Chronic Critical Illness Patients Research Articles

Lipidomic changes in a novel sepsis outcome-based analysis reveals potent pro-inflammatory and pro-resolving signaling lipids.

The purpose of this study was to investigate changes in the lipidome of patients with sepsis to identify signaling lipids associated with poor outcomes that could be linked to future therapies. Adult patients with sepsis were enrolled within 24h of sepsis recognition. Patients meeting Sepsis-3 criteria were enrolled from the emergency department or intensive care unit and blood samples were obtained. Clinical data were collected and outcomes of rapid recovery, chronic critical illness (CCI), or early death were adjudicated by clinicians. Lipidomic analysis was performed on two platforms, the Sciex™ 5500 device to perform a lipidomic screen of 1450 lipid species and a targeted signaling lipid panel using liquid-chromatography tandem mass spectrometry. For the lipidomic screen, there were 274 patients with sepsis: 192 with rapid recovery, 47 with CCI, and 35 with early deaths. CCI and early death patients were grouped together for analysis. Fatty acid (FA) 12:0 was decreased in CCI/early death, whereas FA 17:0 and 20:1 were elevated in CCI/early death, compared to rapid recovery patients. For the signaling lipid panel analysis, there were 262 patients with sepsis: 189 with rapid recovery, 45 with CCI, and 28 with early death. Pro-inflammatory signaling lipids from ω-6 poly-unsaturated fatty acids (PUFAs), including 15-hydroxyeicosatetraenoic (HETE), 12-HETE, and 11-HETE (oxidation products of arachidonic acid [AA]) were elevated in CCI/early death patients compared to rapid recovery. The pro-resolving lipid mediator from ω-3 PUFAs, 14(S)-hydroxy docosahexaenoic acid (14S-HDHA), was also elevated in CCI/early death compared to rapid recovery. Signaling lipids of the AA pathway were elevated in poor-outcome patients with sepsis and may serve as targets for future therapies.

CHRONIC CRITICAL ILLNESS-INDUCED MUSCLE ATROPHY: INSIGHTS FROM A TRAUMA MOUSE MODEL AND POTENTIAL MECHANISM MEDIATED VIA SERUM AMYLOID A.

Background: Chronic critical illness (CCI), which was characterized by persistent inflammation, immunosuppression, and catabolism syndrome (PICS), often leads to muscle atrophy. Serum amyloid A (SAA), a protein upregulated in critical illness myopathy, may play a crucial role in these processes. However, the effects of SAA on muscle atrophy in PICS require further investigation. This study aims to develop a mouse model of PICS combined with bone trauma to investigate the mechanisms underlying muscle weakness, with a focus on SAA. Methods: Mice were used to examine the effects of PICS after bone trauma on immune response, muscle atrophy, and bone healing. The mice were divided into two groups: a bone trauma group and a bone trauma with cecal ligation and puncture group. Tibia fracture surgery was performed on all mice, and PICS was induced through cecal ligation and puncture surgery in the PICS group. Various assessments were conducted, including weight change analysis, cytokine analysis, hematological analysis, grip strength analysis, histochemical staining, and immunofluorescence staining for SAA. In vitro experiments using C2C12 cells (myoblasts) were also conducted to investigate the role of SAA in muscle atrophy. The effects of inhibiting receptor for advanced glycation endproducts (RAGE) or JAK2 on SAA-induced muscle atrophy were examined. Bioinformatic analysis was conducted using a dataset from the GEO database to identify differentially expressed genes and construct a coexpression network. Results: Bioinformatic analysis confirmed that SAA was significantly upregulated in muscle tissue of patients with intensive care unit-induced muscle atrophy. The PICS animal models exhibited significant weight loss, spleen enlargement, elevated levels of proinflammatory cytokines, and altered hematological profiles. Evaluation of muscle atrophy in the animal models demonstrated decreased muscle mass, grip strength loss, decreased diameter of muscle fibers, and significantly increased expression of SAA. In vitro experiment demonstrated that SAA decreased myotube formation, reduced myotube diameter, and increased the expression of muscle atrophy-related genes. Furthermore, SAA expression was associated with activation of the FOXO signaling pathway, and inhibition of RAGE or JAK2/STAT3-FOXO signaling partially reversed SAA-induced muscle atrophy. Conclusions: This study successfully develops a mouse model that mimics PICS in CCI patients with bone trauma. Serum amyloid A plays a crucial role in muscle atrophy through the JAK2/STAT3-FOXO signaling pathway, and targeting RAGE or JAK2 may hold therapeutic potential in mitigating SAA-induced muscle atrophy.

Gut mycobiome dysbiosis after sepsis and trauma

BackgroundSepsis and trauma are known to disrupt gut bacterial microbiome communities, but the impacts and perturbations in the fungal (mycobiome) community after severe infection or injury, particularly in patients experiencing chronic critical illness (CCI), remain unstudied.MethodsWe assess persistence of the gut mycobiome perturbation (dysbiosis) in patients experiencing CCI following sepsis or trauma for up to two-to-three weeks after intensive care unit hospitalization.ResultsWe show that the dysbiotic mycobiome arrays shift toward a pathobiome state, which is more susceptible to infection, in CCI patients compared to age-matched healthy subjects. The fungal community in CCI patients is largely dominated by Candida spp; while, the commensal fungal species are depleted. Additionally, these myco-pathobiome arrays correlate with alterations in micro-ecological niche involving specific gut bacteria and gut-blood metabolites.ConclusionsThe findings reveal the persistence of mycobiome dysbiosis in both sepsis and trauma settings, even up to two weeks post-sepsis and trauma, highlighting the need to assess and address the increased risk of fungal infections in CCI patients.Graphical

The persistent inflammation, immunosuppression, and catabolism syndrome 10 years later.

With the implementation of new intensive care unit (ICU) therapies in the 1970s, multiple organ failure (MOF) emerged as a fulminant inflammatory phenotype leading to early ICU death. Over the ensuing decades, with fundamental advances in care, this syndrome has evolved into a lingering phenotype of chronic critical illness (CCI) leading to indolent late post-hospital discharge death. In 2012, the University of Florida (UF) Sepsis Critical Illness Research Center (SCIRC) coined the term Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PICS) to provide a mechanistic framework to study CCI in surgical patients. This was followed by a decade of research into PICS-CCI in surgical ICU patients in order to define the epidemiology, dysregulated immunity, and long-term outcomes after sepsis. Other focused studies were performed in trauma ICU patients and emergency department sepsis patients. Early deaths were surprisingly low (4%); 63% experienced rapid recovery. Unfortunately, 33% progressed to CCI, of which 79% had a poor post-discharge disposition and 41% were dead within one year. These patients had biomarker evidence of PICS, and these biomarkers enhanced clinical prediction models for dismal one-year outcomes. Emergency myelopoiesis appears to play a central role in the observed persistent immune dysregulation that characterizes PICS-CCI. Older patients were especially vulnerable. Disturbingly, over half of the older CCI patients were dead within one year and older CCI survivors remained severely disabled. Although CCI is less frequent (20%) after major trauma, PICS appears to be a valid concept. This review will specifically detail the epidemiology of CCI, PICS biomarkers, effect of site of infection, acute kidney injury, effect on older patients, dysfunctional high-density lipoproteins, sarcopenia/cachexia, emergency myelopoiesis, dysregulated erythropoiesis, and potential therapeutic interventions.

The effect of enteral nutrition nursing intervention on postoperative treatment of chronic critically ill patients: Health prevention data analysis

The field of genomics has witnessed remarkable advancements, leading to the gradual clarification of the genetic mechanism underlying various cancers. As a result, there has been an increased emphasis on gene prevention and treatment. Against this backdrop, this paper aims to examine the impact of enteral nutrition nursing intervention on the postoperative treatment of patients with chronic critical illness, with a focus on health prevention. Based on an analysis of the clinical data of patients with chronic critical illness, the study found that enteral nutrition nursing intervention plays a crucial role in enhancing the nutritional status of patients, reducing the incidence of complications, shortening the length of hospital stay, and improving the effect of postoperative rehabilitation. The study's results provide valuable insights into the efficacy of enteral nutrition nursing intervention in the postoperative treatment of patients with chronic critical illness. By improving the nutritional status of patients, enteral nutrition nursing intervention can help reduce the risk of complications, shorten the length of hospital stay, and enhance the effectiveness of postoperative rehabilitation. These findings underscore the importance of adopting effective interventions such as enteral nutrition nursing to improve the therapeutic outcomes of chronic critical illness patients and achieve the goal of health prevention.

Challenge in modern intensive care: chronic critical illness - pathophysiology and therapeutic options

The recent developments in intensive care have resulted in improved survival rates of patients treated with acute organ deficiency. As a consequence, the rate of those who survive the acute phase and subsequently require protracted organ support due to persisting organ dysfunction has been growing. Several survivors display chronic health status deterioration leading to prolonged rehabilitation or nursing, and repeated hospitalizations. The condition developed following the survival of the acute phase and requiring long-lasting intensive care is frequently termed as chronic critical illness (CCI). Several definitions exist, most of these are based on the number of ventilator days, or days of stay at the intensive care unit. Nevertheless, in spite of the initially heterogenous etiology of the acute illness, the complications associated with CCI, as well as the pathophysiological processes underlying these, are relatively uniform. This causes CCI to be a unique clinical syndrome characterized by the development of secondary infections, myopathy, central and peripheral neuropathy, and typical alterations of the hormonal and immune system functions. The outcome is heavily influenced by the frailty and comorbidities of the patient, in addition to the severity of the acute illness. The treatment of CCI patients presents a complicated task requiring multidisciplinary view and individualized therapeutic measures. Since the aging of the population and the continuously improving success rates in overcoming acute conditions also facilitate the development of CCI, the systematic overview of the underlying pathophysiological processes is pivotal for the optimization of the medical, nursing, social and economical burden presented by this syndrome. Orv Hetil. 2023; 164(18): 702-712.

Management of the Patient with Chronic Critical Illness - Part 2.

Patients with chronic critical illness (CCI) represent a growing segment of the hospitalized population. Key aspects of care in CCI patients including tracheostomy, prolonged mechanical ventilation, nutritional support, wound care, and others require a comprehensive, goal-directed approach. Infectious complications of CCI including pneumonia, tracheobronchitis and urinary tract infection may be caused by nosocomial organisms requiring awareness and adjustment of treatment regimen. Finally, psychiatric, palliative, rehabilitative components of care impact heavily upon outcomes in CCI patients. As care that is typically associated with the intensive care unit is extended to the hospital ward, we aim to increase awareness among providers and outline a systematic approach to deliver high quality, patient centered care to CCI patients.

Chronic critical illness after trauma injury: outcomes and experience in a trauma center

Objective To determine the prevalence, risk factors and functional results of chronic critical illness (CCI) in polytrauma patients. Design Single-center observational retrospective study Setting ICU at a tertiary hospital in Santander, Spain, between 2015 and 2019. Patients Adult trauma patients who survived beyond 48 h after injury. CCI was defined as the need for mechanical ventilation for at least 14 days or tracheostomy for difficult weaning. Measurements and main results About 62/575 developed CCI. These patients were characterized by higher ISS score [17 (SD 10) vs. 13.8 (SD 8.2); p < 0.001] and higher NISS (26 (SD 11) vs. 19.2 (SD 10.5); p = 0.001). CCI group had greater proportion of hospital-acquired infections (100% vs. 18.1%; p < 0.001), and acute kidney failure (33.9% vs. 22.8% p < 0.001). During the first 24 h of admission, CCI group required in a greater proportion surgical intervention (50% vs. 29%; p = 0.001), and blood products (31.3% vs. 20.5%; p < 0.047). Hospital ward stay was longer in CCI patients [9.5 days (IQR 5–16.9) vs. 43.9 (IQR 30.3–53) p < 0.001]. The CCI mortality was higher (19.5% vs. 8.1%; p = 0.004). Surgical intervention in the first 24 h (OR 2.5 95% CI 1.1–4.1), age (> 55 years) (OR 2.1 95%CI 1.1–4.2), ISS score (OR 1.1 95%CI 1.02–1.3), GCS score (OR 0.8 95%CI 0.4–23.2) and multiple organ failure (OR 9.5 95%CI 3.9–23.2) were predictors of CCI in the multivariate analysis. Conclusions CCI after severe trauma appears in a considerable proportion of patients. Early identification and implementation of specific interventions could change the evolution of this process.

Management of the Patient with Chronic Critical Illness - Part 1: This is part one of a two part series. Part two will be published in September.

Patients with chronic critical illness (CCI) represent a growing segment of the hospitalized population. Key aspects of care in CCI patients including tracheostomy, prolonged mechanical ventilation, nutritional support, wound care, and others require a comprehensive, goal-directed approach. Infectious complications of CCI including pneumonia, tracheobronchitis and urinary tract infection may be caused by nosocomial organisms requiring awareness and adjustment of treatment regimen. Finally, psychiatric, palliative, rehabilitative components of care impact heavily upon outcomes in CCI patients. As care that is typically associated with the intensive care unit is extended to the hospital ward, we aim to increase awareness among providers and outline a systematic approach to deliver high quality, patient centered care to CCI patients.

Chronic Critical Illness in Patients With Sepsis is Associated With Persistent Anemia, Inflammation, and Impaired Functional Outcomes.

Survivors of sepsis will progress towards rapid recovery (RAP) or enter a state of persistent organ dysfunction and chronic critical illness (CCI). Independently, anemia is known to be a significant factor in functional recovery of hospitalized patients. This study aims to analyze long-term hemoglobin levels and functional outcomes following RAP and CCI. A prospective, cohort study was performed in septic patients who were stratified into RAP (N = 54) with ICU length of stay < 14days or CCI (N = 63) with ICU length of stay > 14 days. CBC and plasma inflammatory markers were measured on the day of enrollment, weekly until day 42, then at 3 and 6months. Functional outcomes using Zubrod scale, gait speed test, and total short physical performance battery (SPPB) were assessed at 3, 6, and 12months. Mean age was 59years (range: 20-83) and 62% were male. Hemoglobin was significantly decreased at 3 and 6months in CCI compared to RAP (8.9* and 9.2* vs 10.4 and 11.1 g/dL), despite receiving significantly more red blood cell transfusions. CCI patients had persistent elevation of CRP, IL-6 and TNF-α. CCI patients had worse functional outcome with a significantly higher Zubrod score, and lower SPPB, and gait speed score at 3, 6, and 12months. Despite receiving more pRBC transfusions, CCI patients had a persistent anemia that was associated with chronic systemic inflammation and poor functional outcomes six months following sepsis. Alleviating prolonged inflammation could improve persistent anemia and functional outcomes in CCI patients.

Home Care of Tracheostomized Chronically Critically Ill Patients: A Study of Caregivers' Burden and Comparison with the Burden of Palliative Care Patients in India.

IntroductionChronically critically ill (CCI) patients often have high costs of care and poor outcomes. Disease management programs offering home care may reduce costs but need buy-in from informal caregivers. An understanding of caregiver burden in this population is lacking. We aimed to study the caregiver burden, its change over time, and factors affecting it, in post-ICU tracheostomized patients. We compared the caregiver burden among CCI carers to that of palliative caregivers.Materials and methodsInformal caregivers of thirty chronically critically ill tracheostomized patients (CGcci) were administered the Caregivers Burden Scale (CBS) tool at discharge, 2 and 4 weeks after discharge. A one-point assessment of burden was made in 30 caregivers of patients enrolled in Pain and Palliative care clinic (CGpc). Linear mixed models for repeated measures were used to analyze score of CGcci over time and compared to the burden in physical, psychologic, economic, time, and social domains between groups.ResultsAll 60 caregivers were young (33–35 years), predominantly male, and children of the patients. Both CGcci and CGpc had moderate burden score of 60.5 (14.7) vs 61.5 (13), respectively. Physical burden (11.5 vs 8) was greater in CGcci (p = 0.001) compared to psychologic domain (10 vs 12.5) in CGpc (p = 0.01). Burden score over all domains in CGcci decreased rapidly from 67.5 (8) to 55 (16.5) (p = 0.001) in the first month after discharge.ConclusionBurden of care among caregivers of tracheostomized chronically critically ill patients is comparable to those of palliative caregivers and reduces significantly with time.CTRI2020/11/029443 (registered on: 27/11/2020)How to cite this articleHansda U, Tripathy S, Sahoo AK, Panda I, Shetty AP, Mitra JK, et al. Home Care of Tracheostomized Chronically Critically Ill Patients: A Study of Caregivers’ Burden and Comparison with the Burden of Palliative Care Patients in India. Indian J Crit Care Med 2022;26(5):579–583.

Chronic critical illness in polytrauma. Results of the Spanish trauma in ICU registry.

Chronic critical illness after trauma injury has not been fully evaluated, and there is little evidence in this regard. We aim to describe the prevalence and risk factors of chronic critical illness (CCI) in trauma patients admitted to the intensive care unit. Retrospective observational multicenter study (Spanish Registry of Trauma in ICU (RETRAUCI)). Period March 2015 to December 2019. Trauma patients admitted to the ICU, who survived the first 48h, were included. Chronic critical illness (CCI) was considered as the need for mechanical ventilation for a period greater than 14days and/or placement of a tracheostomy. The main outcomes measures were prevalence and risk factors of CCI after trauma. 1290/9213 (14%) patients developed CCI. These patients were older (51.2±19.4 vs 49±18.9); p<.01) and predominantly male (79.9%). They presented a higher proportion of infectious complications (81.3% vs 12.7%; p<.01) and multiple organ dysfunction syndrome (MODS) (27.02% vs 5.19%; p<.01). CCI patients required longer stays in the ICU and had higher ICU and overall in-hospital mortality. Age, injury severity score, head injury, infectious complications, and development of MODS were independent predictors of CCI. CCI in trauma is a prevalent entity in our series. Early identification could facilitate specific interventions to change the trajectory of this process.

195 Older adults show biomarker evidence of PICS after sepsis

OBJECTIVES/GOALS: Many older sepsis survivors develop chronic critical illness (CCI) with poor outcomes. Sepsis is caused by a dysregulated immune response and biomarkers reflecting PICS. The purpose was to compare serial PICS biomarkers in a) older (versus young) adults and b) older CCI (versus older RAP) patients to gain insight into underlying pathobiology of CCI. METHODS/STUDY POPULATION: Prospective longitudinal study with young (≤ 45 years) and older (≥ 65 years) septic adults who were characterized by a) baseline predisposition, b) hospital outcomes, c) serial SOFA organ dysfunction scores over 14 days, d) Zubrod Performance status at three, six and 12-month follow-up and e) mortality over 12 months. Serial blood samples over 14 days were analyzed for selected biomarkers reflecting PICS. RESULTS/ANTICIPATED RESULTS: Compared to the young, more older adults developed CCI (20% vs 42%) and had markedly worse serial SOFA scores, performance status and mortality over 12 months. Additionally, older (versus young) and older CCI (versus older RAP) patients had more persistent aberrations in biomarkers reflecting inflammation, immunosuppression, stress metabolism, lack of anabolism and anti-angiogenesis over 14 days after sepsis. DISCUSSION/SIGNIFICANCE: Older (versus young) and older CCI (versus older RAP) patient subgroups demonstrate early biomarker evidence of the underlying pathobiology of PICS. The population of older sepsis survivors is need of interventions to lower systemic inflammation and stimulate anabolism to prevent skeletal muscle wasting and disability.

Hi-C Metagenomics in the ICU: Exploring Clinically Relevant Features of Gut Microbiome in Chronically Critically Ill Patients.

Gut microbiome in critically ill patients shows profound dysbiosis. The most vulnerable is the subgroup of chronically critically ill (CCI) patients – those suffering from long-term dependence on support systems in intensive care units. It is important to investigate their microbiome as a potential reservoir of opportunistic taxa causing co-infections and a morbidity factor. We explored dynamics of microbiome composition in the CCI patients by combining “shotgun” metagenomics with chromosome conformation capture (Hi-C). Stool samples were collected at 2 time points from 2 patients with severe brain injury with different outcomes within a 1–2-week interval. The metagenome-assembled genomes (MAGs) were reconstructed based on the Hi-C data using a novel hicSPAdes method (along with the bin3c method for comparison), as well as independently of the Hi-C using MetaBAT2. The resistomes of the samples were derived using a novel assembly graph-based approach. Links of bacteria to antibiotic resistance genes, plasmids and viruses were analyzed using Hi-C-based networks. The gut community structure was enriched in opportunistic microorganisms. The binning using hicSPAdes was superior to the conventional WGS-based binning as well as to the bin3c in terms of the number, completeness and contamination of the reconstructed MAGs. Using Klebsiella pneumoniae as an example, we showed how chromosome conformation capture can aid comparative genomic analysis of clinically important pathogens. Diverse associations of resistome with antimicrobial therapy from the level of assembly graphs to gene content were discovered. Analysis of Hi-C networks suggested multiple “host-plasmid” and “host-phage” links. Hi-C metagenomics is a promising technique for investigating clinical microbiome samples. It provides a community composition profile with increased details on bacterial gene content and mobile genetic elements compared to conventional metagenomics. The ability of Hi-C binning to encompass the MAG’s plasmid content facilitates metagenomic evaluation of virulence and drug resistance dynamics in clinically relevant opportunistic pathogens. These findings will help to identify the targets for developing cost-effective and rapid tests for assessing microbiome-related health risks.

Serum Levels of Acylcarnitines and Amino Acids Are Associated with Liberation from Organ Support in Patients with Septic Shock.

Sepsis-induced metabolic dysfunction is associated with mortality, but the signatures that differentiate variable clinical outcomes among survivors are unknown. Our aim was to determine the relationship between host metabolism and chronic critical illness (CCI) in patients with septic shock. We analyzed metabolomics data from mechanically ventilated patients with vasopressor-dependent septic shock from the placebo arm of a recently completed clinical trial. Baseline serum metabolites were measured by liquid chromatography-mass spectrometry and 1H-nuclear magnetic resonance. We conducted a time-to-event analysis censored at 28 days. Specifically, we determined the relationship between metabolites and time to extubation and freedom from vasopressors using a competing risk survival model, with death as a competing risk. We also compared metabolite concentrations between CCI patients, defined as intensive care unit level of care ≥ 14 days, and those with rapid recovery. Elevations in two acylcarnitines and four amino acids were related to the freedom from organ support (subdistributional hazard ratio < 1 and false discovery rate < 0.05). Proline, glycine, glutamine, and methionine were also elevated in patients who developed CCI. Our work highlights the need for further testing of metabolomics to identify patients at risk of CCI and to elucidate potential mechanisms that contribute to its etiology.

Older adults show biomarker evidence of PICS after sepsis

Background: Hospital deaths after sepsis have decreased substantially and most young adult survivors rapidly recover (RAP). However, many older survivors develop chronic critical illness (CCI) with poor long-term outcomes. The etiology of CCI is multifactorial and the relative importance remains unclear. Sepsis is caused by a dysregulated immune response and biomarkers reflecting a persistent inflammation, immunosuppression and catabolism syndrome (PICS) have been observed in CCI after sepsis. Therefore, the purpose of this study was to compare serial PICS biomarkers in a) older (versus young) adults and b) older CCI (versus older RAP) patients to gain insight into underlying pathobiology of CCI in older adults. Methods: Prospective longitudinal study with young (≤ 45 years) and older (≥ 65 years) septic adults who were characterized by a) baseline predisposition, b) hospital outcomes, c) serial SOFA organ dysfunction scores over 14 days, d) Zubrod Performance status at three, six and 12-month follow-up and e) mortality over 12 months. Serial blood samples over 14 days were analyzed for selected biomarkers reflecting PICS. Results: Compared to the young, more older adults developed CCI (20% vs 42%) and had markedly worse serial SOFA scores, performance status and mortality over 12 months. Additionally, older (versus young) and older CCI (versus older RAP) patients had more persistent aberrations in biomarkers reflecting inflammation, immunosuppression, stress metabolism, lack of anabolism and anti-angiogenesis over 14 days after sepsis. Conclusion: Older (versus young) and older CCI (versus older RAP) patient subgroups demonstrate early biomarker evidence of the underlying pathobiology of PICS.

Efficacy of Bifidobacterium Triple Viable Enteric-Coated Capsules Combined with Enteral Nutrition on Patients with Chronic Critical Illness and Influence on Immune and Coagulation Function.

Objective To investigate the efficacy of enteric-coated Bifidobacterium triple viable capsules combined with enteral nutrition in the treatment of patients with chronic critical illness (CCI) and their effects on the immune and coagulation function of patients. Methods 106 CCI patients admitted to the intensive care unit of our hospital from December 2018 to March 2020 were selected as the research objects, and they were randomly divided into the control group (n = 53) and the observation group (n = 53). The control group was given symptomatic treatment, etiological treatment, clinical nursing, enteral nutrition support, and other conventional treatment methods according to the patient's condition. On this basis, the observation group was treated with enteric-coated Bifidobacterium triple viable capsules, and both groups were treated for 14 days. All patients were followed up for 3 months after treatment, and their death/cure prognosis was recorded. The acute physiological and chronic health (APACHE II) scoring system was used to evaluate the acute physiological and chronic health status of the two groups before and after treatment, and the organs of the patients were scored with sepsis-related organ failure assessment (SOFA) score. T lymphocyte subsets (CD3+, CD4+, CD8+, and CD4+/CD8+), prothrombin time (PT), activated partial thrombin time (APTT), fibrinogen (FIB), and D-dimer (DD) were measured before and after treatment. Results The cure rate of the observation group was slightly higher than that of the control group, and the mortality rate was slightly lower than that of the control group, but the difference was not statistically significant (P < 0.05). After treatment, the APACHE II and SOFA scores of the two groups were lower than before treatment, and the APACHE II and SOFA scores of the observation group were lower than those of the control group, and the differences were both statistically significant (P < 0.05). After treatment, the levels of CD3+, CD4+, and CD4+/CD8+ in the two groups were higher than those before treatment, and the levels of CD8+ were lower than before treatment. The CD3+, CD4+, and CD4+/CD8+ levels of the observation group were higher than those of the control group, and the CD8+ levels were lower than the control group, and the differences were both statistically significant (P < 0.05). After treatment, the PT and APTT levels of the two groups of patients were higher than those before treatment, and the levels of FIB and DD were lower than those before treatment. The PT and APTT levels of the observation group were higher than those of the control group, and the FIB and DD levels were lower than those of the control group, and the differences were both statistically significant (P < 0.05). Conclusion The combination of enteric-coated Bifidobacterium triple viable capsules and enteral nutrition for CCI has high cure rate, which can not only improve the patients' physiological health status and organ dysfunction but also effectively improve the patients' immune and coagulation function, which is worthy of promotion.

Tertiary peritonitis: considerations for complex team-based care.

Peritonitis, as a major consequence of hollow visceral perforation, anastomotic disruption, ischemic necrosis, or other injuries of the gastrointestinal tract, often drives acute care in the emergency department, operating room, and the ICU. Chronic critical illness (CCI) represents a devastating challenge in modern surgical critical care where successful interventions have fostered a growing cohort of patients with prolonged dependence on mechanical ventilation and other organ supportive therapies who would previously have succumbed much earlier in the acute phase of critical illness. An important subset of CCI patients are those who have survived an emergency abdominal operation, but who subsequently require prolonged open abdomen management complicated by persistent peritoneal space infection or colonization, fistula formation, and gastrointestinal (GI) tract dysfunction; these patients are described as having tertiary peritonitis (TP).The organ dysfunction cascade in TP terminates in death in between 30 and 64% of patients. This narrative review describes key—but not all—elements in a framework for the coordinate multiprofessional team-based management of a patient with tertiary peritonitis to mitigate this risk of death and promote recovery. Given the prolonged critical illness course of this unique patient population, early and recurrent Palliative Care Medicine consultation helps establish goals of care, support adjustment to changes in life circumstance, and enable patient and family centered care.

Chronic Critical Illness Elicits a Unique Circulating Leukocyte Transcriptome in Sepsis Survivors.

Surgical sepsis has evolved into two major subpopulations: patients who rapidly recover, and those who develop chronic critical illness (CCI). Our primary aim was to determine whether CCI sepsis survivors manifest unique blood leukocyte transcriptomes in late sepsis that differ from transcriptomes among sepsis survivors with rapid recovery. In a prospective cohort study of surgical ICU patients, genome-wide expression analysis was conducted on total leukocytes in human whole blood collected on days 1 and 14 from sepsis survivors who rapidly recovered or developed CCI, defined as ICU length of stay ≥ 14 days with persistent organ dysfunction. Both sepsis patients who developed CCI and those who rapidly recovered exhibited marked changes in genome-wide expression at day 1 which remained abnormal through day 14. Although summary changes in gene expression were similar between CCI patients and subjects who rapidly recovered, CCI patients exhibited differential expression of 185 unique genes compared with rapid recovery patients at day 14 (p < 0.001). The transcriptomic patterns in sepsis survivors reveal an ongoing immune dyscrasia at the level of the blood leukocyte transcriptome, consistent with persistent inflammation and immune suppression. Furthermore, the findings highlight important genes that could compose a prognostic transcriptomic metric or serve as therapeutic targets among sepsis patients that develop CCI.

Pediatric Chronic Critical Illness: Validation, Prevalence, and Impact in a Children's Hospital.

Large populations of chronically critically ill patients test the critical care system's resource utilization ability. Defining and tracking this group is necessary for census predictions. Retrospective cohort analysis. Tertiary academic center in United States. Patients admitted to PICU or neonatal ICU. None. Demographics and resource utilization variables were sampled in PICU, intermediate care unit, cardiovascular ICU, and neonatal ICU on 3 random days in 3 consecutive months. The attendings' perception of pediatric chronic critical illness was contrasted to Shapiro's definition of chronic critical care criteria. Each unit's active and maximal capacity census was computed: the occurrence rate of pediatric chronic critical illness was 34%, the prevalence was 44.5%, and the tolerance, or percentage pediatric chronic critical illness patients to all available beds, was 36.8%. The median length of stay for the nonpatients with pediatric critical care illness to patients with pediatric critical care illness was 9 versus 46 days (1/5.1). The attending's decision was 58 times more concordant with the criteria. Pediatric chronic critical illness bed occupancy was 40.6% in PICU, 97.2% in intermediate care unit, 47.8% in cardiovascular ICU, and 33.9% in neonatal ICU. Pediatric chronic critical illness patients occupied more than one third of the ICU beds and have five times longer stay. This mounting load needs to be uniformly defined, addressed at regional and national levels, and considered in the current pandemic planning.