Criteria For Severe Sepsis Research Articles

Prehospital intravenous access and fluid resuscitation in severe sepsis: an observational cohort study.

IntroductionPrompt treatment of severe sepsis in the Emergency Department reduces deaths, but the role of prehospital fluid resuscitation is unknown. We sought to determine the risk-adjusted association between prehospital fluid administration and hospital mortality among emergency medical services (EMS) patients admitted with severe sepsis.MethodsWe performed a prospective, observational study of patients hospitalized with severe sepsis on admission among 45,394 adult EMS encounters taken to 15 hospitals from 11/2009 to 12/2010 by a two-tier EMS system in King County, Washington. The region mandated recording of prehospital intravenous catheter and fluid administration in prehospital records, along with detailed demographic, incident, physiologic, and hospital adjustment variables. We determined the effect of prehospital intravenous catheter or fluid versus no catheter or fluid on all-cause mortality using multivariable logistic regression.ResultsOf all encounters, 1,350 met criteria for severe sepsis on admission, of whom 205 (15%) died by hospital discharge, 312 (23%) received prehospital intravenous fluid, 90 (7%) received a prehospital catheter alone and 948 (70%) did not receive catheter or fluid. EMS administered a median prehospital fluid volume of 500 mL (interquartile range (IQR): 200, 1000 mL). In adjusted models, the administration of any prehospital fluid was associated with reduced hospital mortality (Odds ratio =0.46; 95% Confidence interval: 0.23, 0.88; P =0.02) compared to no prehospital fluid. The odds of hospital mortality were also lower among severe sepsis patients treated with prehospital intravenous catheter alone (Odds ratio =0.3; 95% Confidence interval: 0.17 to 0.57; P <0.01).ConclusionsIn a population-based study, the administration of prehospital fluid and placement of intravenous access were associated with decreased odds of hospital mortality compared with no prehospital catheter or fluid.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0533-x) contains supplementary material, which is available to authorized users.

Association between hemodynamic presentation and outcome in sepsis patients.

We aimed to compare outcomes of sepsis patients according to their hemodynamic presentation: cryptic shock (CS), cryptic to overt shock (COS), and overt shock (OS). We analyzed the sepsis registry for adult patients who presented to the emergency department (ED) of a tertiary hospital and met the criteria for severe sepsis or septic shock between August 2008 and March 2012. We classified the patients as having CS, COS, or OS. "Cryptic shock" was defined as severe sepsis with a lactate level of 4 mmol/L or greater and normotension, "COS" was defined as initial CS that progressed to septic shock within 72 h, and "OS" was defined as septic shock on ED arrival. The primary outcome was in-hospital mortality. We performed a multivariable logistic regression analysis to assess variables related to in-hospital mortality and a multivariable Cox regression analysis to assess predictive factors for progression to OS in patients who initially showed CS. A total of 591 patients were included. We assigned 187 (31.6%) patients to the CS group, 157 (26.6%) patients to the COS group, and 247 (41.8%) patients to the OS group. There was a significant difference in unadjusted in-hospital mortality among groups (7.0% in the CS group, 27.4% in the COS group, and 21.9% in the OS group; P < 0.01). Multivariable analysis showed an odds ratio (OR) for in-hospital mortality of 0.17 (95% confidence interval, 0.07 - 0.40; P < 0.01) for the CS group and 0.83 (95% confidence interval, 0.46 - 1.49; P = 0.54) for the COS group compared with the OS group. A higher blood lactate concentration and respiratory failure were significant risk factors for progression to OS. In conclusion, CS without deterioration to hypotension during initial treatment showed significantly lower mortality than OS. The mortality from CS that progressed to apparent hypotension, however, was comparable to the mortality associated with OS.

Chromogranin A (CgA) as a marker of weaning in mechanically ventilated critically ill septic patients

BackgroundChromogranin A (CgA) as a marker of catecholamines may reflect the physiological stress load during the current critical illness which will affect the course of mechanical ventilation and the progress of the weaning process. The aim of the work was to assess the serum chromogranin level (CgA) in mechanically ventilated critically ill septic patients as a predictor of weaning and its relation to other conventional parameters. Patients and methodsThe present study was carried on 65 adult mechanically ventilated patients who presented with severe sepsis and septic shock in the intensive care units. The patients were included in the study after fulfilling the criteria of severe sepsis and septic shock. Patients were categorized consecutively into 2 groups: Group I: included 30 patients who were weaned successfully. Group II: included 19 patients who failed weaning. Serum chromogranin A was measured by commercially available ELISA KIT. ResultsThe mean serum chromogranin A was significantly higher in the failed group compared to the success group on admission, after 24h and after 72h. The means in the failed group were 1922.21±1800.86ng/ml, 2240.16±1927.84ng/ml and 2168.26±1851.16ng/ml on admission, after 24h and after 72h, respectively while in the success group, they were 224.87±177.9ng/ml, 234.17±165.81ng/ml and 256.70±163.81ng/ml on admission, after 24h and after 72h, respectively. ConclusionThe serum chromogranin A can be used as a predictor of the weaning in septic mechanically ventilated patients.

Time to Administration of Antibiotics among Inpatients with Severe Sepsis or Septic Shock.

Current evidence suggests that administration of appropriate antibiotic therapy within 1 h after the onset of hypotension significantly improves mortality rates among patients with severe sepsis and septic shock. To determine the interval from recognition of severe sepsis or septic shock in inpatients to initial administration of antibiotic and to assess institutional compliance with the Surviving Sepsis Campaign's recommendation for early antibiotic therapy. A 6-month retrospective chart analysis was conducted to determine the interval from documented onset of hypotension to initial administration of antibiotic for patients with severe sepsis or septic shock. Patients who were admitted to a general medicine ward, a surgery ward, or the intensive care unit (ICU) of a 475-bed university-affiliated hospital and who met the criteria for severe sepsis or septic shock were eligible for inclusion. Patients who received antibiotics before meeting the criteria for severe sepsis or septic shock were excluded. Charts for 100 patients with severe sepsis or septic shock were reviewed. The mean age was 69.0 years (standard deviation 18.7 years), and 56% were men. The median interval from onset of severe sepsis or septic shock to administration of antibiotic was 4.00 h (interquartile range [IQR] 1.80-6.45 h). The median interval from the time a physician ordered an antibiotic to administration of the drug was 1.28 h (IQR 0.57-3.05 h). The interval between ordering and administration differed significantly for patients on the wards (5.67 h), those with onset in the ICU (4.00 h), and those with onset in the emergency department (3.28 h) (p = 0.039). The overall survival rate was 56%. At the study hospital, the interval from onset of severe sepsis or septic shock to initial administration of antibiotic to inpatients exceeded the 1-h period recommended by the Surviving Sepsis Campaign. These results will be used as a baseline for future quality assurance and improvement initiatives aimed at minimizing the time to antibiotic administration for this group of patients, who are at high risk of death.

Identifying Patients With Severe Sepsis Using Administrative Claims

Severe sepsis is a common and costly problem. Although consistently defined clinically by consensus conference since 1991, there have been several different implementations of the severe sepsis definition using ICD-9-CM codes for research. We conducted a single center, patient-level validation of 1 common implementation of the severe sepsis definition, the so-called "Angus" implementation. Administrative claims for all hospitalizations for patients initially admitted to general medical services from an academic medical center in 2009-2010 were reviewed. On the basis of ICD-9-CM codes, hospitalizations were sampled for review by 3 internal medicine-trained hospitalists. Chart reviews were conducted with a structured instrument, and the gold standard was the hospitalists' summary clinical judgment on whether the patient had severe sepsis. Three thousand one hundred forty-six (13.5%) hospitalizations met ICD-9-CM criteria for severe sepsis by the Angus implementation (Angus-positive) and 20,142 (86.5%) were Angus-negative. Chart reviews were performed for 92 randomly selected Angus-positive and 19 randomly-selected Angus-negative hospitalizations. Reviewers had a κ of 0.70. The Angus implementation's positive predictive value was 70.7% [95% confidence interval (CI): 51.2%, 90.5%]. The negative predictive value was 91.5% (95% CI: 79.0%, 100%). The sensitivity was 50.4% (95% CI: 14.8%, 85.7%). Specificity was 96.3% (95% CI: 92.4%, 100%). Two alternative ICD-9-CM implementations had high positive predictive values but sensitivities of <20%. The Angus implementation of the international consensus conference definition of severe sepsis offers a reasonable but imperfect approach to identifying patients with severe sepsis when compared with a gold standard of structured review of the medical chart by trained hospitalists.

Factores predictivos de mortalidad en la gangrena de Fournier: serie de 59 casos

AimsFournier's gangrene (FG) is the necrotizing fasciitis of the perineum and genital area and presents a high mortality rate. The aim was to assess prognostic factors for mortality, create a new mortality predictive scale and compare it with previously published scales in patients diagnosed with FG in our Emergency Department. MethodsRetrospective analysis study between 1998 and 2012. ResultsOf the 59 patients, 44 survived (74%) (S) and 15 died (26%) (D). Significant differences were found in peripheral vasculopathy (S 5 [11%]; D 6 [40%]; P=.023), hemoglobin (S 13; D 11; P=.014), hematocrit (S 37; D 31.4; P=.009), white blood cells (S 17,400; D 23,800; P=.023), serum urea (S 58; D 102; P<.001), creatinine (S 1.1; D 1.9; P=.032), potassium (S 3.7; D 4.4; P=.012) and alkaline phosphatase (S 92; D 133; P=.014). Predictive scores: Charlson index (S 1; D 4; P=.013), severe sepsis criteria (S 16 [36%]; D 13 [86%]; P=.001), Fournier's gangrene severity index score (FGSIS) (S 4; D 7; P=.002) and Uludag Fournier's Gangrene Severity Index (UFGSI) (S 9; D 13; P=.004). Independent predictive factors were peripheral vasculopathy, serum potassium and severe sepsis criteria, and a model was created with an area under the ROC curve of 0.850 (0.760-0.973), higher than FGSIS (0.746 [0.601-0.981]) and UFGSI (0.760 [0.617-0.904]). ConclusionsFG showed a high mortality rate. Independent predictive factors were peripheral vasculopathy, potassium and severe sepsis criteria creating a predictive model that performed better than those previously described.

Re-emergence of yellow fever in Kedougou, Southeastern Senegal in 2010-2011

Background: Urinary tract infection (UTI) complicates sepsis and/or disseminated intravascular coagulation (DIC) when the disease becomes severe; mortalities of septic DIC is reported to reach to 37% despite current therapy. Cross-talk between the coagulation system and inflammatory reactions during sepsis causes organ damage followed bymultiple organ dysfunction syndrome or even death. Therefore, anticoagulant therapies have been expected to be beneficial in the treatment of severe sepsis. Recombinant human soluble thrombomodulin (rhTM) binds to thrombin to inactivate coagulation, and the thrombin-rhTM complex activates protein C to produce activated protein C. The purpose of this study was to examine the efficacy of rhTM for treating patients with septic UTIinduced DIC. Methods & Materials: This study comprised 45 patients with septic UTI-induced DIC. All patients fulfilled the criteria of severe sepsis and the International Society on Thrombosis and Haemostasis criteria forovertDIC. The initial 25patientswere treatedwithout rhTM (control group), and the following 20 consecutive patients were treatedwith rhTM(0.06mg/kg/day) for sixdays (rhTMgroup). The primary outcome measure was 28-day mortality. Stepwise multivariateCox regression analysiswasused to assesswhich independent variables were associated with mortality. Comparisons of Sequential Organ Failure Assessment (SOFA) score on sequential days between the two groupswere analyzed by repeatedmeasures analysis of variance. Results: Cox regression analysis showed 28-daymortality to be significantly lower in the rhTM group than in the control group (adjusted hazard ratio, 0.301; 95% confidence interval, 0.104 to 0.867; P = 0.028). SOFA score in the rhTM group decreased significantly in comparison with that in the control group (P = 0.029). In the post hoc test, SOFA score decreased rapidly in the rhTM group compared with that in the control group on day 1 (P < 0.05). Conclusion: We found that rhTM administration may improve organ dysfunction in patients with septic UTI-induced DIC. Further clinical investigations are necessary to evaluate the effect of rhTM on the pathophysiology of septic UTI-induced DIC.

Bacteremia with Aerococcus sanguinicola: Case Series with Characterization of Virulence Properties.

Since Aerococcus sanguinicola was designated as a species in 2001, only a few cases of bacteremia have been reported. The aim with this study was to describe the clinical presentation of A sanguinicola bacteremia and to determine the antibiotic susceptibility and the capacity of the bacteria to form biofilm and to induce platelet aggregation. Isolates of A sanguinicola from blood cultures were retrospectively identified from 2 clinical microbiology laboratories for 2006 to 2012. Species identity was confirmed through sequencing of the 16S rRNA gene. The medical charts of patients were reviewed. The minimum inhibitory concentration (MIC) for relevant antibiotics was determined. Biofilm formation was measured as the amount of crystal violet absorbed. Platelet aggregation was determined by aggregometry. Eleven cases of A sanguinicola bacteremia were identified. All patients were male and the median age was 82 years (range 67-93). Nine patients fulfilled criteria for severe sepsis, and 2 patients died at hospital. Two patients were diagnosed with infective endocarditis. Most patients had underlying urinary tract diseases or an indwelling urinary tract catheter. Five patients suffered from dementia. None of the patients was treated with immunosuppressive medications. The MIC values of the isolates were in line with previous reports, with low MICs for penicillin, cefotaxime, and vancomycin. All 11 isolates produced biofilms but not all could induce platelet aggregation. A sanguinicola can cause severe infections in elderly men with urinary tract abnormalities and the bacteria possess potential virulence mechanisms.

Severe sepsis: Low expression of the renin-angiotensin system is associated with poor prognosis.

Severe sepsis has a high fatality rate, but no clinical indices for prognosis have been established. In recent years, the renin-angiotensin system (RAS) has received considerable attention. However, clinical data on RAS are inconsistent. Therefore, the aim of the present study was to assess the significance of RAS in the prognosis of sepsis. Blood samples were collected from patients, who met the diagnostic criteria of severe sepsis, on day 1 (D1) and 3 (D3). For each sample, the levels of angiotensin II (AngII), angiotensin-converting enzyme (ACE) and additional indices were measured. Patients were monitored for 28 days. On the D1 of inclusion, the average Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 22.2 and the Sepsis-related Organ Failure Assessment (SOFA) score was 6.1. Logistic regression analysis revealed that mortality-associated variables included the APACHE II score on D1, the SOFA score on D1, high lactic acid levels on D3 and low AngII and ACE levels on D1 and D3. AngII levels (<86.1 ng/ml) on D1 had a sensitivity of 88.2% and specificity of 77.3% for predicting mortality. ACE levels (<39.2 ng/ml) on D1 had a sensitivity of 88.2% and specificity of 72.7% for predicting mortality. These two indices were better than the APACHE II and SOFA scores. Therefore, low expression levels of AngII and ACE are valuable in predicting the mortality of patients with severe sepsis.

Outcome prediction in sepsis: speckle tracking echocardiography based assessment of myocardial function.

IntroductionSpeckle tracking echocardiography (STE) is a relatively novel and sensitive method for assessing ventricular function and may unmask myocardial dysfunction not appreciated with conventional echocardiography. The association of ventricular dysfunction and prognosis in sepsis is unclear. We sought to evaluate frequency and prognostic value of biventricular function, assessed by STE in patients with severe sepsis or septic shock.MethodsOver an eighteen-month period, sixty patients were prospectively imaged by transthoracic echocardiography within 24 hours of meeting severe sepsis criteria. Myocardial function assessment included conventional measures and STE. Association with mortality was assessed over 12 months.ResultsMortality was 33% at 30 days (n = 20) and 48% at 6 months (n = 29). 32% of patients had right ventricle (RV) dysfunction based on conventional assessment compared to 72% assessed with STE. 33% of patients had left ventricle (LV) dysfunction based on ejection fraction compared to 69% assessed with STE. RV free wall longitudinal strain was moderately associated with six-month mortality (OR 1.1, 95% confidence interval, CI, 1.02-1.26, p = 0.02, area under the curve, AUC, 0.68). No other conventional echocardiography or STE method was associated with survival. After adjustment (for example, for mechanical ventilation) severe RV free wall longitudinal strain impairment remained associated with six-month mortality.ConclusionSTE may unmask systolic dysfunction not seen with conventional echocardiography. RV dysfunction unmasked by STE, especially when severe, was associated with high mortality in patients with severe sepsis or septic shock. LV dysfunction was not associated with survival outcomes.

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Introduction: Mortality from sepsis, severe sepsis and septic shock varies between 20 – 70%. This variability is multifactorial and attributed to comorbidities, access of care, and variations in clinical practices. Additionally, the source of ICU admission may influence the outcomes of patients with different degrees of sepsis. We report the outcomes of a large cohort of critically ill septic patients based on their ICU admission source. Methods: Patients meeting conventional criteria for sepsis, severe sepsis, and septic shock within 24 hrs. of MICU admission between January of 2009 and December of 2012 were studied. Data collected included demographics, APACHE III score, sepsis category and source of infection, and ICU and hospital outcomes. Differences between patients admitted from the emergency department (ED) and general hospital wards (HW) were compared using Pearson's chi-squared and Student's t test. Results: 1661 patients were enrolled in the study, 681 (41%) admitted from the ED and 980 (59%) from HW. APACHE III and Acute Physiology Score (APS) were 85.1 ± 34.5 and 71.3 ± 32.9 vs. 85.2 ± 35.9 and 70.9 ± 33.3 respectively for patients admitted from the ED vs. HW, P = NS. ICU LOS was comparable between groups (5.2 ± 8.0 vs. 5.0 ± 5.0 ± 7.0 days), however, those admitted from the ED had a lower hospital LOS 11.5 ± 10.7 vs. 22.0 ± 14.7; P < 0.01. Intrabdominal source of sepsis was more common in HW patients whereas the urinary tract was more common in patients coming from the ED. Respiratory source was comparable. More patients admitted from the ED required mechanical ventilation on ICU admission (38.4 % vs. 34.2 %, P = 0.08). On admission the APACHE IV ICU mortality was statistically significant (0.27 ± 0.2 vs 0.3 ± 0.2) p < 0.0001. Patients admitted from HW had a higher ICU and hospital mortality 23.7% vs. 19.2% (P = 0.03) and 35.7% vs. 24.4% (P < 0.0001), respectively. Conclusions: Event though both groups had an almost identical APACHE and APS on ICU admission, patients admitted from the ED had better clinical outcomes. A more aggressive resuscitation and/or earlier recognition of the septic picture occurring in the ED settings may help explain our findings.

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Introduction: We designed a Quality Improvement pilot initiative to improve response time and standardize early goal directed therapy (EGDT) for Emergency Department (ED) patients with severe sepsis needing immediate surgery ('surgical sepsis'). Our aim was to reduce mortality for surgical sepsis patients, similar to the reductions seen after initiating our EGDT program for medical sepsis patients Methods: In May 2011, we initiated the 'Surgical Sepsis' pilot initiative at the Kaiser Permanente Northern California Santa Clara Medical Center-one of our tertiary medical centers. This pilot included a 6 month period in which we used standard performance improvement methodology (e.g., small tests of change) to accelerate quality improvement. We screened ED patients to identify those who: (1) were jointly evaluated by the ED physician and the Surgical consultant; (2) were thought to require a direct transfer from the ED to the operating room (OR) because of a surgical source of infection; and (3) met criteria for high-risk severe sepsis or shock. These criteria included a serum lactate equal to or greater than 4 mmol/L, persistent hypotension after 2 liters of intravenous (IV) crystalloid infusion, or a predicted mortality >14% based on our BUN/Lactate grid stratifying risk of mortality based on BUN and Lactate values. Among these 'Surgical Sepsis' patients, we administered a bundle comprised of at least 40 mL/kg of IV fluids, appropriate antibiotics within one hour of surgical consult, insertion of a central venous catheter within 2 hours of surgical consult, and subsequent EGDT-based quantitative resuscitation. Results: We screened a total of 759 patients seen by the Surgical consultation service with 358 deemed appropriate for admission by the surgical service. The most frequent surgical services were general surgery (abdominal surgeries). Of these patients, 273 (76.3%) received antibiotics in the ED and 198 (55.3%) met SIRS criteria. Most SIRS patients had a lactate level checked (178, 89.9%). From this sample, seven patients received our Surgical Sepsis bundle including three who met traditional severe sepsis/shock criteria and four who met BUN/Lactate criteria. Their mean age was 52 (34-85) and their mean lactate level was 3.82 mmol/L (0.94-6.2). All patients underwent emergency surgery with general anesthesia. Thirty-day survival was 100%. Conclusions: A surgical sepsis pathway can effectively enhance patient identification and treatment through a quality improvement process in a nonacademic tertiary care medical center.

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Introduction: Fluid resuscitation to a central venous pressure (CVP) goal of ≥ 8 is a key component in the early management of septic shock; however, there are no specific recommendations that address the amount of fluids and duration of time patients must be maintained at the targeted CVP goal. The purpose of this study was to determine if meeting a target CVP goal during the first six hours of severe sepsis and septic shock treatment had an impact on 28-day mortality. Methods: A single-center retrospective cohort analysis of critically ill adults who met criteria for severe sepsis or septic shock and had CVP recordings documented during the period from September 2011 to September 2012. Patients were identified as maintaining a CVP goal for ≥ 50% of the six-hour fluid resuscitation period or < 50% of the time. Maintaining a CVP goal was defined as having all measured CVP values between targets of 8-12 mm Hg or 12-15 mmHg in mechanically ventilated patients. The relationship between maintaining targeted CVP and mortality was analyzed using the Pearson's chi-square test. Results: A total of 256 adult ICU patients were eligible for study enrollment. 78 patients were included in the final analysis (12 CVP goal and 66 non-CVP goal). A total of 5 patients (42%) in the CVP goal group and 26 patients (39%) in the non-CVP goal group died within 28 days of their severe sepsis or septic shock event (p = 0.882). Non-survivors had a more positive fluid balance than survivors on days 1-3 (Day 1: 4071 mL vs. 1640 mL, respectively; p = 0.002; Day 2: 3473 mL vs. 1082 mL, p = 0.029; Day 3: 1090 mL vs. 59 mL, p = 0.004). Conclusions: There was no significant difference associated with 28-day mortality in patients who met CVP goal versus those that did not. The degree of fluid balance may have an impact on survival, and warrants further investigation.

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Introduction: Cryptic septic shock may show poor outcomes despite the setting of normal hemodynamic indices. Patients with cryptic septic shock often undergo severe tissue hypoperfusion and progressing to overt septic shock within several hours in emergency department (ED). We performed the study to compare clinical characteristics and outcomes of sepsis patients with cryptic shock, cryptic to overt shock, and overt shock. Methods: We analyzed the sepsis registry from August 2008 to March 2012 for adult patients presenting to an ED of a tertiary urban hospital and meeting the criteria for severe sepsis or septic shock. We classified enrolled patients as cryptic shock (CS) group, cryptic to overt shock (COS) group, and overt shock (OS group), defined as sepsis with a lactate ≥ 4 mmol/L and normotension, initially cryptic shock progressed to overt shock within 72 hours, and sepsis with overt hypotension on ED arrival, respectively. The primary outcome was in-hospital mortality. Results: A total 758 patients were included. Of the eligible patients, 212 patients were assigned to the CS group, 145 patients to the COS group, and 401 patients to the OS group. There was significant difference in in-hospital mortality (9.0% in the CS group, 26.2% in the COS group, and 17.2% in the OS group, p<0.001). Compared with the OS group, adjusted odds ratio (OR) for in-hospital mortality was 0.40 (95% confidence interval [CI], 0.20 – 0.81; p=0.011) in the CS group and 1.02 (95% CI 0.57 – 1.85; p=0.93) in the COS group. Among patients who initially showed cryptic shock (the CS and COS group), a higher blood lactate concentration and respiratory failure were significant risk factors for progression to overt septic shock. Conclusions: Cryptic septic shock without deterioration to hypotension during initial treatment showed significantly lower mortality than overt septic shock. The mortality of cryptic septic shock, however, was comparable to overt septic shock when it progressed to apparent hypotension. Prevention and early management of hypotension are critical strategies for improving survival of patients with cryptic septic shock.

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Introduction: Severe sepsis is a leading cause of death in intensive care units with mortality rates up to 30%. However, in pregnancy; the rates of severe sepsis are very low. A retrospective study from an administrative database reported the rate of sepsis in pregnancy to be about 0.3% in the year 2000. The literature with regards to outcomes of severe sepsis in pregnancy is small and mostly from single centers. Methods: Using the Nationwide Inpatient Sample 2000–2009, pregnant patients aged 18 and above were identified using ICD-9-CM codes. Severe sepsis were also identified using appropriate ICD-9CM codes as described in the literature. Outcome variables included frequency, in-hospital mortality and other outcomes. The yearly rates of pregnancies in United States were obtained from National Vital Statistics Reports. Chi square test was used to compare variables for unadjusted analysis. Results: There were total of 45,107,956 pregnancy related discharges from 2000 to 2009. Of these 19,351 (0.04%) met criteria for severe sepsis. The annual incidence of severe sepsis increased from 21 per 100,000 pregnancies in 2000 and 74 per 100,000 pregnancies in 2009. 50% of the severe sepsis was from puerperal infections. The in hospital mortality in pregnant women with severe sepsis was 6.8%; this did not change significantly from 2000 to 2009. In comparison, the in hospital mortality of severe sepsis in non pregnant women was 30.3%. Severe sepsis accounted for 23% of all deaths in pregnant women. The mean length of hospital stay was 2.6 days in pregnant women without sepsis while it was 12.9 days in those with severe sepsis. Conclusions: Severe sepsis in pregnancy is infrequent and has lower overall mortality when compared to the general population. However it accounts for approximately 25% of in-hospital pregnancy related deaths. The in-hospital mortality from severe sepsis in pregnancy has not changed from 2000 to 2009.

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Introduction: Severe sepsis is a prevalent disease with approximately 30% mortality. Currently, resuscitative efforts aim to achieve predefined hemodynamic and physiologic goals. The role of CO2 metabolism as reflected by arterial CO2 (PaCO2), central venous CO2 (CvCO2), and end tidal CO2 (ETCO2) is less well understood. Our goal was to determine the relationship between ETCO2 and PaCO2 and CvCO2 in patients undergoing early quantitative resuscitation in the emergency department (ED). Methods: Adult patients meeting criteria for severe sepsis or septic shock (lactate > 4 or hypotension not responsive to 20 mL/kg isotonic fluids) were approached for enrollment. The study protocol began at the start of quantitative resuscitation. For arterial blood gases (ABGs) or central venous blood gases (VBGs) obtained during the 6 hour resuscitative period, ETCO2 was measured within 5 minutes of arterial or venous blood draw. Three ETCO2 measurements were taken during a one-minute timeframe and averaged together. ABGs or VBGs were ordered at the discretion of the treating physicians. Factors that could potentially affect arterial, venous, or end-tidal CO2 levels were documented. Results: There were 42 patients with either ABG or VBG data and comparison ETCO2 measurements. Thirty four patients survived to discharge and 8 expired prior to discharge. There were 26 patients (20 survived, 6 expired) with ABG data and 30 patients (23 survived, 7 expired) with VBG data. The mean PaCO2-ETCO2 difference for surviving patients was 9 mm Hg (95% CI, 6, 13), and 16 mm Hg (95% CI, 10, 22) for patients who expired (p=0.05). When comparing only patients with pulmonary dysfunction, the mean difference was 10 mm Hg for survivors and 17 mm Hg for non-survivors (95% CI difference, -13.4, -1.0, p = 0.03). The mean CvCO2-ETCO2 difference was 15 mm Hg (95% CI, 12, 19) for survivors, and 19 mm Hg (95% CI, 9, 30) for nonsurvivors (p=0.36). There were significant differences in lactate, ventilatory status, hospital length of stay (LOS), shock, and pulmonary dysfunction among those who survived versus expired. Conclusions: We identified a promising relationship between initial PaCO2-ETCO2 difference as a predictor of mortality in patients with severe sepsis or septic shock undergoing early quantitative resuscitation. After accounting for pulmonary dysfunction, this difference was still present. We were unable to find a relationship between CvCO2-ETCO2 difference and mortality.

Sépsis em gastrenterologia: uma entidade subvalorizada?

IntroductionSepsis is a common disorder in all branches of Medicine, namely in Gastroenterology. Its high mortality rate can be decreased by an adequate early management, according to the international guidelines. AimsTo evaluate the clinical impact of sepsis in a Gastroenterology department and to determine if it was correctly diagnosed and managed. Patients and methodsRetrospective analysis based on data obtained from the clinical records. Selection of all patients admitted to a Gastroenterology department during one year presenting with sepsis criteria on hospital admission. Evaluation of demographic data and variables related to the appropriateness of the initial management – performance of blood cultures, evaluation of organ dysfunction and institution of prioritary interventions and antibiotic therapy. Statistical analysis was performed with SPSS® version 17 and Qui-square test (significance level of 0.05). ResultsWe have identified 55 patients, in 56 hospital admissions (3.9% of the total admissions in the Gastroenterology department). All patients had infection and two or more criteria for systemic inflammatory response syndrome (SIRS), the most frequent being tachycardia (71.4%) and leukocytosis (66.1%). The biliary tract was the infectious source in 64.3% of cases. In 48.2% of the cases severe sepsis or septic shock criteria were present. The following procedures were not performed: blood pressure record in 14.3%, serum lactate measurement in 37.5%, urinary catheterization in 68.9% and central line placement in 94.6%. Blood cultures were obtained in the first 24hours in 66.1% of cases and the median time to start antibiotics was 8.8hours. Only 10.7% were admitted to an intensive care unit. The diagnosis of sepsis was established in the clinical records in only 6 cases. The mortality rate in these patients was higher than the overall mortality rate in the department (30.4% vs. 8.6%, p<.0001). ConclusionsThis study found that sepsis in Gastroenterology has a high mortality rate, but it is rarely recognized and its management is not always completely adequate as shown by the lack of severity signs evaluation, delayed antibiotic therapy and low admission rate to an intensive care unit. Therefore, it is necessary to promote continuing medical education about sepsis and to implement local protocols.

Macrophage Activation Syndrome Secondary to Human Monocytic Ehrlichiosis

To present a case of human monocytic ehrlichiosis (HME) that was complicated by macrophage activation syndrome (MAS), also known as secondary hemophagocytic lymphohistiocytosis (sHLH). Data was collected from patient's electronic medical records at the University of Alabama at Birmingham. The patient is a part of a larger cohort of patients with all-cause MAS treated at our center. A 63year old renal transplant recipient male on maintenance immunosuppressive therapy presented with high grade fever, leukopenia, thrombocytopenia and elevated transaminases and initially met clinical criteria for severe sepsis. On further investigation, clinical and laboratory criteria for MAS were met. He was treated with a combination of doxycycline for HME and a novel combination of anakinra (interleukin-1 receptor antagonist), and high dose corticosteroids. The discussion focuses on clinical presentation, pathogenesis and treatment of MAS with an emphasis on MAS secondary to HME. Macrophage activation syndrome or sHLH is a dysfunctional, hyperactive and potentially fatal immune system response that results in multi-organ dysfunction. With increasing incidence of Ehrlichia chaffeensis as an emerging pathogen, clinicians should be aware of this fulminant and potentially fatal complication of HME.

How well does TOKS identify patients with severe sepsis or septic shock?

Background Several scoring system have been developed with the aim to identify clinical deterioration among hospitalized patients and allocate resources in accordance with the degree of deterioration - most without validation. The aim of the present study was to describe to which degree the system “Tidlig Opsporing af Kritisk Sygdom” (TOKS) is able to identify patients who either have or develop severe sepsis or septic shock within 24 after arrival to hospital. Methods A retrospective descriptive study of patients hospitalized with community acquired severe sepsis or septic shock. Patients were identified based at discharge diagnosis ((IDC10 code A40.0-A41.9). Based at a manual evaluation of all patient records patients were included if they within the first 24 hours after arrival to the hospital fulfilled predefined criteria for severe sepsis or septic shock. Vital values registered at arrival to the hospital were identified and used for the present analysis. TOKS score is based at scores for respiratory frequency, saturation, systolic blood pressure, pulse rate, consciousness and temperature. The score range from 0 to 21 with an indication of need for a doctoral evaluation if the score is 3 or higher. Results

The MISSED score, a new scoring system to predict Mortality In Severe Sepsis in the Emergency Department

To derive and validate a new scoring system to predict in-hospital mortality in septic patients in the emergency department (ED). Septic patients admitted to the ICU and those in whom early goal-directed therapy (EGDT) was carried out in the ED were identified from the ED record. Univariate and multivariate regression analyses identified independent variables associated with mortality. The variables were given a score weighted by the odds ratio, the sum of which yielded the Mortality In Severe Sepsis in the Emergency Department (MISSED) score. The performance of the MISSED score in predicting mortality was compared with that of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, the EGDT criteria and the severe sepsis criteria. The Hosmer-Lemeshow test was performed to calibrate the model. Independent variables identified were age at least 65 years, albumin level up to 27 g/l and international normalized ratio of 1.2 or more. The MISSED score ranged from 0-9; cut-off point 5.5. Mortality rates associated with a score of 0, less than 5.5 and 5.5 or more were 7.4, 17.7 and 40.6%, respectively. The sensitivity of the score was 96.8% (95% confidence interval 87.8-99.4%). The mortality rate and specificity associated with a score of 9 were 62.9 and 91.6% respectively. The area under the curve for the MISSED score and the APACHE II score were equal. The performance of the MISSED score of 5.5 or more in predicting mortality was similar to that of the EGDT criteria. The sensitivity of the score was equal to that for the severe sepsis criteria. The Hosmer-Lemeshow test confirmed good calibration. The MISSED score should be used in the ED.