Serial changes in adiponectin and resistin in critically ill patients with sepsis: associations with sepsis phase, severity, and circulating cytokine levels

Purpose

The aim of the present study was to describe the variation in adiponectin and resistin levels, 2 adipokines with opposing effects on metabolism, in mechanically ventilated patients with sepsis and their relationships to disease severity and cytokine levels.

Materials and Methods

An observational prospective study was conducted in a secondary/tertiary unit. Forty-one mechanically ventilated patients diagnosed as having sepsis were included in the study. The Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment scores were estimated. Adiponectin, resistin, and cytokines were measured upon sepsis diagnosis and every 3 to 4 days thereafter until day 30. Adiponectin and resistin were also measured in 40 controls.

Results

The patients had higher adiponectin (10.9 ± 6.1 μg/mL vs 6.0 ± 2.9 μg/mL, P < .001) and resistin (24.7 ng/mL vs 3.8 ng/mL, P < .001) levels compared with the controls. Adiponectin increased and resistin decreased significantly over time in the entire cohort. Resistin correlated with Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, interleukin (IL)-6, IL-8, and IL-10 and was significantly higher in severe sepsis/septic shock compared with sepsis. No correlations between adiponectin and clinical scores were noted.

Conclusions

Adiponectin and resistin change reciprocally during the course of sepsis. Resistin relates to the severity of sepsis and the degree of inflammatory response. Adiponectin and resistin may play a critical role in the metabolic adaptations observed in sepsis.     

KDIGO标准APACHEⅡ与SOFA评分对脓毒症急性肾损伤患者的预后评估

目的 探讨急性肾损伤国际指南(KDIGO)制定的急性肾损伤(AKI)诊断分期标准、急性生理与慢性健康状况评分Ⅱ(APACHEⅡ)和序贯器官衰竭评估(SOFA)评分对脓毒症AKI患者的预后评估价值.方法 前瞻收集2012-03-01 ～2013-03-01期间在我院ICU接受治疗的脓毒症患者的临床资料,采用KDIGO标准对脓毒症患者进行AKI诊断和分期；根据患者入ICU第1个24h内的生理指标最差值进行APACHEⅡ和SOFA评分,并用受试者工作特征(ROC)曲线评估3项系统对预后评估的准确性.以Logistic多元回归分析对预后的影响.结果 共280例脓毒症患者,占同期ICU住院患者的41.7％ (280/670),总体院内死亡率为29.8％.脓毒症肾损伤168例,占脓毒症患者的60％,其中1期76例,死亡率22.4％；2期48例,死亡率37.5％；3期44例,死亡率72.7％.脓毒症肾损伤患者的APACHEⅡ及SOFA评分均高于非AKI患者(P＜0.05).Logistic多元回归分析显示,APACHEⅡ评分＞22分(OR =4.50),KDIGO分期1、2、3期(OR值分别为2.31、7.44、45.00)是脓毒症并AKI患者院内死亡的独立预测指标.结论 KDIGO诊断标准与APACHEⅡ、SOFA评分对脓毒症肾损伤患者整体预后都有较好的预测价值.     

QSOFA and SOFA scores are valuable tools for predicting postoperative sepsis resulting from ureteroscopic lithotripsy (URSL)

The sequential organ failure assessment (SOFA) and quick sequential organ failure assessment (qSOFA) scores are new tools which are used to assess sepsis based on the Third International Consensus Definitions for Sepsis and Septic Shock Task Force. This study aimed to evaluate the feasibility of using the SOFA and qSOFA to predict post-ureteroscopic lithotripsy (URSL) sepsis. Patients who underwent URSL due to ureteral stone obstruction were retrospectively reviewed using SOFA and qSOFA scores. Patient characteristics including age, gender, comorbidities, American Society of Anesthesiologists Classification, stone burden, stone location, hydronephrosis status, infectious status, preoperative SOFA and qSOFA score were collected. Preoperative factors were analyzed to determine if they were correlated with postoperative sepsis. A total of 830 patients were included in this study, of whom 32 (3.9%) had postoperative sepsis. Multivariate analysis revealed that older age, proximal ureteral stones, severe hydronephrosis, and high preoperative qSOFA or SOFA score were significantly associated with postoperative sepsis. The areas under the curves of a qSOFA score ≥ 1 and SOFA score ≥ 2 for predicting postoperative sepsis were 0.754 and 0.823, respectively. Preoperative qSOFA and SOFA scores are convenient and effective for predicting post-URSL sepsis. Further preventive strategies should be performed in these high-risk patients.     

Sepsis in Internal Medicine wards: current knowledge,uncertainties and new approaches for management optimization

Sepsis represents a global health problem in terms of morbidity, mortality, social and economic costs. Although usually managed in Intensive Care Units, sepsis showed an increased prevalence among Internal Medicine wards in the last decade. This is substantially due to the ageing of population and to multi-morbidity. These characteristics represent both a risk factor for sepsis and a relative contra-indication for the admission to Intensive Care Units. Although there is a lack of literature on the management of sepsis in Internal Medicine, the outcome of these patients seems to be gradually improving. This is due to Internists’ increased adherence to guidelines and “bundles”. The routine use of SOFA score helps physicians in the definition of septic patients, even if the optimal score has still to come. Point-of-care ultrasonography, lactates, procalcitonin and beta-d-glucan are of help for treatment optimization. The purpose of this narrative review is to focus on the management of sepsis in Internal Medicine departments, particularly on crucial concepts regarding diagnosis, risk assessment and treatment.

• Key Messages

• Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection.

• The prevalence of sepsis is constantly increasing, affecting more hospital patients than any other disease.

• At least half of patients affected by sepsis are admitted to Internal Medicine wards.

• Adherence to guidelines, routine use of clinical and lab scores and point-of-care ultrasonography are of help for early recognition of septic patients and treatment optimization.

     

Timing of Intubation in Acute Respiratory Failure Associated With Sepsis: A Mixed Methods Study

Objective

To analyze bedside clinicians' perspectives regarding the decision process to optimize timing of intubation in sepsis-associated acute respiratory failure.

Adjunctive therapy with azithromycin for moderate and severe acute respiratory distress syndrome: a retrospective,propensity score-matching analysis of prospectively collected data at a single center

Effective pharmacological therapy has not been established for patients with acute respiratory distress syndrome (ARDS). Macrolides are antibiotics with potent immunomodulatory and anti-inflammatory effects that may be beneficial in ARDS treatment. The objective of this study was to determine the adjunctive effect of azithromycin on survival for patients with ARDS. This single-center, retrospective cohort evaluation of hospitalized patients with moderate or severe ARDS was conducted to assess the impact of intravenous azithromycin on clinical outcomes using a propensity score analysis. All data were collected prospectively as part of ongoing research on the utility of high-resolution computed tomography in ARDS. The primary outcome was 90-day mortality, and the secondary analysis assessed the effect of azithromycin on time to successful discontinuation of mechanical ventilation and 28-day mortality. Of 191 eligible patients with severe or moderate ARDS, 62 were treated with azithromycin. The 62 patients treated with azithromycin and 62 not treated with azithromycin were matched and analysed. Azithromycin use was associated with a statistically significant improvement in 90-day survival rate (Hazard ratio [HR], 0.49; 95% confidence interval [CI], 0.27–0.87; P?=?0.015) and a shorter time to successful discontinuation of mechanical ventilation (HR, 1.74; 95% CI, 1.07–2.81; P?=?0.026). The 28-day mortality rate tended to be higher in the azithromycin cohort than in the non-azithromycin cohort, but this was not statistically significant. Adjunctive intravenous azithromycin therapy was effective in patients with moderate or severe ARDS. Further prospective randomized controlled trials are needed to confirm this result.