Abdominal Septic Shock Research Articles

Effect of early enteral nutrition on outcomes of trauma patients requiring intensive care

PurposeTo investigate the effect of early enteral nutrition on outcomes of trauma patients in the intensive care unit (ICU). MethodsClinical data of trauma patients in the ICU of Daping Hospital, China from January 2012 to December 2017 was retrospectively analyzed, including patient age, gender, injury mechanism, injury severity score (ISS), nutritional treatment, postoperative complications (wound infection, abdominal abscess, anastomotic rupture, pneumonia), mortality, and adverse events (nausea, vomiting, abdominal distention). Only adult trauma patients who developed bloodstream infection after surgery for damage control were included. Patients were divided into early enteral nutrition group (<48 h) and delayed enteral nutrition group (control group, >48 h). Data of all trauma patients were collected by the same investigator. Data were expressed as frequency (percentage), mean ± standard deviation (normal distribution), or median (Q1, Q3) (non-normal distribution) and analyzed by Chi-square test, Student's t-test, or rank-sum test accordingly. Multiple logistic regression analysis was further adopted to investigate the significant variables with enteral nutrition. ResultsAltogether 876 patients were assessed and 110 were eligible for this study, including 93 males and 17 females, with the mean age of (50.0 ± 15.4) years. Traffic accidents (46 cases, 41.8%) and fall from height (31 cases, 28.2%) were the dominant injury mechanism. There were 68 cases in the early enteral nutrition group and 42 cases in the control group. Comparison of general variables between early enteral nutrition group and control group revealed significant difference regarding surgeries of enterectomy (1.5% vs. 19.0%, p = 0.01), ileum/transverse colon/sigmoid colostomy (4.4% vs. 16.3%, p = 0.01) and operation time (h) (3.2 (1.9, 6.1) vs. 4.2 (1.8, 8.8), p = 0.02). Other variables like ISS (p = 0.31), acute physiology and chronic health evaluation≥20 (p = 0.79), etc. had no obvious difference. Chi-square test showed a much better result in early enteral nutrition group than in control group regarding morality (0 vs. 11.9%, p = 0.03), length of hospital stay (days) (76.8 ± 41.4 vs. 81.4 ± 44.7, p = 0.01) and wound infection (10.3% vs. 26.2%, p = 0.03). Logistic regression analysis showed that the incidence of wound infection was related to the duration required to achieve the enteral nutrition standard (OR = 1.095, p = 0.002). Seventy-six patients (69.1%) achieved the nutritional goal within a week and 105 patients (95.5%) in the end. Trauma patients unable to reach the enteral nutrition target within one week were often combined with abdominal infection, peritonitis, bowel resection, intestinal necrosis, intestinal fistula, or septic shock. ConclusionEarly enteral nutrition for trauma patients in the ICU is correlated with less wound infection, lower mortality, and shorter hospital stay.

N-terminal pro-B-type natriuretic peptide is a biomarker of myocardial stress in abdominal sepsis and septic shock

Aim. To evaluate the dynamics and prognostic significance of serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) level in patients with severe abdominal sepsis.Methods. We analysed survey data of 54 patients (28 men and 26 women) aged 64.5 years [56.25–78.00] with abdominal sepsis or septic shock. Disease severity scored according to the Acute Physiology and Chronic Health Evaluation II criteria was 16.3 ± 0.8 and according to the Sequential Organ Failure Assessment (SOFA) was 3 [3–6]. Statistical analysis of these data was performed using correlation analysis, logistic regression and receiver operating characteristic analysis.Results. Serum NT-proBNP level during the 1st week following admission to the intensive care unit (ICU) exceeded normal values, i.e. 2,570 [116.25–6,559.5] to 4,600 [1,680–18,200] pg/ml. At all disease stages, serum NT-proBNP level correlated with sepsis severity scores (SOFA), procalcitonin (PCT) levels, lactatemia, mean arterial pressure, heart rate and inotropic and vasoactive–inotropic scales (rho = 0.329–0.433; p &lt; 0.02). On ICU days 3–4, serum NT-proBNP level of &gt;5100 pg/ml was associated with increased risk of mortality [65.6%–88.2%; area under the curve (AUC) = 0.806; р &lt; 0.0001]. Similarly, during this interval, elevated serum NT-proBNP level was associated with the use of inotropic drugs (OR = 1.0001, 95% CI = 1.000–1.0002, p &lt; 0.0059). Notably, we found that 76.9%–79.0% of the patients with serum NT-proBNP level of &gt;5250 pg/ml were receiving inotropic drugs including adrenaline, dopamine and dobutamine. We were unable to identify a specific association between serum NT-proBNP level and norepinephrine administration. On ICU days 7 and 8, among patients with serum NT-proBNP level of &gt;3450 pg/ml, we observed a very close relationship between serum NT-proBNP level and PCT (sensitivity = 63.6%, specificity = 66.7%, AUC = 0.708; р = 0.0041).Conclusion. Serum NT-proBNP level is considerably elevated in patients with abdominal sepsis or septic shock. NT-proBNP level was associated with both traditional indicators of sepsis severity and indicators characterising the state of systemic circulation. Notably, serum NT-proBNP level correlates with cardiac failure and inotropic drug requirement. Although the mechanisms underlying the observed increases in serum NT-proBNP level remain unclear, the present findings indicate that this mediator is clearly a significant biomarker and predictor of adverse outcomes related to abdominal sepsis and septic shock. Received 22 January 2020. Revised 27 January 2020. Accepted 11 February 2020. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Author contributionsConception and study design: I.N. Tyurin, D.N. Protsenko, I.A. KozlovData collection and analysis: I.N. Tyurin, S.A. Rautbart, S.N. ShuryginStatistical analysis: I.N. Tyurin, S.A. RautbartDrafting the article: I.N. Tyurin, D.N. Protsenko, I.A. Kozlov, S.N. ShuryginCritical revision of the article: I.N. Tyurin, I.A. KozlovFinal approval of the version to be published: I.N. Tyurin, S.A. Rautbart, D.N. Protsenko, S.N. Shurygin, I.A. Kozlov

Initial Experience of Using Polymyxin B Hemoperfusion in Abdominal Septic Shock: Things to Consider for Better Outcome

Initial Experience of Using Polymyxin B Hemoperfusion in Abdominal Septic Shock: Things to Consider for Better Outcome

Acute fatal group A Streptococcal primary peritonitis following vaginal delivery

Acute primary peritonitis due to group A streptococci (GAS) is a rare but life-threatening disease most often seen in case of liver cirrhosis or nephrotic syndrome. The specific mechanism of this infection remains unknown and according to the literature hematogenous, lymphatic, retrograde inoculation from the genitourinary tract and translocation of intestinal tract flora have all been proposed. We report a case of a 37-year-old previously healthy patient who presented to the emergency, four days after vaginal delivery, with abdominal pain and septic shock. Acute peritonitis was diagnosed and peritoneal and blood culture revealed group A streptococci. Unfortunately, the patient died within 12 h despite adequate resuscitation and antimicrobials. The present case report highlights the importance of an early diagnosis with an adequate therapy in case of GAS peritonitis after vaginal delivery.

Сritical care echocardiography and transpulmonary thermodilution in patients with sepsis. Pilot study

Introduction.The cardiac dysfunction in sepsis (septic cardiopathy) diagnosis is an actual problem. Objectives. To study the correspondence between the indicators obtained with сritical care echocardiography and transpulmonary thermodilution, and to assess their predictive significance in relation to the risk of mortality. Materials and methods. The study involved 25 patients aged 45 (31–68) years with abdominal sepsis or septic shock. The severity of the condition upon admission to the intensive care unit was 13 (11–16) points on the APACHE II scale, and 8 (6.5–9.5) points on the SOFA scale. Septic shock was diagnosed in 52 % of patients. Results. Cardiac index, stroke volume index, left ventricular ejection fraction and global cardiac ejection fraction, as well as heart filling volumes established by echocardiography and transpulmonary thermodilution were moderately correlated with each other (rho 0.408–0.538; p &lt; 0.05). Dilation of the left ventricle (end-diastolic volume index 80–115 ml/m2) was detected in 16 % of patients. A decrease of the left ventricle ejection fraction (48–23 %) was registered in 24 % of cases. Transpulmonary thermodilution indices were not associated with a left ventricular ejection fraction value below 50 %. Neither left ventricular ejection fraction nor left ventricular filling volumes were predictors of adverse sepsis outcomes. The predictor of mortality was the cardiac function index determined with transpulmonary thermodilution (OR 0.3361; 95 % CI 0.1351–0.8363; p = 0.019), the value of which &lt; 5.8 min–1 predicted mortality with sensitivity of 85.7 % and specificity of 72.2 % (AUC 0.817; p = 0.0057). Conclusions. Ultrasound assessment of cardiac activity with the calculation of left ventricular filling volumes and left ventricular ejection fraction should not be considered as a non-invasive alternative to transpulmonary thermodilution in patients with sepsis. The heart function index can diagnose abnormal heart function that increases the risk of mortality in abdominal sepsis.

Polymyxin B hemoperfusion as a feasible therapy after source control in abdominal septic shock.

BACKGROUNDPolymyxin B hemoperfusion (PMX-HP) has been used as a treatment for intra-abdominal septic shock by absorbing and removing endotoxins of gram-negative bacilli.AIMTo investigate the clinical efficacy of PMX-HP in patients with gram-negative septic shock who underwent abdominal surgery.METHODSFrom January 2012 to December 2018, patients who had septic shock secondary to peritonitis were enrolled. They were classified into PMX-HP treated and control groups based on postopreative intervention using PMX-HP. The clinical outcomes were compared using 1:1 propensity score matching methods to balance the overall distribution between the two groups.RESULTSAfter propensity score matching, 40 patients were analyzed (20 patients in the PMX group and 20 patients in the control group). The scores of total Sequential Organ Failure Assessment (SOFA) score, renal SOFA and coagulation SOFA were significantly improved in the PMX group but not in the control group. (from 11.2 ± 5.8 to 4.7 ± 3.5 in PMX group vs 10.0 ± 4.0 to 8.7 ± 7.3 in control group, P = 0.047 from 2.6 ± 1.0 to 0.7 ± 1.0 in PMX group vs 2.6 ± 1.5 to 2.8 ± 1.6 in control group, P = 0.000, from 1.6 ± 1.5 to 1.3 ± 1.3 in PMX group vs 1.2 ± 1.2 to 2.8 ± 1.8 in control group, P = 0.014, respectively). Further, the length of intensive care unit (ICU) stay was significantly shorter in PMX group. However, no statistically significant difference was found in ICU mortality (50% in PMX group vs 50% in control group).CONCLUSIONPMX-HP is a feasible adjunct treatment for peritonitis in ICU patients with peritonitis for improved organ impairment and to stabilize hemodynamics. It would be helpful to enhance clinical outcomes especially in patients with complete elimination of the source of gram-negative bacilli infection by surgical procedure accompanied with conventional treatment of sepsis.

Parenteral Nutrition Therapy for an Achondroplastic Patient: Case Report

Abstract Introduction Achondroplasia is the most common form of dwarfism in humans. At the end of the twentieth century, achondroplasia had its natural history investigated and its morbimortality understood. In dwarves, obesity is one of the causes of morbidity, and it is difficult to evaluate it due to the great disproportion among anthropometric data. The characterization of the nutritional needs of these patients represents an interesting dilemma for physicians. In view of these difficulties, the present case report describes an alternative to obtain the ideal weight value of an elderly dwarf in the use of parenteral nutritional therapy. Case Report A 73-year-old male patient, carrier of achondroplastic dwarfism, was admitted for surgical treatment of colon adenocarcinoma. He was submitted to total colectomy with ileum-rectum anastomosis, evolving with abdominal septic shock by suture dehiscence, which was fixed, and a protective ileostomy was installed. Due to the maintenance of prolonged fasting, without the possibility of starting oral or enteral feeding, the patient used total parenteral nutrition. To estimate the total energy expenditure, we chose to ask the patient what his ideal weight was. The patient used total parenteral nutrition for eight days until he was able to meet his caloric needs orally. Conclusion In the absence of indirect calorimetry, the ideal weight mentioned by the patient seems to be a good option for the estimation of the caloric expenditure by simplified equations.

Analysis on operational safety of chronic radiation intestinal injury

Objective: To investigate the safety and efficacy of surgical treatment for chronic radiation intestinal injury. Methods: A descriptive cohort study was performed. Clinical data of 73 patients with definite radiation history and diagnosed clinically as chronic radiation intestinal injury, undergoing operation at Department of Colorectal Surgery, the Sixth Affiliated Hospital of Sun Yat-sen University from January 1, 2012 to February 28, 2019, were reviewed and analyzed retrospectively. Patients did not undergo operation or only received adhesiolysis were excluded. All the patients had preoperative examination and overall evaluation of the disease. According to severity of intestinal obstruction and patients' diet, corresponding nutritional support and conservative treatment were given. Surgical methods: The one-stage bowel resection and anastomosis was the first choice for surgical treatment of chronic radiation intestinal injury. Patients with poor nutritional condition were given enterostomy and postoperative enteral nutrition and second-stage stoma closure and intestinal anastomosis if nutritional condition improved. For those who were unable to perform stoma closure, a permanent stoma should be performed. Patients with severe abdominal adhesion which was difficult to separate, enterostomy or bypass surgery after adhesiolysis would be the surgical choice. For patients with tumor metastasis or recurrence, enterostomy or bypass surgery should be selected. Observation parameters: the overall and major (Clavien-Dindo grades III to V) postoperative complication within 30 days after surgery or during hospitalization; mortality within postoperative 30 days; postoperative hospital stay; time to postoperative recovery of enteral nutrition; time to removal of drainage tube. Results: Of the 73 patients who had been enrolled in this study, 10 were male and 63 were female with median age of 54 (range, 34-80) years. Preoperative evaluation showed that 61 patients had intestinal stenosis, 63 had intestinal obstruction, 11 had intestinal perforation, 20 had intestinal fistula, 3 had intestinal bleeding, and 6 had abdominal abscess, of whom 64(87.7%) patients had multiple complications. Tumor recurrence or metastasis was found in 15 patients. A total of 65(89.0%) patients received preoperative nutritional support, of whom 35 received total parenteral nutrition and 30 received partial parenteral nutrition. The median preoperative nutritional support duration was 8.5 (range, 6.0-16.2) days. The rate of one-stage intestine resection was 69.9% (51/73), and one-stage enterostomy was 23.3% (17/73). In the 51 patients undergoing bowel resection, the average length of resected bowel was (50.3±49.1) cm. Among the 45 patients with intestinal anastomosis, 4 underwent manual anastomosis and 41 underwent stapled anastomosis; 36 underwent side-to-side anastomosis, 5 underwent end-to-side anastomosis, and 4 underwent end-to-end anastomosis. Eighty postoperative complications occurred in 39 patients and the overall postoperative complication rate was 53.4% (39/73), including 39 moderate to severe complications (Clavien-Dindo grade III-V) in 20 patients (27.4%, 20/73) and postoperative anastomotic leakage in 2 patients (2.7%, 2/73). The mortality within postoperative 30 days was 2.7% (2/73); both patients died of abdominal infection, septic shock, and multiple organ failure caused by anastomotic leakage. The median postoperative hospital stay was 13 (11, 23) days, the postoperative enteral nutrition time was (7.2±6.9) days and the postoperative drainage tube removal time was (6.3±4.2) days. Conclusions: Surgical treatment, especially one-stage anastomosis, is safe and feasible for chronic radiation intestine injury. Defining the extent of bowel resection, rational selection of the anatomic position of the anastomosis and perioperative nutritional support treatment are the key to reduce postoperative complications.

Phlegmonous Colitis: Infectious Entity in Cirrhosis

Phlegmonous colitis is a rare source of infection; the main predisposing factor identified is cirrhosis. Herein, we describe a case of a 36-year-old female with abdominal pain and septic shock, with a thickened ascending colon by tomography; a fulminant pseudomembranous colitis vs. intestinal vasculitis was suspected. A right hemi colectomy was performed; the patient died hours after surgery. Pathology analysis diagnosed phlegmonous colitis, which is the gold standard for the diagnosis. A computed tomography is an important tool in the diagnostic approach to rule out other infectious sources. In most cases, phlegmonous colitis is a fulminant infection.

Rapid progression of aortic and mitral stenosis in a patient with AA amyloidosis: a case report

BackgroundAortic stenosis is a common finding in cardiac amyloidosis (CA). Younger patients often remain asymptomatic. If unrecognized, this can lead to serious complications such as heart failure. Progression of aortic stenosis can be accelerated in patients with chronic kidney disease and need for dialysis. Perioperative risk in these patients is often high due to the underlying systemic disease.Case summaryA 40-year-old Caucasian man with known AA amyloidosis, highly active Ankylosing Spondylitis and need for chronic dialysis due to end-stage chronic renal failure presented for echocardiographic routine exam without reporting any cardiac symptoms. At the last visit 4 years ago, a normal heart valve function was noted and no echocardiographic follow-up was performed in the following. Now, rapid progression with severe aortic valve and mitral valve stenosis was stated and the patient underwent combined aortic and mitral surgical valve replacement following discussion in the multidisciplinary cardiology meeting. Macroscopic examination of the valves revealed significant calcification and histological examination showed the high presence of amyloid by Congo-red staining and immunohistological staining for AA-Amyloid. Both valve prosthetic devices showed normal function as well as a normal left ventricular ejection fraction in initial post-operative transoesophageal echocardiography. After prolonged and complicated post-operative course in the intensive care unit the patient died 3 months after surgery due to intractable multiorgan failure in combined severe abdominal septic and cardiogenic shock.DiscussionConcomitant CA and chronic dialysis can accelerate the onset of severe aortic valve stenosis. Young patients, as in this case, often stay asymptomatic, perioperative risk increases with duration of chronic dialysis and severity of valve stenosis. This increases the need for regular short-term echocardiographic examinations even in clinical stable patients.

Evidence-based interdisciplinary treatment of abdominal sepsis

Abdominal sepsis is the most severe form of abdominal infection. It is characterized by adysregulated host response to infection leading to life-threatening organ failure or septic shock. The latter has amortality of >40%. This article reviews the evidence on the strategic approach to treatment of patients with abdominal sepsis and septic shock. The focus is on the time-critical elements of diagnosis, anti-infective treatment and hemodynamic stabilization.

Venetoclax and Navitoclax in Patients with Relapsed or Refractory Acute Lymphoblastic Leukemia and Lymphoblastic Lymphoma

Background: Patients with relapsed or refractory (R/R) acute lymphoblastic leukemia (ALL) and lymphoblastic lymphoma have an unmet need for new treatment strategies. Navitoclax (Nav), a BCL-2/BCL-XL/BCL-W inhibitor, has shown promising effects in hematologic malignancies, however its usage is limited by prolonged thrombocytopenia mediated by inhibition of BCL-XL in platelets (J Clin Oncol. 2012;30:488). Venetoclax (Ven) is a highly selective BCL-2 inhibitor with similar anti-tumor efficacy. The addition of Nav to Ven has shown synergistic effects in preclinical models and might mitigate the dose-limiting thrombocytopenia associated with Nav monotherapy (Blood. 2016;128:1382). We report updated outcomes for ALL patients treated with Ven, Nav, and chemotherapy. Methods: R/R ALL patients aged ≥4 years were enrolled in this phase 1, multicenter, open-label, dose escalation study (NCT03181126). Patients received the weight-adjusted equivalent of 200 mg Ven on day 1, and a 400 mg equivalent daily thereafter. Daily oral Nav was administered on day 3 onward with up to three dose levels for patients ≥45 kg (25, 50, 100 mg) and up to two dose levels for patients Results: Nine adult patients, ≥45 kg (5 with B-cell ALL and 4 with T-cell ALL) have been enrolled as of the data cutoff of June 1, 2018. All patients treated thus far have received 400 mg QD Ven and 25 mg QD Nav (Dose Level 1). Chemotherapy was started on day 9 for 7 patients; patient A began chemotherapy on day 169 and patient H began on day 10. Baseline characteristics of the first 9 patients are shown in Table 1. The most common adverse events (AEs) of any grade are shown in Table 2. Serious AEs included nausea, vomiting, febrile neutropenia (n=2 each), abdominal pain upper, pseudomonal sepsis, somnolence, septic shock, acute pancreatitis, and pulmonary embolism (n=1 each). Of the serious AEs, only febrile neutropenia was considered possibly related to Ven + Nav. AEs led to dose interruptions in 4 patients. No dose-limiting toxicities (DLTs) have occurred. As of the data cutoff, 2 patients have died. Patient B died due to disease progression on day 148 and Patient E died due to an event of sudden death on day 38 not related to study drug (event was associated with not wearing a LifeVest personal defibrillator). Preliminary efficacy for these 9 patients is shown in Table 3. All 9 patients were evaluated at day 8 after Ven + Nav therapy alone. One patient had a complete response with incomplete marrow recovery (CRi) and 1 patient had a partial response (PR); the remaining patients had stable disease (SD). Five patients had assessments at day 36 or later, including 4 patients who had completed 1 cycle of chemotherapy combined with Ven + Nav, and 1 who had received Ven + Nav only; 3 patients achieved CR, and 1 patient each achieved CRi and CRp as their best response. Patient A achieved CRi after Ven + Nav therapy without chemotherapy on day 8, had a duration of response of 5.1 months before developing progressive disease and is now also receiving chemotherapy. Patient C achieved CR on day 36, stopped all therapy on day 38, and maintains ongoing response at 3.5 months. Overall, in this heavily pretreated group, 5 patients achieved a complete response (CR/CRi/CRp). Two patients with CR had no detectable MRD. The remaining 4 patients have not reached the day 36 assessment as of the data cutoff; of these patients, 1 patient had PR and 3 patients had SD. Conclusions: Ven + Nav in combination with chemotherapy is well tolerated, without any unexpected side effects and no DLTs observed to date. Preliminary data suggest that Ven + Nav with chemotherapy is efficacious in some patients with R/R ALL who have had multiple lines of therapy, including prior stem cell transplant. Enrollment, clinical follow-up, and correlative biology studies are ongoing. Disclosures Alexander:Abbvie: Other: travel expenses. Jabbour:Bristol-Myers Squibb: Consultancy, Research Funding; Abbvie: Research Funding; Takeda: Consultancy, Research Funding; Novartis: Research Funding; Pfizer: Consultancy, Research Funding. Khaw:Abbvie: Research Funding; Amgen: Other: travel expenses, Research Funding; Bristol Myers Squibb: Research Funding; Jazz Pharmaceuticals: Research Funding; Novartis: Other: travel expenses. Mullighan:Cancer Prevention and Research Institute of Texas: Consultancy; Abbvie: Research Funding; Amgen: Honoraria, Speakers Bureau; Loxo Oncology: Research Funding; Pfizer: Honoraria, Research Funding, Speakers Bureau. Leonard:Amgen: Research Funding. Schmidt:Abbvie: Employment, Equity Ownership. Tong:Abbvie: Employment, Equity Ownership. Zhou:Abbvie: Employment, Equity Ownership. Ross:AbbVie, Inc: Employment, Equity Ownership. Rosenwinkel:Abbvie: Employment, Equity Ownership. Jacobson:Abbvie: Employment, Equity Ownership. Kim:Abbvie: Employment, Equity Ownership. Stock:Jazz Pharmaceuticals: Consultancy.

Protracted immune disorders at one year after ICU discharge in patients with septic shock

BackgroundSepsis is a leading cause of mortality and critical illness worldwide and is associated with an increased mortality rate in the months following hospital discharge. The occurrence of persistent or new organ dysfunction(s) after septic shock raises questions about the mechanisms involved in the post-sepsis status. The present study aimed to explore the immune profiles of patients one year after being discharged from the intensive care unit (ICU) following treatment for abdominal septic shock.MethodsWe conducted a prospective, single-center, observational study in the surgical ICU of a university hospital. Eighty-six consecutive patients admitted for septic shock of abdominal origin were included in this study. Fifteen different plasma biomarkers were measured at ICU admission, at ICU discharge and at one year after ICU discharge. Three different clusters of biomarkers were distinguished according to their functions, namely: (1) inflammatory response, (2) cell damage and apoptosis, (3) immunosuppression and resolution of inflammation. The primary objective was to characterize variations in the immune status of septic shock patients admitted to ICU up to one year after ICU discharge. The secondary objective was to evaluate the relationship between these biomarker variations and patient outcomes.ResultsAt the onset of septic shock, we observed a cohesive pro-inflammatory profile and low levels of inflammation resolution markers. At ICU discharge, the immune status demonstrated decreased but persistent inflammation and increased immunosuppression, with elevated programmed cell death protein-1 (PD-1) levels, and a counterbalanced resolution process, with elevated levels of interleukin-10 (IL-10), resolvin D5 (RvD5), and IL-7. One year after hospital discharge, homeostasis was not completely restored with several markers of inflammation remaining elevated. Remarkably, IL-7 was persistently elevated, with levels comparable to those observed after ICU discharge, and PD-1, while lower, remained in the elevated abnormal range.ConclusionsIn this study, protracted immune disturbances were observed one year after ICU discharge. The study results suggested the presence of long-lasting immune illness disorders following a long-term septic insult, indicating the need for long-term patient follow up after ICU discharge and questioning the use of immune intervention to restore immune homeostasis after abdominal septic shock.

Complicated Sigmoid Diverticulitis Presenting as Severe Necrotizing Soft Tissue Infection

Background: Necrotizing soft tissue infection is a rare and aggressive medical and surgical emergency characterized by intense and severe tissue destruction, rapid onset systemic toxicity, and high mortality. Diverticulitis is a common complication of diverticular disease. However, its presentation as necrotizing soft tissue infection is rare. It is always important to identify the precipitating cause of necrotizing soft tissue infection to assist in appropriate treatment and risk stratification. Case Presentation: The patient was an 84-year-old female with a history of hypertension and chronic obstructive pulmonary disease with long-term steroid dependency. She presented to the emergency department with abdominal tenderness, left abdominal wall cellulitis, crepitus, and septic shock. Abdominal and pelvic computed tomography findings showed intra-abdominal abscess secondary to perforated sigmoid diverticulitis with abdominal wall abscess and necrotizing soft tissue infection of abdominal wall, chest wall, groin, and back. After intravenous fluid resuscitation and antibiotics, the patient underwent urgent laparotomy. She was found to have a large abdominal wall abscess, perforated sigmoid diverticulitis, and extensive necrosis of the torso extending from the groin to chest wall including the back. Conclusion: Abdominal wall necrotizing soft tissue infection is an uncommon complication of perforated diverticulitis. In an elderly immunocompromised patient with septic shock, perforated diverticulitis, and necrotizing soft tissue infection, the prognosis is poor.

Necrotizing Clostridium difficile Enteritis Complicating Fulminant Colitis

Background:Clostridium difficile infections result from an imbalance in normal bacterial flora, allowing C. difficile bacteria overgrowth. Whereas such bacterial overgrowth is typically confined to the colon, there have been reports of an increasing prevalence of C. difficile infections involving the small bowel, with the majority of patients presenting with a history of partial or total colectomy. We present two rare cases of necrotizing C. difficile enteritis complicating fulminant C. difficile colitis. Case Presentations: A 74-year-old male presented with a two-week history of watery diarrhea and escalating abdominal pain without recent antibiotic use. Work-up was significant for leukocytosis, bandemia, lactic acidosis, and elevated creatinine. Initial diagnosis of C. difficile was treated with intravenous fluoroquinolone and metronidazole. He deteriorated and a total colectomy with small bowel resection was performed. Final pathology revealed pseudomembranous colitis with focal mucosal ischemia and pseudomembranous necrotizing enteritis. Post-operatively the patient's condition fluctuated, requiring re-initiation of antibiotics and vasopressor therapy; he ultimately recovered. A 72-year-old female presented with severe abdominal pain and septic shock two weeks after total abdominal colectomy with end ileostomy for severe C. difficile colitis. An exploratory laparotomy appeared normal, without an identifiable pathology source. Post-operatively she required vasopressor support and mechanical ventilation. She received intravenous metronidazole and vancomycin enemas. Clostridium difficile assays confirmed the diagnosis of relapsed pseudomembranous enteritis. Antibiotic therapy continued without further incident. Conclusion:Clostridium difficile enteritis presents a unique challenge because of its difficulty in diagnosis, a fact underscored by the high morbidity and mortality of small bowel of C. difficile infections. Clostridium difficile enteritis should be suspected in patients not improving after recent colectomy for C. difficile colitis. Continuation of antibiotics and total colectomy should be considered in patients with un-explained acute intra-abdominal pathology or persistent sepsis after colectomy for fulminant C. difficile colitis.

Preliminary results of polymyxin B hemoperfusion in abdominal septic shock

Preliminary results of polymyxin B hemoperfusion in abdominal septic shock

Comparison of inflammatory cytokines in peritoneal fluid at source control surgery for abdominal sepsis

BackgroundOpen abdomen with vacuum assisted closure (VAC) is an alternate method to primary abdominal closure (PAC) in select situations for the management of severe surgical abdominal sepsis or septic shock. Peritoneal cytokines may potentially correlate with deranged physiology and help stratify severity of sepsis. The primary objective of the study was to identify if cytokines can differentiate between patients who underwent PAC or VAC at primary source control laparotomy (SCL). MethodsProspective case series including patients with severe abdominal sepsis/septic shock requiring urgent SCL. Peritoneal fluid (PF) was collected intra-operatively and blood samples were collected pre- and post SCL. Samples were analyzed with a Cytokine 30-plex Panel. APACHE-IV was used as a measure of disease severity between groups. Results4 PAC and 8 VAC patients were included. PF concentrations of IL 6, IL-17, IL-5 and HGF were significantly elevated in VAC compared to PAC. Serum RANTES was increased in survivors compared to non-survivors. ConclusionsPatients who received VAC management had a more severe degree of local abdominal sepsis based on significantly elevated peritoneal cytokines.

КЛЮЧЕВЫЕ МАРКЕРЫ "КАПИЛЛЯРНОЙ УТЕЧКИ" ПРИ СЕПСИСЕ И СЕПТИЧЕСКОМ ШОКЕ

To identify the most prognostically significant markers of the «increased vascular permeability» syndrome among patients with severe abdominal sepsis and septic shock an open prospective cohort study was carried out. That study involved 70 patients with severe abdominal sepsis and septic shock, the cause of which were generalized peritonitis in acute surgical diseases of abdominal cavity (APACHE II value is 17 marks). All patients were tested on the «capillary leak» presence, colloid «infusion load» and the indicators of Central and peripheral hemodynamics before and after colloid infusion were evaluated. As a result, it turned out that quite simple tests on «capillary leak» are prognostically significant for the severity evaluation of vascular wall damage in severe abdominal sepsis. The tests can be used to select the starting infusion therapy for patients with widespread peritonitis complicated by sepsis, septic shock and multiple organ failure.

36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016.

36th International Symposium on Intensive Care and Emergency Medicine : Brussels, Belgium. 15-18 March 2016.

Mortality prediction of septic shock patients using probabilistic fuzzy systems

Mortality scores based on multiple regressions are common in critical care medicine for prognostic stratification of patients. However, to be used at the point of care, they need to be both accurate and easily interpretable. In this work, we propose the application of one existent type of rule base system using statistical information – probabilistic fuzzy systems (PFS) – to predict mortality of septic shock patients. To assess its accuracy and interpretability, these models are compared to methodologies previously proposed in this domain: Takagi-Sugeno fuzzy models and logistic regression models. The methods are tested using a retrospective cohort study including ICU patients with abdominal septic shock. Regarding accuracy, PFS models are comparable to fuzzy modeling and logistic regression. In terms of interpretability, results indicate that PFS models increase the transparency of the learned system (using fuzzy rules), but at the same time, provide additional means for validating the fuzzy classifier using expert knowledge (from physicians in this paper). By providing accurate and interpretable estimates for the mortality risk, results suggest the usefulness of PFS to develop scores for critical care medicine.