Development Of Septic Complications Research Articles

COMBINED CRITICAL ILLNESS–RELATED CORTICOSTEROID AND THYROID INSUFFICIENCY DURING TARGETED TEMPERATURE MANAGEMENT: A PROSPECTIVE COHORT STUDY

Objective. To study the effect of therapy for adrenal and thyroid dysfunction on the course and outcomes of critical care. Materials and methods. 51 patients requiring targeted temperature management (ТТМ) were included in a single-center prospective cohort study. Results. Group I (with adrenal and thyroid dysfunction) included 39 (76,5%) patients on TTM, group II (without adrenal and thyroid dysfunction ) included 12 (23,5%) patients without endocrinopathies. In patients on TTM, adrenal dysfunction developed on day (D) 0 and manifested only clinically in the form of vascular insufficiency. When evaluating clinical and laboratory data in patients at TTM, thyroid dysfunction was diagnosed at D1, D2, and D3. The manifestation of adrenal and thyroid dysfunction in patients at is primarily due to central nervous system injury rather than sepsis. Treatment of adrenal and thyroid dysfunction was performed with hydrocortisone and levothyroxine. Conclusion. Formation of combination of adrenal and thyroid dysfunction at TTM leads to the development of multiple organ dysfunction not associated with the development of septic complications. Timely diagnosis and adequate correction of adrenal and thyroid dysfunction in patients undergoing critical illness and requiring TTM allows to reliably reduce mortality.

Prognostication of the development of septic complications in children with burn injuries.

Aim: To determine the prognostic criteria for the development of septic complications in children with thermal injury. Materials and Methods: A single-center retrospective-prospective cohort study included a retrospective analysis of 98 medical histories of children of different ages with severe burns who were treated from 2007 to 2017. A prospective study was conducted among children (n=63) from 1 to 5 years old, who received various degrees severity burn injury, according to an open comparative method in the period from 2018 to 2021. Results: Indicators of a high risk of developing sepsis were burns by flames of any etiology, damage severity index ≥75 units, total burn surface ≥25 %, deep burn area ≥ 5%. The threshold value of procalcitonin (PCT) ≥ 0.86 ng/ml on the 1st-3rd day and PCT > 0.51 ng/ml on the 7th day of burn disease, had a prognostic value for assessing the probability of sepsis. On the 1st day of hospitalization, the development of sepsis was predicted if the C-reactive protein (CRP) value was higher than 6.98 ng/ml, on the 3rd - the CRP level was above 7.43 ng/ml, on the 7th day - above 7.28 ng/ml. Conclusions: Based on the obtained data, we selected the criteria with the best prognostic characteristics, which allows us to predict and prevent the development of sepsis in the early stages of burn disease in children.

Treatment of genital prolapse in elderly women with genitourinary infection

Relevance of the study. Genital prolapse (GP) is a disease that unites a group of disorders of the muscular and ligamentous apparatus of the uterus and vagina, which lead to prolapse and prolapse of the internal genital organs. The incidence of HP in women over 50 reaches 50%, and among elderly and senile women, it increases to 60-70%. Frequent recurrence and the development of septic complications are characterised by urinary tract infections that occur against the background of genital abnormalities, hormone deficiency in the postmenopausal period, diabetes mellitus, asymptomatic bacteriuria, neurogenic bladder dysfunction, urinary incontinence, and surgical interventions on the genital or urinary system.The aim of the study is to optimize the treatment of genital prolapse (GP) in elderly women with urinary and genital infections. Materials and methods. We examined 70 elderly patients, including 20 (28.6%) with GP and infectious lesions of the urinary and genital organs (main group), 30 (42.8%) with GP without infectious lesions of the urinary and genital organs (comparison group), 20 (28.6%) women without gynaecological diseases and extragenital pathology (control group). The severity of the inflammatory process was assessed based on the study of complaints, anamnesis, and laboratory results. The degree of GP was determined using the POP-Q quantitative assessment system. The surgical intervention included transvaginal extirpation of the uterus without appendages, anterior colporrhaphy, colpoperineorrhaphy with levatoroplasty, and sacrospinal colpopexy. Before using the «Polymesh» synthetic mesh endoprosthesis, in order to minimise infectious complications caused by the use of synthetic prostheses, hydrodissection was performed with 0.9% sodium chloride saline (200 ml) with the addition of a third-generation cephalosporin antibiotic (1 g). Results of the study. Patients underwent uterine extirpation without vaginal appendages, unilateral sacrospinal colpopexy, anterior colporrhaphy, colpoperineorrhaphy with levatorrhaphy (in 6 (30%) women of the first group and 13 (43%) - of the second group). Uterine extirpation without vaginal appendages, sacrospinal colpopexy on the left using the «Polymesh» mesh prosthesis, anterior colporrhaphy, colpoperineorrhaphy with levatoroplasty - in 14 (70%) women of the first group and 17 (57%) of the second group. In case of stress urinary incontinence, a mid-urethral sling procedure was additionally performed (6 patients in the first group and 5 in the second). Women with genitourinary infection mainly underwent transvaginal uterine extirpation with unilateral sacrospinal colpopexy and the use of a synthetic mesh prosthesis «Polymesh». The volume of the operation in the form of uterine extirpation using the «Polymesh» prosthesis is due to the reliable effect of the mesh prosthesis in order to prevent the recurrence of the disease compared to sacrospinal colpopexy (1/4% of cases). Conclusions. Surgical treatment of genital prolapse in women with infectious lesions of the urinary and genital organs by using the «Polymesh» mesh prosthesis for colposacropexy after transvaginal uterine extirpation increases the effectiveness of its treatment, reducing the number of recurrences of the disease.

Extra-abdominal Intestinal Anastomosis: A New Technique and Problem-solving Tool in Many Critical Circumstances

Background: Anastomosis leakage following intestinal anastomosis and the development of septic complications is a major problem for surgeons in certain clinical situations. There are many circumstances, where surgeons are in great trouble for decision making, where exteriorization of the intestine or performing a primary anastomosis is a risky procedure with a very fatal outcome. The purpose of this paper is to introduce a newer technique “extra-abdominal intestinal anastomosis”. Objective: The ultimate aim of this research is to assess the outcome of this new procedure compatible with such situations with different important surgical aspects. Methods: This prospective study was conducted with a total of 42 patients of extra-abdominal small intestinal done in Khulna Medical College Hospital (KMCH), Bangladesh. The study period was from January 2017 to November 2020. All the operations were done on emergency setup. Convenient purposive sampling was the sampling technique. Results: In this research, approximately 28.6% (12 patients) were undergone emergency operations for gangrenous intestine, followed by 19.0% (08 patients) for postoperative abdominal sepsis. Another important indication was strangulated hernia (07 patients, 11.9%). Extra-abdominal intestinal anastomosis on a trial basis was done in 42 patients in KMCH. Excellent results were observed. Overall mortality and morbidity have been reduced. Moreover, due to fewer complications, hospital stays, and costs have been reduced, on the contrary, patient compliance has been increased. The mortality rate with extra-abdominal intestinal anastomosis was 14.3%, whereas it was reported to be very high previously in KMCH in many circumstances. Extra-intestinal leakage was observed in approximately 26.2% of cases. Approximately in 14.3% patients of with extra-abdominal leakage, extra-abdominal repair was possible without major consequences. Early internalization of the intestinal anastomosis with the closure of the abdominal wall was possible on the 7th to 14th postoperative day in approximately 61.9% of patients with good results. Conclusion: The newer method, extra-abdominal intestinal anastomosis is a resilient procedure in many emergencies with fewer complications, less hospital staying, reduced mortality, morbidity rate and excellent patient compliance. Mediscope 2023;10(2): 56-62

Pathogenetic Mechanisms of Organ Dysfunction in Severe Concomitant Trauma

Severe concomitant trauma has been a major demographic and medical problem for many years , being the cause of high mortality of the able-bodied population . The simultaneous formation of an array of destroyed tissues triggers a systemic inflammatory reaction , which , against the background of traumatic and hemorrhagic shock , leads to an imbalance in immune reactivity and predisposes to the development of septic complications . The review presents the basic concepts of post-traumatic reactions and violations of the balance of cellular and humoral immune mechanisms leading to the development of complications .

A significant association of the APACHE II physiological score with the development of complications in the postoperative colorectal patient

Background: The APACHE II clinical score is one of the most widely utilized clinical scores for disease severity and early prognostic predictor of mortality. This retrospective study aims to examine whether there is an association between the calculated APACHE II score and the development of septic complications in colorectal surgical patients.

The course of infectious arthritis in a patient with hypogammaglobulinemia

Hypogammaglobulinemia is a condition caused by low levels of immunoglobulins in the blood serum. It can be a manifestation of primary immunodeficiency, characterized by a violation of the production of immunoglobulins, in particular common variable immunodeficiency (CVID). A typical clinical sign of CVID is various severe infections, among which infectious arthritis is not uncommon. At the same time, the clinical picture of infections can differ significantly from that in individuals with a normal immune response, including the spectrum of infectious arthritis pathogens.The article describes a clinical case of an unusual course of infectious arthritis in a patient with newly diagnosed hypogammaglobulinemia. The peculiar features of the case were a long (more than 1.5 years) course of the disease, without the development of septic complications, no increase in ESR and CRP, recurrence of arthritis after a 2-month course of antibiotic therapy, and the presence of generalized edema. The causes and diagnosis, features of infectious complications, including infectious arthritis, and probable causes of edematous syndrome in CVID are discussed.

Прогноз септических патологий в ветеринарной пропедевтике на модели панлейкопении кошек

Sepsis is an urgent problem of modern veterinary medicine. One of the key issues remains the establishment of methodologies to improve the accuracy, reproducibility and/or clinical value of the diagnosis of sepsis. The article is devoted to the results of studies of 25 cats aged from 1 month to 9 years. Using the PIRO concept as a basis, we have developed a version of the model for dividing sepsis patients into groups based on their condition. The system is based on the assessment of criteria for the development of sepsis based on a set of clinical and laboratory signs that determine risk factors and prognosis of the course of the disease. A method for predicting the possible development of septic complications on a model of feline panleukopenia has been developed. Criteria for evaluating PIRO indicators in the diagnosis of sepsis have been formed.

TNF-\u03b1-induced protein 8-like 2 negatively regulates the immune function of dendritic cells by suppressing autophagy via the TAK1/JNK pathway in septic mice

Tumor necrosis factor (TNF)-α-induced protein 8-like 2 (TIPE2) is a newly discovered negative immunoregulatory protein that is involved in various cellular immune responses to infections. However, the underlying mechanism by which TIPE2 affects the immune function of dendritic cells (DCs) is not yet understood. This study aimed to determine the correlations among DCs TIPE2 expression, autophagic activity and immune function in the context of sepsis. In addition, the signaling pathway by which TIPE2 regulates autophagy in DCs was investigated. We reported for the first time that TIPE2 overexpression (knock-in, KI) exerted an inhibitory effect on autophagy in DCs and markedly suppressed the immune function of DCs upon septic challenge both in vitro and in vivo. In addition, TIPE2 knockout (KO) in DCs significantly enhanced autophagy and improved the immune response of DCs in sepsis. Of note, we found that the transforming growth factor-β (TGF-β)-activated kinase-1 (TAK1)/c-Jun N-terminal kinase (JNK) pathway was inhibited by TIPE2 in DCs, resulting in downregulated autophagic activity. Collectively, these results suggest that TIPE2 can suppress the autophagic activity of DCs by inhibiting the TAK1/JNK signaling pathway and further negatively regulate the immune function of DCs in the development of septic complications.

Тhe use of corticosteroids in patients with severe burn injuries

Modern treatment of burns has led to a significant reduction in mortality in patients with burns whose injuries were fatal several years ago. However, along with improved survival, new problems arose in the treatment of burn patients. Systemic inflammatory response, capillary leak, sepsis top the list of the most common problems in both adults and children with severe thermal injury. Currently, new strategies are being developed and studied in the treatment of this category of patients. One of the ways to improve the results of treatment of patients with severe burn injury is to prescribe corticosteroids, both in the stage of burn shock and in the development of septic complications. Do corticosteroids reduce mortality and improve recovery in burn patients? The discussion about this has been going on for many years, but the opinion about their effectiveness remains controversial. An analysis of the literature shows that corticosteroids can play a significant role in the treatment of patients with severe burn injury and can be successfully used at any stage of a burn disease. The effect of reducing capillary leakage, increasing myocardial contractility, antiemetic, membrane-stabilizing effect of corticosteroids will be useful in the stage of burn shock. The anti-inflammatory, immunomodulatory effect of corticosteroids will play a role in any stage of a burn disease. With the aim of preventing and treating sepsis, corticosteroids may be useful in the stage of toxemia, septicotoxemia. It is also necessary to remember about adrenal insufficiency, which develops in burn patients. The article analyzes the literature, substantiates the use of corticosteroids in patients with severe burn injury in different periods of a burn disease.

Infectious Complications of Abdominal Wall Damage with a Car Seat Belt. The Experience of Treatment in Four Patients

Seat belt syndrome is a triad of symptoms: body belt marks (hemorrhages, ecchymosis, abrasions on the abdominal wall), intra-abdominal trauma and spinal fractures in the thoracic and lumbar spine. The abdominal mark of a safety belt implies a complex diagnostic algorithm to exclude injury to the intraabdominal organs and the abdominal wall. The clinical picture of damage is not specific, which leads to errors in diagnosis or delays at the beginning of the examination protocol. A dynamic examination of the patient (ultrasound, CT, X-ray) is necessary. The damage to the abdominal wall with a seat belt, which entailed the development of septic complications, require long-term general and local treatment, additional diagnostic methods and surgical interventions.

High-mobility group box-1 inhibition stabilizes intestinal permeability through tight junctions in experimental acute necrotizing pancreatitis.

In acute necrotizing pancreatitis (ANP), bacterial translocation (BT) from the gastrointestinal tract is the essential pathogenesis in the development of septic complications. Although high-mobility group box-1 (HMGB1) is associated with BT and organ dysfunction in ANP, the mechanism of HMGB1 in the intestinal barrier dysfunction and BT has not been well addressed. In this study, we intend to address the role of HMGB1 in ANP involving BT and intestinal barrier dysfunction. Experimental ANP was achieved in male Sprague-Dawley rats through a retrograde injection of taurocholate into the common biliopancreatic duct following a laparotomy operation. HMGB1 blockade intervention was conducted with a subcutaneous injection of anti-HMGB1 antibody immediately before the laparotomy procedure. Twenty-four hours after ANP induction, pancreatic and intestinal tissues and blood samples were collected for a histopathological assessment and lipid peroxidation or glutathione (GSH) evaluation. AP-induced barrier dysfunction was determined by an intestinal permeability assessment. Tight junction proteins and autophagy regulators were investigated by western blotting, immunohistological analysis and confocal immunofluorescence imaging. ANP developed as indicated by microscopic parenchymal necrosis and fat necrosis, which were associated with intestinal mucosal barrier dysfunction. HMGB1 inhibition played a protective role in intestinal mucosal barrier dysfunction, protected against microbiome changes in ANP, and relieved intestinal oxidative stress. Additionally, HMGB1 inhibition attenuated intestinal permeability; preserved the expression of TJs, such as claudin-2 and occludin; and decreased autophagy. Furthermore, the autophagy regulator LC3 and TJ protein claudin-2 were both upregulated in ANP according to dual immunofluorescence analysis. HMGB1 inhibition ameliorated the severity of experimental ANP though beneficial effects on BT, mainly involving in TJ function.

Results of treatment for Boerhaave syndrome

Background. Spontaneous rupture of the esophagus (Boehaave syndrome, BS) is a rare pathology in the surgical practice. Esophageal rupture makes no more than 2-3% of all cases of damage to the esophagus and is associated with a significant number of diagnostic errors and with high mortality.
 Aim. The aim of the study was to analyze the quality of diagnostics and the results of treatment of patients with spontaneous rupture of the esophagus.
 Materials and Methods. We performed a retrospective analysis of medical histories and of treatment results of 10 patients with Boerhaave syndrome hospitalized in the department of thoracic surgery of the Ryazan Regional Clinical Hospital, Ryazan in 2007-2018.
 Results. Four of ten patients were transferred from other medical institutions. At the primary care stage six patients were misdiagnosed; two of them underwent diagnostic laparoscopy for suspicion of acute pancreatitis and perforated gastric ulcer. The average time from the onset of the disease to surgery was 71.723.4 hours. Closure of the esophageal perforation was performed in all cases. Regarding the timing of surgery, all patients with Boerhaave syndrome were divided into 2 groups: patients with early intervention (4 patients operated within 24 hours); patients with late intervention (5 patients operated after 48 hours from the onset of the disease). One patient underwent surgical treatment within 24 hours in a medical facility outside the Ryazan region. In nine out of ten patients the rupture was localized in a typical place in the lower third of the esophagus along the left lateral wall. In the postoperative period eight patients had complete or partial esophageal suture failure, which required prolonged inpatient treatment (54.712.1 days). Postoperative mortality was 10% (1 patient of 10) and was caused by the progressive multi-organ failure and the development of cerebral ischemic stroke.
 Conclusion. The quality of diagnostics of Boerhaave syndrome remains unsatisfactory: due to rare occurrence of this pathology, most specialists of primary care settings, including surgeons, are not well acquainted with the etiopathogenesis and peculiarities of clinical presentation of Boerhaave syndrome. Diagnostic and treatment errors in rendering primary medical assistance reaches 60%. Results of surgical treatment directly correlate with the time from the moment of perforation and development of septic complications. Even with early surgical intervention performed within 24 hours from the moment of perforation, esophageal suture failure may occur in up to 75% of cases. Thus, the success of treatment is determined by early diagnosis, timely hospitalization in a specialized facility, and adequate surgical intervention.

ОСТРОЕ ПОВРЕЖДЕНИЕ ПОЧЕК ПРИ ТЯЖЕЛОМ ОСТРОМ ПАНКРЕАТИТЕ (ОБЗОР ЛИТЕРАТУРЫ)

Acute pancreatitis is characterized as a complex of morphofunctional changes in the stroma of the pancreas, and in parapancreatic fatty tissue, surround- ing organs and tissues, as well as manifestations of the syndrome of multiple organ dysfunction due to the activity of metabolites and enzyme toxemia, which in turn determines the clinical picture of the disease, as well as the risks of complications and high mortality rates. In xx century, the main peak of mortality were patients in the early phase of the disease, while at present to 80% of deaths related to the phase of the development of septic complications and multiple organ failure. In many respects, this trend is explained by the lack of unity of views on the etiopathogenesis of the disease, the difficulties of early diagnosis and the high frequency of diag- nostic errors, which entails a delay in the provision of specialized care to the patient. Another reason is seen in the development of multi-organ dysfunction, which aggravates the patient’s condition and, closing the vicious circle, leading to serious complications and fatal outcomes. One of the leading component of multiple organ dysfunction developing decompensated acute surgical pathology of the abdominal cavity and retroperitoneal space, should be considered as acute renal failure, as- sociated with high mortality isolated (78%), while engaging in decompensation three or more organ systems tends to the absolute. At the same time, the frequency of acute kidney damage becomes the leading problem in the treatment of such patients in recent years. Even in the case of a favorable outcome in the development of isolated or combined renal dysfunction in patients with pancreatic necrosis is a significant weighting of the rehabilitation period, prolonged phase of inpatient treatment and regularly raises its cost. At present, there has been a steady increase in the number of patients with severe forms of acute pancreatitis with acute kidney damage, especially in the working-age group. Not always satisfactory results of their treatment are the reason for further in-depth studies in this direction.

ASSESSMENT OF RISK FACTORS OF SEPTIC COMPLICATIONS OF THE PUERPERIUM

Postpartum purulent-septic complications (PPSC) and their problems are most urgent for modern obstetrics due to their significant frequency. Maternal sepsis is one of the leading causes of maternal mortality around the world, accounting for about one-tenth of the global number of maternal deaths. Understanding the risk factors for the development of septic complications of puerperium is important for preventive strategies. Aim. To study the possibility of forming high-risk groups on the basis of analysis of anamnestic data and the course of puerperium in women with PPSC as part of the preventive measures for the development of such complications. Materials and methods. The first stage of the study involves a retrospective analysis for the allocation of risk factors for the development of PPSC in women, who underwent inpatient treatment for this pathology - main group (n=108); сontrol group (n=35) – parous with uncomplicated flow of the postpartum period. Prospective research enrolled 65 pregnant women with extragenital pathology and/or complicated pregnancy (group 1); 30 pregnant women without severe concomitant somatic pathology with physiological course of pregnancy (group 2). The following were taken into account: age, obstetrical and gynecological history, extragenital pathology, laboratory diagnostic data. Differences in mean values were considered significant with a probability level of at least 95 % (p<0.05). Results. To the risk factors for the development of PPSC, we classified as follows: gynecological diseases in history: menstrual dysfunction, chronic inflammatory diseases of the genital organs, bacterial vaginosis; complications of pregnancy and labor: preeclampsia, preterm labor, premature rupture of membranes, long anhydrous span, chorioamnionitis, weakness of labor, genital tract ruptures, placental attachment pathology, operative vaginal birth, bleeding; concomitant extragenital pathology: diabetes, obesity, diseases of the urinary system, diseases of the cardiovascular system, respiratory diseases, varicose disease, anemia. Conclusions. The connection between the presence of concomitant somatic pathology, the complicated course of pregnancy and labor and the subsequent development of septic complications in the postpartum period have been established. Prediction of the risk of their occurrence at the stage of pregraviditic preparation, with various complications of pregnancy and childbirth, especially in women with extragenital pathology, differential prevention will reduce the frequency of PPSC.

PRESEPSIN AS THE EARLY MARKER OF PURULENT SEPTIC COMPLICATIONS IN PATIENTS WITH SEVERE ACUTE PANCREATITIS

Sepsis is the leading cause of mortality in patients with severe acute pancreatitis (SAP). High mortality rate in patients with SAP is mainly associated with purulent and inflammatory process in parapancreatic fat. Early laboratory diagnosis of infection is vitally important for timely indications for surgery and successful therapy. Aim of study The comparison of prognostic and diagnostic values of presepsin and acute phase proteins (CRP, PCT) in the development of septic complications in patients with SAP at the early stage. Material and methods We examined 37 patients with SAP. Depending on the course and outcome of the disease, patients were divided into two groups: Group 1 (n=10) — deceased patients, Group 2 (n=27) — patients with a favorable outcome. Each of these groups was divided into two subgroups: 1A (n=8) — patients who died of sepsis, 1B (n=2) — patients who died of other causes, 2A (n=7) — patients with a favorable outcome of sepsis and 2B (n=20) — patients without septic complications. The PSEP level was measured with PATHFAST enzyme immunoassay analyzer (LSI Medience Corporation, Japan). Descriptive statistics of quantitative characteristics were represented by medians and quartiles (Me (LQ; UQ)), values of area under the ROC curve (AUC) and 95% confidence interval. To compare the groups, the Mann–Whitney U test was used. Results The concentration of PSEP 785 pg/ml and higher on day 2–5 from the onset of the disease indicated a significant risk of purulent complications in intensive care patients with a sensitivity of 91.2% (95% CI, 77.93–97.89) and a specificity of 77.3% (95% CI, 51.59–97.91). The area under the curve for PSEP was 0.859 (AUC). PCT — 0.804 (AUC), sensitivity — 85%, specificity — 57%. CRP — 0.718 (AUC), sensitivity — 75% and specificity — 50%. Conclusion Based on the data obtained, it can be concluded that PSEP has the most informative value and diagnostic sensitivity compared to other markers of inflammation for an early diagnosis of sepsis in patients with SAP.

Early decreased neutrophil responsiveness is related to late onset sepsis in multitrauma patients: An international cohort study.

BackgroundSevere trauma can lead to the development of infectious complications after several days, such as sepsis. Early identification of patients at risk will aid anticipating these complications. The aim of this study was to test the relation between the acute (<24 hours) inflammatory response after injury measured by neutrophil responsiveness and the late (>5 days) development of septic complications and validate this in different trauma populations.Methods and findingsTwo prospective, observational, cohort series in the Netherlands and South Africa, consisting of severely injured trauma patients. Neutrophil responsiveness by fMLF-induced active FcγRII was measured in whole blood flowcytometry, as read out for the systemic immune response within hours after trauma. Sepsis was scored daily. Ten of the 36 included Dutch patients developed septic shock. In patients with septic shock, neutrophils showed a lower expression of fMLF-induced active FcγRII immediately after trauma when compared to patients without septic shock (P = 0.001). In South Africa 11 of 73 included patients developed septic shock. Again neutrophils showed lower expression of fMLF induced active FcγRII (P = 0.001). In the combined cohort, all patients who developed septic shock demonstrated a decreased neutrophil responsiveness.ConclusionsLow responsiveness of neutrophils for the innate stimulus fMLF immediately after trauma preceded the development of septic shock during admission by almost a week and did not depend on a geographical/racial background, hospital protocols and health care facilities. Decreased neutrophil responsiveness appears to be a prerequisite for septic shock after trauma. This might enable anticipation of this severe complication in trauma patients.

Mechanism of Increased Intestinal Permeability in Acute Pancreatitis: Alteration in Tight Junction Proteins.

Intestinal permeability (IP) has been shown to be increased in acute pancreatitis (AP) and is considered to be responsible for development of septic complications. However, the mechanism of increase in IP is not well studied. We studied whether alteration in tight junction proteins (TJP) has any role in altered IP in patients with AP. This is a prospective study conducted at a tertiary care referral center. Twenty consecutive moderate and severe AP patients fulfilling the study criteria were included along with 20 controls that underwent gastroduodenoscopy for dyspepsia. IP was measured with lactulose mannitol (LM) ratio and TJP were studied by measuring expression of claudin-2 and claudin-4 in duodenal biopsy samples. Statistical analysis was done with STATA 13.0. IP as depicted by LM ratio was significantly higher in AP patients as compared with controls (4.659±10.4 vs. 0.101±0.297; P<0.001). Claudin-4 expression was reduced in duodenal biopsies in AP patients (P<0.001 for crypt intercellular junction and P=0.007 for crypt cytoplasm). However, LM ratio was not associated with either mortality (P=0.12) or development of infected pancreatic necrosis (P=0.3). IP is increased in AP. Alteration in TJP in the form of reduced claudin-4 expressions could be the possible mechanism for increased IP.

Can leukocyte antisedimentation rate (LAR)predict septic complications andcritical care survival early inpolytrauma and burn victims?

In polytrauma and burn injury Systemic Inflammatory Response Syndrome (SIRS) develops. SIRS is presented in many hospitalized patients, including those who never develop infection or sepsis. Both in SIRS and sepsis the leukocyte activation occurs. In acute phase reaction leukocytes' upward flotation i.e. leukocyte antisedimentation rate (LAR) can indicate infectious origin. To evaluate the predictive power of LAR, serum C-reactive protein (CRP) and procalcitonin (PCT) levels regarding mortality risk and development of septic complications. In a prospective, observational study, 36 patients were followed for 5 days (T1-T5) after admission to a critical care unit immediately with severe polytrauma or burn injury. Eleven patients developed septic complications, their LAR, CRP and PCT levels were analyzed before and after 3 days of sepsis was declared. Ten patients died due to septic complications. In survivors LAR at T1 (p < 0.001) and T2 (p < 0.001) as well as CRP at T1 (p < 0.05) were significantly higher compared to controls and non survivors. In septic patients LAR (p < 0.05) and CRP (p < 0.05) showed a significant drop one day before sepsis was declared. PCT levels failed to predict this. Drop in LAR and CRP levels may be warning signs regarding the onset of septic complications after severe polytrauma and burn injury.

Similar change in platelets and leucocytes 24 h after injury is associated with septic shock a week later.

Septic shock is a severe complication in polytrauma patients. Early identification of patients at risk can guide future prevention strategies. Platelets (PLTs) and leucocytes presumably play an important role in the post-injury inflammatory response. The role of early changes in PLT and leucocyte counts was investigated in search for the aetiology of the development of septic complications. Polytrauma patients (aged 16-80 years) admitted to the intensive care unit with an expected stay of at least 3 days were included. PLT and leucocyte counts were measured on a daily basis for 14 days. A total of 41 patients were included, of whom nine (22%) developed septic shock. There was no difference in (New) Injury Severity Score or Acute Physiology and Chronic Health Evaluation II scores between patients who developed septic shock and patients who did not. Three patients died, one of them in septic shock. Patients who developed septic shock during hospital stay had lower PLTs and a slower recovery to normal PLT counts than patients without septic shock. Patients who developed either a decrease in both PLTs and leucocytes or an increase in PLTs and leucocytes in the first 24 h after trauma were more likely to develop septic shock. This correlation was not found in patients who did not develop septic shock. A similar change in PLT and leucocyte counts in the first 24 h after trauma is associated with the development of septic shock after a week. This indicates an early interaction between PLTs and leucocytes, which needs further investigation to gain more insight in the aetiology of post-injury septic complications.