Should heparin-binding protein levels be routinely monitored in patients with severe sepsis and septic shock?

ABSTRACT: Heparin-binding protein (HBP), also known as azurocidin, has multiple functions in the inflammatory process, especially during severe infections. Beside its antimicrobial properties, HBP may induce vascular leakage leading to extravascular efflux, which is an important pathophysiologic event in the development of septic shock. Not surprisingly, high HBP plasma levels are found in severe sepsis patients and in septic shock patients as well as in serious infections associated with endothelial damage. In the present issue of Critical Care, Linder and colleagues demonstrate new aspects of HBP daily monitoring in ICU patients. The authors observed that high HBP plasma levels are associated with an increased mortality rate in both septic and nonseptic critically ill patients, indicating that HBP may be a reliable prognostic biomarker. However, there are some limitations hindering rapid translation of these interesting findings into the daily routine. First, the group of nonseptic critically ill patients (n = 28) enrolled in the study was rather small as compared with the septic group (n = 151). Moreover, 50% of nonseptic patients developed infection while hospitalized in the ICU, and to classify them as truly nonseptic patients is problematic. Second, there is a lack of a routine diagnostic method for HBP analysis. Nevertheless, if the results of the present study are validated in large clinical trials in different ICU populations and cost-effectiveness data become available, the serial HBP measurements will have a promising future.     

Impact of recent intravenous chemotherapy on outcome in severe sepsis and septic shock patients with hematological malignancies

Objective To compare the characteristics and outcome of patients with hematological malignancies referred to the ICU with severe sepsis and septic shock who had or had not received recent intravenous chemotherapy, defined as within 3 weeks prior to ICU admission. Design and setting Retrospective observational cohort study on prospectively collected data in a medical ICU of a university hospital. Patients 186 ICU patients with hematological malignancies with severe sepsis or septic shock (2000–2006). Measurements and results There were 77 patients admitted with severe sepsis and 109 with septic shock; 91 (49%) had received recent intravenous chemotherapy. Patients with recent chemotherapy more often had a high-grade malignancy and were more often neutropenic, less often had pulmonary infiltrates, and less often required mechanical ventilation. ICU, 28-day, in-hospital, and 6-month mortality rates were 33% vs. 48.4%, 40.7% vs. 57.4%, 45.1% vs. 58.9%, and 50.5% vs. 63.2% in patients with and without recent chemotherapy, respectively. Logistic regression identified four variables independently associated with 28-day mortality: SOFA score at ICU admission, pulmonary site of infection, and fungal infection were associated with worse outcome whereas previous intravenous chemotherapy was protective at borderline significance. After adjustment with a propensity score for recent chemotherapy, chemotherapy was not associated with outcome. Conclusions Patients referred to the ICU with severe sepsis and septic shock complicating active chemotherapeutic treatment have better prognosis than commonly perceived. This article is discussed in the editorial available at: .     

B型利钠肽对严重感染及感染性休克患者预后的预测作用

目的 评价B型利钠肽(BNP)对严重感染及感染性休克预后的预测作用.方法 观察102例严重感染及感染性休克患者入重症监护病房(ICU)24 h血浆BNP水平、临床及预后相关资料.将患者分为28 d死亡组和存活组,比较其差异性,并用受试者工作特征曲线(ROC曲线)评价BNP水平对死亡的预测作用;进一步将存活患者分为BNP升高组和正常组,比较其差异性.结果 死亡组(39例)患者急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分显著高于存活组[63例,(28.9±5.9)分比(20.2±5.4)分,P<0.013,但两组白细胞计数、血乳酸值则差异无统计学意义.死亡组患者血浆BNP水平[(1 451.3±531.7)ng/L]明显高于存活组((394.55±81.7)ng/L,P<0.01);以血浆BNP水平>681.4 ng/L作为预测死亡的界点,敏感度为91.4%,特异性为80.3%.在存活组患者中,BNP升高组(48例)的ICU住院天数[(23.75±7.5)d]明显长于正常组(15例,(14.9±5.1)d,P<0.053;但两组APACHE 评分则差异无统计学意义.结论 血浆BNP水平可以预测严重感染及感染性休克的预后.     

早期乳酸清除率与ICU严重脓毒症和脓毒症休克患者预后相关性的研究

目的：探讨早期乳酸清除率与ICU严重脓毒症和脓毒症休克患者预后的相关性。方法：选择2009-01-2012-03入住我院内科ICU的231例严重脓毒症和脓毒症休克患者,按预后分为生存组（139例）和死亡组（92例）,比较2组患者早期不同时段血乳酸清除率及APACHE Ⅱ评分;比较严重脓毒症和脓毒症休克患者早期不同时段血乳酸清除率及APACHE Ⅱ评分;早期不同时段乳酸清除率与APACHE Ⅱ评分进行相关回归分析。结果：2组患者入院时血乳酸、入院后6h及12h乳酸清除率、入院后各时段APACHEⅡ评分比较,差异有显著的统计学意义（P〈0.05及〈0.01）,入院后24h、48h和72h乳酸清除率的差异无统计学意义（P〉0.05）;严重脓毒症和脓毒症休克患者入院后6h乳酸清除率的差异也有显著的统计学意义（P〈0.01）;入院后6h和12h乳酸清除率与同时段APACHEⅡ评分存在负性直线相关关系。结论：ICU严重脓毒症和脓毒症休克患者早期（入院后6h和12h）乳酸清除率对于判断其预后具有重要的临床意义。     

血浆脑钠肽对重度脓毒症患者诊断及预后的影响

目的评价血浆脑钠肽（BNP）水平在预测重度脓毒症患者死亡及诊断中的价值。方法重度脓毒症患者41例,非脓毒组（对照组）20例,比较2组BNP水平的变化。根据脓毒症患者是否于28 d内存活将其分为存活组和死亡组,比较患者入院第1天反应蛋白、危重病评分（APACHEⅡ和SOFA）、血浆BNP水平和第3天血浆BNP水平差异。结果脓毒症组患者入院第1d和第3d血浆BNP水平明显高于对照组;死亡组重度脓毒症患者第1天和第3天血浆BNP水平与存活组相比均明显增高;logistic回归分析发现,在年龄、APACHEⅡ、SOFA、CRP及第1天和第3天BNP水平诸因素中,第3天的BNP水平和SOFA评分为预测ICU死亡的独立危险因素。结论绝大多数老年重度脓毒症患者的血浆BNP水平明显升高,BNP可成为预测老年重度脓毒症患者预后和诊断的实验室指标。     

血浆脑钠肽水平对老年重度脓毒症患者预后的影响

目的 评价血浆脑钠肽(Brain Natriuretic Peptide,BNP)水平预测老年重度脓毒症患者死亡的价值.方法 入选2004年5月至2007年6月在浙江医院重症监护室住院的重度脓毒症老年患者83例,均符合2001年美国胸科医师协会/危重病医学会(ACCP/SCCM)的重度脓毒症诊断标准,排除原有慢性肾功能衰竭患者.根据患者是否于28 d内存活将其分为存活组和死亡组;比较两组患者人院第1天C反应蛋白、危重病评分(APACHEⅡ和SOFA)、血浆BNP水平和第3天血浆BNP水平差异;其后以Logistic回归法分析患者年龄、入住ICU第1天血浆BNP、CRP水平、APACHEⅡ和SOFA评分、第3天血浆BNP水平等变量与患者28天死亡间的关系,同时确定其中预测ICU死亡的独立危险因素.结果 死亡组老年重度脓毒症患者第1天和第3天血浆BNP水平与存活组相比均明显增高,分别为(1056.38+676.34)pg/ml vs.(611.59±610.02)pg/ml,P=0.002和(1448.48±891.11)vs.(522.41±575.20),P<0.001.logistic 回归分析发现,在年龄、APACHEⅡ、SOFA、CRP及第1天和第3天BNP水平诸因素中,第3天的BNP水平和SOFA评分为预测ICU死亡的独立危险因素.BNP水平与28 d死亡率的ROC曲线分析示第1天和第3天BNP水平的曲线面积值分别为0.735(95%CI,0.621～0.848,P<0.001)和0.836(95%CI,0.746～0.926,P<0.001).结论 绝大多数老年重度脓毒症患者的血浆BNP水平明显升高,BNP可成为预测老年重度脓毒症患者预后的实验室指标.     

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

Introduction

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.

Methods

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.

Results

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.

Conclusions

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.     

N末端前B型利钠肽对严重感染及感染性休克患者预后的预测作用

目的 评价N末端前B型利钠肽(NT-proBNP)对严重感染及感染性休克患者预后的预测作用.方法 采用前瞻性研究方法,收集并观察50例严重感染及感染性休克患者的临床资料.于入重症监护病房(ICU)0、24、48、72 h测定血浆NT-proBNP水平,根据住院30 d死亡情况分为死亡组与存活组并进行比较.用受试者工作特征曲线(ROC曲线)评价血浆NT-proBNP水平对死亡的预测作用;采用线性回归分析评价血浆NT-proBNP的干扰因素.结果 死亡组(20例)血浆NT-proBNP水平(μg/L)在入ICU 0 h[20.86(14.28,23.92)]时明显高于存活组[30例,10.02(5.58,16.41),P＜0.01],且这种差异持续至72 h[19.68(13.90,24.02)比9.24(4.30,11.81),P＜0.01],但组内各时间点之间比较均无明显差异;ROC曲线下面积(AUC)为0.842,95%可信区间(95%CI)为0.764～0.922,P＜0.01.以入ICU时血浆NT-proBNP水平＞13.30μg/L作为判断死亡的最佳临界值,其敏感性为80.6%,特异性为70.2%.线性回归分析发现,氧合指数(PaO2/FiO2,r=-0.839,P=0.003)、血小板计数(PLT,r=-0.803,P=0.032)和入ICU 0 h时感染相关器官功能衰竭评分(SOFA,r=0.874,P＜0.001)是NT-proBNP的独立相关因素.结论 血浆NT-proBNP水平可以预测严重感染及感染性休克患者的预后.     

Cell-free plasma DNA as a predictor of outcome in severe sepsis and septic shock

BACKGROUND: Increased concentrations of cell-free DNA have been found in plasma of septic and critically ill patients. We investigated the value of plasma DNA for the prediction of intensive care unit (ICU) and hospital mortality and its association with the degree of organ dysfunction and disease severity in patients with severe sepsis. METHODS: We studied 255 patients with severe sepsis or septic shock. We obtained blood samples on the day of study inclusion and 72 h later and measured cell-free plasma DNA by real-time quantitative PCR assay for the beta-globin gene. RESULTS: Cell-free plasma DNA concentrations were higher at admission in ICU nonsurvivors than in survivors (median 15 904 vs 7522 genome equivalents [GE]/mL, P < 0.001) and 72 h later (median 15 176 GE/mL vs 6758 GE/mL, P = 0.004). Plasma DNA values were also higher in hospital nonsurvivors than in survivors (P = 0.008 to 0.009). By ROC analysis, plasma DNA concentrations had moderate discriminative power for ICU mortality (AUC 0.70-0.71). In multiple regression analysis, first-day plasma DNA was an independent predictor for ICU mortality (P = 0.005) but not for hospital mortality. Maximum lactate value and Sequential Organ Failure Assessment score correlated independently with the first-day plasma DNA in linear regression analysis. CONCLUSIONS: Cell-free plasma DNA concentrations were significantly higher in ICU and hospital nonsurvivors than in survivors and showed a moderate discriminative power regarding ICU mortality. Plasma DNA concentration was an independent predictor for ICU mortality, but not for hospital mortality, a finding that decreases its clinical value in severe sepsis and septic shock.     

Brazilian Sepsis Epidemiological Study (BASES study)

Introduction

Consistent data about the incidence and outcome of sepsis in Latin American intensive care units (ICUs), including Brazil, are lacking. This study was designed to verify the actual incidence density and outcome of sepsis in Brazilian ICUs. We also assessed the association between the Consensus Conference criteria and outcome

Methods

This is a multicenter observational cohort study performed in five private and public, mixed ICUs from two different regions of Brazil. We prospectively followed 1383 adult patients consecutively admitted to those ICUs from May 2001 to January 2002, until their discharge, 28th day of stay, or death. For all patients we collected the following data at ICU admission: age, gender, hospital and ICU admission diagnosis, APACHE II score, and associated underlying diseases. During the following days, we looked for systemic inflammatory response syndrome (SIRS), sepsis, severe sepsis, and septic shock criteria, as well as recording the sequential organ failure assessment score. Infection was diagnosed according to CDC criteria for nosocomial infection, and for community-acquired infection, clinical, radiological and microbiological parameters were used.

Results

For the whole cohort, median age was 65.2 years (49–76), median length of stay was 2 days (1–6), and the overall 28-day mortality rate was 21.8%. Considering 1383 patients, the incidence density rates for sepsis, severe sepsis and septic shock were 61.4, 35.6 and 30.0 per 1000 patient-days, respectively. The mortality rate of patients with SIRS, sepsis, severe sepsis and septic shock increased progressively from 24.3% to 34.7%, 47.3% and 52.2%, respectively. For patients with SIRS without infection the mortality rate was 11.3%. The main source of infection was lung/respiratory tract.

Conclusion

Our preliminary data suggest that sepsis is a major public health problem in Brazilian ICUs, with an incidence density about 57 per 1000 patient-days. Moreover, there was a close association between ACCP/SCCM categories and mortality rate.     

The epidemiology of the systemic inflammatory response

Objective: To examine the incidence, risk factors, aetiologies and outcome of the various forms of the septic syndromes (the systemic inflammatory response syndrome [SIRS] sepsis, severe sepsis, and septic shock) and their relationships with infection.¶Design: Review of published cohort studies examining the epidemiology of the septic syndromes, with emphasis on intensive care unit (ICU) patients.¶Results: The prevalence of SIRS is very high, affecting one-third of all in-hospital patients, and > 50 % of all ICU patients; in surgical ICU patients, SIRS occurs in > 80 % patients. Trauma patients are at particularly high risk of SIRS, and most these patients do not have infection documented. The prevalence of infection and bacteraemia increases with the number of SIRS criteria met, and with increasing severity of the septic syndromes. About one-third of patients with SIRS have or evolve to sepsis. Sepsis may occur in approximately 25 % of ICU patients, and bacteraemic sepsis in 10 %. In such patients, sepsis evolves to severe sepsis in > 50 % of cases, whereas evolution to severe sepsis in non-ICU patients is about 25 %. Severe sepsis and septic shock occur in 2 %–3 % of ward patients and 10 %–15 % or more ICU patients, depending on the case-mix; 25 % of patients with severe sepsis have shock. There is a graded severity from SIRS to sepsis, severe sepsis and septic shock, with an associated 28-d mortality of approximately 10 %, 20 %, 20 %–40 %, and 40 %–60 %, respectively. Mortality rates are similar within each stage, whether infection is documented or not, and microbiological characteristics of infection do not substantially influence outcome, although the source of infection does. While about three of four deaths occur during the first months after sepsis, the septic syndromes significantly impact on long-term outcome, with an estimated 50 % reduction of life expectancy over the following five years. The major determinants of outcome, both short-term and long-term, of patients with sepsis are the severity of underlying diseases and comorbidities, the presence of shock and organ failures at onset of sepsis or evolving thereafter. It has been estimated that two-thirds of the overall mortality can be attributed to sepsis.¶Conclusions: The prevalence of sepsis in ICU patients is very high, and most patients have clinically or microbiologically documented infection, except in specific subset of patients. The prognosis of septic syndromes is related to underlying diseases and the severity of the inflammatory response and its sequelae, reflected in shock and organ dysfunction/failures.     

Plasmapheresis in severe sepsis and septic shock: a prospective,randomised, controlled trial

OBJECTIVE: To determine the therapeutic efficacy and safety of plasmapheresis in the treatment of patients with severe sepsis and septic shock. DESIGN: Prospective, randomised, clinical trial with a planned, midstudy, interim analysis. SETTING: Intensive care unit in a university hospital in Archangels, Russia. PATIENTS: Consecutive patients with severe sepsis or septic shock. INTERVENTIONS: One hundred and six patients were randomised to receive either standard therapy or an add-on treatment with plasmapheresis. MEASUREMENTS AND RESULTS: The primary endpoint was 28-day survival. Septic shock was diagnosed in 57% of the plasmapheresis-treated patients and 54% of the control patients. Mean APACHE III score at entry was 56.4 in the plasmapheresis group and 53.5 in the control group. The 28-day, all-cause mortality rate was 33.3% (18/54) in the plasmapheresis group and 53.8% (28/52) in the control group. This represents a relative risk for fatal outcome in the plasmapheresis group of 0.61, an absolute risk reduction of 20.5% and a number of patients needed to treat of 4.9. Apart from six transient episodes of hypotension and one allergic reaction to fresh frozen plasma, no adverse reactions were attributable to the plasmapheresis treatment in this study. CONCLUSIONS: Plasmapheresis may be an important adjuvant to conventional treatment to reduce mortality in patients with severe sepsis or septic shock. Plasmapheresis is a safe procedure in the treatment of septic patients. A prospective randomised multicentre trial is warranted to confirm our results and to determine which subgroups of septic patients will benefit most from this treatment modality.     

One-year mortality of bloodstream infection-associated sepsis and septic shock among patients presenting to a regional critical care system

Objective The long-term mortality outcome associated with sepsis and septic shock has not been well defined in a nonselected critically ill population. This study investigated the occurrence and the role of bloodstream infection (BSI) associated sepsis and septic shock at time of intensive care unit (ICU) admission on the 1-year mortality of patients admitted to a regional critical care system.Design and setting Population-based inception cohort in all adult multidisciplinary and cardiovascular ICUs in the Calgary Health Region (population approx. 1 million) between 1 July 1999 and 31 March 2002.Patients and participants Adults (18 years; n=4,845) who had at least one ICU admission to CHR ICUs.Results In 251 (5%) patients there was BSI-associated sepsis at presentation to ICU, and 159 of these also had septic shock. The 28-day, 90-day, and 1-year mortality rates overall were 18%, 21%, and 24%: 23%, 30%, and 36% for BSI-associated sepsis without shock, and 51%, 57%, and 61% with shock, respectively. Surgical diagnosis, BSI-associated sepsis, and increasing age were independently associated with late (28-day to 1-year) mortality whereas higher APACHE II and TISS scores were associated with reduced odds in logistic regression analysis.Conclusions BSI-associated sepsis and septic shock are associated with increased risk of mortality persisting after 28-days up to 1 year or more. Follow-up duration beyond 28 days better defines the burden of illness associated with these syndromes.Electronic Supplementary Material Electronic supplementary material to this paper can be obtained by using the Springer Link server located at .     

Quality of life of survivors from severe sepsis and septic shock may be similar to that of others who survive critical illness

Introduction

The objective of the present study was to compare the health-related quality of life (HR-QoL) of survivors from severe sepsis and septic shock with HR-QoL in others who survived critical illness not involving sepsis.

Methods

From March 1997 to March 2001, adult patients in an eight-bed medical/surgical intensive care unit (ICU) of a tertiary care hospital admitted with severe sepsis or septic shock (sepsis group; n = 305) were enrolled and compared with patients admitted without sepsis (control group; n = 392). Patients younger than 18 years (n = 48) and those whose ICU stay was 1 day or less (n = 453) were excluded. In addition, patients exhibiting nonsevere sepsis on admission were excluded (n = 87). Finally, patients who developed nonsevere sepsis or severe sepsis/septic shock after admission were also excluded (n = 88).

Results

In-hospital mortality rates were 34% in the sepsis group and 26% in the control group. There were no differences in sex, age, main activity (work status), and previous health state between groups. Survivors in the sepsis group had a significantly higher Acute Physiology and Chronic Health Evaluation II score on admission (17 versus 12) and stayed significantly longer in the ICU. A follow-up appointment was held 6 months after ICU discharge, and an EQ-5D (EuroQol five-dimension) questionnaire was administered. A total of 104 sepsis survivors and 133 survivors in the control group answered the EQ-5D questionnaire. Sepsis survivors reported significantly fewer problems only in the anxiety/depression dimension. Although there were no significant differences in the other dimensions of the EQ-5D, there was a trend towards fewer problems being reported by sepsis survivors.

Conclusion

Evaluation using the EQ-5D at 6 months after ICU discharge indicated that survivors from severe sepsis and septic shock have a similar HR-QoL to that of survivors from critical illness admitted without sepsis.     

动态观察脓毒症患者T细胞亚群变化的临床意义

目的动态观察脓毒症患者T细胞亚群变化,探讨其与脓毒症患者病情和预后关系。方法以60例脓毒症患者、40例严重脓毒症患者和同期住院的30例非脓毒症患者为观察对象,采用流式细胞仪于患者入院第1天和第7天分别测定患者外周血CD3＋T、CD4＋T、CD8＋T及CD4＋T/CD8＋T比值,同时记录患者急性生理和慢性健康Ⅱ（APACHEⅡ）评分。并根据脓毒症患者转归将其分为存活组和死亡组,比较上述检测指标。结果入院第1天,与脓毒症和非脓毒症患者比较,严重脓毒症组CD3＋T、CD4＋T及CD4＋T/CD8＋T明显降低（P〈0.05）,APACHEⅡ评分升高（P〈0.05）。脓毒症组CD3＋T、CD4＋T、CD8＋T、CD4＋T/CD8＋T和APACHEⅡ评分与非脓毒症比较均无明显差异（P〉0.05）。入院第7天,脓毒症患者死亡组CD3＋T、CD4＋T及CD4＋T/CD8＋T进行性降低（P〈0.05）,APACHEⅡ评分升高（P〈0.05）;严重脓毒症患者死亡组CD3＋T、CD4＋T及CD4＋T/CD8＋T无明显变化（P〉0.05）,且持续处于低水平状态,APACHEⅡ评分升高（P〈0.05）。相关性分析显示,CD4＋T和APACHEⅡ评分存在线性负相关。多因素logistic回归分析显示,CD4＋T、APACHEⅡ评分和功能不全器官数是脓毒症患者预后的独立危险因素。结论脓毒症患者T淋巴细胞亚群在疾病不同阶段表现各异,随病情进展,CD4＋T持续降低患者预后不良。动态观察脓毒症患者的T淋巴细胞亚群对判断病情的严重程度和预后具有重要临床意义。     

Procalcitonin in the diagnosis of inflammation in intensive care units

OBJECTIVES: To assess the effectiveness of different procalcitonin cutoff values to distinguish non-infected (negative+SIRS) from infected (sepsis+severe sepsis+septic shock) medical and surgical patients. DESIGN AND METHODS: PCT plasma concentration was measured using an automated chemiluminescence analyzer in 1013 samples collected in 103 patients within 24 h of admission in ICU and daily during the ICU stay. We compared PCT levels in medical and surgical patients. We also compared PCT plasma levels in non-infected versus infected patients and in SIRS versus infected patients both in medical and in surgical groups. RESULTS: Median values of PCT plasma concentrations were significantly higher in infected than in non-infected groups, both in medical (3.18 vs. 0.45 microg/L) (p<0.0001) and in surgical (10.45 vs. 3.89 microg/L; p<0.0001) patients. At the cutoff of 1 microg/L, the LR+ was 4.78, at the cutoff of 6 microg/L was 12.53, and at the cutoff of 10 microg/L was 18.4. CONCLUSIONS: This study highlights the need of different PCT cutoff values in medical and surgical critically ill patients, not only at the ICU admission but also in the entire ICU stay.     

Adequate antibiotic therapy prior to ICU admission in patients with severe sepsis and septic shock reduces hospital mortality

IntroductionIn patients with severe sepsis and septic shock as cause of Intensive Care Unit (ICU) admission, we analyze the impact on mortality of adequate antimicrobial therapy initiated before ICU admission.MethodsWe conducted a prospective observational study enrolling patients admitted to the ICU with severe sepsis or septic shock from January 2008 to September 2013. The primary end-point was in-hospital mortality. We considered two groups for comparisons: patients who received adequate antibiotic treatment before or after the admission to the ICU.ResultsA total of 926 septic patients were admitted to ICU, and 638 (68.8%) had available microbiological isolation: 444 (69.6%) received adequate empirical antimicrobial treatment prior to ICU and 194 (30.4%) after admission. Global hospital mortality in patients that received treatment before ICU admission, between 0-6h ICU, 6–12h ICU, 12–24h ICU and after 24 hours since ICU admission were 31.3, 53.2, 57.1, 50 and 50.8% (p<0.001). The multivariate analysis showed that urinary focus (odds ratio (OR) 0.20; 0.09–0.42; p<0.001) and adequate treatment prior to ICU admission (OR 0.37; 0.24–0.56; p<0.001) were protective factors whereas APACHE II score (OR 1.10; 1.07–1.14; p<0.001), septic shock (OR 2.47; 1.57–3.87; p<0.001), respiratory source (OR 1.91; 1.12–3.21; p=0.016), cirrhosis (OR 3.74; 1.60–8.76; p=0.002) and malignancy (OR 1.65; 1.02–2.70; p=0.042) were variables independently associated with in-hospital mortality. Adequate treatment prior to ICU was a protective factor for mortality in patients with severe sepsis (n=236) or in septic shock (n=402).ConclusionsThe administration of adequate antimicrobial therapy before ICU admission is decisive for the survival of patients with severe sepsis and septic shock. Our efforts should be directed to assure the correct administration antibiotics before ICU admission in patients with sepsis.     

脓毒症患者外周血祖细胞和内皮祖细胞数量的变化

目的 检测脓毒症患者外周血单个核细胞(peripheral blood mononuelear cell,PBMC)中祖细胞和血管内皮祖细胞(endothelial progenitor cells,EPC)相对数量的变化,探讨感染性休克和非休克患者外周血EPC变化的特点.方法 收集2007年8月至2008年2月复大学附属中山医院急诊科收治的脓毒症患者27例进行前瞻性研究,其中感染性休克患者12例、非休克患者15例,另选10例健康成年人作为正常对照,ICU非脓毒症患者10例作为ICU对照.Ficoll梯度离心法分离外周血PBMC,通过流式细胞仪检测外周血PBMC标记的CDl33,CIY34和血管内皮牛长因子受体-2(vascular endothelialgrowth factor receptor-2.VEGFR-2)的表达情况,计算祖细胞以及内皮祖细胞的相对数量.组间比较采用单因素方差分析.结果 健康成年人外周血祖细胞、EPC数量较少,分别占PBMC的0.25%.4-0.14%和0.09%.4-0.02%;ICU非脓毒症患者祖细胞和EPC数量分别占PBMC的0.38%.4-0.29%和0.12%.4-O.02%,与正常对照组相比无明显的变化(P>0.05);脓毒症非休克组患者外周血祖细胞、EPC的数量明显增加,分别占PBMC的0.57%±0.12%和0.22%±0.10%,与正常对照组相比差异具有统计学意义(P<0.05);感染性休克患者外周血祖细胞和EPE的数量明显减少,分别占PBMC的0.20%.4-0.12%和0.04%±O.01%,与非休克组、ICU对照组和正常对照组相比差异均具有统计学意义(P相似文献   

Beneficial effects of the heme oxygenase-1/carbon monoxide system in patients with severe sepsis/septic shock

Purpose

We evaluated the relations among the arterial carbon monoxide (CO) concentration, heme oxygenase (HO)-1 expression by monocytes, oxidative stress, plasma levels of cytokines and bilirubin, and the outcome of patients with severe sepsis or septic shock.

Methods

Thirty-six patients who fulfilled the criteria for severe sepsis or septic shock and 21 other patients without sepsis during their stay in the intensive care unit were studied. HO-1 protein expression by monocytes, arterial CO, oxidative stress, bilirubin, and cytokines were measured.

Results

Arterial blood CO, cytokine, and bilirubin levels, and monocyte HO-1 protein expression were higher in patients with severe sepsis/septic shock than in non-septic patients. Increased HO-1 expression was related to the arterial CO concentration and oxidative stress. There was a positive correlation between survival and increased HO-1 protein expression or a higher CO level.

Conclusions

Arterial CO and monocyte HO-1 protein expression were increased in critically ill patients, particularly those with severe sepsis or septic shock, suggesting that oxidative stress is closely related to HO-1 expression. The HO-1/CO system may play an important role in sepsis.     

Effects on management and outcome of severe sepsis and septic shock patients admitted to the intensive care unit after implementation of a sepsis program: a pilot study

Introduction  

The application in clinical practice of evidence-based guidelines for the management of patients with severe sepsis/septic shock is still poor in the emergency department, while little data are available for patients admitted to the intensive care unit (ICU). The aim of this study was to evaluate the effect of an in-hospital sepsis program on the adherence to evidence-based guidelines and outcome of patients with severe sepsis/septic shock admitted to the ICU.