Systemic inflammatory response syndrome,sepsis, severe sepsis and septic shock: Incidence,morbidities and outcomes in surgical ICU patients

Objectives To determine the incidence of systemic inflammatory response syndrome (SIRS), sepsis and severe sepsis in surgical ICU patients and define patient characteristics associated with their acquisition and outcome.Design One-month prospective study of critically ill patients with a 28 day in-hospital follow up.Setting Surgical intensive care unit (SICU) at a tertiary care institution.Methods All patients (n=170) admitted to the SICU between April 1 and April 30, 1992 were prospectively followed for 28 days. Daily surveillance was performed by two dedicated, specifically-trained research nurses. Medical and nursing chart reviews were performed, and follow up information at six and twelve months was obtained.Results The in-hospital surveillance represented 2246 patient-days, including 658 ICU patient-days. Overall, 158 patients (93%) had SIRS for an incidence of 542 episodes/1000 patients-days. The incidence of SIRS in the ICU was even higher (840 episodes/1000 patients-days). A total of 83 patients (49%) had sepsis; among them 28 developed severe sepsis. Importantly, 13 patients had severe sepsis after discharge from the ICU. Patient groups were comparable with respect to age, sex ratio, and type of surgery performed. Apach II score on admission to the ICU and ASA score at time of surgery were significantly higher (p<0.05) only for patients who subsequently developed severe sepsis. The crude mortality at 28 days was 8.2% (14/170); it markedly differed among patient groups: 6% for those with SIRS vs. 35% for patients with severe sepsis. Patients with sepsis and severe sepsis had a longer mean length of ICU stay (2.1±0.2 and 7.5±1.5, respectively) than those with SIRS (1.45±0.1) or control patients (1.16±0.1). Total length of hospital stay also markedly differed among groups (35±9 (severe sepsis), 24±2 (sepsis), 11±0.8 (SIRS), and 9±0.1 (controls, respectively).Conclusions Almost everyone in the SICU had SIRS. Therefore, because of its poor specificity, SIRS was not helpful predicting severe sepsis and septic shock. Patients who developed sepsis or severe sepsis had higher crude mortality and length of stay than those who did not. Studies designed to identify those who develop complications of SIRS would be very useful.     

Ionized calcium level predicts in-hospital mortality of severe sepsis patients: A retrospective cross-sectional study

Objective: To evaluate the effect of serum ionized calcium levels on the prognosis of severe sepsis patients. Methods: This retrospective cross-sectional study included sepsis patients who were hospitalized in an intensive care unit between January 2011 and December 2014. The demographic and baseline data of the patients who died and survived were compared. The cutoff value of ionized calcium for in-hospital mortality was determined by the receiver operating characteristics curve (ROC). In-hospital mortalities and the survival rates were compared between patients with different ionized calcium levels. Besides, the risk factor of in-hospital mortality was determined. Results: This study included 145 patients with 113 patients who died in the hospital. The patients who died had significantly lower ionized calcium levels (U=2.25, P=0.034). A cut-off value of 0.93 mmol/L of ionized calcium was determined by the ROC curve. The patients with ionized calcium>0.93 mmol/L showed a significantly lower morality (χ2=9.90, P=0.002) and higher survival rate than with ≤0.93 mmol/L (log rank=6.20, P=0.010). Multivariate Cox regression revealed that ionized calcium ≤0.93 mmol/L was a risk factor of in-hospital mortality. Conclusions: Ionized calcium level≤0.93 mmol/L was an independent predictor of in-hospital mortality of severe sepsis.     

Absolute eosinophils count as a marker of mortality in patients with severe sepsis and septic shock in an intensive care unit

Introduction

Eosinophils in the circulating blood undergo apoptosis during sepsis syndromes induced by the action of certain cytokines.

Objective

The aim of the study was to evaluate the absolute eosinophils count (EC) as a marker of mortality in severe sepsis and septic shock.

Patients and Method

A prospective cohort study of patients with a diagnosis of sepsis or septic shock admitted to the intensive care unit (ICU) of the Dr Gustavo Fricke Hospital between January 2008 and December 2009 was conducted. Daily EC in all patients was analyzed. Receiver operating characteristic curve analysis was used to assess the performance of the diagnostic test.

Results

We studied a total of 240 patients. The median age was 62 years (interquartile range [IQR], 48-72 years), and 67 (27.9%) died. The median EC in patients who died was 43 (IQR, 14-121), whereas in surviving patients, it was 168 (IQR, 98-292) (P < .001). When the EC on the fifth day of hospital stay was assessed, an area under the curve (AUC) of 0.64 (95% confidence interval, 0.55-0.73) was observed. Eosinophils count at intensive care unit discharge showed an area under the curve of 0.81 (95% confidence interval, 0.76-0.87).

Discussion

Eosinophils counts were lower in patients who died of sepsis than in those who survived, but its clinical usefulness seems limited. Their role as an indicator of clinical stability seems to be important.     

Emergency department septic shock patient mortality with refractory hypotension vs hyperlactatemia: A retrospective cohort study

Background

Our objective was to compare in-hospital mortality among emergency department (ED) patients meeting trial-based criteria for septic shock based upon whether presenting with refractory hypotension (systolic blood pressure < 90 mm Hg after 1 L intravenous fluid bolus) versus hyperlactatemia (initial lactate ≥ 4 mmol/L).

Renal outcome after vancomycin treatment and renal replacement therapy in patients with severe sepsis and septic shock: A retrospective study

Purpose

Acute kidney injury during systemic infections is common; however, renal outcome is poorly investigated. The increase of multiresistant pathogens leads to the use of potential nephrotoxic antibiotics as vancomycin. We investigated the impact of vancomycin and renal replacement therapy (RRT) for renal recovery during sepsis.

Materials and methods

This is a retrospective data analysis of 1159 patients with severe sepsis or septic shock. Logistic regression models were performed.

Results

In total, 390 (33.6%) patients required RRT during intensive care unit (ICU) stay; 233 (20.1%), at discharge. Admission estimated glomerular filtration rate (eGFR) predicted the need of RRT during stay (odds ratio [OR] 0.969 [0.959-0.979] per increase of 1 mL/min, P < .001) and the prolonged need of RRT at ICU discharge (OR 0.979 [0.967-0.990], P < .001). Survivors without any RRT showed an improvement of eGFR at discharge, whereas patients after RRT did not (7.1 vs 0.8 mL/[min 1.73 m²], P < .001). The use (OR 1.648 [1.067-2.546], P < .05) and duration of vancomycin treatment (OR 1.043 [1.004-1.084] per each additional treatment day, P < .05) were predictors for ongoing RRT at discharge.

Conclusions

Estimated GFR at ICU admission predicts renal outcome, whereas the use of vancomycin increases the probability of a prolonged need for RRT at discharge from ICU. The use of alternative antibiotics for certain patients, indicated by eGFR at admission, might be considered.     

Prognostic factors of mortality in patients with community-acquired bloodstream infection with severe sepsis and septic shock

Purpose

The purpose of the study was to determine the independent risk factors on mortality in patients with community-acquired severe sepsis and septic shock.

Methods

A single-site prospective cohort study was carried out in a medical-surgical intensive care unit in an academic tertiary care center. One hundred twelve patients with community-acquired bloodstream infection with severe sepsis and septic shock were identified. Clinical, microbiologic, and laboratory parameters were compared between hospital survivors and hospital deaths.

Results

One-hundred twelve patients were included. The global mortality rate was 41.9%, 44.5% in septic shock and 34.4% in severe sepsis. One or more comorbidities were present in 66% of patients. The most commonly identified bloodstream pathogens were Escherichia coli (25%) and Staphylococcus aureus (21.4%). The proportion of patients receiving inadequate antimicrobial treatment was 8.9%. By univariate analysis, age, Acute Physiology and Chronic Health Evaluation II score, at least 3 organ dysfunctions, and albumin, but neither microbiologic characteristics nor site of infection, differed significantly between survivors and nonsurvivors. Acute Physiology and Chronic Health Evaluation II (odds ratio, 1.13; 95% confidence interval, 1.06-1.21) and albumin (odds ratio, 0.34; 95% confidence interval, 0.15-0.76) were independent risk factors associated with global mortality in logistic regression analysis.

Conclusion

In addition to the severity of illness, hypoalbuminemia was identified as the most important prognostic factor in community-acquired bloodstream infection with severe sepsis and septic shock.     

Being overweight or obese is associated with decreased mortality in critically ill patients: A retrospective analysis of a large regional Italian multicenter cohort

Purpose

To describe the epidemiology of obesity in a large cohort of intensive care unit (ICU) patients and study its impact on outcomes.

Methods

All 3902 patients admitted to one of 24 ICUs in the Piedmont region of Italy from April 3 to September 29, 2006, were included in this retrospective analysis of data from a prospective, multicenter study.

Results

Mean body mass index (BMI) was 26.0 ± 5.4 kg/m²: 32.8% of patients had a normal BMI, 2.6% were underweight, 45.1% overweight, 16.5% obese, and 2.9% morbidly obese. ICU mortality was significantly (P < .05) lower in overweight (18.8%) and obese (17.5%) patients than in those of normal BMI (22%). In multivariate logistic regression analysis, being overweight (OR = 0.73; 95%CI: 0.58-0.91, P = .007) or obese (OR = 0.62; 95%CI: 50.45-0.85, P = .003) was associated with a reduced risk of ICU death. Being morbidly obese was independently associated with an increased risk of death in elective surgery patients whereas being underweight was independently associated with an increased risk of death in patients admitted for short-term monitoring and after elective surgery.

Conclusions

In this cohort, overweight and obese patients had a reduced risk of ICU death. Being underweight or morbidly obese was associated with an increased risk of death in some subgroups of patients.     

Endotoxaemia in patients with severe sepsis or septic shock

Objective: To examine the incidence and the bacteriological and clinical significance of endotoxaemia in ICU patients with severe sepsis or septic shock. Design: Prospective review. Setting: A 15-bed general ICU in a university hospital. Patients: One hundred sixteen patients hospitalised in our ICU fulfilling Bone's criteria for severe sepsis or septic shock and with an available early endotoxin assay (chromogenic limulus assay). Interventions: None. Measurements and results: The clinical characteristics of the population were: age 63.6 ± 11.4 years; SAPS II: 45.4 ± 15.6; mechanical ventilation: 72.4 %; septic shock: 51.7 % (n = 60); bacteraemia: 28.4 % (n = 33); gram-negative bacteria (GNB) infection 47.4 % (n = 55); ICU mortality: 39.6 % (n = 46). Detectable endotoxin occurred in 61 patients (51.2 %; mean level: 310 ± 810 pg/ml). There was no relationship between detectable endotoxin and severity of infection at the moment of the assay. Endotoxaemia was associated with a higher incidence of bacteraemia (39.3 % vs 16.3 %; p = 0.01). There was a trend (p = 0.09) towards an association between positive endotoxin and gram-negative bacteraemia or GNB infection but this was non-significant. This relationship became significant only in the case of bacteraemia associated with GNB infection irrespective of the site of infection. Conclusion: Early detection of endotoxaemia appeared to be associated with GNB infection only in cases of bacteraemic GNB infection. Early endotoxaemia correlated neither to occurrence of organ dysfunction nor mortality in patients with severe sepsis or septic shock. This study suggests that the use of endotoxaemia as a diagnostic or a prognostic marker in daily practice remains difficult. Received: 28 September 1999 Final revision received: 31 January 2000 Accepted: 1 February 2000     

Increased colorectal permeability in patients with severe sepsis and septic shock

Objective To develop a method for the assessment of colorectal permeability in septic patients.Design and setting Observational study in ICUs at two university hospitals.Participants Nine patients with septic shock and abdominal focus of infection, 7 with severe sepsis and pulmonary focus and 8 healthy subjects.Measurements and results Colorectal permeability was assessed as the initial appearance rate of ^99mTc-DTPA in plasma after instillation into the rectal lumen and as the cumulative systemic recovery at 1 h. To calculate the latter, volume of distribution and renal clearance of ^99mTc-DTPA was estimated by an i. v. bolus of ⁵¹Cr-EDTA. The initial rate of permeability was increased in patients with septic shock and severe sepsis compared with controls [29.0 (3.7–83.3), 20.6 (3.6–65.5) and 6.0 (2.2–9.6) cpm ml⁻¹ min⁻¹, respectively, p < 0.05)] with a positive linear trend (r ² = 0.27, p = 0.01) and correlated to L-lactate concentrations in the rectal lumen (r ² = 0.39, p < 0.05). The cumulative permeability was also increased in patients with septic shock and severe sepsis compared with controls [2.07 (0.05–15.7), 0.32 (0.01–1.2) and 0.03 (0.01–0.06)‰, respectively, p < 0.01] and correlated to the initial permeability rate (r ² = 0.26, p = 0.01).Conclusions In septic patients, the systemic recovery of a luminally applied marker of paracellular permeability was increased and related to the luminal concentrations of L-lactate and possibly to disease severity. This suggests that the assessment of colorectal permeability by systemic recovery of ^99mTc-DTPA is valid and that metabolic dysfunction of the mucosa contributes to increased permeability of the large bowel in patients with severe sepsis and septic shock.     

Outcomes and prognostic factors in patients with head and neck cancer and severe acute illnesses

Objectives To evaluate the outcomes of patients with head and neck cancer and severe acute illnesses, and to identify characteristics associated with hospital mortality. Design Cohort study. Setting Ten-bed medical–surgical oncologic intensive care unit (ICU). Patients Consecutive patients admitted to the ICU over a 68-month period. Interventions None. Measurements and results Demographic, clinical and cancer-related data were collected. Multivariate logistic regression analysis was performed to identify predictive factors of hospital mortality. One hundred and twenty-one patients aged 63.3 ± 14.7 years were enrolled in the study. The main sites of primary tumor were oral cavity (30%), larynx (25%), pharynx (14%) and thyroid (9%). The main reasons for ICU admission were sepsis (37%) and acute respiratory failure (20%). The mean SAPS II score was 49.6 ± 17.8 points, and during ICU stay 100 (83%) patients received mechanical ventilation, 70 (58%), vasopressors, and 12 (10%), dialysis. The ICU, hospital and 6-month mortality rates were 39%, 56% and 72%, respectively. A performance status ≥ 2 [odds ratio (OR) = 5.17 (95% confidence interval, CI = 1.84–14.53)], advanced cancer (TNM stage IV) [OR = 3.80 (95% CI = 1.28–11.28)], and the number of organ failures [OR=2.87 (95% CI=1.83–4.50)] were associated with increased mortality in multivariate analysis. Conclusions In conjunction with clinical judgment and taking into consideration the patient's preferences and values, the knowledge of these outcome predictors may be useful in helping physicians to identify patients who might benefit from the intensive care and to improve discussions on patients' prognosis. This work was performed at the Intensive Care Unit, Instituto Nacional de Cancer, Rio de Janeiro, Brazil. This study is original and was not previously submitted to another primary scientific journal. Preliminary data were presented as a poster at the 2005 American Head & Neck Society Annual Meeting in Boca Raton, FL, USA, and at the 9th Congress of the World Federation of Intensive and Critical Care Medicine in Buenos Aires, Argentina, 27–31 August 2005. Financial support: Institutional departmental funds Conflicts of interest: None     

Improved survival of critically ill cancer patients with septic shock

Objective To identify predictors of 30-day mortality in critically ill cancer patients with septic shock.Design Retrospective study over a 6-year period.Setting Twelve-bed medical intensive care unit (ICU).Patients Eighty-eight patients (55 men, 33 women) aged 55 (43.5–63) years admitted to the ICU for septic shock.Interventions None.Measurements and main results Eighty (90.9%) patients had hematological malignancies and eight (9.1%) had solid tumors; 47 patients (53.4%) were neutropenic, 19 (21.6%) were hematopoietic stem cell transplantation (HSCT) recipients, and 27 (30.7%) were in remission. Microbiologically documented infections were found in 60 (68.2%) patients. The Simplified Acute Physiologic Score II (SAPS II) and Logistic Organ Dysfunction (LOD) scores at ICU admission were 66 (47–89) and 7 (5–10), respectively, and the LOD score on day 3 was 8 (4–10). Sixty-eight (78.1%) patients received invasive mechanical ventilation (MV), 12 (13.6%) noninvasive MV, 22 (25%) dialysis. Thirty-day mortality was 65.5% (57/88). By multivariable analysis, mortality was higher when time to antibiotic treatment was >2 h [odds ratio (OR), 7.05; 95% confidence interval (95% CI), 1.17–42.21] and when DLOD (day 3–day 1 LOD score/day 3 LOD score) was high (OR, 3.47; 95% CI, 1.44–8.39); mortality was lower when admission occurred between 1998 and 2000 (OR, 0.23; 95% CI, 0.05–0.98) and when initial antibiotics were adapted (OR, 0.24; 95% CI, 0.06–0.09).Conclusions Earlier ICU admission and antibiotic treatment of critically ill cancer patients with septic shock is associated with higher 30-day survival. The LOD score change on day 3 as compared to admission is useful for predicting survival.Funding: none     

Effect of low high-density lipoprotein levels on mortality of septic patients: A systematic review and meta-analysis of cohort studies

BACKGROUND:An increase in high-density lipoprotein(HDL)is well associated with a decreased cardiovascular risk,especially atherosclerosis.Recent studies suggest that lower levels of HDL may also be associated with an increased risk of sepsis and an increased rate of mortality in septic patients.However,this conclusion remains controversial.METHODS:MEDLINE,EMBASE,and CENTRAL databases were searched from inception to September 30,2019.All studies were conducted to evaluate the correlation of lipoprotein levels and the risk and outcomes of sepsis in adult patients.The primary outcomes were the risk and mortality of sepsis.RESULTS:Seven studies comprising 791 patients were included.Lower levels of HDL had no marked relevance with the risk of sepsis(odds radio[OR]for each 1 mg/dL increase,0.94;95%CI 0.86–1.02;P=0.078),whereas lower HDL levels were related to an increased mortality rate in septic patients(OR for below about median HDL levels,2.00;95%CI 1.23–3.24;P=0.005).CONCLUSION:This meta-analysis did not reveal a signifi cant association between lower HDL levels and an increase in the risk of sepsis,whereas it showed that lower HDL levels are associated with a higher mortality rate in septic adult patients.These findings suggest that HDL may be considered as a promising factor for the prevention and treatment of sepsis in the future.     

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.     

Apheresis in patients with sepsis: A multicenter retrospective study

Background and objectivesTo consider the effectiveness of apheresis, which is a supportive treatment method, in sepsis.Materials and methodsA hundred and eleven adults with sepsis or septic shock were included in this retrospective study. The demographic characteristics of the patients, the focus and source of infection causing sepsis or septic shock, characteristics of the pathogen, Acute Physiological and Chronic Health Assessment (APACHE) II score, routine laboratory values, which apheresis method was used, the characteristics of the replacement fluids used during the apheresis procedure, the number of apheresis procedures, complications related to the apheresis procedure, the follow-up time after the procedure, and mortality were recorded. The primary outcome was 28-day mortality.ResultsSixty-nine (62.2 %) of the patients were male. The mean age of the patients was 47.7 ± 18.6 years. The most common source of sepsis was hospital-acquired (79.3 %), the most common pathogen causing sepsis was gram-negative bacteria (41.4 %), and the most common infection site was the respiratory tract (58.7 %). The median APACHE II score was 19 (13−24). 92 (82.9 %) of the patients had septic shock. Theropeutic plasma exchange (TPE) was performed in 11.7 % of the patients and immunoabsorbtion IA in 88.3 %. The median number of sessions was 3 (3−5). No procedure-related fatal complication was observed in the study. While 28-day mortality was 61.3 % in all patients, when the mortality according to the apheresis procedures was examined, it was 11.3 % and 88.2 % in the patients who underwent TPE and IA, respectively. The most common cause of mortality was multiorgan failure.ConclusionsApheresis in sepsis can be considered as a salvage treatment. The indication for apheresis in sepsis is still at the level of patient-based individualized decision in line with the studies done so far, including our study. However, there is a need for a multicenter randomized controlled study with a large number of patients in order to give positive or negative recommendations about its effectiveness.     

他汀类药物对中国老年脓毒症患者住院期间病死率的影响

目的探讨他汀类药物对中国老年脓毒症患者住院病死率的影响。 方法对212例2009年3月至2012年3月在浙江大学医学院附属第一医院老年科住院的老年脓毒症患者进行研究。以出院为观察终点,将患者分为死亡组和存活组。采用多因素Logistic回归模型分析,以确定应用他汀类药物是否为住院期间病死率的的独立影响因素。 结果存活组使用他汀类药物的患者比例高于死亡组[13.9%（5/36）vs. 34.7%（61/176）,χ² = 6.014,P = 0.014],调整后的比值比（OR）有统计学意义（OR：0.17;95%CI：0.04 ~ 0.85;P = 0.03）。 结论他汀类药物的使用可能可以降低中国老年脓毒症患者住院期间的病死率。     

Relationship between the timing of administration of IgM and IgA enriched immunoglobulins in patients with severe sepsis and septic shock and the outcome: a retrospective analysis

Purpose

Because the use of IgM and IgA enriched polyclonal intravenous immunoglobulins (eIg) is a standard of care in critically ill patients admitted to our intensive care unit (ICU) with the diagnosis of severe sepsis or septic shock, we investigated if the delay from the onset of severe sepsis and septic shock and their administration could influence the outcome.

Materials and Methods

The medical records of all patients with severe sepsis or septic shock admitted to our ICU from July 2004 through October 2009 and treated with eIg (Pentaglobin®; Biotest, Dreieich, Germany) were retrospectively examined.

Results

A total of 129 adult patients with severe sepsis or septic shock were considered eligible. Thirty-two percent of patients died during the ICU stay. Survivors were given eIg significantly earlier than nonsurvivors (23 vs 63 hours, P < .05). The delay in the administration of eIg and the Simplified Acute Physiology Score II were the only variables that entered stepwise a propensity score-adjusted logistic model. The delay in the administration of eIg was a significant predictor of the odds of dying during the ICU stay (odds ratio for 1 hour of delay, 1.007; P < .01; 99% confidence interval from 1.001 to 1.010) and proved to be independent from the Simplified Acute Physiology Score II and other variables.

Conclusions

The efficacy of eIg, being maximal in early phases of severe sepsis and/or septic shock, is probably time dependent.     

重症肺炎及感染性休克的集束治疗

目的 探讨国内严重感染集束治疗的疗效.方法 在广州医学院附属第二医院呼吸重症监护病房中选用43例重症肺炎及感染性休克患者,进行14个月(2006年11月1日至2007年12月31日)前瞻性观察研究.患者入进标准参照2001年国际脓毒症会议.分教育、试验和运作3个连续阶段实施6 h严重感染集束治疗和24 h严重感染集束治疗.历史对照期内(2004年1月1日至2006年10月31日)合格患者门入对照组.计最资料以(x±s)表示,计数资料以率表爪.采用γ2检验、独立样本t榆验、配对t检验、单因素和多冈素Logistic回归分析,P＜0.05为差异具有统计学意义.结果 1)对照组和集束治疗组问的基础特征差异基本上无统计学意义.2)血清乳酸测定率、休克业组液体复苏率及6 h内所输入液体量、血糖榨制,与对照组相比较,其差异均有统计学意义(P值分别是0.024,0.009,0.045和0.000).3)72 h时,集束治疗组呼吸频率和氧合指数,与对照组相比较,其差异均有统计学意义(P值分别是0.033和0.041);集束治疗组中休克业绀急性生理和慢性疾病评分(A-PACHE)Ⅱ分值和预计死亡率的下降值,与对照组中休克业组比较,其差异均有统计学意义(P值分别是0.017和0.040).4)与对照组比较,集束治疗组病死率绝对值下降23.30%(P=0.019).结论 严重感染集束治疗能显著降低重症肺炎及感染性休克患者病死率.     

Acute kidney injury in septic shock: clinical outcomes and impact of duration of hypotension prior to initiation of antimicrobial therapy

Objective  To describe the incidence and outcomes associated with early acute kidney injury (AKI) in septic shock and explore the association between duration from hypotension onset to effective antimicrobial therapy and AKI. Design  Retrospective cohort study. Subjects  A total of 4,532 adult patients with septic shock from 1989 to 2005. Setting  Intensive care units of 22 academic and community hospitals in Canada, the United States and Saudi Arabia. Measurements and main results  In total, 64.4% of patients with septic shock developed early AKI (i.e., within 24 h after onset of hypotension). By RIFLE criteria, 16.3% had risk, 29.4% had injury and 18.7% had failure. AKI patients were older, more likely female, with more co-morbid disease and greater severity of illness. Of 3,373 patients (74.4%) with hypotension prior to receiving effective antimicrobial therapy, the median (IQR) time from hypotension onset to antimicrobial therapy was 5.5 h (2.0–13.3). Patients with AKI were more likely to have longer delays to receiving antimicrobial therapy compared to those with no AKI [6.0 (2.3–15.3) h for AKI vs. 4.3 (1.5–10.8) h for no AKI, P < 0.0001). A longer duration to antimicrobial therapy was also associated an increase in odds of AKI [odds ratio (OR) 1.14, 95% CI 1.10–1.20, P < 0.001, per hour (log-transformed) delay]. AKI was associated with significantly higher odds of death in both ICU (OR 1.73, 95% CI 1.60–1.9, P < 0.0001) and hospital (OR 1.62, 95% CI, 1.5–1.7, P < 0.0001). By Cox proportional hazards analysis, including propensity score-adjustment, each RIFLE category was independently associated with a greater hazard ratio for death (risk 1.31; injury 1.45; failure 1.56). Conclusion  Early AKI is common in septic shock. Delays to appropriate antimicrobial therapy may contribute to significant increases in the incidence of AKI. Survival was considerably lower for septic shock associated with early AKI, with increasing severity of AKI, and with increasing delays to appropriate antimicrobial therapy.     

Inadvertent hypothermia and mortality in critically ill adults: Systematic review and meta-analysis

Objective

Considering that inadvertent hypothermia (IH) is common in Intensive Care Unit (ICU) patients and can be followed by severe complications, this systematic review identified, appraised and synthesised the published literature about the association between IH and mortality in adults admitted to the ICU.