Sepsis and Septic Shock

“Anesthesia Stat” to Intubate a Coronavirus Disease 2019 (COVID-19) Patient: Implications for the Anesthesiologist

Objective To evaluate the impact of sepsis bundle treatment on morbidity of sepsis or septic shock in burned patients. Methods A retrospective clinical study was conducted on burned patients with severe sepsis or sepsis shock in burn intensive care unit. 95 patients were divided into control group(43 patients) and study group (52 patients)according to their treatment. The relationship between sepsis bundle index and sepsis, septic shock and 28-day mortality respectively were analyzed with logistic regression analysis. The compliance of sepsis bundles,and 28-day mortality were noted. Results The 28-day mortility rate,the mobidity of sepsis and septic shock in study group was lower than that of control group (P ＜ 0. 05). It could be found that 6-hour EGDT and 24-hour EGDT was the independent protective factor of sepsis and septic shock through logistic regression analysis ,and blood gas analysis, EGDT and vasoactive drug were correlated with 28-day mortality(P ＜0. 05). Compliance with sepsis bundles of 6-hour EGDT and 24-hour EGDT in study group was only 51.9%, and 63.2% respectively. Conclusion Sepsis bundle was able to improve survival rate in severe burn patients. Compliance with sepsis bundles in burn medical staff needed a buring improve. Key words: Burn; Sepsis; Septic shock; Sepsis bundle treatment

Postoperative sepsis and septic shock after hip fracture surgery

Case fatality in pregnancy-associated severe sepsis or septic shock appears reduced compared with nonpregnant women with severe sepsis or septic shock. It remains unclear if this difference is due to pregnancy or better baseline health status, among others. Our study compared adverse outcomes of pregnancy-associated severe sepsis or septic shock with nonpregnant women with severe sepsis or septic shock while controlling for age and chronic comorbidities. Retrospective cohort study. Nationwide Inpatient Sample, a stratified sample of 20% acute care hospital admissions in the United States. Each entry includes patient and hospital characteristics as well as International Classification of Diseases, 9th revision, Clinical Modification, diagnoses and procedures. Women of childbearing age (15-44 yr) with severe sepsis or septic shock-related hospitalizations during 1998-2012 identified using International Classification of Diseases, 9th revision, Clinical Modification, codes. Case fatality, hospital length of stay, length of stay until death, number of organ failures, rates of mechanical ventilation, and hemodialysis were compared in women according to pregnancy status, controlling for age, and chronic comorbidities. We identified 5,968 pregnancy-associated severe sepsis or septic shock and 85,240 nonpregnant women with severe sepsis or septic shock hospitalizations. Crude case fatality of pregnancy-associated severe sepsis or septic shock (9.6%) was lower than nonpregnant women with severe sepsis or septic shock (16.8%). The rate ratio for case fatality adjusted for socioeconomic status and race was 0.57 (95% CI, 0.52-0.62) while sequential adjustments for age and chronic comorbidities did not eliminate the association (rate ratio, 0.62 [95% CI, 0.57-0.68]) and 0.63 [95% CI, 0.57-0.68], respectively). Pregnancy-associated severe sepsis or septic shock was associated with shorter hospital length of stay (-0.83 d [95% CI, -1.32 to -0.34 d]), longer length of stay until death (2.61 d; [95% CI, 1.28-3.94 d]), and fewer organ failures (rate ratio, 0.95 [95% CI, 0.94-0.97]). Case fatality and adverse outcomes are reduced in women with pregnancy-associated severe sepsis or septic shock compared with nonpregnant women with severe sepsis or septic shock, and this is not explained by differences in age or chronic comorbidities alone. A less severe presentation of sepsis or protective effect of pregnancy may account for the difference observed with pregnancy-associated severe sepsis or septic shock.

Point: Adherence to Early Goal-Directed Therapy: Does It Really Matter? Yes. After a Decade, the Scientific Proof Speaks for Itself

To investigate a possible relationship between plasma erythropoietin and interleukin-6 (IL-6) in critically ill children with sepsis or septic shock. To examine the modulatory effects of plasma from these patients on erythropoietin production in vitro, employing a cell culture system that uses the erythropoietin-producing Hep 3B cell line. A prospective, controlled clinical and laboratory study. A pediatric intensive care unit and research laboratory facility at a children's hospital. Children admitted to the pediatric intensive care unit with the diagnosis of sepsis or septic shock (n = 16), and control patients without infection or anemia (n = 16) were admitted to the study. None. Blood samples were obtained from 16 children with sepsis or septic shock, and 16 age-matched controls. Plasma erythropoletin and IL-6 concentrations were measured using an enzyme-linked immunoassay. Plasma erythropoietin concentrations were significantly higher in children with sepsis or septic shock (120 +/- 26 mlU/mL) than in controls (10 +/- 2 mlU/mL) (p < .001). Plasma IL-6 concentrations were greater in children diagnosed with sepsis or septic shock (12,405 +/- 6662 pg/mL) than in control patients (7 +/- 1 pg/mL) (p < .001), and higher in septic shock patients (27,469 +/- 13,647 pg/mL) than sepsis patients (688 +/- 258 pg/mL) (p = .03). Hep 3B cells were incubated under hypoxic conditions in media containing plasma from control patients, or patients diagnosed with sepsis or septic shock. Media concentrations of erythropoietin were measured using an enzymelinked immunoassay. Hep 3B cells incubated with plasma from patients diagnosed with sepsis or septic shock produced more erythropoietin (216 +/- 23 mlU/mL) than Hep 3B cells incubated under the same conditions in media containing plasma from control patients (152 +/- 11 mlU/mL) (p = .04). Hypoxic Hep 3B cell erythropoietin production in media incubated with plasma from patients diagnosed with sepsis or septic shock correlated significantly (although weakly) with plasma IL-6 values from these same patients (p = .03, r2 = .28). Plasma erythropoietin and IL-6 values are increased in critically ill children with sepsis or septic shock in comparison with controls. The data indicate that one or more plasma factors are responsible for stimulation of hypoxia-induced erythropoietin production in the Hep 3B cell line and suggest a possible role for IL-6 in the regulation of erythropoletin production in critically ill children with sepsis or septic shock.

Risk factors and pathogenic significance of severe sepsis and septic shock in 2286 patients with gram-negative bacteremia

Đặt vấn đề: Giảm tiểu cầu (GTC) là vấn đề thường gặp ở những bệnh nhân nhiễm khuẩn nặng và sốc nhiễm khuẩn nhập khoa Hồi sức cấp cứu. GTC và tăng thể tích trung bình tiểu cầu (MPV) được xem là yếu tố tiên lượng mức độ nặng vì có tương quan với tăng tỷ lệ suy đa tạng, tình trạng xuất huyết, tăng thời gian nằm viện cũng như tỷ lệ tử vong tại khoa hồi sức. Nghiên cứu đánh giá mối liên quan giữa giảm tiểu cầu, tăng MPV và kết cục lâm sàng ở bệnh nhân nhiễm khuẩn nặng và sốc nhiễm khuẩn.Phương pháp nghiên cứu: Nghiên cứu mô tả cắt ngang trên 112 bệnh nhân trên 16 tuổi được chẩn đoán nhiễm khuẩn nặng và sốc nhiễm khuẩn theo tiêu chuẩn Sepsis - 3 từ tháng 01/2022 đến tháng 05/2023.Kết quả: Tỉ lệ nam giới chiếm 55,4%, độ tuổi trung bình 66 tuổi với tình trạng nhiễm khuẩn nặng chiếm 54,5% và sốc nhiễm khuẩn chiếm tỷ lệ 45,5%. 57/112 (50,9%) bệnh nhân nhiễm khuẩn nặng và sốc nhiễm khuẩn có giảm tiểu cầu với tỉ lệ giảm tiểu cầu nhẹ chiếm 27,7%, trung bình chiếm 17,9% và nặng chiếm 5,4%. Đường tiêu hóa (43,8%) và hô hấp (37,5%) là 2 tiêu điểm nhiễm khuẩn hay gặp với tác nhân gây bệnh phân lập được là P. aeruginosa (32,3%) và E.coli (29%). Bệnh nhân nhiễm khuẩn nặng và sốc nhiễm khuẩn kèm GTC có thời gian nằm viện dài hơn (6 ngày so với 4 ngày), tỷ lệ suy tạng cao hơn (96,5% so với 69,1%) và tỷ lệ tử vong cao hơn (49,1% so với 10,9%) so với nhóm không có tình trạng GTC với p &lt; 0,01. GTC là yếu tố nguy cơ tiên lượng tử vong với OR=5,2 (95%CI [1,30-20,68], p &lt; 0,05). MPV ở nhóm tử vong (10,37 ± 1,55) tăng cao hơn có ý nghĩa so với nhóm sống sót (9,63 ± 1,62), p &lt; 0,05.Kết luận: 50,9% bệnh nhân nhiễm khuẩn nặng, sốc nhiễm khuẩn có tình trạng GTC. GTC và tăng MPV là yếu tố tiên lượng kết cục lâm sàng xấu ở bệnh nhân nhiễm khuẩn nặng và sốc nhiễm khuẩn.

Introduction. Sepsis, severe sepsis and septic shock are major public health problems worldwide. The consequences of sepsis are especially unfavorable for people with weakened immunity. Biomarkers of inflammation play an important role in the diagnosis of sepsis: C-reactive protein and procalcitonin, the indices of which increase significantly in this pathology. The aim of the study. To investigate quantitative indices of cytokines and biomarkers of inflammation in patients with peritoneal sepsis with different degrees of severity. Materials and methods. A group under examination included 101 patients. The esteemed laboratory indices included interleukins-1β, -2, -6, -10; tumor necrosis factor-α; C-reactive protein and procalcitonin concentration. Results. In patients with sepsis, the interleukin-1β index exceeded control values by 2.9 times. In the severe sepsis group this same index increased by 1.2 times, and in septic shock – by 1.4 times, compared to patients with sepsis. The concentration of tumor necrosis factor-α in the blood of patients with peritoneal sepsis, severe sepsis, and septic shock was 1.1, 9.2, and 2.9 times higher than control values, respectively. While measuring the concentration of interleukin-6, it was detected this index enhancement in all three groups of septic patients. Also it was documented certain decrease in the interleukin-2 index in all patients under investigation, compared to control. In patients with severe sepsis and septic shock, an increase in the level of interleukin-10 in comparison to control values was estimated up to 4.9 and 5.1 times. An increase in C-reactive protein and procalcitonin registered in all groups of septic patients, as well as the observed cytokine imbalance apparently reflect disability of the immune system to respond adequately and resist pathogenic microorganisms due to the deepening of the sepsis severity. Conclusions. In patients with peritoneal sepsis, the level of interleukin-1β exceeded control values by 2.9 times, in patients with severe sepsis – 3.7 times, and with septic shock – 4.2 times. The concentration of tumor necrosis factor-α in the blood of patients with peritoneal sepsis, severe sepsis, and septic shock was 1.1, 9.2, and 2.9 times higher than control values, respectively. Concentration of interleukin-6 in patients with peritoneal sepsis exceeded by 8.4 times, in the severe sepsis – by 18.8 times, and in septic shock – by 17.4 times control values. In patients with sepsis and severe sepsis of peritoneal genesis, the level of interleukin-2 decreased by 1.85 times, and in the septic shock group – by 1.6 times compared to the control values. Interleukin-10 indices in patients with sepsis increased by 1.28 times, in severe sepsis – by 4.9 times, and in septic shock – by 5.1 times in comparison with control values. An increase in C-reactive protein compared to its control values was detected in all patients under investigation: in the sepsis group – by 77.8 times, in severe sepsis – by 128.1 times, and in patients with septic shock – by 95.7 times. Similar enhancement of procalcitonin levels was observed in all patients under investigation with these indices correlation to the severity of the disease. Indices of pro-inflammatory and anti-inflammatory cytokines, as well as C-reactive protein and procalcitonin can be recommended as a reliable markers of the severity of the inflammatory process in patients with peritoneal sepsis. Digital values of cytokines and inflammatory biomarkers can serve as a valuable additional criteria for the assessment severity of the pathological process (sepsis, severe sepsis, and septic shock) of peritoneal origin. Keywords: peritoneal sepsis, severe sepsis, septic shock, interleukins, cytokines, immune imbalance.

To compare the performance of three methods of identifying children with severe sepsis and septic shock from the Virtual Pediatric Systems database to prospective screening using consensus criteria. Observational cohort study. Single-center PICU. Children admitted to the PICU in the period between March 1, 2012, and March 31, 2014. None. During the study period, all PICU patients were prospectively screened daily for sepsis, and those meeting consensus criteria for severe sepsis or septic shock on manual chart review were entered into the sepsis registry. Of 7,459 patients admitted to the PICU during the study period, 401 met consensus criteria for severe sepsis or septic shock (reference standard cohort). Within Virtual Pediatric Systems, patients identified using "Martin" (n = 970; κ = 0.43; positive predictive value = 34%; F1 = 0.48) and "Angus" International Classification of Diseases, 9th Edition, Clinical Modification codes (n = 1387; κ = 0.28; positive predictive value = 22%; F1 = 0.34) showed limited agreement with the reference standard cohort. By comparison, explicit International Classification of Diseases, 9th Edition, Clinical Modification codes for severe sepsis (995.92) and septic shock (785.52) identified a smaller, more accurate cohort of children (n = 515; κ = 0.61; positive predictive value = 57%; F1 = 0.64). PICU mortality was 8% in the reference standard cohort and the cohort identified by explicit codes; age, illness severity scores, and resource utilization did not differ between groups. Analysis of discrepancies between the reference standard and Virtual Pediatric Systems explicit codes revealed that prospective screening missed 66 patients with severe sepsis or septic shock. After including these patients in the reference standard cohort as an exploratory analysis, agreement between the cohort of patients identified by Virtual Pediatric Systems explicit codes and the reference standard cohort improved (κ = 0.73; positive predictive value = 70%; F1 = 0.75). Children with severe sepsis and septic shock are best identified in the Virtual Pediatric Systems database using explicit diagnosis codes for severe sepsis and septic shock. The accuracy of these codes and level of clinical detail available in the Virtual Pediatric Systems database allow for sophisticated epidemiologic studies of pediatric severe sepsis and septic shock in this large, multicenter database.

Independent Clinical Criteria in Medicine: The Unusual Case of Septic Shock

53 The Performance of an Electronic Medical Record-Based Alert to Identify Emergency Department Patients With Severe Sepsis and Septic Shock

The aim of this study was to investigate the current awareness status of nurses on the "Treatment Guidelines for Sepsis and Septic Shock." According to the "International Guidelines for Management of Sepsis and Septic Shock 2021," a self-made questionnaire on nursing knowledge related to sepsis and septic shock was used to evaluate nurses' level of knowledge-attitude-belief-practice (KAP) in sepsis and septic shock, and to explore the influential factors on their awareness level. The awareness rate of nurses was 46.67% toward the treatment guidelines for sepsis and septic shock. Nurses' mastery rate was < 60.00%; and 85.00% of nurses scored 10-18 points using the sepsis and septic shock-related questionnaire. The power order of related factors affecting the KAP level of nurses on sepsis and septic shock was listed as follows: years of service > guideline-related training duration > guideline-related training or not > professional title > degree of education. The years of service had the most significant impact on nurses' level of KAP in sepsis or septic shock (r = 0.521). Nurses have poor awareness of the "Treatment Guidelines for Sepsis and Septic Shock." The findings suggest that guidelines- and standards-based training with longer duration should be carried out to improve the KAP level of nurses.

Background: Literature is scarce on the assessment of vitamin E status in septic children. We aim to investigate the prevalence of vitamin E deficiency in critically ill children with sepsis and septic shock and its association with clinical features and outcomes.Methods: We compared serum vitamin E status between the confirmed or suspected infection and no infection groups, the sepsis shock and no sepsis shock groups upon pediatric intensive care unit admission. Clinical characteristics were compared in subgroup patients with and without vitamin E deficiency. The association between vitamin E deficiency and septic shock were evaluated using univariate and multivariable methods.Results: 182 critically ill children with confirmed or suspected infection and 114 without infection were enrolled. The incidence of vitamin E deficiency was 30.2% in the infection group and 61.9% in the septic shock subgroup (P < 0.001). Thirty-days mortality in critically ill children with vitamin E deficiency was significantly higher than that without vitamin E deficiency (27.3 vs. 14.2%, P < 0.05). Vitamin E levels were inversely associated with higher pediatric risk of mortality (r = − 0.238, P = 0.001) and cardiovascular sequential organ failure assessment (r = −0.249, p < 0.001) scores in critically ill children with infection. In multivariable logistic regression, vitamin E deficiency showed an independent effect on septic shock (adjusted OR: 6.749, 95%CI: 2.449–18.60, P < 0.001).Conclusion: Vitamin E deficiency is highly prevalent in critically ill children with sepsis and contributed to the septic shock.

Sepsis and septical shock clinical criteria were agreed in Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2016. Despite the imperfections of SIRS criteria (low specificity), their sensitivity reaches 100%. According to modern ideas, sepsis is a systemic inflammatory response to infection (Systemic Inflammatory Response Syndrome – SIRS) always associated with the presence of infectious agent in the body. Clinical and metabolical manifestations of sepsis are similar to symptoms and criteria of system inflammatory response syndrome. Physiological features of pregnant women are making adjustments to the classical picture of diagnosis and treatment. In the first trimester of pregnancy 15% of women are suffering from dyspnea. Increased heart rate is normal manifestation of the third mechanism of regulation of cardiac output (volume of circulating blood – first, the contractile ability of the myocardium – second). Increase in the number of leukocytes in peripheral blood of pregnant/postpartum women is a physiological process and creates difficulties in diagnostic process. The aim of study was to determine peculiarities of sepsis and septical shock in pregnant and postpartum women according to instructions of Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. The problem of sepsis is currently very severe in obstetrics. In now days, infections occupy third place in the structure of maternal mortality and make up about 15%. Systemic manifestations of sepsis/septical shock in pregnant/postpartum women (including the development of multiple organ dysfunction) can significantly outpace local changes of purulent source. If the primal source of infection is located in the uterus, the development of septical shock is not always accompanied by symptoms of “classical” metroendometritis, making it difficult to diagnose. It also detains radical sanation of the infectious source contributing to progression of multiple organ dysfunction. In 2001 E.P. Rivers et al. published an article in highly ranked journal N Eng J Med, which is cited by various authors until now. The whole algorithm of infusion and inotropic therapy was developed on its basis for patients with sepsis and septic shock. Despite this, in present time many authors doubt in expediency of achieving CVP 8-13 mmHg (J.H.Boyd et al 2011; M.Cessoni et al 2011; Marik P.E. et al 2008)., sodium ions accumulate in the extracellular space (interstitial and intravascular) in pregnant; as a result tissues become hydrophilic and tissue “phisiological edema” develops. Given the presence of capillary loss syndrome in pregnant/ postpartum women (preeclampsia / eclampsia) controversial is the question of the qualitative composition of the infusion therapy. There are no safe antibiotics for pregnant women according to Food and Drug Administration – FDA (USA). Therefore, the problem of antibiotic therapy in these patients also have its own features. Physiological features of pregnant woman are making adjustments to the classical picture of diagnosis and treatment of sepsis/septical shock in this group of patients. The aim of study was to determine peculiarities of sepsis and septical shock in pregnant and postpartum women according to instructions of Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. The problem of sepsis is currently very severe in obstetrics. In now days, infections occupy third place in the structure of maternal mortality and make up about 15%.In this article we have discussed the results of the diagnosis and treatment of 14 pregnant /postpar tum women with sepsis, who came to the clinic of anesthesiology and intensive care of the Lviv Regional Hospital from 2010 to 2016.Chorioamnionitis and endometritis were the main reasons of peritonitis and sepsis. Intensive therapy (volemic resuscitation, cardio-respiratory support, antibiotic therapy) and surgical intervention (eliminating the causes of peritonitis, sanitation and drainage of the abdominal cavity) were conducted to all the patients. The patient’s general condition was evaluated by APACHE II scale at 14,5 ± 1,5 points and multiple organ dysfunction was evaluated at 5,0 ± 1 points by SOFA scale.