Alteco endotoxin hemoadsorption in Gram-negative septic shock patients

Results:This study was terminated early as interim analysis showed a low probability of significant findings. No significant difference was noted between the two groups with respect to change in SOFA score, vasopressor score, PFR, LOS, and 28-day mortality. Side-effect was minimal.Conclusions:We could not identify any clinical benefit on the addition of Alteco endotoxin hemoadsorption to conventional therapy in patients who suffered from intra-abdominal sepsis with shock. The side effect profile of this novel device was acceptable.     

Serum lactate levels as the predictor of outcome in pediatric septic shock

Background and Aims:

An association of high lactate levels with mortality has been found in adult patients with septic shock. However, there is controversial literature regarding the same in children. The aim of this study was to find the correlation of serum lactate levels in pediatric septic shock with survival.

Settings and Design:

This was a prospective observational study at PICU of a tertiary care center of North India.

Materials and Methods:

A total of 30 children admitted to PICU with diagnosis of septic shock were included in the study. PRISM III score and demographic characteristics of all children were recorded. Serum lactate levels were measured in arterial blood at 0-3, 12, and 24 h of PICU admission. The outcome (survival or death) was correlated with serum lactate levels.

Results:

Septic shock was the most common (79.3%) type of shock and had 50% mortality. Initial as well as subsequent lactate levels were significantly higher in nonsurvivors. A lactate value of more than 45 mg/dl (5 mmol/l) at 0–3, 12, and 24 h of PICU admission had an odds ratio for death of 6.7, 12.5, and 8.6 (95% CI: 1.044–42.431, 1.850–84.442, 1.241–61.683) with a positive predictive value (PPV) of 38%, 71%, 64% and a negative predictive value (NPV) of 80%, 83%, and 83%, respectively.

Conclusions:

Nonsurvivors had higher blood lactate levels at admission as well as at 12 and 24 h. A lactate value of more than 45 mg/dl (5 mmol/l) was a good predictor of death.     

感染性休克中与氧自由基有关参数之间的关系

本实验表明犬感染性休克时与氧自由基有关参数之间的变化存在一定关系。血浆丙二醛(MDA)升高与血中超氧化物歧化酶(SOD)、谷胱甘肽过氧化物酶(GSH-Px)活性降低和血浆β-葡萄糖醛酸酶(β-GC)、血浆游离血红蛋白(PHb)升高呈正相关;β-GC升高与SOD,GSH-Px活性降低正相关,SOD活性降低与PHb升高正相关,存活时间与MDA,β-GC升高及SOD活性降低负相关(P<0.05或P<0.01)。结果提示氧自由基在感染性休克发病过程中起着重要作用,MDA、β-GC、SOD改变可作为判断感染性休克严重程度的指标。     

Bedside echocardiography is useful in assessing children with fluid and inotrope resistant septic shock

Objective:

To report changes in the cardiovascular management of fluid and inotropic resistant septic shock in children based on echocardiography.

Design:

Retrospective case series.

Setting:

Tertiary care Pediatric Intensive Care Unit (PICU), Chennai.

Patients:

Twenty-two patients with unresolved septic shock after 60 ml/kg fluid plus inotropic agents in the first hour.

Interventions:

Bedside echocardiography (echo) within 6 h of admission to the PICU.

Results:

Over a 28-month period, of 37 patients with septic shock, 22 children remained in shock despite 60 ml/kg fluid and dopamine and/or dobutamine infusions as per guidelines. On clinical exam, 12 patients had warm shock and ten had cold shock, however, six exhibited an unusual pattern of cold shock with wide pulse pressures on invasive arterial monitoring. The most common echocardiographic finding was uncorrected hypovolemia in 12/22 patient while ten patients had impaired left ± right ventricular function. Echocardiography permitted an appreciation of the underlying disordered pathophysiology and a rationale for adjustment of treatment. Shock resolved in 17 (77%) and 16 patients (73%) survived to discharge.

Conclusions:

Bedside echo provided crucial information that was not apparent on clinical assessment and affords a simple noninvasive tool to determine the cause of low cardiac output in patients who remain in shock despite 60 ml/kg fluid and inotropic support. Most patients in our series had vasodilatory shock with wide pulse pressures and most common finding on echo was uncorrected hypovolemia. The echo findings allowed adjustment of therapy which was not possible based on clinical examination alone.     

Does vasopressin improve the mortality of septic shock patients treated with high-dose NA

Aim of Study:

In Surviving Sepsis Campaign Guidelines 2012, noradrenalin (NA) is recommended as a first choice vasopressor. Although vasopressin (VP) is recommended for the treatment of NA-resistant septic shock, the optimal parameters for its administration remain unclear.

Materials and Methods:

We conducted a retrospective study to evaluate the clinical outcomes of the administration of VP to adult septic shock patients who were undergoing high-dose NA (≥0.25 μg/kg/min) therapy in our Intensive Care Unit between January 2010 and December 2013. We defined high-dose NA as a dose of >0.25 μg/kg/min, based on the definition of low-dose NA as a dose of 5–14 μg/min because the average body weight of the patients in this study was 53.0 kg.

Results:

Among 29 patients who required the administration of high-dose NA, 18 patients received VP. Although the patient background physiological conditions and NA dose did not differ between the two groups, the survival rate of the VP-treated patients was significantly lower (33%) than that of the patients who were managed with a high-dose of NA-alone (82%) (P = 0.014). The lactate clearance did not change after the administration of VP, whereas it improved when in NA treatment alone.

Conclusion:

The results suggest that the administration of VP did not improve the mortality among septic shock patients when administered in addition to high-dose NA.     

Risk factors for mortality in patients with low lactate level and septic shock

BackgroundAccording to the new definition of septic shock, vasopressor therapy and hyperlactatemia are essential for diagnosis. However, there is controversy regarding the cutoff value for lactate, and prognostic factors in patients with septic shock and hypolactatemia. This study evaluated the prognostic significance of the cutoff value for lactate level in septic shock patients.MethodsThe retrospective observational cohort study enrolled 1043 patients aged ≥18 years who meet the revised definition of septic shock. Clinical outcomes of patients with hyperlactatemia were compared with hypolactatemia.ResultsOf the 1022 eligible patients, 369 had an arterial lactate level ≤2 mmol/L. More patients in the high lactate group had poor prognosis than in the low lactate group. A high Sequential Organ Failure Assessment score (SOFA) score group was significant (p < 0.001) in predicting lactate levels. On the subgroup analysis of risk factors affecting mortality in the low lactate group, high Acute Physiology And Chronic Health Evaluation Ⅱ (APACHEⅡ) score (p = 0.003), high C-reactive protein (p = 0.034), and chronic heart failure (p = 0.001) were independently associated with 28-day mortality.ConclusionArterial lactate is a very reliable diagnostic and prognostic predictor of septic shock. However, despite low arterial lactate, patients with a high APACHEⅡ score, high C-reactive protein levels, and chronic heart failure had a poorer prognosis.     

Norepinephrine supplemented with dobutamine or epinephrine for the cardiovascular support of patients with septic shock

Background and Aims:

Sepsis management remains a great challenge for intensive care medicine. The aim of this study was to evaluate the effect of adding dobutamine versus epinephrine to norepinephrine in treating septic shock patients refractory to fluid therapy.

Materials and Methods:

Sixty adult patients with the diagnosis of septic shock were included in this study. Norepinephrine infusion was started at a dose of 0.05 μg/kg/min, and increased gradually up to 0.1 μg/kg/min. Upon reaching this dose, patients with mean arterial pressure <70 mmHg were further divided randomly into two equal groups. In group I: the patients continued on norepinephrine and dobutamine was added at a starting dose of 3 μg/kg/min and increased in increments of 2 μg/kg/min up to 20 μg/kg/min. In group II: the patients continued on norepinephrine and epinephrine was added in a starting dose of 0.05 μg/kg/ min and increased in increments of 0.03 μg/kg/min up to 0.3 μg/kg/min.

Results:

Group II patients developed significantly better cardiovascular parameters, lower arterial pH and higher serum lactate and urine output; however, the 28-day mortality and major adverse effects were comparable in both groups.

Conclusions:

The addition of epinephrine to norepinephrine has positive effects on the cardiovascular parameters but negative results on the serum lactate concentration and systemic pH compared with the addition of dobutamine to norepinephrine.     

Prevalence of occult adrenal insufficiency and the prognostic value of a short corticotropin stimulation test in patients with septic shock

Background:

Corticosteroid insufficiency in acute illness can be difficult to discern clinically. Occult adrenal insufficiency (i.e., Δmax ≤9 μg/dL) after corticotropin may be associated with a high mortality rate.

Objective:

To assess the prevalence of occult adrenal insufficiency and the prognostic value of short corticotropin stimulation test in patients with septic shock.

Materials and Methods:

A total of 30 consecutive patients admitted in the adult intensive care unit of the Sheri Kashmir Institute of Medical Sciences who met the clinical criteria for septic shock were prospectively enrolled in the study. A low dose (1 μg) short corticotropin stimulation test was performed; blood samples were taken before the injection (T0) and 30 (T30) and 60 (T60) minutes afterward.

Results:

The prevalence of occult adrenal insufficiency was 57%. The 28-day mortality rate was 60% and the median time to death was 12 days. The following seven variables remained independently associated with death: organ system failure scores, simplified acute physiology score II score, mean arterial pressure, low platelet count, PaO₂:FIO₂, random baseline cortisol (T0) >34 μg/dL, and maximum variation after test (Δmax) of ≤9 μg/dL. Three different mortality patterns were observed: (I) low (T0 ≤34 μg/dL and Δmax >9 μg/dL; a 28-day mortality rate of 33%),(II) intermediate (T0 >34 μg/dL and Δmax >9 μg/dL or T0 ≤34 μg/dL and Δmax ≤9 μg/dL; a 28-day mortality rate of 71%), and (III) high (T0 >34 μg/dL and Δmax ≤9 μg/dL; a 28-day mortality rate of 82%).

Conclusion:

A short corticotropin test using low-dose corticotropin (1 μg) 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.     

Impact of positive fluid balance on mortality and length of stay in septic shock patients

Background:

Fluid management is important in critically patients. The aim of this study was to determine the relationship between fluid balance and adverse outcomes of septic shock.

Methods:

A retrospective study was conducted in the medical Intensive Care Unit (ICU) of a tertiary university hospital in Thailand, over a 7-year period.

Results:

A total of 1048 patients with an ICU mortality rate of 47% were enrolled. The median cumulative fluid intake at 24, 48, and 72 h from septic shock onset were 4.2, 7.7, and 10.5 L, respectively. Nonsurvivors had a significantly higher median cumulative fluid intake at 24, 48, and 72 h (4.6 vs. 3.9 L, 8.2 vs. 7.1 L, and 11.4 vs. 9.9 L, respectively, P < 0.001 for all). Nonsurvivors also had a significantly higher cumulative and mean fluid balance within 72 h (5.4 vs. 4.4 L and 2.8 vs. 1.6 L, P < 0.001 for both). In multivariate logistic regression analysis, mean fluid balance quartile within 72 h, was independently associated with an increase in ICU and hospital mortality. Quartile 3 and 4 have statistically significant increases in mortality compared with quartile 1 (odds ratio [95% confidence interval] 3.04 [1.9–4.48] and 4.16 [2.49–6.95] for ICU mortality and 2.75 [1.74–4.36] and 3.16 [1.87–5.35] for hospital mortality, respectively, P < 0.001 for all). In addition, the higher amount of mean fluid balance was associated with prolonged ICU stays.

Conclusions:

Positive fluid balance over 3 days is associated with increased ICU and hospital mortality along with prolonged ICU stays in septic shock patients.     

Selection of acute blood purification therapy according to severity score and blood lactic acid value in patients with septic shock

Aim:

As an alternative method for acute blood purification therapy, continuous venovenous hemodiafiltration (CVVHDF) has been reported as an effective clinical treatment for critically ill patients, but the optimal column for performing CVVHDF remains controversial.

Patients and Methods:

We used direct hemoperfusion using a polymyxin B-immobilized fiber column (DHP-PMX) to treat 88 patients with septic shock. To determine the optimal acute blood purification therapy, we subsequently divided the patients into three groups: the first group underwent CVVHDF using a polymethylmethacrylate membrane hemofilter (PMMA) after undergoing DHP-PMX (28 cases), the second group underwent CVVHDF using a polyacrylonitrile membrane hemofilter (PAN) after undergoing DHP-PMX (26 cases), and the third group did not undergo CVVHDF after undergoing DHP-PMX (34 cases).

Results:

The overall survival rate was 54.5%, and patient outcome was significantly related to the Acute Physiology and Chronic Health Evaluation (APACHE) II score, the sepsis-related organ failure assessment (SOFA) score, and the blood lactic acid value before treatment (all P<0.0001). Only the PMMA-CVVHDF group showed a better outcome (survival rate of 78.6%) compared with the other groups (P = 0.0190). In addition, only the PMMA-CVVHDF group showed a significant improvement in the blood lactic acid level on day 3 (P = 0.0011).

Conclusion:

Our study suggests that the PMX column might be effective during the early phase of septic shock, before a high level of lactic acid is present. Furthermore, a PMMA column might be the most useful column for performing CVVHDF after DHP-PMX treatment, as suggested by the blood lactic acid value.     

败血症休克大鼠组织中性内肽酶与肾上腺髓质素的相关关系研究

目的:观察败血症休克大鼠组织肾上腺髓质素(ADM)含量和中性内肽酶(NEP)的活性及其表达水平,以探讨NEP的变化在休克时组织ADM水平变化中的意义。方法:盲肠结扎穿孔方法复制大鼠败血症性休克模型,采用放射免疫方法和荧光分光光度法分别检测血浆和组织的ADM含量和NEP的活性,用半定量RT-PCR和免疫组织化学法分别检测NEP的mRNA及其蛋白的组织分布。结果: ADM和NEP广泛分布于大鼠的血浆和组织。休克早期,大鼠各组织ADM含量普遍高于对照组,NEP活性在心脏和小肠低于对照组,在血浆中高于对照组,在肺、肾和主动脉无明显变化。免疫组化结果显示,休克早期NEP在大鼠心脏、主动脉内膜和中膜的分布低于对照组。休克晚期,除大鼠小肠的ADM含量低于休克早期,血浆和其余组织的ADM含量均高于休克早期;与休克早期比较, NEP的活性除在大鼠肾脏无明显变化外,在血浆和其余组织均明显降低。NEP的免疫组化结果显示,休克晚期,NEP在大鼠心脏、主动脉内膜和中膜、肺和肾的分布弱于休克早期,在主动脉外膜无明显变化。RT-PCR结果显示,休克晚期大鼠心脏、主动脉、肺脏和小肠的NEP mRNA 表达均显著低于对照组。 结论:NEP在大鼠败血症休克的不同时期和不同组织中的变化与ADM含量的变化不一致,提示休克过程中,不同组织局部的NEP对ADM含量的影响不同。     

老年重症感染性休克患者病原菌分布特点及心功能、炎性因子指标变化的临床分析

目的 探讨老年重症感染性休克患者病原菌分布特点及心功能状态、炎性因子变化趋势与病情的关系.方法 选取首都医科大学附属北京世纪坛医院2017年6月至2019年6月收治的96例老年重症感染性休克患者为研究对象,根据患者预后情况分为存活组(n =66)和死亡组(n=30).对患者进行病原菌的采集与鉴定;检测患者入院后心功能指...     

丙酮酸乙酯拮抗内毒素诱导的脓毒症休克犬急性肺损伤

目的:探讨丙酮酸乙酯(EP)对内毒素诱导脓毒症休克犬急性肺损伤的影响。方法:健康雄性杂种犬20只,内毒素的主要活性成分脂多糖（LPS）静脉注射复制脓毒症休克模型,随机分为对照组（n=8）和EP治疗组（n=12）。对照组只接受林格氏液复苏。EP治疗组另外给予丙酮酸乙酯首剂0.05 g/kg,然后0.05 g· kg-1·h-1持续泵入。休克模型建立前及建立后0 h、4 h、8 h、12 h监测血气分析及呼吸力学指标,包括肺动态顺应性(Cdyn)、肺总顺应性(Ctot)、吸气相气道阻力(Rawi)、吸气峰压(PIP)、呼吸功(WOBvt),并用ELISA方法检测血浆肿瘤坏死因子TNF-α、白介素IL-6、白介素IL-10水平。结果:内毒素诱导建立脓毒症休克犬模型后,血气分析及呼吸力学改变符合急性肺损伤。氧合指数（OI）、HCO-3、pH下降,PaCO2上升（与模型前比较,休克后4 h P<0.05）。肺动态顺应性和肺总顺应性下降,吸气峰压、气道阻力、呼吸功增加（与模型前比较,休克后8 h P<0.05）。与EP治疗组比较,对照组改变更加明显,休克后8 h动脉血气各项指标组间比较有显著差异(P<0.05)。丙酮酸乙酯虽未能改善脓毒症休克犬的呼吸力学指标,但能阻止呼吸力学参数的进一步恶化,休克后12 h组间差异显著(P<0.05)。丙酮酸乙酯可以降低血浆中TNF-α、IL-6水平,提高IL-10水平,休克 8 h组间差异显著(P<0.05)。结论:丙酮酸乙酯可以对抗内毒素诱导的脓毒症休克犬的急性肺损伤。     

Role of steroids in septic shock: Assessment of knowledge, attitudes and practices among intensivists practising in Hyderabad

Context:

Use of steroids in septic shock is an issue of contention, more so with two major trials reporting conflicting results.

Aims:

To assess the current knowledge, attitudes and practices (KAP) related to the role of steroids in septic shock among intensivists practising in Hyderabad.

Setting, Design, Materials and Methods:

Questionnaires containing 10 questions pertaining to the role of steroids in septic shock, were distributed to 76 intensivists during the monthly critical care meeting.

Results:

A great majority of intensivists (82%) agreed that the role of steroids is restricted to septic shock not responding to vasopressors. There was no clear consensus regarding the role of corticotropin stimulation test or the timing of total cortisol level testing, if it has to be performed. Hydrocortisone was clearly the choice of steroid for most intensivists and intravenous bolus injection being the preferred route of administration. There was no agreement regarding the dose of steroids, the role of fludrocortisone and whether steroids should be tapered. Most of the respondents did not extend the steroid therapy beyond seven days and the most common side effect reported was hyperglycemia.

Conclusion:

There is a lot of ambiguity in the knowledge, attitudes or practices regarding role of steroids in septic shock among intensivists in Hyderabad. Uniform policies and protocols need to be devised at institutional level, with multispecialty inputs, and doctors need to be familiarized accordingly.     

Accuracy of a real-time continuous glucose monitoring system in children with septic shock: A pilot study

Aims:

The aim of this prospective, observational study was to determine the accuracy of a real-time continuous glucose monitoring system (CGMS) in children with septic shock.

Subjects and Methods:

Children aged 30 days to 18 years admitted to the Pediatric Intensive Care Unit with septic shock were included. A real-time CGMS sensor was used to obtain interstitial glucose readings. CGMS readings were compared statistically with simultaneous laboratory blood glucose (BG).

Results:

Nineteen children were included, and 235 pairs of BG-CGMS readings were obtained. BG and CGMS had a correlation coefficient of 0.61 (P < 0.001) and a median relative absolute difference of 17.29%. On Clarke''s error grid analysis, 222 (94.5%) readings were in the clinically acceptable zones (A and B). When BG was < 70, 70–180, and > 180 mg/dL, 44%, 100%, and 76.9% readings were in zones A and B, respectively (P < 0.001). The accuracy of CGMS was not affected by the presence of edema, acidosis, vasopressors, steroids, or renal replacement therapy. On receiver operating characteristics curve analysis, a CGMS reading <97 mg/dL predicted hypoglycemia (sensitivity 85.2%, specificity 75%, area under the curve [AUC] =0.85). A reading > 141 mg/dL predicted hyperglycemia (sensitivity 84.6%, specificity 89.6%, AUC = 0.87).

Conclusion:

CGMS provides a fairly, accurate estimate of BG in children with septic shock. It is unaffected by a variety of clinical variables. The accuracy over extremes of blood sugar may be a concern. We recommend larger studies to evaluate its use for the early detection of hypoglycemia and hyperglycemia.     

Clinical outcome and predictors of mortality in children with sepsis,severe sepsis,and septic shock from Rohtak,Haryana: A prospective observational study

Background:

Information regarding early predictive factors for mortality and morbidity in sepsis is limited from developing countries.

Methods:

A prospective observational study was conducted to determine the clinical outcome and predictors of mortality in children with sepsis, severe sepsis, and septic shock. Children aged 1 month to 14 years admitted to a tertiary care pediatric intensive care unit (PICU) with a diagnosis of sepsis, severe sepsis, or septic shock were enrolled in the study. Hemodynamic and laboratory parameters which discriminate survivors from nonsurvivors were evaluated.

Results:

A total of 50 patients (30 [60%] males) were enrolled in the study, of whom 21 (42%) were discharged (survivors) and rest 29 (58%) expired (nonsurvivor). Median (interquartile range) age of enrolled patients were 18 (6, 60) months. Mortality was not significantly predicted individually by any factor including age (odds ratio [OR] [95% confidence interval [CI]]: 0.96 [0.91-1.01], P = 0.17), duration of PICU stay (OR [95% CI]: 1.18 [0.99-1.25], P = 0.054), time lag to PICU transfer (OR [95% CI]: 1.02 [0.93-1.12], P = 0.63), Pediatric Risk of Mortality (PRISM) score at admission (OR [95% CI]: 0.71 [0.47-1.04], P = 0.07) and number of organ dysfunction (OR [95% CI]: 0.03 [0.01-1.53], P = 0.08).

Conclusion:

Mortality among children with sepsis, severe sepsis, and septic shock were not predicted by any individual factors including the time lag to PICU transfer, duration of PICU stay, presence of multiorgan dysfunction, and PRISM score at admission.     

Impact of early central venous catheter removal on outcome in patients with candidaemia

Removal of central venous catheters (CVCs) from candidaemic patients is considered the reference standard of care, although this practice is not always possible. The impact of prompt catheter removal on outcome was investigated by analysing data from an active population-based surveillance study in Barcelona, Spain. Patients with candidaemia and a CVC were identified between January 2002 and December 2003. Cases with CVC removal within 2 days were classified as having early CVC removal. Outcome, defined as in-hospital mortality 2-30 days after diagnosis of candidaemia, was determined among hospitalised adults using univariate, Kaplan-Meier and multivariate logistic regression analysis. Outpatients, paediatric patients and those who died or were discharged within 2 days were excluded. The study identified 265 patients with candidaemia and a CVC. Median time from diagnosis of candidaemia to catheter removal was 1 day (range 0-29 days). Overall, 172 patients met the criteria for inclusion in the outcome study. Patients with early CVC removal differed significantly from those with delayed CVC removal. According to univariate, Kaplan-Meier and multivariate analysis, the marker most predictive of in-hospital mortality among candidaemic patients with CVCs was severity of illness. These data suggest that timing of CVC removal may best be determined after carefully considering the risks and benefits to individual patients.     

The impact of packed red blood cell transfusion on clinical outcomes in patients with septic shock treated with early goal directed therapy

Background:

The optimal hemoglobin level and transfusion threshold in patients with septic shock treated with an early, goal oriented approach to resuscitation remains unknown.

Aims:

To assess the impact of packed red blood cell (PRBC) transfusion on clinically relevant outcomes in patients with septic shock treated with early goal directed therapy (EGDT).

Settings and Design:

Retrospective cohort study of 93 patients who presented with septic shock, to a single center academic intensive care unit and received EGDT.

Materials and Methods:

Data were collected on patients identified via the Surviving Sepsis Campaign Chart Review database and linked to Project IMPACT database. The PRBC group and no PRBC group were compared by the Pearson chi-square and Fisher’s exact test to analyze statistical significance.

Results:

The PRBC group had a mortality of 41.2% vs. 33.9% in the no PRBC transfusion group (P = NS). The PRBC group also had more mechanical ventilation days (11.2 days vs. 5.0 days, (P ≤ 0.05), longer hospital length of stay (25.9 days vs. 12.5 days, (P ≤ 0.05), and longer intensive care unit length of stay (11.4 days vs. 3.8 days, (P ≤ 0.05).

Conclusions:

In this retrospective cohort study, transfusion of PRBCs was associated with worsened clinical outcomes in patients with septic shock treated with EGDT. Further studies are needed to determine the impact of transfusion of PRBC within the context of early resuscitation of patients with septic shock, as the beneficial effects gained by an early and goal oriented approach to resuscitation may be lost by the negative effects associated with PRBC transfusion.