

    Science.gov (United States)

    Dellinger, R Phillip; Levy, Mitchell M; Rhodes, Andrew; Annane, Djillali; Gerlach, Herwig; Opal, Steven M; Sevransky, Jonathan E; Sprung, Charles L; Douglas, Ivor S; Jaeschke, Roman; Osborn, Tiffany M; Nunnally, Mark E; Townsend, Sean R; Reinhart, Konrad; Kleinpell, Ruth M; Angus, Derek C; Deutschman, Clifford S; Machado, Flavia R; Rubenfeld, Gordon D; Webb, Steven A; Beale, Richard J; Vincent, Jean-Louis; Moreno, Rui

    2013-02-01

    at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and

  12. Multicountry survey of emergency and critical care medicine physicians' fluid resuscitation practices for adult patients with early septic shock

    DEFF Research Database (Denmark)

    McIntyre, Lauralyn; Rowe, Brian H; Walsh, Timothy S

    2016-01-01

    administered in early septic shock to inform the design of future septic shock fluid resuscitation trials. METHODS: Using a web-based survey tool, we invited critical care and emergency physicians in Canada, the UK, Scandinavia and Saudi Arabia to complete a self-administered electronic survey. RESULTS...... that a large randomised controlled trial comparing 5% albumin to a crystalloid fluid in early septic shock was important to conduct. CONCLUSIONS: Critical care and emergency physicians stated that they rapidly infuse volumes of 500-1000 mL of resuscitation fluid in early septic shock. Colloid use, specifically...... the use of albumin, was infrequently reported. Our survey identifies the need to conduct a trial on the efficacy of albumin and crystalloids on 90-day mortality in patients with early septic shock....

  13. A randomized trial comparing terlipressin and noradrenaline in patients with cirrhosis and septic shock.

    Science.gov (United States)

    Choudhury, Ashok; Kedarisetty, Chandan K; Vashishtha, Chitranshu; Saini, Deepak; Kumar, Sachin; Maiwall, Rakhi; Sharma, Manoj K; Bhadoria, Ajeet S; Kumar, Guresh; Joshi, Yogendra K; Sarin, Shiv K

    2017-04-01

    The choice of vasopressor for treating cirrhosis with septic shock is unclear. While noradrenaline in general is the preferred vasopressor, terlipressin improves microcirculation in addition to vasopressor action in non-cirrhotics. We compared the efficacy and safety of noradrenaline and terlipressin in cirrhotics with septic shock. Cirrhotics with septic shock underwent open label randomization to receive either terlipressin (n=42) or noradrenaline (n=42) infusion at a titrated dose. The primary outcome was mean arterial pressure (MAP) >65 mm Hg at 48 h. Baseline characteristics were comparable between the terlipressin and noradrenaline groups.SBP and pneumonia were major sources of sepsis. A higher proportion of patients on terlipressin were able to achieve MAP >65 mm of Hg (92.9% vs 69.1% P=.005) at 48 h. Subsequent discontinuation of vasopressor after hemodynamic stability was better with terlipressin (33.3% vs 11.9%, Pseptic shock and can serve as a useful drug. Terlipressin additionally provides early survival benefit and reduces the risk of variceal bleed. Lactate clearance is a better predictor of outcome even after achieving target MAP, suggesting the role of microcirculation in septic shock. © 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

  14. Septic arthritis and subsequent fatal septic shock caused by Vibrio vulnificus infection

    DEFF Research Database (Denmark)

    Emamifar, Amir; Asmussen Andreasen, Rikke; Andersen, Nanna Skaarup

    2015-01-01

    Vibrio vulnificus is a rare but potential fatal bacterium that can cause severe infections. Wound infections, primary sepsis and gastroenteritis are the most common clinical features. Septic arthritis caused by V. vulnificus is an atypical presentation that has been reported in only two case...... reports; however, it has not been previously noted in Denmark. The authors report a case of septic arthritis caused by V. vulnificus in an immunocompromised patient. The disease progressed to severe sepsis and subsequent death within 10 h of admission....

  15. Sublingual microcirculatory changes during high-volume hemofiltration in hyperdynamic septic shock patients.

    Science.gov (United States)

    Ruiz, Carolina; Hernandez, Glenn; Godoy, Cristian; Downey, Patricio; Andresen, Max; Bruhn, Alejandro

    2010-01-01

    Previous studies have suggested that high volume hemofiltration (HVHF) may contribute to revert hypotension in severe hyperdynamic septic shock patients. However, arterial pressure stabilization occurs due to an increase in systemic vascular resistance, which could eventually compromise microcirculatory blood flow and perfusion. The goal of this study was to determine if HVHF deteriorates sublingual microcirculation in severe hyperdynamic septic shock patients. This was a prospective, non-randomized study at a 16-bed, medical-surgical intensive care unit of a university hospital. We included 12 severe hyperdynamic septic shock patients (norepinephrine requirements > 0.3 μg/kg/min and cardiac index > 3.0 L/min/m2) who underwent a 12-hour HVHF as a rescue therapy according to a predefined algorithm. Sublingual microcirculation (Microscan for NTSC, Microvision Medical), systemic hemodynamics and perfusion parameters were assessed at baseline, at 12 hours of HVHF, and 6 hours after stopping HVHF. Microcirculatory flow index increased after 12 hours of HVHF and this increase persisted 6 hours after stopping HVHF. A similar trend was observed for the proportion of perfused microvessels. The increase in microcirculatory blood flow was inversely correlated with baseline levels. There was no significant change in microvascular density or heterogeneity during or after HVHF. Mean arterial pressure and systemic vascular resistance increased while lactate levels decreased after the 12-hour HVHF. The use of HVHF as a rescue therapy in patients with severe hyperdynamic septic shock does not deteriorate sublingual microcirculatory blood flow despite the increase in systemic vascular resistance.

  16. Human recombinant protein C for severe sepsis and septic shock in adult and paediatric patients

    DEFF Research Database (Denmark)

    Martí-Carvajal, Arturo J; Solà, Ivan; Gluud, Christian

    2012-01-01

    Sepsis is a common and frequently fatal condition. Human recombinant activated protein C (APC) has been introduced to reduce the high risk of death associated with severe sepsis or septic shock. This systematic review is an update of a Cochrane review originally published in 2007....

  17. More complications in patients with septic shock treated with dextran compared with crystalloids

    DEFF Research Database (Denmark)

    Rasmussen, Anders Mølgaard; Peter Jakobsen, Rasmus; Strøm, Thomas

    2015-01-01

    of patients admitted to our intensive care unit with septic shock and treated with dextran-70 in the period from 1 January 2009 to 31 December 2009. The controls were included from 1 March 2012 to 28 February 2013 when dextran-70 was replaced with crystalloids. RESULTS: There were 91 patients in the dextran...

  18. Evidence of Netosis in Septic Shock-Induced Disseminated Intravascular Coagulation.

    Science.gov (United States)

    Delabranche, Xavier; Stiel, Laure; Severac, François; Galoisy, Anne-Cécile; Mauvieux, Laurent; Zobairi, Fatiha; Lavigne, Thierry; Toti, Florence; Anglès-Cano, Eduardo; Meziani, Ferhat; Boisramé-Helms, Julie

    2017-03-01

    Neutrophils extracellular traps (NETs) have recently emerged as a new potential link between inflammation, immunity, and thrombosis and could play a key role in septic shock-induced disseminated intravascular coagulation (DIC) pathogenesis. The objective of our study was to investigate a potential link between NETosis and septic shock-induced DIC. Twenty patients with septic shock (10 without and 10 with DIC according to JAAM 2006 score) were prospectively included in our study. Vascular cell activation was assessed by microparticle (MP) measurement. NETosis was investigated at days 1, 3, and 7 using two different approaches: probing and measurement of neutrophil DNA decompaction by neutrophil-side fluorescence light (NEUT-SFL) as recorded by an automated blood cell cytometer and the assessment of nucleosomes and NETs (DNA-bound myeloperoxidase, DNA-MPO). Endothelial-derived CD105-MPs, leucocyte-derived CD11a-MPs/leucocyte, and neutrophil-derived CD66b-MPs/neutrophil count ratios significantly increased in DIC compared with non-DIC patients, indicating on-going cell activation (P septic shock-induced DIC.

  19. [Adherence to international guidelines on early management in severe sepsis and septic shock].

    Science.gov (United States)

    Quintero, Ricardo Andrés; Martínez, Carlos Arturo; Gamba, Juan Diego; Ortiz, Isadora; Jaimes, Fabián

    2012-09-01

    Complete adherence to early goal-directed therapy has shown a significant reduction in 28-day mortality rate, whereas partial adherence has not shown beneficial effect. The effect of adherence to 6 hour sepsis bundle treatment was evaluated on patients with severe sepsis and septic shock. A prospective cohort study was conducted during a six-month period. The patients were limited to those 16 years or older and included admissions to intensive care units, special care units or emergency departments with severe sepsis or septic shock. The adherence to the 6-hour sepsis bundle was evaluated through 8 interventions as follows: (1) serum lactate measure,( 2) early antibiotic administration, (3) blood culture samples, (4) infusion of intravenous fluids, (5) vasopressor use, (6) central venous catheter, (7) central venous pressure >8 mm Hg, and (8) central venous oxygen saturation >70%. Seven hundred and twenty three patients were screened; 16% (n=116) met the inclusion criteria; 92.2% (n=107) met the criteria for severe sepsis and 37.9% (44) for septic shock; 62.9% (n=73) were subdiagnosed. Complete adherence to the 8 interventions of 6-hour sepsis bundle was 0%; 6 to 7 (19%, n=22), 3 to 5 (67.2%, n=78), and 0 to 2 (98.3%, n=114). Adherence to 6-hour sepsis bundle treatment for severe sepsis and septic shock was not done for the full 8 interventions and only partial accomplishment of the first 4 interventions.

  20. Paediatric community-acquired septic shock: Results from the REPEM network study

    NARCIS (Netherlands)

    P. van de Voorde (Patrick); B. Emerson; B. Gómez (Borja); J. Willems; D. Yildizdas; I. Iglowstein; E. Kerkhof (Evelien); N. Mullen; C.R. Pinto; T. Detaille; N. Qureshi (Nadeem); J. Naud; J. de Dooy; R. van Lancker; A.G. Dupont (Alain); N. Boelsma; M. Mor; D. Walker; M. Sabbe (Marc); S. Hachimi-Idrissi; L. Da Dalt (Liviana); H. Waisman; D. Biarent; I.K. MacOnochie (Ian); H.A. Moll (Henriëtte); J. Benito (Javier)

    2013-01-01

    textabstractIntroduction and purpose of the study With this study we aimed to describe a "true world" picture of severe pae-diatric 'community-acquired' septic shock and establish the feasibility of a future prospective trial on early goal-directed therapy in children. During a 6-month to 1-year

  1. Interleukin-10 rs2227307 and CXCR2 rs1126579 polymorphisms modulate the predisposition to septic shock

    Directory of Open Access Journals (Sweden)

    Cristina Padre Cardoso

    2015-06-01

    Full Text Available Despite major improvements in its treatment and diagnosis, sepsis is still a leading cause of death and admittance to the intensive care unit (ICU. Failure to identify patients at high risk of developing septic shock contributes to an increase in the sepsis burden and rapid molecular tests are currently the most promising avenue to aid in patient risk determination and therapeutic anticipation. The primary goal of this study was to evaluate the genetic susceptibility that affects sepsis outcome in 72 sepsis patients admitted to the ICU. Seven polymorphisms were genotyped in key inflammatory response genes in sepsis, including tumour necrosis factor-α, interlelukin (IL-1β, IL-10, IL-8, Toll-like receptor 4, CXCR1 and CXCR2. The primary finding showed that patients who were homozygous for the major A allele in IL-10 rs1800896 had almost five times higher chance to develop septic shock compared to heterozygotes. Similarly, selected clinical features and CXCR2 rs1126579 single nucleotide polymorphisms modulated septic shock susceptibility without affecting survival. These data support the hypothesis that molecular testing has clinical usefulness to improve sepsis prognostic models. Therefore, enrichment of the ICU portfolio by including these biomarkers will aid in the early identification of sepsis patients who may develop septic shock.

  2. Dynamics of brain natriuretic peptide in critically ill patients with severe sepsis and septic shock

    Directory of Open Access Journals (Sweden)

    Amr S Omar

    2013-01-01

    Full Text Available Purpose: Changes of B-type natriuretic peptide (BNP in sepsis and its utility in predicting intensive care unit outcomes remains a conflicting issue. To investigate the changes in plasma levels of BNP in patients with severe sepsis/septic shock and to study the association of BNP levels with the severity of the disease and prognosis of those patients. Methods: Thirty patients with severe sepsis or septic shock were enrolled in our study. BNP measurements and echocardiography were carried out on admission and on 4 th and 7 th days. Blood concentrations of BNP were measured by commercially available assays (Abbott methods. In-hospital mortality and length of stay were recorded multivariate analyses adjusted for acute physiology and chronic health evaluation score II (APACHE II score was used for mortality prediction. Results: Twenty patients admitted with the diagnosis of severe sepsis and 10 patients with septic shock. The in-hospital mortality was 23.3% (7 patients. Admission BNP was significantly higher in the non-survivors 1123±236.08 versus 592.7±347.1 ( P<0.001. By doing multivariate logestic regression, the predicatable variables for mortality was APACHE II score, BNP, and then EF. Conclusion: BNP concentrations were increased in patients with severe sepsis or septic shock and poor outcome was associated with high BNP levels; thus, it may serve as a useful laboratory marker to predict survival in these patients.

  3. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

    NARCIS (Netherlands)

    Rhodes, Andrew; Evans, Laura E.; Alhazzani, Waleed; Levy, Mitchell M.; Antonelli, Massimo; Ferrer, Ricard; Kumar, Anand; Sevransky, Jonathan E.; Sprung, Charles L.; Nunnally, Mark E.; Rochwerg, Bram; Rubenfeld, Gordon D.; Angus, Derek C.; Annane, Djillali; Beale, Richard J.; Bellinghan, Geoffrey J.; Bernard, Gordon R.; Chiche, Jean-Daniel; Coopersmith, Craig; de Backer, Daniel P.; French, Craig J.; Fujishima, Seitaro; Gerlach, Herwig; Hidalgo, Jorge Luis; Hollenberg, Steven M.; Jones, Alan E.; Karnad, Dilip R.; Kleinpell, Ruth M.; Koh, Younsuk; Lisboa, Thiago Costa; Machado, Flavia R.; Marini, John J.; Marshall, John C.; Mazuski, John E.; McIntyre, Lauralyn A.; McLean, Anthony S.; Mehta, Sangeeta; Moreno, Rui P.; Myburgh, John; Navalesi, Paolo; Nishida, Osamu; Osborn, Tiffany M.; Perner, Anders; Plunkett, Colleen M.; Ranieri, Marco; Schorr, Christa A.; Seckel, Maureen A.; Seymour, Christopher W.; Shieh, Lisa; Shukri, Khalid A.; Simpson, Steven Q.; Singer, Mervyn; Thompson, B. Taylor; Townsend, Sean R.; van der Poll, Thomas; Vincent, Jean-Louis; Wiersinga, W. Joost; Zimmerman, Janice L.; Dellinger, R. Phillip

    2017-01-01

    To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012". A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee

  4. Adrenal gland volume measurement in septic shock and control patients: a pilot study

    Energy Technology Data Exchange (ETDEWEB)

    Nougaret, Stephanie; Aufort, S.; Gallix, B. [Hopital Saint Eloi, Department of Abdominal Imaging, CHU Montpellier, Montpellier, Cedex 5 (France); Jung, B.; Chanques, G.; Jaber, S. [Hopital Saint Eloi, Intensive Care Unit, Department of Critical Care and Anesthesiology: DAR B, CHU Montpellier, Montpellier, Cedex 5 (France)

    2010-10-15

    To compare adrenal gland volume in septic shock patients and control patients by using semi-automated volumetry. Adrenal gland volume and its inter-observer variability were measured with tomodensitometry using semi-automated software in 104 septic shock patients and in 40 control patients. The volumes of control and septic shock patients were compared and the relationship between volume and outcome in intensive care was studied. The mean total volume of both adrenal glands was 7.2 {+-} 2.0 cm{sup 3} in control subjects and 13.3 {+-} 4.7 cm{sup 3} for total adrenal gland volume in septic shock patients (p < 0.0001). Measurement reproducibility was excellent with a concordance correlation coefficient value of 0.87. The increasing adrenal gland volume was associated with a higher rate of survival in intensive care. The present study reports that with semi-automated software, adrenal gland volume can be measured easily and reproducibly. Adrenal gland volume was found to be nearly double in sepsis compared with control patients. The absence of increased volume during sepsis would appear to be associated with a higher rate of mortality and may represent a prognosis factor which may help the clinician to guide their strategy. (orig.)

  5. [Septic shock in a patient with the Fournièr gangrene with fatal outcome].

    Science.gov (United States)

    Zonca, P; Mrázek, T; Matusek, A; Hajek, M; Stiglerová, S; Jurytko, A; Kucera, C; Nieslanik, M

    2009-07-01

    The authors present a case of a patient with developed Fournièr gangrene and septic shock. Fournièr gangrene belongs to the group of local non-specific infection of soft tissues (NSTI). Its incidence is relatively low, but the infection is extraordinary aggressive with a possible lethal end. 39 years old patient with 4 days history of Fournier gangrene's development was admitted in irreversible septic shock. The initial APACHE II score was 36. The delay in treatment was an important factor in the further course of illness with lethal end. Above the mentioned 39 years old patient died because of septic shock. The hemorrhagic cystitis was the original source of infection with further development of Fournièr gangrene according to the pathological record. We often come across all different kinds of stages of sepsis from the MODS to the septic shock for patients with Fournièr gangrene. Causal treatment should be started early. The local surgical excision and wide broad antibiotic administrations are basic treatments in the context of other treatment modalities according to the current patient's needs. The adjuvant hyperbaric oxygen treatment takes place in patients with Fournièr gangrene as well and is beneficial. The following factor even worsens the illness prognosis: delay in diagnostic, higher age, anorectal origin of infection, the amount of organ with dysfunction or failure, diabetes mellitus and significant immunodeficiency.

  6. Muscle oxygenation as an indicator of shock severity in patients with suspected severe sepsis or septic shock.

    Directory of Open Access Journals (Sweden)

    Kenneth A Schenkman

    Full Text Available The aim of this pilot study was to evaluate the potential of a new noninvasive optical measurement of muscle oxygenation (MOx to identify shock severity in patients with suspected sepsis.We enrolled 51 adult patients in the emergency department (ED who presented with possible sepsis using traditional Systematic Inflammatory Response Syndrome criteria or who triggered a "Code Sepsis." Noninvasive MOx measurements were made from the first dorsal interosseous muscles of the hand once potential sepsis/septic shock was identified, as soon as possible after admission to the ED. Shock severity was defined by concurrent systolic blood pressure, heart rate, and serum lactate levels. MOx was also measured in a control group of 17 healthy adults.Mean (± SD MOx in the healthy control group was 91.0 ± 5.5% (n = 17. Patients with mild, moderate, and severe shock had mean MOx values of 79.4 ± 21.2%, 48.6 ± 28.6%, and 42.2 ± 4.7%, respectively. Mean MOx for the mild and moderate shock severity categories were statistically different from healthy controls and from each other based on two-sample t-tests (p < 0.05.We demonstrate that noninvasive measurement of MOx was associated with clinical assessment of shock severity in suspected severe sepsis or septic shock. The ability of MOx to detect even mild septic shock has meaningful implications for emergency care, where decisions about triage and therapy must be made quickly and accurately. Future longitudinal studies may validate these findings and the value of MOx in monitoring patient status as treatment is administered.

  7. Association of Kidney Tissue Barrier Disrupture and Renal Dysfunction in Resuscitated Murine Septic Shock.

    Science.gov (United States)

    Stenzel, Tatjana; Weidgang, Clair; Wagner, Katja; Wagner, Florian; Gröger, Michael; Weber, Sandra; Stahl, Bettina; Wachter, Ulrich; Vogt, Josef; Calzia, Enrico; Denk, Stephanie; Georgieff, Michael; Huber-Lang, Markus; Radermacher, Peter; McCook, Oscar

    2016-10-01

    Septic shock-related kidney failure is characterized by almost normal morphological appearance upon pathological examination. Endothelial barrier disrupture has been suggested to be of crucial importance for septic shock-induced organ dysfunction. Therefore, in murine resuscitated cecal ligation and puncture (CLP)-induced septic shock, we tested the hypothesis whether there is a direct relationship between the kidney endothelial barrier injury and renal dysfunction. Anesthetized mice underwent CLP, and 15 h later, were anesthetized again and surgically instrumented for a 5-h period of intensive care comprising lung-protective mechanical ventilation, fluid resuscitation, continuous i.v. norepinephrine to maintain target hemodynamics, and measurement of creatinine clearance (CrCl). Animals were stratified according to low or high CrCl. Nitrotyrosine formation, expression of the inducible isoform of the nitric oxide synthase, and blood cytokine (tumor necrosis factor, interleukin-6, interleukin-10) and chemokine (monocyte chemoattractant protein-1, keratinocyte-derived chemokine) levels were significantly higher in animals with low CrCl. When plotted against CrCl and neutrophil gelatinase-associated lipocalin levels, extravascular albumin accumulation, and tissue expression of the vascular endothelial growth factor and angiopoietin-1 showed significant mathematical relationships related to kidney (dys)function. Preservation of the constitutive expression of the hydrogen sulfide producing enzyme cystathione-γ-lyase was associated with maintenance of organ function. The direct quantitative relation between microvascular leakage and kidney (dys)function may provide a missing link between near-normal tissue morphology and septic shock-related renal failure, thus further highlighting the important role of vascular integrity in septic shock-related renal failure.

  8. CT-proAVP IS NOT A GOOD PREDICTOR OF VASOPRESSOR NEED IN SEPTIC SHOCK.

    Science.gov (United States)

    Laribi, Said; Lienart, Daphné; Castanares-Zapatero, Diego; Collienne, Christine; Wittebole, Xavier; Laterre, Pierre-François

    2015-10-01

    Septic shock features a high hospital mortality. Improving our ability to risk stratify these patients at admission may help better define management strategies and design studies. The primary objective of this study was to determine if patients dead or with sustained vasopressor need at day 7 had a relative arginine vasopressin (AVP) deficiency as compared with vasopressor-free patients at day 7. Another objective was to explore if plasma CT-proAVP (C terminal part of preprovasopressin) measured within 24 h of sepsis onset could predict patient severity. This was a prospective observational study in a medical and surgical intensive care unit. One hundred thirteen patients were included in this analysis: 102 patients with severe sepsis or septic shock and 11 nonseptic controls. The CT-proAVP was measured at three time points within the first week after sepsis onset. The CT-proAVP measured within 24 h of sepsis onset failed to predict vasopressor need. More importantly, CT-proAVP plasma levels in patients with a sustained need of vasopressors did not differ from vasopressor-free patients at days 1 and 2. The CT-proAVP was more elevated in septic shock as compared with severe sepsis or nonseptic patients. When analyzing 28-day mortality, nonsurvivors featured higher levels of the CT-proAVP compared with survivors. Patients with septic shock and sustained need of vasopressors do not seem to present a relative AVP deficiency. In sepsis, the subgroup of patients that may benefit from AVP supplementation still needs to be identified. Our study further confirms previous data on the ability of the CT-proAVP to predict patient severity in severe sepsis and septic shock.

  9. Differential diagnostic value of procalcitonin in surgical and medical patients with septic shock.

    Science.gov (United States)

    Clec'h, Christophe; Fosse, Jean-Philippe; Karoubi, Philippe; Vincent, Francois; Chouahi, Imad; Hamza, Lilia; Cupa, Michel; Cohen, Yves

    2006-01-01

    To assess whether different diagnostic and prognostic cutoff values of procalcitonin should be considered in surgical and in medical patients with septic shock. Prospective observational study. Intensive care unit of the Avicenne teaching hospital, France. All patients with septic shock or noninfectious systemic inflammatory response syndrome within 48 hrs after admission. None. Patients were allocated to one of the following groups: group 1 (surgical patients with septic shock), group 2 (surgical patients with noninfectious systemic inflammatory response syndrome), group 3 (medical patients with septic shock), and group 4 (medical patients with noninfectious systemic inflammatory response syndrome). Procalcitonin at study entry was compared between group 1 and group 2 and between group 3 and group 4 to determine the diagnostic cutoff value in surgical and in medical patients, respectively. Procalcitonin was compared between survivors and nonsurvivors from group 1 and group 3 to determine its prognostic cutoff value. One hundred forty-three patients were included: 31 in group 1, 36 in group 2, 36 in group 3, and 40 in group 4. Median procalcitonin levels (ng/mL [interquartile range]) were higher in group 1 than in group 3 (34.00 [7.10-76.00] vs. 8.40 [3.63-24.70], p = .01). In surgical patients, the best diagnostic cutoff value was 9.70 ng/mL, with 91.7% sensitivity and 74.2% specificity. In medical patients, the best diagnostic cutoff value was 1.00 ng/mL, with 80% sensitivity and 94% specificity. Procalcitonin was a reliable early prognostic marker in medical but not in surgical patients with septic shock. A cutoff value of 6.00 ng/mL had 76% sensitivity and 72.7% specificity for separating survivors from nonsurvivors. The diagnostic cutoff value of procalcitonin was higher in surgical than in medical patients. Early procalcitonin was of prognostic interest in medical patients.

  10. The effectiveness of synthetic glucocorticoids on the disease course, treatment, and outcome of severe sepsis and septic shock

    Directory of Open Access Journals (Sweden)

    Jelena Dumančić

    2016-03-01

    Full Text Available Due to the high morbidity and mortality rates, severe sepsis and septic shock, present a major global public health problem. The treatment and management of severe sepsis and septic shock is based on a set of international guidelines called the Surviving sepsis campaign (SSC. SSC guidelines suggest the use of hydrocortisone at a dose of 200 mg IV in adult patients with septic shock refractory to fluid resuscitation and vasopressors. During the last century, the importance of cortisol as an essential hormone at times of stress, such as septic shock, has been recognized. Therefore, the therapeutic use of synthetic glucocorticoids has been the subject of many studies during the last few decades but their results are not consistent. Two of the largest studies (CORTICUS and French study showed different effects of synthetic glucocorticoids on mortality rates, but they both showed a significantly shorter duration of septic shock. There is an ongoing large, multicenter, double-blind, randomized study (ADRENAL study and its primary goal is to assess the impact of hydrocortisone therapy on 90-day survival rate. It is expected that the results of this study might provide answers to the questions raised by previously conducted studies. This review will summarize the pathophysiology of sepsis and septic shock and the role of cortisol in its development, and will highlight the most important clinical studies pertaining to synthetic glucocorticoid administration in sepsis and septic shock.

  11. Ion transport in circulatory and/or septic shock

    International Nuclear Information System (INIS)

    Sayeed, M.M.

    1987-01-01

    This review surveys investigations of membrane ion transport in animals in hemorrhagic, endotoxic, or bacteremic shock. The focus of the review is on ion transport studies in the skeletal muscle and liver. Skeletal muscle Na + -K + transport alterations have been shown during the induction of shock via hemorrhage, endotoxin, or live Gram-negative bacteria in the rodent, canine, and primate species. These alterations include impairment of active cellular K + accumulation, increased permeability to 24 Na + and Cl - , and membrane depolarization. The ion transport alterations in the skeletal muscle are compatible with movement of extracellular fluid into the intracellular compartment. Such fluid movements can potentially lead to decreases in circulating plasma volume and thus to circulatory deficits in shock. Studies in the liver of rats subjected to hemorrhagic or endotoxic shock indicated the failure of electrogenic Na + pump. Although the hepatic cellular membrane permeability to Na + relative to permeability to K + appeared unaltered in hemorrhagic shock, endotoxic shock caused an increase in permeability to Na + . Hepatic cellular 45 Ca + regulation also appeared to be adversely affected during endotoxic shock. Alterations in hepatic Na + -K + transport and Ca + regulation could contribute to impairment in hepatic glucose production during shock. Although mechanisms of altered membrane ion transport during shock states remain unknown, such changes could occur prior to any substantial loss of cellular metabolic energy

  12. Integration of metabolic and inflammatory mediator profiles as a potential prognostic approach for septic shock in the intensive care unit.

    Science.gov (United States)

    Mickiewicz, Beata; Tam, Patrick; Jenne, Craig N; Leger, Caroline; Wong, Josee; Winston, Brent W; Doig, Christopher; Kubes, Paul; Vogel, Hans J

    2015-01-15

    Septic shock is a major life-threatening condition in critically ill patients and it is well known that early recognition of septic shock and expedient initiation of appropriate treatment improves patient outcome. Unfortunately, to date no single compound has shown sufficient sensitivity and specificity to be used as a routine biomarker for early diagnosis and prognosis of septic shock in the intensive care unit (ICU). Therefore, the identification of new diagnostic tools remains a priority for increasing the survival rate of ICU patients. In this study, we have evaluated whether a combined nuclear magnetic resonance spectroscopy-based metabolomics and a multiplex cytokine/chemokine profiling approach could be used for diagnosis and prognostic evaluation of septic shock patients in the ICU. Serum and plasma samples were collected from septic shock patients and ICU controls (ICU patients with the systemic inflammatory response syndrome but not suspected of having an infection). (1)H Nuclear magnetic resonance spectra were analyzed and quantified using the targeted profiling methodology. The analysis of the inflammatory mediators was performed using human cytokine and chemokine assay kits. By using multivariate statistical analysis we were able to distinguish patient groups and detect specific metabolic and cytokine/chemokine patterns associated with septic shock and its mortality. These metabolites and cytokines/chemokines represent candidate biomarkers of the human response to septic shock and have the potential to improve early diagnosis and prognosis of septic shock. Our findings show that integration of quantitative metabolic and inflammatory mediator data can be utilized for the diagnosis and prognosis of septic shock in the ICU.

  13. Metabolic profiling of serum samples by 1H nuclear magnetic resonance spectroscopy as a potential diagnostic approach for septic shock.

    Science.gov (United States)

    Mickiewicz, Beata; Duggan, Gavin E; Winston, Brent W; Doig, Christopher; Kubes, Paul; Vogel, Hans J

    2014-05-01

    To determine whether a nuclear magnetic resonance-based metabolomics approach can be useful for the early diagnosis and prognosis of septic shock in ICUs. Laboratory-based study. University research laboratory. Serum samples from septic shock patients and ICU controls (ICU patients with systemic inflammatory response syndrome but not suspected of having an infection) were collected within 24 hours of admittance to the ICU. None. H nuclear magnetic resonance spectra of septic shock and ICU control samples were analyzed and quantified using a targeted profiling approach. By applying multivariate statistical analysis (e.g., orthogonal partial least squares discriminant analysis), we were able to distinguish the patient groups and detect specific metabolic patterns. Some of the metabolites were found to have a significant impact on the separation between septic shock and control samples. These metabolites could be interpreted in terms of a biological human response to septic shock and they might serve as a biomarker pattern for septic shock in ICUs. Additionally, nuclear magnetic resonance-based metabolomics was evaluated in order to detect metabolic variation between septic shock survivors and nonsurvivors and to predict patient outcome. The area under the receiver operating characteristic curve indicated an excellent predictive ability for the constructed orthogonal partial least squares discriminant analysis models (septic shock vs ICU controls: area under the receiver operating characteristic curve = 0.98; nonsurvivors vs survivors: area under the receiver operating characteristic curve = 1). Our results indicate that nuclear magnetic resonance-based metabolic profiling could be used for diagnosis and mortality prediction of septic shock in the ICU.

  14. Short- and long-term mortality in patients with community-acquired severe sepsis and septic shock

    DEFF Research Database (Denmark)

    Storgaard, Merete; Hallas, Jesper; Gahrn-Hansen, Bente

    2013-01-01

    Background: Severe sepsis and septic shock have a high 30-day mortality (10-50%), but the long-term mortality is not well described. The purpose of this study was to describe long-term mortality among patients with community-acquired severe sepsis or septic shock compared to a population...... (multivariate Cox regression controlling for age, sex, and Charlson comorbidity index). Conclusions: Patients with severe sepsis and septic shock who survived the first 30 days had a 2.7 times higher mortality hazard in the first year and a 2.3 times higher mortality hazard in the next 3 y, compared to persons...

  15. Exchange Transfusion in the Treatment of Neonatal Septic Shock: A Ten-Year Experience in a Neonatal Intensive Care Unit

    OpenAIRE

    Pugni, Lorenza; Ronchi, Andrea; Bizzarri, Bianca; Consonni, Dario; Pietrasanta, Carlo; Ghirardi, Beatrice; Fumagalli, Monica; Ghirardello, Stefano; Mosca, Fabio

    2016-01-01

    Septic shock, occurring in about 1% of neonates hospitalized in neonatal intensive care unit (NICU), is a major cause of death in the neonatal period. In the 1980s and 90s, exchange transfusion (ET) was reported by some authors to be effective in the treatment of neonatal sepsis and septic shock. The main aim of this retrospective study was to compare the mortality rate of neonates with septic shock treated only with standard care therapy (ScT group) with the mortality rate of those treated w...

  16. Protocol Adherence for Severe Sepsis and Septic Shock Management in the Emergency Department; a Clinical Audit.

    Science.gov (United States)

    Alavi-Moghaddam, Mostafa; Anvari, Ali; Soltani Delgosha, Reaza; Kariman, Hamid

    2017-01-01

    Although significant development in the field of medicine is achieved, sepsis is still a major issue threatening humans' lives. This study was aimed to audit the management of severe sepsis and septic shock patients in emergency department (ED) according to the present standard guidelines. This is a prospective audit on approaching adult septic patients who were admitted to ED. The audit checklist was created based on the protocols of Surviving Sepsis Campaign and British Royal College recommendations. The mean knowledge score and the compliance rate of studied measures regarding standard protocols were calculated using SPSS version 21. 30 emergency medicine residents were audited (63.3% male). The mean knowledge score of studied residents regarding standard guidelines were 5.07 ± 1.78 (IQR = 2) in pre education and 8.17 ± 1.31 (IQR = 85) in post education phase (p management of severe sepsis and septic shock for urine output measurement, central venous pressure monitoring, administration of inotrope agents, blood transfusion, intravenous antibiotic and hydration therapy, and high flow O 2 delivery were disappointingly low. It seems training workshops and implementation of Clinical audit can improve residents' adherence to current standard guidelines regarding severe sepsis and septic shock.

  17. The Predictive Value of Adrenomedullin for Development of Severe Sepsis and Septic Shock in Emergency Department

    Directory of Open Access Journals (Sweden)

    Yun-Xia Chen

    2013-01-01

    Full Text Available Objective. The aim of the study was to assess adrenomedullin (AM as a predictor for development of severe sepsis and septic shock in emergency department (ED. Method. From December 2011 to October 2012, 372 consecutive septic patients admitted to ED were enrolled. AM was examined in every patient. All patients were followed up for 3 days. The outcome variable was development of severe sepsis or septic shock. The predictive ability of AM was evaluated by binary logistic regression analysis and receiver operating characteristic (ROC curve. Result. On admission, the differences of AM among patients with different comorbidities, infections, and culture results were not significant. AM level was higher in patients who progressed than in who did not (41.63 ± 6.55 versus 31.31 ± 7.71 ng/L, . AM was the only independent predictor of outcome. The area under ROC curve of AM was 0.847. With a cutoff value of 41.24 ng/L, the sensitivity was 67.6%, the specificity was 90.0%, the positive predictive value was 61.5%, the negative predictive value was 92.2%, the positive likelihood ratio was 6.78, and the negative likelihood ratio was 0.36. Conclusion. Adrenomedullin is valuable for predicting development of severe sepsis and septic shock in ED.

  18. POLYMYXIN-SEWN HEMOSORBENT FOR THE TREATMENT OF PATIENTS WITH SEPTIC SHOCK

    Directory of Open Access Journals (Sweden)

    V. V. Kirkovsky

    2015-01-01

    Full Text Available ABSTRACT. The key component of the sepsis pathogenesis is the gram-negative bacteria endotoxin. It is a lipopolysaccharide of the bacterial wall, which circulation in the bloodstream results in unlimited activation of some biological systems, causing serious complications. Nowadays, there are developed and practiced sorption methods, based on the selective removal of the lipopolysaccharide from the blood during perfusion through the sorption column with covalently immobilized polymyxin on a bioinert matrix, which can bind and inactivate it. The therapeutic effect of hemosorption using the biospecific antilipopolysaccharide hemosorbent has been studied in patients with septic shock, associated with peritonitis and septic complications of destructive pancreatitis. 

  19. Aldosterone and Vascular Mineralocorticoid Receptors in Murine Endotoxic and Human Septic Shock.

    Science.gov (United States)

    Fadel, Fouad; André-Grégoire, Gwennan; Gravez, Basile; Bauvois, Brigitte; Bouchet, Sandrine; Sierra-Ramos, Catalina; Polito, Andrea; Mansart, Arnaud; Alvarez de la Rosa, Diego; Annane, Djillali; Jaisser, Frédéric

    2017-09-01

    Vascular mineralocorticoid receptors play a role in vascular tone and blood pressure regulation, might participate in the pathophysiology of circulatory failure during sepsis, and represent a potential therapeutic target in this disease. We aimed to study the effects of mineralocorticoids and the involvement of vascular mineralocorticoid receptors in murine endotoxic and human septic shock. Experimental study. Translational investigation including animal research and in vitro experiments using human vascular cells and plasma from septic patients. Adult male C57Black 6 mice, adult patients with septic shock. Mice were injected with lipopolysaccharide and/or aldosterone. Human endothelial and smooth muscle cells were treated with pro-inflammatory cytokines with or without aldosterone, nuclear factor-κB inhibitor BAY 11-7082, or plasma from septic patients. Aldosterone improved 5-day survival, invasive arterial pressure, and in vivo and ex vivo arterial response to phenylephrine at 18 hours after induction of murine endotoxic shock. Both α1-adrenoceptor and mineralocorticoid receptor expressions studied in mouse aortas were down-regulated at 6 and 18 hours in endotoxemic mice and restored in aldosterone-treated mice. Furthermore, tumor necrosis factor-α decreased both mineralocorticoid receptor and α1-adrenoceptor expressions within 5 hours in human vascular cells in a nuclear factor-κB pathway-dependent manner. Mineralocorticoid receptor expression was also blunted in human cells treated with plasma from septic patients. We found a beneficial effect of mineralocorticoids on survival, blood pressure, and vascular reactivity, associated with a restoration of α1-adrenoceptor expression in endotoxic shock. Furthermore, blunted vascular mineralocorticoid receptor expression might participate in hemodynamic failure during sepsis.

  20. Left Ventricular Longitudinal Systolic Function in Septic Shock Patients with Normal Ejection Fraction: A Case-control Study.

    Science.gov (United States)

    Zhang, Hong-Min; Wang, Xiao-Ting; Zhang, Li-Na; He, Wei; Zhang, Qing; Liu, Da-Wei

    2017-05-20

    Septic cardiomyopathy is a common finding in septic shock patients. The accepted definition of septic cardiomyopathy is often based on the left ventricular ejection fraction (LVEF). The aim of this study was to determine whether the left ventricular longitudinal systolic function was more sensitive than the LVEF in heart function appraisal of septic shock patients. This was a case-control study conducted at a 40-bed Intensive Care Unit (ICU) of Peking Union Medical College Hospital. Septic shock patients admitted to the ICU were consecutively enrolled in the study group from March 1, 2016 to September 1, 2016. The control group was selected from nonsepsis patients who were admitted to the ICU and were comparable to the study group. Transthoracic echocardiography was performed to obtain the LVEF measurement, mitral annular plane systolic excursion (MAPSE), tissue Doppler velocity measurement of mitral annulus (Sa), and tricuspid annular plane systolic excursion. The study group consisted of 45 septic shock patients. Another 45 nonsepsis patients were selected as the control group. There was no difference in the LVEF between the two groups (64.6% vs. 67.2%, t= -1.426, P= 0.161). MAPSE in the study group was much lower than in the control group (1.2 cm vs. 1.5 cm, t= -4.945, Pseptic shock patients. In the heart function appraisal of septic shock patients with a normal ejection fraction, more attention should be given to longitudinal function parameters such as MAPSE and Sa.

  1. Acute glyco-metabolic decompensation during septic shock

    Directory of Open Access Journals (Sweden)

    Maria Marta Cravino

    2010-09-01

    Full Text Available Hyper-glycemy is commonly described as a complication in patients affected by septic states, regardless of their having had diabetes. Numerous studies also record the presence of glyco-metabolic decompensations in patients affected by leukemia and lymphoma treated with chemotherapy. The case under study interesting and peculiar as there is no mention of glycemy levels so high to be not suitable for life. It is interesting also the patient's good therapeutical response, their marrow aplasia status and general poor health condition notwithstanding.

  2. Pulmonary extraction of biogenic amines during septic shock

    International Nuclear Information System (INIS)

    Kerstein, M.D.; Kohler, J.; Gould, S.; Moseley, P.

    1982-01-01

    The effect of live Escherichia coli on the pulmonary extraction of the biogenic amines 14 C 5-hydroxytryptamine, (5-HT) and 3 H-epinephrine was investigated. The labeled isotopes were injected into a central venous catheter and collected from an aortic catheter. One hundred per cent of the labeled epinephrine was recovered in the control and septic state. Only 32.8 +/- 3.6% SEM of the 5-hydroxytryptamine was recovered before sepsis and 42.5 +/- 4.9% SEM after sepsis. During sepsis, mean arterial pressure fell to 58 mm Hg from 121 mm Hg. Pulmonary shunt increased from .7 +/- .05 SEM to .33 +/- .09 SEM

  3. Septic Shock Alters Mitochondrial Respiration of Lymphoid Cell-Lines and Human Peripheral Blood Mononuclear Cells: The Role of Plasma.

    Science.gov (United States)

    Clere-Jehl, Raphael; Helms, Julie; Kassem, Mohamad; Le Borgne, Pierrick; Delabranche, Xavier; Charles, Anne-Laure; Geny, Bernard; Meziani, Ferhat; Bilbault, Pascal

    2018-02-14

    In septic shock patients, post-septic immunosuppression state following the systemic inflammatory response syndrome is responsible for nosocomial infections, with subsequent increased mortality. The aim of the present study was to assess the underlying cellular mechanisms of the post-septic immunosuppression state, by investigating mitochondrial functions of peripheral blood mononuclear cells (PBMCs) from septic shock patients over 7 days. Eighteen patients admitted to a French intensive care unit for septic shock were included. At days 1 and 7, PBMCs were isolated by Ficoll density gradient centrifugation. Mitochondrial respiration of intact septic PBMCs was assessed versus control group PBMCs, by measuring O2 consumption in plasma, using high-resolution respirometry. Mitochondrial respiration was then compared between septic plasmas and control plasmas for control PBMCs, septic PBMCs and lymphoid cell-line (CEM). To investigate the role of plasma, we measured several plasma cytokines, among them HMGB1, by ELISA. Basal O2 consumption of septic shock PBMCs was of 8.27 ± 3.39 and 10.48 ± 3.99 pmol/s/10 cells at days 1 and 7 respectively, significantly higher than in control PBMCs (5.37 ± 1.46 pmol/s/10 cells, p Septic patient PBMCs showed a lower response to oligomycin, suggesting a reduced ATP-synthase activity, as well as an increased response to FCCP suggesting an increased mitochondrial respiratory capacity. At 6 hours, septic plasmas showed a decreased O2 consumption of CEM (4.73 ± 1.46 vs. 6.58 ± 1.53, p Septic plasma impairs mitochondrial respiration in immune cells, with a possible role of the proinflammatory protein HMGB1, leading to a subsequent compensation, probably by enzymatic activation. This compensation result is an improvement of global mitochondrial respiratory capacity, but without restoring ATP-synthase activity.

  4. Association Between US Norepinephrine Shortage and Mortality Among Patients With Septic Shock.

    Science.gov (United States)

    Vail, Emily; Gershengorn, Hayley B; Hua, May; Walkey, Allan J; Rubenfeld, Gordon; Wunsch, Hannah

    2017-04-11

    Drug shortages in the United States are common, but their effect on patient care and outcomes has rarely been reported. To assess changes to patient care and outcomes associated with a 2011 national shortage of norepinephrine, the first-line vasopressor for septic shock. Retrospective cohort study of 26 US hospitals in the Premier Healthcare Database with a baseline rate of norepinephrine use of at least 60% for patients with septic shock. The cohort included adults with septic shock admitted to study hospitals between July 1, 2008, and June 30, 2013 (n = 27 835). Hospital-level norepinephrine shortage was defined as any quarterly (3-month) interval in 2011 during which the hospital rate of norepinephrine use decreased by more than 20% from baseline. Use of alternative vasopressors was assessed and a multilevel mixed-effects logistic regression model was used to evaluate the association between admission to a hospital during a norepinephrine shortage quarter and in-hospital mortality. Among 27 835 patients (median age, 69 years [interquartile range, 57-79 years]; 47.0% women) with septic shock in 26 hospitals that demonstrated at least 1 quarter of norepinephrine shortage in 2011, norepinephrine use among cohort patients declined from 77.0% (95% CI, 76.2%-77.8%) of patients before the shortage to a low of 55.7% (95% CI, 52.0%-58.4%) in the second quarter of 2011; phenylephrine was the most frequently used alternative vasopressor during this time (baseline, 36.2% [95% CI, 35.3%-37.1%]; maximum, 54.4% [95% CI, 51.8%-57.2%]). Compared with hospital admission with septic shock during quarters of normal use, hospital admission during quarters of shortage was associated with an increased rate of in-hospital mortality (9283 of 25 874 patients [35.9%] vs 777 of 1961 patients [39.6%], respectively; absolute risk increase = 3.7% [95% CI, 1.5%-6.0%]; adjusted odds ratio = 1.15 [95% CI, 1.01-1.30]; P = .03). Among patients with septic shock in US

  5. [Septic shock. Update of treatment using hypertonic saline and antidiuretic hormone-vasopressin].

    Science.gov (United States)

    Pascual-Ramírez, J; Aguirre Sánchez-Covisa, M; Araujo, F; Gil Trujillo, S; Collar, L G; Bocharán, S

    2012-01-01

    Safety in the use of small volumes of hypertonic saline solution for hypovolaemic shock and in the treatment of intracranial hypertension has been demonstrated in studies in the field of resuscitation. There is little experience of this for septic shock in humans. Beneficial immunomodulatory effects have been detected in pre-clinical studies. Interactions with the pituitary-adrenal axis and with the secretion of anti-diuretic hormone are varied and suggestive, but are not sufficiently understood. On the other hand, vasopressin has cardiovascular, osmoregulatory, and coagulation effects, and also acts on the hypothalamic-pituitary-adrenal axis. There is a relative deficit of vasopressin in septic shock. Its use in these patients does not seem to have any advantages as regards mortality, but may be beneficial in patients at risk from acute renal failure, or those who receive corticosteroids. Terlipressin is a vasopressin analogue that has also been studied. The synergy between vasopressin and hypertonic saline is a hypothesis that is mainly supported in pre-clinical studies. The use of hypertonic saline solution in septic shock, although promising, is still experimental, and must be restricted to the field of controlled clinical trials. Copyright © 2010 Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor. Published by Elsevier España. All rights reserved.

  6. Neutrophil gelatinase-associated lipocalin predicts myocardial dysfunction and mortality in severe sepsis and septic shock.

    Science.gov (United States)

    Wang, Biao; Chen, Gang; Li, Jia; Zeng, Yuanying; Wu, Yunfu; Yan, Xiaoye

    2017-01-15

    This study examines the clinical utility of plasma neutrophil gelatinase-associated lipocalin (NGAL) as an indicator of myocardial dysfunction and mortality in severe sepsis and septic shock. We designed a prospective cohort study in an intensive care unit, and 53 patients with severe sepsis or septic shock were included. Data were used to determine a relationship between NGAL and the development of myocardial dysfunction and mortality. These associations were determined by the Mann-Whitney test, multiple logistic regression, plotting the receiver operating characteristic (ROC) curve, Kaplan-Meier curves and Spearman test. The High NGAL group had higher need for inotropic/vasopressor support (92% vs. 52%, p=0.0186), higher incidence of regional wall motion abnormalities (46% vs. 13%, p=0.0093), higher B-type natriuretic peptide (BNP) level (p=0.0197), higher cardiac troponin I (cTnI) level (p=0.0016), lower ejection fraction (EF) (pseptic shock was significant. High plasma NGAL correlates with high mortality and myocardial dysfunction in severe sepsis and septic shock. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

  7. A case of Lemierre's syndrome with septic shock and complicated parapneumonic effusions requiring intrapleural fibrinolysis

    Directory of Open Access Journals (Sweden)

    Daniel P. Croft

    2015-01-01

    Full Text Available Lemierre's syndrome is a septic thrombophlebitis of the internal jugular vein, which can lead to severe systemic illness. We report a case of an otherwise healthy 26-year-old man who suffered from pharyngitis followed by septic shock requiring intubation and vasopressor support from Fusobacterium necrophorum bacteremia. The septic emboli to his lungs caused complicated bilateral parapneumonic effusions, which recurred after initial drainage. He required bilateral chest tubes and intrapleural tPA to successfully drain his effusions. His fever curve and overall condition improved with the resolution of his effusions and after a 33-day hospitalization, he recovered without significant disability. The severity of his illness and difficult to manage complicated parapneumonic effusions were the unique facets of this case. Using an evidence-based approach of tPA and DNase for complicated parapneumonic effusions in Lemierre's syndrome can be safe and effective.

  8. Impairment of exogenous lactate clearance in experimental hyperdynamic septic shock is not related to total liver hypoperfusion

    NARCIS (Netherlands)

    P. Tapia (Pablo); D. Soto (Dagoberto); A. Bruhn (Alejandro); L. Alegría (Leyla); N. Jarufe (Nicolás); C. Luengo (Cecilia); E. Kattan (Eduardo); T. Regueira (Tomas); A. Meissner (Arturo); R. Menchaca (Rodrigo); M.I. Vives (María Ignacia); N. Echeverría (Nicolas); G.A. Ospina-Tascon (Gustavo A); J. Bakker (Jan); G. Hernandez (Glenn)

    2015-01-01

    textabstractIntroduction: Although the prognostic value of persistent hyperlactatemia in septic shock is unequivocal, its physiological determinants are controversial. Particularly, the role of impaired hepatic clearance has been underestimated and is only considered relevant in patients with liver

  9. Ruptured Tubo-Ovarian Abscess in a Postmenopausal Woman Presenting with Septic Shock: a Case Report and Literature Review

    Directory of Open Access Journals (Sweden)

    Chun-Chieh Chi

    2006-03-01

    Conclusion: Tubo-ovarian abscesses in postmenopausal women are uncommon but should be kept in mind with a pelvic tumor accompanied by septic shock, as this may cause a terrible outcome and other sequelae.

  10. Oxidative stress and septic shock: metabolic aspects of oxygen-derived free radicals generated in the liver during endotoxemia.

    Science.gov (United States)

    Sakaguchi, Shuhei; Furusawa, Shinobu

    2006-07-01

    This review describes the role of oxidative stress caused by endotoxin challenge in sepsis or septic shock symptoms. We observed that endotoxin injection resulted in lipid peroxide formation and membrane damage (near 60-150 kDa) in the livers of experimental animals, causing decreased levels of scavengers or quenchers of free radicals. The administration of alpha-tocopherol completely prevented injury to the liver plasma membrane caused by endotoxin, and suggested that lipid peroxidation by free radicals might occur in a tissue ischemic state, probably by disseminated intravascular coagulation (DIC), in endotoxemia. In mice, depression of Ca(2+)-ATPase activity in the liver plasma membrane may contribute to the membrane damage caused by endotoxin, and the increase of [Ca(2+)](i) in the liver cytoplasm may partially explain the oxidative stress that occurs in endotoxemia. It seems that endotoxin-induced free radical formation is regulated by Ca(2+) mobilization. Moreover, we have suggested that the oxidative stress caused by endotoxin may be due, at least in part, to the changes in endogenous zinc or selenium regulation during endotoxemia. Interestingly, the extent of TNF-alpha-induced oxidative stress may be the result of a synergism between TNF-alpha and gut-derived endotoxin. It is likely that bacterial or endotoxin translocation plays a significant role in TNF-alpha-induced septic shock. On the other hand, although nitric oxide (NO) has been implicated in the pathogenesis of vascular hyporesponsiveness and hypotension in septic shock in our experimental model, it is unlikely that NO plays a significant role in liver injury caused by free radical generation in endotoxemia.

  11. Histocompatibility leukocyte antigen-D related expression is specifically altered and predicts mortality in septic shock but not in other causes of shock.

    Science.gov (United States)

    Caille, Vincent; Chiche, Jean-Daniel; Nciri, Noureddine; Berton, Christine; Gibot, Sébastien; Boval, Bernadette; Payen, Didier; Mira, Jean-Paul; Mebazaa, Alexandre

    2004-12-01

    Although the expression of monocyte histocompatibility leukocyte antigen (HLA)-DR has been shown to be decreased during human sepsis, its level of expression in other nonseptic critical conditions is unclear. The aim of this study was to compare the level of HLA-DR expression on circulating monocytes among patients with septic, hemorrhagic, and cardiogenic shocks and severe sepsis without shock. At admission, HLA-DR expression was exclusively decreased in patients with septic shock (n = 30; P shock (n = 16), hemorrhagic shock (n = 11), severe sepsis without shock (n = 18), and healthy volunteers (n = 8). HLA-DR expression was not predictive for overall mortality, but at day 1, an HLA-DR expression of less than 14 of mean fluorescence intensity (that corresponds to 40% labeled monocytes) was predictive of mortality exclusively in patients with septic shock (odds ratio, 11.4 and 95% confidence interval, 1.7; 78.4; P culture, and number of units of blood or plasma transfused did not correlate with decreased HLA-DR expression. Thus, the decrease in HLA-DR expression is specific to septic shock and is associated, in septic shock patients, with increased mortality risk.

  12. Incidence of severe sepsis and septic shock in German intensive care units: the prospective, multicentre INSEP study.

    Science.gov (United States)

    2016-12-01

    To estimate the incidence density, point prevalence and outcome of severe sepsis and septic shock in German intensive care units (ICUs). In a prospective, multicentre, longitudinal observational study, all patients already on the ICU at 0:00 on 4 November 2013 and all patients admitted to a participating ICU between 0:00 on 4 November 2013 and 2359 hours on 1 December 2013 were included. The patients were followed up for the occurrence of severe sepsis or septic shock (SEPSIS-1 definitions) during their ICU stay. A total of 11,883 patients from 133 ICUs at 95 German hospitals were included in the study, of whom 1503 (12.6 %) were diagnosed with severe sepsis or septic shock. In 860 cases (57.2 %) the infections were of nosocomial origin. The point prevalence was 17.9 % (95 % CI 16.3-19.7).The calculated incidence rate of severe sepsis or septic shock was 11.64 (95 % CI 10.51-12.86) per 1000 ICU days. ICU mortality in patients with severe sepsis/septic shock was 34.3 %, compared with 6 % in those without sepsis. Total hospital mortality of patients with severe sepsis or septic shock was 40.4 %. Classification of the septic shock patients using the new SEPSIS-3 definitions showed higher ICU and hospital mortality (44.3 and 50.9 %). Severe sepsis and septic shock continue to be a frequent syndrome associated with high hospital mortality. Nosocomial infections play a major role in the development of sepsis. This study presents a pragmatic, affordable and feasible method for the surveillance of sepsis epidemiology. Implementation of the new SEPSIS-3 definitions may have a major effect on future epidemiological data.

  13. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016)

    OpenAIRE

    Nishida, Osamu; Ogura, Hiroshi; Egi, Moritoki; Fujishima, Seitaro; Hayashi, Yoshiro; Iba, Toshiaki; Imaizumi, Hitoshi; Inoue, Shigeaki; Kakihana, Yasuyuki; Kotani, Joji; Kushimoto, Shigeki; Masuda, Yoshiki; Matsuda, Naoyuki; Matsushima, Asako; Nakada, Taka-aki

    2018-01-01

    Background and purpose The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] 10.3918/jsicm.24S0001 and Journal of Japanese Association for ...

  14. The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG 2016)

    OpenAIRE

    Nishida, Osamu; Ogura, Hiroshi; Egi, Moritoki; Fujishima, Seitaro; Hayashi, Yoshiro; Iba, Toshiaki; Imaizumi, Hitoshi; Inoue, Shigeaki; Kakihana, Yasuyuki; Kotani, Joji; Kushimoto, Shigeki; Masuda, Yoshiki; Matsuda, Naoyuki; Matsushima, Asako; Nakada, Taka‐aki

    2018-01-01

    Background and Purpose The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG 2016), a Japanese‐specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 in Japanese. An English‐language version of these guidelines was created based on the contents of the original Japanese‐language versi...

  15. Fatal septic shock due to a disseminated chronic form of paracoccidioidomycosis in an aged woman.

    Science.gov (United States)

    Benard, Gil; Patzina, Roseli L; Schwab, Juliana Barbosa; Gabriel, Thiago C; Ho, Yeh-Li

    2012-05-01

    Once rare, septic shock (SS) due to disseminated fungal infections has been increasingly reported due to a growing number of immunocompromised patients, but remains rare in non-immune-compromised individuals. In paracoccidioidomycosis, it has been described in only three patients with the severe, acute form of the disease. We describe the development of a refractory, fatal septic shock due to a severe disseminated chronic form of paracoccidioidomycosis in an older woman without any other microbial insults. A striking event in the evolution of her case was the severe depletion of lymphocytes from the peripheral blood and lymphoid organs. Lymphocyte depletion due to apoptosis is described in the late phase of sepsis and can contribute both to immunosuppression and the progression of SS. The possible mechanisms involved in the induction of SS in the chronic form of paracoccidioidomycosis are discussed.

  16. The effects of norepinephrine infusion on oxygen consumption in a patient with septic shock.

    Science.gov (United States)

    Bouffard, Y; Tissot, S; Viale, J P; Delafosse, B; Annat, G; Bachmann, P; Motin, J

    1990-01-01

    A 65-year-old man developed postsurgical septic shock, unresponsive to plasma volume expansion and administration of dopamine and dobutamine. A continuous norepinephrine infusion was then started and the dose increased to 0.62 micrograms.kg-1.min-1 until the mean arterial pressure was 70 mmHg. Prior to and during the norepinephrine infusion, oxygen consumption was continuously measured with a mass spectrometer system. There was a parallel increase in mean arterial pressure and oxygen consumption (+ 35%). There was also an increase in cardiac index and oxygen delivery. Systemic vascular resistance was only transiently increased. In this case with septic shock, norepinephrine infusion improved hemodynamic variables with an associated increase in oxygen consumption.

  17. Enrollment into a time sensitive clinical study in the critical care setting: results from computerized septic shock sniffer implementation

    Science.gov (United States)

    Pieper, Matthew S; Pulido, Juan; Gajic, Ognjen

    2011-01-01

    Objective Recruitment of patients into time sensitive clinical trials in intensive care units (ICU) poses a significant challenge. Enrollment is limited by delayed recognition and late notification of research personnel. The objective of the present study was to evaluate the effectiveness of the implementation of electronic screening (septic shock sniffer) regarding enrollment into a time sensitive (24 h after onset) clinical study of echocardiography in severe sepsis and septic shock. Design We developed and tested a near-real time computerized alert system, the septic shock sniffer, based on established severe sepsis/septic shock diagnostic criteria. A sniffer scanned patients' data in the electronic medical records and notified the research coordinator on call through an institutional paging system of potentially eligible patients. Measurement The performance of the septic shock sniffer was assessed. Results The septic shock sniffer performed well with a positive predictive value of 34%. Electronic screening doubled enrollment, with 68 of 4460 ICU admissions enrolled during the 9 months after implementation versus 37 of 4149 ICU admissions before sniffer implementation (p<0.05). Efficiency was limited by study coordinator availability (not available at nights or weekends). Conclusions Automated electronic medical records screening improves the efficiency of enrollment and should be a routine tool for the recruitment of patients into time sensitive clinical trials in the ICU setting. PMID:21508415

  18. Risk factors for death in septic shock: A retrospective cohort study comparing trauma and non-trauma patients.

    Science.gov (United States)

    Medam, Sophie; Zieleskiewicz, Laurent; Duclos, Gary; Baumstarck, Karine; Loundou, Anderson; Alingrin, Julie; Hammad, Emmanuelle; Vigne, Coralie; Antonini, François; Leone, Marc

    2017-12-01

    The aim of this study was to compare septic shock directly associated-mortality between severe trauma patients and nontrauma patients to assess the role of comorbidities and age. We conducted a retrospective study in an intensive care unit (ICU) (15 beds) of a university hospital (928 beds). From January 2009 to May 2015, we reviewed 2 anonymized databases including severe trauma patients and nontrauma patients. We selected the patients with a septic shock episode. Among 385 patients (318 nontrauma patients and 67 severe trauma patients), the ICU death rate was 43%. Septic shock was directly responsible for death among 35% of our cohort, representing 123 (39%) nontrauma patients and 10 (15%) trauma patients (P septic shock associated-mortality, whereas severe trauma was a protective factor (OR: 0.26; 95% CI [0.08-0.78], P = 0.01). From these independent risk factors, we determined the probability of septic shock associated-mortality. The receiver-operating characteristics curve has an area under the curve at 0.76 with sensitivity of 55% and specificity of 86%. Trauma appears as a protective factor, whereas the severity of organ failure has a major role in the mortality of septic shock. However, because of the study's design, unmeasured confounding factors should be taken into account in our findings. Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.

  19. Diagnostic value of Pentraxin-3 in patients with sepsis and septic shock in accordance with latest sepsis-3 definitions.

    Science.gov (United States)

    Hamed, Sonja; Behnes, Michael; Pauly, Dominic; Lepiorz, Dominic; Barre, Max; Becher, Tobias; Lang, Siegfried; Akin, Ibrahim; Borggrefe, Martin; Bertsch, Thomas; Hoffmann, Ursula

    2017-08-09

    Pentraxin-3 (PTX-3) is an acute-phase protein involved in inflammatory and infectious processes. This study assesses its diagnostic and prognostic value in patients with sepsis or septic shock in a medical intensive care unit (ICU). The study includes 213 ICU patients with clinical criteria of sepsis and septic shock. 77 donors served as controls. Plasma levels of PTX-3, procalcitonin (PCT) and interleukin-6 were measured on day 1, 3 and 8. PTX-3 correlated with higher lactate levels as well as with APACHE II and SOFA scores (p = 0.0001). PTX-3 levels of patients with sepsis or septic shock were consistently significantly higher than in the control group (p ≤ 0.001). Plasma levels were able to discriminate sepsis and septic shock significantly on day 1, 3 and 8 (range of AUC 0.73-0.92, p = 0.0001). Uniform cut-off levels were defined at ≥5 ng/ml for at least sepsis, ≥9 ng/ml for septic shock (p = 0.0001). PTX-3 reveals diagnostic value for sepsis and septic shock during the first week of intensive care treatment, comparable to interleukin-6 according to latest Sepsis-3 definitions. NCT01535534 . Registered 14.02.2012.

  20. Refractory septic shock in children: a European Society of Paediatric and Neonatal Intensive Care definition.

    Science.gov (United States)

    Morin, Luc; Ray, Samiran; Wilson, Clare; Remy, Solenn; Benissa, Mohamed Rida; Jansen, Nicolaas J G; Javouhey, Etienne; Peters, Mark J; Kneyber, Martin; De Luca, Daniele; Nadel, Simon; Schlapbach, Luregn Jan; Maclaren, Graeme; Tissieres, Pierre

    2016-12-01

    Although overall paediatric septic shock mortality is decreasing, refractory septic shock (RSS) is still associated with high mortality. A definition for RSS is urgently needed to facilitate earlier identification and treatment. We aim to establish a European society of paediatric and neonatal intensive care (ESPNIC) experts' definition of paediatric RSS. We conducted a two-round Delphi study followed by an observational multicentre retrospective study. One hundred and fourteen paediatric intensivists answered a clinical case-based, two-round Delphi survey, identifying clinical items consistent with RSS. Multivariate analysis of these items in a development single-centre cohort (70 patients, 30 % mortality) facilitated development of RSS definitions based on either a bedside or computed severity score. Both scores were subsequently tested in a validation cohort (six centres, 424 patients, 11.6 % mortality). From the Delphi process, the draft definition included evidence of myocardial dysfunction and high blood lactate levels despite high vasopressor treatment. When assessed in the development population, each item was independently associated with the need for extracorporeal life support (ECLS) or death. Resultant bedside and computed septic shock scores had high discriminative power against the need for ECLS or death, with areas under the receiver operating characteristics curve of 0.920 (95 % CI 0.89-0.94), and 0.956 (95 % CI 0.93-0.97), respectively. RSS defined by a bedside score equal to or higher than 2 and a computed score equal to or higher than 3.5 was associated with a significant increase in mortality. This ESPNIC definition of RSS accurately identifies children with the most severe form of septic shock.

  1. Cardiopulmonary Arrest and Resuscitation in Severe Sepsis and Septic Shock: A Research Model.

    Science.gov (United States)

    Chalkias, Athanasios; Spyropoulos, Vaios; Koutsovasilis, Anastasios; Papalois, Apostolos; Kouskouni, Evaggelia; Xanthos, Theodoros

    2015-03-01

    Cardiopulmonary resuscitation in patients with severe sepsis and septic shock is challenging and usually unsuccessful. The aim of the present study is to describe our swine model of cardiac arrest and resuscitation in severe sepsis and septic shock. In this prospective randomized animal study, 10 healthy female Landrace-Large White pigs with an average weight of 20 ± 1 kg (aged 19 - 21 weeks) were the study subjects. Septicemia was induced by an intravenous infusion of a bolus of 20-mL bacterial suspension in 2 min, followed by a continuous infusion during the rest of the experiment. After septic shock was confirmed, the animals were left untreated until cardiac arrest occurred. All animals developed pulseless electrical activity between the fifth and sixth hours of septicemia, whereas five (50%) of 10 animals were successfully resuscitated. Coronary perfusion pressure was statistically significantly different between surviving and nonsurviving animals. We found a statistically significant correlation between mean arterial pressure and unsuccessful resuscitation (P = 0.046), whereas there was no difference in end-tidal carbon dioxide (23.05 ± 1.73 vs. 23.56 ± 1.70; P = 0.735) between animals with return of spontaneous circulation and nonsurviving animals. During the 45-min postresuscitation monitoring, we noted a significant decrease in hemodynamic parameters, although oxygenation indices and lactate clearance were constantly increased (P = 0.001). This successful basic swine model was for the first time developed and may prove extremely useful in future studies on the periarrest period in severe sepsis and septic shock.

  2. Association of positive fluid balance and mortality in sepsis and septic shock in an Australian cohort.

    Science.gov (United States)

    Pittard, M G; Huang, S J; McLean, A S; Orde, S R

    2017-11-01

    In patients with septic shock, a correlation between positive fluid balance and worsened outcomes has been reported in multiple observational studies worldwide. No published data exists in an Australasian cohort. We set out to explore this association in our institution. We conducted a retrospective audit of patient records from August 2012 to May 2015 in a single-centre, 24-bed surgical and medical intensive care unit (ICU) in Sydney, Australia. All patients with septic shock were included. Exclusion criteria included length of stay less than 24 hours or vasopressors needed for less than six hours. Data was gathered on fluid balance for the first seven days of ICU admission, biochemical data and other clinical indices. The primary outcome measure was survival to hospital discharge. One hundred and eighty-six patients with septic shock were included, with an overall hospital mortality of 23.7%. Seventy-five percent of patients required mechanical ventilation, and 27.4% required haemodialysis. The mean daily fluid balance on the first day of admission was positive 1,424 ml and 1,394 ml for ICU and hospital survivors, respectively. On average, the daily fluid balance for non-survivors was higher than the survivors: ICU non-survivors were 602 (95% confidence intervals 230, 974) ml (P=0.0015) and hospital non-survivors were 530 [95% confidence intervals 197, 863] ml (P=0.0017) more than the survivors. In line with other recently published data, after adjustment for confounders (severity of illness based on the Acute Physiology and Chronic Health Evaluation score) we found a correlation between positive fluid balance and worsened hospital mortality in critically ill patients with sepsis and septic shock. Further research investigating rational use of fluids in this patient group is needed.

  3. Intensity of Vasopressor Therapy for Septic Shock and the Risk of In-Hospital Death.

    Science.gov (United States)

    Brand, Donald A; Patrick, Patricia A; Berger, Jeffrey T; Ibrahim, Mediha; Matela, Ajsza; Upadhyay, Shweta; Spiegler, Peter

    2017-05-01

    Given the high mortality of 30%-60% associated with septic shock, distinguishing which patients do or do not have a reasonable chance of surviving with aggressive treatment could help clinicians and families make informed decisions. To determine if intensity of vasopressor therapy accurately predicts in-hospital death. This observational cohort study analyzed in-hospital mortality as a function of intensity of vasopressor therapy in a consecutive series of adults with septic shock treated over a four-year period. Receiver operating characteristic curve analysis assessed the overall strength of the intensity-mortality relationship. A total of 808 patients with septic shock experienced an in-hospital death rate of 41.0% (331/808; 95% CI, 38.5%-44.5%). The greater the peak number of vasopressors required, the higher the death rate, which reached 92.3% (12/13; 95% CI, 79.4%-100.0%) when three different pressors were being infused at full dose. The receiver operating characteristic curve analysis revealed that number of simultaneous vasopressors and vasopressor dose load performed equally well in predicting death or survival. When a standard full dose of a vasopressor fails to normalize blood pressure in a patient with septic shock, escalation begins to yield diminishing returns as the dose and multiplicity of agents approach practical upper limits. Although it is not possible to specify a precise cutoff for limiting vs. intensifying therapy, a mortality of 80% or higher-characterized by two or more concurrent vasopressors at full dose-should prompt shared decision making with the patient's family. Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.

  4. SEPTIC SHOCK IN PATIENT WITH DISSEMINATED HISTOPLASMOSIS ASSOCIATED WITH AIDS: A CASE REPORT

    OpenAIRE

    Poswar, Fabiano de Oliveira; Carneiro, Jair Almeida; Stuart, Janice Mendes; Feliciano, Jorge Patrick Oliveira; Nassau, Daniella Cristina

    2013-01-01

    SUMMARY Histoplasmosis is a systemic mycosis caused by Histoplasma capsulatum, which may present itself as a serious infection in immunocompromised individuals. We present a case of 31-year-old female with newly diagnosed HIV infection and history of fever, general and respiratory symptoms and diffuse hyperchromic papules through the body. She was admitted, with rapid progression to septic shock, and the presence of neutrophils filled with yeast-like organisms was detected on peripheral blood...

  5. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).

    Science.gov (United States)

    Singer, Mervyn; Deutschman, Clifford S; Seymour, Christopher Warren; Shankar-Hari, Manu; Annane, Djillali; Bauer, Michael; Bellomo, Rinaldo; Bernard, Gordon R; Chiche, Jean-Daniel; Coopersmith, Craig M; Hotchkiss, Richard S; Levy, Mitchell M; Marshall, John C; Martin, Greg S; Opal, Steven M; Rubenfeld, Gordon D; van der Poll, Tom; Vincent, Jean-Louis; Angus, Derek C

    2016-02-23

    Definitions of sepsis and septic shock were last revised in 2001. Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management, and epidemiology of sepsis, suggesting the need for reexamination. To evaluate and, as needed, update definitions for sepsis and septic shock. A task force (n = 19) with expertise in sepsis pathobiology, clinical trials, and epidemiology was convened by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Definitions and clinical criteria were generated through meetings, Delphi processes, analysis of electronic health record databases, and voting, followed by circulation to international professional societies, requesting peer review and endorsement (by 31 societies listed in the Acknowledgment). Limitations of previous definitions included an excessive focus on inflammation, the misleading model that sepsis follows a continuum through severe sepsis to shock, and inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria. Multiple definitions and terminologies are currently in use for sepsis, septic shock, and organ dysfunction, leading to discrepancies in reported incidence and observed mortality. The task force concluded the term severe sepsis was redundant. Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock

  6. Rescue treatment with terlipressin in children with refractory septic shock: a clinical study

    Science.gov (United States)

    Rodríguez-Núñez, Antonio; López-Herce, Jesús; Gil-Antón, Javier; Hernández, Arturo; Rey, Corsino

    2006-01-01

    Introduction Refractory septic shock has dismal prognosis despite aggressive therapy. The purpose of the present study is to report the effects of terlipressin (TP) as a rescue treatment in children with catecholamine refractory hypotensive septic shock. Methods We prospectively registered the children with severe septic shock and hypotension resistant to standard intensive care, including a high dose of catecholamines, who received compassionate therapy with TP in nine pediatric intensive care units in Spain, over a 12-month period. The TP dose was 0.02 mg/kg every four hours. Results Sixteen children (age range, 1 month–13 years) were included. The cause of sepsis was meningococcal in eight cases, Staphylococcus aureus in two cases, and unknown in six cases. At inclusion the median (range) Pediatric Logistic Organ Dysfunction score was 23.5 (12–52) and the median (range) Pediatric Risk of Mortality score was 24.5 (16–43). All children had been treated with a combination of at least two catecholamines at high dose rates. TP treatment induced a rapid and sustained improvement in the mean arterial blood pressure that allowed reduction of the catecholamine infusion rate after one hour in 14 out of 16 patients. The mean (range) arterial blood pressure 30 minutes after TP administration increased from 50.5 (37–93) to 77 (42–100) mmHg (P < 0.05). The noradrenaline infusion rate 24 hours after TP treatment decreased from 2 (1–4) to 1 (0–2.5) µg/kg/min (P < 0.05). Seven patients survived to the sepsis episode. The causes of death were refractory shock in three cases, withdrawal of therapy in two cases, refractory arrhythmia in three cases, and multiorgan failure in one case. Four of the survivors had sequelae: major amputations (lower limbs and hands) in one case, minor amputations (finger) in two cases, and minor neurological deficit in one case. Conclusion TP is an effective vasopressor agent that could be an alternative or complementary therapy in

  7. Echocardiography and ultrasound dopplerography assessment of central and peripheral hemodynamics in children with septic shock

    Directory of Open Access Journals (Sweden)

    V.V. Yevtushenko

    2017-08-01

    Full Text Available Background. The severe course of sepsis is usually associated with the development of septic shock and multiple organ failure. For effective treatment, it is recommended to perform instrumental monitoring of preload, contractile capacity of the heart and tissue perfusion. We aimed to evaluate changes in central and peripheral hemodynamics by echocardiography and Doppler ultrasound in children with septic shock. Materials and methods. A retrospective study of cases of septic shock in children aged 0 to 18 years who underwent treatment in the intensive care unit was conducted. Patients were monitored for central and peripheral hemodynamics by echocardiography and Doppler ultrasound. The initial study of hemodynamic parameters was carried out over the first 3 hours after hospitalization. The second study was carried out in 24–36 hours after the hospitalization. The third study was conducted in the period of convalescence within 24–48 hours after the withdrawal of sympathomimetic drugs. Results. Thirty-four cases of sepsis associated with septic shock were investigated. In 24 (70.6 % patients, the etiological factor was meningococcus, in 1 (2.9 % staphylococcus, and in 9 (26.5 % no aetiology was established. In 6 children from the study group fatal outcome occurred. Values of mean blood pressure, ejection fraction, peripheral resistance were relatively lower in the acute shock period, and increased after stabilization of hemodynamics. Evaluation of peripheral blood circulation at admission showed decreased diastolic velocity in abdominal aorta and upper mesenteric artery and systolic velocity in posterior tibial artery. The results of initial investigation demonstrated that 44.1 % patients had increased cardiac output along with decreased systemic vascular resistance (‘warm shock’, and just 8.8 % had features of ‘cold shock’ (decreased cardiac output and increased vascular resistance. The fatal course of the disease was associated with

  8. Can base excess and anion gap predict lactate level in diagnosis of septic shock?

    Science.gov (United States)

    Pongmanee, Werapon; Vattanavanit, Veerapong

    2018-01-01

    Lactate measurement is the key component in septic shock identification and resuscitation. However, point-of-care lactate testing is not widely used due to the lack of access to nearby test equipment. Biomarkers such as serum lactate, anion gap (AG), and base excess (BE) are used in determining shock in patients with seemingly normal vital signs. We aimed to determine if these biomarkers can be used interchangeably in patients with septic shock in the emergency setting. A prospective observational cohort study was undertaken at a tertiary hospital in southern Thailand. Baseline point-of-care BE, AG, and serum lactate were recorded in all patients presenting with septic shock at the emergency department. Overall correlations including area under the receiver operating characteristic curve (AUROC) for both BE and AG to predict serum lactate level were calculated. One hundred and fifteen patients were enrolled. Pearson correlation of serum lactate to BE was -0.59 ( r 2 = 0.35; 95% confidence interval [CI], -0.69 to -0.44; P < 0.001) and BE to AG was -0.67 ( r 2 = 0.49; 95% CI, -0.76 to -0.55; P < 0.001), and serum lactate to AG was 0.64 ( r 2 = 0.41; 95% CI, 0.52 to 0.74; P < 0.001). A cut-off point of 15.8 for AG identified a lactate level ≥2 mmol/L (sensitivity, 71.4%; specificity, 80.7%; and AUROC, 0.76), and the best cut-off value to predict a lactate level ≥4 mmol/L was 18.5 (sensitivity, 64.2%; specificity, 85.5%; and AUROC 0.78). In patients with septic shock, lactate and AG showed a strong correlation with each other, whereas lactate and BE showed a moderate correlation with each other. Thus, these biomarkers can be used interchangeably to help determine septic shock earlier in patients.

  9. Does body weight impact the efficacy of vasopressin therapy in the management of septic shock?

    Science.gov (United States)

    Miller, James T; Welage, Lynda S; Kraft, Michael D; Alaniz, Cesar

    2012-06-01

    Vasopressors used for the management of septic shock are often dosed according to body weight. Use of vasopressin for physiologic replacement in patients with septic shock is usually administered as a standard non-weight-based dose. We hypothesized that the efficacy of vasopressin may be influenced by body weight. The primary objective was to determine if the effects of vasopressin on other vasopressor dosing requirements is related to body weight. Secondary objectives included evaluation of blood pressure and heart rate after the start of vasopressin infusion. A retrospective, cohort study in a large academic health center was conducted. Sixty-four adult inpatients with septic shock (26 medical intensive care unit and 38 surgical intensive care unit) who required vasopressor administration including vasopressin therapy were included. Dosing requirements of vasopressors were captured 1 hour before and during the hour of vasopressin initiation and 2 and 4 hours later. Other information collected during the study period included blood pressure, mean arterial pressure, and heart rate. Most of the patients (n = 61) received vasopressin at a dose of 0.04 U/min. Changes in vasopressor dosing were significantly correlated with weight-adjusted vasopressin at 2 hours (correlation coefficient = -0.36, P = .03) and 4 hours (correlation coefficient = -0.46, P weight. Prospective studies are needed to examine weight-based dosing of vasopressin in this setting. Copyright © 2012 Elsevier Inc. All rights reserved.

  10. Misdirected Sympathy: The Role of Sympatholysis in Sepsis and Septic Shock.

    Science.gov (United States)

    Ferreira, Jason A; Bissell, Brittany D

    2018-02-01

    The spectrum of sepsis and septic shock remains a highly prevalent disease state, carrying a high risk of morbidity and mortality. The sympathetic nervous system (SNS) plays an important role in this initial cascade, enabling the host to respond to invading pathogens; however, prolonged activation can become pathological. The potential for unregulated sympathetic tone to become of detriment in patients with sepsis has fueled interest in the role and impact of sympatholysis, the selective inhibition of sympathetic tone. The cornerstone of septic shock therapy for decades has been the supplementation of catecholamines and thus potential further perpetuation of this sympathetic dysregulation. Although the theory of sympatholysis circulates around cardiovascular effects and stroke volume optimization, the impact of augmenting the SNS may extend well beyond this, including the impacts on the immune system, inflammatory cascade, and even gene transcription. Presently, the most robust clinical evidence involves the use of the cardioselective β-blocker esmolol in patients with septic shock with persistent tachycardia secondary to catecholamine use. Evidence is isolated only to animal models with α-agonists. Future evidence stands to elucidate the balance of sympathetic and autonomic tone as well as the potential role of redirecting and maximizing sympathetic activity.

  11. Effects and safety of different anisodamine doses on EVLW at early stage of septic shock patients

    Directory of Open Access Journals (Sweden)

    Ri-Xing Wang

    2017-04-01

    Full Text Available Objective: To investigate the effects and safety of different anisodamine doses on EVLW at early stage of septic shock patients. Method: A total of 63 patients with septic shock were enrolled in ICU, and they were randomly divided into control group (C group, 20 cases, normal anisodamine doses group (N group, 25 cases, anisodamine 20–40 mg/d, high anisodamine doses group (H group, 18 cases,anisodamine 80 mg/d. To observe the dynamic changes of temperature (T, heart rate (HR, oxygenation index (OI, cardiac index (CI, intrathoracic blood volume index (ITBVI, and extravascular lung water index (EVLWI. Results: 12 h after treatment, compared with C and N group, CI and ITBVI significantly increased in H group, EVLWI significantly decreased in H group. Meanwhile, T and HR significantly increased in H group, oxygenation index significantly decreased in H group. Some patients are unable to tolerate anisodamine treatment which leads to cessation of experiment. Compared with C group, EVLWI, CI, ITBVI, oxygenation index significantly improved in N group (P<0.05, mortality rates significantly decreased (P<0.05. Conclusions: Normal anisodamine doses would significantly decreased EVLWI and significantly improved outcomes, high anisodamine dose is not recommended on EVLWI in patients with septic shock.

  12. A multicenter study of septic shock due to candidemia: outcomes and predictors of mortality.

    Science.gov (United States)

    Bassetti, Matteo; Righi, Elda; Ansaldi, Filippo; Merelli, Maria; Trucchi, Cecilia; Cecilia, Trucchi; De Pascale, Gennaro; Diaz-Martin, Ana; Luzzati, Roberto; Rosin, Chiara; Lagunes, Leonel; Trecarichi, Enrico Maria; Sanguinetti, Maurizio; Posteraro, Brunella; Garnacho-Montero, Jose; Sartor, Assunta; Rello, Jordi; Rocca, Giorgio Della; Antonelli, Massimo; Tumbarello, Mario

    2014-06-01

    Candida is the most common cause of severe yeast infections worldwide, especially in critically ill patients. In this setting, septic shock attributable to Candida is characterized by high mortality rates. The aim of this multicenter study was to investigate the determinants of outcome in critically ill patients with septic shock due to candidemia. This was a retrospective study in which patients with septic shock attributable to Candida who were treated during the 3-year study period at one or more of the five participating teaching hospitals in Italy and Spain were eligible for enrolment. Patient characteristics, infection-related variables, and therapy-related features were reviewed. Multiple logistic regression analysis was performed to identify the risk factors significantly associated with 30-day mortality. A total of 216 patients (mean age 63.4 ± 18.5 years; 58.3 % males) were included in the study. Of these, 163 (75 %) were admitted to the intensive care unit. Overall 30-day mortality was 54 %. Significantly higher Acute Physiology and Chronic Health Evaluation (APACHE) II scores, dysfunctional organs, and inadequate antifungal therapy were compared in nonsurvivors and survivors. No differences in survivors versus nonsurvivors were found in terms of the time from positive blood culture to initiation of adequate antifungal therapy. Multivariate logistic regression identified inadequate source control, inadequate antifungal therapy, and 1-point increments in the APACHE II score as independent variables associated with a higher 30-day mortality rate.

  13. Septic Shock following Prostate Biopsy: Aggressive Limb Salvage for Extremities after Pressor-Induced Ischemic Gangrene

    Directory of Open Access Journals (Sweden)

    Jocelyn Lu, BS

    2017-09-01

    Full Text Available Summary:. Vasopressors used to treat patients with septic shock can cause ischemic necrosis of appendages such as the ears and nose, as well as the extremities. Cases of quadruple-extremity necrosis have high morbidity and mortality, and a profound negative impact on quality of life. This case report details the successful limb salvage and return to function using free tissue transfer as a means to salvage bilateral lower extremities in a patient who suffered vasopressor-induced ischemia of upper and lower extremities after prostate biopsy–induced septic shock. Septic shock following transrectal ultrasound–guided prostate biopsy is a rare, yet life-threatening complication. Successful treatment included thorough planning and staging of therapies such as awaiting tissue demarcation and serial surgical debridement to adequately prepare the tissue bed for free tissue transfer. Adjunctive treatments such as hyperbaric oxygen therapy, negative-pressure wound therapy, and meticulous wound care played a crucial role in wound healing. This vigilant planning and coordinated care resulted in the successful lower extremity salvage, consisting of bilateral transmetatarsal amputations and free tissue transfer to both limbs. We present our long-term follow-up of a functional ambulatory patient after catastrophic, life-threatening infection and appropriate multidisciplinary care.

  14. Shoulder Pain after Fall, Septic Shock, and Pyomyositis Associated with Breast Cancer Chemotherapy and Lymphedema

    Directory of Open Access Journals (Sweden)

    Hiromitsu Kitayama

    2016-11-01

    Full Text Available Background: As a symptom of pyomyositis, sepsis usually follows local inflammation signs. Here, we report pyomyositis with lymphedema of upper extremity in which septic shock and poor local findings initially presented during chemotherapy for breast cancer. Case Report: An 80-year-old woman presented with chronic right shoulder pain during chemotherapy for the recurrent disease. She had a history of postmastectomy lymphedema, diabetes mellitus, and repeated hyaluronic acid injections to the shoulder joint. The pain suddenly worsened with septic shock and no apparent local signs. Magnetic resonance imaging revealed myonecrosis, and no pus was yielded by ultrasound-guided needle aspiration. After 2 weeks of recovery by conservative medical management, surgical drainage was performed. Late formulated massive intramuscular pus showed severe neutrophil infiltration and myonecrosis. Conclusion: Pyomyositis can develop into septic shock with poor local signs. Myelosuppression after chemotherapy can cause myonecrosis without macroabscess, and magnetic resonance imaging was useful for the diagnosis of this condition. When unspecified local pain appears during cancer chemotherapy we should consider this disease, too.

  15. Lactate clearance cut off for early mortality prediction in adult sepsis and septic shock patients

    Science.gov (United States)

    Sinto, R.; Widodo, D.; Pohan, H. T.

    2018-03-01

    Previous lactate clearance cut off for early mortality prediction in sepsis and septic shock patient was determined by consensus from small sample size-study. We investigated the best lactate clearance cut off and its ability to predict early mortality in sepsis and septic shock patients. This cohort study was conducted in Intensive Care Unit of CiptoMangunkusumo Hospital in 2013. Patients’ lactate clearance and eight other resuscitationendpoints were recorded, and theoutcome was observed during the first 120 hours. The clearance cut off was determined using receiver operating characteristic (ROC) analysis, and its ability was investigated with Cox’s proportional hazard regression analysis using other resuscitation endpoints as confounders. Total of 268 subjects was included, of whom 70 (26.11%) subjects died within the first 120 hours. The area under ROC of lactate clearance to predict early mortality was 0.78 (95% % confidence interval [CI] 0.71-0.84) with best cut off was sepsis and septic shock patients is 7.5%.

  16. Feasibility, Utility, and Safety of Midodrine During Recovery Phase From Septic Shock.

    Science.gov (United States)

    Whitson, Micah R; Mo, Edwin; Nabi, Tasnima; Healy, Lauren; Koenig, Seth; Narasimhan, Mangala; Mayo, Paul H

    2016-06-01

    We describe the feasibility, utility, and safety of oral midodrine to replace IV vasopressors during recovery from septic shock. This was a retrospective study performed in a medical ICU. All study subjects had a diagnosis of septic shock requiring at least 24 hours of IV vasopressors and demonstrated clinical stability with stable or decreasing doses of IV vasopressors. The two groups compared were those who received IV vasopressors only and those who received IV vasopressors with adjunctive midodrine. Of the 275 study patients, 140 received an IV vasopressor only and 135 received midodrine in addition to an IV vasopressor. There was no difference between the groups' demographics (age, sex, Acute Physiology and Chronic Health Evaluation 4 score). Mean IV vasopressor duration was 3.8 days in the IV vasopressor only group and 2.9 days in the IV vasopressor with midodrine group (P midodrine group (P = .007). ICU length of stay was 9.4 days in the IV vasopressor only group and 7.5 days in the IV vasopressor with midodrine group (P = .017). There were no complications associated with midodrine use except transient bradycardia in one patient, which resolved upon discontinuation of midodrine. Midodrine may reduce the duration of IV vasopressors during recovery phase from septic shock and may be associated with a reduction in length of stay in the ICU. Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

  17. Early initiation of low-dose hydrocortisone treatment for septic shock in adults: A randomized clinical trial.

    Science.gov (United States)

    Lv, Qing-Quan; Gu, Xiao-Hua; Chen, Qi-Hong; Yu, Jiang-Quan; Zheng, Rui-Qiang

    2017-12-01

    Physiologic dose hydrocortisone is part of the suggested adjuvant therapies for patients with septic shock. However, the association between the corticosteroid therapy and mortality in patients with septic shock is still not clear. Some authors considered that the mortality is related to the time frame between development of septic shock and start of low dose hydrocortisone. Thus we designed a placebo-controlled, randomized clinical trial to assess the importance of early initiation of low dose hydrocortisone for the final outcome. A total of 118 patients with septic shock were recruited in the study. All eligible patients were randomized to receive hydrocortisone (n=58) or normal saline (n=60). The study medication (hydrocortisone and normal saline) was initiated simultaneously with vasopressors. The primary end-point was 28-day mortality. The secondary end-points were the reversal of shock, in-hospital mortality and the duration of ICU and hospital stay. The proportion of patients with reversal of shock was similar in the two groups (P=0.602); There were no significant differences in 28-day or hospital all-cause mortality; length of stay in the ICU or hospital between patients treated with hydrocortisone or normal saline. The early initiation of low-dose of hydrocortisone did not decrease the risk of mortality, and the length of stay in the ICU or hospital in adults with septic shock. www.clinicaltrials.govNCT02580240. Copyright © 2017 Elsevier Inc. All rights reserved.

  18. Prognostic value of brachioradialis muscle oxygen saturation index and vascular occlusion test in septic shock patients.

    Science.gov (United States)

    Marín-Corral, J; Claverias, L; Bodí, M; Pascual, S; Dubin, A; Gea, J; Rodriguez, A

    2016-05-01

    To compare rSO2 (muscle oxygen saturation index) static and dynamic variables obtained by NIRS (Near Infrared Spectroscopy) in brachioradialis muscle of septic shock patients and its prognostic implications. Prospective and observational study. Intensive care unit. Septic shock patients and healthy volunteers. The probe of a NIRS device (INVOS 5100) was placed on the brachioradialis muscle during a vascular occlusion test (VOT). Baseline, minimum and maximum rSO2 values, deoxygenation rate (DeOx), reoxygenation slope (ReOx) and delta value. Septic shock patients (n=35) had lower baseline rSO2 (63.8±12.2 vs. 69.3±3.3%, p<0.05), slower DeOx (-0.54±0.31 vs. -0.91±0.35%/s, p=0.001), slower ReOx (2.67±2.17 vs. 9.46±3.5%/s, p<0.001) and lower delta (3.25±5.71 vs. 15.1±3.9%, p<0.001) when compared to healthy subjects (n=20). Among septic shock patients, non-survivors showed lower baseline rSO2 (57.0±9.6 vs. 69.8±11.3%, p=0.001), lower minimum rSO2 (36.0±12.8 vs. 51.3±14.8%, p<0.01) and lower maximum rSO2 values (60.6±10.6 vs. 73.3±11.2%, p<0.01). Baseline rSO2 was a good mortality predictor (AUC 0.79; 95%CI: 0.63-0.94, p<0.01). Dynamic parameters obtained with VOT did not improve the results. Septic shock patients present an important alteration of microcirculation that can be evaluated by NIRS with prognostic implications. Monitoring microvascular reactivity in the brachioradialis muscle using VOT with our device does not seem to improve the prognostic value of baseline rSO2. Copyright © 2015 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

  19. The therapeutic value of protein (de)nitrosylation in experimental septic shock.

    Science.gov (United States)

    Benedet, Patrícia O; Menegatti, Angela C O; Gonçalves, Muryel C; Terenzi, Hernán; Assreuy, Jamil

    2018-01-01

    Cardiovascular dysfunction and organ damage are hallmarks of sepsis and septic shock. Protein S-nitrosylation by nitric oxide has been described as an important modifier of protein function. We studied whether protein nitrosylation/denitrosylation would impact positively in hemodynamic parameters of septic rats. Polymicrobial sepsis was induced by cecal ligation and puncture. Female Wistar rats were treated with increasing doses of DTNB [5,5'-dithio-bis-(2-nitrobenzoic acid)] 30min before or 4 or 12h after sepsis induction. Twenty-four hours after surgery the following data was obtained: aorta response to phenylephrine, mean arterial pressure, vascular reactivity to phenylephrine, biochemical markers of organ damage, survival and aorta protein nitrosylation profile. Sepsis substantially decreases blood pressure and the response of aorta rings and of blood pressure to phenylephrine, as well as increased plasma levels of organ damage markers, mortality of 60% and S-nitrosylation of aorta proteins increased during sepsis. Treatment with DTNB 12h after septic shock induction reversed the loss of response of aorta rings and blood pressure to vasoconstrictors, reduced organ damage and protein nitrosylation and increased survival to 80%. Increases in protein S-nitrosylation are related to cardiovascular dysfunction and multiple organ injury during sepsis. Treatment of rats with DTNB reduced the excessive protein S-nitrosylation, including that in calcium-dependent potassium channels (BK Ca ), reversed the cardiovascular dysfunction, improved markers of organ dysfunction and glycemic profile and substantially reduced mortality. Since all these beneficial consequences were attained even if DTNB was administered after septic shock onset, protein (de)nitrosylation may be a suitable target for sepsis treatment. Copyright © 2017 Elsevier B.V. All rights reserved.

  20. Protocol Adherence for Severe Sepsis and Septic Shock Management in the Emergency Department; a Clinical Audit

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    Mostafa Alavi-Moghaddam

    2017-01-01

    Full Text Available Introduction: Although significant development in the field of medicine is achieved, sepsis is still a major issue threatening humans’ lives. This study was aimed to audit the management of severe sepsis and septic shock patients in emergency department (ED according to the present standard guidelines.Method: This is a prospective audit on approaching adult septic patients who were admitted to ED. The audit checklist was created based on the protocols of Surviving Sepsis Campaign and British Royal College recommendations. The mean knowledge score and the compliance rate of studied measures regarding standard protocols were calculated using SPSS version 21.Results: 30 emergency medicine residents were audited (63.3% male. The mean knowledge score of studied residents regarding standard guidelines were 5.07 ± 1.78 (IQR = 2 in pre education and 8.17 ± 1.31 (IQR = 85 in post education phase (p < 0.001. There was excellent compliance with standard in 4 (22% studied measures, good in 2 (11%, fair in 1 (6%, weak in 2 (11%, and poor in 9 (50%. 64% of poor compliance measures correlated to therapeutic factors. After training, score of 5 measures including checking vital signs in < 20 minute, central vein pressure measurement in < 1 hour, blood culture request, administration of vasopressor agents, and high flow O2 therapy were improved clinically, but not statistically.Conclusion: The protocol adherence in management of severe sepsis and septic shock for urine output measurement, central venous pressure monitoring, administration of inotrope agents, blood transfusion, intravenous antibiotic and hydration therapy, and high flow O2 delivery were disappointingly low. It seems training workshops and implementation of Clinical audit can improve residents’ adherence to current standard guidelines regarding severe sepsis and septic shock.

  1. [Protocol of the management of patients with severe sepsis and septic shock].

    Science.gov (United States)

    Nakashidze, I M; Tsintsadze, N G; Potskhishvili, Sh N

    2012-11-01

    Severe sepsis and septic shock remains the most urgent problem. In severe sepsis and septic shock should be early goal-directed resuscitation of the septic patient during the first 6 hrs after recognition; -appropriate diagnostic studies to ascertain causative organisms before starting antibiotics; -early administration of broad-spectrum antibiotic therapy; -reassessment of antibiotic therapy with microbiology and clinical data to narrow coverage, when appropriate; -a usual 7-10 days of antibiotic therapy guided by clinical response; -source control with attention to the method that balances risks and benefits; -equivalence of crystalloid and colloid resuscitation; aggressive fluid challenge to restore mean circulating filling pressure; -vasopressor preference for norepinephrine and dopamine; -cautious use of vasopressin pending further studies; -avoiding low-dose dopamine administration for renal protection; consideration of dobutamine inotropic therapy in some clinical situations; -stress-dose steroid therapy for septic shock; use of recombinant activated protein C in patients with severe sepsis and high risk for death; -with resolution of tissue hypoperfusion and in the absence of coronary artery disease or acute hemorrhage, targeting a hemoglobin of 7-9 g/dL; -a low tidal volume and limitation of inspiratory plateau pressure strategy for acute lung injury and acute respiratory distress syndrome; -application of a minimal amount of positive end-expiratory pressure in acute lung injury/acute respiratory distress syndrome; -protocols for weaning and sedation, using either intermittent bolus sedation or continuous infusion sedation with daily interruptions/lightening; -avoidance of neuromuscular blockers, if at all possible; -maintenance of blood glucose <150 mg/dL after initial stabilization.

  2. Body temperature control in patients with refractory septic shock: too much may be harmful.

    Science.gov (United States)

    Yang, Yan-Li; Liu, Da-Wei; Wang, Xiao-Ting; Long, Yun; Zhou, Xiang; Chai, Wen-Zao

    2013-01-01

    The lowering of body temperature is a common, almost reflexive step in the daily care of septic shock patient. However, the effect of different magnitudes of fever control on the outcome of refractory septic patients with a very poor outcome is controversial and has yet to be explored. This prospective trial examined sixty-five refractory septic shock patients with a core temperature higher than 38.5°C. Patients were randomly assigned to a group achieving a "low temperature" range (LT group: 36.0 - 37.5°C) or to a group achieving a "high temperature" range (HT group: 37.5 - 38.3°C) by physical methods including a water-flow cooling blanket and ice packs. A target core temperature was achieved in 1 - 2 hours post-treatment, and maintained for 72 hours. Averaged values of core temperature as well as hemodynamic, respiratory, and laboratory variables were analyzed at baseline and during the first 72 hours after fever control. Thirty-four (52.31%) patients were assigned to the LT group and thirty-one (47.69%) patients were assigned to the HT group. The mean core temperature was significantly lower in the LT group than in the HT group (36.61 vs. 37.85°C, respectively; P temperature during the 72 h period was an independent predictor of 28 days mortality (odds ratio (OR) = 0.42, 95%CI 0.25, 0.6; P = 0.001). Controlling fever to a lower range (36.0 - 37.5°C) may be harmful to patients with refractory septic shock by worsening tissue perfusion, compared to controlling it within a higher range (37.5 - 38.3°C). An understanding of the mechanisms responsible for these observations requires further investigation.

  3. Relationship Between Alternative Resuscitation Strategies, Host Response and Injury Biomarkers, and Outcome in Septic Shock: Analysis of the Protocol-Based Care for Early Septic Shock Study.

    Science.gov (United States)

    Kellum, John A; Pike, Francis; Yealy, Donald M; Huang, David T; Shapiro, Nathan I; Angus, Derek C

    2017-03-01

    The Protocol-based Care for Early Septic Shock trial found no differences across alternative resuscitation strategies in all-cause mortality. A separate aim was to determine whether differences in resuscitation strategies affected trajectories of biomarkers of key pathways associated with downstream clinical outcomes of sepsis and whether there were differences in survival across treatment arms for patients with different baseline biomarker profiles. Secondary analysis of a large randomized clinical trial. Thirty-one U.S. hospitals. Six hundred twenty-eight patients with septic shock. Two resuscitation protocols versus usual care. We measured a panel of biomarkers representing four pathophysiologic domains: "inflammation" (tumor necrosis factor, interleukin-6, and -10); "coagulation" (D-dimers, thrombin-antithrombin complex); "oxidative stress" (urine isoprostane); and "tissue hypoxia" (lactate) at 0, 6, 24, and 72 hours after treatment. We analyzed whether alternative resuscitation strategies affected biomarker trajectories over 72 hours and whether effects on 90-day hospital mortality varied by baseline (time 0) biomarker profiles-both using regression models with interaction terms for treatment arms. For all baseline biomarkers, higher concentrations were associated with increased risk of death by 90 days. However, there was no significant effect of treatment assignment on subsequent biomarker trajectories. We did find evidence for heterogeneity of treatment effect of protocol-based care on mortality for patients with different baseline [interleukin-6] and [interleukin-6] × [interleukin-10] profiles, whereas patients with the lowest quartiles fared better with protocol-based care (odds ratios, 0.32 [0.13-075]; p = 0.01 and 0.32 [0.14-0.73]; p = 0.01, respectively). In patients with septic shock, alterations in inflammation, coagulation, oxidative stress, and tissue hypoxia are common and associated with adverse outcomes but are not influenced by protocol

  4. Presence of hypogammaglobulinemia - a risk factor of mortality in patients with severe sepsis, septic shock, and SIRS.

    Science.gov (United States)

    Průcha, M; Zazula, R; Herold, I; Dostál, M; Hyánek, T; Bellingan, G

    2013-01-01

    In this retrospective study we assessed the frequency of hypogammaglobulinemia in 708 patients with SIRS, severe sepsis and septic shock. We evaluated the relationship between hypogammaglobulinemia IgG, IgM and 28 day mortality. Total of 708 patients and 1,513 samples were analyzed. In the three subgroups we investigated, patients met the criteria of SIRS, severe sepsis and septic shock. IgG hypogammaglobulinemia was demonstrated in 114 patients with severe sepsis (25.2%), 11 septic shock patients (24.4%), and in 29 SIRS patients (13.9%). IgM hypogammaglobulinemia was documented in 55 patients with severe sepsis (12.2%), 6 septic shock patients (13.3%), and in 17 SIRS patients (8.1%). Mortality of patients with severe sepsis and normal IgG levels was significantly lower (111 patients; 32.8%) compared with those with IgG hypogammaglobulinemia (49 patients; 43.0%; p=0.001). Mortality of patients with septic shock and IgG hypogammaglobulinemia (n=5) was significantly higher compared with those with normal IgG levels (45.5% vs. 38.2%; p=0.001). Mortality of patients with severe sepsis and IgM hypogammaglobulinemia did not differ from that of patients with normal IgM levels (37.0 vs. 41.8%). Mortality of patients with septic shock and IgM hypogammaglobulinemia was significantly higher compared with those with normal IgM levels (50% vs. 38.5%; p=0.0001). This study documented relatively high incidence of hypogammaglobulinemia IgG and IgM in patients with severe sepsis, septic shock and SIRS respectively. The presence of IgG hypogammaglobulinemia in patients with severe sepsis is independent factor of mortality.

  5. THE EFFECTS OF FENOLDOPAM ON RENAL FUNCTION AND METABOLISM IN AN OVINE MODEL OF SEPTIC SHOCK.

    Science.gov (United States)

    Post, Emiel Hendrik; Su, Fuhong; Taccone, Fabio Silvio; Hosokawa, Koji; Herpain, Antoine; Creteur, Jacques; Vincent, Jean-Louis; De Backer, Daniel

    2016-04-01

    The importance of renal perfusion and metabolism in septic acute kidney injury (AKI) remains unclear. Prophylactic administration of the dopaminergic agent, fenoldopam, has been suggested to reduce the occurrence of AKI, but its effects in septic shock are poorly defined. Sepsis was induced in 15 adult female sheep by injecting autologous feces into the abdominal cavity. Two hours later, the animals were randomized to one of three groups: low-dose fenoldopam (1.0 μg/kg/min, n = 5), high-dose fenoldopam (5.0 μg/kg/min, n = 5), or placebo (control, n = 5). A perivascular flow probe was placed around the renal artery and a catheter in the renal vein for measurement of renal blood flow index (RBFI) and oxygen consumption (VO2renI). Metabolism in the renal cortex was evaluated using microdialysis. Serum creatinine was measured 6-hourly and the sublingual microcirculation assessed using sidestream dark-field videomicroscopy. High-dose fenoldopam was associated with a lower RBFI at 18 h (P = 0.032) than in the control group, but VO2renI was maintained by a higher oxygen extraction (P septic shock, fenoldopam did not improve renal blood flow, worsened microcirculatory alterations, and induced metabolic changes that were indicative of increased glycolysis.

  6. Targeted tissue perfusion versus macrocirculation-guided standard care in patients with septic shock (TARTARE-2S)

    DEFF Research Database (Denmark)

    Pettilä, Ville; Merz, Tobias; Wilkman, Erika

    2016-01-01

    at least 200 patients with septic shock in four European intensive care units (ICUs) to test whether a tissue perfusion-guided treatment strategy based on capillary refill time, peripheral temperature, arterial lactate concentrations, and accepting lower MAP levels, leads to a faster resolution of shock...

  7. Exogenous heat shock cognate protein 70 pretreatment attenuates cardiac and hepatic dysfunction with associated anti-inflammatory responses in experimental septic shock.

    Science.gov (United States)

    Hsu, Jong-Hau; Yang, Rei-Cheng; Lin, Shih-Jen; Liou, Shu-Fen; Dai, Zen-Kong; Yeh, Jwu-Lai; Wu, Jiunn-Ren

    2014-12-01

    It has been recently demonstrated that intracellular heat shock cognate protein 70 (HSC70) can be released into extracellular space with physiologic effects. However, its extracellular function in sepsis is not clear. In this study, we hypothesize that extracellular HSC70 can protect against lipopolysaccharide (LPS)-induced myocardial and hepatic dysfunction because of its anti-inflammatory actions. In Wistar rats, septic shock developed with hypotension, tachycardia, and myocardial and hepatic dysfunction at 4 h following LPS administration (10 mg/kg, i.v.). Pretreatment with recombinant bovine HSC70 (20 μg/kg, i.v.) attenuated LPS-induced hypotension and tachycardia by 21% and 23%, respectively (P shock cognate protein 70 also prevented LPS-induced hypoglycemia (217 vs. 59 mg/dL, P shock, extracellular HSC70 conveys pleiotropic protection on myocardial, hepatic, and systemic derangements, with associated inhibition of proinflammatory mediators including tumor necrosis factor α, nitric oxide, cyclooxygenase 2, and matrix metalloproteinase 9, through mitogen-activated protein kinase/nuclear factor κB signaling pathways. Therefore, extracellular HSC70 may have a promising role in the prophylactic treatment of sepsis.

  8. Septic Participation in Cardiogenic Shock: Exposure to Bacterial Endotoxin.

    Science.gov (United States)

    Ramirez, Paula; Villarreal, Esther; Gordon, Monica; Gómez, María Dolores; de Hevia, Luis; Vacacela, Karla; Gisbert, Teresa; Quinzá, Adrian; Ruiz, Jesús; Alonso, Ricardo; Bonastre, Juan; Vila, Jordi

    2017-05-01

    In cardiogenic shock (CS), presence of fever, leukocytosis, relatively low systemic vascular resistances, and high serum procalcitonin levels are quite frequent and recurrently involve the search for an infectious complication. We hypothesized that endotoxin exposure in CS could explain this sepsis-like syndrome. Prospective observational study of consecutive CS patients admitted to our intensive care unit (ICU). Patients were followed during the first 3 days after CS onset. All clinical, hemodynamic, and microbiological data were collected. Inflammatory biomarkers and anti-endotoxin antibodies (IgM EndoCAb) were daily measured. We included 37 consecutive CS patients. Twenty-two patients (60%) had body temperature >38.3°C or 14,000/mm or <4,000/mm. Microbiological study was performed in 30 patients (81%). No infection was diagnosed in the studied patients. All the patients had serum inflammatory biomarkers levels above normal values including procalcitonin (19 patients [51%] had serum procalcitonin above 2 ng/mL). All the patients had IgM EndoCAb below the normal median value; 22 patients (59.5%) had IgM anti-endotoxin value below 10th percentile range for healthy people. Hemodynamic and respiratory stabilization was achieved in 23 patients (62%) and the ICU mortality rate was 38%, only procalcitonin and interleuquin-6 were associated with higher mortality rate. We have detected extremely low titers of IgM EndoCAb in CS suggesting endotoxin exposure. However, only inflammatory biomarkers were related to ICU mortality.

  9. Changes in kidney perfusion and renal cortex metabolism in septic shock: an experimental study.

    Science.gov (United States)

    Post, Emiel Hendrik; Su, Fuhong; Hosokawa, Koji; Taccone, Fabio Silvio; Herpain, Antoine; Creteur, Jacques; Vincent, Jean-Louis; De Backer, Daniel

    2017-01-01

    The etiology of renal dysfunction in sepsis is currently attributed to altered perfusion, microcirculatory abnormalities and cellular alterations. To clarify these mechanisms, we characterized the changes in renal perfusion and cortex metabolism in a large animal model of sepsis. We studied 12 adult female sheep randomized to peritonitis-induced sepsis (n = 8) or to sham procedure (n = 4). A flow probe was positioned around the renal artery to measure renal blood flow (RBF). Laser Doppler was used to measure regional flow in the kidney cortex and medulla. A microdialysis probe was inserted into the renal cortex to measure cortical glucose, lactate, and pyruvate. Fluid resuscitation was provided to keep pulmonary artery occlusion pressure at baseline levels. All animals were observed for 18 h. Hypotension occurred after 9 h in the septic animals (P = 0.02 versus baseline). RBF and cortical flow were significantly lower than at baseline from 12 h in the septic animals (P = 0.01 and P = 0.03, respectively). Cortical lactate and pyruvate levels increased in the septic animals from 3 and from 6 h, respectively (both P = 0.02 versus baseline), and the L/P ratio from 15 h (P = 0.01). There was a correlation between cortical flow and cortical L/P ratio after shock onset (r = -0.60, P = 0.002) but not before. In this peritonitis model, sepsis was associated with metabolic alterations that may reflect early induction of cortical glycolysis. Septic shock was associated with reduced renal perfusion and decreased cortical and medullary blood flow, followed by signs of anaerobic metabolism in the cortex when flow reductions became critical. Copyright © 2016 Elsevier Inc. All rights reserved.

  10. Prognostic value of extravascular lung water and its potential role in guiding fluid therapy in septic shock after initial resuscitation.

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    Wang, Hao; Cui, Na; Su, Longxiang; Long, Yun; Wang, Xiaoting; Zhou, Xiang; Chai, Wenzhao; Liu, Dawei

    2016-06-01

    To explore whether extravascular lung water (EVLW) provides a valuable prognostic tool guiding fluid therapy in septic shock patients after initial resuscitation. We performed a retrospective study of septic shock patients who achieved adequate initial fluid resuscitation with extended hemodynamic monitoring, analyzing the prognostic value of EVLW and whether fluid therapy for 24 (T24) or 24-48 hours (T24-48) after initial resuscitation with a recommended value of EVLW yielded a 28-day mortality advantage. One hundred five patients with septic shock were included in this study, 60 (57.1%) of whom died after 28 days. For 48 hours after initial resuscitation, the daily fluid balance (DFB; T24: 2494 ± 1091 vs 1965 ± 964 mL [P = .011] and T24-48: 2127 ± 783 vs 1588 ± 665 mL [P septic shock patients after initial resuscitation was associated with a more positive fluid balance and increased mortality, which is an independent predictor of the 28-day mortality in septic shock patients after initial resuscitation. Copyright © 2016 Elsevier Inc. All rights reserved.

  11. Protocol-Based Resuscitation for Septic Shock: A Meta-Analysis of Randomized Trials and Observational Studies.

    Science.gov (United States)

    Lee, Woo Kyung; Kim, Ha Yeon; Lee, Jinae; Koh, Shin Ok; Kim, Jeong Min; Na, Sungwon

    2016-09-01

    Owing to the recommendations of the Surviving Sepsis Campaign guidelines, protocol-based resuscitation or goal-directed therapy (GDT) is broadly advocated for the treatment of septic shock. However, the most recently published trials showed no survival benefit from protocol-based resuscitation in septic shock patients. Hence, we aimed to assess the effect of GDT on clinical outcomes in such patients. We performed a systematic review that included a meta-analysis. We used electronic search engines including PubMed, Embase, and the Cochrane database to find studies comparing protocol-based GDT to common or standard care in patients with septic shock and severe sepsis. A total of 13269 septic shock patients in 24 studies were included [12 randomized controlled trials (RCTs) and 12 observational studies]. The overall mortality odds ratio (OR) [95% confidence interval (CI)] for GDT versus conventional care was 0.746 (0.631-0.883). In RCTs only, the mortality OR (95% CI) for GDT versus conventional care in the meta-analysis was 0.93 (0.75-1.16). The beneficial effect of GDT decreased as more recent studies were added in an alternative, cumulative meta-analysis. No significant publication bias was found. The result of this meta-analysis suggests that GDT reduces mortality in patients with severe sepsis or septic shock. However, our cumulative meta-analysis revealed that the reduction of mortality risk was diminished as more recent studies were added.

  12. Pressor Response to Noradrenaline in the Setting of Septic Shock: Anything New under the Sun—Dexmedetomidine, Clonidine? A Minireview

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    A. Géloën

    2015-01-01

    Full Text Available Progress over the last 50 years has led to a decline in mortality from ≈70% to ≈20% in the best series of patients with septic shock. Nevertheless, refractory septic shock still carries a mortality close to 100%. In the best series, the mortality appears related to multiple organ failure linked to comorbidities and/or an intense inflammatory response: shortening the period that the subject is exposed to circulatory instability may further lower mortality. Treatment aims at reestablishing circulation within a “central” compartment (i.e., brain, heart, and lung but fails to reestablish a disorganized microcirculation or an adequate response to noradrenaline, the most widely used vasopressor. Indeed, steroids, nitric oxide synthase inhibitors, or donors have not achieved overwhelming acceptance in the setting of septic shock. Counterintuitively, α2-adrenoceptor agonists were shown to reduce noradrenaline requirements in two cases of human septic shock. This has been replicated in rat and sheep models of sepsis. In addition, some data show that α2-adrenoceptor agonists lead to an improvement in the microcirculation. Evidence-based documentation of the effects of alpha-2 agonists is needed in the setting of human septic shock.

  13. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.

    Science.gov (United States)

    Rhodes, Andrew; Evans, Laura E; Alhazzani, Waleed; Levy, Mitchell M; Antonelli, Massimo; Ferrer, Ricard; Kumar, Anand; Sevransky, Jonathan E; Sprung, Charles L; Nunnally, Mark E; Rochwerg, Bram; Rubenfeld, Gordon D; Angus, Derek C; Annane, Djillali; Beale, Richard J; Bellinghan, Geoffrey J; Bernard, Gordon R; Chiche, Jean-Daniel; Coopersmith, Craig; De Backer, Daniel P; French, Craig J; Fujishima, Seitaro; Gerlach, Herwig; Hidalgo, Jorge Luis; Hollenberg, Steven M; Jones, Alan E; Karnad, Dilip R; Kleinpell, Ruth M; Koh, Younsuck; Lisboa, Thiago Costa; Machado, Flavia R; Marini, John J; Marshall, John C; Mazuski, John E; McIntyre, Lauralyn A; McLean, Anthony S; Mehta, Sangeeta; Moreno, Rui P; Myburgh, John; Navalesi, Paolo; Nishida, Osamu; Osborn, Tiffany M; Perner, Anders; Plunkett, Colleen M; Ranieri, Marco; Schorr, Christa A; Seckel, Maureen A; Seymour, Christopher W; Shieh, Lisa; Shukri, Khalid A; Simpson, Steven Q; Singer, Mervyn; Thompson, B Taylor; Townsend, Sean R; Van der Poll, Thomas; Vincent, Jean-Louis; Wiersinga, W Joost; Zimmerman, Janice L; Dellinger, R Phillip

    2017-03-01

    To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012." A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable. The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions. Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.

  14. Outcomes in critically ill cancer patients with septic shock of pulmonary origin.

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    de Montmollin, Etienne; Tandjaoui-Lambiotte, Yacine; Legrand, Mattieu; Lambert, Jérôme; Mokart, Djamel; Kouatchet, Achille; Lemiale, Virginie; Pène, Frédéric; Bruneel, Fabrice; Vincent, François; Mayaux, Julien; Chevret, Sylvie; Azoulay, Elie

    2013-03-01

    Increased therapeutic intensity has translated into better survival at a price of infectious and toxic life-threatening complications, chiefly affecting the lungs. Yet, no study specifically evaluated outcomes in cancer patients admitted to the intensive care unit (ICU) for septic shock of pulmonary origin. This is a multicenter cohort study of cancer patients admitted to the ICU for septic shock and pneumonia between 1998 and 2008. Independent determinants of hospital mortality were assessed using a multivariate logistic regression model. Prognostic impact of persistence or acquisition of organ failures was evaluated by survival conditional probabilities. During the 10-year study period, 218 patients were included. Hematologic malignancy (mostly non-Hodgkin lymphoma and acute leukemia) affected 84%, and solid tumors (mostly lung cancer) affected 16% of patients. Chemotherapy was recently administered in 89% of patients, and 24.5% of patients were recipients of hematopoietic stem cell transplantation (35 autologous, 18 allogeneic). At the time of ICU admission, 60% of patients were in partial or complete remission. All patients received vasopressors; invasive mechanical ventilation (MV) was needed in 78.4% and dialysis in 30% of patients. Intensive care unit and hospital mortality rates were 56.4% and 62.4%, respectively. Independent risk factors for hospital mortality were age older than 60 years, time between first symptoms and ICU admission, use of invasive MV, need for invasive MV after use of noninvasive ventilation, and coma. Analysis of survival probability showed that there was no temporal threshold after which persistence or gain of organ dysfunction indicated no hope for survival. Survival in cancer patients with septic shock from pulmonary origin is substantial, even when organ dysfunctions are not rapidly reversible. Delayed ICU management is an independent predictor of death. Studies assessing survival benefits from early ICU management are warranted.

  15. Outcomes Of Intensive Care Patients Having Septic Shock At A Tertiary Care Hospital Of Islamabad.

    Science.gov (United States)

    Ali, Azmat; Abbasi, Awais Saeed; Sheikh, Maliha

    2017-01-01

    Septic shock is defined as sepsis with circulatory, cellular and metabolic abnormalities which are associated with greater mortality more than 40%. The objective of this study was to identify shortcomings and act promptly and adequately. This case series included 32 patients over a period of 03 months, September to November 2016 done at ICU of KRL Hospital Islamabad. The study only enrolled patients who fulfilled the criteria of septic shock. Mortality was as high as 50%. (UTI) was the most common infection (43.75%). In patients who died Pneumonia was commonest infection (43.75%). Mean TLC, CRP and lactate was 17.48×109/l, 29.28 mg/L and 6.81mmom/L respectively. Escherichia Coli (E. coli) was the most common isolated pathogen (31.25%) followed by Staphylococcus Aureus (12.5%). Mean initial MAP was 49.7 mmHg and mean MAP at end of 3-day period was 71.4 mmHg. Mean norepinephrine dose given on day 1, 2 & 3 was 0.90 μg/kg/min, 1.01 μg/kg/min & 1.28 μg/kg/min respectively. Mean hospital stay was 7.1 days. Six out of 08 (75%) patients who needed ventilator support died while 02 out of 08 (25%) patients survived. Acute Kidney Injury (AKI) was the most common End Organ Damage (EOD). Mortality remains high in septic shock despite maximum efforts. In current study MAP, serum lactate level, hospital stay, need for ventilator support, comorbidities, need for newer generation antimicrobials were the important cofounders in differentiating patients who died and those who survived with significant p-values in the 1st four conditions.

  16. Comparative study of dopamine and norepinephrine in the management of septic shock

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    Avinash Agrawal

    2011-01-01

    Full Text Available Objective: The objective was to compare the ability of norepinephrine and dopamine in reversing the hemodynamic and metabolic abnormalities of septic shock using Edwards Vigileo Monitor with Flotrac Sensor. Design: Prospective randomized control study. Methods: Fifty consecutive patients presenting with hyperdynamic septic shock who fulfilled the inclusion criteria were randomly allocated to either group I or group II. The goal of therapy was to achieve and maintain for 6 hours, all of the following - systolic blood pressure (SBP >90 mmHg, systemic vascular resistance index (SVRI >1800 dynes.s/cm 5 m 2 ,cardiac index (CI >4.0 lt/min/m 2 , index of oxygen delivery >550 ml/min/m 2 , index of oxygen uptake >150 ml/min/m 2 . The patients in group I were started on dopamine infusion at 10 μg/kg/min which was increased by 2.5 μg/kg/min, every 15 minutes till the goals were achieved. The patients in group II received norepinephrine infusion started at a dose of 0.5 μg/kg/min with a dose increment of 0.25 μg/kg/min, every 15 minutes till the goals were achieved. Results: Post-treatment heart rate showed an increase in the mean value in group I patients and a decrease in group II patients. The post-treatment mean SBP and SVRI in group II was significantly higher than that in group I. Patients in group I showed a significantly higher increase in post-treatment CI and index of oxygen delivery compared to patients in group II. Nineteen out of 25 patients responded to the treatment in group II while only 10 out of 25 responded in group I. Conclusion: Norepinephrine was more useful in reversing the hemodynamic and metabolic abnormalities of hyperdynamic septic shock compared to dopamine.

  17. Increased PD-1 Expression and Altered T Cell Repertoire Diversity Predict Mortality in Patients with Septic Shock: A Preliminary Study.

    Science.gov (United States)

    Tomino, Atsutoshi; Tsuda, Masanobu; Aoki, Ruri; Kajita, Yuka; Hashiba, Masamitsu; Terajima, Tsuguaki; Kano, Hideki; Takeyama, Naoshi

    2017-01-01

    Sepsis causes impairment of innate and adaptive immunity by multiple mechanisms, including depletion of immune effector cells and T cell exhaustion. Although lymphocyte dysfunction is associated with increased mortality and potential reactivation of latent viral infection in patients with septic shock, the relation between viral reactivation and lymphocyte dysfunction is obscure. The objectives of this study were 1) to determine the relation of lymphocyte dysfunction to viral reactivation and mortality, and 2) to evaluate recovery of lymphocyte function during septic shock, including T cell receptor (TCR) diversity and the expression of programmed death 1 (PD-1). In 18 patients with septic shock and latent cytomegalovirus (CMV) infection, serial blood samples were obtained on days 1, 3, and 7 after the onset of shock, and immune cell subsets and receptor expression were characterized by flow cytometry. TCR diversity of peripheral blood mononuclear cells was analyzed by Multi-N-plex PCR, and CMV DNA was quantified using a real-time PCR kit. A decrease of TCR diversity and monocyte HLA-DR expression were observed in the early stage of septic shock, while CD4+ T cells displayed an increase of PD-1 expression. Significant lymphopenia persisted for at least 7 days following the onset of septic shock. Normalization of TCR diversity and PD-1 expression was observed by day 7, except in patients who died. CMV reactivation was detected in 3 of the 18 patients during the first week of their ICU stay and all 3 patients died. These changes are consistent with the early stage of immune cell exhaustion and indicate the importance of normal lymphocyte function for recovery from septic shock. Ongoing lymphocyte dysfunction is associated with CMV reactivation and dissemination, as well as with unfavorable outcomes.

  18. Increased PD-1 Expression and Altered T Cell Repertoire Diversity Predict Mortality in Patients with Septic Shock: A Preliminary Study.

    Directory of Open Access Journals (Sweden)

    Atsutoshi Tomino

    Full Text Available Sepsis causes impairment of innate and adaptive immunity by multiple mechanisms, including depletion of immune effector cells and T cell exhaustion. Although lymphocyte dysfunction is associated with increased mortality and potential reactivation of latent viral infection in patients with septic shock, the relation between viral reactivation and lymphocyte dysfunction is obscure. The objectives of this study were 1 to determine the relation of lymphocyte dysfunction to viral reactivation and mortality, and 2 to evaluate recovery of lymphocyte function during septic shock, including T cell receptor (TCR diversity and the expression of programmed death 1 (PD-1. In 18 patients with septic shock and latent cytomegalovirus (CMV infection, serial blood samples were obtained on days 1, 3, and 7 after the onset of shock, and immune cell subsets and receptor expression were characterized by flow cytometry. TCR diversity of peripheral blood mononuclear cells was analyzed by Multi-N-plex PCR, and CMV DNA was quantified using a real-time PCR kit. A decrease of TCR diversity and monocyte HLA-DR expression were observed in the early stage of septic shock, while CD4+ T cells displayed an increase of PD-1 expression. Significant lymphopenia persisted for at least 7 days following the onset of septic shock. Normalization of TCR diversity and PD-1 expression was observed by day 7, except in patients who died. CMV reactivation was detected in 3 of the 18 patients during the first week of their ICU stay and all 3 patients died. These changes are consistent with the early stage of immune cell exhaustion and indicate the importance of normal lymphocyte function for recovery from septic shock. Ongoing lymphocyte dysfunction is associated with CMV reactivation and dissemination, as well as with unfavorable outcomes.

  19. Severe sepsis and septic shock: clinical overview and update on management.

    Science.gov (United States)

    Cawcutt, Kelly A; Peters, Steve G

    2014-11-01

    Sepsis is among the oldest themes in medicine; however, despite modern advances, it remains a leading cause of death in the United States. Every clinician should be able to recognize the signs and symptoms of sepsis, along with early management strategies, to expeditiously provide appropriate care and decrease resultant morbidity and mortality. This review addresses the definitions, pathogenesis, clinical manifestations, management, and outcomes of patients with sepsis, severe sepsis, and septic shock. Copyright © 2014 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.

  20. Hepatic Perfusion Alterations in Septic Shock Patients: Impact of Early Goal-directed Therapy.

    Science.gov (United States)

    Zhang, Xi-Wen; Xie, Jian-Feng; Liu, Ai-Ran; Huang, Ying-Zi; Guo, Feng-Mei; Yang, Cong-Shan; Yang, Yi; Qiu, Hai-Bo

    2016-07-20

    Early goal-directed therapy (EGDT) has become an important therapeutic management in early salvage stage of septic shock. However, splenic organs possibly remained hypoperfused and hypoxic despite fluid resuscitation. This study aimed to evaluate the effect of EGDT on hepatic perfusion in septic shock patients. A prospective observational study was carried out in early septic shock patients who were admitted to Intensive Care Unit within 24 h after onset and who met all four elements of the EGDT criteria after treatment with the standard EGDT procedure within 6 h between December 1, 2012 and November 30, 2013. The hemodynamic data were recorded, and oxygen metabolism and hepatic functions were monitored. An indocyanine green clearance test was applied to detect the hepatic perfusion. The patients' characteristics were compared before treatment (T0), immediately after EGDT (T1), and 24 h after EGDT (T2). This study is registered at ClinicalTrials.org, NCT02060773. Twenty-one patients were included in the study; however, the hepatic perfusion data were not included in the analysis for two patients; therefore, 19 patients were eligible for the study. Hemodynamics data, as monitored by pulse-indicator continuous cardiac output, were obtained from 16 patients. There were no significant differences in indocyanine green plasma disappearance rate (ICG-PDR) and 15-min retention rate (R15) at T0 (11.9 ± 5.0%/min and 20.0 ± 13.2%), T1 (11.4 ± 5.1%/min and 23.6 ± 14.9%), and T2 (11.0 ± 4.5%/min and 23.7 ± 15.3%) (all P > 0.05). Both of the alterations of ICG-PDR and R15 showed no differences at T0, T1, and T2 in the patients of different subgroups that achieved different resuscitation goal numbers when elected (P > 0.05). There were no hepatic perfusion improvements after EGDT in the early phase of patients with septic shock. Clinicaltrials.gov NCT02060773 (https://clinicaltrials.gov/ct2/show/NCT02060773).

  1. Implications of Plasma Renin Activity and Plasma Aldosterone Concentration in Critically Ill Patients with Septic Shock

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    Kyung Soo Chung

    2017-05-01

    Full Text Available Background The renin-angiotensin-aldosterone system is closely associated with volume status and vascular tone in septic shock. The present study aimed to assess whether plasma renin activity (PRA and plasma aldosterone concentration (PAC measurements compared with conventional severity indicators are associated with mortality in patients with septic shock. Methods We evaluated 105 patients who were admitted for septic shock. Plasma levels of the biomarkers PRA and PAC, the PAC/PRA ratio, C-reactive protein (CRP level, and cortisol level on days 1, 3, and 7 were serially measured. During the intensive care unit stay, relevant clinical information and laboratory results were recorded. Results Patients were divided into two groups according to 28-day mortality: survivors (n = 59 and non-survivors (n = 46. The survivor group showed lower PRA, PAC, Acute Physiologic and Chronic Health Evaluation (APACHE II score, and Sequential Organ Failure Assessment (SOFA score than did the non-survivor group (all P < 0.05. The SOFA score was positively correlated with PRA (r = 0.373, P < 0.001 and PAC (r = 0.316, P = 0.001. According to receiver operating characteristic analysis, the areas under the curve of PRA and PAC to predict 28-day mortality were 0.69 (95% confidence interval [CI], 0.58 to 0.79; P = 0.001 and 0.67 (95% CI, 0.56 to 0.77; P = 0.003, respectively, similar to the APACHE II scores and SOFA scores. In particular, the group with PRA value ≥3.5 ng ml-1 h-1 on day 1 showed significantly greater mortality than did the group with PRA value <3.5 ng ml-1 h-1 (log-rank test, P < 0.001. According to multivariate analysis, SOFA score (hazard ratio, 1.11; 95% CI, 1.01 to 1.22, PRA value ≥3.5 ng ml-1 h-1 (hazard ratio, 3.25; 95% CI, 1.60 to 6.60, previous history of cancer (hazard ratio, 3.44; 95% CI, 1.72 to 6.90, and coronary arterial occlusive disease (hazard ratio, 2.99; 95% CI, 1.26 to 7.08 were predictors of 28-day mortality. Conclusions Elevated

  2. Septic shock in pregnancy due to pyogenic sacroiliitis: a case report

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    Moros María Lapresta

    2009-03-01

    Full Text Available Abstract Introduction Lower back pain due to sacroiliac joint dysfunction is a common symptom during pregnancy. However, infection of the sacroiliac joint is rare, even more so if no predisposing factors are present. Case presentation After the onset of unspecific acute pain in the left buttock region, a 31-year-old pregnant woman developed septic shock due to pyogenic sacroiliitis. The medical and obstetric management, treatment applied and patient's experience are described. Conclusion The correct diagnosis and treatment of pyogenic sacroiliitis during pregnancy may avoid joint and bone destruction in addition to maternal and fetal complications.

  3. Success of applying early goal-directed therapy for septic shock patients in the emergency department

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    Worapratya P

    2016-01-01

    Full Text Available Panita Worapratya,1 Apisit Wanjaroenchaisuk,2 Jutharat Joraluck,3 Prasit Wuthisuthimethawee1 1Department of Emergency Medicine, Songklanagarind Hospital, Faculty of Medicine, Prince of Songkla University, Songkhla, 2Emergency Department, Samitivej Thonburi Hospital, Bangkok, 3Emergency Department, Hatyai Hospital, Hatyai, Songkhla, Thailand Background: Since early goal-directed therapy (EGDT became standard care in severe sepsis and septic shock patients in intensive care units many years ago, we suppose that the survival rate of severe sepsis and septic shock patients improves if the resuscitative procedure is quickly implemented and is initiated in the emergency room. Objective: We aimed at recording emergency department time to improve our patient care system as well as determine the rate at which EGDT goals can be achieved. The second analysis is to find out how much we can improve the survival rate. Methods: This was a prospective observational study in an emergency room setting at a tertiary care facility where EGDT was applied for resuscitation of severe sepsis and septic shock patients. The data recorded were the initial vital signs, APACHE II (Acute Physiology and Chronic Health Evaluation II score, SAP II (Simplified Acute Physiology II score, SOFA (Sequential Organ Failure Assessment score, time at which EGDT goals were achieved (central venous oxygen saturation [Scvo2] >70%, initial and final diagnosis, and outcome of treatment. The t-test and Mann–Whitney U-test were used to compare between the achieved goal and nonachieved goal groups. Results: There were 63 cases of severe sepsis in the study period. Only 55 patients submitted a signed consent form and had central line insertion. Twenty-eight (50.9% cases were male. Thirty-nine (70.9% patients achieved the goal, and the mean SAP II score was 8. There were no statistically significant differences between the two groups (P-value =0.097. Thirty of the 39 patients (70.9% survived in

  4. Liver perfusion in sepsis, septic shock, and multiorgan failure.

    Science.gov (United States)

    Spapen, Herbert

    2008-06-01

    Sepsis causes significant alterations in the hepatic macro- and microcirculation. Diverging views exist on global hepatic blood flow during experimental sepsis because of the large variety in animal and sepsis models. Fluid-resuscitated clinical sepsis is characterized by ongoing liver ischemia due to a defective oxygen extraction despite enhanced perfusion. The effects of vasoactive agents on the hepatosplanchnic circulation are variable, mostly anecdotal, and depend on baseline perfusion, time of drug administration, and use of concomitant medication. Microvascular blood flow disturbances are thought to play a pivotal role in the development of sepsis-induced multiorgan failure. Redistribution of intrahepatic blood flow in concert with a complex interplay between sinusoidal endothelial cells, liver macrophages, and passing leukocytes lead to a decreased perfusion and blood flow velocity in the liver sinusoids. Activation and dysfunction of the endothelial cell barrier with subsequent invasion of neutrophils and formation of microthrombi further enhance liver tissue ischemia and damage. Substances that regulate (micro)vascular tone, such as nitric oxide, endothelin-1, and carbon monoxide, are highly active during sepsis. Possible interactions between these mediators are not well understood, and their therapeutic manipulation produces equivocal or disappointing results. Whether and how standard resuscitation therapy influences the hepatic microvascular response to sepsis is unknown. Indirect evidence supports the concept that improving the microcirculation may prevent or ameliorate sepsis-induced organ failure.

  5. Terlipressin increased the concentration of L-lactate in the rectal lumen in a patient with septic shock

    DEFF Research Database (Denmark)

    Perner, A; Jørgensen, V L; Waldau, T

    2004-01-01

    Terlipressin--a long-acting analogue of vasopressin--has been described to restore blood pressure in patients with catecholamine-resistant septic shock without obvious complications. We administered low-dose terlipressin (a single i.v.-bolus of 0.5 mg) to a patient with severe, hyperdynamic septic...... in this patient with noradrenalin-treated septic shock....... shock requiring high dosage of noradrenalin. After terlipressin the dose of noradrenalin could be reduced by 2/3 to obtain the same blood pressure. Two hours after terlipressin, the cardiac index had decreased from 6.2 to 3.3 l min(-1) m(-2) and the concentration of L-lactate in the rectal lumen...

  6. Long-term outcomes in patients with septic shock transfused at a lower versus a higher haemoglobin threshold

    DEFF Research Database (Denmark)

    Brandstrup, Sofie Louise Rygaard; Holst, Lars B; Wetterslev, Jørn

    2016-01-01

    PURPOSE: We assessed the predefined long-term outcomes in patients randomised in the Transfusion Requirements in Septic Shock (TRISS) trial. METHODS: In 32 Scandinavian ICUs, we randomised 1005 patients with septic shock and haemoglobin of 9 g/dl or less to receive single units of leuko-reduced red...... % CI -2.4 to 3.1; P = 0.79) and in mental HRQoL 0.5 (95 % CI -3.1 to 4.0; P = 0.79). CONCLUSIONS: Long-term mortality rates and HRQoL did not differ in patients with septic shock and anaemia who were transfused at a haemoglobin threshold of 7 g/dl versus a threshold of 9 g/dl. We may reject a more than...

  7. Is there any role for terlipressin in the extremely low birth weight infant with refractory septic shock?

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    Francesca Bissolo

    2012-10-01

    Full Text Available Terlipressin, a synthetic long-acting analogue of vasopressin, has been investigated as a second line vasopressor in adults and children with refractory septic shock, i.e. not responding to fluid resuscitation and high-dose catecholamine administration. Little experience is available about the safety and efficacy of terlipressin in term and preterm newborns. We report the case of an extremely low birth weight infant with severe septic shock, unresponsive to fluids, noradrenalin and hydrocortisone, in whom terlipressin was attempted as a rescue drug. Despite three doses of terlipressin, administered 6-hourly, the patient remained profoundly hypotensive and eventually died. Further studies are required before any recommendation on the use of terlipressin in term or preterm newborns with septic shock can be made.

  8. The impact of delayed biliary decompression and anti-microbial therapy in 260 patients with cholangitis-associated septic shock.

    Science.gov (United States)

    Karvellas, C J; Abraldes, J G; Zepeda-Gomez, S; Moffat, D C; Mirzanejad, Y; Vazquez-Grande, G; Esfahani, E K; Kumar, A

    2016-10-01

    Cholangitis-associated septic shock carries significant mortality. There is uncertainty regarding the most appropriate time to achieve biliary decompression. To determine whether the timing of biliary decompression and anti-microbial therapy affect the survival in cholangitis patients with septic shock. Nested retrospective cohort study of all cholangitis-associated septic shock patients (hypotension requiring vasopressors) from an international, multi-centre database between 1996 and 2011. Among 260 patients (mean age 69 years, 57% male), overall mortality was 37%. Compared to nonsurvivors (n = 96), survivors (n = 164) had lower mean admission Acute Physiology And Chronic Health Evaluation (APACHE) II (22 vs. 28, P shock, P 12 h [OR 3.40 (1.12-10.31)] were all significantly associated with increased mortality (P septic shock secondary to acute cholangitis have significant mortality. Endoscopic biliary decompression >12 h after the onset of shock and delayed receipt of appropriate anti-microbial therapy were both significantly associated with adverse hospital outcome. This might suggest that early initiation of anti-microbial therapy and urgent biliary decompression (within 12 h) could potentially improve outcomes in this high-risk patient population. © 2016 John Wiley & Sons Ltd.

  9. Prognostic value of ventricular diastolic dysfunction in patients with severe sepsis and septic shock

    Science.gov (United States)

    Rolando, Gustavo; Espinoza, Emilio Daniel Valenzuela; Avid, Emelin; Welsh, Sebastián; Pozo, Juan Del; Vazquez, Alejandro Risso; Arzani, Yanina; Masevicius, Fabio Daniel; Dubin, Arnaldo

    2015-01-01

    Objectives To evaluate the prevalence of myocardial dysfunction and its prognostic value in patients with severe sepsis and septic shock. Methods Adult septic patients admitted to an intensive care unit were prospectively studied using transthoracic echocardiography within the first 48 hours after admission and thereafter on the 7th-10th days. Echocardiographic variables of biventricular function, including the E/e' ratio, were compared between survivors and non-survivors. Results A total of 99 echocardiograms (53 at admission and 46 between days 7 - 10) were performed on 53 patients with a mean age of 74 (SD 13) years. Systolic and diastolic dysfunction was present in 14 (26%) and 42 (83%) patients, respectively, and both types of dysfunction were present in 12 (23%) patients. The E/e' ratio, an index of diastolic dysfunction, was the best predictor of hospital mortality according to the area under the ROC curve (0.71) and was an independent predictor of outcome, as determined by multivariate analysis (OR = 1.36 [1.05 - 1.76], p = 0.02). Conclusion In septic patients admitted to an intensive care unit, echocardiographic systolic dysfunction is not associated with increased mortality. In contrast, diastolic dysfunction is an independent predictor of outcome. PMID:26761470

  10. Community- versus nosocomial-acquired severe sepsis and septic shock in patients admitted to a tertiary intensive care in Saudi Arabia, etiology and outcome.

    Science.gov (United States)

    Baharoon, Salim; Telmesani, Ayman; Tamim, Hani; Alsafi, Eiman; Aljohani, Sameerah; Mahmoud, Ebrahim; Al-Jahdali, Hamdan

    2015-01-01

    Sepsis syndrome is a major worldwide cause of morbidity and mortality. While community-acquired severe sepsis and septic shock constitutes a major cause of admission to the intensive care unit, hospital-acquired severe sepsis and septic shock remain major preventable causes of ICU admission. This study evaluates the rate, etiology, complication and outcome of community- and hospital-acquired sepsis in a tertiary care hospital in Saudi Arabia. This is a retrospective evaluation of all admissions with severe sepsis and septic shock to a general intensive care unit over a period of six months. A total number of 96 patients were included, which represented 15% of the total number of admissions during the study period. The mean age was 57.4 (SD 21). Sixty percent of cases were due to hospital-acquired infections, and 40% were community-acquired. The majority of the infections acquired in the hospital occurred in medical wards and intensive care units (27% and 21%, respectively). At least one co-morbid condition was present in 94% of the sample patients, with cardiovascular disease and diabetes being the most frequently encountered disorders (58%). Both community and hospital-acquired severe sepsis and septic shock carry very high mortality (58%). The ICU length of stay was significantly longer for hospital and ICU acquired infections. Both community and hospital-acquired infections carry high mortality. Hospital-acquired severe sepsis is frequent in medical wards and ICUs, and measures to further evaluate risk factors are prudent. Copyright © 2015. Published by Elsevier Ltd.

  11. C-terminal agrin fragment (CAF) reflects renal function in patients suffering from severe sepsis or septic shock.

    Science.gov (United States)

    Drey, Michael; Behnes, Michael; Kob, Robert; Lepiorz, Dominic; Hettwer, Stefan; Bollheimer, Cornelius; Sieber, Cornel C; Bertsch, Thomas; Hoffmann, Ursula

    2015-01-01

    One of the main causes of acute kidney injury (AKI) in patients treated on an intensive care unit (ICU) is sepsis. The identification of new biomarkers indicating the early development and future course of AKI are of utmost medical interest. The C-terminal agrin fragment (CAF) is measurable in blood serum and might reflect kidney function. Therefore, this study evaluates CAF in patients presenting to an internal ICU with severe sepsis or septic shock. Serum levels of CAF are correlated with biomarkers of kidney function, markers of systemic inflammation, and the presence of AKI and renal replacement therapy (RRT). 61 patients suffering from severe sepsis or septic shock were included during the first 24 hours of ICU treatment and blood samples for biomarker measurements, i.e., CAF, creatinine, cystatin C, procalcitonin (PCT), interleukin 6, C reactive protein (CRP), and white blood cells (WBC) were collected on the first day of intensive care treatment. The number of RRT days and the incidence of AKI were documented. 13% of the patients (8/61) suffered from SIRS/sepsis, 20% (12/61) from severe sepsis, and 67% (41/61) from septic shock. Serum levels of CAF significantly correlated with creatinine (r = 0.623, p patients suffering from severe sepsis and septic shock, serum levels of CAF were significantly associated with kidney function and RRT and were not influenced by severe septic conditions.

  12. Vasopressor Cumulative Dose Requirement and Risk of Early Death During Septic Shock: An Analysis from the Episs Cohort.

    Science.gov (United States)

    Dargent, Auguste; Nguyen, Maxime; Fournel, Isabelle; Bourredjem, Abderrahmane; Charles, Pierre-Emmanuel; Quenot, Jean-Pierre

    2017-10-16

    Septic shock is the primary cause of death in intensive care units, with about 20% of patients dying in the first 3 days. To design future trials focused on early mortality, we require knowledge of early indicators that can detect patients at high risk of early death from refractory septic shock.The aim of this study was to assess whether the cumulative dose of vasopressors (CDV), calculated as the cumulative dose of epinephrine + norepinephrine, is a predictor of early death (within 72 hours) attributable to refractory septic shock (EDASS). This substudy of the EPISS trial was based on 370 patients admitted to a French ICU for septic shock between 2009 and 2011. The area under the receiving operating characteristic (ROC) curve was calculated for the CDV at 6, 12, 24, 36, and 48 hours after vasopressor initiation, and a strategy to predict the risk of EDASS was built based on selected times and thresholds.Among the 370 patients included, 51 (14%) died within the first 72 hours with 40 (11%) EDASS. A strategy in two steps (CDV ≥ 800 μg/kg at 6 hours and/or CDV ≥ 2600 μg/kg at 24 hours) was able to predict EDASS with sensitivity of 45%, specificity 97%, positive predictive value 78% and negative predictive value 94%. Overall, our results confirm that early death directly attributable to septic shock could be effectively predicted by the CDV in the first hours of treatment. These results will help to select patients eligible for innovative therapies aimed at improving early mortality in septic shock.

  13. A Novel Porcine Model of Septic Shock Induced by Acute Respiratory Distress Syndrome due to Methicillin-resistantStaphylococcus aureus.

    Science.gov (United States)

    Wang, Shuo; Wang, Jun-Yu; Wang, Tao; Hang, Chen-Chen; Shao, Rui; Li, Chun-Sheng

    2017-05-20

    Sepsis is one of the main causes of mortality in critically ill patients following progression to septic shock. To investigate the pathophysiologic changes of sepsis, we developed a novel porcine model of septic shock induced by acute respiratory distress syndrome (ARDS) due to methicillin-resistant Staphylococcus aureus(MRSA) pneumonia. Twenty-six male Landraces (Lvyuanweiye, Beijing, China) weighing 30 ± 2 kg were divided into four groups: sham group (SH; n = 5); cotton smoke inhalation group (SM; n = 6); MRSA pneumonia group (MR; n = 6); and septic shock group with cotton smoke inhalation + MRSA pneumonia (SS; n = 9). Extensive hemodynamics, oxygen dynamics, and lung function were monitored for 24 h following the injury or until death. Tissues were collected, and histopathology evaluations were carried out. Blood cultures from 6 of 9 animals in the SS group were positive for MRSA. Two hours following the injury, decreased mean arterial blood pressure (60-70 mmHg) and cardiac index (septic shock were only observed in the SS group but not significant in the other groups. The PO2/FiO2in the SM and SS groups decreased to 300 and 100, respectively. In the SS group, extravascular lung water index increased to 20 ml/kg, whereas thoracopulmonary compliance decreased to 10 ml/H2O after injury. Deterioration of pulmonary function in the SS group was more serious than the SM and MR groups. Severe lung injury in the SS group was confirmed by the histopathology evaluations. The lung injury confirmed by high-resolution thin-section computed tomography and histopathology in the SS group was more serious than those of other groups. In the present study, we developed a novel porcine model of septic shock induced by ARDS due to severe MRSA pneumonia with characteristic hyperdynamic and hypodynamic phases in 24 h, which mimicked the hemodynamic changing of septic shock in human.

  14. Prognostic impact of isolated right ventricular dysfunction in sepsis and septic shock: an 8-year historical cohort study.

    Science.gov (United States)

    Vallabhajosyula, Saraschandra; Kumar, Mukesh; Pandompatam, Govind; Sakhuja, Ankit; Kashyap, Rahul; Kashani, Kianoush; Gajic, Ognjen; Geske, Jeffrey B; Jentzer, Jacob C

    2017-09-07

    Echocardiographic myocardial dysfunction is reported commonly in sepsis and septic shock, but there are limited data on sepsis-related right ventricular dysfunction. This study sought to evaluate the association of right ventricular dysfunction with clinical outcomes in patients with severe sepsis and septic shock. Historical cohort study of adult patients admitted to all intensive care units at the Mayo Clinic from January 1, 2007 through December 31, 2014 for severe sepsis and septic shock, who had an echocardiogram performed within 72 h of admission. Patients with prior heart failure, cor-pulmonale, pulmonary hypertension and valvular disease were excluded. Right ventricular dysfunction was defined by the American Society of Echocardiography criteria. Outcomes included 1-year survival, in-hospital mortality and length of stay. Right ventricular dysfunction was present in 214 (55%) of 388 patients who met the inclusion criteria-isolated right ventricular dysfunction was seen in 100 (47%) and combined right and left ventricular dysfunction in 114 (53%). The baseline characteristics were similar between cohorts except for the higher mechanical ventilation use in patients with isolated right ventricular dysfunction. Echocardiographic findings demonstrated lower right ventricular and tricuspid valve velocities in patients with right ventricular dysfunction and lower left ventricular ejection fraction and increased mitral E/e' ratios in patients with combined right and left ventricular dysfunction. After adjustment for age, comorbidity, illness severity, septic shock and use of mechanical ventilation, isolated right ventricular dysfunction was independently associated with worse 1-year survival-hazard ratio 1.6 [95% confidence interval 1.2-2.1; p = 0.002) in patients with sepsis and septic shock. Isolated right ventricular dysfunction is seen commonly in sepsis and septic shock and is associated with worse long-term survival.

  15. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

    Science.gov (United States)

    Singer, Mervyn; Deutschman, Clifford S.; Seymour, Christopher Warren; Shankar-Hari, Manu; Annane, Djillali; Bauer, Michael; Bellomo, Rinaldo; Bernard, Gordon R.; Chiche, Jean-Daniel; Coopersmith, Craig M.; Hotchkiss, Richard S.; Levy, Mitchell M.; Marshall, John C.; Martin, Greg S.; Opal, Steven M.; Rubenfeld, Gordon D.; van der Poll, Tom; Vincent, Jean-Louis; Angus, Derek C.

    2016-01-01

    IMPORTANCE Definitions of sepsis and septic shock were last revised in 2001. Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management, and epidemiology of sepsis, suggesting the need for reexamination. OBJECTIVE To evaluate and, as needed, update definitions for sepsis and septic shock. PROCESS A task force (n = 19) with expertise in sepsis pathobiology, clinical trials, and epidemiology was convened by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Definitions and clinical criteria were generated through meetings, Delphi processes, analysis of electronic health record databases, and voting, followed by circulation to international professional societies, requesting peer review and endorsement (by 31 societies listed in the Acknowledgment). KEY FINDINGS FROMEVIDENCE SYNTHESIS Limitations of previous definitions included an excessive focus on inflammation, the misleading model that sepsis follows a continuum through severe sepsis to shock, and inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria. Multiple definitions and terminologies are currently in use for sepsis, septic shock, and organ dysfunction, leading to discrepancies in reported incidence and observed mortality. The task force concluded the term severe sepsis was redundant. RECOMMENDATIONS Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a

  16. Norepinephrine in low to moderate doses may not increase luminal concentrations of L-lactate in the gut in patients with septic shock

    DEFF Research Database (Denmark)

    Ibsen, M; Jørgensen, V L; Perner, A

    2007-01-01

    To investigate the effect of different doses of norepinephrine (noradrenaline) on luminal concentrations of L-lactate in the rectum and stomach in patients with fluid-resuscitated septic shock.......To investigate the effect of different doses of norepinephrine (noradrenaline) on luminal concentrations of L-lactate in the rectum and stomach in patients with fluid-resuscitated septic shock....

  17. Mortality trends in U.S. adults with septic shock, 2005-2011: a serial cross-sectional analysis of nationally-representative data.

    Science.gov (United States)

    Goto, Tadahiro; Yoshida, Kazuki; Tsugawa, Yusuke; Filbin, Michael R; Camargo, Carlos A; Hasegawa, Kohei

    2016-06-14

    We aimed to investigate mortality trends in hospitalized patients with septic shock in the US. To achieve this objective, we tested hypothesis that mortality decreased in patients identified by the code of septic shock while mortality did not change in those with septic shock identified by vasopressor use. We conducted a serial cross-sectional analysis using Nationwide Inpatient Sample database from 2005 through 2011. First, we identified all adult patients aged ≥18 years hospitalized for septic shock by the following criteria: 1) primary ICD-9 diagnosis of infection plus procedure code for vasopressor use, 2) primary ICD-9 diagnosis of infection plus septic shock in non-primary field, and 3) primary ICD-9 diagnosis of septic shock. Second, we stratified all identified patients by record of vasopressor use. The outcome of interest was year-to-year changes in the in-hospital all-cause mortality. From 2005 to 2011, we identified 109,812 weighted hospitalizations with septic shock. Overall, there was a significant downward trend in in-hospital mortality (from 46 % in 2005 to 42 % in 2011; P trend  = 0.003); the adjusted mortality also decreased significantly (OR for comparison of 2005 with 2011, 0.98; 95 % CI, 0.96-1.00; P septic shock. However, in the subgroup with vasopressor use, we found no significant change in mortality. Our data challenge the conventional wisdom that mortality in this population has improved during the last decade.

  18. "Immunonutrition" Has Failed to Improve Peritonitis-Induced Septic Shock in Rodents.

    Directory of Open Access Journals (Sweden)

    Julie Boisramé-Helms

    Full Text Available Immunonutrition in sepsis, including n-3 poly-unsaturated fatty acids (PUFAs or L-arginine supplementation, is a controversial issue that has yielded a great number of studies for the last thirty-five years, and the conclusions regarding the quantity and quality of this support in patients are deceiving. The aim of the present experimental study is to investigate the effects of a pretreatment with enteral nutrition enriched with n-3 PUFAs or L-arginine on vascular dysfunctions, inflammation and oxidative stress during septic shock in rats.Rats were fed with enteral Peptamen® HN (HN group, Peptamen® AF containing n-3 PUFAs (AF group or Peptamen® AF enriched with L-arginine (AFA group. On day 4, peritonitis by cecal ligation and puncture (CLP was performed. Rats were resuscitated (H18 once septic shock was established. After a 4-hour resuscitation, vessels and organs were harvested to assess inflammation, superoxide anion, nitric oxide and prostacyclin levels. Ex-vivo vascular reactivity was also performed.Compared to CLP-AF or CLP-HN groups, 47.6% of CLP-AFA rats died before the beginning of hemodynamic measurements (vs. 8.0% and 20.0% respectively, p<0.05. AF and AFA rats required significantly increased norepinephrine infusion rates to reach the mean arterial pressure objective, compared to CLP-HN rats. Both CLP-AF and CLP-AFA reduced mesenteric resistance arterial contractility, decreased vascular oxidative stress, but increased NF-κB (0.40±0.15 in CLP-AF and 0.69±0.06 in CLP-AFA vs. 0.09±0.03 in SHAM rats and 0.30±0.06 in CLP-HN, ß-actin ratio, p<0.05 and pIκB expression (0.60±0.03 in CLP-AF and 0.94±0.15 in CLP-AFA vs. 0.04±0.01 in SHAM rats and 0.56±0.07 in CLP-HN, ß-actin ratio, p<0.05, nitric oxide and prostacyclin production in septic rats.Although n-3 PUFAs or L-arginine supplementation exhibited an antioxidant effect, it worsened the septic shock-induced vascular dysfunction. Furthermore, mortality was higher after L

  19. Lethal Hyperammonemia due to Ornithine Transcarbamylase Deficiency in a Patient with Severe Septic Shock

    Directory of Open Access Journals (Sweden)

    Ji An Hwang

    2016-05-01

    Full Text Available Severe hyperammonemia can occur as a result of inherited or acquired liver enzyme defects in the urea cycle, among which ornithine transcarbamylase deficiency (OTCD is the most common form. We report a very rare case of a 45-year-old Korean male who was admitted to the intensive care unit (ICU due to severe septic shock with acute respiratory failure caused by Pneumocystis jiroveci pneumonia. During his ICU stay with ventilator care, the patient suffered from marked hyperammonemia (>1,700 μg/dL with abrupt mental change leading to life-threatening cerebral edema. Despite every effort including continuous renal replacement therapy and use of a molecular adsorbent recirculating system (extracorporeal liver support–albumin dialysis to lower his serum ammonia level, the patient was not recovered. The lethal hyperammonemia in the patient was later proven to be a manifestation of acquired liver enzyme defect known as OTCD, which is triggered by serious catabolic conditions, such as severe septic shock with acute respiratory failure.

  20. The Role of Mannose-Binding Lectin in Severe Sepsis and Septic Shock

    Directory of Open Access Journals (Sweden)

    Gennaro De Pascale

    2013-01-01

    Full Text Available Severe sepsis and septic shock are a primary cause of death in patients in intensive care unit (ICU. Investigations upon genetic susceptibility profile to systemic complications during severe infections are a field of increasing scientific interest. Particularly when adaptive immune system is compromised or immature, innate immunity plays a key role in the immediate defense against invasive pathogens. Mannose-binding lectin (MBL is a serum protein that recognizes a wide range of pathogenic microorganisms and activates complement cascade via the antibody-independent pathway. More than 30% of humans harbor mutations in MBL gene (MBL2 resulting in reduced plasmatic levels and activity. Increased risk of infection acquisition has been largely documented in MBL-deficient patients, but the real impact of this form of innate immunosuppression upon clinical outcome is not clear. In critically ill patients higher incidence and worse prognosis of severe sepsis/septic shock appear to be associated with low-producers haplotypes. However an excess of MBL activation might be also harmful due to the possibility of an unbalanced proinflammatory response and an additional host injury. Strategies of replacement therapies in critically ill patients with severe infections are under investigation but still far to be applied in clinical practice.

  1. Maximally effective dosing regimens of meropenem in patients with septic shock

    DEFF Research Database (Denmark)

    Sjövall, Fredrik; Alobaid, Abdulaziz S; Wallis, Steven C

    2018-01-01

    Objectives: To use a population pharmacokinetic approach to define maximally effective meropenem dosing recommendations for treatment of Acinetobacter baumannii and Pseudomonas aeruginosa infections in a large cohort of patients with septic shock. Methods: Adult patients with septic shock...... of empirical or targeted therapy of A. baumannii and P. aeruginosa . EudraCT-no. 2014-002555-26 and NCT02240277. Results: Fifty patients were included, 26 male and 24 female, with a median age of 64 years with an all-cause 90 day mortality of 34%. A two-compartment linear model including creatinine clearance...... (CL CR ) as a covariate best described meropenem pharmacokinetics. For empirical treatment of A. baumannii , 2000 mg/6 h was required by intermittent (30 min) or prolonged (3 h) infusion, whereas 6000 mg/day was required with continuous infusion. For P. aeruginosa , 2000 mg/8 h or 1000 mg/6 h...

  2. Cost analysis of real-time polymerase chain reaction microbiological diagnosis in patients with septic shock.

    Science.gov (United States)

    Alvarez, J; Mar, J; Varela-Ledo, E; Garea, M; Matinez-Lamas, L; Rodriguez, J; Regueiro, B

    2012-11-01

    Antibiotic treatment for septic shock is generally prescribed on an empirical basis using broad-spectrum antibiotics. Molecular diagnostic techniques can detect the presence of microbial DNA in blood within a few hours and facilitate early, targeted treatment. The aim of this study was to evaluate the economic impact of a real-time polymerase chain reaction technique, LightCycler SeptiFast (LSC), in patients with sepsis. A cost-minimisation study was carried out in patients admitted with a diagnosis of severe sepsis or septic shock to the intensive care unit of a university hospital. The stay in the intensive care unit, hospital admission, 28-day and six-month mortality, and the economic cost of the clinical process were also evaluated. The study involved 48 patients in the LSC group and 54 patients in the control group. The total cost was €42,198 in the control group versus €32,228 in the LCS group with statistically significant differences (P average net saving of €9970 per patient. The mortality rate was similar in both groups. The main finding of this study was the significant economic saving afforded by the use of the LCS technique, due to the shortening of intensive care unit stay and the use of fewer antibiotics.

  3. Anthrapyrazolone analogues intercept inflammatory JNK signals to moderate endotoxin induced septic shock

    Science.gov (United States)

    Prasad, Karothu Durga; Trinath, Jamma; Biswas, Ansuman; Sekar, Kanagaraj; Balaji, Kithiganahalli N.; Guru Row, Tayur N.

    2014-11-01

    Severe sepsis or septic shock is one of the rising causes for mortality worldwide representing nearly 10% of intensive care unit admissions. Susceptibility to sepsis is identified to be mediated by innate pattern recognition receptors and responsive signaling pathways of the host. The c-Jun N-terminal Kinase (JNK)-mediated signaling events play critical role in bacterial infection triggered multi-organ failure, cardiac dysfunction and mortality. In the context of kinase specificities, an extensive library of anthrapyrazolone analogues has been investigated for the selective inhibition of c-JNK and thereby to gain control over the inflammation associated risks. In our comprehensive biochemical characterization, it is observed that alkyl and halogen substitution on the periphery of anthrapyrazolone increases the binding potency of the inhibitors specifically towards JNK. Further, it is demonstrated that hydrophobic and hydrophilic interactions generated by these small molecules effectively block endotoxin-induced inflammatory genes expression in in vitro and septic shock in vivo, in a mouse model, with remarkable efficacies. Altogether, the obtained results rationalize the significance of the diversity oriented synthesis of small molecules for selective inhibition of JNK and their potential in the treatment of severe sepsis.

  4. Experimental models of acute infection and Toll-like receptor driven septic shock.

    Science.gov (United States)

    Ferstl, Ruth; Spiller, Stephan; Fichte, Sylvia; Dreher, Stefan; Kirschning, Carsten J

    2009-01-01

    Mainly Gram-negative and Gram-positive bacterial infections, but also other infections such as with fungal or viral pathogens, can cause the life-threatening clinical condition of septic shock. Transgression of the host immune response from a local level limited to the pathogen's place of entry to the systemic level is recognised as a major mode of action leading to sepsis. This view has been established upon demonstration of the capacity of specific pathogen-associated molecular patterns (PAMPs) to elicit symptoms of septic shock upon systemic administration. Immune stimulatory PAMPs are agonists of soluble, cytoplasmic, as well as/or cell membrane-anchored and/or -spanning pattern recognition receptors (PRRs) such as Toll-like receptors (TLRs). However, reflection of pathogen-host crosstalk triggering sepsis pathogenesis upon an infection by a host response to challenge with an isolated PAMP is incomplete. Therefore, an experimental model more reflective of pathogen-host interaction requires experimental host confrontation with a specific pathogen in its viable form resulting in a collective stimulation of a variety of specific PRRs. This chapter describes methods to analyse innate pathogen sensing by the host on both a cellular and systemic level.

  5. Clinical management for patients admitted to a critical care unit with severe sepsis or septic shock.

    Science.gov (United States)

    Cheung, Wai Keung; Chau, Lai Sheung; Mak, Iun Ieng Laurinda; Wong, Mei Yi; Wong, Sai Leung; Tiwari, Agnes Fung Yee

    2015-12-01

    The Surviving Sepsis Campaign promotes the use of norepinephrine as the first-line inotropic support for patients presenting with severe sepsis or septic shock in cases of persistent hypotension, despite adequate fluid resuscitation. However, there is little published evidence on how much noradrenaline is administered to such patients when admitted to the intensive care unit (ICU). The authors report the clinical management of this group of patients, with a special focus on the total amount and duration of norepinephrine infusion required. A chart review of the admission records of an ICU in Hong Kong was carried out in 2013. A total of 5000 patients were screened by their diagnosis of severe sepsis or septic shock (in the admissions book) between 1 January 2011 and 31 December 2013. A total of 150 of these were identified and 100 included in the study after simultaneous in-depth reviews of their case notes by two of the investigators. The analysis covers those with severe sepsis or septic shock who required ICU admission for further care. Clinical management and outcomes were analysed. 100 patients (median age 61.6; M/F ratio 2:1) met the inclusion criteria. The mean ICU stay was 13.4 days (range=1-371). 14 patients (14%) died in the ICU, with a 28-day mortality rate of 22%. The mean period of mechanical ventilation was 6.1 days (range=0-137). 91.5% (n=43) of patients had been operated on immediately before admission to the ICU, and the majority of these operations had been of the emergency type (97.7%, n=43). The mean total volumes of crystalloid and colloid administered were 3420ml and 478ml, respectively. The mean wean-off period for norepinephrine infusion was 4234minutes (70.5hours). All patients were prescribed norepinephrine for persistent hypotension despite adequate fluid resuscitation, and the mean total amount administered was 87,211mg. Final multiple linear and logistic regression analysis showed different clinical outcomes associated with different

  6. Serial measurements of serum free thyroid hormones in patients with septic and traumatic shock

    International Nuclear Information System (INIS)

    Mahlstedt, J.; Hotze, A.; Pasch, T.; Buheitel, G.; Pscheidl, E.

    1985-01-01

    A study in intensive care unit patients was undertaken for analyzing the changes of thyroid function parameters during shock. From a total of 36 patients 16 septic patients were classified into two groups of different severity by use of a sepsis score, and the same was done in 20 posttraumatic patients resulting in three groups by use of a traumatic score. TSH-levels showed a clear relation to the sepsis score during follow-up with very low TSH in severe shock and increase during relief. T 3 -parameters (TT 3 , FT 3 , T 3 /TBG, T 3 xT 3 RU) show a strong relation to TSH-changes generally being decreased outside of the normal range. T 4 -parameters (TT 4 , FT 4 , T 4 /TBG, T 4 xT 3 RU) are not as clearly related to TSH-changes, they are in the normal ranges except FT 4 , which is slightly decreased in severe shock. Therefore, in shock patients FT 3 and FT 4 measured by the analogue tracer principle do not provide different information compared to the respective indices of free hormone concentrations. Slight differences in relation to the respective normal ranges could raise misclassification problems for FT 4 (false hypothyroid), however, this deviation will not be a cause to overlook hyperthyroidism in NTI as shown up by a clinical case. (orig.)

  7. Medium-chain triglyceride supplementation exacerbates peritonitis-induced septic shock in rats: role on cell membrane remodeling.

    Science.gov (United States)

    Boisramé-Helms, Julie; Said, Amissi; Burban, Mélanie; Delabranche, Xavier; Stiel, Laure; Zobairi, Fatiha; Hasselmann, Michel; Schini-Kerth, Valérie; Toti, Florence; Meziani, Ferhat

    2014-12-01

    Lipid emulsions for parenteral nutrition interfere with immunity and may alter the cell plasma membrane and microparticle release, thus modulating their biological effects. Our aim was to evaluate the effect of two lipid emulsions for parenteral nutrition containing either a mixture of long- and medium-chain triglycerides (LCTs and MCTs) or LCTs only, to assess their role on microparticle release and acute inflammation during septic shock in rats. Septic rats (cecal ligation and puncture) and sham rats were infused with 5% dextrose or a lipid emulsion during 22 h. After 18 h, rats were resuscitated during 4 h and hemodynamic parameters monitored. Circulating microparticles and their phenotype were measured by prothrombinase assay; heart and aorta were collected for Western blotting and electron paramagnetic resonance measurements. No significant effect of lipid emulsions was observed in sham rats. In septic rats, norepinephrine requirements were increased in MCT/LCT-infused rats compared with 5% dextrose- or LCT-infused rats (2.7 ± 0.2 vs. 1.9 ± 0.8 and 1.2 ± 0.3 μg/kg per minute, respectively; P septic shock in rats induced deleterious effects with increased inflammation and cell activation, associated to vascular hyporeactivity. During septic shock, LCT supplementation seemed to be neutral compared with 5% dextrose infusion.

  8. Randomized, placebo-controlled trial of HA-1A, a human monoclonal antibody to endotoxin, in children with meningococcal septic shock. European Pediatric Meningococcal Septic Shock Trial Study Group

    NARCIS (Netherlands)

    Derkx, B.; Wittes, J.; McCloskey, R.

    1999-01-01

    Meningococcal septic shock has a rapid onset and characteristic skin hemorrhages that allow bedside diagnosis. Initial plasma endotoxin levels are high and correlate closely with clinical outcome. In a double-blind, randomized, placebo-controlled trial (planned, n = 270; actual, n = 269), we

  9. Abdominal Septic Shock - Endotoxin Adsorption Treatment (ASSET) - endotoxin removal in abdominal and urogenital septic shock with the Alteco® LPS Adsorber: study protocol for a double-blinded, randomized placebo-controlled trial.

    Science.gov (United States)

    Lipcsey, Miklos; Tenhunen, Jyrki; Sjölin, Jan; Frithiof, Robert; Bendel, Stepani; Flaatten, Hans; Kawati, Rafael; Kuitunen, Anne; Tønnessen, Tor Inge; Rubertsson, Sten

    2016-12-08

    Severe sepsis and septic shock are common in intensive care and carry high mortality rates. In patients with Gram-negative infections, early and extensive removal of endotoxin may limit the inflammatory response that characterizes septic shock. The Alteco® LPS Adsorber (hereafter referred to cited as the lipopolysaccharide (LPS) Adsorber) can be used for endotoxin removal and attenuate the deleterious inflammatory and clinical responses seen in septic shock. The Abdominal Septic Shock - Endotoxin Adsorption Treatment (ASSET) trial is a pilot study investigating the feasibility and safety of LPS Adsorber therapy. This pilot, multicenter, stratified, parallel, double-blinded, randomized, phase IIa, feasibility clinical investigation will be performed in five Scandinavian intensive care units. Thirty-two subjects with early septic shock and organ failure, following adequate resuscitation, will be randomized to receive either: extracorporeal veno-venous hemoperfusion therapy with the LPS Adsorber or veno-venous hemoperfusion therapy with a placebo adsorber (without active LPS-binding peptide). Patients will be stratified by infection focus such that 20 subjects with an abdominal focus (stratum A) and 12 subjects with a urogenital focus (stratum B) will be included in a parallel design. Thereafter, an interim analysis will be performed and an additional 12 patients may be included in the study. The study is designed as adaptive a priori: the patients from this study can be included in a later phase IIb study. The aim of the study is to investigate the feasibility of LPS Adsorber therapy commenced early in the time-course of septic shock. The primary endpoint will be a characterization of all reported unanticipated serious adverse device effects and anticipated serious adverse device effects. Secondary outcomes are decrease in endotoxin plasma concentration, impact on clinical outcome measures and impact on inflammatory response by LPS Adsorber therapy, as well as

  10. Klebsiella pneumoniae invasive liver abscess syndrome with purulent meningitis and septic shock: A case from mainland China.

    Science.gov (United States)

    Qian, Yun; Wong, Chi-Chun; Lai, San-Chuan; Lin, Zheng-Hua; Zheng, Wei-Liang; Zhao, Hui; Pan, Kong-Han; Chen, Shu-Jie; Si, Jian-Min

    2016-03-07

    We present a rare case of invasive liver abscess syndrome due to Klebsiella pneumoniae (K. pneumoniae) with metastatic meningitis and septic shock. A previously healthy, 55-year-old female patient developed fever, liver abscess, septic shock, purulent meningitis and metastatic hydrocephalus. Upon admission, the clinical manifestations, laboratory and imaging examinations were compatible with a diagnosis of K. pneumoniae primary liver abscess. Her distal metastasis infection involved meningitis and hydrocephalus, which could flare abruptly and be life threatening. Even with early adequate drainage and antibiotic therapy, the patient's condition deteriorated and she ultimately died. To the best of our knowledge, this is the first case of K. pneumoniae invasive liver abscess syndrome with septic meningitis reported in mainland China. Our findings reflect the need for a better understanding of the epidemiology, risk factors, complications, comorbid medical conditions and treatment of this disease.

  11. Implementing ACCM critical care guidelines for septic shock management in a Cuban pediatric intensive care unit.

    Science.gov (United States)

    Cartaya, José M; Rovira, Luis E; Segredo, Yamilet; Alvarez, Idalys; Acevedo, Yoandra; Moya, Ariel

    2014-01-01

    INTRODUCTION Sepsis is the most common direct cause of death worldwide and septic shock the syndrome's most serious complication. In 2002, the pediatric intensive care unit of the José Luis Miranda Pediatric University Hospital in Santa Clara (Villa Clara Province), Cuba, began implementing the recently published guidelines of the American College of Critical Care Medicine (ACCM) for management of pediatric and neonatal septic shock, observing a drop in case fatality from 34.6% to 19% between the years 2003 and 2007. ACCM updated these Guidelines in 2007. OBJECTIVE Describe experiences with the use of the 2007 ACCM updated Guidelines and discuss their possible impact in reducing case fatality. METHODS Between 2008 and 2010, a study was conducted of 280 children and adolescents, from newborns through 18 years, admitted to the pediatric intensive care unit with a diagnosis of septic shock. The diagnostic and therapeutic criteria used were those recommended in the ACCM's 2007 updated Guidelines. The dependent variable was case fatality. Independent variables were age, sex, comorbidity or prior chronic disease, origin and course of sepsis, hemodynamic state, blood glucose level, hyperglycemia, organ dysfunction, volume of fluid therapy administered, use of mechanical ventilation and therapeutic response. RESULTS In the 3-year period, 28-day case fatality was 11.1% (31/280). A total of 45 patients had comorbidities, with 14 deaths and a case fatality rate of 31.1% vs. 7.2% (17/235) in previously healthy patients. Cold shock with a hemodynamic state of low cardiac output and high systemic vascular resistance predominated (68.9%), with low cardiac output and low systemic vascular resistance the least common type (12.5%), but the one with highest case fatality (34.4%). Hyperglycemia was present in 39.6% of patients, with 15.3% case fatality; case fatality was higher (25.6%) when hyperglycemia was in the 10-15.9 mmol/L range. Fluid therapy of 40-100 mL/kg was administered

  12. A dose-finding study of methylene blue to inhibit nitric oxide actions in the hemodynamics of human septic shock

    NARCIS (Netherlands)

    Juffermans, Nicole P.; Vervloet, Marc G.; Daemen-Gubbels, Catharina Rg; Binnekade, Jan M.; Jong, Martin de; Groeneveld, Ab Johan

    2010-01-01

    Methylene blue increases blood pressure and myocardial function in septic shock mainly by inhibiting nitric oxide (NO) actions. However, a dose-dependency of methylene blue has not been established. Therefore, the compound is currently used as rescue treatment only. To evaluate dose-dependency, a

  13. Evolution of Blood Lactate and 90-Day Mortality in Septic Shock. A Post Hoc Analysis of the FINNAKI Study.

    Science.gov (United States)

    Varis, Elina; Pettilä, Ville; Poukkanen, Meri; Jakob, Stephan M; Karlsson, Sari; Perner, Anders; Takala, Jukka; Wilkman, Erika

    2017-05-01

    Hyperlactatemia predicts mortality in patients with sepsis and septic shock, and its normalization is a potential treatment goal. We investigated the association of blood lactate and its changes over time with 90-day mortality in septic shock. We performed a post hoc analysis of 513 septic shock patients with admission blood lactate measurements in the prospective, observational, multicenter FINNAKI study. Repetitive lactate measurements were available in 496 patients for analyses of change in lactate values during intensive care unit stay.The 90-day mortality for all patients was 33.3%. Patients with admission lactate >2 mmol/L had higher 90-day mortality than those with admission lactate ≤2 mmol/L (43.4% vs. 22.6%, P 2 mmol/L) at ≥72 h had higher 90-day mortality compared with those with a lactate value of ≤2.0 mmol/L (52.0% vs. 24.3%, P septic shock patients.

  14. Compliance and barriers to implementing the sepsis resuscitation bundle for patients developing septic shock in the general medical wards

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    Yao-Wen Kuo

    2012-02-01

    Conclusion: Compliance with the SRB for patients developing septic shock in the general medical wards is very low. Besides providing educational programs to improve awareness and acceptance of the SRB, measures to help in central venous catheterization and completion of SRB may be considered.

  15. Epidemiology, Prognosis, and Evolution of Management of Septic Shock in a French Intensive Care Unit: A Five Years Survey

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    Nicolas Boussekey

    2010-01-01

    Full Text Available Purpose. To evaluate the epidemiology, prognosis, and management of septic shock patients hospitalized in our intensive care unit (ICU. Materiel and Methods. Five-year monocenter observational study including 320 patients. Results. ICU mortality was 54.4%. Independent mortality risk factors were mechanical ventilation (OR=4.97, Simplify Acute Physiology Score (SAPS II > 60 (OR=4.28, chronic alcoholism (OR=3.38, age >65 years (OR=2.65, prothrombin ratio <40% (OR=2.37, and PaO2/FiO2 ratio <150 (OR=1.91. These six mortality risk factors recovered allow screening immediately septic shock patients with a high mortality risk. Morbidity improved with time (diminution of septic shock complications, increase of the number of days alive free from mechanical ventilation and vasopressors on day 28, concomitant to an evolution of the management (earlier institution of all replacement and medical therapies and more initial volume expansion. There was no difference in mortality. Conclusion. Our study confirms a high mortality rate in septic shock patients despite a new approach of treatment.

  16. Central venous oxygen saturation in septic shock - a marker of cardiac output, microvascular shunting and/or dysoxia?

    DEFF Research Database (Denmark)

    Haase, Nicolai; Perner, Anders

    2011-01-01

    Shock therapy aims at increasing central venous oxygen saturation (ScvO2), which is a marker of inadequate oxygen delivery. In this issue of Critical Care, Textoris and colleagues challenge this notion by reporting that high levels of ScvO2 are associated with mortality in patients with septic...

  17. Arterial bicarbonate may be a useful indicator of inadequate cortisol response in children with catecholamine resistant septic shock

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    M B Maralihalli

    2013-01-01

    Full Text Available Objective: To study the clinical and biochemical parameters that can predict cortisol insufficiency in children with septic shock. Design: prospective, observational study. Setting: tertiary health-care center. Patients/Subjects: Fifty children admitted with the catecholamine resistant septic shock to a tertiary health-care center. Materials and Methods: At the time of hospitalization all patients underwent detailed clinical evaluation including, history and physical examination, evaluation with the complete blood count, serum cortisol, renal function tests, liver function tests, prothrombin time activated partial thromboplastin time, arterial blood gas analysis, urine analysis, chest roentgenogram, ultrasonography of the abdomen and chest, urine, and blood culture for bacteria and fungi. Results: Out of 50 children with the catecholamine resistant septic shock, seven had adrenal insufficiency (serum cortisol <18 μg/dl. Of all parameters studied, only arterial bicarbonate at the time of admission to intensive care predicted adrenal insufficiency. On Receptor operative characteristic curve analysis, a bicarbonate level of 10.9 mEq/L had the best accuracy to predict adrenal insufficiency. Conclusion: Arterial bicarbonate may be used as a rapid test for provisional identification of adrenal insufficiency among children with the catecholamine resistant septic shock.

  18. Terlipressin increased the concentration of L-lactate in the rectal lumen in a patient with septic shock

    DEFF Research Database (Denmark)

    Perner, A; Jørgensen, V L; Waldau, T

    2004-01-01

    Terlipressin--a long-acting analogue of vasopressin--has been described to restore blood pressure in patients with catecholamine-resistant septic shock without obvious complications. We administered low-dose terlipressin (a single i.v.-bolus of 0.5 mg) to a patient with severe, hyperdynamic septi...

  19. Self-esteem in children and adolescents after septic shock caused by Neisseria meningitidis: scars do matter

    NARCIS (Netherlands)

    Vermunt, Lindy C.; Buysse, Corinne M.; Joosten, Koen F.; Oranje, Arnold P.; Hazelzet, Jan A.; Verhulst, Frank C.; Utens, Elisabeth M.

    2008-01-01

    To investigate self-esteem and its relation to scars, amputations, and orthopedic sequelae in children and adolescents long term after meningococcal septic shock (MSS) caused by Neisseria meningitidis. The Dutch versions of the Self-Perception Profile for Children (SPP-C; 8-11 years) and the

  20. Hospital staff education on severe sepsis/septic shock and hospital mortality: an original hypothesis

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    Capuzzo Maurizia

    2012-11-01

    Full Text Available Abstract Background Signs of serious clinical events overlap with those of sepsis. We hypothesised that any education on severe sepsis/septic shock may affect the outcome of all hospital patients. We designed this study to assess the trend of the mortality rate of adults admitted to hospital for at least one night in relationship with a hospital staff educational program dedicated to severe sepsis/septic shock. Methods This study was performed in six Italian hospitals in the same region. Multidisciplinary Sepsis Teams members were selected by each hospital management among senior staff. The education included the following steps: i the Teams were taught about adult learning, problem based learning, and Surviving Sepsis guidelines, and provided with educational material (literature, electronic presentations, scenarios of clinical cases for training and booklets; ii they started delivering courses and seminars each to their own hospital staff in the last quarter of 2007. To analyse mortality, we selected adult patients, admitted for at least one night to the wards or units present in all the study hospitals and responsible for 80% of hospital deaths. We fitted a Poisson model with monthly hospital mortality rates from December 2003 to August 2009 as dependent variable. The effect of the educational program on hospital mortality was measured as two dummy variables identifying a first (November 2007 to December 2008 and a second (January to August 2009 education period. The analysis was adjusted for a linear time trend, seasonality and monthly average values of age, Charlson score, length of stay in hospital and urgent/non-urgent admission. Results The hospital staff educated reached 30.6% at the end of June 2009. In comparison with the pre-education period, the Relative Risk of death of the patient population considered was 0.93 (95% confidence interval [CI] 0.87-0.99; p 0.025 for in-patients in the first, and 0.89 (95% CI 0.81-0.98; p 0.012 for

  1. Clinical effect of alprostadil in patients with septic shock associated with acute respiratory distress syndrome

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    Li-ping LIU

    2017-10-01

    Full Text Available Objective To evaluate the clinical efficacy of alprostadil in patients with septic shock associated with acute respiratory distress syndrome (ARDS, and to explore its possible mechanism. Methods From January 2015 to June 2016, patients with septic shock associated with ARDS and meeting the inclusion criteria were involved in the study in department of critical care medicine in First Hospital of Lanzhou University and randomly divided into the control group and alprostadil group. The standard treatment was given in control group, alprostadil 10μg 2/d was given in alprostadil group on base of standard treatment. Monitoring indexes were recorded in 1, 3 and 6 days after enrollment. General condition of patients, APACHE Ⅱ score, ventilator conditions (PO2, PCO2, RR, PEEP, FiO2, oxygenation index, airway resistance, lung compliance, mechanical ventilation time, ICU stay time, hospital follow-up, 28-day follow-up, immune index (CD4+/CD8+, inflammatory markers (CRP, PCT, IL-6 were monitored. Results Sixty-five patients were included in this study, 32 in control group and 33 in alprostadil group. At 3 and 6 days after the treatment, APACHE Ⅱ score, respiratory rate (RR, the inspired oxygen concentration (FiO2, airway resistance, and C reactive protein (CRP, procalcitonin (PCT -6 and interleukin (IL-6 levels significantly decreased, compared with pretreatment and 1 day posttreatment, in the two groups and lower in alprostadil group than in the control group on the 6th day (P<0.05; at the same time, these indexes such as arterial partial pressure of oxygen (PaO2, lung compliance, oxygenation index, CD4+/CD8+ significantly increased 3 and 6 days after the treatment compared with pretreatment and 1 day posttreatment in the two groups, and on the 6th day, significantly higher in the alprostadil group than in the control group (P<0.05. Time of mechanical ventilation, ICU stay and hospital stay in the alprostadil group was respectively lower than that in

  2. A Case of Invasive Pneumococcal Infection with Septic Shock and Rare Complications

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    John R. Woytanowski

    2017-01-01

    Full Text Available Invasive pneumococcus is a serious illness with potentially devastating outcomes. A 64-year-old female with a medical history of psoriatic arthritis and diabetes was transferred from an outside hospital for ventilator dependent respiratory failure and altered mental status. She initially presented with worsening back pain and was found to have leukocytosis with bandemia and acute renal failure but she was in septic shock upon arrival to our tertiary care center. Her blood cultures grew Streptococcus pneumoniae and MRI of the brain revealed pus within the posterior lateral ventricles and multiple infarcts. MRI of the spine revealed a psoas abscess. Transesophageal echocardiogram revealed mitral valve vegetation and her right eye developed endogenous endophthalmitis. She was treated with intravenous and intravitreal antibiotics and underwent drainage of the abscess with no improvement in mental status. Repeat imaging revealed multiple new thalamic, basal ganglia, and parietal lobe infarcts likely from septic emboli. After a protracted ICU stay, the patient’s family opted for comfort care. The incidence of invasive pneumococcal infections has declined rapidly since the advent of antibiotics and vaccines. With the growing incidence of antibiotic resistance as well as the emergence of new immunomodulating drugs for various pathologies, there is a concern that invasive infections will reemerge. Ventriculitis and endogenous endophthalmitis are very rare complications of pneumococcal bacteremia.

  3. American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock.

    Science.gov (United States)

    Davis, Alan L; Carcillo, Joseph A; Aneja, Rajesh K; Deymann, Andreas J; Lin, John C; Nguyen, Trung C; Okhuysen-Cawley, Regina S; Relvas, Monica S; Rozenfeld, Ranna A; Skippen, Peter W; Stojadinovic, Bonnie J; Williams, Eric A; Yeh, Tim S; Balamuth, Fran; Brierley, Joe; de Caen, Allan R; Cheifetz, Ira M; Choong, Karen; Conway, Edward; Cornell, Timothy; Doctor, Allan; Dugas, Marc-Andre; Feldman, Jonathan D; Fitzgerald, Julie C; Flori, Heidi R; Fortenberry, James D; Graciano, Ana Lia; Greenwald, Bruce M; Hall, Mark W; Han, Yong Yun; Hernan, Lynn J; Irazuzta, Jose E; Iselin, Elizabeth; van der Jagt, Elise W; Jeffries, Howard E; Kache, Saraswati; Katyal, Chhavi; Kissoon, Niranjan Tex; Kon, Alexander A; Kutko, Martha C; MacLaren, Graeme; Maul, Timothy; Mehta, Renuka; Odetola, Fola; Parbuoni, Kristine; Paul, Raina; Peters, Mark J; Ranjit, Suchitra; Reuter-Rice, Karin E; Schnitzler, Eduardo J; Scott, Halden F; Torres, Adalberto; Weingarten-Abrams, Jacki; Weiss, Scott L; Zimmerman, Jerry J; Zuckerberg, Aaron L

    2017-06-01

    The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock." Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups. The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations. The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.

  4. Early initiation of low-dose corticosteroid therapy in the management of septic shock: a retrospective observational study.

    Science.gov (United States)

    Park, Hye Yun; Suh, Gee Young; Song, Jae-Uk; Yoo, Hongseok; Jo, Ik Joon; Shin, Tae Gun; Lim, So Yeon; Woo, Sookyoung; Jeon, Kyeongman

    2012-01-07

    The use of low-dose steroid therapy in the management of septic shock has been extensively studied. However, the association between the timing of low-dose steroid therapy and the outcome has not been evaluated. Therefore, we evaluated whether early initiation of low-dose steroid therapy is associated with mortality in patients with septic shock. We retrospectively analyzed the clinical data of 178 patients who received low-dose corticosteroid therapy for septic shock between January 2008 and December 2009. Time-dependent Cox regression models were used to adjust for potential confounding factors in the association between the time to initiation of low-dose corticosteroid therapy and in-hospital mortality. The study population consisted of 107 men and 71 women with a median age of 66 (interquartile range, 54 to 71) years. The 28-day mortality was 44% and low-dose corticosteroid therapy was initiated within a median of 8.5 (3.8 to 19.1) hours after onset of septic shock-related hypotension. Median time to initiation of low-dose corticosteroid therapy was significantly shorter in survivors than in non-survivors (6.5 hours versus 10.4 hours; P=0.0135). The mortality rates increased significantly with increasing quintiles of time to initiation of low-dose corticosteroid therapy (P=0.0107 for trend). Other factors associated with 28-day mortality were higher Simplified Acute Physiology Score (SAPS) 3 (Pshock, n=66) had a 37% lower mortality rate than the late therapy group (administered more than 6 hours after the onset of septic shock, n=112) (32% versus 51%, P=0.0132). Early initiation of low-dose corticosteroid therapy was significantly associated with decreased mortality.

  5. Acute Kidney Injury in Severe Sepsis and Septic Shock in Patients with and without Diabetes Mellitus: A Multicenter Study.

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    Marion Venot

    Full Text Available Whether diabetes mellitus increases the risk of acute kidney injury (AKI during sepsis is controversial.We used a case-control design to compare the frequency of AKI, use of renal replacement therapy (RRT, and renal recovery in patients who had severe sepsis or septic shock with or without diabetes. The data were from the Outcomerea prospective multicenter database, in which 12 French ICUs enrolled patients admitted between January 1997 and June 2009.First, we compared 451 patients with severe sepsis or septic shock and diabetes to 3,277 controls with severe sepsis or septic shock and without diabetes. Then, we compared 318 cases (with diabetes to 746 matched controls (without diabetes. Diabetic patients did not have a higher frequency of AKI (hazard ratio [HR], 1.18; P = 0.05] or RRT (HR, 1.09; P = 0.6. However, at discharge, diabetic patients with severe sepsis or septic shock who experienced acute kidney injury during the ICU stay and were discharged alive more often required RRT (9.5% vs. 4.8%; P = 0.02, had higher serum creatinine values (134 vs. 103 µmoL/L; P<0.001 and had less often recovered a creatinine level less than 1.25 fold the basal creatinine (41.1% vs. 60.5%; P<0.001.In patients with severe sepsis or septic shock, diabetes is not associated with occurrence of AKI or need for RRT but is an independent risk factor for persistent renal dysfunction in patients who experience AKI during their ICU stay.

  6. Variability in targeted arterial oxygenation levels in patients with severe sepsis or septic shock

    DEFF Research Database (Denmark)

    Dahl, R. M.; Grønlykke, L.; Haase, N.

    2015-01-01

    BACKGROUND: Supplemental oxygen therapy is used for intensive care (ICU) patients with severe sepsis, but with no general guidelines and few safety data. The aim of this observational study was to describe the variability in oxygen administration as well as the association between partial pressure...... of arterial oxygen (PaO2 ) and mortality. METHODS: We extracted data from two Scandinavian clinical trials of ICU patients with severe sepsis or septic shock. We calculated average PaO2 and fraction of inspired oxygen (FiO2 ) from trial inclusion and the following 5 days, and assessed the association between...... to patients with an average FiO2 ≤ 0.40. CONCLUSION: Administration of oxygen in patients with severe sepsis resulted in a wide range of PaO2 . Significantly higher mortality was observed in patients with an average PaO2

  7. Infected cystic hygroma resulting in septic shock and respiratory failure: A case report

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    Maria E. Linnaus

    2016-06-01

    Full Text Available Macrocystic lymphatic malformations (cystic hygromas are a common cause of cystic neck lesions. These lesions are often diagnosed prenatally in children. In cases without airway compromise, these children are discharged from the hospital for elective treatment. Surgical excision is one treatment modality while sclerotherapy has recently shown adequate results as well. While infection is a relatively common problem for lymphatic malformations, the majority can be treated with antibiotics alone. We present a case in which septic shock and respiratory failure resulted from primary infection of a macrocystic lymphatic malformation in a term infant discharged with a lymphatic malformation of the neck. Urgent surgical drainage failed, and complete excision was ultimately required for source control due to numerous small multiloculated small cysts inaccessible via incision and drainage.

  8. Esophagopericardial fistula, septic shock and intracranial hemorrhage with hydrocephalus after lung transplantation

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    M.M. Schuurmans

    2017-05-01

    Full Text Available A 57-year old woman underwent lung transplantation for non-specific interstitial pneumonia. Primary graft dysfunction was diagnosed requiring continued use of extracorporeal membrane oxygenation (ECMO. Within three days she developed recurring hemothoraces requiring two surgical evacuations. After ECMO removal a series of complications occurred within four months: femoral thrombosis, persisting tachycardic atrial fibrillation, pneumopericardium with an esophagopericardial fistula and purulent pericarditis, septic shock, multiorgan failure and intracerebral hemorrhage with ventricular involvement requiring external ventricular drainage. Interdisciplinary management coordinated by the intensive care specialist, transplant surgeon and pulmonologist with various interventions by the respective specialists followed by intensive physical rehabilitation allowed for discharge home on day 235 post transplant. Subsequently quality of life was considered good by the patient and family. Keywords: Lung transplantation, Esophagopericardial fistula, Intracranial hemorrhage, Complications, Treatment

  9. Basic and advanced echocardiographic evaluation of myocardial dysfunction in sepsis and septic shock.

    Science.gov (United States)

    Vallabhajosyula, S; Pruthi, S; Shah, S; Wiley, B M; Mankad, S V; Jentzer, J C

    2018-01-01

    Sepsis continues to be a leading cause of mortality and morbidity in the intensive care unit. Cardiovascular dysfunction in sepsis is associated with worse short- and long-term outcomes. Sepsis-related myocardial dysfunction is noted in 20%-65% of these patients and manifests as isolated or combined left or right ventricular systolic or diastolic dysfunction. Echocardiography is the most commonly used modality for the diagnosis of sepsis-related myocardial dysfunction. With the increasing use of ultrasonography in the intensive care unit, there is a renewed interest in sepsis-related myocardial dysfunction. This review summarises the current scope of literature focused on sepsis-related myocardial dysfunction and highlights the use of basic and advanced echocardiographic techniques for the diagnosis of sepsis-related myocardial dysfunction and the management of sepsis and septic shock.

  10. Endothelial Permeability and Hemostasis in Septic Shock: Results From the ProCESS Trial.

    Science.gov (United States)

    Hou, Peter C; Filbin, Michael R; Wang, Henry; Ngo, Long; Huang, David T; Aird, William C; Yealy, Donald M; Angus, Derek C; Kellum, John A; Shapiro, Nathan I

    2017-07-01

    We studied patients from the Protocolized Care in Early Septic Shock (ProCESS) trial to determine the effects of alternative resuscitation strategies on circulating markers of endothelial cell permeability and hemostasis and the association between biomarkers and mortality. This was a prospective study of biomarkers of endothelial cell permeability (vascular endothelial growth factor [VEGF], soluble fms-like tyrosine kinase 1 [sFLT-1], angiopoietin 2 [Ang-2]) and biomarkers of hemostasis (von Willebrand factor [vWF], thrombomodulin [TM], tissue plasminogen activator [tPA] in 605 of the 1,341 ProCESS participants in a derivation cohort and 305 participants in a validation cohort. Analyses assessed (1) the impact of varying resuscitation strategies on biomarker profiles and (2) the association of endothelial biomarkers with 60-day in-hospital mortality. The study was conducted in 31 US EDs in adult patients with septic shock. Patients were randomly assigned to one of three resuscitation strategies. Blood samples were collected at enrollment, at 6 h, and at 24 h. There were 116 (19.2%) and 52 (17.0%) deaths in the derivation and validation cohorts, respectively. There was no significant association between treatment strategy and any biomarker levels. Permeability (Ang-2 and sFLT-1) and hemostasis (vWF, TM, tPA) biomarkers were higher and VEGF levels were lower in nonsurvivors (P hemostasis were associated with increased mortality. ClinicalTrials.gov; No.: NCT00510835 and NCT00793442; URL: www.clinicaltrials.gov. Copyright © 2017 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.

  11. Septic shock: a major cause of hospital death after intensive care unit discharge.

    Science.gov (United States)

    Giacomini, Matheus Gomes; Lopes, Márcia Valéria Caldeira Angelucci; Gandolfi, Joelma Villafanha; Lobo, Suzana Margareth Ajeje

    2015-01-01

    To assess the causes and factors associated with the death of patients between intensive care unit discharge and hospital discharge. The present is a pilot, retrospective, observational cohort study. The records of all patients admitted to two units of a public/private university hospital from February 1, 2013 to April 30, 2013 were assessed. Demographic and clinical data, risk scores and outcomes were obtained from the Epimed monitoring system and confirmed in the electronic record system of the hospital. The relative risk and respective confidence intervals were calculated. A total of 581 patients were evaluated. The mortality rate in the intensive care unit was 20.8% and in the hospital was 24.9%. Septic shock was the cause of death in 58.3% of patients who died after being discharged from the intensive care unit. Of the patients from the public health system, 73 (77.6%) died in the intensive care unit and 21 (22.4%) died in the hospital after being discharged from the unit. Of the patients from the Supplementary Health System, 48 (94.1%) died in the intensive care unit and 3 (5.9%) died in the hospital after being discharged from the unit (relative risk, 3.87%; 95% confidence interval, 1.21 - 12.36; p intensive care unit hospitalization time longer than 6 days. The main cause of death of patients who were discharged from the intensive care unit and died in the ward before hospital discharge was septic shock. Coverage by the public healthcare system and longer hospitalization time in the intensive care unit were factors associated with death after discharge from the intensive care unit.

  12. Alkalosis in Critically Ill Patients with Severe Sepsis and Septic Shock.

    Science.gov (United States)

    Kreü, Simon; Jazrawi, Allan; Miller, Jan; Baigi, Amir; Chew, Michelle

    2017-01-01

    Although metabolic alkalosis is a common occurrence in intensive care units (ICUs), no study has evaluated its prevalence or outcomes in patients with severe sepsis or septic shock. This is a retrospective cohort study of critically ill patients suffering from severe sepsis and septic shock admitted to the ICUs of Halmstad and Varberg County hospitals. From 910 patient records, 627 patients met the inclusion criteria. We investigated the relationship between metabolic alkalosis and mortality. Further, we studied the relationship between metabolic alkalosis and ICU length of stay (LOS). Metabolic alkalosis was associated with decreased 30-day and 12-month mortalities. This effect was however lost when a multivariate analysis was conducted, correcting for age, gender, pH on admission, base excess (BE) on admission, Simplified Acute Physiology Score III (SAPS III) and acute kidney injury (AKI). We then analyzed for any dose-response effect between the severity of metabolic alkalosis and mortality and found no relationship. Bivariate analysis showed that metabolic alkalosis had a significant effect on the length of ICU stay. When adjusting for age, sex, pH at admission, BE at admission, SAPS III and AKI in a multivariate analysis, metabolic alkalosis significantly contributed to prolonged ICU length of stay. In two separate sensitivity analyses pure metabolic alkalosis and late metabolic alkalosis (time of onset >48 hours) were the only significant predictor of increased ICU length of stay. Metabolic alkalosis did not have any effect on 30-day and 12-month mortalities after adjusting for age, sex, SAPS III-score, pH and BE on admission and AKI in a multivariate analysis. The presence of metabolic alkalosis was independently associated with an increased ICU length of stay.

  13. Analysis and modelling of septic shock microarray data using Singular Value Decomposition.

    Science.gov (United States)

    Allanki, Srinivas; Dixit, Madhulika; Thangaraj, Paul; Sinha, Nandan Kumar

    2017-06-01

    Being a high throughput technique, enormous amounts of microarray data has been generated and there arises a need for more efficient techniques of analysis, in terms of speed and accuracy. Finding the differentially expressed genes based on just fold change and p-value might not extract all the vital biological signals that occur at a lower gene expression level. Besides this, numerous mathematical models have been generated to predict the clinical outcome from microarray data, while very few, if not none, aim at predicting the vital genes that are important in a disease progression. Such models help a basic researcher narrow down and concentrate on a promising set of genes which leads to the discovery of gene-based therapies. In this article, as a first objective, we have used the lesser known and used Singular Value Decomposition (SVD) technique to build a microarray data analysis tool that works with gene expression patterns and intrinsic structure of the data in an unsupervised manner. We have re-analysed a microarray data over the clinical course of Septic shock from Cazalis et al. (2014) and have shown that our proposed analysis provides additional information compared to the conventional method. As a second objective, we developed a novel mathematical model that predicts a set of vital genes in the disease progression that works by generating samples in the continuum between health and disease, using a simple normal-distribution-based random number generator. We also verify that most of the predicted genes are indeed related to septic shock. Copyright © 2017 Elsevier Inc. All rights reserved.

  14. Application of a simplified definition of diastolic function in severe sepsis and septic shock.

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    Lanspa, Michael J; Gutsche, Andrea R; Wilson, Emily L; Olsen, Troy D; Hirshberg, Eliotte L; Knox, Daniel B; Brown, Samuel M; Grissom, Colin K

    2016-08-04

    Left ventricular diastolic dysfunction is common in patients with severe sepsis or septic shock, but the best approach to categorization is unknown. We assessed the association of common measures of diastolic function with clinical outcomes and tested the utility of a simplified definition of diastolic dysfunction against the American Society of Echocardiography (ASE) 2009 definition. In this prospective observational study, patients with severe sepsis or septic shock underwent transthoracic echocardiography within 24 h of onset of sepsis (median 4.3 h). We measured echocardiographic parameters of diastolic function and used random forest analysis to assess their association with clinical outcomes (28-day mortality and ICU-free days to day 28) and thereby suggest a simplified definition. We then compared patients categorized by the ASE 2009 definition and our simplified definition. We studied 167 patients. The ASE 2009 definition categorized only 35 % of patients. Random forest analysis demonstrated that the left atrial volume index and deceleration time, central to the ASE 2009 definition, were not associated with clinical outcomes. Our simplified definition used only e' and E/e', omitting the other measurements. The simplified definition categorized 87 % of patients. Patients categorized by either ASE 2009 or our novel definition had similar clinical outcomes. In both definitions, worsened diastolic function was associated with increased prevalence of ischemic heart disease, diabetes, and hypertension. A novel, simplified definition of diastolic dysfunction categorized more patients with sepsis than ASE 2009 definition. Patients categorized according to the simplified definition did not differ from patients categorized according to the ASE 2009 definition in respect to clinical outcome or comorbidities.

  15. Septic shock: a major cause of hospital death after intensive care unit discharge

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    Giacomini, Matheus Gomes; Lopes, Márcia Valéria Caldeira Angelucci; Gandolfi, Joelma Villafanha; Lobo, Suzana Margareth Ajeje

    2015-01-01

    Objective To assess the causes and factors associated with the death of patients between intensive care unit discharge and hospital discharge. Methods The present is a pilot, retrospective, observational cohort study. The records of all patients admitted to two units of a public/private university hospital from February 1, 2013 to April 30, 2013 were assessed. Demographic and clinical data, risk scores and outcomes were obtained from the Epimed monitoring system and confirmed in the electronic record system of the hospital. The relative risk and respective confidence intervals were calculated. Results A total of 581 patients were evaluated. The mortality rate in the intensive care unit was 20.8% and in the hospital was 24.9%. Septic shock was the cause of death in 58.3% of patients who died after being discharged from the intensive care unit. Of the patients from the public health system, 73 (77.6%) died in the intensive care unit and 21 (22.4%) died in the hospital after being discharged from the unit. Of the patients from the Supplementary Health System, 48 (94.1%) died in the intensive care unit and 3 (5.9%) died in the hospital after being discharged from the unit (relative risk, 3.87%; 95% confidence interval, 1.21 - 12.36; p < 0.05). The post-discharge mortality rate was significantly higher in patients with intensive care unit hospitalization time longer than 6 days. Conclusion The main cause of death of patients who were discharged from the intensive care unit and died in the ward before hospital discharge was septic shock. Coverage by the public healthcare system and longer hospitalization time in the intensive care unit were factors associated with death after discharge from the intensive care unit. PMID:25909313

  16. Effects of a selective iNOS inhibitor versus norepinephrine in the treatment of septic shock.

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    Su, Fuhong; Huang, Hongchuan; Akieda, Kazuki; Occhipinti, Giovanna; Donadello, Katia; Piagnerelli, Michael; De Backer, Daniel; Vincent, Jean-Louis

    2010-09-01

    Inhibition of NOS is not beneficial in septic shock; selective inhibition of the inducible form (iNOS) may represent a better option. We compared the effects of the selective iNOS inhibitor BYK191023 with those of norepinephrine (NE) in a sheep model of septic shock. Twenty-four anesthetized, mechanically ventilated ewes received 1.5 g/kg body weight of feces into the abdominal cavity to induce sepsis. Animals were randomized into three groups (each n = 8): NE-only, BYK-only, and NE + BYK. The sublingual microcirculation was evaluated with sidestream dark-field videomicroscopy. MAP was higher in the NE + BYK group than in the other groups, but there were no significant differences in cardiac index or systemic vascular resistance. Mean pulmonary arterial pressure was lower in BYK-treated animals than in the NE-only group. PaO2/FiO2 was higher and lactate concentration lower in the BYK groups than in the NE-only group. Mesenteric blood flow was higher in BYK groups than in the NE-only group. Renal blood flow was higher in the NE + BYK group than in the other groups. Functional capillary density and proportion of perfused vessels were higher in the BYK groups than in the NE-only group 18 h after induction of peritonitis. Survival times were similar in the three groups. In this model of peritonitis, selective iNOS inhibition had more beneficial effects than NE on pulmonary artery pressures, gas exchange, mesenteric blood flow, microcirculation, and lactate concentration. Combination of this selective iNOS inhibitor with NE allowed a higher arterial pressure and renal blood flow to be maintained.

  17. Cardiac Contractile Reserve Parameters Are Related to Prognosis in Septic Shock

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    Antoine Kimmoun

    2013-01-01

    Full Text Available Introduction. Cardiac reserve could be defined as the spontaneous magnitude from basal to maximal cardiac power under stress conditions. The aim of this study was to evaluate the prognostic value of cardiac reserve parameters in resuscitated septic shock patients. Methods. Seventy patients with septic shock were included in a prospective and observational study. Prior to inclusion, patients were resuscitated to reach a mean arterial pressure of 65–75 mmHg with an euvolemic status. General, hemodynamic, and cardiac reserve-related parameters (cardiac index, double product, and cardiac power index were collected at inclusion and at day 1. Results. Seventy patients were included with 28-day mortality at 38.5%. Ten of the 70 patients died during the first day. In multivariate analysis, independent predictors of death were SAPS II ≥58 (OR: 3.36 [1.11–10.17]; , a high double product at inclusion (OR [95% IC]: 1.20 [1.00–1.45] per 103 mmHg·min; , and at day 1, a decrease in cardiac index (1.30 [1.08–1.56] per 0.5 L/min/m2; or cardiac power index (1.84 [1.18–2.87] per 0.1 W/m2, . Conclusion. In the first 24 hours, parameters related to cardiac reserve, such as double product and cardiac index evolution, provide crucial and easy to achieve hemodynamic physiological information, which may impact the outcome.

  18. The Prevalence and Significance of Overt Disseminated Intravascular Coagulation in Patients with Septic Shock in the Emergency Department According to the Third International Consensus Definition

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    Byuk Sung Ko

    2016-11-01

    Full Text Available Background The prevalence and prognostic value of overt disseminated intravascular coagulation (DIC in patients with septic shock presenting to emergency departments (EDs is poorly understood, particularly following the release of a new definition of septic shock. The purpose of this study was to investigate the prevalence and prognostic value of DIC in septic shock. Methods We performed retrospective review of 391 consecutive patients with septic shock admitting to the ED of tertiary care, university-affiliated hospital during a 16-month. Septic shock was defined as fluid-unresponsive hypotension requiring vasopressor to maintain a mean arterial pressure of 65 mmHg or greater, and serum lactate level ≥ 2 mmol/L. Overt DIC was defined as an International Society on Thrombosis and Hemostasis (ISTH score ≥ 5 points. The primary endpoint was 28-day mortality. Results Of 391 patients with septic shock, 290 were included in the present study. The mean age was 65.6 years, the 28-day mortality rate was 26.9%, and the prevalence of overt DIC was 17.6% (n = 51 according to the ISTH score. The median DIC score was higher in non-survivors than in survivors (5.0 vs. 2.0, p = 0.001. Significant higher risk of mortality was observed in overt DIC patients compared to those without (28.2% vs. 13.7%, p = 0.005. Multivariable logistic regression analysis identified DIC to be independently associated with 28-day mortality (odds ratio, 2.689 [95% confidence interval, 1.390-5.201]. Conclusions Using the ISTH criteria of DIC, overt DIC in septic shock was found to be common among patients admitting to the ED and to be associated with higher mortality when it is accompanied with septic shock. Efforts are required to identify presence of overt DIC during the initial treatment of septic shock in patients presenting the the ED.

  19. The Prevalence and Clinical Significance of Low Procalcitonin Levels Among Patients With Severe Sepsis or Septic Shock in the Emergency Department.

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    Choe, Eun A; Shin, Tae Gun; Jo, Ik Joon; Hwang, Sung Yeon; Lee, Tae Rim; Cha, Won Chul; Sim, Min Seob

    2016-07-01

    The aims of this study were to evaluate the prevalence of low procalcitonin (PCT) levels among patients with severe sepsis or septic shock, and to investigate clinical characteristics and outcomes associated with low PCT levels. We analyzed data from the sepsis registry for patients with severe sepsis or septic shock in the emergency department. Based on a specific PCT cutoff value, patients were classified into two groups: a low PCT group, PCT septic shock in the emergency department, suggesting favorable outcomes. The prevalence of low PCT levels was significantly different according to obesity, the source of infection, C-reactive protein levels, lactate levels, bacteremia, and organ failure.

  20. Hyperchloremia and moderate increase in serum chloride are associated with acute kidney injury in severe sepsis and septic shock patients.

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    Suetrong, Bandarn; Pisitsak, Chawika; Boyd, John H; Russell, James A; Walley, Keith R

    2016-10-06

    Acute kidney injury and hyperchloremia are commonly present in critically ill septic patients. Our study goal was to evaluate the association of hyperchloremia and acute kidney injury in severe sepsis and septic shock patients. In this retrospective cohort study in a provincial tertiary care hospital, adult patients with severe sepsis or septic shock and serum chloride measurements were included. Serum chloride was measured on a daily basis for 48 hours. Primary outcome was development of acute kidney injury (AKI) and association of AKI and serum chloride parameters was analyzed. A total of 240 patients were included in the study, 98 patients (40.8 %) had hyperchloremia. The incidence of acute kidney injury (AKI) was significantly higher in the hyperchloremia group (85.7 % vs 47.9 %; p septic shock and independently associated with AKI. A moderate increase in serum chloride (Δ[Cl - ] ≥5 mmol/L) is associated with AKI even in patients without hyperchloremia.

  1. The influence of esmolol on septic shock and sepsis: A meta-analysis of randomized controlled studies.

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    Liu, Ping; Wu, Qi; Tang, Yu; Zhou, Zhiguo; Feng, Malong

    2018-03-01

    Esmolol may have some potential in treating septic shock and sepsis. However, the results remain controversial. We conduct a systematic review and meta-analysis to explore the efficacy of esmolol in patients with septic shock and sepsis. PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases are systematically searched. Randomized controlled trials (RCTs) assessing the efficacy of esmolol for septic shock and sepsis are included. Two investigators independently search articles, extract data, and assess the quality of included studies. Meta-analysis is performed using the random-effect model. Five RCTs are included in the meta-analysis. Overall, compared with control intervention in septic patients, esmolol intervention is found to significantly increase survival rate (risk ratio (RR)=2.06; 95% confidence interval (CI)=1.52 to 2.79; P=0.006), decrease heart rate (Standard Mean difference (Std. MD)=-2.43; 95% CI=-4.13 to -0.72; P=0.005) and TnI (Std. MD=-1.91; 95% CI=-2.39 to -1.43; P<0.00001), but has no significant impact on mean arterial pressure (MAP) (Std. MD=0.11; 95% CI=-0.21 to 0.44; P=0.49), central venous pressure (CVP) (Std. MD=-0.11; 95% CI=-0.50 to 0.28; P=0.58) and central venous oxygen saturation (ScvO2) (Std. MD=1.87; 95% CI=-1.53 to 5.26; P=0.28). Esmolol treatment may be able to improve survival rate, and reduce heart rate and TnI, but has no influence on MAP, CVP and ScvO2 in patients with septic shock and sepsis. Copyright © 2017. Published by Elsevier Inc.

  2. Cardiac Troponin Is a Predictor of Septic Shock Mortality in Cancer Patients in an Emergency Department: A Retrospective Cohort Study.

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    Yang, Zhi; Qdaisat, Aiham; Hu, Zhihuang; Wagar, Elizabeth A; Reyes-Gibby, Cielito; Meng, Qing H; Yeung, Sai-Ching J

    2016-01-01

    Septic shock may be associated with myocardial damage; however, the prognostic value of cardiac enzymes in cancer patients with septic shock is unknown. In this study, we evaluated the prognostic significance of cardiac enzymes in combination with established prognostic factors in predicting the 7-day mortality rate of patients with septic shock, and we constructed a new scoring system, Septic Oncologic Patients in Emergency Department (SOPED), which includes cardiac enzymes, to predict 7-day mortality rates. We performed a retrospective cohort study of 375 adult cancer patients with septic shock who visited the emergency department of a comprehensive cancer center between 01/01/2004 and 12/31/2013. The 7-day and 28-day mortality rates were 19.7% and 37.6%, respectively. The creatine kinase myocardial band fraction and troponin-I were significantly higher in patients who died in ≤7 days and ≤28 days than in those who did not. In Cox regression models, troponin-I >0.05 ng/mL plus Predisposition, Infection, Response, and Organ Failure (PIRO2011) or Mortality in Emergency Department Sepsis (MEDS) score was a significant predictor of survival for ≤7 days. With our new SOPED scoring system, the receiver operating characteristic area under the curve was 0.836, higher than those for PIRO2011 and MEDS. Troponin-I >0.05 ng/mL was an important predictor of short-term mortality (≤7 days). The SOPED scoring system, which incorporated troponin-I, was more prognostically accurate than were other scores for 7-day mortality. Large multicenter studies are needed to verify our results and prospectively validate the prognostic performance of the SOPED score.

  3. Cardiac Troponin Is a Predictor of Septic Shock Mortality in Cancer Patients in an Emergency Department: A Retrospective Cohort Study.

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    Zhi Yang

    Full Text Available Septic shock may be associated with myocardial damage; however, the prognostic value of cardiac enzymes in cancer patients with septic shock is unknown. In this study, we evaluated the prognostic significance of cardiac enzymes in combination with established prognostic factors in predicting the 7-day mortality rate of patients with septic shock, and we constructed a new scoring system, Septic Oncologic Patients in Emergency Department (SOPED, which includes cardiac enzymes, to predict 7-day mortality rates.We performed a retrospective cohort study of 375 adult cancer patients with septic shock who visited the emergency department of a comprehensive cancer center between 01/01/2004 and 12/31/2013. The 7-day and 28-day mortality rates were 19.7% and 37.6%, respectively. The creatine kinase myocardial band fraction and troponin-I were significantly higher in patients who died in ≤7 days and ≤28 days than in those who did not. In Cox regression models, troponin-I >0.05 ng/mL plus Predisposition, Infection, Response, and Organ Failure (PIRO2011 or Mortality in Emergency Department Sepsis (MEDS score was a significant predictor of survival for ≤7 days. With our new SOPED scoring system, the receiver operating characteristic area under the curve was 0.836, higher than those for PIRO2011 and MEDS.Troponin-I >0.05 ng/mL was an important predictor of short-term mortality (≤7 days. The SOPED scoring system, which incorporated troponin-I, was more prognostically accurate than were other scores for 7-day mortality. Large multicenter studies are needed to verify our results and prospectively validate the prognostic performance of the SOPED score.

  4. Effects of Increasing Hydrocortisone to 300 mg Per Day in the Treatment of Septic Shock: a Pilot Study.

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    Hyvernat, Hervé; Barel, Rémy; Gentilhomme, Anne; Césari-Giordani, Jean François; Freche, Annie; Kaidomar, Michel; Goubaux, Bernard; Pradier, Christian; Dellamonica, Jean; Bernardin, Gilles

    2016-11-01

    The Surviving Sepsis Campaign guidelines recommend hydrocortisone in septic shock only when fluid resuscitation and vasopressors fail to restore hemodynamic stability. Hydrocortisone administration modalities are supported only by low-grade recommendations. Our main objective here was to determine differences in 28-day mortality between two low-dose hydrocortisone regimens for the treatment of septic shock. We performed a multicenter, prospective, randomized, double-blind, pilot study in four adult medical intensive care units. Patients presenting septic shock were rapidly administered one of two regimens of hydrocortisone, either a 50-mg intravenous bolus every 6 h during 7 days (200-mg group; n = 59) or a 100-mg initial bolus followed by a continuous infusion of 300 mg daily for 5 days (300-mg group; n = 63). Hydrocortisone was stopped abruptly at the end of treatment. There were no significant differences between the 200-mg and 300-mg groups as concerns 28-day mortality (respectively 52.5% vs. 44.4% [RR 0.84, 95% CI, 0.58-1.22, P = 0.47]), refractory shock incidence or delay from shock to vasopressor cessation. There were also no differences in adverse events between the groups. Shock relapse after hydrocortisone cessation was independent of hydrocortisone regimens, but it was associated with the persistence of infection and the use of etomidate. The resumption of hydrocortisone due to shock relapse was significantly more frequent in the 300-mg group. We found no differences in mortality or adverse events between the two hydrocortisone administration regimens. Shock relapse was significantly associated with the persistence of infection and the use of etomidate.

  5. Clostridium sordellii as a Cause of Fatal Septic Shock in a Child with Hemolytic Uremic Syndrome

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    Rebekah Beyers

    2014-01-01

    Full Text Available Clostridium sordellii is a toxin producing ubiquitous gram-positive anaerobe, mainly associated with trauma, soft tissue skin infections, and gynecologic infection. We report a unique case of a new strain of Clostridium sordellii (not present in the Center for Disease Control (CDC database infection induced toxic shock syndrome in a previously healthy two-year-old male with colitis-related hemolytic uremic syndrome (HUS. The patient presented with dehydration, vomiting, and bloody diarrhea. He was transferred to the pediatric critical care unit (PICU for initiation of peritoneal dialysis (PD. Due to increased edema and intolerance of PD, he was transitioned to hemodialysis through a femoral vascular catheter. He subsequently developed severe septic shock with persistent leukocytosis and hypotension, resulting in subsequent death. Stool culture confirmed Shiga toxin producing Escherichia coli 0157:H7. A blood culture was positively identified for Clostridium sordellii. Clostridium sordelli is rarely reported in children; to our knowledge this is the first case described in a pediatric patient with HUS.

  6. Serum lactate is a useful predictor of death in severe sepsis and septic shock

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    Jafar Malmir

    2014-06-01

    Full Text Available The severe sepsis and septic shock are as common and lethal that emergency physicians routinely confront. Actually, more than two thirds of sepsis patients present initially to the ED. Only a few laboratory tests for markers of sepsis are currently available. The serum lactate level can help in determining prognosis and to risk-stratify patients with severe sepsis. This independent review of the literature includes 83 studies published in all electronic-based database such as Elsevier, PubMed, and SID during the last 18 years (40–320 patients in each. Data gathered from English language articles and books published between 1995 and 2013. The serum lactate concentrations measured in almost all patients with severe sepsis raised at admission and were higher in patients who had the worst outcomes such as higher Apache-II and SOFA score. Serum lactate was associated with mortality independent of clinically apparent organ dysfunction and shock in patients with severe sepsis admitted to the emergency department and intensive care unit.  This review focuses on the association between initial and serial serum lactate level and mortality in patients presenting to the emergency department with severe sepsis.

  7. Aminoglycosides in septic shock: an overview, with specific consideration given to their nephrotoxic risk.

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    Boyer, Alexandre; Gruson, Didier; Bouchet, Stéphane; Clouzeau, Benjamin; Hoang-Nam, Bui; Vargas, Frédéric; Gilles, Hilbert; Molimard, Mathieu; Rogues, Anne-Marie; Moore, Nicholas

    2013-04-01

    Aminoglycoside nephrotoxicity has been reported in patients with sepsis, and several risk factors have been described. Once-daily dosing and shorter treatment have reduced nephrotoxicity risk, and simplified aminoglycoside monitoring. This review focuses on nephrotoxicity associated with aminoglycosides in the subset of patients with septic shock or severe sepsis. These patients are radically different from those with less severe sepsis. They may have, for instance, renal impairment due to the shock per se, sepsis-related acute kidney injury, frequent association with pre-existing risk factors for renal failure such as diabetes, dehydration and other nephrotoxic treatments. In this category of patients, these risk factors might modify substantially the benefit-risk ratio of aminoglycosides. In addition, aminoglycoside administration in critically ill patients with sepsis is complicated by an extreme inter- and intra-individual variability in drug pharmacokinetic/pharmacodynamic characteristics: the volume of distribution (Vd) is frequently increased while the elimination constant can be either increased or decreased. Consequently, and although its effect on nephrotoxicity has not been explored, a different administration schedule, i.e. a high-dose once daily (HDOD), and several therapeutic drug monitoring (TDM) options have been proposed in these patients. This review describes the historical perspective of these different options, including those applying to subsets of patients in which aminoglycoside administration is even more complex (obese intensive care unit [ICU] patients, patients needing continuous or discontinuous renal replacement therapy [CRRT/DRRT]). A simple linear dose adjustment according to aminoglycoside serum concentration can be classified as low-intensity TDM. Nomograms have also been proposed, based on the maximum (peak) plasma concentration (Cmax) objectives, weight and creatinine clearance. The Sawchuk and Zaske method (based on the

  8. High-fidelity medical simulation training improves medical students' knowledge and confidence levels in septic shock resuscitation

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    Vattanavanit V

    2016-12-01

    Full Text Available Veerapong Vattanavanit, Jarernporn Kawla-ied, Rungsun Bhurayanontachai Division of Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand Background: Septic shock resuscitation bundles have poor compliance worldwide partly due to a lack of knowledge and clinical skills. High-fidelity simulation-based training is a new teaching technology in our faculty which may improve the performance of medical students in the resuscitation process. However, since the efficacy of this training method in our institute is limited, we organized an extra class for this evaluation.Purpose: The aim was to evaluate the effect on medical students’ knowledge and confidence levels after the high-fidelity medical simulation training in septic shock management.Methods: A retrospective study was performed in sixth year medical students during an internal medicine rotation between November 2015 and March 2016. The simulation class was a 2-hour session of a septic shock management scenario and post-training debriefing. Knowledge assessment was determined by a five-question pre-test and post-test examination. At the end of the class, the students completed their confidence evaluation questionnaire.Results: Of the 79 medical students, the mean percentage score ± standard deviation (SD of the post-test examination was statistically significantly higher than the pre-test (66.83%±19.7% vs 47.59%±19.7%, p<0.001. In addition, the student mean percentage confidence level ± SD in management of septic shock was significantly better after the simulation class (68.10%±12.2% vs 51.64%±13.1%, p<0.001. They also strongly suggested applying this simulation class to the current curriculum.Conclusion: High-fidelity medical simulation improved the students’ knowledge and confidence in septic shock resuscitation. This simulation class should be included in the curriculum of the sixth year medical students

  9. Timing of antibiotic administration and lactate measurement in septic shock patients: a comparison between hospital wards and the emergency department

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    Vattanavanit V

    2018-01-01

    Full Text Available Veerapong Vattanavanit,1 Theerapat Buppodom,2 Bodin Khwannimit1 1Department of Internal Medicine, Division of Critical Care Medicine, 2Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand Background: The timing of intravenous antibiotic administration and lactate measurement is associated with survival of septic shock patients. Septic shock patients were admitted to the medical intensive care unit (MICU from 2 major sources: hospital ward and emergency department (ED. This study aimed to compare the timing of antibiotic administration and lactate measurement between hospital wards and the ED.Patients and methods: Medical data were collected from adult patients admitted to the MICU with septic shock from January 2015 to December 2016. “Time Zero” was defined as the time of diagnosis of sepsis. The associations between the times and risk-adjusted 28-day mortality were assessed. Results: In total, 150 septic shock patients were admitted to the MICU. The median time interval (hour [h] interquartile range [IQR] from time zero to antibiotic administration was higher in patients from the hospital wards compared to those from the ED (4.84 [3.5–8.11] vs 2.04 [1.37–3.54], P<0.01, but the lactate level measurement time interval (h [IQR] from time zero was not different between the hospital wards and the ED (1.6 [0.2–2.7] vs 1.6 [0.9–3.0], P=0.85. In multivariate analysis, higher risk-adjusted 28-day mortality was associated with antibiotic monotherapy (odds ratio [OR]: 19.3, 95% confidence interval [CI]: 2.4–153.1, P<0.01 and admission during the weekends (OR: 24.4, 95% CI: 2.9–199.8, P<0.01.Conclusion: Antibiotic administration in septic shock patients from the hospital wards took longer, and there was also less appropriate antibiotic prescriptions seen in this group compared with those admitted from the ED. However, neither the timing of antibiotic administration nor lactate

  10. Early combination antibiotic therapy yields improved survival compared with monotherapy in septic shock: a propensity-matched analysis.

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    Kumar, Anand; Zarychanski, Ryan; Light, Bruce; Parrillo, Joseph; Maki, Dennis; Simon, Dave; Laporta, Denny; Lapinsky, Steve; Ellis, Paul; Mirzanejad, Yazdan; Martinka, Greg; Keenan, Sean; Wood, Gordon; Arabi, Yaseen; Feinstein, Daniel; Kumar, Aseem; Dodek, Peter; Kravetsky, Laura; Doucette, Steve

    2010-09-01

    Septic shock represents the major cause of infection-associated mortality in the intensive care unit. The possibility that combination antibiotic therapy of bacterial septic shock improves outcome is controversial. Current guidelines do not recommend combination therapy except for the express purpose of broadening coverage when resistant pathogens are a concern. To evaluate the therapeutic benefit of early combination therapy comprising at least two antibiotics of different mechanisms with in vitro activity for the isolated pathogen in patients with bacterial septic shock. Retrospective, propensity matched, multicenter, cohort study. Intensive care units of 28 academic and community hospitals in three countries between 1996 and 2007. A total of 4662 eligible cases of culture-positive, bacterial septic shock treated with combination or monotherapy from which 1223 propensity-matched pairs were generated. The primary outcome of study was 28-day mortality. Using a Cox proportional hazards model, combination therapy was associated with decreased 28-day mortality (444 of 1223 [36.3%] vs. 355 of 1223 [29.0%]; hazard ratio, 0.77; 95% confidence interval, 0.67-0.88; p = .0002). The beneficial impact of combination therapy applied to both Gram-positive and Gram-negative infections but was restricted to patients treated with beta-lactams in combination with aminoglycosides, fluoroquinolones, or macrolides/clindamycin. Combination therapy was also associated with significant reductions in intensive care unit (437 of 1223 [35.7%] vs. 352 of 1223 [28.8%]; odds ratio, 0.75; 95% confidence interval, 0.63-0.92; p = .0006) and hospital mortality (584 of 1223 [47.8%] vs. 457 of 1223 [37.4%]; odds ratio, 0.69; 95% confidence interval, 0.59-0.81; p shock. Prospective randomized trials are needed.

  11. Positive predictive value of International Classification of Diseases, 10th revision, diagnosis codes for cardiogenic, hypovolemic, and septic shock in the Danish National Patient Registry.

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    Lauridsen, Marie Dam; Gammelager, Henrik; Schmidt, Morten; Nielsen, Henrik; Christiansen, Christian Fynbo

    2015-03-20

    Large registries are important data sources in epidemiological studies of shock, if these registries are valid. Therefore, we examined the positive predictive value (PPV) of diagnosis codes for shock, the procedure codes for inotropic/vasopressor therapy among patients with a diagnosis of shock, and the combination of a shock diagnosis and a code for inotropic/vasopressor therapy in the Danish National Patient Registry (DNPR). We randomly selected 190 inpatients with an International Classification of Diseases, 10th revision (ICD-10) diagnosis of shock at Aarhus University Hospital from 2005-2012 using the DNPR; 50 patients were diagnosed with cardiogenic shock, 40 patients with hypovolemic shock, and 100 patients with septic shock. We used medical charts as the reference standard and calculated the PPV with 95% confidence intervals (CI) for overall shock and for each type of shock separately. We also examined the PPV for inotropic/vasopressor therapy and the PPV for shock when a concurrent code for inotropic/vasopressor therapy was also registered. The PPV was 86.1% (95% CI: 79.7-91.1) for shock overall, 93.5% (95% CI: 82.1-98.6) for cardiogenic shock, 70.6% (95% CI: 52.5-84.9) for hypovolemic shock, and 69.2% (95% CI: 57.7-79.2) for septic shock. The PPV of use of inotropes/vasopressors among shock patients was 88.9% (95% CI: 79.3-95.1). When both a shock code and a procedure code for inotropic/vasopressor therapy were used, the PPV for shock overall was 93.1% (95% CI: 84.5-97.7). ICD-10 codes for subtypes of shock and simultaneously registered use of inotropes/vasopressors provided PPVs of 96.0% (95% CI: 79.6-99.9) for cardiogenic shock, 69.2% (95% CI: 38.6-90.9) for hypovolemic shock, and 82.4% (95% CI: 65.5-93.2) for septic shock. Overall, we found a moderately high PPV for shock in the DNPR. The PPV was highest for cardiogenic shock but lower for hypovolemic and septic shock. Combination diagnoses of shock with codes for inotropic/vasopressor therapy further

  12. Disparities in hemodynamic resuscitation of the obese critically ill septic shock patient.

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    Adams, Chere; Tucker, Calvin; Allen, Bryan; McRae, Andrew; Balazh, Julia; Horst, Spencer; Johnson, Donald; Ferreira, Jason

    2017-02-01

    With a growing obesity epidemic, the approach to care of this patient remains controversial and in many circumstances different than the general population. Appropriate hemodynamic support, although still controversial, remains a cornerstone of septic shock therapy. Catecholamines are currently recommended by guidelines without a preferred dosing strategy. However, the use of weight-based (μg kg -1 min -1 ) or nonweight-based (μg/min) vasopressor drip rates may impact patient care in these populations. A multicenter retrospective chart review was conducted. Patients receiving nonweight-based catecholamine infusions for septic shock were grouped into nonobese (n = 112) or obese (n = 196), and evaluated based on hemodynamic resuscitation. For the primary outcome, groups were analyzed for the requirement of a secondary hemodynamic support agent to obtain a goal mean arterial pressure of greater than or equal to 65 mm Hg. Secondary outcomes included an evaluation of time to a secondary hemodynamic support agent, time to hemodynamic stability (HDS), ability to obtain HDS at 24 hours, and death due to cardiovascular collapse. With the exception of weight and sex, baseline characteristics were similar among groups. Early resuscitative fluids were given at a lower weight based, but not total volume dose in the obese group (nonobese, 34.8 mL/kg vs obese, 22.4 mL/kg; P < .0001). The primary end point of addition of any secondary hemodynamic support agent was significantly greater in obese patients when adjusted for institution (nonobese, 19% vs obese, 27%; adjusted odds ratio, 0.42; 95% confidence interval, 0.23-0.77). Time to HDS was also prolonged (nonobese, 3.5 hours vs obese, 5.3 hours; P = .006). This study calls into question the adequacy of a nonweight-based approach to hemodynamic support of critically ill obese patients. This strategy seems to result in less aggressive, lower weight-based vasopressor and fluid doses, and more diverse approach than their nonobese

  13. Levosimendan does not provide mortality benefit over dobutamine in adult patients with septic shock: A meta-analysis of randomized controlled trials.

    Science.gov (United States)

    Bhattacharjee, Sulagna; Soni, Kapil D; Maitra, Souvik; Baidya, Dalim K

    2017-06-01

    Despite of advancement in intensive care medicine, sepsis and septic shock carry a high mortality. Levosimendan, an inodilator, may be promising for septic shock patients with myocardial dysfunction; however, firm evidence is lacking. In this meta- analysis of randomized controlled trials, levosimendan has been compared with dobutamine in adult patients with sepsis and septic shock. Meta-analysis of randomized controlled trial. Intensive-care unit. Adult septic shock patients. Adult septic shock patients received dobutamine or levosimendan. Mortality at longest follow-up, blood lactate level, cardiac index and noradrenaline requirement. Data from 7 randomized trials have been included in this meta-analysis. Levosimendan has no benefit in terms of mortality at longest follow up in comparison to dobutamine (Odds ratio 0.77, 95% CI 0.45, 132; p=0.34) and length of ICU stay (MD -4.7days, 95% CI -10.3, 0.9days, p=0.10). Patients received levosimendan had less blood lactate level (standardized mean difference -0.95; 95% CI -1.64, -0.27; p=0.006) and higher cardiac index (mean difference 0.44; 95% CI 0.17, 0.71; p=0.001). Noradrenaline requirements are similar in both the groups. There is no evidence that levosimendan is superior to dobutamine in adult patients with sepsis and septic shock. Further large randomized trials are necessary in this area. Copyright © 2017 Elsevier Inc. All rights reserved.

  14. The impact of duration of organ dysfunction on the outcome of patients with severe sepsis and septic shock

    Directory of Open Access Journals (Sweden)

    Flávio G. R. Freitas

    2008-01-01

    Full Text Available OBJECTIVES: This study aimed to assess the impact of the duration of organ dysfunction on the outcome of patients with severe sepsis or septic shock. METHODS: Clinical data were collected from hospital charts of patients with severe sepsis and septic shock admitted to a mixed intensive care unit from November 2003 to February 2004. The duration of organ dysfunction prior to diagnosis was correlated with mortality. Results were considered significant if p<0.05. RESULTS: Fifty-six patients were enrolled. Mean age was 55.6 ± 20.7 years, mean APACHE II score was 20.6 ± 6.9, and mean SOFA score was 7.9 ± 3.7. Thirty-six patients (64.3% had septic shock. The mean duration of organ dysfunction was 1.9 ± 1.9 days. Within the univariate analysis, the variables correlated with hospital mortality were: age (p=0.015, APACHE II (p=0.008, onset outside the intensive care unit (p=0.05, blood glucose control (p=0.05 and duration of organ dysfunction (p=0.0004. In the multivariate analysis, only a duration of organ dysfunction persisting longer than 48 hours correlated with mortality (p=0.004, OR: 8.73 (2.37-32.14, whereas the APACHE II score remained only a slightly significant factor (p=0.049, OR: 1.11 (1.00-1.23. Patients who received therapeutic interventions within the first 48 hours after the onset of organ dysfunction exhibited lower mortality (32.1% vs. 82.1%, p=0.0001. CONCLUSIONS: These findings suggest that the diagnosis of organ dysfunction is not being made in a timely manner. The time elapsed between the onset of organ dysfunction and initiation of therapeutic intervention can be quite long, and this represents an important determinant of survival in cases of severe sepsis and septic shock.

  15. Vascular ATP-sensitive potassium channels are over-expressed and partially regulated by nitric oxide in experimental septic shock.

    Science.gov (United States)

    Collin, Solène; Sennoun, Nacira; Dron, Anne-Gaëlle; de la Bourdonnaye, Mathilde; Montemont, Chantal; Asfar, Pierre; Lacolley, Patrick; Meziani, Ferhat; Levy, Bruno

    2011-05-01

    To study the activation and expression of vascular (aorta and small mesenteric arteries) potassium channels during septic shock with or without modulation of the NO pathway. Septic shock was induced in rats by peritonitis. Selective inhibitors of vascular K(ATP) (PNU-37883A) or BK(Ca) [iberiotoxin (IbTX)] channels were used to demonstrate their involvement in vascular hyporeactivity. Vascular response to phenylephrine was measured on aorta and small mesenteric arteries mounted on a wire myograph. Vascular expression of potassium channels was studied by PCR and Western blot, in the presence or absence of 1400W, an inducible NO synthase (iNOS) inhibitor. Aortic activation of the transcriptional factor nuclear factor-kappaB (NF-κB) was assessed by electrophoretic mobility shift assay. Arterial pressure as well as in vivo and ex vivo vascular reactivity were reduced by sepsis and improved by PNU-37883A but not by IbTX. Sepsis was associated with an up-regulation of mRNA and protein expression of vascular K(ATP) channels, while expression of vascular BK(Ca) channels remained unchanged. Selective iNOS inhibition blunted the sepsis-induced increase in aortic NO, decreased NF-κB activation, and down-regulated vascular K(ATP) channel expression. Vascular K(ATP) but not BK(Ca) channels are activated, over-expressed, and partially regulated by NO via NF-κB activation during septic shock. Their selective inhibition restores arterial pressure and vascular reactivity and decreases lactate concentration. The present data suggest that selective vascular K(ATP) channel inhibitors offer potential therapeutic perspectives for septic shock.

  16. [Consequences of autopsies for the living : Causes of death in the clinical diagnosis "septic and toxic shock"].

    Science.gov (United States)

    Ozretić, L; Schwindowski, A; Dienes, H-P; Büttner, R; Drebber, U; Fries, J W U

    2017-09-01

    There is reason to believe that the diagnosis of septic and toxic shock, as indicated on the death certificate, cannot be confirmed as the cause of death without autopsy and subsequent histological analysis. The external examination of the corpse can therefore not represent the sole basis for a reliable statement about the infection status of a corpse, e. g. as a prerequisite for embalming. The validity of autopsy in determining septic and toxic shock as the cause of death is demonstrated in 7 exemplary cases. Decades of experience in a university pathology institute have shown that an external examination of the corpse alone is not suitable for certifying the cause of death if an infectious disease is suspected. Consequently, only autopsy with subsequent histological analysis provides reliable statements on the etiopathogenesis of the underlying process. Possible problems and discrepancies between clinical and pathological diagnoses are discussed on the basis of several cases with or without autoptic confirmation of the septic shock. The case of a missionary from Africa infected with Lassa virus serves to point out the seriousness of the threat an undiagnosed infection may represent to the attending staff. During the treatment of patients suspected to have an infectious cause of fever of unknown origin, compliance with the usual safety regulations, including adequate disinfecting measures, is essential. In cases with fatal outcome, not infrequently under the clinical picture of a septic and toxic shock, autopsy should be regularly performed to confirm the type of infection and the infectious cause of death. Rapid and open communication between the professional groups involved plays a crucial role in this process.

  17. Severe sepsis and septic shock in patients with pre-existing non-cardiac pulmonary hypertension: contemporary management and outcomes.

    Science.gov (United States)

    Tsapenko, Mykola V; Herasevich, Vitaly; Mour, Girish K; Tsapenko, Arseniy V; Comfere, Thomas B O; Mankad, Sunil V; Cartin-Ceba, Rodrigo; Gajic, Ognjen; Albright, Robert C

    2013-06-01

    To review treatment and outcomes of septic shock in patients with pulmonary hypertension (PH) managed at a tertiary care institution. We identified consecutive patients with non-cardiac PH (non-Group 2 in the World Health Organization classification) who were treated for septic shock in four intensive care units at a tertiary care institution between July 2004 and July 2007. Patients with a left ventricular ejection fraction patients. The major causes of PH were chronic obstructive pulmonary disease, interstitial lung disease and portopulmonary hypertension. PH was mild in 46 patients (56%), moderate in 21 (26%) and severe in 15 (18%). Vasopressor treatment was initiated in 69 patients (84%) within the first 48 hours: noradrenaline was most commonly used (53 patients, 65%), and 51 patients (62%) were treated with more than one agent. Sixty-seven patients (82%) were mechanically ventilated, and 33 (40%) required renal replacement therapy. Fortythree patients (52%) survived to hospital discharge; 23 (28%) remained alive at 1 year. Hospital mortality increased with severity of PH: 28% in mild, 67% in moderate and 80% in severe PH. Nonsurvivors were more likely to have plateau pressures beyond 30 cm H(2)O while mechanically ventilated within the first 48 hours in the ICU (56% v 29%, P = 0.03), to develop atrial fibrillation (AF) (46% v 12%, P patients with PH who developed severe sepsis and septic shock.

  18. A highly purified vegetal fraction able to modulate HMGB1 and to attenuate septic shock in mice.

    Science.gov (United States)

    Apetrei, Natalia Simona; Călugăru, Ana; Kerek, F; Panteli, Minerva; Rasit, I; Cremer, Lidia; Szegli, G; Lupu, Andreea-Roxana

    2011-01-01

    High-mobility group box protein 1 (HMGB1) is an intracellular protein that may be released actively from monocytes and macrophages or passively from necrotic or damaged cells. Its inhibition in animal experiments, even in the late phase of septic shock, significantly enhanced the survival rate of rodents. The aim of our study was to investigate the effect of a vegetal fraction isolated and highly purified from Helleborus purpurascens regarding the modulation of HMGB1 release either from tumor cells or human blood mononuclear cells. Our results showed that the vegetal fraction was able to down-regulate the release of HMGB1 from activated human blood mononuclear cells (PBMCs) and tumor cells. By combining the purified fraction with Cyclophosphamide the release of HMGB1 from tumor cells was strongly decreased. This synergism was not noticed when the ve getal product was associated with Doxorubicin. We also studied the effect of the purified fraction in mice with septic shock induced by cecal ligation and puncture (CLP) method. The tested vegetal product increased significantly the survival rate of animals compared to the mice not treated with it. Our data suggest that the purified vegetal fraction may modulate inflammation by down-regulating the HMGB1, which can also explain its efficacy in septic shock in mice.

  19. Central venous oxygen saturation in septic shock - a marker of cardiac output, microvascular shunting and/or dysoxia?

    DEFF Research Database (Denmark)

    Haase, Nicolai; Perner, Anders

    2011-01-01

    Shock therapy aims at increasing central venous oxygen saturation (ScvO2), which is a marker of inadequate oxygen delivery. In this issue of Critical Care, Textoris and colleagues challenge this notion by reporting that high levels of ScvO2 are associated with mortality in patients with septic...... shock. This is of obvious interest, but as their retrospective design has inherent limitations, the association should be confirmed in a prospective, multicenter study with protocolized ScvO2 measurements and detailed registration of potentially confounding factors....

  20. Citrobacter braakii bacteremia-induced septic shock after colonoscopy preparation with polyethylene glycol in a critically ill patient: a case report.

    Science.gov (United States)

    Yumoto, Tetsuya; Kono, Yoshiyasu; Kawano, Seiji; Kamoi, Chihiro; Iida, Atsuyoshi; Nose, Motoko; Sato, Keiji; Ugawa, Toyomu; Okada, Hiroyuki; Ujike, Yoshihito; Nakao, Atsunori

    2017-04-04

    Polyethylene glycol (PEG) is widely used for bowel cleaning in preparation for colonoscopy because of its safety. Septic shock after PEG preparation is an extremely rare complication. Herein, we describe a case of septic shock that occurred immediately after colonoscopy preparation with PEG. A 75-year-old Japanese male who had previously developed diabetes after total pancreatectomy received PEG in preparation for colonoscopy. He had been admitted to the emergency intensive care unit 4 days earlier due to hematochezia presenting with shock. He ingested PEG to prepare for a colonoscopy examination, which was performed to identify the source of his bleeding over a 5-h period, but suddenly exhibited septic shock and markedly elevated procalcitonin levels. A blood culture subsequently revealed Citrobacter braakii. Immediate resuscitation and intensive care with appropriate antibiotics improved his condition. Clinicians should be aware of the possibility of deteriorating conditions after bowel preparation with PEG among severely ill patients with recent episodes of hemorrhagic shock.

  1. Acute respiratory distress syndrome and septic shock in a cat with disseminated toxoplasmosis.

    Science.gov (United States)

    Evans, Natashia A; Walker, Julie M; Manchester, Alison C; Bach, Jonathan F

    2017-07-01

    To describe acute respiratory distress syndrome (ARDS) and septic shock in a cat with disseminated toxoplasmosis. A 2-year-old neutered male domestic shorthair cat was presented for acute respiratory distress. At the time of presentation it had been receiving cyclosporine for treatment of eosinophilic dermatitis. Thoracic radiographs revealed severe mixed nodular interstitial and alveolar patterns. An endotracheal wash was performed, which confirmed a diagnosis of pulmonary toxoplasmosis. Despite initial treatment with oxygen supplementation and intravenous clindamycin, the cat developed refractory hypoxemia and hypotension requiring mechanical ventilation and vasopressor support within 24 hours of hospital admission. Cardiac arrest occurred 56 hours after admission. Necropsy was performed and histopathology revealed protozoal organisms disseminated throughout the heart, lungs, liver, and brain. The clinical and necropsy findings presented here are consistent with ARDS secondary to disseminated toxoplasmosis in a cat. This is the first detailed report of ARDS in a cat. Toxoplasma titer testing and antimicrobial prophylaxis should be considered in cats prior to immunosuppressive treatment with cyclosporine. © Veterinary Emergency and Critical Care Society 2017.

  2. Use of CytoSorb in Traumatic Amputation of the Forearm and Severe Septic Shock

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    Heinz Steltzer

    2017-01-01

    Full Text Available Severe trauma associated with later disability and mortality still constitutes a major health and socioeconomic problem throughout the world. While primary morbidity and mortality are mostly related to initial injuries and early complications, secondary lethality is strongly linked to the development of systemic inflammatory response syndrome, sepsis, and ultimately multiple organ dysfunction syndrome. We herein report on a 49-year-old male patient who was admitted to the hospital after a traumatic amputation of his right forearm that was cut off while working on a landfill. After initial treatment for shock, he received immediate replantation and was transferred to the ICU. Due to the anticipated risk of a complex infection, continuous renal replacement therapy in combination with CytoSorb was initiated. During the course of the combined treatment, a rapid improvement in hemodynamics was noticed, as well as a significant reduction of IL-6 and lactate levels. Despite a recurring septic episode and the necessity for amputation, the patient clinically stabilized and underwent complete recovery. The early treatment with a combination of CVVHDF and CytoSorb was accompanied by an attenuation of the systemic inflammatory reaction, which subsided without major or permanent organ damage, despite the impressive pathogen spectrum and the pronounced local damage.

  3. Metabolic Requirement of Septic Shock Patients Before and After Liberation From Mechanical Ventilation.

    Science.gov (United States)

    Lee, Peggy Siu-Pik; Lee, Kar Lung; Betts, James A; Law, Kin Ip

    2017-08-01

    This study identified the difference in energy expenditure and substrate utilization of patients during and upon liberation from mechanical ventilation. Patients under intensive care who were diagnosed with septic shock and dependent on mechanical ventilation were recruited. Indirect calorimetry measurements were performed during and upon liberation from mechanical ventilation. Thirty-five patients were recruited (20 men and 15 women; mean age, 69 ± 10 years). Measured energy expenditures during ventilation and upon liberation were 2090 ± 489 kcal·d -1 and 1910 ± 579 kcal·d -1 , respectively ( P mechanical ventilation compared with 0.15 ± 0.09 g·min -1 upon liberation ( P mechanical ventilation ( P > .05). Measured energy expenditure was higher during than upon liberation from mechanical ventilation. This could be the increase in work of breathing from the continuous positive pressure support, repeated weaning cycles from mechanical ventilation, and/or the asynchronization between patients' respiration and ventilator support. Future studies should examine whether more appropriately matching energy expenditure with energy intake would promote positive health outcomes.

  4. Protective effect of Cl-amidine against CLP-induced lethal septic shock in mice.

    Science.gov (United States)

    Zhao, Ting; Pan, Baihong; Alam, Hasan B; Liu, Baoling; Bronson, Roderick T; Deng, Qiufang; Wu, Erxi; Li, Yongqing

    2016-11-07

    Production of innate and adaptive immune cells from hematopoietic stem cells, and maturation of T lymphocytes are effective immune responses to fight severe microbial infection. In sepsis, this emergency myelopoiesis is damaged, leading to failure of bacterial clearance, and excessive stress-induced steroids cause immature T-lymphocyte apoptosis in thymus. We recently found that Cl-amidine, a peptidylarginine deiminase (PAD) inhibitor, improves survival in a mouse model of cecal ligation and puncture (CLP)-induced septic shock. In the present study we investigated how Cl-amidine promotes survival, focusing on protective effects of Cl-amidine on immune response. We confirmed survival-improving effect of Cl-amidine and are the first to explore the role of Cl-amidine in immune response. CLP caused bone marrow (BM) and thymus atrophy, decreased innate immune cells in BM. CLP increased levels of cytokines (IL-1β, IL-6, and TNF-α) and bacteria load in blood/liver. In primary splenocyte culture, lipopolysaccharide increased TNF-α production. In contrast, Cl-amidine attenuated these CLP and lipopolysaccharide-induced alterations. Moreover, Cl-amidine increased circulating monocytes. Collectively, our results demonstrate Cl-amidine plays protective roles by significantly decreasing BM and thymus atrophy, restoring innate immune cells in BM, increasing blood monocytes and blood/liver bacteria clearance, and attenuating pro-inflammatory cytokine production in a murine model of lethal sepsis.

  5. Glycaemic variability in patients with severe sepsis or septic shock admitted to an Intensive Care Unit.

    Science.gov (United States)

    Silveira, L M; Basile-Filho, A; Nicolini, E A; Dessotte, C A M; Aguiar, G C S; Stabile, A M

    2017-08-01

    Sepsis is associated with morbidity and mortality, which implies high costs to the global health system. Metabolic alterations that increase glycaemia and glycaemic variability occur during sepsis. To verify mean body glucose levels and glycaemic variability in Intensive Care Unit (ICU) patients with severe sepsis or septic shock. Retrospective and exploratory study that involved collection of patients' sociodemographic and clinical data and calculation of severity scores. Glycaemia measurements helped to determine glycaemic variability through standard deviation and mean amplitude of glycaemic excursions. Analysis of 116 medical charts and 6730 glycaemia measurements revealed that the majority of patients were male and aged over 60 years. Surgical treatment was the main reason for ICU admission. High blood pressure and diabetes mellitus were the most usual comorbidities. Patients that died during the ICU stay presented the highest SOFA scores and mean glycaemia; they also experienced more hypoglycaemia events. Patients with diabetes had higher mean glycaemia, evaluated through standard deviation and mean amplitude of glycaemia excursions. Organic impairment at ICU admission may underlie glycaemic variability and lead to a less favourable outcome. High glycaemic variability in patients with diabetes indicates that monitoring of these individuals is crucial to ensure better outcomes. Copyright © 2017 Elsevier Ltd. All rights reserved.

  6. [Septic shock secondary to non-congenital chikungunya fever in a young infant: A clinical case].

    Science.gov (United States)

    Méndez-Domínguez, Nina; Achach-Asaf, Jorge Augusto; Basso-García, Luis Manuel; Quiñones-Pacheco, Yazmín Berenice; Gómez-Carro, Salvador

    2016-01-01

    A chikungunya outbreak took place in the State of Yucatan starting in the second half of 2015 OBJECTIVE: To analyse the clinical course of a case of chikungunya in a previously healthy infant, providing practical evidence to guide future diagnoses and treatment during outbreak seasons in endemic areas Clinical manifestation started with a sudden onset of fever and a diffuse macular-papillary erythema, originally treated in the community with non-steroidal anti-inflammatory drugs. Two days later, the fever relapsed with hypoactivity, severe thrombocytopenia and neutropenia (without lymphopenia), respiratory distress, liver dysfunction, sepsis, followed by septic shock with a fatal outcome. IgM test was positive to chikungunya, while her mother tested negative. Pseudomonas aeruginosa was isolated from the blood culture possible due to contamination, without ruling out the possibility of a mixed origin sepsis. Chikungunya is a disease in which the manifestations in neonates and young infants can be severe, and even fatal. It is important to suspect it in this age group at risk of vector contact, in the presence of fever without apparent source of infection and cutaneous manifestations. It is important to use the antipyretics cautiously, considering the possibility of aggravating the underlying infection, and the potential hepatic and haematological damage. Copyright © 2016 Sociedad Chilena de Pediatría. Publicado por Elsevier España, S.L.U. All rights reserved.

  7. Frontline Science: HMGB1 induces neutrophil dysfunction in experimental sepsis and in patients who survive septic shock.

    Science.gov (United States)

    Grégoire, Murielle; Tadié, Jean-Marc; Uhel, Fabrice; Gacouin, Arnaud; Piau, Caroline; Bone, Nathaniel; Le Tulzo, Yves; Abraham, Edward; Tarte, Karin; Zmijewski, Jaroslaw W

    2017-06-01

    Sepsis is accompanied by the initial activation of proinflammatory pathways and long-lasting immunosuppression that appears to contribute to late-occurring mortality. Although high-mobility group box 1 (HMGB1) is involved in many aspects of inflammation, its role in sepsis-induced immune suppression remains unclear. In this study, we examined HMGB1's contribution to neutrophil NADPH oxidase activity dysfunction and associated neutrophil-dependent bacterial clearance in mice subjected to sepsis and in patients who survive septic shock. Using a murine model of polymicrobial septic peritonitis, we demonstrated that treatment with anti-HMGB1 Ab significantly diminished sepsis-induced dysfunction of neutrophil NADPH oxidase activity. In a subsequent set of experiments, we found that blocking HMGB1 preserved the ability of neutrophils from patients recovering from septic shock to activate NADPH oxidase. Taken together, our data suggest that HMGB1 accumulation in the late phase of sepsis plays a specific role in the development of postsepsis immunosuppression and specifically affects neutrophil-dependent antibacterial defense mechanisms. Thus, blocking HMGB1 may be a promising therapeutic intervention to diminish the adverse effects of sepsis-induced immunosuppression. © Society for Leukocyte Biology.

  8. [The hemodynamic characteristics of septic shock and relationship with syndrome types of traditional Chinese medicine].

    Science.gov (United States)

    He, Jianzhuo; Wang, Lei; Yin, Xin; Guo, Liheng; Zhang, Minzhou

    2016-02-01

    To observe hemodynamic characteristics and the correlation with syndrome types of traditional Chinese medicine (TCM) in patients with septic shock, so as to direct the treatment based on syndrome differentiation. A prospective observation was conducted. Sixty-eight patients with septic shock admitted to the Department of Critical Care Medicine of Dade Road General Hospital of Guangdong Hospital of TCM from January 2013 to July 2015 were enrolled. Pulse indicating continuous cardiac output (PiCCO) was used to monitor the hemodynamic changes, including heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), cardiac index (CI), global end diastolic volume index (GEDVI), extravascular lung water index (EVLWI), maximum rate of the increase in pressure (dPmax) and systemic vascular resistance index (SVRI), for assessment of hemodynamics. According to the CI, the patients were divided into two groups , i.e. high CI group (CI ≥ 50.0 mL×s(-1)×m(-2), n = 34) and low CI group (CI characteristics of two groups were investigated. The TCM differentiation was conducted with "four syndromes and four methods", and the hemodynamic characteristics of different syndrome types were investigated, the correlation between the TCM syndrome factors and hemodynamic parameters was analyzed. The patients were divided into survival group and death group, and clinical parameters and hemodynamic characteristics were compared between two groups. The acute physiology and chronic health evaluation II (APACHEII) score and blood glucose of low CI group were higher than those of high CI group [APACHEII score: 24.4±7.2 vs. 19.8±7.4, t = -2.279, P = 0.023; blood glucose (mmol/L): 9.7 (7.7, 14.6) vs. 6.7 (5.6, 10.0), Z = -2.257, P = 0.024], CI and GEDVI were lowered [CI (mL×s(-1)×m(-2)): 36.7±8.3 vs. 68.4±16.7, t = 10.285, P = 0.000; GEDVI (mL/m(2)): 689.0 (566.0, 883.8) vs. 838.5 (692.8, 1?247.3), Z = -2.711, P = 0.007], while SVRI was increased [kPa×s×L(-1)×m(-2): 248

  9. Genetic Variants of Intron Region of Aquaporin AQP5 Gene and Development of Pulmonary Edema in Lung Infection Complicated by Septic Shock

    Directory of Open Access Journals (Sweden)

    A. E. Myazin

    2016-01-01

    Full Text Available Purpose of the study. Determine the value of genetic variants of a single nucleotide polymorphic site rs3736309 of intron 3 of aquaporin5 (AQP5 gene in the course of critical illness in patients with documented pulmonary infection. Materials and methods. Patients with critical illness admitted to the intensive care units were examined during the course of treatment (n=86, age 27 to 82 years, mean age 53.20±14.34 years. Main diagnosis included malignancies (15%, peritonitis (16% and necrotizing pancreatitis (37%. Patients developed nosocomial pneumonia (55%, acute respiratory distress syndrome (ARDS (54%, septic shock (48%, ARDS combined with septic shock (33%. Bacterial species of Pseudomonas aeruginosa , Klebsiella pneumoniae, Acinetobacter baumannii, and/or Proteus mirabilis alone or in association were revealed in lavage fluid. DNA genotyping DNA was carried out using tetraprimer polymerase chain reaction (PCR. Statistical processing was performed using GraphPad InStat program (GraphPad, USA.Results. The distribution of frequencies of genotypes AA, GA and GG (AQP5, rs3736309 in cohort of patients corresponded to HardyWeinberg equilibrium (P=0.923 and was similar to frequencies of same alleles determined in a conditionally healthy Caucasian individuals (literature data (P>0.05. In a subgroup of patients with septic shock and AQP5 AA (rs3736309 genotype the lower EVLWI values were found compared to patients with genotypes GG and GA with septic shock in spite of the same approach to treatment. The differences between genetically different subgroups of patients with septic shock were maintained throughout the life of the survey (P<0.05,days 1, 3, 5 and 7. Genetic variant AQP5 G+ (rs3736309 contributed to the development of pulmonary edema resistant to treatment (odds ratio, OR = 6,75; P=0.032. Only the subgroup of patients with septic shock and genotype G + (but not all patients or the subgroup of patients without septic shock of the

  10. Effect of dobutamine on extravascular lung water index, ventilator function, and perfusion parameters in acute respiratory distress syndrome associated with septic shock.

    Science.gov (United States)

    Zhou, Min; Dai, Ji; Du, Min; Wang, Wei; Guo, Changxing; Wang, Yi; Tang, Rui; Xu, Fengling; Rao, Zhuqing; Sun, Gengyun

    2016-08-01

    The role of dobutamine in the relief of pulmonary edema during septic shock-induced acute respiratory distress syndrome (ARDS) remains undetermined, due to a lack of controllable and quantitative clinical studies. Our objective was to assess the potential effects of dobutamine on extravascular lung water index (ELWI) in septic shock-induced ARDS, reflecting its importance in pulmonary edema. At the same time, ventilator function and perfusion parameters were evaluated. We designed a prospective, non-randomized, non-blinded, controlled study to compare the differences in PiCCO parameters after 6 h of constant dobutamine infusion (15 μg/kg/min), in the baseline parameters in 26 septic shock-related ARDS patients with cardiac index ≥ 2.5I/min/m(2) and hyperlactatemia. These patients (12 survivors/14 non-survivors) were monitored using the PiCCO catheter system within 48 h of onset of septic shock. The dynamic changes in ELWI, which is typically used for quantifying the extent of pulmonary edema, were evaluated, and the corresponding ventilator function and tissue perfusion parameters were also measured. Decreasing ELWI (p = 0.0376) was accompanied by significantly decreased SVRI (p septic shock-induced ARDS, dobutamine treatment demonstrated a beneficial effect by relieving pulmonary edema in patients, without a negative elevation in preload or hemodynamics, which might account for the improvements in ventilator function and tissue hypoperfusion.

  11. Effects of Shenfu Injection in the Treatment of Septic Shock Patients: A Multicenter, Controlled, Randomized, Open-Label Trial

    Directory of Open Access Journals (Sweden)

    Yi Li

    2016-01-01

    Full Text Available The effect of Shenfu on biochemical parameters and survival during resuscitation in patients with septic shock was examined. This was a multicenter, controlled, randomized, open-label trial carried out in 210 patients with septic shock from seven medical centers in China. They were randomized to Shenfu or saline. The primary outcome was lactate clearance. The secondary outcomes were shock index normalization, dose of vasopressors, ICU stay, hospital stay, and mortality. A total of 199 patients completed the trial. Blood pressure, heart rate, and other routine lab tests showed no difference between the groups. Lactate levels and lactate clearance were similar between the two groups. Hospital and ICU stay were similar between the two groups. When considering all patients, the 7- and 28-day mortality were similar between the two groups, but when considering only patients with lactate levels ≥4.5 mmol/L, the Shenfu group showed a better 7-day survival than the control group (7 days: 83.3% versus 54.5%, P=0.034; 28 days: 72.7% versus 47.6%, P=0.092. Shenfu may improve the 7-day survival in patients with impaired lactate clearance (≥4.5 mmol/L, but the mechanism for this effect is unclear. Additional studies are necessary to characterize the hemodynamic changes after Shenfu infusion. This trial is registered with ChiCTR-TRC-11001369.

  12. Fluid management and risk factors for renal dysfunction in patients with severe sepsis and/or septic shock.

    Science.gov (United States)

    Muller, Laurent; Jaber, Samir; Molinari, Nicolas; Favier, Laurent; Larché, Jérôme; Motte, Gilles; Lazarovici, Sonia; Jacques, Luc; Alonso, Sandrine; Leone, Marc; Constantin, Jean Michel; Allaouchiche, Bernard; Suehs, Carey; Lefrant, Jean-Yves

    2012-02-29

    The causative role of new hydroxyethyl starch (HES 130/0.4) in renal dysfunction frequency (a > 50% increase in serum creatinine or need for renal replacement therapy (RRT)) remains debated. Using the database of a multicenter study focusing on patients with severe sepsis and septic shock, the present study aimed at identifying factors associated with the occurrence of renal dysfunction. Among the 435 patients in a multicenter study of patients with severe sepsis and septic shock in 15 Southern French ICUs, 388 patients surviving after 24 hour, without a history of renal failure were included. Factors associated with renal dysfunction and RRT were isolated using a multivariate analysis with logistic regression. Renal dysfunction was reported in 117 (33%) patients. Ninety patients required RRT. Among study participants, 379 (98%) were administered fluids in the first 24 hours of management: HES 130/0.4 only (n=39), crystalloids only (n=63), or both HES 130/0.4 and crystalloids (n=276). RRT was independently associated with the need for vasopressors and the baseline value of serum creatinine in the first 24 hours. Multivariate analysis indicated that male gender, SAPS II score, being a surgical patient, lack of decrease in SOFA score during the first 24 hours, and the interventional period of the study were independently associated with renal dysfunction. Mortality increased in the presence of renal dysfunction (48% versus 24%, Ppatients with severe sepsis and/or septic shock, the administration of HES 130/0.4 in the first 24 hours of management was not associated with the occurrence of renal dysfunction.

  13. Applying dynamic parameters to predict hemodynamic response to volume expansion in spontaneously breathing patients with septic shock

    Science.gov (United States)

    Lanspa, Michael J.; Grissom, Colin K.; Hirshberg, Eliotte L.; Jones, Jason P.; Brown, Samuel M.

    2013-01-01

    Background Volume expansion is a mainstay of therapy in septic shock, although its effect is difficult to predict using conventional measurements. Dynamic parameters, which vary with respiratory changes, appear to predict hemodynamic response to fluid challenge in mechanically ventilated, paralyzed patients. Whether they predict response in patients who are free from mechanical ventilation is unknown. We hypothesized that dynamic parameters would be predictive in patients not receiving mechanical ventilation. Methods This is a prospective, observational, pilot study. Patients with early septic shock and who were not receiving mechanical ventilation received 10 ml/kg volume expansion (VE) at their treating physician's discretion after initial resuscitation in the emergency department. We used transthoracic echocardiography to measure vena cava collapsibility index (VCCI) and aortic velocity variation (AoVV) prior to VE. We used a pulse contour analysis device to measure stroke volume variation (SVV). Cardiac index was measured immediately before and after VE using transthoracic echocardiography. Hemodynamic response was defined as an increase in cardiac index ≥ 15%. Results 14 patients received VE, 5 of which demonstrated a hemodynamic response. VCCI and SVV were predictive (Area under curve = 0.83, 0.92, respectively). Optimal thresholds were calculated: VCCI ≥ 15% (Positive predictive value, PPV 62%, negative predictive value, NPV 100%, p = 0.03); SVV ≥ 17% (PPV 100%, NPV 82%, p = 0.03). AoVV was not predictive. Conclusions VCCI and SVV predict hemodynamic response to fluid challenge patients with septic shock who are not mechanically ventilated. Optimal thresholds differ from those described in mechanically ventilated patients. PMID:23324885

  14. An increase in mean platelet volume from baseline is associated with mortality in patients with severe sepsis or septic shock.

    Directory of Open Access Journals (Sweden)

    Chan Ho Kim

    Full Text Available Mean platelet volume (MPV is suggested as an index of inflammation, disease activity, and anti-inflammatory treatment efficacy in chronic inflammatory disorders; however, the effect of MPV on sepsis mortality remains unclear. Therefore, we investigated whether the change in MPV between hospital admission and 72 hours (ΔMPV72h-adm predicts 28-day mortality in severe sepsis and/or septic shock.We prospectively enrolled 345 patients admitted to the emergency department (ED who received standardized resuscitation (early goal-directed therapy for severe sepsis and/or septic shock between November 2007 and December 2011. Changes in platelet indices, including ΔMPV72h-adm, were compared between survivors and non-survivors by linear mixed model analysis. The prognostic value of ΔMPV72h-adm for 28-day mortality was ascertained by Cox proportional hazards model analysis.Thirty-five (10.1% patients died within 28 days after ED admission. MPV increased significantly during the first 72 hours in non-survivors (P = 0.001 and survivors (P < 0.001; however, the rate of MPV increase was significantly higher in non-survivors (P = 0.003. Nonetheless, the difference in the platelet decline rate over the first 72 hours did not differ significantly between groups (P = 0.360. In multivariate analysis, ΔMPV72h-adm was an independent predictor of 28-day mortality, after adjusting for plausible confounders (hazard ratio, 1.44; 95% confidence interval, 1.01-2.06; P = 0.044.An increase in MPV during the first 72 hours of hospitalization is an independent risk factor for adverse clinical outcomes. Therefore, continuous monitoring of MPV may be useful to stratify mortality risk in patients with severe sepsis and/or septic shock.

  15. Development and validation of a clinical prediction rule for candidemia in hospitalized patients with severe sepsis and septic shock.

    Science.gov (United States)

    Guillamet, Cristina Vazquez; Vazquez, Rodrigo; Micek, Scott T; Ursu, Oleg; Kollef, Marin

    2015-08-01

    To develop and internally validate a prediction rule for the presence of candidemia in patients with severe sepsis and septic shock (candidemia rule) that will fill the gap left by previous rules. To compare the accuracy of the available Candida prediction models. Retrospective cohort study. Barnes-Jewish Hospital, St. Louis, Missouri. Two thousand five hundred ninety-seven consecutive patients with a positive blood culture and severe sepsis or septic shock. Logistic regression and a bootstrap resampling procedure were employed for model development and internal validation. Two hundred sixty-six (10.2%) had blood cultures positive for Candida spp. Mortality was significantly higher in patients with candidemia than in patients with bacteremia (47.0% versus 28.4%; Pcandidemia while the lung as a source for infection was protective. The prediction rule had an area under the receiver operating characteristic curve of 0.798 (95% CI 0.77-0.82). Internal validation using bootstrapping technique with 1000 repetitions produced a similar area under the receiver operating characteristic curve of 0.797 (bias, -0.037; root mean square error 0.039). Our prediction rule outperformed previous rules with a better calibration slope of 0.96 and Brier score of 0.08. We developed and internally validated a prediction rule for candidemia in hospitalized patients with severe sepsis and septic shock that outperformed previous prediction rules. Our study suggests that locally derived prediction models may be superior by accounting for local case mix and risk factor distribution. Copyright © 2015 Elsevier Inc. All rights reserved.

  16. Population pharmacokinetics of piperacillin in the early phase of septic shock: does standard dosing result in therapeutic plasma concentrations?

    Science.gov (United States)

    Öbrink-Hansen, Kristina; Juul, Rasmus Vestergaard; Storgaard, Merete; Thomsen, Marianne Kragh; Hardlei, Tore Forsingdal; Brock, Birgitte; Kreilgaard, Mads; Gjedsted, Jakob

    2015-11-01

    Antibiotic dosing in septic shock patients poses a challenge for clinicians due to the pharmacokinetic (PK) variability seen in this patient population. Piperacillin-tazobactam is often used for empirical treatment, and initial appropriate dosing is crucial for reducing mortality. Accordingly, we determined the pharmacokinetic profile of piperacillin (4 g) every 8 h, during the third consecutive dosing interval, in 15 patients treated empirically for septic shock. We developed a population pharmacokinetic model to assess empirical dosing and to simulate alternative dosing regimens and modes of administration. Time above the MIC (T>MIC) predicted for each patient was evaluated against clinical breakpoint MIC for Pseudomonas aeruginosa (16 mg/liter). Pharmacokinetic-pharmacodynamic (PK/PD) targets evaluated were 50% fT>4×MIC and 100% fT>MIC. A population PK model was developed using NONMEM, and data were best described by a two-compartment model. Central and intercompartmental clearances were 3.6 liters/h (relative standard error [RSE], 15.7%) and 6.58 liters/h (RSE, 16.4%), respectively, and central and peripheral volumes were 7.3 liters (RSE, 11.8%) and 3.9 liters (RSE, 9.7%), respectively. Piperacillin plasma concentrations varied considerably between patients and were associated with levels of plasma creatinine. Patients with impaired renal function were more likely to achieve predefined PK/PD targets than were patients with preserved or augmented renal function. Simulations of alternative dosing regimens showed that frequent intermittent bolus dosing as well as dosing by extended and continuous infusion increases the probability of attaining therapeutic plasma concentrations. For septic shock patients with preserved or augmented renal function, dose increment or prolonged infusion of the drug needs to be considered. (This study has been registered at ClinicalTrials.gov under registration no. NCT02306928.). Copyright © 2015, American Society for Microbiology

  17. An increase in mean platelet volume from baseline is associated with mortality in patients with severe sepsis or septic shock.

    Science.gov (United States)

    Kim, Chan Ho; Kim, Seung Jun; Lee, Mi Jung; Kwon, Young Eun; Kim, Yung Ly; Park, Kyoung Sook; Ryu, Han Jak; Park, Jung Tak; Han, Seung Hyeok; Yoo, Tae-Hyun; Kang, Shin-Wook; Oh, Hyung Jung

    2015-01-01

    Mean platelet volume (MPV) is suggested as an index of inflammation, disease activity, and anti-inflammatory treatment efficacy in chronic inflammatory disorders; however, the effect of MPV on sepsis mortality remains unclear. Therefore, we investigated whether the change in MPV between hospital admission and 72 hours (ΔMPV72h-adm) predicts 28-day mortality in severe sepsis and/or septic shock. We prospectively enrolled 345 patients admitted to the emergency department (ED) who received standardized resuscitation (early goal-directed therapy) for severe sepsis and/or septic shock between November 2007 and December 2011. Changes in platelet indices, including ΔMPV72h-adm, were compared between survivors and non-survivors by linear mixed model analysis. The prognostic value of ΔMPV72h-adm for 28-day mortality was ascertained by Cox proportional hazards model analysis. Thirty-five (10.1%) patients died within 28 days after ED admission. MPV increased significantly during the first 72 hours in non-survivors (P = 0.001) and survivors (P increase was significantly higher in non-survivors (P = 0.003). Nonetheless, the difference in the platelet decline rate over the first 72 hours did not differ significantly between groups (P = 0.360). In multivariate analysis, ΔMPV72h-adm was an independent predictor of 28-day mortality, after adjusting for plausible confounders (hazard ratio, 1.44; 95% confidence interval, 1.01-2.06; P = 0.044). An increase in MPV during the first 72 hours of hospitalization is an independent risk factor for adverse clinical outcomes. Therefore, continuous monitoring of MPV may be useful to stratify mortality risk in patients with severe sepsis and/or septic shock.

  18. Benefits of ethyl gallate versus norepinephrine in the treatment of cardiovascular collapse in Pseudomonas aeruginosa septic shock in dogs.

    Science.gov (United States)

    Gotes, Jose; Kasian, Krika; Jacobs, Hans; Cheng, Zhao-Qin; Mink, Steven N

    2012-02-01

    Vasopressor therapy is required in septic shock to maintain tissue perfusion in the face of hypotension. Unfortunately, there are significant side effects of current vasopressors, and newer agents need to be developed. We recently discovered that ethyl gallate, a nonflavonoid phenolic antioxidant found in food substances, could reverse low mean arterial pressure found in an experimental model of septic shock due to inhibition of hydrogen peroxide signaling. In the present study, we compared the hemodynamic and biochemical effects of ethyl gallate vs. those of the commonly used vasopressor, norepinephrine, in a bacteremic canine model of Pseudomonas aeruginosa sepsis in two protocols. We performed these studies in anesthetized and mechanically ventilated dogs. In the early treatment protocol, we infused P. aeruginosa until mean arterial pressure first decreased to ∼60 mm Hg (about 2-3 hrs), after which we stopped the infusion and randomly administered ethyl gallate or norepinephrine in respective groups. In the late treatment protocol, we administered ethyl gallate or norepinephrine after a sustained ∼5-hr decrease in mean arterial pressure to 60 mm Hg and continued the infusion for the duration of the experiment. We followed parameters for over 10 hrs after the initiation of P. aeruginosa in both groups. We measured stroke work, urine output, serum creatinine, among other parameters, and used serum troponin T as an index of myocardial injury. We found that in both protocols, ethyl gallate and norepinephrine improved mean arterial pressure and stroke work to similar extents over the duration of the study. Particularly in the late treatment protocol, ethyl gallate resulted in a lower heart rate, a lower troponin T, and a greater urine output as compared with norepinephrine (p < .05). These results suggest that phenolic antioxidants, such as ethyl gallate, that inhibit hydrogen peroxide signaling, may represent an alternative class of vasopressors for use in

  19. The Impact of Timing of Antibiotics on Outcomes in Severe Sepsis and Septic Shock: A Systematic Review and Meta-analysis

    Science.gov (United States)

    Sterling, Sarah A.; Miller, W. Ryan; Pryor, Jason; Puskarich, Michael A.; Jones, Alan E.

    2015-01-01

    Objectives We sought to systematically review and meta-analyze the available data on the association between timing of antibiotic administration and mortality in severe sepsis and septic shock. Data Sources and Study Selection A comprehensive search was performed using a pre-defined protocol. Inclusion criteria: adult patients with severe sepsis or septic shock, reported time to antibiotic administration in relation to ED triage and/or shock recognition, and mortality. Exclusion criteria: immunosuppressed populations, review article, editorial, or non-human studies. Data Extraction Two reviewers screened abstracts with a third reviewer arbitrating. The effect of time to antibiotic administration on mortality was based on current guideline recommendations: 1) administration within 3 hours of ED triage; 2) administration within 1 hour of severe sepsis/septic shock recognition. Odds Ratios (OR) were calculated using a random effect model. The primary outcome was mortality. Data Synthesis 1123 publications were identified and 11 were included in the analysis. Among the 11 included studies, 16,178 patients were evaluable for antibiotic administration from ED triage. Patients who received antibiotics more than 3 hours after ED triage (antibiotic administration from severe sepsis/septic shock recognition. Patients who received antibiotics more than 1 hour after severe sepsis/shock recognition (5 hours in antibiotic administration from severe sepsis/shock recognition. Conclusion Using the available pooled data we found no significant mortality benefit of administering antibiotics within 3 hours of ED triage or within 1 hour of shock recognition in severe sepsis and septic shock. These results suggest that currently recommended timing metrics as measures of quality of care are not supported by the available evidence. PMID:26121073

  20. Determinants of functional status among survivors of severe sepsis and septic shock: One-year follow-up

    Directory of Open Access Journals (Sweden)

    Mustafa S Al Khalaf

    2015-01-01

    Full Text Available RATIONALE: Sepsis is a leading cause of intensive care unit (ICU admissions worldwide and a major cause of morbidity and mortality. Limited data exist regarding the outcomes and functional status among survivors of severe sepsis and septic shock. OBJECTIVES: This study aimed to determine the functional status among survivors of severe sepsis and septic shock a year after hospital discharge. METHODS: Adult patients admitted between April 2007 and March 2010 to the medical-surgical ICU of a tertiary hospital in Saudi Arabia, were included in this study. The ICU database was investigated for patients with a diagnosis of severe sepsis or septic shock. Survival status was determined based on hospital discharge. Patients who required re-admission, stayed in ICU for less than 24 hours, had incomplete data were all excluded. Survivors were interviewed through phone calls to determine their functional status one-year post-hospital discharge using Karnofsky performance status scale. RESULTS: A total of 209 patients met the eligibility criteria. We found that 38 (18.1% patients had severe disability before admission, whereas 109 (52.2% patients were with severe disability or died one-year post-hospital discharge. Only one-third of the survivors had good functional status one-year post-discharge (no/mild disability. After adjustment of baseline variables, age [adjusted odds ratio (aOR = 1.03, 95% confidence interval (CI = 1.01-1.04] and pre-sepsis functional status of severe disability (aOR = 50.9, 95% CI = 6.82-379.3 were found to be independent predictors of functional status of severe disability one-year post-hospital discharge among survivors. CONCLUSIONS: We found that only one-third of the survivors of severe sepsis and septic shock had good functional status one-year post-discharge (no/mild disability. Age and pre-sepsis severe disability were the factors that highly predicted the level of functional status one-year post-hospital discharge.

  1. An Emergency Department Validation of the SEP-3 Sepsis and Septic Shock Definitions and Comparison With 1992 Consensus Definitions.

    Science.gov (United States)

    Henning, Daniel J; Puskarich, Michael A; Self, Wesley H; Howell, Michael D; Donnino, Michael W; Yealy, Donald M; Jones, Alan E; Shapiro, Nathan I

    2017-10-01

    The Third International Consensus Definitions Task Force (SEP-3) proposed revised criteria defining sepsis and septic shock. We seek to evaluate the performance of the SEP-3 definitions for prediction of inhospital mortality in an emergency department (ED) population and compare the performance of the SEP-3 definitions to that of the previous definitions. This was a secondary analysis of 3 prospectively collected, observational cohorts of infected ED subjects aged 18 years or older. The primary outcome was all-cause inhospital mortality. In accordance with the SEP-3 definitions, we calculated test characteristics of sepsis (quick Sequential Organ Failure Assessment [qSOFA] score ≥2) and septic shock (vasopressor dependence plus lactate level >2.0 mmol/L) for mortality and compared them to the original 1992 consensus definitions. We identified 7,754 ED patients with suspected infection overall; 117 had no documented mental status evaluation, leaving 7,637 patients included in the analysis. The mortality rate for the overall population was 4.4% (95% confidence interval [CI] 3.9% to 4.9%). The mortality rate for patients with qSOFA score greater than or equal to 2 was 14.2% (95% CI 12.2% to 16.2%), with a sensitivity of 52% (95% CI 46% to 57%) and specificity of 86% (95% CI 85% to 87%) to predict mortality. The original systemic inflammatory response syndrome-based 1992 consensus sepsis definition had a 6.8% (95% CI 6.0% to 7.7%) mortality rate, sensitivity of 83% (95% CI 79% to 87%), and specificity of 50% (95% CI 49% to 51%). The SEP-3 septic shock mortality was 23% (95% CI 16% to 30%), with a sensitivity of 12% (95% CI 11% to 13%) and specificity of 98.4% (95% CI 98.1% to 98.7%). The original 1992 septic shock definition had a 22% (95% CI 17% to 27%) mortality rate, sensitivity of 23% (95% CI 18% to 28%), and specificity of 96.6% (95% CI 96.2% to 97.0%). Both the new SEP-3 and original sepsis definitions stratify ED patients at risk for mortality, albeit with

  2. High dosage of dextran 70 is associated with severe bleeding in patients admitted to the intensive care unit for septic shock

    DEFF Research Database (Denmark)

    Hvidt, Lisa Nebelin; Perner, Anders

    2012-01-01

    Synthetic colloids are frequently used in fluid resuscitation of septic patients. Despite this, little is known about the potential side effects including the risk of renal failure and bleeding. As practice has changed, we performed a before-and-after study of fluid resuscitation and outcome in p...... in patients with septic shock.......Synthetic colloids are frequently used in fluid resuscitation of septic patients. Despite this, little is known about the potential side effects including the risk of renal failure and bleeding. As practice has changed, we performed a before-and-after study of fluid resuscitation and outcome...

  3. Increased Neutrophil Gelatinase-Associated Lipocalin is Associated with Mortality and Multiple Organ Dysfunction Syndrome in Severe Sepsis and Septic Shock.

    Science.gov (United States)

    Wang, Biao; Chen, Gang; Zhang, Jun; Xue, Jiping; Cao, Yifei; Wu, Yunfu

    2015-09-01

    This study examines the clinical utility of increased neutrophil gelatinase-associated lipocalin (NGAL) as an indicator of mortality and multiple organ dysfunction syndrome (MODS) in severe sepsis and septic shock. We designed a prospective cohort study in an intensive care unit, and 123 patients with severe sepsis or septic shock were included. Data were used to determine a relationship between NGAL and the development of MODS and mortality. These associations were determined by the Mann-Whitney U test, log-rank test, Cox proportional hazards regression analyses, and plotting the receiver operating characteristic curve. Patients with high NGAL (75th percentile) had increased risk of mortality and MODS compared with patients with low NGAL (log-rank test, P septic shock.

  4. Comparison of procalcitonin and high-sensitivity C-reactive protein for the diagnosis of sepsis and septic shock in the oldest old patients.

    Science.gov (United States)

    Zhang, Hongmin; Wang, Xiaoting; Zhang, Qing; Xia, Ying; Liu, Dawei

    2017-08-01

    Although the role of serum procalcitonin (PCT) and high-sensitivity C-reactive protein (hs-CRP) in the diagnosis of sepsis and septic shock is well studied, it has not been investigated among oldest old patients. The aim of our study is to determine the role of PCT and hs-CRP in the assessment of sepsis and septic shock in this specific group of patients in the ICU. This is a prospective observational study. Patients >85 years of age admitted to the ICU from May 1st, 2016 to February 1st, 2017 were evaluated. Patients were divided into a sepsis and septic shock group(sepsis/SS) and a non-sepsis group. Serum levels of PCT, hs-CRP and the WBC were measured within 12 h of admission. A total of 70 patients aged 85 years and older were enrolled in this study. Fifty patients were labelled as sepsis/SS and the other 20 were labelled non-sepsis. A ROC analysis showed that the area under the curves (AUC) of hs-CRP and PCT for the discrimination of sepsis/SS patients were 0.825 (95% confidence interval[CI]: 0.73-0.92; P sepsis/SS group, 27 patients had sepsis, while the other 23 patients had septic shock. The ROC analysis showed that the AUCs of hs-CRP and PCT for the discrimination of septic shock patients from sepsis patients were 0.751 (95% CI: 0.62-0.88; P = 0.002) and 0.719 (95% CI:0.57-0.86; p = 0.007), respectively. For the oldest old patients, hs-CRP is not inferior to PCT in the diagnosis of sepsis and septic shock.

  5. The effect of fluid therapy on hemodynamic and venous blood gas parameters in patients with septic shock

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    Sahar Mirbaha

    2016-11-01

    Full Text Available Background: Hemodynamics and venous blood gas (VBG may be used to guide fluid therapy in septic shock patients. However, the influence of fluid therapy on hemodynamic and blood gas parameters is not fully understood. In this study, we aimed to investigate the effect of fluid therapy on hemodynamic and VBG parameters. Methods: This cross-sectional study was conducted from January to April 2016. All patients with diagnosis of severe sepsis were enrolled in the study. Systolic blood pressure (SBP, diastolic blood pressure (DBP, mean arterial pressure (MAP, central venous pressure (CVP shock index, VBG parameters, serum sodium (Na and chloride (Cl levels, anion gap, and oxygen saturation (O2sat were assessed before fluid resuscitation, after resuscitation, and after fluid challenge test. Results: A total of 100 patients were included (mean age were 72.54 ± 12.77 years, 66% male. Fluid therapy significantly increased DBP (df: 2; F= 4.17; p = 0.017, MAP (df: 2; F= 6.06; p= 0.003, and CVP (df: 2; F= 27.54; p < 0.001, while the shock index was significantly reduced After fluid challenge test (df: 2; F= 7.6; p= 0.001. In addition, fluid therapy had no effect on pH (p= 0.90, HCO3 (p= 0.23, base excess (p= 0.13, SCVO2 (p= 0.73, O2sat (p= 0.73, anion gap (p= 0.96, serum Na level (p= 0.71, and serum Cl level (p= 0.64. Conclusion: Administration of fluid therapy in septic shock patients had no significant effect on SBP, heart rate, or blood gas parameters. Future studies on a larger sample of patients should confirm these findings and correlate them to clinical outcomes.

  6. Serum Procalcitonin and Procalcitonin Clearance as a Prognostic Biomarker in Patients with Severe Sepsis and Septic Shock

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    Min-Yi Huang

    2016-01-01

    Full Text Available We evaluated the tendency of the plasma concentration and procalcitonin (PCT clearance (PCTc to act as biomarkers of prognosis in patients with severe sepsis and septic shock. From 2011 to 2013, we prospectively analyzed patients with sepsis admitted to the intensive care unit (ICU. The serum PCT was evaluated at the time of sepsis diagnosis and again after 48 h (day 3 and 96 h (day 5. PCTc after 48 h (PCTc-day 3 and 96 h (PCTc-day 5 was also calculated to evaluate the prognostic value for survival in patients with sepsis. A total of 48 patients were included. Overall mortality was 16.7% (8 patients. PCTc was higher in survivors than in nonsurvivors, with significant differences on day 3 and day 5 (p=0.033; p=0.002, resp.; however, serum PCT levels on day 1, day 3, and day 5 were not significant prognostic factors for survival. The prognosis of patients with severe sepsis and septic shock may be associated with PCTc. Dynamic changes of PCT reflected as PCTc at 48 h (day 3 and 96 h (day 5 after admission to the ICU may serve as a predictor of survival in critically ill patients with severe sepsis.

  7. Imbalances in serum angiopoietin concentrations are early predictors of septic shock development in patients with post chemotherapy febrile neutropenia

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    Lorand-Metze Irene

    2010-05-01

    Full Text Available Abstract Background Febrile neutropenia carries a high risk of sepsis complications, and the identification of biomarkers capable to identify high risk patients is a great challenge. Angiopoietins (Ang - are cytokines involved in the control microvascular permeability. It is accepted that Ang-1 expression maintains endothelial barrier integrity, and that Ang-2 acts as an antagonizing cytokine with barrier-disrupting functions in inflammatory situations. Ang-2 levels have been recently correlated with sepsis mortality in intensive care units. Methods We prospectively evaluated concentrations of Ang-1 and Ang-2 at different time-points during febrile neutropenia, and explored the diagnostic accuracy of these mediators as potential predictors of poor outcome in this clinical setting before the development of sepsis complications. Results Patients that evolved with septic shock (n = 10 presented higher levels of Ang-2 measured 48 hours after fever onset, and of the Ang-2/Ang-1 ratio at the time of fever onset compared to patients with non-complicated sepsis (n = 31. These levels correlated with sepsis severity scores. Conclusions Our data suggest that imbalances in the concentrations of Ang-1 and Ang-2 are independent and early markers of the risk of developing septic shock and of sepsis mortality in febrile neutropenia, and larger studies are warranted to validate their clinical usefulness. Therapeutic strategies that manipulate this Ang-2/Ang-1 imbalance can potentially offer new and promising treatments for sepsis in febrile neutropenia.

  8. Comparison of severity of illness scoring systems in the prediction of hospital mortality in severe sepsis and septic shock

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    Crowe Colleen

    2010-01-01

    Full Text Available Background : New scoring systems, including the Rapid Emergency Medicine Score (REMS, the Mortality in Emergency Department Sepsis (MEDS score, and the confusion, urea nitrogen, respiratory rate, blood pressure, 65 years and older (CURB-65 score, have been developed for emergency department (ED use in various patient populations. Increasing use of early goal directed therapy (EGDT for the emergent treatment of sepsis introduces a growing population of patients in which the accuracy of these scoring systems has not been widely examined. Objectives : To evaluate the ability of the REMS, MEDS score, and CURB-65 score to predict mortality in septic patients treated with modified EGDT. Materials and Methods : Secondary analysis of data from prospectively identified patients treated with modified EGDT in a large tertiary care suburban community hospital with over 85,000 ED visits annually and 700 inpatient beds, from May 2007 through May 2008. We included all patients with severe sepsis or septic shock, who were treated with our modified EGDT protocol. Our major outcome was in-hospital mortality. The performance of the scores was compared by area under the ROC curves (AUCs. Results : A total of 216 patients with severe sepsis or septic shock were treated with modified EGDT during the study period. Overall mortality was 32.9%. Calculated AUCs were 0.74 [95% confidence interval (CI: 0.67-0.81] for the MEDS score, 0.62 (95% CI: 0.54-0.69 for the REMS, and 0.59 (95% CI: 0.51-0.67 for the CURB-65 score. Conclusion : We found that all three ED-based systems for scoring severity of illness had low to moderate predictive capability. The MEDS score demonstrated the largest AUC of the studied scoring systems for the outcome of mortality, although the CIs on point estimates of the AUC of the REMS and CURB-65 scores all overlap.

  9. Central venous oxygen saturation for the diagnosis of low cardiac output in septic shock patients

    DEFF Research Database (Denmark)

    Perner, A; Haase, N; Wiis, J

    2010-01-01

    Simple diagnostic tests are needed to screen septic patients for low cardiac output because intervention is recommended in these patients. We assessed the diagnostic value of central venous oxygen saturation in the superior vena cava (ScvO(2)) for detecting low cardiac output in patients with sep......Simple diagnostic tests are needed to screen septic patients for low cardiac output because intervention is recommended in these patients. We assessed the diagnostic value of central venous oxygen saturation in the superior vena cava (ScvO(2)) for detecting low cardiac output in patients...

  10. Hemodynamic management of septic shock: is it time for "individualized goal-directed hemodynamic therapy" and for specifically targeting the microcirculation?

    Science.gov (United States)

    Saugel, Bernd; Trepte, Constantin J; Heckel, Kai; Wagner, Julia Y; Reuter, Daniel A

    2015-06-01

    Septic shock is a life-threatening condition in both critically ill medical patients and surgical patients during the perioperative phase. In septic shock, specific alterations in global cardiovascular dynamics (i.e., the macrocirculation) and in the microcirculatory blood flow (i.e., the microcirculation) have been described. However, the presence and degree of microcirculatory failure are in part independent from systemic macrohemodynamic variables. Macrocirculatory and microcirculatory failure can independently induce organ dysfunction. We review current diagnostic and therapeutic approaches for the assessment and optimization of both the macrocirculation and the microcirculation in septic shock. There are various technologies for the determination of macrocirculatory hemodynamic variables. We discuss the data on early goal-directed therapy for the resuscitation of the macrocirculation. In addition, we describe the concept of "individualized goal-directed hemodynamic therapy." Technologies to assess the local microcirculation are also available. However, adequate resuscitation goals for the optimization of the microcirculation still need to be defined. At present, we are not ready to specifically monitor and target the microcirculation in clinical routine outside studies. In the future, concepts for an integrative approach for individualized hemodynamic management of the macrocirculation and in parallel the microcirculation might constitute a huge opportunity to define additional resuscitation end points in septic shock.

  11. Metabolic and Neurologic Sequelae in a Patient with Long-Standing Anorexia Nervosa Who Presented with Septic Shock and Deep Hypoglycemia

    NARCIS (Netherlands)

    de Jager, Corine M.; Hoekstra, Miriam; Nijsten, Maarten W. N.; Oude Lansink, Annemieke; Ismael, Farouq

    2011-01-01

    Objective: To report the case of a 48-year female with chronic remitting anorexia nervosa who was found comatose at home and admitted to our hospital with a deep hypoglycemia (glucose level 0.6 mmol/L; 11 mg/dL) and septic shock secondary to a bilateral pneumonia. Method: Case report. Results: After

  12. The effect of sepsis and septic shock on the viscoelastic properties of clot quality and mass using rotational thromboelastometry: A prospective observational study.

    Science.gov (United States)

    Davies, Gareth R; Lawrence, Matthew; Pillai, Suresh; Mills, Gavin M; Aubrey, Robert; Thomas, Dafydd; Williams, Rhodri; Morris, Keith; Evans, Phillip Adrian

    2018-04-01

    The study purpose was to define changes in coagulation across the sepsis spectrum using rotational thromboelastometry (ROTEM). Sepsis patients were recruited on admission to the Emergency Department and Intensive Care Units of a large teaching hospital in Wales. ROTEM markers of clot development and fibrinolysis were determined, as well as standard coagulation markers. A healthy control group matched for age and gender was also recruited (n=44). 100 patients were recruited (50 sepsis, 20 severe sepsis and 30 septic shock). Maximum clot firmness was significantly higher in the sepsis (p<0.001) and severe sepsis (p=0.012) groups than the healthy control (71.6±4.5 and 70.4±4.1 vs 64.4 respectively). In septic shock there was prolonged clot development; however, maximum clot firmness remained normal. Fibrinolytic function was significantly impaired in septic shock, which was also significantly associated with 28-day mortality (p<0.001). ROTEM indicated significantly enhanced clot structural development in sepsis and severe sepsis, which could be indicative of a hypercoagulable phase. In septic shock, despite there being a prolongation of clotting pathways and impaired fibrinolysis, clot mass was comparably normal, suggestive of the development of a clot with healthy characteristics. Copyright © 2017 Elsevier Inc. All rights reserved.

  13. Selepressin, a novel selective vasopressin V1A agonist, is an effective substitute for norepinephrine in a phase IIa randomized, placebo-controlled trial in septic shock patients

    DEFF Research Database (Denmark)

    Russell, James A; Vincent, Jean-Louis; Kjølbye, Anne Louise

    2017-01-01

    BACKGROUND: Vasopressin is widely used for vasopressor support in septic shock patients, but experimental evidence suggests that selective V1A agonists are superior. The initial pharmacodynamic effects, pharmacokinetics, and safety of selepressin, a novel V1A-selective vasopressin analogue, was e...

  14. Vitamin D deficiency at admission is not associated with 90-day mortality in patients with severe sepsis or septic shock: Observational FINNAKI cohort study.

    Science.gov (United States)

    Ala-Kokko, Tero I; Mutt, Shivaprakash J; Nisula, Sara; Koskenkari, Juha; Liisanantti, Janne; Ohtonen, Pasi; Poukkanen, Meri; Laurila, Jouko J; Pettilä, Ville; Herzig, Karl-Heinz

    2016-01-01

    Introduction Low levels of vitamin D have been associated with increased mortality in patients that are critically ill. This study explored whether vitamin D levels were associated with 90-day mortality in severe sepsis or septic shock. Methods Plasma vitamin D levels were measured on admission to the intensive care unit (ICU) in a prospective multicentre observational study. Results 610 patients with severe sepsis were included; of these, 178 (29%) had septic shock. Vitamin D deficiency ( 0.9; and <25 nmol/L: HR 0.44 (95% CI: 0.22-0.87), p = 0.018). Conclusions Vitamin D deficiency detected upon ICU admission was not associated with 90-day mortality in patients with severe sepsis or septic shock. Key messages In severe sepsis and septic shock, a vitamin D deficiency upon ICU admission was not associated with increased mortality. Compared to patients with sufficient vitamin D, patients with deficient vitamin D more frequently exhibited diabetes, elevated C-reactive protein levels, and hospital-acquired infections upon ICU admission, and they more frequently developed acute kidney injury.

  15. Temporizing surgical management improves outcome in patients with Vibrio necrotizing fasciitis complicated with septic shock on admission.

    Science.gov (United States)

    Hong, Guang-Liang; Dai, Xiao-Qin; Lu, Cai-Jiao; Liu, Jia-Ming; Zhao, Guang-Ju; Wu, Bin; Li, Meng-Fang; Lu, Zhong-Qiu

    2014-05-01

    Necrotizing fasciitis (NF) caused by Vibrio infection is one of the most fatal diseases, resulting in high morbidity and mortality. Early diagnosis and effective surgical intervention are the mainstays for better outcomes for affected patients. Currently, standard surgical management calls for prompt and aggressive debridement and amputation. However, due to its rapid progression and deterioration, 50-60% of Vibrio NF cases present with septic shock and multiple organ dysfunction on admission. These patients, who usually have many surgical contraindications, are unable to tolerate a prolonged aggressive surgical debridement. Therefore, determining the optimal surgical intervention for these particularly severe patients remains a formidable problem in emergency medicine. A retrospective study was conducted on patients who underwent surgery for Vibrio NF and septic shock on admission to the emergency room from April 2001 to October 2012. These patients received the same treatment protocol, with the exception of the initial surgical intervention strategy. Nineteen patients were treated with a temporizing strategy, which called for simple incisions and drainage under regional anesthesia, followed by complete debridement 24h later. Another fifteen patients underwent aggressive surgical debridement during the first operative procedure. Basic demographics, laboratory results on admission, clinical course and outcomes were compared to assess the efficacy and safety of two initial surgical treatment methods: the temporizing strategy and the aggressive strategy. Thirty-four patients were included in this study, and the average age was 51.65 years. Chronic liver disease was the most prevalent preexisting condition (50.00%) and the lower limbs were most commonly involved in infection (76.47%). In this patient population, 19 cases underwent surgery with a temporizing therapeutic strategy, while the remaining 15 cases were treated with an aggressive surgical strategy. There were

  16. The accuracy of pulse oximetry in emergency department patients with severe sepsis and septic shock: a retrospective cohort study

    Directory of Open Access Journals (Sweden)

    Lord Jason A

    2010-05-01

    Full Text Available Abstract Background Pulse oximetry is routinely used to continuously and noninvasively monitor arterial oxygen saturation (SaO2 in critically ill patients. Although pulse oximeter oxygen saturation (SpO2 has been studied in several patient populations, including the critically ill, its accuracy has never been studied in emergency department (ED patients with severe sepsis and septic shock. Sepsis results in characteristic microcirculatory derangements that could theoretically affect pulse oximeter accuracy. The purposes of the present study were twofold: 1 to determine the accuracy of pulse oximetry relative to SaO2 obtained from ABG in ED patients with severe sepsis and septic shock, and 2 to assess the impact of specific physiologic factors on this accuracy. Methods This analysis consisted of a retrospective cohort of 88 consecutive ED patients with severe sepsis who had a simultaneous arterial blood gas and an SpO2 value recorded. Adult ICU patients that were admitted from any Calgary Health Region adult ED with a pre-specified, sepsis-related admission diagnosis between October 1, 2005 and September 30, 2006, were identified. Accuracy (SpO2 - SaO2 was analyzed by the method of Bland and Altman. The effects of hypoxemia, acidosis, hyperlactatemia, anemia, and the use of vasoactive drugs on bias were determined. Results The cohort consisted of 88 subjects, with a mean age of 57 years (19 - 89. The mean difference (SpO2 - SaO2 was 2.75% and the standard deviation of the differences was 3.1%. Subgroup analysis demonstrated that hypoxemia (SaO2 2 was in the 90-93% range the SaO2 was Conclusions Pulse oximetry overestimates ABG-determined SaO2 by a mean of 2.75% in emergency department patients with severe sepsis and septic shock. This overestimation is exacerbated by the presence of hypoxemia. When SaO2 needs to be determined with a high degree of accuracy arterial blood gases are recommended.

  17. Anti-inflammatory effect of a Nuphar lutea partially purified leaf extract in murine models of septic shock.

    Science.gov (United States)

    Ozer, J; Levi, T; Golan-Goldhirsh, A; Gopas, J

    2015-02-23

    Various plant organs of Nuphar lutea (L.) SM. (Nymphaeaceae) are used in traditional medicine for the treatment of arthritis, fever, aches, pains and inflammation. The main purpose of this study was to determine the anti-inflammatory effect of Nuphar lutea leaf extract (NUP) in two septic shock models: (1) Survival of mice challenged with a lethal dose of LPS, determination of pro-inflammatory and anti-inflammatory cytokines in serum, as well as in peritoneal macrophages in cell culture. (2) The effect of NUP in a murine model of fecal-induced peritonitis. NUP pre-treatment partially protected mice in two models of acute septic shock. We concluded that NUP is anti-inflammatory by inhibiting the NF-κB pathway, modulating cytokine production and ERK phosphorylation. A significant average survival rate (60%) of LPS lethally-challenged mice was achieved by pre-treatment with NUP. In addition, NUP pre-treatment reduced nuclear NF-κB translocation in peritoneal macrophages. The production of pro-inflammatory cytokines, TNF-α, IL-6 and IL-12, in the sera of LPS-treated mice or in the supernatants of peritoneal macrophages stimulated with LPS for 2-6 h was also decreased by NUP. Pre-treatment with NUP caused a significant increase in the anti-inflammatory cytokine IL-10. The NUP pre-treatment reduced and delayed mortality in mice with fecal-induced peritonitis. Our studies also revealed that NUP pre-treatment induced a dose-dependent phosphorylation of ERK in peritoneal macrophages. Since most of the reports about the anti-inflammatory effect of Nuphar lutea refer to rhizome and root powder and extracts, it is important to clarify the effectiveness of leaf extract as a source for such activity. NUP pre-treatment partially protected mice in two models of acute septic shock. We concluded that NUP is anti-inflammatory by inhibiting the NF-κB pathway, modulating cytokine production and ERK phosphorylation. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

  18. An increase in red blood cell distribution width from baseline predicts mortality in patients with severe sepsis or septic shock.

    Science.gov (United States)

    Kim, Chan Ho; Park, Jung Tak; Kim, Eun Jin; Han, Jae Hyun; Han, Ji Suk; Choi, Jun Yong; Han, Seung Hyeok; Yoo, Tae-Hyun; Kim, Young Sam; Kang, Shin-Wook; Oh, Hyung Jung

    2013-12-09

    A potential independent association was recently demonstrated between high red blood cell distribution width (RDW) and the risk of all-cause mortality in critically ill patients, although the mechanism underlying this relationship remains unclear. Little is known about the impact changes in RDW may have on survival in critically ill patients. Therefore, we investigated the prognostic significance of changes in RDW during hospital stay in patients with severe sepsis or septic shock. We prospectively enrolled 329 patients who were admitted to the emergency department (ED) and received a standardized resuscitation algorithm (early-goal directed therapy) for severe sepsis or septic shock. The relationship between the changes in RDW during the first 72 hours after ED admission and all-cause mortality (28-day and 90-day) were analyzed by categorizing the patients into four groups according to baseline RDW value and ΔRDW72hr-adm (RDW at 72 hours - RDW at baseline). The 28-day and 90-day mortality rates were 10% and 14.6%, respectively. Patients with increased RDW at baseline and ΔRDW72hr-adm >0.2% exhibited the highest risks of 28-day and 90-day mortality, whereas the patients with normal RDW level at baseline and ΔRDW72hr-adm ≤0.2% (the reference group) had the lowest mortality risks. For 90-day mortality, a significantly higher mortality risk was observed in the patients whose RDW increased within 72 hours of ED admission (normal RDW at baseline and ΔRDW72hr-adm >0.2%), compared to the reference group. These associations remained unaltered even after adjusting for age, sex, Sequential Organ Failure Assessment (SOFA) score, Charlson Comorbidity Index, renal replacement therapy, albumin, hemoglobin, lactate, C-reactive protein and infection sites in multivariable models. We found that an increase in RDW from baseline during the first 72 hours after hospitalization is significantly associated with adverse clinical outcomes. Therefore, a combination of baseline RDW

  19. Estimating Ten-Year Trends in Septic Shock Incidence and Mortality in United States Academic Medical Centers Using Clinical Data.

    Science.gov (United States)

    Kadri, Sameer S; Rhee, Chanu; Strich, Jeffrey R; Morales, Megan K; Hohmann, Samuel; Menchaca, Jonathan; Suffredini, Anthony F; Danner, Robert L; Klompas, Michael

    2017-02-01

    Reports that septic shock incidence is rising and mortality rates declining may be confounded by improving recognition of sepsis and changing coding practices. We compared trends in septic shock incidence and mortality in academic hospitals using clinical vs claims data. We identified all patients with concurrent blood cultures, antibiotics, and vasopressors for ≥ two consecutive days, and all patients with International Classification of Diseases, 9th edition (ICD-9) codes for septic shock, at 27 academic hospitals from 2005 to 2014. We compared annual incidence and mortality trends. We reviewed 967 records from three hospitals to estimate the accuracy of each method. Of 6.5 million adult hospitalizations, 99,312 (1.5%) were flagged by clinical criteria, 82,350 (1.3%) by ICD-9 codes, and 44,651 (0.7%) by both. Sensitivity for clinical criteria was higher than claims (74.8% vs 48.3%; P Septic shock incidence, based on clinical criteria, rose from 12.8 to 18.6 cases per 1,000 hospitalizations (average, 4.9% increase/y; 95% CI, 4.0%-5.9%), while mortality declined from 54.9% to 50.7% (average, 0.6% decline/y; 95% CI, 0.4%-0.8%). In contrast, septic shock incidence, based on ICD-9 codes, increased from 6.7 to 19.3 per 1,000 hospitalizations (19.8% increase/y; 95% CI, 16.6%-20.9%), while mortality decreased from 48.3% to 39.3% (1.2% decline/y; 95% CI, 0.9%-1.6%). A clinical surveillance definition based on concurrent vasopressors, blood cultures, and antibiotics accurately identifies septic shock hospitalizations and suggests that the incidence of patients receiving treatment for septic shock has risen and mortality rates have fallen, but less dramatically than estimated on the basis of ICD-9 codes. Copyright © 2016 American College of Chest Physicians. All rights reserved.

  20. Prevention of lymphocyte apoptosis in septic mice with cancer increases mortality.

    Science.gov (United States)

    Fox, Amy C; Breed, Elise R; Liang, Zhe; Clark, Andrew T; Zee-Cheng, Brendan R; Chang, Katherine C; Dominguez, Jessica A; Jung, Enjae; Dunne, W Michael; Burd, Eileen M; Farris, Alton B; Linehan, David C; Coopersmith, Craig M

    2011-08-15

    Lymphocyte apoptosis is thought to have a major role in the pathophysiology of sepsis. However, there is a disconnect between animal models of sepsis and patients with the disease, because the former use subjects that were healthy prior to the onset of infection while most patients have underlying comorbidities. The purpose of this study was to determine whether lymphocyte apoptosis prevention is effective in preventing mortality in septic mice with preexisting cancer. Mice with lymphocyte Bcl-2 overexpression (Bcl-2-Ig) and wild type (WT) mice were injected with a transplantable pancreatic adenocarcinoma cell line. Three weeks later, after development of palpable tumors, all animals received an intratracheal injection of Pseudomonas aeruginosa. Despite having decreased sepsis-induced T and B lymphocyte apoptosis, Bcl-2-Ig mice had markedly increased mortality compared with WT mice following P. aeruginosa pneumonia (85 versus 44% 7-d mortality; p = 0.004). The worsened survival in Bcl-2-Ig mice was associated with increases in Th1 cytokines TNF-α and IFN-γ in bronchoalveolar lavage fluid and decreased production of the Th2 cytokine IL-10 in stimulated splenocytes. There were no differences in tumor size or pulmonary pathology between Bcl-2-Ig and WT mice. To verify that the mortality difference was not specific to Bcl-2 overexpression, similar experiments were performed in Bim(-/-) mice. Septic Bim(-/-) mice with cancer also had increased mortality compared with septic WT mice with cancer. These data demonstrate that, despite overwhelming evidence that prevention of lymphocyte apoptosis is beneficial in septic hosts without comorbidities, the same strategy worsens survival in mice with cancer that are given pneumonia.

  1. Early outcome of early-goal directed therapy for patients with sepsis or septic shock: a systematic review and meta-analysis of randomized controlled trials.

    Science.gov (United States)

    Chen, Xiaofan; Zhu, Weifeng; Tan, Jing; Nie, Heyun; Liu, Liangming; Yan, Dongmei; Zhou, Xu; Sun, Xin

    2017-04-18

    Various trials and meta-analyses have reported conflicting results concerning the application of early goal-directed therapy (EGDT) for sepsis and septic shock. The aim of this study was to update the evidence by performing a systematic review and meta-analysis. Multiple databases were searched from initial through August, 2016 for randomized controlled trials (RCTs) which investigated the associations between the use of EGDT and mortality in patients with sepsis or septic shock. Meta-analysis was performed using random-effects model and heterogeneity was examined through subgroup analyses. The primary outcome of interest was patient all-cause mortality including hospital or ICU mortality. Seventeen RCTs including 6207 participants with 3234 in the EGDT group and 2973 in the control group were eligible for this study. Meta-analysis showed that EGDT did not significantly reduce hospital or intensive care unit (ICU) mortality (relative risk [RR] 0.89, 95% CI 0.78 to 1.02) compared with control group for patients with sepsis or septic shock. The findings of subgroup analyses stratified by study region, number of research center, year of enrollment, clinical setting, sample size, timing of EGDT almost remained constant with that of the primary analysis. Our findings provide evidence that EGDT offers neutral survival effects for patients with sepsis or septic shock. Further meta-analyses based on larger well-designed RCTs or individual patient data meta-analysis are required to explore the survival benefits of EDGT in patients with sepsis or septic shock.

  2. Mortality rate among patients with septic shock after implementation of 6-hour sepsis protocol in the emergency department of Thammasat University Hospital.

    Science.gov (United States)

    Apibunyopas, Yajai

    2014-08-01

    Septic shock is a major healthcare problem effecting people worldwide with high mortality rate. Administering early and appropriate interventions can help improve the outcome. The 6-hour bundle, launched by the Surviving Sepsis Campaign committee was part of efforts to incorporate evidence-based guideline to clinical practice. There were many reports on outcome improvement of septic shock patients after implementation of the 6-hour bundle at the emergency department. To compare mortality rate of septic shockpatients before and after implementing the 6-hour sepsis protocol at the emergency department of Thammasat University Hospital. Study was conducted at the emergency department of Thammasat University Hospital. This is an interrupted time, before and after study, comparing between the prospective cohort period after (Oct 2012 to Nov 2013) and the historical control period before (Feb 2011 to July 2012) implementation of 6-hour sepsis protocol. Primary outcome was hospital mortality of septic shock patients. Secondary outcomes included length of hospital stay and predictive factors for mortality ofseptic shock patients. There were 80patients included in the pre-intervention group and 75patients in the post-intervention group. There was significant improvement in management of septic shock patients. Totalfluid given in 2 hours in the post-intervention group was significantly higher[2,000 (500-3,000) vs. 1,600 (100-3,600);p = 0.038)] when compared with thepre-intervention group. The entire resuscitation bundles compliance rate was significantly increased in the post-intervention group (37.3% vs. 0%; pshock mortality was decreased after implementation of the 6-hour sepsis protocol at the emergency department of Thammasat University Hospital.

  3. Effective antibiotic treatment prescribed by emergency physicians in patients admitted to the intensive care unit with severe sepsis or septic shock: where is the gap?

    Science.gov (United States)

    Capp, Roberta; Chang, Yuchiao; Brown, David F M

    2011-12-01

    Antibiotic selection made within the first hour of recognition of severe sepsis and septic shock has been shown to decrease mortality. The purpose of this study was to determine what antibiotics are being prescribed and to identify factors influencing ineffective antibiotic coverage in patients with severe sepsis or septic shock. In addition, we explore an alternative method for antibiotic selection that could improve organism coverage. This was a retrospective review of emergency department (ED) patients admitted to an intensive care unit (ICU) over a 12-month period with a culture-positive diagnosis of either severe sepsis or septic shock. Appropriate antibiotic therapy was defined as effective coverage of the offending organism based on final culture results. Of the 1400 patients admitted to the ICU, 137 patients were culture positive and met the criteria for severe sepsis or septic shock. Effective antibiotic coverage was prescribed by emergency physicians in 82% (95% confidence interval [CI] .74-.88) of cases. Of the 25 patients who received ineffective antibiotics, the majority had infections caused by resistant Gram-negative organisms. Health care-associated pneumonia guidelines were applied to all patients, regardless of the source of infection, and were 100% sensitive (95% CI .93-1) for selecting patients who had infections caused by highly resistant organisms. Emergency physicians achieved 82% effective antibiotic coverage in patients with severe sepsis or septic shock. The gap seems to be in coverage of highly resistant Gram-negative organisms. An alternative approach to antibiotic prescription, utilizing a set of guidelines for community- and health care-associated infections, was found to be 100% sensitive in selecting patients who had infections caused by the more resistant organisms. Copyright © 2011 Elsevier Inc. All rights reserved.

  4. Procalcitonin as a diagnostic biomarker for septic shock and bloodstream infection in burn patients from the Formosa Fun Coast dust explosion

    Directory of Open Access Journals (Sweden)

    Rui-Xin Wu

    2017-12-01

    Full Text Available Background/Purpose: Infection is the most common cause of death following burn injury. The study was conducted to compare the diagnostic value of serum procalcitonin (PCT with the other current benchmarks as early predictors of septic shock and bloodstream infection in burn patients. Methods: We included 24 patients admitted to the Burn Unit of a medical center from June 2015 to December 2015 from the Formosa Fun Coast dust explosion. We categorized all patients at initial admission into either sepsis or septic shock groups. Laboratory tests including the worst PCT and C-reactive protein (CRP levels, platelet (PLT, and white blood cell (WBC count were performed at <48 h after admission. Patients were also classified in two groups with subsequent bacteremia and non-bacteremia groups during hospitalization. Results: Significantly higher PCT levels were observed among participants with septic shock compared to those with sepsis (47.19 vs. 1.18 ng/mL, respectively; p < 0.001. Patients with bacteremia had significantly elevated PCT levels compared to patients without bacteremia (29.54 versus 1.81 ng/mL, respectively, p < 0.05. No significant differences were found in CRP levels, PLT, and WBC count between the two groups. PCT levels showed reasonable discriminative power (cut-off: 5.12 ng/mL; p = 0.01 in predicting of bloodstream infection in burn patients and the area under receiver operating curves was 0.92. Conclusions: PCT levels can be helpful in determining the septic shock and bloodstream infection in burn patients but CRP levels, PLT, and WBC count were of little diagnostic value. Keywords: Procalcitonin, Septic shock, Bloodstream infection, Burn patient, Formosa fun coast dust explosion

  5. Early and innovative interventions for severe sepsis and septic shock: taking advantage of a window of opportunity

    Science.gov (United States)

    Rivers, Emanuel P.; McIntyre, Lauralyn; Morro, David C.; Rivers, Kandis K.

    2005-01-01

    The pathogenic, diagnostic and therapeutic landscape of sepsis is no longer confined to the intensive care unit: many patients from other portals of entry to care, both outside and within the hospital, progress to severe disease. Approaches that have led to improved outcomes with other diseases (e.g., acute myocardial infarction, stroke and trauma) can now be similarly applied to sepsis. Improved understanding of the pathogenesis of severe sepsis and septic shock has led to the development of new therapies that place importance on early identification and aggressive management. This review emphasizes approaches to the early recognition, diagnosis and therapeutic management of sepsis, giving the clinician the most contemporary and practical approaches with which to treat these patients. PMID:16247103

  6. [Esmolol improves clinical outcome and tissue oxygen metabolism in patients with septic shock through controlling heart rate].

    Science.gov (United States)

    Xinqiang, Liu; Weiping, Huang; Miaoyun, Wen; Wenxin, Zeng; Wenqiang, Jiang; Shenglong, Chen; Juhao, Zeng; Hongki, Zeng

    2015-09-01

    To investigate whether esmolol could improve clinical outcome and tissue oxygen metabolism by controlling heart rate (HR) in patients with septic shock. A single-center double-blinded randomized controlled trial was conducted. The patients suffering from septic shock received 6-hour early goal directed herapy (EGDT) with pulmonary artery wedge pressure ≥ 12 mmHg (1 mmHg = 0.133 kPa) or central venous pressure CVP) ≥ 12 mmHg requiring norepinephrine to maintain mean arterial pressure (MAP) ≥ 65 mmHg and HR ≥ 95 bpm admitted to intensive care unit (ICU) of Guangdong General Hospital from September 2013 to September 2014 were enrolled. They were randomly divided into esmolol group and control group by computer-based random number generator. All patients received conventional basic treatment, while those in the esmolol group received in addition persistent esmolol infusion by micro pump with dosage of 0.05 mg · kg(-1) · min(-1) with the dosage adjusted to maintain HR lower than 100 bpm within 24 hours. The patients in control group did not receive drug intervention for HR. The primary end-points consisted of length of stay in ICU and 28-day mortality. The secondary end-points included hemodynamic parameters [HR, MAP, CVP, cardiac index (CI), stroke volume index (SVI), systemic vascular resistance index (SVRI)] and tissue oxygen metabolism parameters [central venous oxygen saturation (ScvO2), lactate level (Lac)] before and 24, 48, 72 hours after the treatment. A total of 48 patients with septic shock were enrolled with 24 patients in esmolol group and 24 in control group. (1) The primary end-points: compared with control group, the length of stay in the ICU in the esmolol group was significantly shortened (days: 13.75 ± 8.68 vs. 21.70 ± 6.06, t = 3.680, P = 0.001), and 28-day mortality was significantly lowered [25.0% (6/24) vs. 62.5% (15/24 ), χ2 = 6.857, P = 0.009]. (2) The secondary end-points: there were no significant difference in the hemodynamic and

  7. Prevalence of occult adrenal insufficiency and the prognostic value of a short corticotropin stimulation test in patients with septic shock.

    Science.gov (United States)

    Maqbool, Muzaffar; Shah, Zafar Amin; Wani, Fayaz Ahmad; Wahid, Abdul; Parveen, Shaheena; Nazir, Arjumand

    2009-01-01

    Corticosteroid insufficiency in acute illness can be difficult to discern clinically. Occult adrenal insufficiency (i.e., Deltamax 34 microg/dL, and maximum variation after test (Deltamax) of 9 microg/dL; a 28-day mortality rate of 33%),(II) intermediate (T0 > 34 microg/dL and Deltamax> 9 microg/dL or T0 34 microg/dL and Deltamax < or =9 microg/dL; a 28-day mortality rate of 82%). A short corticotropin test using low-dose corticotropin (1 microg) has a good prognostic value. High basal cortisol and a low increase in cortisol on corticotropin stimulation test are predictors of a poor outcome in patients with septic shock.

  8. Population pharmacokinetics of piperacillin in the early phase of septic shock – does standard dosing result in therapeutic plasma concentrations?

    DEFF Research Database (Denmark)

    Öbrink-Hansen, Kristina Margareta; Juul, Rasmus Vestergaard; Storgaard, Merete

    2015-01-01

    of administration. Time above the minimal inhibitory concentration (T>MIC) predicted for each patient was evaluated against clinical breakpoint MIC for Pseudomonas aeruginosa (16 mg/L). Pharmacokinetic-pharmacodynamic (PK/PD) targets evaluated were 50% fT>4xMIC and 100% f T>MIC. A population PK model was developed...... between patients and were associated with levels of plasma creatinine. Patients with impaired renal function were more likely to achieve predefined PK/PD targets compared to patients with preserved or augmented renal function. Simulations of alternative dosing regimens showed that frequent intermittent...... bolus dosing as well as dosing by extended and continuous infusion increases the probability of attaining therapeutic plasma concentrations. For septic shock patients with preserved or augmented renal function, dose increment or prolonged infusion of the drug need to be considered....

  9. Fluid administration in severe sepsis and septic shock, patterns and outcomes: an analysis of a large national database.

    Science.gov (United States)

    Marik, Paul E; Linde-Zwirble, Walter T; Bittner, Edward A; Sahatjian, Jennifer; Hansell, Douglas

    2017-05-01

    The optimal strategy of fluid resuscitation in the early hours of severe sepsis and septic shock is controversial, with both an aggressive and conservative approach being recommended. We used the 2013 Premier Hospital Discharge database to analyse the administration of fluids on the first ICU day, in 23,513 patients with severe sepsis and septic shock, who were admitted to an ICU from the emergency department. Day 1 fluid was grouped into categories 1 L wide, starting with 1-1.99 L up to ≥9 L, to examine the effect of day 1 fluids on patient mortality. We built binary response models for hospital mortality and the propensity for receiving more than 5 L of fluids on day 1, using patient age and acute conditions present on admission. Patients were grouped by the requirement for mechanical ventilation and the presence or absence of shock. We assessed trends in the difference between actual and expected mortality, in the low fluid range (1-5 L day 1 fluids) and the high fluid range (5 to ≥9 L day 1 fluids) categories, using weighted linear regression controlling for the effects of sample size and variation within the day 1 fluid category. Day 1 fluid administration averaged 4.4 L being lowest in the group with no mechanical ventilation and no shock (3.6 L) and highest (5.4 L) in the group receiving mechanical ventilation and in shock. The administration of day 1 fluids was remarkably consistent on the basis of hospital size, teaching status, rural/urban location, and region of the country. The hospital mortality in the entire cohort was 25.8%, with a mean ICU and hospital length of stay of 5.1 and 9.1 days, respectively. In the entire cohort, low volume resuscitation (1-4.99 L) was associated with a small but significant reduction in mortality, of -0.7% per litre (95% CI -1.0%, -0.4%; p = 0.02). However, in patients receiving high volume resuscitation (5 to ≥9 L), the mortality increased by 2.3% (95% CI 2.0, 2.5%; p = 0.0003) for

  10. Acute bag-valve breathing maneuvers plus manual chest compression is safe during stable septic shock: a randomized clinical trial.

    Science.gov (United States)

    Blattner, Clarissa Netto; Santos, Rafael Saldanha Dos; Dias, Fernando Suparregui; Dias, Alexandre Simões; Mestriner, Régis Gemerasca; Vieira, Silvia Regina Rios

    2017-01-01

    To evaluate the effects of bag-valve breathing maneuvers combined with standard manual chest compression techniques on safety, hemodynamics and oxygenation in stable septic shock patients. A parallel, assessor-blinded, randomized trial of two groups. A computer-generated list of random numbers was prepared by an independent researcher to allocate treatments. The Intensive Care Unit at Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul. Fifty-two subjects were assessed for eligibility, and 32 were included. All included subjects (n = 32) received the allocated intervention (n = 19 for the Experimental Group and n = 13 for the Control Group). Twenty minutes of bag-valve breathing maneuvers combined with manual chest compression techniques (Experimental Group) or chest compression, as routinely used at our intensive care unit (Control Group). Follow-up was performed immediately after and at 30 minutes after the intervention. Mean artery pressure. All included subjects completed the trial (N = 32). We found no relevant effects on mean artery pressure (p = 0.17), heart rate (p = 0.50) or mean pulmonary artery pressure (p = 0.89) after adjusting for subject age and weight. Both groups were identical regarding oxygen consumption after the data adjustment (p = 0.84). Peripheral oxygen saturation tended to increase over time in both groups (p = 0.05), and there was no significant association between cardiac output and venous oxygen saturation (p = 0.813). No clinical deterioration was observed. A single session of bag-valve breathing maneuvers combined with manual chest compression is hemodynamically safe for stable septic-shocked subjects over the short-term.

  11. [Prognostic value of lipopolysaccharide binding protein and procalcitonin in patients with severe sepsis and septic shock admitted to intensive care].

    Science.gov (United States)

    García de Guadiana-Romualdo, L M; Rebollo-Acebes, S; Esteban-Torrella, P; Jiménez-Sánchez, R; Hernando-Holgado, A; Ortín-Freire, A; Viqueira-González, M; Trujillo-Santos, J; Jiménez Santos, E; Pedregosa Díaz, J; Albaladejo-Otón, M D; Allegue-Gallego, J M

    2015-05-01

    1) To assess the prognostic value of levels on admission and serial measurements of lipopolysaccharide binding protein (LBP) and procalcitonin (PCT) in relation to in-hospital mortality; and 2) to determine whether the addition of these parameters to severity scores (APACHE II and SOFA) is able to improve prognostic accuracy. A single-center, prospective observational study was carried out. Intensive Care unit of a university hospital. One hundred severe sepsis and septic shock patients were included. Demographic data, APACHE II and SOFA scores, PCT and LBP levels on admission and after 48 hours, and in-hospital mortality. The best area under the curve for predicting in-hospital mortality corresponded to APACHE II on admission and SOFA after 48 h (AUC ROC: 0.75 for both). PCT and LBP levels on admission and LBP clearance were not statistically different between in-hospital survivors and non-survivors. Only PCT clearance was higher among in-hospital survivors than in non-survivors (AUC ROC: 0.66). The combination of severity scores and PCT clearance did not result in superior areas under the curve. LBP and PCT levels on admission and LBP clearance showed no prognostic value in severe sepsis and septic shock patients. Only PCT clearance was predictive of in-hospital mortality. The prognostic accuracy was significantly better for APACHE on admission and SOFA after 48 h than for any of the analyzed biomarkers, and the addition of PCT clearance did not improve their prognostic value. Copyright © 2013 Elsevier España, S.L.U. and SEMICYUC. All rights reserved.

  12. Infection site is predictive of outcome in acute lung injury associated with severe sepsis and septic shock.

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    Fujishima, Seitaro; Gando, Satoshi; Daizoh, Saitoh; Kushimoto, Shigeki; Ogura, Hiroshi; Mayumi, Toshihiko; Takuma, Kiyotsugu; Kotani, Joji; Yamashita, Norio; Tsuruta, Ryosuke; Takeyama, Naoshi; Shiraishi, Shin-Ichiro; Araki, Tsunetoshi; Suzuki, Koichiro; Ikeda, Hiroto; Miki, Yasuo; Suzuki, Yasushi; Yamaguchi, Yoshihiro; Aikawa, Naoki

    2016-07-01

    Sepsis is a leading cause of acute lung injury (ALI); however, the characteristics and outcome of sepsis-associated ALI are poorly understood. We aimed to elucidate factors that predict patient outcome in sepsis-associated ALI. Secondary analysis of a multicenter, prospective, observational study was performed. Among 624 patients with severe sepsis and septic shock, 251 (40.2%) fulfilled the definition of American-European Consensus Conference definition of ALI. All-cause 28-day and in-hospital mortalities were 30.7% and 38.6%, respectively. More than 40% of ALI patients had neurological, cardiovascular and haematological dysfunctions or disseminated intravascular coagulation, all of which were associated with higher mortality. We report a significant correlation between infection site and mortality in patients with ALI, but not in those without ALI. The proportion of ALI was significantly higher in pulmonary sepsis; further, a complication of ALI was associated with higher mortality in sepsis from pulmonary and other sources, but not in abdominal sepsis. Among the other sepsis sites, urinary tract, central nervous system, catheter-related and undetermined foci of infection had worse outcomes when associated with ALI. None of the individual severe sepsis bundles, including fluid resuscitation and early antibiotic administration, correlated with mortality. Compliance with a set of sepsis management bundles was associated with better outcomes. In severe sepsis and septic shock, the proportion and effect on outcome was not uniform among infection sites. The infection site was predictive of outcome in patients with ALI but not in those without ALI. © 2016 Asian Pacific Society of Respirology.

  13. Prescribing patterns of hydrocortisone in septic shock: a single-center experience of how surviving sepsis guidelines are interpreted and translated into bedside practice.

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    Contrael, Katlynd M; Killian, Alley J; Gregg, Sara R; Buchman, Timothy G; Coopersmith, Craig M

    2013-10-01

    The Surviving Sepsis Campaign suggests giving hydrocortisone to septic patients only if their "blood pressure is poorly responsive to fluid resuscitation and vasopressor therapy." Because the definition of "poorly responsive" is not provided, the purpose of this study was to identify prescribing triggers for hydrocortisone in septic shock. Retrospective chart review of patients with septic shock over 17 months, who received hydrocortisone, followed by a survey of all intensivists who attended in the study ICUs to determine whether provider attitudes matched clinical practice. Eight ICUs in an academic hospital and a hybrid academic/community hospital. A total of 155 patients with septic shock in whom vasopressors were initiated and hydrocortisone was prescribed. Ninety-nine patients (64%) were already receiving two vasopressors before hydrocortisone was prescribed. An additional 22 patients were on a single high-dose vasopressor prior to corticosteroid initiation. Of patients who survived to have their hydrocortisone dose changed, 57% had their corticosteroids tapered, whereas 43% were abruptly discontinued. Seventy-six percent of patients were no longer on vasopressors when the first dosing change was made. Twenty-seven out of 36 intensivists (75%) completed the survey. The majority (72%) defined "poorly responsive to vasopressors" as the presence of two vasopressors, and 70% stated that they required patients to be off vasopressors prior to altering the corticosteroid dose. Significant variability exists when corticosteroids are prescribed for septic shock, with the most common interpretation in our institution of "poorly responsive to fluid resuscitation and vasopressor therapy" being the presence of two vasopressors. The method and timing of corticosteroid discontinuation also differed among providers. Self-described prescribing patterns from intensivists closely matched their actual behavior, suggesting variability is due to differing interpretations of the

  14. Beneficial Effect of Intermedin 1-53 in Septic Shock Rats: Contributions of Rho Kinase and BKCA Pathway-Mediated Improvement in Cardiac Function.

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    Zhu, Yu; Wu, Huiling; Wu, Yue; Zhang, Jie; Peng, Xiaoyong; Zang, Jiatao; Xiang, Xinming; Liu, Liangming; Li, Tao

    2016-11-01

    Intermedin (IMD) is a calcitonin gene-related peptide shown to have a protective effect on myocardial function in ischemia-reperfusion injury. Whether IMD has beneficial effect in severe sepsis and septic shock (and its underlying mechanisms) is not known. We induced septic shock using cecal ligation and puncture (CLP). We focused on the potential beneficial effect of IMD1-53 on cardiac papillary muscle and cardiomyocytes against septic shock and its relationship with the protection of cardiac function. Early (immediately after CLP) and late (12 h after CLP) administration of IMD1-53 (0.5 μg/kg) improved animal survival significantly, increased cardiac contractility and function, and improved tissue perfusion and oxygen delivery. The effect of early administration of IMD1-53 was better than that of late administration. The Rho kinase/TnI and BKCa pathways participated in the protective effect of IMD1-53 on cardiac function in septic rats. An inhibitor of Rho kinase (Y-27632) or a BKCa opener (NS1619) abolished the protective effect of IMD1-53 on cardiac function. IMD1-53 increased expression of Rho kinase in cardiac muscle and inhibited TnI phosphorylation. IMD1-53 inhibited currents in BKCa channels and intracellular calcium concentration in cardiomyocytes. IMD1-53 is beneficial against severe sepsis/septic shock. IMD1-53 can improve cardiac contractility and cardiac function significantly, and then improve tissue perfusion and oxygen delivery. Rho kinase and the BKCa pathways have important roles in these effects. These findings provide a new treatment strategy for severe sepsis with cardiac dysfunction.

  15. Decreasing mortality in severe sepsis and septic shock patients by implementing a sepsis bundle in a hospital setting.

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    Sandra Christina Pereira Lima Shiramizo

    Full Text Available BACKGROUND: The Surviving Sepsis Campaign (SSC guidelines for the management of severe sepsis (SS and septic shock (SSh have been recommended to reduce morbidity and mortality. MATERIALS AND METHODS: A quasi-experimental study was conducted in a medical-surgical ICU. Multiple interventions to optimize SS and SSh shock patients' clinical outcomes were performed by applying sepsis bundles (6- and 24-hour in May 2006. We compared bundle compliance and patient outcomes before (July 2005-April 2006 and after (May 2006-December 2009 implementation of the interventions. RESULTS: A total of 564 SS and SSh patients were identified. Prior to the intervention, compliance with the 6 hour-sepsis resuscitation bundle was only 6%. After the intervention, compliance was as follows: 8.2% from May to December 2006, 9.3% in 2007, 21.1% in 2008 and 13.7% in 2009. For the 24 hour-management bundle, baseline compliance was 15.0%. After the intervention, compliance was 15.1% from May to December 2006, 21.4% in 2007, 27.8% in 2008 and 44.4% in 2009. The in-hospital mortality was 54.0% from July 2005 to April 2006, 41.1% from May to December 2006, 39.3% in 2007, 41.4% in 2008 and 16.2% in 2009. CONCLUSION: These results suggest reducing SS and SSh patient mortality is a complex process that involves multiple performance measures and interventions.

  16. A survey of critical care nurses' practices and perceptions surrounding early intravenous antibiotic initiation during septic shock.

    Science.gov (United States)

    Roberts, Russel J; Alhammad, Abdullah M; Crossley, Lindsay; Anketell, Eric; Wood, LeeAnn; Schumaker, Greg; Garpestad, Erik; Devlin, John W

    2017-08-01

    Delays in antibiotic administration after severe sepsis recognition increases mortality. While physician and pharmacy-related barriers to early antibiotic initiation have been well evaluated, those factors that affect the speed by which critical care nurses working in either the emergency department or the intensive care unit setting initiate antibiotic therapy remains poorly characterized. To evaluate the knowledge, practices and perceptions of critical care nurses regarding antibiotic initiation in patients with newly recognised septic shock. A validated survey was distributed to 122 critical care nurses at one 320-bed academic institution with a sepsis protocol advocating intravenous(IV) antibiotic initiation within 1hour of shock recognition. Among 100 (82%) critical care nurses responding, nearly all (98%) knew of the existence of the sepsis protocol. However, many critical care nurses stated they would optimise blood pressure [with either fluid (38%) or both fluid and a vasopressor (23%)] before antibiotic initiation. Communicated barriers to rapid antibiotic initiation included: excessive patient workload (74%), lack of awareness IV antibiotic(s) ordered (57%) or delivered (69%), need for administration of multiple non-antibiotic IV medications (54%) and no IV access (51%). Multiple nurse-related factors influence IV antibiotic(s) initiation speed and should be incorporated into sepsis quality improvement efforts. Copyright © 2017 Elsevier Ltd. All rights reserved.

  17. Simultaneous use of traditional Chinese medicine (Si-Ni-Tang to treat septic shock patients: study protocol for a randomized controlled trial

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    Wu Shin-Hwar

    2011-08-01

    Full Text Available Abstract Background Even though there are continually upgraded recommendations for managing sepsis, such as "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock", mortality is still high. Si-Ni-Tang, a remedy documented in Shanghan Lun, a medical collection from ancient China, is used for treating patients with sepsis and septic shock. Using a well-designed clinical trial, we are eager to survey the effectiveness of the concurrent use of this remedy in restoring these patients' hemodynamic status, or "Yang Qi". Methods/Design Patients admitted to our medical intensive care units with the diagnosis of septic shock, defined as persistent hypotension induced by sepsis despite adequate fluid resuscitation, are eligible for participation. The inclusion criteria include: age from 20 to 85 years, conditions meeting the definition of septic shock, use of vasopressors within 24 hours of entering the study, and use of a nasogastric tube for feeding. The enrolled patients are randomly allocated either to the Si-Ni-Tang group or the placebo group. The prescription of the trial drugs (Si-Ni-Tang/placebo is 2.25 grams 4 times a day for 7 days or till shock reversal (if shock reversal occurs in less than 7 days. Data, including duration of vasopressor infusion, gender, age, co-morbidities, APACHE II score, predicted mortality, ICU mortality, ICU length of stay, hospital mortality, hospital length of stay, source of sepsis, and culture results, are collected for the following analysis. Discussion Si-Ni-Tang is composed of processed Zingiber officinale, Glycyrrhiza uralensis, and Aconitum carmichaeli. Zingiber officinale and Glycyrrhiza uralensis are found to have the ability to reduce pro-inflammatory cytokine production, to inhibit lipopolisaccharide-induced macrophage activation and function, and to lessen the bacterial load and suppress acute and chronic inflammation. Aconitum carmichaeli is known to have

  18. Initial Emergency Department Diagnosis and Management of Adult Patients with Severe Sepsis and Septic Shock

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    Perman Sarah M

    2012-06-01

    Full Text Available Abstract Severe sepsis is a medical emergency affecting up to 18 million individuals world wide, with an annual incidence of 750,000 in North America alone. Mortality ranges between 28-50% of those individuals stricken by severe sepsis. Sepsis is a time critical illness, requiring early identification and prompt intervention in order to improve outcomes. This observation has led to increased awareness and education in the field of Emergency Medicine; it has also led to the implementation of critical interventions early in the course of patient management, specifically Early-Goal Directed Therapy, and rapid administration of appropriate antimicrobials. This review begins with a brief summary of the pathophysiology of sepsis, and then addresses the fundamental clinical aspects of ED identification and resuscitation of the septic patient.

  19. Revisiting steroid treatment for septic shock: molecular actions and clinical effects - a review

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    André M Japiassú

    2009-07-01

    Full Text Available Corticosteroids are widely used to treat a diversity of pathological conditions including allergic, autoimmune and some infectious diseases. These drugs have complex mechanisms of action involving both genomic and non-genomic mechanisms and interfere with different signal transduction pathways in the cell. The use of corticosteroids to treat critically ill patients with acute respiratory distress syndrome and severe infections, such as sepsis and pneumonia, is still a matter of intense debate in the scientific and medical community with evidence both for and against its use in these patients. Here, we review the basic molecular mechanisms important for corticosteroid action as well as current evidence for their use, or not, in septic patients. We also present an analysis of the reasons why this is still such a controversial point in the literature.

  20. Increased lactate/pyruvate ratio with normal beta-hydroxybutyrate/acetoacetate ratio and lack of oxygen supply dependency in a patient with fatal septic shock.

    Science.gov (United States)

    Gallet, D; Goudable, J; Vedrinne, J M; Viale, J P; Annat, G

    1997-01-01

    We report a case of fatal septic shock, with hyperlactatemia and blood cultures positive for Streptococcus pneumoniae, in a 70-year-old patient. On two occasions (5 days, and 2 days before the patient's death), the relationship between oxygen delivery (DO2) and consumption (VO2) was examined in conjunction with two presumed markers of tissue oxygenation: the lactate/pyruvate ratio (L/P), and the beta-hydroxybutyrate acetoacetate ratio (beta OHB/AcAc). Increasing DO2 by about 30% ("oxygen flux test") failed to increase VO2. The beta OHB/AcAc ratio remained within normal limits, thus suggesting uncompromised tissue oxygenation at the hepatic level. The L/P ratio remained persistently above normal limits, thus suggesting actual organ or regional hypoxia. This case shows that during an overwhelming septic shock, the "oxygen flux test" can be negative, despite the presence of hyperlactatemia and of an increased L/P ratio suggestive of impaired tissue oxygenation.

  1. Effects of severe smoke inhalation injury and septic shock on global hemodynamics and microvascular blood flow in sheep.

    Science.gov (United States)

    Maybauer, Dirk M; Maybauer, Marc O; Traber, Lillian D; Westphal, Martin; Nakano, Yoshimitsu Y; Enkhbaatar, Perenlei; Morita, Naoki; Herndon, David N; Traber, Daniel L

    2006-11-01

    This prospective, randomized, controlled experimental study looks at the effects on global and regional microvascular blood flow (RMBF) in an ovine model of septic shock after severe smoke inhalation injury. Sixteen sheep were randomized into two groups, a control group (no injury, n = 8) and a smoke/sepsis (SS) group (n = 8), which received an insufflation of 4 sets of 12 breaths of cotton smoke (sheep were mechanically ventilated with 100% oxygen, and fluid resuscitated with lactated Ringer's solution for the entire duration of the 24-h experimental period to maintain hematocrit at baseline (BL) levels. Healthy control animals were not subjected to the injury and received only 4 x 12 breaths of room air and instillation of the vehicle (normal saline). Blood flow was analyzed using colored microspheres. Control animals remained hemodynamically stable and had no statistical changes from BL in visceral or cerebral blood flow during the entire experimental period. All SS animals developed a hypotensive, hyperdynamic circulation, characterized by a significant increase in heart rate and cardiac output with a simultaneous significant fall in mean arterial pressure, which, in combination, led to a fall in systemic vascular resistance index versus BL (P < 0.001, each). In visceral organs, the trachea showed a significant increase in RMBF (P < 0.001). In addition, skeletal muscle significantly increased versus BL and versus controls over time (P < 0.01). Whereas the pancreas displayed a significant drop in RMBF versus BL and controls (P < 0.05), no statistical differences occurred in the renal cortex, spleen, and ileum. All investigated cerebral structures, such as the cortex cerebri, basal ganglia, thalamus, hippocampus, pons, medulla oblongata, and cerebellum showed a significant increase in RMBF versus BL and versus control animals (P < 0.05, each). These data differ in areas of normal, increased, and decreased RMBF during septic shock after smoke inhalation injury and

  2. A multicentre study of acute kidney injury in severe sepsis and septic shock: association with inflammatory phenotype and HLA genotype.

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    Didier Payen

    Full Text Available BACKGROUND: To investigate the association between severity of acute kidney injury (AKI and outcome, systemic inflammatory phenotype and HLA genotype in severe sepsis. METHODOLOGY/PRINCIPAL FINDINGS: Prospective multicenter observational study done in 4 intensive care units in two university hospitals. Severe sepsis and septic shock patients with at least 2 organ failures based on the SOFA score were classified: 1 "no AKI", 2 "mild AKI" (grouping stage 1 and 2 of AKIN score and 3 "severe AKI" (stage 3 of AKIN score. Sequential measurements: The vasopressor dependency index (VDI; dose and types of drugs to evaluate the association between hemodynamic status and the development of early AKI; plasma levels of IL-10, macrophage migration inhibitory factor (MIF, IL-6 and HLA-DR monocyte expression. Genotyping of the 13 HLA-DRB1 alleles with deduction of presence of HLA-DRB3, -DRB4 and -DRB5 genes. We used multivariate analysis with competitive risk model to study associations. Overall, 176 study patients (146 with septic shock were classified from AKIN score as "no AKI" (n = 43, "mild AKI" (n = 74 or "severe AKI" (n = 59. The VDI did not differ between groups of AKI. After adjustment, "mild and severe AKI" were an independent risk factor for mortality (HR 2.42 95%CI[1.01-5.83], p = 0.048 and HR 1.99 95%CI[1.30-3.03], p = 0.001 respectively. "Severe AKI" had higher levels of plasma IL-10, MIF and IL-6 compared to "no AKI" and mild AKI (p<0.05 for each, with no difference in mHLA-DR at day 0. HLA-DRB genotyping showed a significantly lower proportion of 4 HLA-DRB alleles among patients requiring renal replacement therapy (RRT (58% than in patients with severe AKI who did not receive RRT (84% (p = 0.004. CONCLUSIONS: AKI severity is independently associated with mortality and plasma IL-10, MIF or IL-6 levels. Presence of 4 alleles of HLA-DRB in severe AKI patients seems associated with a lower need of RRT.

  3. [The effect of body temperature control on organ function and prognosis in patients with refractory septic shock].

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    Wang, Xiaoting; Liu, Dawei; Yang, Yanli; Zhou, Xiang; Chai, Wenzhao; Long, Yun; Zhang, Hongmin; Zhang, Qing; He, Huaiwu

    2014-04-01

    To investigate the effect of body temperature control on organ function and prognosis in patients with refractory septic shock. A total of 67 eligible patients with the body temperature over 38.5 °C were enrolled in the study and all patients were treated with a water-flow cooling blanket to control the body temperature below 38.3 °C for 72 hours. The core and peripheral temperature was tested at 1 hour interval. All patients were devised into the following two groups according to their mean core temperature within the 72 hours: the HT group with a mean core temperature ≥ 37.5 °C and the LT group with a mean core temperature temperature increased above 38.5 °C. Thirty-four patients (50.7%) were classified into the HT group, while thirty-three patients (49.3%) were in the LT group. Compared with the HT group, higher mortality rate at Day 28 was observed in the LT group (69.7% vs 35.3%, P = 0.005). Significant difference in the increase of sepsis-related organ failure assessment (SOFA) score was found between of the HT and the LT groups (1.30 ± 0.90 vs 2.30 ± 2.10, P = 0.02). Statistical differences were observed between the two groups in mean core temperature [(37.90 ± 0.30) °C vs (36.80 ± 0.60) °C, P peripheral temperature [(37.20 ± 0.30) °C vs (36.30 ± 0.60) °C, P temperature [(36.90 ± 0.30)°C vs (35.80 ± 0.60) °C, P peripheral temperature [(36.20 ± 0.40) °C vs (35.50 ± 0.60) °C, P peripheral temperature.Statistical difference was also shown in troponin I, fibrinogen, partial thromboplastin and activated partial thromboplastin between the two groups. Cox regression analysis revealed that the mean core temperature was the only independent predictor for the mortality rate at Day 28. Body temperature control within the normal range may exert potentially detrimental effect on organ function and prognosis in patients with refractory septic shock with fever.

  4. Impact of Norepinephrine Weight-Based Dosing Compared With Non-Weight-Based Dosing in Achieving Time to Goal Mean Arterial Pressure in Obese Patients With Septic Shock.

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    Vadiei, Nina; Daley, Mitchell J; Murthy, Manasa S; Shuman, Carrie S

    2017-03-01

    Currently, a lack of standardization exists in norepinephrine dosing units, the first-line vasopressor for septic shock. Timely achievement of goal mean arterial pressure (MAP) is dependent on optimal vasopressor dosing. To determine if weight-based dosing (WBD) of norepinephrine leads to earlier time to goal MAP compared with non-WBD in obese patients with septic shock. This was a retrospective, multicenter cohort study. Patients had a body mass index (BMI) ≥30 kg/m 2 and received norepinephrine for septic shock with either a non-WBD strategy (between December 2009 and January 2013) or WBD strategy (between January 2013 and December 2015). The primary outcome was time to goal MAP. Secondary outcomes were norepinephrine duration, dose requirements, and development of treatment-related complications. A total of 287 patients were included (WBD 144; non-WBD 143). There was no difference in median time to goal MAP (WBD 58 minutes, interquartile range [IQR] = 16.8-118.5, vs non-WBD 60 minutes, IQR = 17.5-193.5; P = 0.28). However, there was a difference in median cumulative norepinephrine dose (WBD 12.6 mg, IQR = 4.9-45.9, vs non-WBD 10.5 mg, IQR = 3.9-25.6; P = 0.04) and time to norepinephrine discontinuation (WBD 33 hours, IQR = 15-69, vs non-WBD 27 hours, IQR = 12-51; P = 0.03). There was no difference in rates of atrial fibrillation (WBD 15.3% vs non-WBD 23.7%; P = 0.07) or mortality (WBD 23.6% vs non-WBD 23.1%; P = 0.92). WBD of norepinephrine does not achieve time to goal MAP earlier in obese patients with septic shock. However, WBD may lead to higher norepinephrine cumulative dose requirements and prolonged time until norepinephrine discontinuation.

  5. Analgesia-sedation in PICU and neurological outcome: a secondary analysis of long-term neuropsychological follow-up in meningococcal septic shock survivors*.

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    van Zellem, Lennart; Utens, Elisabeth M; de Wildt, Saskia N; Vet, Nienke J; Tibboel, Dick; Buysse, Corinne

    2014-03-01

    To investigate whether analgesic and sedative drug use during PICU treatment is associated with long-term neurodevelopmental outcome in children who survived meningococcal septic shock. This study concerned a secondary analysis of data from medical and psychological follow-up of a cross-sectional cohort of all consecutive surviving patients with septic shock and purpura requiring intensive care treatment between 1988 and 2001 at the Erasmus MC-Sophia Children's Hospital. At least 4 years after PICU admission, these children showed impairments on several domains of neuropsychological functioning. In the present study, type, number, and dose of sedatives and analgesics were retrospectively evaluated. Tertiary care university hospital. Seventy-seven meningococcal septic shock survivors (median age, 2.1 yr). None. Forty-five patients (58%) received one or more analgesic and/or sedative drugs during PICU admission, most commonly benzodiazepines (n = 39; 51%), followed by opioids (n = 23; 30%). In total, 12 different kinds of analgesic or sedative drugs were given. The use and dose of opioids were significantly associated with poor test outcome on full-scale intelligence quotient (p = 0.02; Z = -2.28), verbal intelligence quotient (p = 0.02; Z = -2.32), verbal intelligence quotient subtests (verbal comprehension [p = 0.01; Z = -2.56] and vocabulary [p = 0.01; Z = -2.45]), and visual attention/executive functioning (Trial Making Test part B) (p = 0.03; Z = -2.17). In multivariate analysis adjusting for patient and disease characteristics, the use of opioids remained significant on most neuropsychological tests. The use of opioids during PICU admission was significantly associated with long-term adverse neuropsychological outcome independent of severity of illness scores in meningococcal septic shock survivors.

  6. Comprehensive Interpretation of Central Venous Oxygen Saturation and Blood Lactate Levels During Resuscitation of Patients With Severe Sepsis and Septic Shock in the Emergency Department.

    Science.gov (United States)

    Shin, Tae Gun; Jo, Ik Joon; Hwang, Sung Yeon; Jeon, Kyeongman; Suh, Gee Young; Choe, Euna; Lee, Young Kun; Lee, Tae Rim; Cha, Won Chul; Sim, Min Seob

    2016-01-01

    We evaluated central venous oxygen saturation (Scvo2) and lactate levels as a combination measure to predict mortality in patients with severe sepsis or septic shock. We included patients older than 18 years of age who presented to a single tertiary emergency center with septic shock or severe sepsis and received early goal-directed therapy. We classified the sample into four groups according to lactate (cut-off: 4 mmol/L) and Scvo2 (cut-off: 70%) levels at the time of initial resuscitation: Group 1, high-Scvo2, and low-lactate; Group 2, low-Scvo2, and low-lactate; Group 3, high-Scvo2, and high-lactate; Group 4, low-Scvo2, and high-lactate. The primary outcome was 28-day mortality determined by multivariable Cox-regression analysis. A total of 880 patients were included in this study. The 28-day mortality was 6.7% in Group 1, 15.7% in Group 2, 26.7% in Group 3, and 25.5% in Group 4 (P septic shock. Associations between Scvo2 ≥70% and 28-day survival were observed only in patients without severe lactic acidosis.

  7. The impact of serial lactate monitoring on emergency department resuscitation interventions and clinical outcomes in severe sepsis and septic shock: an observational cohort study.

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    Dettmer, Matthew; Holthaus, Christopher V; Fuller, Brian M

    2015-01-01

    Monitoring in the setting of critical illness must be linked to beneficial therapy to affect clinical outcome. Elevated serum lactate is associated with an increase in mortality in emergency department (ED) patients with severe sepsis and septic shock. The reduction of lactate levels toward normal during acute resuscitation is associated with improved clinical outcomes. The majority of data demonstrating the interventions used to achieve a reduction in lactate levels and the associated clinical outcomes have been obtained during protocolized randomized trials. We therefore conducted a retrospective observational cohort study of 243 adult patients with severe sepsis and septic shock to assess the interventions associated with nonprotocolized serial lactate monitoring and to assess clinical outcomes. A multivariable model was used to assess outcome differences between the serial lactate (SL) and no serial lactate (NL) cohorts. The SL group received more crystalloid resuscitation (3.6 L vs. 2.5 L; P septic shock. This suggests that serial lactate monitoring, targeting a reduction in lactate levels to normal, is a generalizable resuscitation target in the ED.

  8. Antibiotic therapy prior to hospital admission is associated with reduced septic shock and need for mechanical ventilation in patients with community-acquired pneumonia.

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    Amaro, Rosanel; Sellarés, Jacobo; Polverino, Eva; Cillóniz, Catia; Ferrer, Miquel; Fernández-Barat, Laia; Mensa, Josep; Niederman, Michael S; Torres, Antoni

    2017-05-01

    A subgroup of patients admitted to the hospital with a diagnosis of community-acquired pneumonia (CAP) have received antibiotic therapy prior to admission for the current episode of pneumonia. The objective of this study was to assess the clinical course of patients receiving antibiotics prior to admission, compared to patients not previously treated. An observational cohort of 3364 CAP patients consecutively admitted to our hospital, and prospectively included, were studied. We collected clinical, microbiological and biochemical parameters, focusing on recent antibiotics received prior to admission. 610 (18%) patients received antibiotics prior to hospital admission for the current CAP episode. Patients with previous antibiotic use developed septic shock less frequently (4% vs. 7%, p = 0.007) and required invasive ventilation less often (3% vs. 6%, p = 0.002). After adjustment by different covariate factors and propensity score, antibiotic therapy was still independently associated with a lower incidence of septic shock at admission (OR 0.54 [95% CI 0.31-0.95], p = 0.03) and less need for invasive ventilation (OR 0.38 [95% CI 0.16-0.91], p = 0.03). In this cohort, recent use of antibiotics before hospital admission in CAP seems to be associated with a lower incidence of septic shock on admission and a lower need for invasive ventilation. Copyright © 2017 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

  9. Selective iNOS inhibition prevents hypotension in septic rats while preserving endothelium-dependent vasodilation.

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    Strunk, V; Hahnenkamp, K; Schneuing, M; Fischer, L G; Rich, G F

    2001-03-01

    Nitric oxide (NO) derived from inducible nitric oxide synthase (iNOS) mediates hypotension and metabolic derangements in sepsis. We hypothesized that selective iNOS-inhibition would prevent hypotension in septic rats without inhibiting endothelium-dependent vasodilation caused by the physiologically important endothelial NOS. Rats were exposed to lipopolysaccharide (LPS) for 6 h and the selective iNOS-inhibitor L-N6-(1-iminoethyl)-lysine (L-NIL), the nonselective NOS-inhibitor N:(G)-nitro-L-arginine methyl ester (L-NAME), or control. Mean arterial pressure (MAP) and vasodilation to acetylcholine (ACh, endothelium-dependent), sodium nitroprusside (SNP, endothelium-independent), and isoproterenol (ISO, endothelium-independent beta agonist) were determined. Exhaled NO, nitrate/nitrite-(NOx) levels, metabolic data, and immunohistochemical staining for nitrotyrosine, a tracer of peroxynitrite-formation were also determined. In control rats, L-NAME increased MAP, decreased the response to ACh, and increased the response to SNP, whereas L-NIL did not alter these variables. LPS decreased MAP by 18% +/- 1%, decreased vasodilation (ACh, SNP, and ISO), increased exhaled NO, NOx, nitrotyrosine staining, and caused acidosis and hypoglycemia. L-NIL restored MAP and vasodilation (ACh, SNP, and ISO) to baseline and prevented the changes in exhaled NO, NOx, pH, and glucose levels. In contrast, L-NAME restored MAP and SNP vasodilation, but did not alter the decreased response to ACh and ISO or prevent the changes in exhaled NO and glucose levels. Finally, L-NIL but not L-NAME decreased nitrotyrosine staining in LPS rats. In conclusion, L-NIL prevents hypotension and metabolic derangements in septic rats without affecting endothelium-dependent vasodilation whereas L-NAME does not. Sepsis causes hypotension and metabolic derangements partly because of increased nitric oxide. Selective inhibition of nitric oxide produced by the inducible nitric oxide synthase enzyme prevents

  10. Procalcitonina em crianças com sepse e choque séptico Procalcitonin in children with sepsis and septic shock

    Directory of Open Access Journals (Sweden)

    José R. Fioretto

    2007-08-01

    Full Text Available OBJETIVOS: Estudar o comportamento da procalcitonina e verificar se é capaz de diferenciar crianças com quadros sépticos. MÉTODOS: Crianças de 28 dias a 14 anos de idade, admitidas de 01/2004 a 12/2005 na unidade de tratamento intensivo pediátrica da UNESP com sepse ou choque séptico, foram incluídas prospectivamente. Dois grupos foram constituídos: grupo sepse (GS; n = 47 e grupo choque séptico (GCS; n = 43. Procalcitonina foi medida à admissão (T0 e depois de 12 h (T12h, e os resultados apresentados em classes: 0,5 a 2 a 10 = choque séptico. RESULTADOS: No T0, foi maior a freqüência de pacientes do GCS na classe mais alta de procalcitonina, comparada às crianças do GS [GCS: 30 (69,7% > GS: 14 (29,8%; p 10 = 69,7%; > 2 a 0,5 a OBJECTIVES: To study the behavior of procalcitonin and to verify whether it can be used to differentiate children with septic conditions. METHODS: Children were enrolled prospectively from among those aged 28 days to 14 years, admitted between January 2004 and December 2005 to the pediatric intensive care unit at Universidade Estadual Paulista UNESP with sepsis or septic shock. The children were classified as belonging to one of two groups: the sepsis group (SG; n = 47 and the septic shock group (SSG; n = 43. Procalcitonin was measured at admission (T0 and again 12 hours later (T12h, and the results classed as: 0.5 to 2 to 10 = septic shock. RESULTS: At T0 there was a greater proportion of SSG patients than SG patients in the highest PCT class [SSG: 30 (69.7% > SG: 14 (29.8%; p 10 = 69.7%; > 2 to 0.5 to < 2 = 11.6%; < 0.5 = 0.0%; p < 0.05. The behavior of procalcitonin at T12h was similar to at T0. The pediatric risk of mortality (PRISM scores for the SSG patients in the highest procalcitonin class were more elevated than for children in the SG [SSG: 35.15 (40.5-28.7 vs. SG: 18.6 (21.4-10.2; p < 0.05]. CONCLUSIONS: Procalcitonin allows sepsis to be differentiated from septic shock, can be of aid when

  11. A qualitative feasibility study to inform a randomised controlled trial of fluid bolus therapy in septic shock

    Science.gov (United States)

    O’Hara, Caitlin B; Canter, Ruth R; Mouncey, Paul R; Carter, Anjali; Jones, Nicola; Nadel, Simon; Peters, Mark J; Lyttle, Mark D; Harrison, David A; Rowan, Kathryn M; Inwald, David; Woolfall, Kerry

    2018-01-01

    Objective The Fluids in Shock (FiSh) Trial proposes to evaluate whether restrictive fluid bolus therapy (10 mL/kg) is more beneficial than current recommended practice (20 mL/kg) in the resuscitation of children with septic shock in the UK. This qualitative feasibility study aimed to explore acceptability of the FiSh Trial, including research without prior consent (RWPC), potential barriers to recruitment and participant information for a pilot trial. Design Qualitative interview study involving parents of children who had presented to a UK emergency department or been admitted to a paediatric intensive care unit with severe infection in the previous 3 years. Participants Twenty-one parents (seven bereaved) were interviewed 16 (median) months since their child’s hospital admission (range: 1–41). Results All parents said they would have provided consent for the use of their child’s data in the FiSh Trial. The majority were unfamiliar with RWPC, yet supported its use. Parents were initially concerned about the change from currently recommended treatment, yet were reassured by explanations of the current evidence base, fluid bolus therapy and monitoring procedures. Parents made recommendations about the timing of the research discussion and content of participant information. Bereaved parents stated that recruiters should not discuss research immediately after a child’s death, but supported a personalised postal ‘opt-out’ approach to consent. Conclusions Findings show that parents whose child has experienced severe infection supported the proposed FiSh Trial, including the use of RWPC. Parents’ views informed the development of the pilot trial protocol and site staff training. Trial registration number ISRCTN15244462—results. PMID:28847877

  12. Infectious Diseases Team for the Early Management of Severe Sepsis and Septic Shock in the Emergency Department.

    Science.gov (United States)

    Viale, Pierluigi; Tedeschi, Sara; Scudeller, Luigia; Attard, Luciano; Badia, Lorenzo; Bartoletti, Michele; Cascavilla, Alessandra; Cristini, Francesco; Dentale, Nicola; Fasulo, Giovanni; Legnani, Giorgio; Trapani, Filippo; Tumietto, Fabio; Verucchi, Gabriella; Virgili, Giulio; Berlingeri, Andrea; Ambretti, Simone; De Molo, Chiara; Brizi, Mara; Cavazza, Mario; Giannella, Maddalena

    2017-10-15

    The impact on patient survival of an infectious disease (ID) team dedicated to the early management of severe sepsis/septic shock (SS/SS) in Emergency Department (ED) has yet to be assessed. A quasiexperimental pre-post study was performed at the general ED of our hospital. During the pre phase (June 2013-July 2014), all consecutive adult patients with SS/SS were managed according to the standard of care, data were prospectively collected. During the post phase (August 2014-October 2015), patients were managed in collaboration with a dedicated ID team performing a bedside patient evaluation within 1 hour of ED arrival. Overall, 382 patients were included, 195 in the pre phase and 187 in the post phase. Median age was 82 years (interquartile range, 70-88). The most common infection sources were lung (43%) and urinary tract (17%); in 22% of cases, infection source remained unknown. During the post phase, overall compliance with the Surviving Sepsis Campaign (SSC) bundle and appropriateness of initial antibiotic therapy improved from 4.6% to 32% (P management of SS/SS in the ED improved the adherence to SSC recommendations and patient survival. © The Author 2017. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.

  13. Aetiology of Bacteraemia as a Risk Factor for Septic Shock at the Onset of Febrile Neutropaenia in Adult Cancer Patients

    Directory of Open Access Journals (Sweden)

    Regis Goulart Rosa

    2014-01-01

    Full Text Available Septic shock (SS at the onset of febrile neutropaenia (FN is an emergency situation that is associated with high morbidity and mortality. The impact of the specific aetiology of bloodstream infections (BSIs in the development of SS at the time of FN is not well established. The aim of this study was to evaluate the association between the aetiology of BSIs and SS at the time of FN in hospitalised adult cancer patients. This prospective cohort study was performed at a single tertiary hospital from October 2009 to August 2011. All adult cancer patients admitted consecutively to the haematology ward with FN were evaluated. A stepwise logistic regression was conducted to verify the association between the microbiological characteristics of BSIs and SS at the onset of FN. In total, 307 cases of FN in adult cancer patients were evaluated. There were 115 cases with documented BSI. A multivariate analysis showed that polymicrobial bacteraemia (P=0.01 was associated with SS. The specific blood isolates independently associated with SS were viridans streptococci (P=0.02 and Escherichia coli (P=0.01. Neutropaenic cancer patients with polymicrobial bacteraemia or BSI by viridans streptococci or Escherichia coli are at increased risk for SS at the time of FN.

  14. Hypoxaemia and septic shock were independent risk factors for mechanical ventilation in Bangladeshi children hospitalised for diarrhoea.

    Science.gov (United States)

    Chisti, Mohammod Jobayer; Shahunja, K M; Afroze, Farzana; Shahid, Abu S M S B; Sharifuzzaman; Ahmed, Tahmeed

    2017-07-01

    In Bangladesh, approximately 6% of children under five years of age die due to diarrhoea. We evaluated the admission and hospitalisation risk factors for mechanical ventilation and outcomes in children with diarrhoea. This retrospective case-control chart analysis was conducted in the intensive care unit of Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh. We enrolled 219 children with diarrhoea aged 0-59 months between August 2009 and July 2013. The 73 cases were children who were initially identified as requiring mechanical ventilation during the study period, and the 146 controls were randomly selected from those who did not require mechanical ventilation. We compared the groups to determine the risk factors for mechanical ventilation. Mortality was significantly higher among the cases than the controls (p mechanical ventilation on admission were hypoxaemia (p mechanical ventilation frequently had hypoxaemia and septic shock and were more likely to die than unventilated controls. ©2017 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.

  15. Fatal Candida septic shock during systemic chemotherapy in lung cancer patient receiving corticosteroid replacement therapy for hypopituitarism. A case report

    International Nuclear Information System (INIS)

    Morichika, Daisuke; Sato-Hisamoto, Akiko; Hotta, Katsuyuki

    2014-01-01

    Invasive candidiasis has increased as nosocomial infection recently in cancer patients who receive systemic chemotherapy, and the timely risk assessment for developing such specific infection is crucial. Especially in those concomitantly with hypopituitarism, febrile neutropenia with candidiasis can cause severe stress and lead potentially to sudden fatal outcome when the temporal steroid coverage for the adrenal insufficiency is not fully administered. We report a 72-year-old male case diagnosed as non-small-cell lung cancer, Stage 3A. He had received a steroid replacement therapy for the prior history of hypophysectomy due to pituitary adenoma with hydrocortisone of 3.3 mg/day, equivalent to prednisolone of 0.8 mg/day. This very small dosage of steroid was hardly supposed to weaken his immune system, but rather potentially led to an inappropriate supplementation of his adrenal function, assuming that the serum sodium and chlorine levels decreased. On Day 6 of second cycle of chemotherapy with carboplatin and paclitaxel, he developed sudden febrile neutropenia, septic shock and ileus, leading to death. After his death, the venous blood culture on Day 7 detected Candida albicans. Autopsy findings showed a massive necrotizing enterocolitis with extensive Candida invasion into submucous tissue. In conclusion, this case may suggest that (1) immediate initiation of antifungal therapy soon after the careful risk assessment of Candida infection and (2) adequate administration of both basal steroid replacement therapy and temporal steroid coverage for febrile neutropenia might have improved his fatal outcome. (author)

  16. Nosography of systemic inflammatory response syndrome, sepsis, severe sepsis, septic shock, and multiple organ dysfunction syndrome in internal medicine patients

    Directory of Open Access Journals (Sweden)

    Silvia Spoto

    2015-09-01

    Full Text Available Sepsis is defined by the presence of at least two systemic inflammatory response syndrome criteria associated with an infection microbiologically or clinically evidenced. In Italy sepsis is responsible for 80,000 hospital admissions per year and, in the last decades, severe sepsis and septic shock cases are increasing, in correlation with the increased prevalence of multi-drugresistant microbial strains. The predominant etiologic agents are Gram-positive and Gram-negative bacteria, but sepsis caused by fungi is increasing. The host response with both inflammatory and anti-inflammatory processes is responsible for organic failures, which complicate the syndrome, and for the susceptibility to secondary infections. The impairment of one or more organs or systems may be the onset clinical presentation. The organ dysfunctions complicating sepsis involve mainly cardiorespiratory system, kidneys, hemostatis and central nervous system. Fever or hypothermia, tachycardia, tachypnea, leukocytosis or leukopenia, elevated blood levels of lactate and procalcitonin, hypotension are diagnostically sensitive findings for sepsis. Definitive diagnosis requires isolation of the pathogen from blood sample or from the focus of infection. Therapeutic success against sepsis depends on the appropriate use of antibiotics, on the treatment of hemodynamic and respiratory disorder and on general supportive care. In some cases the use of activated protein C is to take in consideration.

  17. 4G/5G polymorphism of PAI-1 gene is associated with multiple organ dysfunction and septic shock in pneumonia induced severe sepsis: prospective, observational, genetic study.

    Science.gov (United States)

    Madách, Krisztina; Aladzsity, István; Szilágyi, Agnes; Fust, George; Gál, János; Pénzes, István; Prohászka, Zoltán

    2010-01-01

    Activation of inflammation and coagulation are closely related and mutually interdependent in sepsis. The acute-phase protein, plasminogen activator inhibitor-1 (PAI-1) is a key element in the inhibition of fibrinolysis. Elevated levels of PAI-1 have been related to worse outcome in pneumonia. We aimed to evaluate the effect of functionally relevant 4G/5G polymorphism of PAI-1 gene in pneumonia induced sepsis. We enrolled 208 Caucasian patients with severe sepsis due to pneumonia admitted to an intensive care unit (ICU). Patients were followed up until ICU discharge or death. Clinical data were collected prospectively and the PAI-1 4G/5G polymorphism was genotyped by polymerase chain reaction-restriction fragment length polymorphism technique. Patients were stratified according to the occurrence of multiple organ dysfunction syndrome, septic shock or death. We found that carriers of the PAI-1 4G/4G and 4G/5G genotypes have a 2.74-fold higher risk for multiple organ dysfunction syndrome (odds ratio [OR] 95% confidence interval [CI] = 1.335 - 5.604; p = 0.006) and a 2.57-fold higher risk for septic shock (OR 95%CI = 1.180 - 5.615; p = 0.018) than 5G/5G carriers. The multivariate logistic regression analysis adjusted for independent predictors, such as age, nosocomial pneumonia and positive microbiological culture also supported that carriers of the 4G allele have a higher prevalence of multiple organ dysfunction syndrome (adjusted odds ratio [aOR] = 2.957; 95%CI = 1.306 -6.698; p = 0.009) and septic shock (aOR = 2.603; 95%CI = 1.137 - 5.959; p = 0.024). However, genotype and allele analyses have not shown any significant difference regarding mortality in models non-adjusted or adjusted for acute physiology and chronic health evaluation (APACHE) II. Patients bearing the 4G allele had higher disseminated intravascular coagulation (DIC) score at admission (p = 0.007) than 5G/5G carriers. Moreover, in 4G allele carriers the length of ICU stay of non-survivors was longer

  18. Simvastatin and a plant galactolipid protect animals from septic shock by regulating oxylipin mediator dynamics through the MAPK-cPLA2 signaling pathway.

    Science.gov (United States)

    Apaya, Maria Karmella; Lin, Chih-Yu; Chiou, Ching-Yi; Yang, Chung-Chih; Ting, Chen-Yun; Shyur, Lie-Fen

    2015-12-14

    Sepsis remains a major medical issue despite decades of research. Identification of important inflammatory cascades and key molecular mediators are crucial for developing intervention and prevention strategies. In this study, we conducted a comparative oxylipin metabolomics study to gain a comprehensive picture of lipid mediator dynamics during the initial hyper-inflammatory phase of sepsis, and demonstrated, in parallel, the efficacy of simvastatin and plant galactolipid, 1,2-di-O-α-linolenoyl-3-O-β-galactopyranosyl-sn-glycerol (dLGG) in the homeostatic regulation of the oxylipin metabolome using a lipopolysaccharide (LPS)-induced sepsis C57BL/6J mouse model. LPS increased the systemic and organ levels of pro-inflammatory metabolites of linoleic acid including leukotoxin diols, i.e., 9,10-DHOME, 12,13-DHOME, and octadecadienoic acids, i.e., 9-HODE and 13-HODE; and arachidonic acid-derived prostanoid, PGE 2 , and hydroxyeicosatetraenoic acids, i.e., 8, 12- and 15-HETE. Treatment with either compound decreased the levels of pro-inflammatory metabolites and elevated pro-resolution lipoxin A 4 , 5(6)-EET, 11(12)-EET and 15-deoxy-PGJ 2 . dLGG and simvastatin ameliorated the effects of LPS-induced MAPK-dependent activation of cPLA 2 , cyclooxygenase-2, lipoxygenase, cytochrome P450, and/or epoxide hydrolase, lowered systemic TNF-α and IL-6 levels and aminotransferase activities and decreased organ-specific infiltration of inflammatory leukocytes and macrophages, and septic shock-induced multiple organ damage. Furthermore, both dLGG and simvastatin increased the survival rates in the cecal ligation and puncture (CLP) sepsis model. This study provides new insights into the role of oxylipins in sepsis pathogenesis and highlights the potential of simvastatin and dLGG in sepsis therapy and prevention.

  19. Hemofiltrastion does not influence early S-100B serum levels in septic shock patients receiving stress doses of hydrocortisone or placebo.

    Science.gov (United States)

    Mussack, Thomas; Briegel, J; Schelling, G; Jochum, M

    2005-01-28

    The prognosis in patients with hyperdynamic septic shock correlates with the presence and the severity of septic encephalopathy. However, the neurological evaluation is considerably influenced by the use of analgesia sedation during mechanical ventilation. An early concentration peak of the neuroprotein S-100B in serum reflects both cellular damage at an increased permeability of the blood-brain-barrier and a delayed renal elimination. Thus, the objective of this study was to analyze the effect of continuous veno-venous hemofiltration (CVVH) on early S-100B serum levels in septic shock patients, who were treated with either stress doses of hydrocortisone or placebo. Twenty-four consecutive patients, who met the ACCP / SCCM criteria for septic shock, were enrolled in this prospective, randomised, double-blind, single-center trial. The severity of illness at recruitment was graded using the APACHE II and SAPS II scoring systems; the MODS was described by the SOFA score. All patients were prospectively randomised to receive either stress doses of hydrocortisone or placebo. Hydrocortisone was started in 12 patients with a loading dose of 100 mg and followed by a continuous infusion of 0.18 mg/kg/h for 6 days. Median S-100B serum levels of the hydrocortisone group decreased from 0.32 ng/ml (0.19-.60) at study entry to 0.07 ng/ml (0.04-0.32) 6 days later without significant differences compared to the placebo group. Patients undergoing CVVH showed significantly higher S-100B serum values compared to patients without CVVH (p>0.001). However, initial median S-100B serum levels of the CVVH group even increased from 0.92 ng/ml (0.16 - 4.63) to 2.33 ng/ml (0.59-2.44) 30 hours after study entry, reaching data ranges already known in patients with out-of-hospital cardiac arrest or severe traumatic brain injury. Early S-100B serum levels in septic shock patients receiving either stress doses of hydrocortisone or placebo were not influenced by CVVH. For the first time, we

  20. Persistent hyperlactatemia-high central venous-arterial carbon dioxide to arterial-venous oxygen content ratio is associated with poor outcomes in early resuscitation of septic shock.

    Science.gov (United States)

    Zhou, Juandi; Song, Jia; Gong, Shijin; Li, Li; Zhang, Haixiang; Wang, Minjia

    2017-08-01

    Several studies reported Pv-aCO 2 /Ca-vO 2 ratio as a surrogate of VCO 2 /VO 2 to detect global tissue hypoxia. The present study aimed to evaluate the prognostic value of Pv-aCO 2 /Ca-vO 2 ratio combined with lactate levels during the early phases of resuscitation in septic shock. A retrospective study was conducted in 144 septic shock patients in a 30-bed mixed ICU. A Pv-aCO 2 /Ca-vO 2 ratio>1.4 was considered abnormal. Patients were classified into four predefined groups according to lactate levels and Pv-aCO 2 /Ca-vO 2 ratio after the first 6h of resuscitation. Sequential Organ Failure Assessment (SOFA) score at day 3 was assessed. A Kaplan-Meier curve showed the survival probabilities at day 28 using a log-rank test to evaluate the differences between groups. A receiver operating characteristics (ROC) curve evaluated the ability of lactate, Pv-aCO 2 /Ca-vO 2 ratio and Pv-aCO 2 /Ca-vO 2 ratio combined with lactate to predict mortality at day 28. Combination of hyperlactatemia and high Pv-aCO 2 /Ca-vO 2 ratio was associated with poor SOFA scores and low survival rates at day 28 (Pseptic shock can better predict the prognosis of patients. The Pv-aCO 2 /Ca-vO 2 ratio may become a useful parameter supplementary to lactate in the resuscitation of septic shock. Copyright © 2017 Elsevier Inc. All rights reserved.

  1. Clinical practice parameters for hemodynamic support of pediatric and neonatal septic shock: 2007 update from the American College of Critical Care Medicine

    Science.gov (United States)

    Brierley, Joe; Carcillo, Joseph A.; Choong, Karen; Cornell, Tim; DeCaen, Allan; Deymann, Andreas; Doctor, Allan; Davis, Alan; Duff, John; Dugas, Marc-Andre; Duncan, Alan; Evans, Barry; Feldman, Jonathan; Felmet, Kathryn; Fisher, Gene; Frankel, Lorry; Jeffries, Howard; Greenwald, Bruce; Gutierrez, Juan; Hall, Mark; Han, Yong Y.; Hanson, James; Hazelzet, Jan; Hernan, Lynn; Kiff, Jane; Kissoon, Niranjan; Kon, Alexander; Irazusta, Jose; Lin, John; Lorts, Angie; Mariscalco, Michelle; Mehta, Renuka; Nadel, Simon; Nguyen, Trung; Nicholson, Carol; Peters, Mark; Okhuysen-Cawley, Regina; Poulton, Tom; Relves, Monica; Rodriguez, Agustin; Rozenfeld, Ranna; Schnitzler, Eduardo; Shanley, Tom; Skache, Sara; Skippen, Peter; Torres, Adalberto; von Dessauer, Bettina; Weingarten, Jacki; Yeh, Timothy; Zaritsky, Arno; Stojadinovic, Bonnie; Zimmerman, Jerry; Zuckerberg, Aaron

    2013-01-01

    Background The Institute of Medicine calls for the use of clinical guidelines and practice parameters to promote “best practices” and to improve patient outcomes. Objective 2007 update of the 2002 American College of Critical Care Medicine Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock. Participants Society of Critical Care Medicine members with special interest in neonatal and pediatric septic shock were identified from general solicitation at the Society of Critical Care Medicine Educational and Scientific Symposia (2001–2006). Methods The Pubmed/MEDLINE literature database (1966–2006) was searched using the keywords and phrases: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation (ECMO), and American College of Critical Care Medicine guidelines. Best practice centers that reported best outcomes were identified and their practices examined as models of care. Using a modified Delphi method, 30 experts graded new literature. Over 30 additional experts then reviewed the updated recommendations. The document was subsequently modified until there was greater than 90% expert consensus. Results The 2002 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and AHA sanctioned recommendations. Centers that implemented the 2002 guidelines reported best practice outcomes (hospital mortality 1%–3% in previously healthy, and 7%– 10% in chronically ill children). Early use of 2002 guidelines was associated with improved outcome in the community hospital emergency department (number needed to treat = 3.3) and tertiary pediatric intensive care setting (number needed to treat = 3.6); every hour that went by without guideline adherence was associated with a 1.4-fold increased mortality risk. The updated 2007 guidelines continue to recognize an increased likelihood that

  2. Early induction of direct hemoperfusion with a polymyxin-B immobilized column is associated with amelioration of hemodynamic derangement and mortality in patients with septic shock.

    Science.gov (United States)

    Chihara, Shinya; Masuda, Yoshiki; Tatsumi, Hiroomi; Nakano, Kota; Shimada, Tomokazu; Murohashi, Takao; Yamakage, Michiaki

    2017-03-01

    This study was conducted to clarify the effectiveness of induction timing of direct hemoperfusion with a polymyxin-B immobilized column (PMX-DHP) for amelioration of hemodynamic derangement and outcome in patients with septic shock. Suspected Gram-negative septic shock patients who received PMX-DHP therapy from January 2010 to December 2014 in our ICU were enrolled in this study. The patients were divided into two groups that received PMX-DHP therapy within 8 h (early group) and more than 8 h (late group) from catecholamine administration. Changes in catecholamine dose [catecholamine index (CAI)], catecholamine dose/mean arterial pressure [catecholamine index pressure (CAIP)], PaO 2 /FiO 2 and PEEP level were determined at the start of and 24 h after the start of PMX-DHP therapy. Ventilator-free days (VFD), ICU-free days (IFD), 28-day and hospital mortality were also determined. There were no significant differences in patients' characteristics between the two groups. CAI and CAIP were significantly decreased in the early group. PaO 2 /FiO 2 was not changed whereas PEEP level in the early group was significantly decreased during PMX-DHP therapy. IFD and VFD were not different in the two groups. Mortality at 28 days was significantly improved in the early group. Endotoxin acts as an early mediator in sepsis patients with suspected Gram-negative infection. Earlier induction of PMX-DHP therapy as in our study is closely associated with earlier weaning from hemodynamic derangement and with improvement of mortality. Therefore, early induction of PMX-DHP therapy is recommended for the treatment of septic shock in patients with presumed Gram-negative infection.

  3. Association between exposure to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers prior to septic shock and acute kidney injury.

    Science.gov (United States)

    Suberviola, B; Rodrigo, E; González-Castro, A; Serrano, M; Heras, M; Castellanos-Ortega, Á

    To evaluate the association between angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) use prior to a septic shock episode and the development, prognosis and long-term recovery from acute kidney injury (AKI). A single-centre, prospective observational study was carried out between September 2005 and August 2010. Patients admitted to the ICU of a third level hospital. A total of 386 septic shock patients were studied. None. Use of ACEIs/ARBs, AKI development, recovery of previous creatinine levels and time to recovery. A total of 386 patients were included, of which 312 (80.8%) developed AKI during ICU stay and 23% were receiving ACEIs/ARBs. The percentage of patients on ACEIs/ARBs increased significantly in relation to more severe stages of AKI irrespective of the kind of AKI score. After adjusting for confounders, the development of AKI was independently associated to the use of ACEIs/ARBs (OR 2.19; 95%CI 1.21-3.84; p=.04). With respect to the recovery of kidney function, the group of patients on ACEIs/ARBs had significantly higher creatinine levels at ICU discharge and needed hemodialysis more frequently thereafter. However, use of ACEIs/ARBs affected neither recovery of previous creatinine levels nor significantly delayed recovery. The use of ACEIs/ARBs before septic shock episodes was correlated to AKI development and severity, but did not affect the recovery of kidney function after sepsis resolution. Copyright © 2016 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

  4. Soluble membrane receptors, interleukin 6, procalcitonin and C reactive protein as prognostic markers in patients with severe sepsis and septic shock.

    Directory of Open Access Journals (Sweden)

    Juan-Jesús Ríos-Toro

    Full Text Available The objective of this study was to explore the diagnostic and prognostic value of soluble triggering receptor expressed on myeloid cell 1 (sTREM-1, soluble cluster of differentiation 14 (sCD14, soluble cluster of differentiation 163 (sCD163, interleukin-6 (IL-6, procalcitonin (PCT, and C-reactive protein (CRP serum levels for patients with severe sepsis and septic shock in an intensive care unit (ICU.Fifty patients admitted at the ICU with the diagnosis of severe sepsis or septic shock were studied. SOFA and APACHE II scores as well as serum biomarkers were measured at days 0, 2 and 5. The influence of these variables on 28-day mortality was analyzed. Twenty healthy individuals served as controls.Baseline serum concentrations of sTREM-1, sCD163, IL-6 and PCT correlated with SOFA score. Only sTREM-1 levels correlated with APACHE II score. The 28-day mortality rate for all patients was 42%. The absence of risk factors for infection, presence of septic shock, baseline values of sCD14 and decrease of PCT and IL-6 from baseline to day 5 were variables associated to mortality in the univariate analysis. The unique independent factor associated to mortality in the multivariate analysis was a decrease of PCT higher than 50% from days 0 to 5.Serum levels of sTREM-1 are correlated with the severity of sepsis. A 50% decrease of PCT was the unique variable associated with survival in the multivariate analysis.

  5. Early goal-directed therapy in pediatric septic shock: comparison of outcomes "with" and "without" intermittent superior venacaval oxygen saturation monitoring: a prospective cohort study*.

    Science.gov (United States)

    Sankar, Jhuma; Sankar, M Jeeva; Suresh, C P; Dubey, Nandkishore K; Singh, Archana

    2014-05-01

    To evaluate the effect of intermittent central venous oxygen saturation monitoring (ScvO(2)) on critical outcomes in children with septic shock, as continuous monitoring may not be feasible in most resource-restricted settings. Prospective cohort study. PICU of a tertiary care teaching hospital. Consecutive children younger than 17 years with fluid refractory septic shock admitted to our ICU from November 2010 to October 2012 were included. Enrolled children were subjected to subclavian/internal jugular catheter insertion. Those in whom it was successful formed the "exposed" group (ScvO(2) group), whereas the rest constituted the control group (no ScvO(2) group). In the former group, intermittent ScvO(2) monitoring at 1, 3, and 6 hours was used to guide resuscitation, whereas in the latter, only clinical variables were used. The major outcomes were in-hospital mortality and achievement of therapeutic goals within first 6 hours. One hundred twenty children were enrolled in the study-63 in the ScvO(2) group and 57 in the no ScvO(2) group. Baseline characteristics including the organ dysfunction and mortality risk scores were comparable between the groups. Children in the ScvO(2) group had significantly lower in-hospital mortality (33.3% vs 54%; relative risk, 0.61; 95% CI, 0.4, 0.93; number needed to treat, 5; 95% CI, 3, 27). A greater proportion of children in exposed group achieved therapeutic endpoints in first 6 hours (43% vs 23%, p = 0.02) and during entire ICU stay (71% vs 51%, p = 0.02). The mean number of dysfunctional organs was also significantly lesser in ScvO(2) group in comparison with no ScvO(2) group (2 vs 3, p therapy using intermittent ScvO(2) monitoring seemed to reduce the mortality rates and improved organ dysfunction in children with septic shock as compared with those without such monitoring.

  6. Class A CpG Oligonucleotide Priming Rescues Mice from Septic Shock via Activation of Platelet-Activating Factor Acetylhydrolase

    Directory of Open Access Journals (Sweden)

    Yoshinari Yamamoto

    2017-08-01

    Full Text Available Sepsis is a life-threatening, overwhelming immune response to infection with high morbidity and mortality. Inflammatory response and blood clotting are caused by sepsis, which induces serious organ damage and death from shock. As a mechanism of pathogenesis, platelet-activating factor (PAF induces excessive inflammatory responses and blood clotting. In this study, we demonstrate that a Class A CpG oligodeoxynucleotide (CpG-A1585 strongly induced PAF acetylhydrolase, which generates lyso-PAF. CpG-A1585 rescued mice from acute lethal shock and decreased fibrin deposition, a hallmark of PAF-induced disseminated intravascular coagulation. Furthermore, CpG-A1585 improved endotoxin shock induced by lipopolysaccharide, which comprises the cell wall of Gram-negative bacteria and inhibits inflammatory responses induced by cytokines such as interleukin-6 and tumor necrosis factor-α. These results suggest that CpG-A1585 is a potential therapeutic target to prevent sepsis-related induction of PAF.

  7. The effect of ex vivo CDDO-Me activation on nuclear factor erythroid 2-related factor 2 pathway in white blood cells from patients with septic shock.

    Science.gov (United States)

    Noel, Sanjeev; Zheng, Laura; Navas-Acien, Ana; Fuchs, Ralph J

    2014-11-01

    Nuclear factor erythroid 2-related factor 2 (NRF2) has been shown to protect against experimental sepsis in mice and lipopolysaccharide (LPS)-induced inflammation in ex vivo white blood cells from healthy subjects by upregulating cellular antioxidant genes. The objective of this study was to test the hypothesis that ex vivo methyl 2-cyano-3,12-dioxoolean-1,9-dien-28-oate (CDDO-Me) activates NRF2-regulated antioxidant genes in white blood cells from patients with septic shock and protects against LPS-induced inflammation and reactive oxidative species production. Peripheral blood was collected from 18 patients with septic shock who were being treated in medical and surgical intensive care units. Real-time polymerase chain reaction was used to quantify the expression of NRF2 target genes (NQO1, HO-1, GCLM, and FTL) and IL-6 in peripheral blood mononuclear cells (PBMCs), monocytes, and neutrophils after CDDO-Me treatment alone or after subsequent LPS exposure. Superoxide anion (O2) was measured to assess the effect of CDDO-Me pretreatment on subsequent LPS exposure. Treatment with CDDO-Me increased the gene expression of NQO1 (P = 0.04) and decreased the expression of HO-1 (P = 0.03) in PBMCs from patients with septic shock. Purified monocytes exhibited significant increases in the expression of NQO1 (P = 0.01) and GCLM (P = 0.003) after CDDO-Me treatment. Levels of other NRF2 target genes (HO-1 and FTL) remained similar to those of vehicle-treated cells. Peripheral blood mononuclear cells showed a trend toward increased IL-6 gene expression after CDDO-Me treatment, whereas purified monocytes showed a trend toward decreased IL-6. There was no discernible trend in the IL-6 expression subsequent to LPS treatment in either vehicle-treated or CDDO-Me-treated PBMCs and monocytes. Treatment with CDDO-Me significantly increased O2 production in PBMCs (P = 0.04). Although CDDO-Me pretreatment significantly attenuated O2 production to subsequent LPS exposure (P = 0.03), the

  8. Temperature variability analysis using wavelets and multiscale entropy in patients with systemic inflammatory response syndrome, sepsis, and septic shock.

    Science.gov (United States)

    Papaioannou, Vasilios E; Chouvarda, Ioanna G; Maglaveras, Nikos K; Pneumatikos, Ioannis A

    2012-12-12

    Even though temperature is a continuous quantitative variable, its measurement has been considered a snapshot of a process, indicating whether a patient is febrile or afebrile. Recently, other diagnostic techniques have been proposed for the association between different properties of the temperature curve with severity of illness in the Intensive Care Unit (ICU), based on complexity analysis of continuously monitored body temperature. In this study, we tried to assess temperature complexity in patients with systemic inflammation during a suspected ICU-acquired infection, by using wavelets transformation and multiscale entropy of temperature signals, in a cohort of mixed critically ill patients. Twenty-two patients were enrolled in the study. In five, systemic inflammatory response syndrome (SIRS, group 1) developed, 10 had sepsis (group 2), and seven had septic shock (group 3). All temperature curves were studied during the first 24 hours of an inflammatory state. A wavelet transformation was applied, decomposing the signal in different frequency components (scales) that have been found to reflect neurogenic and metabolic inputs on temperature oscillations. Wavelet energy and entropy per different scales associated with complexity in specific frequency bands and multiscale entropy of the whole signal were calculated. Moreover, a clustering technique and a linear discriminant analysis (LDA) were applied for permitting pattern recognition in data sets and assessing diagnostic accuracy of different wavelet features among the three classes of patients. Statistically significant differences were found in wavelet entropy between patients with SIRS and groups 2 and 3, and in specific ultradian bands between SIRS and group 3, with decreased entropy in sepsis. Cluster analysis using wavelet features in specific bands revealed concrete clusters closely related with the groups in focus. LDA after wrapper-based feature selection was able to classify with an accuracy of more

  9. Effect of stress doses of hydrocortisone on S-100B vs. interleukin-8 and polymorphonuclear elastase levels in human septic shock.

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    Mussack, Thomas; Briegel, Josef; Schelling, Gustav; Biberthaler, Peter; Jochum, Marianne

    2005-01-01

    Stress doses of hydrocortisone are known to have immunomodulatory effects in patients with hyperdynamic septic shock. The prognosis correlates with the presence and severity of septic encephalopathy. However, neurological evaluation is influenced by the use of analgesia sedation during artificial ventilation. The objective of this study was to demonstrate the effect of stress doses of hydrocortisone during the initial phase of human septic shock on the serum values of the neurospecific protein S-100B in comparison to the inflammation markers interleukin (IL)-8 in serum and polymorphonuclear (PMN) elastase in plasma. A total of 24 consecutive patients, who met the American College of Chest Physicians/Society of Critical Care Medicine criteria for septic shock, were enrolled in this prospective, randomized, double-blind, single-center trial. The severity of illness at recruitment was graded using the Acute Physiology and Chronic Health Evaluation II and the Simplified Acute Physiology Score II scoring systems. Multi-organ dysfunction syndrome was described by the Sepsis-related Organ Failure Assessment (SOFA) score. All patients were prospectively randomized to receive either stress doses of hydrocortisone or placebo. Hydrocortisone was started in 12 patients with a loading dose of 100 mg and followed by a continuous infusion of 0.18 mg/kg/h for 6 days. Median S-100B serum levels of the hydrocortisone group decreased from 0.32 ng/mL at study entry to 0.07 ng/mL 6 days later without significant differences compared to the placebo group. Initial IL-8 serum levels were significantly higher in the hydrocortisone group up to 12 h after study entry, and significantly decreased from 715 to 17 pg/mL at the end of the observation period. Median PMN elastase plasma levels were not affected by hydrocortisone infusion. Patients with initial S-100B serum levels > 0.50 ng/mL revealed significantly higher SOFA scores up to 30 h, IL-8 serum levels up to 12 h, and PMN elastase plasma

  10. From amino acids polymers, antimicrobial peptides, and histones, to their possible role in the pathogenesis of septic shock: a historical perspective

    Directory of Open Access Journals (Sweden)

    Ginsburg I

    2017-02-01

    Full Text Available Isaac Ginsburg,1 Peter Vernon van Heerden,2 Erez Koren1 1Institute of Dental Sciences, Faculty of Dental Medicine, The Hebrew University of Jerusalem, 2General Intensive Care Unit, Hadassah University Hospital, Jerusalem, Israel Abstract: This paper describes the evolution of our understanding of the biological role played by synthetic and natural antimicrobial cationic peptides and by the highly basic nuclear histones as modulators of infection, postinfectious sequelae, trauma, and coagulation phenomena. The authors discuss the effects of the synthetic polymers of basic poly α amino acids, poly l-lysine, and poly l-arginine on blood coagulation, fibrinolysis, bacterial killing, and blood vessels; the properties of natural and synthetic antimicrobial cationic peptides as potential replacements or adjuncts to antibiotics; polycations as opsonizing agents promoting endocytosis/phagocytosis; polycations and muramidases as activators of autolytic wall enzymes in bacteria, causing bacteriolysis and tissue damage; and polycations and nuclear histones as potential virulence factors and as markers of sepsis, septic shock, disseminated intravasclar coagulopathy, acute lung injury, pancreatitis, trauma, and other additional clinical disorders Keywords: histones, sepsis, septic shock

  11. Initial fractal exponent of heart rate variability is associated with success of early resuscitation in patients with severe sepsis or septic shock: a prospective cohort study.

    Science.gov (United States)

    Brown, Samuel M; Tate, Quinn; Jones, Jason P; Knox, Daniel B; Kuttler, Kathryn G; Lanspa, Michael; Rondina, Matthew T; Grissom, Colin K; Behera, Subhasis; Mathews, V J; Morris, Alan

    2013-12-01

    Heart rate variability (HRV) reflects autonomic nervous system tone as well as the overall health of the baroreflex system. We hypothesized that loss of complexity in HRV upon intensive care unit (ICU) admission would be associated with unsuccessful early resuscitation of sepsis. We prospectively enrolled patients admitted to ICUs with severe sepsis or septic shock from 2009 to 2011. We studied 30 minutes of electrocardiogram, sampled at 500 Hz, at ICU admission and calculated heart rate complexity via detrended fluctuation analysis. Primary outcome was vasopressor independence at 24 hours after ICU admission. Secondary outcome was 28-day mortality. We studied 48 patients, of whom 60% were vasopressor independent at 24 hours. Five (10%) died within 28 days. The ratio of fractal alpha parameters was associated with both vasopressor independence and 28-day mortality (P = .04) after controlling for mean heart rate. In the optimal model, Sequential Organ Failure Assessment score and the long-term fractal α parameter were associated with vasopressor independence. Loss of complexity in HRV is associated with worse outcome early in severe sepsis and septic shock. Further work should evaluate whether complexity of HRV could guide treatment in sepsis. © 2013.

  12. Classification of sepsis, severe sepsis and septic shock: the impact of minor variations in data capture and definition of SIRS criteria.

    Science.gov (United States)

    Klein Klouwenberg, Peter M C; Ong, David S Y; Bonten, Marc J M; Cremer, Olaf L

    2012-05-01

    To quantify the effects of minor variations in the definition and measurement of systemic inflammatory response syndrome (SIRS) criteria and organ failure on the observed incidences of sepsis, severe sepsis and septic shock. We conducted a prospective, observational study in a tertiary intensive care unit in The Netherlands between January 2009 and October 2010. A total of 1,072 consecutive adults were included. We determined the upper and lower limits of the measured incidence of sepsis by evaluating the influence of the use of an automated versus a manual method of data collection, and variations in the number of SIRS criteria, concurrency of SIRS criteria, and duration of abnormal values required to make a particular diagnosis. The measured incidence of SIRS varied from 49% (most restrictive setting) to 99% (most liberal setting). Subsequently, the incidences of sepsis, severe sepsis and septic shock ranged from 22 to 31%, from 6 to 27% and from 4 to 9% for the most restrictive versus the most liberal measurement settings, respectively. In non-infected patients, 39-98% of patients had SIRS, whereas still 17-6% of patients without SIRS had an infection. The apparent incidence of sepsis heavily depends on minor variations in the definition of SIRS and mode of data recording. As a consequence, the current consensus criteria do not ensure uniform recruitment of patients into sepsis trials.

  13. Impact of serial measurements of lysophosphatidylcholine on 28-day mortality prediction in patients admitted to the intensive care unit with severe sepsis or septic shock.

    Science.gov (United States)

    Park, Dong Won; Kwak, Dong Shin; Park, Yun Young; Chang, Youjin; Huh, Jin Won; Lim, Chae-Man; Koh, Younsuck; Song, Dong-Keun; Hong, Sang-Bum

    2014-10-01

    The purpose of this study is to investigate the effect of serial lysophosphatidylcholine (LPC) measurement on 28-day mortality prediction in patients with severe sepsis or septic shock admitted to the medical intensive care unit (ICU). This is a prospective observational study of 74 ICU patients in a tertiary hospital. Serum LPC, white blood cell, C-reactive protein, and procalcitonin (PCT) levels were measured at baseline (day 1 of enrollment) and day 7. The LPC concentrations were compared with inflammatory markers using their absolute levels and relative changes. The LPC concentration on day 7 was significantly lower in nonsurvivors than in survivors (68.45 ± 42.36 μmol/L and 99.76 ± 73.65 μmol/L; P = .04). A decreased LPC concentration on day 7 to its baseline as well as a sustained high concentration of PCT on day 7 at more than 50% of its baseline value was useful for predicting the 28-day mortality. Prognostic utility was substantially improved when combined LPC and PCT criteria were applied to 28-day mortality outcome predictions. Furthermore, LPC concentrations increased over time in patients with appropriate antibiotics but not in those with inappropriate antibiotics. Serial measurements of LPC help in the prediction of 28-day mortality in ICU patients with severe sepsis or septic shock. Copyright © 2014 Elsevier Inc. All rights reserved.

  14. Typhi–Induced Septic Shock and Acute Respiratory Distress Syndrome in a Previously Healthy Teenage Patient Treated With High-Dose Dexamethasone

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    Melissa Brosset Ugas MD

    2016-05-01

    Full Text Available Typhoid fever is commonly characterized by fever and abdominal pain. Rare complications include intestinal hemorrhage, bowel perforation, delirium, obtundation, and septic shock. Herein we describe the case of a previously healthy 16-year-old male without history of travel, diagnosed with typhoid fever complicated by septic shock and acute respiratory distress syndrome treated with high-dose dexamethasone. This case details severe complications of typhoid fever that are uncommonly seen in developed countries, and the successful response to high-dose dexamethasone as adjunct therapy. High-dose dexamethasone treatment has reportedly decreased Salmonella Typhi mortality, but controlled studies specifically performed in children are lacking, and most reports of its use are over 30 years old and all have originated in developing countries. Providers should include Salmonella Typhi in the differential diagnosis of the pediatric patient with fever, severe abdominal pain, and enteritis, and be aware of its potentially severe complications and the limited data on safety and efficacy of adjunctive therapies that can be considered in addition to antibiotics.

  15. The duration of hypotension before the initiation of antibiotic treatment is a critical determinant of survival in a murine model of Escherichia coli septic shock: association with serum lactate and inflammatory cytokine levels.

    Science.gov (United States)

    Kumar, Anand; Haery, Cameron; Paladugu, Bhanu; Kumar, Aseem; Symeoneides, Simon; Taiberg, Leo; Osman, Jailan; Trenholme, Gordon; Opal, Steven M; Goldfarb, Roy; Parrillo, Joseph E

    2006-01-15

    This study was designed to examine the relationship between the timing of antibiotic treatment and both survival rates and hemodynamic/inflammatory correlates of survival in a murine model of Escherichia coli septic shock. Surgical implantation of an E. coli (O18:K1:H7)-laced, gelatin capsule-encased fibrinogen clot was used to generate a bacteremic model of murine septic shock. Survival duration, hemodynamic responses, and circulating serum tumor necrosis factor (TNF)-alpha , interleukin (IL)-6, and lactate levels were assessed in relation to increasing delays in or absence of antibiotic treatment. A critical inflection point with respect to survival occurred between 12 and 15 h after implantation. When initiated at or before 12 h, antibiotic treatment resulted in 85% mortality. Physiologically relevant hypotension developed in untreated septic mice by 12 h after implantation. Values for heart rate differed between untreated septic mice and sham-infected control mice by 6 h after implantation, whereas values for cardiac output and stroke volume did not differ until at least 18-24 h after implantation. Antibiotic treatment initiated > or = 12 h after implantation was associated with persistence of increased circulating serum lactate, TNF- alpha , and IL-6 levels. The timing of antibiotic treatment relative to hypotension is closely associated with survival in this murine model of septic shock. Delay in antibiotic treatment results in the persistence of inflammatory/stress markers even after antibiotic treatment is initiated.

  16. Is the inferior vena cava diameter measured by bedside ultrasonography valuable in estimating the intravascular volume in patients with septic shock?

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    Mortaza Talebi Doluie

    2016-07-01

    Full Text Available Introduction:Resuscitation should be initiated immediately in shock. Early goal-directed therapy is an established algorithm for the resuscitation in septic shock. The first step is to maintain cardiac preload. Central venous pressure (CVP plays an important role in goal-directed therapy. Central venous catheterization is invasive and time-consuming in emergency conditions. There are some alternative and noninvasive methods for estimating the intravascular volume such as measuring the inferior vena cava (IVC diameter by ultrasonography. Methods: We searched PubMed, Google scholar, and Scopus databases with keywords (central venous pressure OR venous pressure OR CVP AND (ultrasonography OR sonography AND (sepsis OR septic shock AND (inferior vena cava OR IVC.Result: The search resulted in 2550 articles. The articles were appraised regarding the relevance, type of article, and statistical methods. Finally, 12 articles were selected. The number of patients was between 30 and 83 cases (mean age=57-67 years, intubated and non-intubated in each study. The IVC diameter was measured in respiratory cycle by bedside ultrasonography in longitudinal subxiphoid view and caval index was calculated, then they were compared with the CVP measured by central venous catheter.Discussion: CVP is an indicator of intravascular fluid status and right heart function. CVP measurement is an invasive method and of course with some complications. The IVC is the biggest vein of venous system with low-pressure; expansion of the vein reflects intravascular volume.Conclusion: It seems that IVC diameter measured by ultrasonography could be used as an alternative method for the determination of CVP in the emergency or critical patients.

  17. Long-term outcomes in patients with septic shock transfused at a lower versus a higher haemoglobin threshold: the TRISS randomised, multicentre clinical trial.

    Science.gov (United States)

    Rygård, Sofie L; Holst, Lars B; Wetterslev, Jørn; Winkel, Per; Johansson, Pär I; Wernerman, Jan; Guttormsen, Anne B; Karlsson, Sari; Perner, Anders

    2016-11-01

    We assessed the predefined long-term outcomes in patients randomised in the Transfusion Requirements in Septic Shock (TRISS) trial. In 32 Scandinavian ICUs, we randomised 1005 patients with septic shock and haemoglobin of 9 g/dl or less to receive single units of leuko-reduced red cells when haemoglobin level was 7 g/dl or less (lower threshold) or 9 g/dl or less (higher threshold) during ICU stay. We assessed mortality rates 1 year after randomisation and again in all patients at time of longest follow-up in the intention-to-treat population (n = 998) and health-related quality of life (HRQoL) 1 year after randomisation in the Danish patients only (n = 777). Mortality rates in the lower- versus higher-threshold group at 1 year were 53.5 % (268/501 patients) versus 54.6 % (271/496) [relative risk 0.97; 95 % confidence interval (CI) 0.85-1.09; P = 0.62]; at longest follow-up (median 21 months), they were 56.7 % (284/501) versus 61.0 % (302/495) (hazard ratio 0.88; 95 % CI 0.75-1.03; P = 0.12). We obtained HRQoL data at 1 year in 629 of the 777 (81 %) Danish patients, and mean differences between the lower- and higher-threshold group in scores of physical HRQoL were 0.4 (95 % CI -2.4 to 3.1; P = 0.79) and in mental HRQoL 0.5 (95 % CI -3.1 to 4.0; P = 0.79). Long-term mortality rates and HRQoL did not differ in patients with septic shock and anaemia who were transfused at a haemoglobin threshold of 7 g/dl versus a threshold of 9 g/dl. We may reject a more than 3 % increased hazard of death in the lower- versus higher-threshold group at the time of longest follow-up.

  18. Insuficiência adrenal na criança com choque séptico Adrenal insufficiency in children with septic shock

    Directory of Open Access Journals (Sweden)

    Carlos H. Casartelli

    2003-11-01

    for diagnosing and treating adrenal insufficiency in patients with septic shock. SOURCES OF DATA: Articles published in Brazilian and foreign journals selected through these publications' websites and Medline, as well as references cited in key articles. SUMMARY OF THE FINDINGS: The literature reports a range betwen 17 and 54 % for the finding of adrenal insufficiency in patients with septic shock. There is no consensus for diagnosing adrenal insufficiency in patients suffering from critical diseases, particularly in patients with septic shock. The presence of volume-refractory and catecholamine-resistant septic shock suggests this condition, while basal cortisol under 25 µg/dl is a diagnostic criterion indicating adrenal insufficiency. The adrenal stimulation test is a useful resource for identifying patients with relative adrenal insufficiency. Our testing option for adrenal stimulation in children is the use of corticotropin in low doses (0.5 µg/1,73 m². An increase of less than 9 µg/dl in the value of postcorticotropin-stimulated cortisol suggests the presence of occult (relative adrenal insufficiency. In patients with septic shock presenting adrenal insufficiency, either suspected or confirmed, the administration of hydrocortisone in shock or stress doses can be vital for a favorable clinical outcome. CONCLUSIONS: The existing data, although controversial, already provides a basis to determine when to begin hormone replacement therapy, the serum level of cortisol accepted as adequate, and the choice of corticotropin doses for performing the adrenal stimulation test and diagnosing occult or relative adrenal insufficiency in patients with septic shock.

  19. Metabolic, Cardiac, and Renal Effects of the Slow Hydrogen Sulfide-Releasing Molecule GYY4137 During Resuscitated Septic Shock in Swine with Pre-Existing Coronary Artery Disease.

    Science.gov (United States)

    Nußbaum, Benedikt L; Vogt, Josef; Wachter, Ulrich; McCook, Oscar; Wepler, Martin; Matallo, José; Calzia, Enrico; Gröger, Michael; Georgieff, Michael; Wood, Mark E; Whiteman, Matthew; Radermacher, Peter; Hafner, Sebastian

    2017-08-01

    Decreased levels of endogenous hydrogen sulfide (H2S) contribute to atherosclerosis, whereas equivocal data are available on H2S effects during sepsis. Moreover, H2S improved glucose utilization in anaesthetized, ventilated, hypothermic mice, but normothermia and/or sepsis blunted this effect. The metabolic effects of H2S in large animals are controversial. Therefore, we investigated the effects of the H2S donor GYY4137 during resuscitated, fecal peritonitis-induced septic shock in swine with genetically and diet-induced coronary artery disease (CAD). Twelve and 18 h after peritonitis induction, pigs received either GYY4137 (10 mg kg, n = 9) or vehicle (n = 8). Before, at 12 and 24 h of sepsis, we assessed left ventricular (pressure-conductance catheters) and renal (creatinine clearance, blood NGAL levels) function. Endogenous glucose production and glucose oxidation were derived from the plasma glucose isotope and the expiratory CO2/CO2 enrichment during continuous i.v. 1,2,3,4,5,6-C6-glucose infusion. GYY4137 significantly increased aerobic glucose oxidation, which coincided with higher requirements of exogenous glucose to maintain normoglycemia, as well as significantly lower arterial pH and decreased base excess. Apart from significantly lower cardiac eNOS expression and higher troponin levels, GYY4137 did not significantly influence cardiac and kidney function or the systemic inflammatory response. During resuscitated septic shock in swine with CAD, GYY4137 shifted metabolism to preferential carbohydrate utilization. Increased troponin levels are possibly due to reduced local NO availability. Cautious dosing, the timing of GYY4137 administration, and interspecies differences most likely account for the absence of any previously described anti-inflammatory or organ-protective effects of GYY4137 in this model.

  20. The impact of a multifaceted intervention including sepsis electronic alert system and sepsis response team on the outcomes of patients with sepsis and septic shock.

    Science.gov (United States)

    Arabi, Yaseen M; Al-Dorzi, Hasan M; Alamry, Ahmed; Hijazi, Ra'ed; Alsolamy, Sami; Al Salamah, Majid; Tamim, Hani M; Al-Qahtani, Saad; Al-Dawood, Abdulaziz; Marini, Abdellatif M; Al Ehnidi, Fatimah H; Mundekkadan, Shihab; Matroud, Amal; Mohamed, Mohamed S; Taher, Saadi

    2017-12-01

    Compliance with the clinical practice guidelines of sepsis management has been low. The objective of our study was to describe the results of implementing a multifaceted intervention including an electronic alert (e-alert) with a sepsis response team (SRT) on the outcome of patients with sepsis and septic shock presenting to the emergency department. This was a pre-post two-phased implementation study that consisted of a pre-intervention phase (January 01, 2011-September 24, 2012), intervention phase I (multifaceted intervention including e-alert, from September 25, 2012-March 03, 2013) and intervention phase II when SRT was added (March 04, 2013-October 30, 2013) in a 900-bed tertiary-care academic hospital. We recorded baseline characteristics and processes of care in adult patients presenting with sepsis or septic shock. The primary outcome measures were hospital mortality. Secondary outcomes were the need for mechanical ventilation and length of stay in the intensive unit and in the hospital. After implementing the multifaceted intervention including e-alert and SRT, cases were identified with less severe clinical and laboratory abnormalities and the processes of care improved. When adjusted to propensity score, the interventions were associated with reduction in hospital mortality [for intervention phase II compared to pre-intervention: adjusted odds ratio (aOR) 0.71, 95% CI 0.58-0.85, p = 0.003], reduction in the need for mechanical ventilation (aOR 0.45, 95% CI 0.37-0.55, p mechanical ventilation and reduction in hospital mortality and LOS.

  1. Venous-to-arterial carbon dioxide difference in the resuscitation of patients with severe sepsis and septic shock: A systematic review.

    Science.gov (United States)

    Diaztagle Fernández, J J; Rodríguez Murcia, J C; Sprockel Díaz, J J

    2017-10-01

    The way to assess tissue perfusion during the resuscitation of patients with severe sepsis and septic shock is a current subject of research and debate. Venous oxygen saturation and lactate concentration have been the most frequently used criteria, though they involve known limitations. The venous-to-arterial difference of carbon dioxide (pCO 2 delta) is a parameter than can be used to indicate tissue perfusion, and its determination therefore may be useful in these patients. A qualitative systematic review of the literature was made, comprising studies that assessed pCO 2 delta in adult patients with severe sepsis or septic shock, and published between January 1966 and November 2016 in the Medline-PubMed, Embase-Elsevier, Cochrane Library, and LILACS databases. There was no language restriction. The PRISMA statement was followed, and methodological quality was evaluated. Twelve articles were included, all of an observational nature, and including 10 prospective studies (9 published since 2010). Five documented greater mortality among patients with high pCO 2 delta values, in 3 cases even when achieving venous oxygen saturation targets. In 4 studies, a high pCO 2 delta was related to lower venous oxygen saturation and higher lactate levels, and another 3 documented lesser percentage lactate reductions. The parameter pCO 2 delta has been more frequently assessed in the management of patients with severe sepsis during the last few years. The studies demonstrate its correlation to mortality and other clinical outcomes, defining pCO 2 delta as a useful tool in the management of these patients. Copyright © 2017 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.

  2. Função adrenal na sepse e choque séptico Adrenal function in sepsis and septic shock

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    Cristiane Freitas Pizarro

    2007-11-01

    Full Text Available OBJETIVO: Rever os critérios diagnósticos e o tratamento de insuficiência adrenal, em pacientes da faixa etária pediátrica, com sepse grave e choque séptico. FONTES DOS DADOS: Os artigos foram selecionados através das bases de dados MEDLINE (1966-junho 2007, Embase (1994-2007 e Cochrane Library (2000-2007. As seguintes palavras-chave foram utilizadas: choque séptico, sepse, corticosteróides, insuficiência adrenal e crianças. SÍNTESE DOS DADOS: Não existe um critério bem estabelecido e aceito para definir insuficiência adrenal em pacientes criticamente enfermos. A incidência de insuficiência adrenal varia de acordo com o critério utilizado, podendo alcançar desde valores inferiores a 15% até superiores a 61%. O teste rápido de estímulo com hormônio adrenocorticotrófico (ACTH é largamente utilizado como um teste simples para a identificação de não responsividade adrenocortical, mas existe muita discussão quanto à dose de corticotropina a ser utilizada. A dose de 250 µg é a dose padrão. Recentemente, baixas doses de corticotropina (1 µg têm sido propostas, com a sugestão de que elas possam ter uma maior sensibilidade. Dúvidas ainda persistem quanto à eficácia da reposição com baixas doses de corticosteróides em crianças com choque refratário às catecolaminas. Mais estudos são necessários para determinar se o tratamento de tais pacientes alteraria morbidade e/ou mortalidade. CONCLUSÃO: Insuficiência adrenal é comum em crianças com sepse grave e choque séptico e pode contribuir para o desenvolvimento de choque refratário às catecolaminas. Contudo, dúvidas ainda persistem em relação à eficácia da terapêutica com baixas doses de corticosteróides.OBJECTIVE:To review diagnostic criteria and treatment of adrenal insufficiency in pediatric patients with severe sepsis and septic shock. SOURCES: Articles were selected using MEDLINE (1966-June 2007, Embase (1994-2007 and Cochrane Library (2000

  3. Sepse e choque séptico no período neonatal: atualização e revisão de conceitos Neonatal sepsis and septic shock: concepts update and review

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    Rita de Cássia Silveira

    2010-09-01

    Full Text Available A sepse neonatal e a síndrome da resposta inflamatória sistêmica, que antecede o choque séptico, se manifestam como um estado não específico, o que pode retardar o diagnóstico precoce do choque séptico, razão pela qual a mortalidade desta condição permanece elevada. O diagnóstico precoce envolve a suspeita de choque séptico em todo recém nascido apresentando taquicardia, desconforto respiratório, dificuldade de alimentação, tônus alterado, cor alterada, taquipnéia e perfusão reduzida, especialmente na presença de histórico materno de infecção periparto, como corioamnionite ou ruptura prolongada de membranas ovulares. O presente artigo tem como objetivo revisar o conhecimento atual a respeito das peculiaridades do período neonatal, da dinâmica da circulação fetal e da variável idade gestacional. O choque séptico no recém-nascido não é choque séptico do adulto pequeno. No recém-nascido, o choque séptico é predominantemente frio, caracterizado por redução do débito cardíaco e alta resistência vascular sistêmica (vasoconstrição. O tempo é fundamental no tratamento para reversão do choque séptico. A revisão da literatura, baseada em buscas em bases indexadas, fornece subsídios para o manejo do recém-nascido.The nonspecific presentation of neonatal sepsis and systemic inflammatory response syndrome preceding septic shock delay the early diagnosis of septic shock and increase its mortality rate. Early diagnosis involves suspecting septic shock in every newborn with tachycardia, respiratory distress, difficult feeding, altered tonus and skin coloration, tachypnea and reduced perfusion, specially in case of maternal peripartum infection, chorioamnionitis or long-term membranes rupture. This article aims to review current knowledge on neonatal period peculiarities, fetal circulation dynamics, and the pregnancy age variable. Newborn septic shock is not just a small adult shock. In the newborn, the septic

  4. Antimicrobial resistance patterns, clinical features, and risk factors for septic shock and death of nosocomial E coli bacteremia in adult patients with hematological disease: A monocenter retrospective study in China.

    Science.gov (United States)

    Ma, Jie; Li, Ning; Liu, Yajie; Wang, Chong; Liu, Xiaoyan; Chen, Shengmei; Xie, Xinsheng; Gan, Silin; Wang, Meng; Cao, Weijie; Wang, Fang; Liu, Yanfan; Wan, Dingming; Sun, Ling; Sun, Hui

    2017-05-01

    The aim of this retrospective analysis was to evaluate the antimicrobial resistance, clinical features, and risk factors for septic shock and death of nosocomial E coli bacteremia in adult patients in a single hematological center in China. A retrospective case-control study of 157 adult hematological patients with 168 episodes of E coli bacteremia was initiated from April 2012 to July 2015. Antimicrobial susceptibility as well as antimicrobial co-resistance rates were analyzed. Clinical features and outcomes were also studied. In addition, risk factors for septic shock and death were investigated. Among the 553 positive blood isolates during the study period, the prevalence of E coli was 33.3% and ESBL production strains represented 61.9% of those examined. In all the E coli strains isolated, 85.6% were multidrug-resistance (MDR), 2.4% were extensive drug resistance (XDR), and 6.0% were resistant to carbapenems. More MDR phenotype was noted in ESBL-EC strains (98.6% vs 62.8%, PE coli (94.0% and 92.0%, respectively), but lower co-resistance rates to other antibiotics. Carbapenem resistant strains retained full sensitivity to tigecycline and 60% to amikacin. Piperacillin/tazobatam was the third sensitive drug to both ESBL-EC (77.1%) and non-ESBL-EC (86.0%). In our series, 81.6% episodes received appropriate initial antibiotic treatment and no significant decrease in it was found in bacteremia due to ESBL E coli and patients with neutropenia, septic shock. Septic shock was noted in 15.5% patients and the overall 30-day mortality rate was 21.7%. Multivariate analysis revealed that induction chemotherapy (OR 2.126; 95% CI 1.624-11.332; P = .003) and polymicrobial infection (OR 3.628; 95% CI 1.065-21.219; P = .041) were risk factors for septic shock, whereas male (OR 2.223; 95% CI 1.132-12.022; P E coli bacteremia which is still a major life-threatening problem, especially for patients with septic shock. For empirical antimicrobial therapy, combination based on

  5. Procalcitonina como biomarcador de prognóstico da sepse grave e choque séptico Procalcitonin as a prognostic biomarker of severe sepsis and septic shock

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    José Raimundo Araujo de Azevedo

    2012-12-01

    como, redução do PCT-c 24 horas, associaram-se à elevação expressiva da mortalidade de pacientes com sepse grave e choque séptico.OBJECTIVE: To evaluate the tendency of the plasma concentration and clearance of procalcitonin (PCT-c as biomarkers of prognosis of patients with severe sepsis and septic shock, compared to another early prognosis marker, the number of SIRS criteria at sepsis diagnosis. METHODS: We conducted a prospective, observational, cohort study, with patients with severe sepsis and septic shock. The serum procalcitonin was determined at diagnosis of sepsis and after 24 and 48 hours. Demographic data, APACHE IV, SOFA score on arrival, number of SIRS criteria at diagnosis, site of infection and microbiological results were recorded. RESULTS: Twenty-eight patients were included, 19 clinical and nine surgical. In 13 (46.4% the source of sepsis was pulmonary, abdominal in seven (25.0%, urinary in five (17.9% and soft tissue in three cases (10.7%. Fifteen patients had severe sepsis and 13 septic shock. Overall mortality was 17.9% (five patients, three with septic shock. Twenty-eight PCT determinations were performed at sepsis diagnosis, 27 after 24 hours and 26 after 48 hours. The initial concentration was not significantly different between survivors and non-survivors groups, but the differences between the two groups after 24 and 48 hours were statistically significant. There was no difference in the number of SIRS criteria. The 24-hour procalcitonin clearance proved to be significantly higher in the group of survivors (-3.0 versus -300.0, p = 0.028. Although the 48-hour procalcitonin clearance has shown to be higher in the group of survivors when compared to non-survivors, the difference did not reach statistical significance. CONCLUSION: Persistently high procalcitonin concentrations in plasma, as well as reduced 24-hours PCT clearence, were associated with a significant increase in mortality in patients with severe sepsis and septic shock.

  6. High molecular weight hydroxyethyl starch solutions are not more effective than a low wmolecular weight hydroxyethyl starch solution in a porcine model of septic shock.

    Science.gov (United States)

    Simon, T-P; Schuerholz, T; Haugvik, S P; Forberger, C; Burmeister, M-A; Marx, G

    2013-01-01

    There is evidence that suggests that early fluid resuscitation is beneficial in the treatment of sepsis. We previously demonstrated that hydroxyethyl starch (HES) 130/0.42 attenuated capillary leakage better than HES 200/0.5. Using a similar porcine fecal sepsis model, we tested the effects of two new synthetic high molecular weight (700 kDa) hydroxyethyl starches with the same molar substitution of 0.42 but with a different C2/C6 ratio compared to 6% HES 130/0.42 on plasma volume (PV), systemic and tissue oxygenation. This was a prospective, randomized, controlled animal study. Twenty-five anesthetized and mechanically ventilated pigs (28.4±2.3 kg) were observed over 8 h. Septic shock was induced with fecal peritonitis. Animals were randomized for volume-replacement therapy with HES 700/0.42 C2/C6/2.5:1 (N.=5), HES 700/0.42 C2/C6/6:1 (N.=5), HES 130/0.42 C2/C6/5:1 (N.=5) or Ringer’s Solution (RS, N.=5), and compared to non-septic controls receiving RS (N.=5). The albumin escape rate (AER) was calculated and plasma volume was determined at the end of the study. Tissue Oxygen Saturation was measured with the InSpectra™ Device (InSpectra Tissue Spectrometer, Hutchinson Technology Inc., Hutchinson, MN, USA). The AER increased in all groups compared to control. All colloids (HES 700/6:1 68±15; HES 130 67±4; HES 700/2.5:1 71±12; Peffective in maintaining plasma volume and systemic and tissue oxygenation than HES 130. In comparison to crystalloid RS, all HES solutions were more effective at maintaining plasma volume, mean arterial pressure (MAP), and systemic and tissue oxygenation.

  7. [Assessment of central venous-to-arterial CO(2) difference during early goal-directed therapy in patients with septic shock].

    Science.gov (United States)

    Liu, Ling; Zhao, Hong-jie; Huang, Ying-zi; Liu, Song-qiao; Yang, Cong-shan; Guo, Feng-mei; Qiu, Hai-bo; Yang, Yi

    2012-10-01

    To detect the changes of central venous-to-arterial carbon dioxide difference (P(cv-a)CO(2)) during early goal-directed therapy (EGDT) in patients with septic shock and evaluate its' value in predicting adequate resuscitation and prognosis. From April 2009 to October 2010, 26 septic shock patients were enrolled in the study. EGDT was performed in all the patients immediately after enrollment. According to the whether they achieved early goal with in the 6 hour or not, patients were separated to EGDT achievement and un-achievement groups. At the onset and after the 6 hours EGDT, mean arterial pressure (MAP), cardiac index (CI), central venous oxygen saturation (ScvO(2)), oxygen delivery (DO(2)), oxygen consumption (VO(2)), oxygen extraction ratio (O(2) ext), lactate, P(cv-a)CO(2) were recorded. The Acute Physiology and Chronic Health Evaluation II (APACHE II) score and 28 day mortality were compared between 2 groups. There were no significant difference of age and sex between the 15 patients who achieved early goals and 11 patients who did not. EGDT un-achievement patients had higher APACHE II score (21 ± 5) and 28 day mortality (9/11) when compared with EGDT achievement patients (t = 2.985, χ(2) = 4.547, P un-achievement group, MAP, CI, DO(2), VO(2), O(2)ext, ScvO(2), Lac, P(cv-a)CO(2) were comparable between the onset and 6 hours after EGDT. However, in EGDT achievement group, MAP ((90 ± 9) mmHg (1 mmHg = 0.133 kPa)), CI ((4.0 ± 1.8) L×min(-1)×m(-2)), DO(2) ((596 ± 274) ml×min(-1)×m(-2)), ScvO(2) (76.9% ± 4.1%) increased, and P(cv-a)CO(2) ((4.2 ± 2.7) mmHg) decreased significantly after 6 hours of EGDT (t values were -3.393, -2.985, -2.103 and -3.195 respectively, all P < 0.05). The changes of P(cv-a)CO(2) between the onset and 6 hours after EGDT, demonstrated high value for predictability of outcome, according to the area under the ROC curve (AUC) was 0.839 (P = 0.004). As a predictor for death, increasing of P(cv-a)CO(2) after 6 hours of EGDT has a

  8. Hyperoxia and hypertonic saline in patients with septic shock (HYPERS2S): a two-by-two factorial, multicentre, randomised, clinical trial.

    Science.gov (United States)

    Asfar, Pierre; Schortgen, Frédérique; Boisramé-Helms, Julie; Charpentier, Julien; Guérot, Emmanuel; Megarbane, Bruno; Grimaldi, David; Grelon, Fabien; Anguel, Nadia; Lasocki, Sigismond; Henry-Lagarrigue, Matthieu; Gonzalez, Frédéric; Legay, François; Guitton, Christophe; Schenck, Maleka; Doise, Jean Marc; Devaquet, Jérôme; Van Der Linden, Thierry; Chatellier, Delphine; Rigaud, Jean Philippe; Dellamonica, Jean; Tamion, Fabienne; Meziani, Ferhat; Mercat, Alain; Dreyfuss, Didier; Seegers, Valérie; Radermacher, Peter

    2017-03-01

    There is insufficient research into the use of mechanical ventilation with increased inspiratory oxygen concentration (FiO 2 ) and fluid resuscitation with hypertonic saline solution in patients with septic shock. We tested whether these interventions are associated with reduced mortality. This two-by-two factorial, multicentre, randomised, clinical trial (HYPERS2S) recruited patients aged 18 years and older with septic shock who were on mechanical ventilation from 22 centres in France. Patients were randomly assigned 1:1:1:1 to four groups by a computer generated randomisation list stratified by site and presence or absence of acute respiratory distress syndrome by use of permuted blocks of random sizes. Patients received, in an open-labelled manner, mechanical ventilation either with FiO 2 at 1·0 (hyperoxia) or FiO 2 set to target an arterial haemoglobin oxygen saturation of 88-95% (normoxia) during the first 24 h; patients also received, in a double-blind manner, either 280 mL boluses of 3·0% (hypertonic) saline or 0·9% (isotonic) saline for fluid resuscitation during the first 72 h. The primary endpoint was mortality at day 28 after randomisation in the intention-to-treat population. This study was registered with ClinicalTrials.gov, number NCT01722422. Between Nov 3, 2012, and June 13, 2014, 442 patients were recruited and assigned to a treatment group (normoxia [n=223] or hyperoxia [n=219]; isotonic [n=224] or hypertonic [n=218]). The trial was stopped prematurely for safety reasons. 28 day mortality was recorded for 434 patients; 93 (43%) of 217 patients had died in the hyperoxia group versus 77 (35%) of 217 patients in the normoxia group (hazard ratio [HR] 1·27, 95% CI 0·94-1·72; p=0·12). 89 (42%) of 214 patients had died in the hypertonic group versus 81 (37%) of 220 patients in the isotonic group (HR 1·19, 0·88-1·61; p=0·25). We found a significant difference in the overall incidence of serious adverse events between the hyperoxia (185 [85

  9. Terlipressina como novo recurso terapêutico no choque séptico Terlipressin as a new therapeutic agent in septic shock

    Directory of Open Access Journals (Sweden)

    Valter Nilton Felix

    2006-06-01

    Full Text Available JUSTIFICATIVA E OBJETIVOS: A terlipressina tem sido inserida em protocolos de suporte hemodinâmico da sepse, como recurso em casos de choque refratário, o que motiva análise crítica a respeito do assunto. CONTEÚDO: Foram revistas para a análise terapias hemodinâmicas com objetivos finais bem delineados e novas recomendações para reanimação volêmica, uso de vasopressores e agentes inotrópicos em adultos e crianças sépticos. CONCLUSÕES: A terlipressina tem sido considerada nova alternativa nos cuidados intensivos da sepse, embora ainda controversa.BACKGROUND AND OBJECTIVES: The hemodynamic support of sepsis is now formulated trying to insert terlipressin as salvage drug in catecholamine resistant shock, justifying a broad critical analysis. CONTENTS: The analysis included hemodynamic therapies with defined specific goals and new recommendations for fluid resuscitation, vasopressor therapy, and inotropic therapy of septic in adult and pediatric patients. CONCLUSIONS: Terlipressin appears as a new but controversial alternative for vasopressor therapy in sepsis.

  10. Intravenous immunoglobulin for severe sepsis and septic shock: clinical effectiveness, cost-effectiveness and value of a further randomised controlled trial.

    Science.gov (United States)

    Soares, Marta O; Welton, Nicky J; Harrison, David A; Peura, Piia; Shankar-Hari, Manu; Harvey, Sheila E; Madan, Jason; Ades, Anthony E; Rowan, Kathryn M; Palmer, Stephen J

    2014-12-01

    Prior to investing in a large, multicentre randomised controlled trial (RCT), the National Institute for Health Research in the UK called for an evaluation of the feasibility and value for money of undertaking a trial on intravenous immunoglobulin (IVIG) as an adjuvant therapy for severe sepsis/septic shock. In response to this call, this study assessed the clinical and cost-effectiveness of IVIG (using a decision model), and evaluated the value of conducting an RCT (using expected value of information (EVI) analysis). The evidence informing such assessments was obtained through a series of systematic reviews and meta-analyses. Further primary data analyses were also undertaken using the Intensive Care National Audit & Research Centre Case Mix Programme Database, and a Scottish Intensive Care Society research study. We found a large degree of statistical heterogeneity in the clinical evidence on treatment effect, and the source of such heterogeneity was unclear. The incremental cost-effectiveness ratio of IVIG is within the borderline region of estimates considered to represent value for money, but results appear highly sensitive to the choice of model used for clinical effectiveness. This was also the case with EVI estimates, with maximum payoffs from conducting a further clinical trial between £ 137 and £ 1,011 million. Our analyses suggest that there is a need for a further RCT. Results on the value of conducting such research, however, were sensitive to the clinical effectiveness model used, reflecting the high level of heterogeneity in the evidence base.

  11. Utility of the systemic inflammatory response syndrome (SIRS) criteria in predicting the onset of septic shock in hospitalized patients with hematologic malignancies.

    Science.gov (United States)

    Mato, Anthony; Fuchs, Barry D; Heitjan, Daniel F; Mick, Rosemarie; Halpern, Scott D; Shah, Payal D; Jacobs, Samamtha; Olson, Erin M; Schuster, Stephen J; Ujjani, Chaitra; Chong, Elise A; Loren, Alison W; Miltiades, Andrea N; Luger, Selina

    2009-06-01

    The systemic inflammatory response syndrome (SIRS) criteria have not been validated in patients with hematologic malignancies (HM). To determine whether daily assessment of SIRS criteria allows early identification of HM patients who will develop septic shock (SS). Observational, single-center,nested case-control study. Oncology unit of a tertiary care center. 547 consecutive, hospitalized, HM subject were enrolled. Using incidence-density sampling, 184 controls were matched to 46 SS cases. The study exposure was the SIRS score. The study outcome was the development of SS during the hospitalization. 8.4% of subjects developed SS. SIRS scores measured 24 hours prior to SS were significantly higher in cases than in controls (2.1 vs. 1.4,pSIRS cutpoints, fever, tachypnea and tachycardia were each associated with the onset of SS. Population-specific SIRS criteria were empirically derived. Single-center study. Further validation is warranted. SIRS can identify HM patients at risk for SS at least 24 hours before SS onset. These data may lead to evidence-based guidelines using routine vital signs to risk-stratify HM patients for SS.

  12. Tratamiento quirúrgico de las complicaciones del shock meningocóccico grave Surgical treatment of the severe meningococcal septic shock complications

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    P. Casteleiro Roca

    2010-06-01

    Full Text Available El shock meningocóccico es una entidad relativamente frecuente y de pronóstico muy grave, que provoca fallo multiorgánico con una alta mortalidad y que precisa ingreso en Unidad de Cuidados Intensivos. En los casos grandes puede provocar necrosis de tejidos mediante una fisiopatología poco clara. En los últimos años la supervivencia de estos pacientes ha aumentado debido al diagnóstico precoz y a medidas de reanimación más agresivas. Como consecuencia encontramos un aumento del número de pacientes con necrosis extensas de tejidos que precisan tratamiento. Lo fundamental ante el diagnóstico de un shock meningocóccico es establecer el tratamiento médico precoz con medidas de reanimación agresivas y antibioterapia. Sugerimos que la necrosis extensa de tejidos que sufren estos pacientes debe tratarse como si se tratase de un paciente quemado, realizando curas diarias con sulfadiacina argéntica y cirugías seriadas (desbridamiento - amputación - cobertura tan pronto como la situación clínica del paciente lo permita. Es necesario un seguimiento muy cercano de estos pacientes, dada la necesidad de cirugías secundarias que van a precisar a lo largo de su vida, así como la realización de pruebas de imagen para descartar la presencia de osteomielitis secundarias.Meningococcal shock is a relatively frequent disease with a serious prognosis, that causes a multiorganic failure with high mortality and Intensive Care Unit admission. Serious meningococcal shock causes tissue necrosis by uncertain physiopathology. In the last years, there is an increase of the survival, as a result of early diagnosis and aggressive resuscitation. So, there is an increase of patient's tissue necrosis that needs surgery. The most important aspect in front of meningococcal shock is to establish early medical treatment with aggressive resuscitation and antibiotics. Tissue necrosis should be treated like burn patient: argentic sulfadiazine daily cure and serial

  13. Nylon shock absorber prevents injury to parachute jumpers

    Science.gov (United States)

    Mandel, J. A.

    1966-01-01

    Nylon shock absorbers reduce the canopy-opening shock of a parachute to a level that protects the wearer from injury. A shock absorber is mounted on each of the four risers between the shroud lines and the harness. Because of their size and location, they pose no problem in repacking the chute and harness after a jump.

  14. Prolonged direct hemoperfusion using a polymyxin B immobilized fiber cartridge provides sustained circulatory stabilization in patients with septic shock: a retrospective observational before-after study

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    Kyohei Miyamoto

    2017-02-01

    Full Text Available Abstract Background Direct hemoperfusion therapy with polymyxin B immobilized fiber cartridges (PMX-DHP is widely used for septic shock in Japan and parts of Europe. Although this treatment is usually administered for 2 h, the optimal duration has not been established. Methods This retrospective study compared the effects of prolonged and conventional PMX-DHP durations (2 and 12 h, respectively for septic shock. Between October 2013 and March 2015, 18 patients underwent conventional PMX-DHP, and between April 2015 and May 2016, 18 patients underwent prolonged PMX-DHP. The primary outcome was the vasopressor dependency index during the 12 h after starting the first PMX-DHP session. The vasopressor dependency index was calculated as (inotropic score/(mean blood pressure. Results The patients’ characteristics were almost similar in the conventional and prolonged PMX-DHP groups. The major site of infection was the abdomen in both groups (61 and 72%, respectively. The conventional PMX-DHP group had mean blood pressure values of 68.4 ± 8.9 mmHg and 78.2 ± 16.9 mmHg at 0 and 12 h after starting PMX-DHP (P = 0.13. The prolonged PMX-DHP group had mean blood pressure values of 70.3 ± 15.7 mmHg and 87.7 ± 16.9 mmHg at 0 and 12 h after starting PMX-DHP (P = 0.004. The conventional PMX-DHP group had vasopressor dependency index values of 0.52 ± 0.29 and 0.39 ± 0.25 at 0 and 12 h after starting PMX-DHP (P = 0.29. The prolonged PMX-DHP group had vasopressor dependency index values of 0.50 ± 0.26 and 0.28 ± 0.18 at 0 and 12 h after starting PMX-DHP (P = 0.01. Hospital mortality was similar in both groups (8/18 [44%] and 8/18 [44%]. Conclusions These findings suggest that prolonged PMX-DHP provides more sustained circulatory stabilization compared to conventional PMX-DHP. However, our study failed to detect any improvement in mortality. Well-designed prospective trials are needed to examine the

  15. Reversible tetraplegia after percutaneous nephrostolithotomy and septic shock: a case of critical illness polyneuropathy and myopathy with acute onset and complete recovery

    Directory of Open Access Journals (Sweden)

    Li Hai

    2013-02-01

    Full Text Available Abstract Background Critical illness polyneuropathy (CIP and critical illness myopathy (CIM are complications causing weakness of respiratory and limb muscles in critically ill patients. As an important differential diagnosis of Guillain-Barré syndrome (GBS, CIP and CIM should be diagnosed with caution, after a complete clinical and laboratory examination. Although not uncommon in ICU, CIP and CIM as severe complications of percutaneous nephrostolithotomy (PNL have not been documented in literature. Case presentation A 48-year-old Chinese woman was referred to our hospital, complaining of occasional pain in the right lower back for one month. Lithiasis was diagnosed by ultrasonographical and radiological examinations on the urinary system. PNL was indicated and performed. The patient developed CIP and CIM on the fourth day after PNL. Early recognition and treatment of the severe complications contributed to a satisfactory recovery of the patient. Conclusion This case expands our understanding of the complications of PNL and underscores the importance of differentiating CIP/CIM from GBS in case of such patients developing weakness after the treatment. Clinical characteristics and examination results should be carefully evaluated to make the diagnosis of CIP or CIM. Both anti-septic prophylaxis and control of hyperglycemia might be effective for the prevention of CIP or CIM; aggressive treatment on sepsis and multiple organ failure is considered to be the most effective measure to reduce the incidence of CIP/CIM.

  16. Reversible tetraplegia after percutaneous nephrostolithotomy and septic shock: a case of critical illness polyneuropathy and myopathy with acute onset and complete recovery

    Science.gov (United States)

    2013-01-01

    Background Critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) are complications causing weakness of respiratory and limb muscles in critically ill patients. As an important differential diagnosis of Guillain-Barré syndrome (GBS), CIP and CIM should be diagnosed with caution, after a complete clinical and laboratory examination. Although not uncommon in ICU, CIP and CIM as severe complications of percutaneous nephrostolithotomy (PNL) have not been documented in literature. Case presentation A 48-year-old Chinese woman was referred to our hospital, complaining of occasional pain in the right lower back for one month. Lithiasis was diagnosed by ultrasonographical and radiological examinations on the urinary system. PNL was indicated and performed. The patient developed CIP and CIM on the fourth day after PNL. Early recognition and treatment of the severe complications contributed to a satisfactory recovery of the patient. Conclusion This case expands our understanding of the complications of PNL and underscores the importance of differentiating CIP/CIM from GBS in case of such patients developing weakness after the treatment. Clinical characteristics and examination results should be carefully evaluated to make the diagnosis of CIP or CIM. Both anti-septic prophylaxis and control of hyperglycemia might be effective for the prevention of CIP or CIM; aggressive treatment on sepsis and multiple organ failure is considered to be the most effective measure to reduce the incidence of CIP/CIM. PMID:23409743

  17. Infusion-Compatible Antibiotic Formulations for Rapid Administration to Improve Outcomes in Cancer Outpatients With Severe Sepsis and Septic Shock: The Sepsis STAT Pack.

    Science.gov (United States)

    Goldman, Jason D; Gallaher, Amelia; Jain, Rupali; Stednick, Zach; Menon, Manoj; Boeckh, Michael J; Pottinger, Paul S; Schwartz, Stephen M; Casper, Corey

    2017-04-01

    Background: Patients with cancer are at high risk for severe sepsis and septic shock (SS/SSh), and a delay in receiving effective antibiotics is strongly associated with mortality. Delays are due to logistics of clinic flow and drug delivery. In an era of increasing antimicrobial resistance, combination therapy may be superior to monotherapy for patients with SS/SSh. Patients and Methods: At the Seattle Cancer Care Alliance, we implemented the Sepsis STAT Pack (SSP) program to simplify timely and effective provision of empiric antibiotics and other resuscitative care to outpatients with cancer with suspected SS/SSh before hospitalization. Over a 49-month period from January 1, 2008, through January 31, 2012, a total of 162 outpatients with cancer received the intervention. A retrospective cohort study was conducted to determine outcomes, including mortality and adverse events associated with the use of a novel care bundle designed for compatibility of broad-spectrum antibiotics and other supportive care administered concurrently via rapid infusion at fixed doses. Results: Of 162 sequential patients with cancer and suspected SS/SSh who received the SSP, 71 (44%) were diagnosed with SS/SSh. Median age was 53 years and 65% were men; 141 (87%) had hematologic malignancies, 77 (48%) were transplant recipients, and 80 (49%) were neutropenic. Median time to completion of antibiotics was 111 minutes (interquartile range, 60-178 minutes). A total of 71 patients (44%) had bacteremia and 17% of 93 isolates were multidrug-resistant. Possibly related nephrotoxicity occurred in 7 patients, and 30-day mortality occured in 6 of 160 patients (4%), including 3 of 71 (4%) with SS/SSh. Risk of developing SSh or death within 30 days increased 18% (95% CI, 4%-34%) for each hour delay to completion of antibiotics ( P =.01). Conclusions: Rapidly administered combination antibiotics and supportive care delivered emergently to ambulatory patients with cancer with suspected SS/SSh was well

  18. Correlation of left ventricular systolic dysfunction determined by low ejection fraction and 30-day mortality in patients with severe sepsis and septic shock: a systematic review and meta-analysis.

    Science.gov (United States)

    Sevilla Berrios, Ronaldo A; O'Horo, John C; Velagapudi, Venu; Pulido, Juan N

    2014-08-01

    The prognostic implications of myocardial dysfunction in patients with sepsis and its association with mortality are controversial. Several tools have been proposed to evaluate cardiac function in these patients, but their usefulness beyond guiding therapy is unclear. We review the value of echocardiographic estimate of left ventricular ejection fraction (LVEF) in the setting of severe sepsis and/or septic shock and its correlation with 30-day mortality. We conducted a systematic review and meta-analysis to evaluate the prognostic functionality of newly diagnosed LV systolic dysfunction by transthoracic echocardiography on critical ill patients admitted to the intensive care unit with severe sepsis or septic shock. A search of EMBASE and PubMed, Ovide MEDLINE, and Cochrane CENTRAL medical databases yielded 7 studies meeting inclusion criteria reporting on a total of 585 patients. The pooled sensitivity of depressed LVEF for mortality was 52% (95% confidence interval [CI], 29%-73%), and pooled specificity was 63% (95% CI, 53%-71%). Summary receiver operating characteristic curve showed an area under the curve of 0.62 (95% CI, 0.58-0.67). The overall mortality diagnostic odd ratio for septic patients with LV systolic dysfunction was 1.92 (95% CI, 1.27-2.899). Statistical heterogeneity of studies was moderate. The presence of new LV systolic dysfunction associated with sepsis and defined as low LVEF is neither a sensitive nor a specific predictor of mortality. These findings are limited because of the heterogeneity and underpower of the studies. Further research into this method is warranted. Copyright © 2014 Elsevier Inc. All rights reserved.

  19. Suporte farmacológico a lactentes e crianças com choque séptico Pharmacologic support of infants and children in septic shock

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    José Irazuzta

    2007-05-01

    resposta hemodinâmica do CS é um processo variável que requer avaliação e ajustes terapêuticos freqüentes.OBJECTIVES: Septic shock (SS is a frequent cause for admission to the pediatric intensive care unit, requiring prompt recognition and intervention to improve outcome. Our aim is to review the relevant literature related to the diagnosis and management of SS and present a sequential management for its treatment. SOURCES: Non-systematic review of medical literature using the MEDLINE database. Articles were selected according to their relevance to the objective and according to the authors’ opinions. SUMMARY OF THE FINDINGS: The outcome of sepsis and SS is dependent on the early recognition and implementation of time-sensitive goal-directed therapies. These include rapid aggressive fluid resuscitation followed by a well-designed pharmacotherapy. The goals of the resuscitation are the restoration of microcirculation and improved organ tissue perfusion. Clinical and laboratory markers are needed to assess the adequacy of the treatments. Altered pharmacokinetic and pharmacodynamic responses dictate that vasoactive agents should be adjusted to achieve the predetermined goals. In initial resuscitation with isotonic solutions (> 60 mL/kg, either crystalloid (normal saline or colloid infusion could be used. Despite adequate fluid resuscitation, if: (a wide pulse pressure, low blood pressure, or bounding pulses (high cardiac output, low systemic vascular resistance - SVR are present, norepinephrine should be considered; (b prolonged capillary refill, weak pulses, narrow pulse pressure, normotensive (low cardiac output, high SVR, dopamine, epinephrine or dobutamine should be considered. Adjunctive therapy with stress dose of corticosteroid is indicated in selected populations. CONCLUSIONS: Septic shock hemodynamics is a changing process that requires frequent assessment and therapeutic adjustments.

  20. Study of qinolones usage in prevention and therapy of septic complications of radiation damage

    International Nuclear Information System (INIS)

    Petyrek, P.; Spelda, S.

    1994-01-01

    A standard model of experimental sepsis was elaborated at rats in dependence on a gamma irradiation dose and a time interval between irradiation and application infectious agents E. coli O 83:K 24:H 31. For a development of experimental sepsis was proved that it is not decisive in these laboratory animals when infectious agents is i.v. or i.p. applicated. Such amount of organisms (1-20.10 7-8 ) was applicated in particular not to develop sepsis in non-irradiated laboratory animals. Laboratory animals were irradiated with sublethal doses and approximately. LD 50-30 doses of gamma radiation. The laboratory animals were treated only in experiments and qinolone drug ofloxacin was used in the treatment of experimental sepsis. Ofloxacin perorally administrated in the dose of 40 mg/kg in an hour after application of infectious agents and its administration for 5 days in the 24-h intervals confirmed in fact 100% therapeutic effectiveness in irradiated experimental animals. In non-treated experimental groups, animals died in 24-28 hours interval after application of infectious agents and sepsis was a cause of death. In treated experimental groups, animal survived by day 30 after irradiation with sublethal doses or died during the period typical for a bone marrow syndrome of acute radiation injury after irradiation with lethal doses of gamma radiation. Acquired experimental outcomes may suggest that fluorochinolone chemotherapeuticals in the respect of their essential pharmacokinetic properties will be used for a prevention of infectious complications in acute radiation injury. (author)

  1. High dosage of dextran 70 is associated with severe bleeding in patients admitted to the intensive care unit for septic shock

    DEFF Research Database (Denmark)

    Hvidt, Lisa Nebelin; Perner, Anders

    2012-01-01

    Synthetic colloids are frequently used in fluid resuscitation of septic patients. Despite this, little is known about the potential side effects including the risk of renal failure and bleeding. As practice has changed, we performed a before-and-after study of fluid resuscitation and outcome in p...

  2. Blockade of the action of nitric oxide in human septic shock increases systemic vascular resistance and has detrimental effects on pulmonary function after a short infusion of methylene blue

    Directory of Open Access Journals (Sweden)

    Weingartner R.

    1999-01-01

    Full Text Available To investigate the role of nitric oxide in human sepsis, ten patients with severe septic shock requiring vasoactive drug therapy and mechanical ventilation were enrolled in a prospective, open, non-randomized clinical trial to study the acute effects of methylene blue, an inhibitor of guanylate cyclase. Hemodynamic and metabolic variables were measured before and 20, 40, 60, and 120 min after the start of a 1-h intravenous infusion of 4 mg/kg of methylene blue. Methylene blue administration caused a progressive increase in mean arterial pressure (60 [55-70] to 70 [65-100] mmHg, median [25-75th percentiles]; P<0.05, systemic vascular resistance index (649 [479-1084] to 1066 [585-1356] dyne s-1 cm-5 m-2; P<0.05 and the left ventricular stroke work index (35 [27-47] to 38 [32-56] g m-1 m-2; P<0.05 from baseline to 60 min. The pulmonary vascular resistance index increased from 150 [83-207] to 186 [121-367] dyne s-1 cm-5 m-2 after 20 min (P<0.05. Mixed venous saturation decreased from 65 [56-76] to 63 [55-69]% (P<0.05 after 60 min. The PaO2/FiO2 ratio decreased from 168 [131-215] to 132 [109-156] mmHg (P<0.05 after 40 min. Arterial lactate concentration decreased from 5.1 ± 2.9 to 4.5 ± 2.1 mmol/l, mean ± SD (P<0.05 after 60 min. Heart rate, cardiac filling pressures, cardiac output, oxygen delivery and consumption did not change. Methylene blue administration was safe and no adverse effect was observed. In severe human septic shock, a short infusion of methylene blue increases systemic vascular resistance and may improve myocardial function. Although there was a reduction in blood lactate concentration, this was not explained by an improvement in tissue oxygenation, since overall oxygen availability did not change. However, there was a significant increase in pulmonary vascular tone and a deterioration in gas exchange. Further studies are needed to demonstrate if nitric oxide blockade with methylene blue can be safe for patients with septic shock

  3. Clinical Characteristics and Current Interventions in Shock Patients in Chinese Emergency Departments: A Multicenter Prospective Cohort Study

    Directory of Open Access Journals (Sweden)

    Shu-Bin Guo

    2017-01-01

    Conclusions: In China, short-term mortality of shock patients in EDs is still high, especially among those with cardiogenic and septic shock. HES application needs to be restricted – particularly in septic shock patients.

  4. A preventive maintenance policy based on dependent two-stage deterioration and external shocks

    International Nuclear Information System (INIS)

    Yang, Li; Ma, Xiaobing; Peng, Rui; Zhai, Qingqing; Zhao, Yu

    2017-01-01

    This paper proposes a preventive maintenance policy for a single-unit system whose failure has two competing and dependent causes, i.e., internal deterioration and sudden shocks. The internal failure process is divided into two stages, i.e. normal and defective. Shocks arrive according to a non-homogeneous Poisson process (NHPP), leading to the failure of the system immediately. The occurrence rate of a shock is affected by the state of the system. Both an age-based replacement and finite number of periodic inspections are schemed simultaneously to deal with the competing failures. The objective of this study is to determine the optimal preventive replacement interval, inspection interval and number of inspections such that the expected cost per unit time is minimized. A case study on oil pipeline maintenance is presented to illustrate the maintenance policy. - Highlights: • A maintenance model based on two-stage deterioration and sudden shocks is developed. • The impact of internal system state on external shock process is studied. • A new preventive maintenance strategy combining age-based replacements and periodic inspections is proposed. • Postponed replacement of a defective system is provided by restricting the number of inspections.

  5. Frequent Home Monitoring of ICD Is Effective to Prevent Inappropriate Defibrillator Shock Delivery

    Directory of Open Access Journals (Sweden)

    Paolo Bifulco

    2014-01-01

    Full Text Available Recently, in the context of telemedicine, telemonitoring services are gaining attention. They are offered, for example, to patients with implantable cardioverter defibrillators (ICDs. A major problem associated with ICD therapy is the occurrence of inappropriate shocks which impair patients’ quality of life and may also be arrhythmogenic. The telemonitoring can provide a valid support to intensify followup visits, in order to improve the prevention of inappropriate defibrillator shock, thus enhancing patient safety. Inappropriate shock generally depends on atrial fibrillation, supraventricular tachycardia, and abnormal sensing (such as those caused by electromagnetic interferences. As a practical example, an unusual case of an ICD patient who risked an inappropriate shock while taking a shower is reported. Continuous remote telemonitoring was able to timely warn cardiologist via GSM-SMS, who were able to detect improper sensing examining the intracardiac electrogram via Web. Patient was promptly contacted and warned to not further come in contact with the hydraulic system and any electrical appliance to prevent an inappropriate defibrillator shock. This demonstrates the effectiveness and usefulness of continuous remote telemonitoring in supporting ICD patients.

  6. Postdiarrheal Shiga Toxin-Mediated Hemolytic Uremic Syndrome Similar to Septic Shock Síndrome urémico hemolítico símil shock séptico, posterior a diarrea mediada por toxina shiga

    Directory of Open Access Journals (Sweden)

    Patricia G. Valles

    2005-10-01

    Full Text Available The inflammatory response of host endothelial cells is included in the development of vascular damage observed in enterohemorrhagic Escherichia coli (EHEC infection, resulting in hemolytic uremic syndrome (HUS. The response to a non-conventional treatment for a group of D+ HUS (diarrhea positive HUS patients, with clinical hemodynamic parameters of septic shock was evaluated in this prospective study (1999-2003. Twelve children 2.8 ± 0.6 years old, with D+ HUS produced by E. coli infection with serological evidence of Shiga toxin, presenting severe unstable hemodynamic parameters and neurological dysfunction at onset, were studied. The protocol included fresh frozen plasma infusions, methylprednisolone pulses (10mg/k/day for three consecutive days and plasma exchange for five days, starting after admission to the intensive care unit (ICU. The twelve patients with increased pediatric risk of mortality (PRISM score: 18 ± 2 after admission to intensive care unit (ICU, required dialysis for 17.4 ± 4 days, mechanical ventilator assistance for 10 ± 1 days and early inotropic drugs support for 10.5 ± 1 days. Neurological dysfunction included generalized tonic-clonic seizures lasting for 5.4 ± 1 days, n:8. Focal seizures were present in the remaining patients. Dilated cardiomyopathy was present in 6 children. Eight children suffered hemorrhagic colitis. Nine patients survived. Within one year of the injury, neurological sequelae, Glasgow outcome scale (GOS 3 and 4, were present in two patients, chronic renal failure in one patient. We suggest that early introduction of this protocol could benefit D+ HUS patients with hemodynamic instability and neurological dysfunction at onset. Further studies are likely to elucidate the mechanisms involved in this early adverse clinical presentation of D+ HUS patients.La respuesta inflamatoria de la célula endotelial se incluye en el desarrollo del daño vascular observado en la infección por Escherichia coli

  7. Oral Supplementation with Bovine Colostrum Prevents Septic Shock and Brain Barrier Disruption During Bloodstream Infection in Preterm Newborn Pigs

    DEFF Research Database (Denmark)

    Brunse, Anders; Worsøe, Päivi; Pors, Susanne Elisabeth

    2018-01-01

    Preterm infants have increased risk of neonatal sepsis, potentially inducing brain injury, and they may benefit from early initiation of enteral milk feeding. Using preterm pigs as models, we hypothesized that early provision of bovine colostrum to parentally nourished newborns protects against...... hemorrhages, cellular responses (leukopenia, thrombocytopenia), brain barrier disruption and neuroinflammation. At 24