Episodes Of Septic Shock Research Articles

COVID-19 and acute pancreatitis clinical outcomes among hospitalized patients in the United States: A propensity matched analysis of national inpatient sample

BackgroundPancreatitis is one of the leading causes of gastrointestinal-related hospitalization, with significant morbidity and mortality. SARS-COV-2 virus can access the pancreas via angiotensin-converting enzymes and can cause direct and indirect injury to the pancreatic parenchyma. The objective of this study to understand clinical outcomes of hospitalized patients with COVID-19 with and without pancreatitis utilizing National Inpatient Sample database. MethodsWe utilized the United States National Inpatient Sample database to study clinical outcomes in hospitalized patients with COVID-19 infection (a total of 1,659,040 hospitalized patients with 10,075 (0.6 %) with pancreatitis) between January 1 to December 31, 2020, along with propensity matching. ResultsWhile after propensity matching, we did not find a statistical difference in in-hospital mortality amongst COVID-19 patients with pancreatitis compared to COVID-19 patients without pancreatitis (13.2 % vs 10.3 %, adjusted odds ratio: 0.7 [95 % CI 0.5–1], p = 0.11). Patients with COVID-19 and pancreatitis had more episodes of septic shock, higher incidence of acute kidney injury and acute kidney injury requiring hemodialysis. We also found an increased prevalence of NASH cirrhosis, alcohol liver cirrhosis, and a lesser incidence of pulmonary embolisms in the COVID-19 with pancreatitis cohort. ConclusionWorse in-hospital outcomes, including increased incidence of septic shock, acute kidney injury, and acute kidney injury requiring hemodialysis in hospitalized patients with COVID-19 infection and pancreatitis, emphasize the need for more research to understand the effect of COVID-19 disease in hospitalized patients with pancreatitis and in the role of vaccination to improve long term outcome in this patient population.

Use of vasopressors for septic shock in the neonatal intensive care unit.

To describe outcomes for infants in the neonatal intensive care unit with septic shock based on the vasopressor administered. This is a multicenter cohort study of infants with an episode of septic shock. We evaluated the primary outcomes of mortality and pressor-free days alive in the first week after shock using multivariable logistic and Poisson regressions. We identified 1592 infants. Mortality was 50%. Dopamine was the most used vasopressor (92% of episodes) and hydrocortisone was co-administered with a vasopressor in 38% of episodes. Compared to infants treated with dopamine alone, adjusted odds of mortality were significantly higher for those treated with epinephrine alone (aOR 4.7 [95% CI: 2.3-9.2]). Adjuvant hydrocortisone was associated with significantly lower adjusted odds of mortality (aOR 0.60 [0.42-0.86]) CONCLUSIONS: The use of epinephrine as either a solo agent or in combination therapy was associated with significantly worse outcomes, while adjuvant hydrocortisone was associated with decreased mortality.

Vasoactive inotropic score as a predictor of mortality in neonatal septic shock.

Although many improvements in neonatal care have been achieved, mortality rates for sepsis and septic shock in newborns are still high. The vasoactive inotropic score (VIS) was designed and studied to predict mortality in different settings. There are currently no data on the predictive ability of the VIS for mortality in newborn patients with septic shock. Patients with late-onset neonatal sepsis who required inotropes because of fluid-refractory septic shock during the study period were included in the study. Four distinct VISvalues were calculated for each septic shock episode after inotropic treatment had begun, that is, at the initiation of inotropic treatment and at 24 and 48 h after inotropic treatment had begun, and the highest VIS (VISmax) at any time after initiation of inotropic agents. The 98 episodes studied were divided into two groups according to the outcomes of their sepsis episodes as survivors (n = 39) or nonsurvivors (n = 59). The areas under the curve of the VIS values for the prediction of mortality were the VISmax (0.819, p < 0.001), followed by the VIS48 (0.802, p < 0.001), VIS24 (0.762, p = 0.001) and VIS0 (0.699, p = 0.015). Patients with a VISmax of greater than 20 had significantly higher odds of mortality (p < 0.001, β = 14.7, 95% confidence interval [4.7-45.9]). We found that the VISmax was an easy-to-use and helpful tool for predicting a poor outcome in neonatal sepsis. Physicians should be aware that the prognosis is poor for any newborn with a VIS of 20 or greater at any point after the onset of sepsis.

SUCCESSFUL BIOPSY OF AORTOPULMONARY WINDOW LYMPH NODE WITH ROBOTIC-ASSISTED BRONCHOSCOPY

SUCCESSFUL BIOPSY OF AORTOPULMONARY WINDOW LYMPH NODE WITH ROBOTIC-ASSISTED BRONCHOSCOPY

Systemic infections associated with tattoos or permanent makeup: A systematic review

IntroductionThe aim of this article is to summarize published information on systemic infective complications of tattoos to gain an update of the current picture. MethodsA literature search was performed in PubMed database (2009–2019), and compared with a search without year restriction. Eligibility criteria were studies on systemic tattoo-related infections, including case reports, case series, outbreak investigations, reviews, and systematic reviews. ResultsWe identified 17 manuscripts with systemic infections between 2009 and 2019, with one reported fatality. In contrast to the historical records, no reports of systemic tuberculosis, syphilis or viral (hepatitis or HIV) infections were reported within the study period. A few sporadic cases or Mycobacterium leprae (India) or regional lymphadenopathy associated with skin lesions in non-tuberculosis mycobacteria were identified. Persistent fever with rigour was common in bacterial bloodstream infections. One episode of staphylococcal toxic shock syndrome and several episodes of septic shock were reported, associated with cellulitis or necrotizing fasciitis within two weeks of the procedure, predominantly caused by pyogenic bacteria (S. aureus or streptococcus). Identification of lung or systemic embolisms in the absence of local symptoms, was indicative of (right or left) infective endocarditis. ConclusionsBacterial bloodstream infections should be considered in subjects developing fever and rigour after tattoos, regardless of local symptoms. A shift in causative organisms has been documented, when comparing with historical reports. NTM are emerging organisms causing lymphadenopathy. Strict hygiene conditions are essential when performing a tattoo.

Repeat percutaneous tracheostomy in a COVID-19 patient

A 73-year-old man with history of hypertension and chronic obstructive pulmonary disease was admitted to the emergency department with acute respiratory failure from COVID-19. After 10 days of mechanical ventilation (MV) the patient underwent a successful trial of extubation. However, 3 days later his neurological status deteriorated and required re-intubation. A brain computed tomography (CT) scan showed right cerebellar hemorrhage. Considering extent and location of the hemorrhage we decided to perform a percutaneous tracheostomy on the 18th day. The patient was then successfully weaned from MV (day 47th), and finally decannulated (day 50th). On day 62nd, the patient experienced an episode of septic shock, requiring oro-tracheal re-intubation, for we decided to perform a repeat percutaneous tracheostomy. All the procedure steps were uneventful. The patient was subsequently transferred to another ICU, and then successfully discharged to the Respiratory Ward. Keywords: coronavirus; airways; dilational tracheostomy

Brain Abscess Due to Neglected Tetralogy of Fallot: A Case Report

Backgroiund: Tetralogy of Fallot (TOF) is a type of congenital heart disease accounts for about 10% of all congenital cardiac deformities, and is the most common cyanotic lesion after the first year of life. The ideal age for correction of tetralogy of Fallot is still under discussion. Non-cardiac manifestation due to oxygen deficiency has to be aware of in cyanotic patient is brain abscess, because of the right-left shunt in long standing TOF.&#x0D; Objectives: To report a case of neglected TOF.&#x0D; Case And Discussion: A one-year-old male presented to Murni Teguh Memorial Hospital with the chief complaint of stiffed neck for the past 3 days and got fever for 10 days before admitted, with nausea and vomiting. He was diagnosed with Tetralogy of Fallot through an echocardiography examination when he was 2 months old, but never go through any medical nor surgical treatment. The boy responded to verbal, no eye contact, high grade fever, stiffed neck, Kernig sign and Brudzinski sign was found, and the right extremities were spastic, clubbing finger. On cardiac examination, there was systolic murmur grade ¾ in the left second intercostal space. Echocardiography evaluation revealed dilated RA-RV, no PDA shunt, large mal alignment ventricular septal defect, overriding aorta &gt; 50%, right ventricular hypertrophy, and severe infundibular pulmonary stenosis, consistent with Tetralogy of Fallot. During hospitalization, there were several episodes of seizure and decreased of consciousness, brain CT investigation was done. The abscess was evacuated and a ventriculoperitoneal shunt was performed. One week after the operation, the patient developed abdominal distention, green bile like vomiting, decreased bowel movement and soon muscular defense. From the plain abdominal x-ray and CT revealed peritonitis and intestinal obstruction. An emergency laparotomy was performed, followed by adhesiolysis and jejunostomy due to jejunal perforation. The boy passed away after several episodes of septic shock.&#x0D; Conclusions: We would like to emphasis the consequence of the neglected treatment in infant with TOF.

Systemic infections associated with tattoos or permanent makeup: A systematic review

IntroductionThe aim of this article is to summarize published information on systemic infective complications of tattoos to gain an update of the current picture. MethodsA literature search was performed in PubMed database (2009–2019), and compared with a search without year restriction. Eligibility criteria were studies on systemic tattoo-related infections, including case reports, case series, outbreak investigations, reviews, and systematic reviews. ResultsWe identified 17 manuscripts with systemic infections between 2009 and 2019, with one reported fatality. In contrast to the historical records, no reports of systemic tuberculosis, syphilis or viral (hepatitis or HIV) infections were reported within the study period. A few sporadic cases or Mycobacterium leprae (India) or regional lymphadenopathy associated with skin lesions in non-tuberculosis mycobacteria were identified. Persistent fever with rigour was common in bacterial bloodstream infections. One episode of staphylococcal toxic shock syndrome and several episodes of septic shock were reported, associated with cellulitis or necrotizing fasciitis within two weeks of the procedure, predominantly caused by pyogenic bacteria (S. aureus or streptococcus). Identification of lung or systemic embolisms in the absence of local symptoms, was indicative of (right or left) infective endocarditis. ConclusionsBacterial bloodstream infections should be considered in subjects developing fever and rigour after tattoos, regardless of local symptoms. A shift in causative organisms has been documented, when comparing with historical reports. NTM are emerging organisms causing lymphadenopathy. Strict hygiene conditions are essential when performing a tattoo.

The Impact of Extracerebral Infection After Subarachnoid Hemorrhage: A Single-Center Cohort Study

Subarachnoid hemorrhage (SAH) is associated with high morbidity. Among all complications, infections, in particular if hospital acquired, could represent an important cause of death in patients with SAH. The aim of this study was to describe infectious complications in patients with SAH and to evaluate their impact on outcome. A single-center cohort study included all patients with SAH admitted from January 2011 to December 2016, who stayed in the intensive care unit for at least 24 hours. Infection diagnosis was retrieved from medical files; central nervous system infections were not included. A multivariable analysis was performed to identify risk factors for development of infection. Logistic regression was performed to identify risks for unfavorable neurologic outcome at 3 months, defined as a Glasgow Outcome Scale score of 1-3. Of the 248 patients with SAH, 70 (28.2%) developed at least 1 infection; the most frequent site of infection was respiratory (57.1%), primary bloodstream (16%), and urinary tract infections (15.7%). Twenty-eight patients (11.3% of all patients) had at least 1 episode of septic shock. Infected patients had a higher unfavorable outcome rate (60.0% vs. 33.3%; P= 0.001). Diabetes mellitus (subdistribution hazard ratio, 1.79; 95% confidence interval [CI], 1.03-3.13) and intracranial hypertension (subdistribution hazard ratio, 1.92; 95% CI, 1.14-3.25) were independently associated with the occurrence of infections. Septic shock (odds ratio, 6.36; 95% CI, 1.24-32.51; P= 0.02) was independently associated with unfavorable outcome. Infections in patients with SAH are prevalent, especially pneumonia. Septic shock is associated with a poor neurologic outcome in this group of patients.

Cutaneous Intravascular/Angiotropic Lymphoma Following a Septic Shock Episode. Case Report and Literature Review

Angiotropic lymphoma is a rare aggressive disease characterized by exclusive or predominant accumulation of malignant lymphoid cells within the lumen of small arteries, veins and capillaries. We describe a 74-year-old female patient who presented at the department of dermatology with widespread cutaneous telangiectasia and generalized edema. No neurologic symptoms were present during the course of these clinical manifestations. After close-up examination and further laboratory and radiological studies, the final diagnosis of cutaneous intravascular lymphoma was made in the histopathological report. Immunochemistry evaluation confirmed a B-cell subtype. Diagnosis of this rare disease, in most cases, is achieved by surgical biopsy. The biopsy and immunohistochemistry have increased the chances of an ante mortem diagnosis. Afterward, the patient was referred to Hematologic Department to follow the combined chemotherapy treatment, which resulted to be successful, and the cutaneous lesions began to disappear

Venous-to-Arterial Carbon Dioxide Partial Pressure Difference: Predictor of Septic Patient Prognosis Depending on Central Venous Oxygen Saturation.

This study aimed to assess the viability of using the venous-to-arterial carbon dioxide partial pressure difference (P(v-a)CO2) to predict clinical worsening of septic shock, depending on central venous oxygen saturation (ScvO2). The prospective, observational, multicentric study conducted in three intensive care units (ICUs) included all patients with a septic shock episode during the first 6 h, with 122 patients assessed. Clinical worsening was defined as an increase of sequential organ failure assessment (SOFA) scores ≥1 (ΔSOFA ≥1) within 2 days. To assess the ability of P(v-a)CO2 to predict clinical worsening, univariate and multivariate analyses were performed according to ΔSOFA. A receiver-operating characteristic (ROC) analysis was used to confirm model predictions. Associations between P(v-a)CO2 and mortality were explored using correlations. Using multivariate analyses, two independent factors associated with ΔSOFA at least 1 were identified: an averaged 6-h value of lactate concentration (Lac [1-6]) (odds ratios [ORs], 2.43 [95% confidence interval, CI, 1.20-4.89]; P = 0.013) and an averaged 6-h value of P(v-a)CO2 (P(v-a)CO2 [1-6]) (OR, 1.49 [95% CI, 1.04-2.15]; P = 0.029). ROC analysis confirmed that Lac [1-6] and P(v-a)CO2 [1-6] were significantly associated with ΔSOFA at least 1, whereas ScvO2 [1-6] was not. Finally, ΔSOFA at least 1 was associated with higher 28-day (76% vs. 10%, P = 0.001) and ICU (83% vs. 12%, P = 0.001) mortality rates, which were higher in patients with P(v-a)CO2 [1-6] more than 5.8 mmHg (57% vs. 33%; P = 0.012). In conclusion, P(v-a)CO2 may help predict outcomes for septic shock patients regardless of ScvO2 values.

Cure of recurring Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae septic shock episodes due to complicated soft tissue infection using a ceftazidime and avibactam-based regimen: a case report

BackgroundInfections caused by multidrug-resistant Enterobacteriaceae are hard to treat and life-threatening due to reduced therapeutic options. Systemic infections caused by Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae strains have increased in many European regions, becoming frequent in many clinical settings, and are associated with high mortality. The co-formulation of ceftazidime, a third-generation cephalosporin, with avibactam, a new suicide inhibitor beta-lactamase inhibitor able to block most Klebsiella pneumoniae carbapenemases, has been recently licensed, with promising results in patients with limited or absent therapeutic options. Little is known, however, as to the efficacy of such a combination in patients with soft tissue infections caused by multidrug-resistant Klebsiella pneumoniae carbapenemase-producing strains of Klebsiella pneumoniae.Case presentationA Caucasian 53-year-old man with paraplegia suffered multiple vertebral fractures due to a car crash. He was treated with external fixators that became infected early after insertion and were repeatedly and inefficiently treated with multiple antibiotics. He suffered repeated septic episodes caused by Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae strains with a multidrug-resistant profile. Meropenem, tigecycline, and colistin combinations allowed only temporary improvements, but septic shock episodes recurred, in spite of removal of infected external fixators. After approval of pre-marketing prescription by our local Ethics Committee, full clinical resolution was obtained with a compassionate treatment using meropenem and ceftazidime/avibactam in combination for 16 days.ConclusionsOur experience provides additional evidence that ceftazidime/avibactam, possibly in combination with meropenem rescued by avibactam, may be an efficacious treatment option also for complicated skin and soft tissue infections caused by multidrug-resistant strains of Klebsiella pneumoniae carbapenemase-producing Klebsiella pneumoniae.

Intensive Care Unit Admission and Survival in Stage IV Cancer Patients with Septic Shock: A Population-Based Cohort Study.

Background: The impact of intensive care unit (ICU) admission during life-threatening critical illness on survival of patients with advanced cancer remains unknown.Methods: We identified incident stage IV cancer patients from Taiwan Cancer Registry during 2009-2013 and ascertained the first episode of septic shock after cancer diagnosis. Patient was classified as ICU admission and no ICU admission during the index hospitalization. Primary outcome of interest was overall survival. Propensity score (PS) and proportional hazards regression were used to control potential confounders.Results: A total of 11,825 stage IV cancer patients with septic shock were identified. Among them, 6,089 (51.5%) patients were admitted to ICU during the index hospitalization and 3,626 (30.7%) patients survived the index hospitalization. A 1:1 propensity score (PS)-matched cohort of 7,186 patients were created for patients with/without ICU admission among the total study population. Both the PS-stratified analysis among the overall population (pooled hazard ratio [HR]: 0.78, 95% confidence interval [CI]: 0.74-0.81) and analysis among the PS-matched population (HR: 0.76, 95% CI: 0.72-0.79) showed association between ICU admission and better overall survival. ICU admission was also associated with a lower risk of in-hospital mortality in both PS-stratified analysis (pooled odds ratio [OR]: 0.69, 95% CI: 0.63-0.75) and PS-matched analysis (OR: 0.61, 95% CI: 0.55-0.68). In PS-stratified analysis for long-term survival after discharge among hospital survivors, ICU admission was associated with improved long-term survival after discharge (pooled HR: 0.73, 95% CI: 0.68-0.80). Also ICU admission was associated with better long-term survival after discharge (HR: 0.77, 95% CI: 0.70-0.85) in PS-matched analysis.Conclusions: Though ICU admission with aggressive treatment may be associated with improved survival, the majority (70%) of stage IV cancer patients with septic shock were unable to survive until hospital discharge.

Incidence and pattern of brain lesions in paediatric septic shock patients.

Brain injury is frequently observed during septic shock and may be primarilyrelated to the direct effects of the septic insult on the brain or to secondary/indirectinjuries (e.g. hypotension, hypoxaemia and hyperglycaemia). We sought to assessincidence and pattern of brain lesions diagnosed by neuroimaging in paediatric septicshock patients. Retrospective descriptive hospital-based study included paediatric patientswith a single episode of septic shock admitted to our tertiary paediatric intensive careunit from January 2010 to December 2013. 49 of 193 septic shock patients had a neuroimaging examination[CT only 22 (45%), MRIonly 14 (29%) and both 13 (27%)]. Neuroimaging was normal in 16 patients (33%) andshowed acute lesions in 20 patients (40%). The most frequent findings were: cerebralinfarcts/hypoxic ischaemic injury in 8 (16%) and cerebritis in 7 (14%). The incidence ofacute brain lesion in our septic shock cohort was 10% (20 of 193). The diagnosis of brain dysfunction in septic shock patients reliesessentially on neurological examination and neurological tests, such as electroencephalography andneuroimaging. Neuroimaging can reveal acute intracerebral structural lesions andtheir reversibility, helping with management and prognosis. Advances in knowledge: Ischaemic lesions and cerebritis are the most common brainanomalies complicating paediatric septic shock.

Association between exposure to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers prior to septic shock and acute kidney injury

ObjectiveTo evaluate the association between angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) use prior to a septic shock episode and the development, prognosis and long-term recovery from acute kidney injury (AKI). DesignA single-centre, prospective observational study was carried out between September 2005 and August 2010. ScopePatients admitted to the ICU of a third level hospital. PatientsA total of 386 septic shock patients were studied. InterventionsNone. Variables of interestUse of ACEIs/ARBs, AKI development, recovery of previous creatinine levels and time to recovery. ResultsA total of 386 patients were included, of which 312 (80.8%) developed AKI during ICU stay and 23% were receiving ACEIs/ARBs. The percentage of patients on ACEIs/ARBs increased significantly in relation to more severe stages of AKI irrespective of the kind of AKI score. After adjusting for confounders, the development of AKI was independently associated to the use of ACEIs/ARBs (OR 2.19; 95%CI 1.21–3.84; p=.04). With respect to the recovery of kidney function, the group of patients on ACEIs/ARBs had significantly higher creatinine levels at ICU discharge and needed hemodialysis more frequently thereafter. However, use of ACEIs/ARBs affected neither recovery of previous creatinine levels nor significantly delayed recovery. ConclusionsThe use of ACEIs/ARBs before septic shock episodes was correlated to AKI development and severity, but did not affect the recovery of kidney function after sepsis resolution.

Prognostic factors in the survival of patients with blood disorders recovering from septic shock

ABSTRACTBackground: Septic shock is one of the major direct causes of death in patients in hematology departments.Objectives: The knowledge about clinical outcomes and factors associated with negative outcome in these patients can be important and useful for physicians to identify the patients who are most likely to benefit from ICU therapy.Methods: We retrospectively analyzed records of 214 episodes of septic shock in patients with different blood diseases hospitalized between 1998 and 2011 in the Department of Hematology, Oncology and Internal Medicine, the Medical University of Warsaw, Poland.Results: Direct survival with resolution of septic shock was 46%. Among these survivors, 75% continued to live at 30 days, 49% at 6 months, and 12% at 5 years after shock resolution. It was found that the most important prognostic factors for direct (short-term) mortality were multiorgan failure, lack of concordance of empiric antibiotic treatment with results of in vitro sensitivity testing, the Karnofsky score below 60%, presence of more than two comorbidities. Long-term prognosis (3-year follow-up) was affected by multiple factors with the most significant being Karnofsky score, higher organ failure score, hematologic disease relapse or resistance to treatment.Discussion: Septic shock in patients with blood disorders treated in the hematology ward was associated with very high risk of mortality in all periods after its completion. However, although the results of treatment of septic shock in patients with blood diseases are poor, they were comparable to the results of treatment of septic shock in mixed populations treated in intensive care units.

Association between exposure to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers prior to septic shock and acute kidney injury

ObjectiveTo evaluate the association between angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) use prior to a septic shock episode and the development, prognosis and long-term recovery from acute kidney injury (AKI). DesignA single-centre, prospective observational study was carried out between September 2005 and August 2010. ScopePatients admitted to the ICU of a third level hospital. PatientsA total of 386 septic shock patients were studied. InterventionsNone. Variables of interestUse of ACEIs/ARBs, AKI development, recovery of previous creatinine levels and time to recovery. ResultsA total of 386 patients were included, of which 312 (80.8%) developed AKI during ICU stay and 23% were receiving ACEIs/ARBs. The percentage of patients on ACEIs/ARBs increased significantly in relation to more severe stages of AKI irrespective of the kind of AKI score. After adjusting for confounders, the development of AKI was independently associated to the use of ACEIs/ARBs (OR 2.19; 95%CI 1.21–3.84; p=.04). With respect to the recovery of kidney function, the group of patients on ACEIs/ARBs had significantly higher creatinine levels at ICU discharge and needed hemodialysis more frequently thereafter. However, use of ACEIs/ARBs affected neither recovery of previous creatinine levels nor significantly delayed recovery. ConclusionsThe use of ACEIs/ARBs before septic shock episodes was correlated to AKI development and severity, but did not affect the recovery of kidney function after sepsis resolution.

New-onset supraventricular arrhythmia during septic shock: prevalence, risk factors and prognosis.

BackgroundThe aims of this study were to prospectively assess the prevalence of sustained (lasting more than 30 s) new-onset supraventricular arrhythmia (NOSVA) during septic shock, identify the associated factors (including septic myocardial dysfunction), and evaluate its impact on hemodynamics and prognosis.MethodsPatients with a diagnosis of septic shock were screened in a medical intensive care unit of a tertiary hospital center in France with a continuous 12-lead EKG for the occurrence of NOSVA. Biological and clinical data (including septic myocardial dysfunction characterized by echocardiography) were collected. We also assessed the hemodynamic tolerance and prognosis of NOSVA.ResultsAmong the 71 septic shock episodes assessed during the study, NOSVA occurred in 30 [prevalence of 42 %, 95 % confidence interval (CI) 30–53 %]. Among all recorded factors, only renal failure (as assessed by renal SOFA score at day 1) was associated with NOSVA and this difference persisted by multivariable analysis (odds ratio of 1.29, 95 % CI 1.03–1.62, p = 0.03). There was a significant increase in norepinephrine dosage during the first hour after SVA onset. NOSVA was associated with longer catecholamine use during septic shock as compared with patients in sinus rhythm, whereas ICU mortality was identical between groups.ConclusionsWe found a high prevalence of sustained NOSVA during septic shock. NOSVA was not related to septic myocardial dysfunction, but rather to acute renal failure, raising the hypothesis of an acute renocardiac syndrome.

Long-Term Renal Functional Outcomes after Primary Gastrocystoplasty

We assessed long-term renal function, morbidities and mortality in 50 patients who had undergone primary gastrocystoplasty at our institution. We retrospectively reviewed patients 21 years or younger who had undergone primary gastrocystoplasty between 1984 and 2004. Patients who underwent secondary gastrocystoplasty or primary composite augmentation or had cloacal exstrophy were excluded. Primary outcome was progression to end-stage renal disease. Secondary outcomes included mortality, bladder malignancy, hematuria-dysuria syndrome, electrolyte abnormalities and surgical revisions. Of 50 patients who had undergone gastrocystoplasty 35 met inclusion criteria. Median age was 9.4 years and 60% of the patients were male. Median followup was 19 years (IQR 11 to 25). Of the 35 patients 15 (43%) had normal preoperative estimated glomerular filtration rate and 5 (14%) had stage 2, 10 (29%) stage 3 and 5 (14%) stage 4 chronic kidney disease. Five of the 15 patients with stage 3 or 4 chronic kidney disease improved to normal estimated glomerular filtration rate, 1 remained with stage 3 disease and 9 progressed to end-stage renal disease. In 1 patient with normal estimated glomerular filtration rate end-stage renal disease developed following an episode of septic shock due to osteomyelitis. Seven patients in the cohort (20%) died, with 1 each dying of ventriculoperitoneal shunt infection, pneumonia, end-stage renal disease, complications of pregnancy and unknown cause, and 2 patients dying of septic shock due to urinary tract infection. There were no bladder malignancies. Hematuria-dysuria syndrome developed in 9 patients (24%). Eight patients (23%) underwent surgical revision. The majority of patients had preserved or improved renal function after gastrocystoplasty. There were no deaths attributable to gastric augmentation and no bladder malignancies. Approximately a fourth of patients required surgical revision.

Sepsis, venous return, and teleology

An understanding of heart-circulation interaction is crucial to our ability to guide our patients through an episode of septic shock. Our knowledge has advanced greatly in the last one hundred years. There are, however, certain empirical phenomena that may lead us to question the wisdom of our prevailing treatment algorithm. Three extreme but iatrogenically possible haemodynamic states exist. Firstly, inappropriately low venous return; secondly, overzealous arteriolar constriction; and finally, misguided inotropy and chronotropy. Following an unsuccessful fluid challenge, it would be logical to first set the venous tone, then set the cardiac rate and contractility, and finally set the peripheral vascular resistance. It is hypothesized that a combination of dihydroergotamine, milrinone and esmolol should be superior to a combination of noradrenaline and dobutamine for surviving sepsis.