ICU Septic Patients Research Articles

Heparin binding protein as a reliable prognostic biomarker for severity of sepsis in the intensive care unit

ABSTRACT Background It is still challenging to identify people who are at risk for developing sepsis quickly and early. Heparin-binding protein (HBP) has been demonstrated a promising data that can be used as predictive qualities in identifying organ failure. Methods This prospective observational investigation of 55 adult patients who have been proven to have sepsis, and were hospitalized into the intensive care unit. By carrying out HBP, procalcitonin (PROCAL), C-reactive protein (CRP), serum lactate, SOFA score on admission and after 72 hours and detecting 28-day mortality. Results Despite PROCAL and HBP were higher in survival than non-survival patients at day 0 (1010.32 ± 341.72 vs 770.21 ± 327.97, p = 0.0112) (16.73 ± 7.19 vs 13.19 ± 7.26, p = 0.077) respectively, It was significantly lower in survival than non-survival at day 3 (542.09 ± 191.98 vs 995.00 ± 333.74, p =<0.0001) (9.03 ± 2.92 vs 16.67 ± 7.55,p =<0.0001) respectively. Our main marker HBP decreased significantly from day 0 to day 3 for survival patients with paired difference −7.69 ± 6.78 with p value < 0.0001, while it is increased with non-significant value for non-survival patients with paired difference 3.48 ± 9.45 with p value 0.084. ROC analysis for mortality showed for HBP that AUC at day 0 was 0.323 (p=0.025). At cut-off value of>15.5ng/ml, sensitivity was 29.2%, specificity was 64.5%, while at day 3 was 0.831 (p=0.000). At cut-off value of>9.5ng/ml, sensitivity was 83.33%, specificity was 77.42%. Conclusion HPB showed a strong prognostic marker of mortality in ICU septic patients at day 3 more than day 0 with important value and trend.

The use of muscle ultrasound to detect critical illness myopathy in patients with sepsis: an observational cohort study

BackgroundCritical illness myopathy (CIM) has negative impact on patient outcomes. We aimed to explore the diagnostic value of bedside ultrasonography for early identification of CIM in septic patients and its correlation with other diagnostic methods. This prospective observational study included 40 ICU patients diagnosed with sepsis on admission or within 48 h later according to the third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). They were evaluated using muscle ultrasound, electrodiagnostic and clinical muscle assessment (Medical Research Council, MRC) at two time points, the first was between days 2 and 5 and the second was between days 10 and 15.ResultsThere was significant deterioration of neuromuscular function between the two evaluation points demonstrated by decline in MRC, abnormal nerve conduction and electromyography (EMG) and increased muscle echogenicity on ultrasonography (P ≤ 0.001). Sepsis-Related Organ Failure Assessment (SOFA) score significantly correlated with different neuromuscular assessment tools. MRC had significant correlation with myopathic EMG (P ≤ 0.001, r = − 0.869) and increased muscle echogenicity (P ≤ 0.001, r = − 0.715). Abnormal ultrasonographic muscle architecture had sensitivity of 100%, specificity of 75% and positive likelihood ratio of 4 in detecting muscle dysfunction compared to myopathic EMG.ConclusionsBedside peripheral muscle ultrasound echogenicity grade could be used as an additional screening test in ICU septic patients for early detection of CIM.

Early administration of norepinephrine in sepsis: Multicenter randomized clinical trial (EA-NE-S-TUN) study protocol.

One of the most important components of sepsis management is hemodynamic restoration. If the target mean arterial pressure (MAP) is not obtained, the first recommendation is for volume expansion, and the second is for norepinephrine (NE). We describe the methodology of a randomized multicenter trial aiming to assess the hypothesis that low-dose NE given early in adult patients with sepsis will provide better control of shock within 6 hours from therapy starting compared to standard care. This trial includes ICU septic patients in whom MAP decrease below 65 mmHg to be randomized into 2 groups: early NE-group versus standard care-group. The patient's attending clinician will determine how much volume expansion is necessary to meet the target of a MAP > 65 mm Hg. If this target not achieved, after at least 30 ml/kg and guided by the available indices of fluid responsiveness, NE will be used in a usual way. The latter must follow a consensual schedule elaborated by the investigating centers. Parameters to be taken at inclusion and at H6 are: lactates, cardiac ultrasound parameters (stroke volume (SV), cardiac output (CO), E/E' ratio), and P/F ratio. MAP and diuresis are recorded hourly. Our primary outcome is the shock control defined as a composite criterion (MAP > 65 mm Hg for 2 consecutive measurements and urinary output > 0.5 ml/kg/h for 2 consecutive hours) within 6 hours. Secondary outcomes: Decrease in serum lactate> 10% from baseline within 6 hours, the received fluid volume within 6 hours, variation of CO and E/E', and 28 days-Mortality. The study is ongoing and aims to include at least 100 patients per arm. This study is likely to contribute to support the indication of early initiation of NE with the aim to restrict fluid intake in septic patients. (ClinicalTrials.gov ID: NCT05836272).

The diagnostic role of C2PAC index in cases of sepsis-induced coagulopathy (SIC)

BackgroundTo study the potential role of the C2PAC index (a ratio of soluble type C lectin-like receptor 2 level sCLEC-2 and platelet count) in sepsis-induced coagulopathy with the possibility of using this index as an early predictor in sepsis and sepsis-induced coagulopathy.MethodsOur case–control study included a total of 86 participants divided into 2 groups: group I is the case group consisting of 56 patients of sepsis or septic shock and group II (control group) of 30 healthy persons: sex and age-matched healthy individuals. All patients were subjected to assessment of C lectin domain family 2 receptor (sCLEC2), by enzyme-linked immunosorbent assay ELIZA kit, then C2PAC index (a ratio of soluble type C lectin-like receptor 2 level sCLEC-2 and platelet count) was calculated using the platelet count.ResultsOur study demonstrated that sCLEC-2 levels and C2PAC in group I were higher than in group II (p value < 0.001), and Klebsiella was the most common organism detected in ICU septic patients; detected in 25 patients (44.6%), there is a statistical significance (p value 0.045) between sCLEC2 levels and streptococcal infections. It was detected also that the SIC group was 17 patients (30.4%) and the sepsis without coagulopathy group was 39 patients (69.6%). Compared with the sepsis without coagulopathy group, the SIC group was significantly older and had a significantly higher SOFA score, sCLEC-2 levels, and C2PAC index. Lastly, the strong potentiality of using C2PAC as a diagnostic and prognostic marker for sepsis-induced coagulopathy with high statistical significance < 0. 001.ConclusionsC2PAC index can be validated as an accurate marker of sepsis-induced coagulopathy with higher sensitivity when using the C2PAC index (82.4%) than using sCLEC-2 (58.8%) and both have the same specificity (89.7%). The C2PAC index is a useful predictor of SIC progression.

Identification of metabolomics-based prognostic prediction models for ICU septic patients

Sepsis-related global mortality remains unacceptably high in intensive care units. Identifying the various molecular processes between survival and death in septic patients may assist in better treatment. Accurate prognostic evaluation of sepsis is an essentially unmet need. This study analyzed the metabolite changes in plasma between healthy controls and septic patients, as well as between survival and dead septic patients using liquid chromatography/mass spectrometry. Univariate and multivariate analyses were applied to identify differential metabolites. The differential metabolites and clinical indicators within 24 h after sepsis diagnosis were run through multivariate logistic regression models to determine the 28-day, hospital, and 90-day septic mortality prediction models. The results suggested markedly changed amino acids metabolism in septic patients compared to healthy controls; 10, 4, and 22 primary differential metabolites related to amino acid and fatty acid metabolisms were identified in the survival and death groups at 28-day, hospital, and 90-day, respectively. Further, we found that model 1 (indoleacetic acid, 3-methylene-indolenine, heart rate, respiratory support, and application of pressure drugs), model 2 (lymphocyte count, alkaline phosphatase, SOFA, and L-alpha-amino-1H-pyrrole-1-hexanoic acid), and model 3 (dopamine, delta-12-prostaglandin J2, heart rate, respiratory support, and application of pressure drugs) could predict 28-day, hospital, and 90-day mortality of sepsis with a sensitivity of 75.51%, 73.58%, and 83.33%, specificity of 78.72%, 72.09%, and 78.57%, and the area under the receiver operating characteristic curve of 0.881, 0.830, 0.886, respectively. Thus, this research presents three multiple-biomarker-based prognostic models for 28-day, hospital, and 90-day mortality septic patients and could be used to guide sepsis treatment.

Oxidative stress-induced endothelial dysfunction and decreased vascular nitric oxide in COVID-19 patients.

SummaryBackgroundSARS-CoV-2 targets endothelial cells through the angiotensin-converting enzyme 2 receptor. The resulting endothelial injury induces widespread thrombosis and microangiopathy. Nevertheless, early specific markers of endothelial dysfunction and vascular redox status in COVID-19 patients are currently missing.MethodsObservational study including ICU and non-ICU adult COVID-19 patients admitted in hospital for acute respiratory failure, compared with control subjects matched for cardiovascular risk factors similar to ICU COVID-19 patients, and ICU septic shock patients unrelated to COVID-19.FindingsEarly SARS-CoV-2 infection was associated with an imbalance between an exacerbated oxidative stress (plasma peroxides levels in ICU patients vs. controls: 1456.0 ± 400.2 vs 436 ± 272.1 mmol/L; P < 0.05) and a reduced nitric oxide bioavailability proportional to disease severity (5-α-nitrosyl-hemoglobin, HbNO in ICU patients vs. controls: 116.1 ± 62.1 vs. 163.3 ± 46.7 nmol/L; P < 0.05). HbNO levels correlated with oxygenation parameters (PaO2/FiO2 ratio) in COVID-19 patients (R2 = 0.13; P < 0.05). Plasma levels of angiotensin II, aldosterone, renin or serum level of TREM-1 ruled out any hyper-activation of the renin-angiotensin-aldosterone system or leucocyte respiratory burst in ICU COVID-19 patients, contrary to septic patients.InterpretationEndothelial oxidative stress with ensuing decreased NO bioavailability appears as a likely pathogenic factor of endothelial dysfunction in ICU COVID-19 patients. A correlation between NO bioavailability and oxygenation parameters is observed in hospitalized COVID-19 patients. These results highlight an urgent need for oriented research leading to a better understanding of the specific endothelial oxidative stress that occurs during SARS-CoV-2.FundingStated in the acknowledgments section.

Benefit of Hemoadsorption Therapy in Patients Suffering Sepsis-Associated Acute Kidney Injury: A Case Series

Introduction: Sepsis is defined as life-threatening organ dysfunction in result of the host’s dysregulated response to infection and septic shock. Sepsis-associated kidney injury is usually defined as concurrent presence of acute kidney injury (AKI) and sepsis without other significant causative factors. Method: The current retrospective study was conducted to elucidate beneficial and side effects of CytoSorb®. A total of 17 patients were primarily treated with continuous renal replacement therapy in combination with CytoSorb. The demand for norepinephrine, mean arterial pressure, lactate, and procalcitonin (PCT) levels, as well as ICU length of stay, was measured. Result: The blood lactate levels decreased by 32.30% when comparing mean levels before and after treatment. All patients who survived (n = 14) had reduction in vasopressor demand to 68.96% of their initial dose before the start of treatment. Hospital survival was greater in patients who initially had higher vasopressor demand compared to their nonsurviving counterparts, but in whom vasopressor dosages were reduced significantly during their treatments. Mortality as predicted by APACHE II score in the overall patient population was 79.9%, whereas, the observed ICU mortality was 31%. The baseline PCT levels on patients received 1, 2, and 3 CytoSorbs were 27.08 ± 5.81 ng/mL, 13.28 ± 2.62 ng/mL, and 21.03 ± 6.56 ng/mL, respectively. Observed PCT levels at 24 h after the last treatment on patients received 1, 2, and 3 CytoSorb were 31.55 ± 15.70 ng/mL, 5.61 ± 1.77 ng/mL, and 8.11 ± 3.62 ng/mL, respectively. Conclusion: In conclusion, it seems that applying the CytoSorb in combination with CRRT in ICU septic patients with AKI, is related to a significant decrease in mortality, if the integrity and continuity of the treatment be kept, as much as possible. This study presented an effectively positive outcome with cytokine adsorber treatment as an adjuvant along with standard treatment in a high-risk mortality case of septic shock with organ failure.

Construction of the Metabolomics-Based Prognosis-Prediction Models for ICU Septic Patients

Construction of the Metabolomics-Based Prognosis-Prediction Models for ICU Septic Patients

Thiamine, Ascorbic Acid, and Hydrocortisone As a Metabolic Resuscitation Cocktail in Sepsis: A Meta-Analysis of Randomized Controlled Trials With Trial Sequential Analysis.

Sepsis is a common condition in the ICU. Despite much research, its prognosis remains poor. In 2017, a retrospective before/after study reported promising results using a combination of thiamine, ascorbic acid, and hydrocortisone called "metabolic resuscitation cocktail" and several randomized controlled trials assessing its effectiveness were performed. We conducted a systematic review and meta-analysis of randomized controlled trials in septic ICU patients to assess the effects of this combination therapy. PubMed, Embase, and the Cochrane library databases were searched from inception to March of 2021. Data were extracted independently by two authors. The main outcome was the change in Sequential Organ Failure Assessment score within 72 hours. Secondary outcomes included renal composite endpoints (acute kidney injury) Kidney Disease - Improving Global Outcome organization stage 3 or need for renal replacement therapy, vasopressor duration, and 28-day mortality. We included randomized controlled trials with patients admitted to the ICU with sepsis or septic shock. The trials compared a combination of thiamine, ascorbic acid, and hydrocortisone to standard care or placebo in patients admitted to ICU with sepsis or septic shock. We included eight randomized controlled trials (n = 1,335 patients). Within 72 hours, the median of mean improvement was -1.8 and -3.2 in the control and intervention groups, respectively (eight randomized controlled trials, n = 1,253 patients); weighted mean difference -0.82 (95% CI, -1.15 to -0.48). Data were homogeneous and the funnel plot did not suggest any publication bias. Duration of vasopressor requirement was significantly reduced in the intervention group (six randomized controlled trials). There was no evidence of a difference regarding the ICU mortality and the renal composite outcome (acute kidney injury KDIGO 3 or need for renal replacement therapy, seven randomized controlled trials). Metabolic resuscitation cocktail administrated in ICU septic patients improves change in Sequential Organ Failure Assessment score within 72 hours. However, this improvement is modest and its clinical relevance is questionable. The impact on renal failure and mortality remains unclear.

Prognostic Value of Variations in Serum Biomarkers and Prognostic Scores Values Between Admission and Second Day in Intensive Care Unit Septic Patients.

ObjectiveTo determinate the prognostic value of procalcitonin (PCT) and C-reactive protein (CRP) changes during the first two days of admission to the ICU with sepsis and/or septic shock, and to compare it with changes in Acute Physiology And Chronic Health Evaluation II (APACHE-II) and Sepsis-related Organ Failure Assessment (SOFA) prognostic scores.MethodsA single-center prospective observational study was performed. Fifty consecutive patients admitted to the ICU, diagnosed of severe sepsis/septic shock were included. We considered risk factors for infection: diabetes mellitus, chronic obstructive pulmonary disease (COPD), previous antibiotic treatment, central intravascular catheter, bladder catheter, active neoplasia.ResultsMedian aged 67(52-75) years with median APACHE-II 19(14-25) points and SOFA scores 7(5-11) points on admission, and 28-day mortality of 42%. When we studied the relationship between mortality and the changes between the day of admission and the second day of the variables studied, we found that APACHE-II (p = 0.001) and SOFA (p = 0.002) between admission and second day raised significantly in no survivors, with no significant changes in CRP and PCT. Multivariate analysis showed that mortality was significantly associated to changes in SOFA score (odds ratio [OR], 2.13; 95% confidence interval [CI], 1.18-3.86) and to the presence of one or more risk factors for infection (OR, 6.01; 95% CI, 1.01-35.78) but not with PCT changes. Mortality was also related to the variations between the day of admission and the fifth day on APACHE-II (p = 0.002), SOFA (p < 0.001) and PCT (p = 0.012).ConclusionsChanges in SOFA and APACHE-II scores between admission and second day in ICU septic patients are more sensitive mortality predictors than the observed changes in CRP and PCT values. Changes in PCT levels between the day of ICU admission and the fifth day are significantly related to mortality and may be useful as an additional marker in patient outcome.

Role of central venous-arterial PCO2 difference in prediction of clinical outcome in ICU septic patients

ABSTRACT Background: Identification of tissue hypoxia and hypoperfusion plays an important role in the management of critically ill patients. Although the venous-arterial PCO2 difference (ΔPCO2) cannot serve as a marker of tissue hypoxia, it is considered a marker of the adequacy of venous blood flow (Cardiac output). The present study aimed to evaluate the role of venous-arterial PCO2 gradient in prediction of outcome in septic patients admitted to ICU. Patients and methods: 100 adult patients fulfilled the criteria of severe sepsis or septic shock admitted to Emergency Intensive Care Unit, were divided in two groups according to ΔPCO2. The high ΔpCO2 group (ΔpCO2 > 6 mmHg) included 58 patients and the normal ΔpCO2 (ΔpCO2 ≤ 6 mmHg) included 42 patients. Clinical scoring systems were recorded. Clinical outcome including organ dysfunction and mortality was recorded. Results: The high ΔPCO2 group showed significant lower blood glucose level (p = 0.038) than the normal ΔPCO2 group. Serum lactate, heart rate, and APACHE score were significantly higher in high ΔPCO2 group than normal ΔPCO2 group (p, 0.012, 0.013, and 0.020, respectively). As regard to the clinical outcome, patient mortality was significantly higher (p = 0.042) in high ΔPCO2 group than normal ΔPCO2 group and the number of organ dysfunction was higher in high ΔPCO2 group than normal ΔPCO2 group but not reached a significant level (p = 0.625). Conclusions: ΔPCO2 is a reliable index for early prediction of clinical outcome including organ dysfunction and mortality in patients with sepsis and septic shock.

Long-term health-related quality of life of critically ill patients with haematological malignancies: a prospective observational multicenter study

BackgroundAlthough outcomes of critically ill patients with haematological malignancies (HMs) have been fully investigated in terms of organ failure and mortality, data are scarce on health-related quality of life (HRQOL) in this population. We aim to assess post-intensive care unit (ICU) burden and HRQOL of critically ill patients with HMs and to identify risk factors for quality-of-life (QOL) impairment.ResultsIn total, 1011 patients with HMs who required ICU admission in 17 ICUs in France and Belgium were included in the study; 278 and 117 patients were evaluated for QOL at 3 months and 1 year, respectively, after ICU discharge. HRQOL was determined by applying the interview form of the Short Form 36 (SF-36) questionnaire. Psychological distress symptoms were evaluated using the Hospital Anxiety Depression Score (HADS) and the Impact of Event Scale (IES). In-hospital mortality rates at 3 months and 1 year were, respectively, 39.1, 50.7 and 57.2%, respectively. At 3 months, median [IQR] physical and mental component summary scores (PCS and MCS) (SF-36) were 37 [28–46] and 51 [45–58], respectively. PCS was lower in ICU patients with HMs when compared to general ICU septic patients (52 [5–13], p = 0.00001). The median combined HAD score was 8 [5–13], and the median IES score was 8 [3–16]. However, recovery during the first year after ICU discharge was not consistent in all dimensions of HRQOL. Three months after ICU discharge, the maximum daily Sequential Organ Failure Assessment score and status of the underlying malignancy at ICU admission were significantly associated with MCS impairment (− 0.54 points [95% CI − 0.99; − 0.1], p = 0.018 and − 4.83 points [95% CI − 8.44; − 1.22], p = 0.009, respectively).ConclusionHRQOL is strongly impaired in critically ill patients with HMs at 3 months and 1 year after ICU discharge. Organ failure and disease status are strongly associated with QOL. The kinetic evaluation of QOL at 3 months and 1 year offers the opportunity to focus on QOL aspects that may be improved by therapeutic interventions during the first year after ICU discharge.

Effects of comprehensive nursing measures on septic shock patients' resuscitation related index in ICU

Objective To discuss the effects of comprehensive nursing measures on ICU septic shock patients' resuscitation related index at different time points, in order to summarize the most optimum nursing measures. Methods A total of 86 septic shock patients who were treated in ICU of Beijing Tongren Hospital Affiliated to Capital Medical University were selected as research objects, and divided them into observation group which was adopted comprehensive nursing model and control group which was adopted normal nursing model according to coin toss random method, with 43 cases in each group. Patients' heart rate (HR) , mean arterial pressure (MAP) , cardiac output index (CI) and oxygen saturation of mixed venose blood (SvO2) at 0 h (T0) , 3 h (T1) and 6 h (T2) were compared between the two groups. Serum C reactive protein (CRP) was detected before and after intervention, and the curative effect was evaluated. The data in this study were collated and analyzed by statistical software SPSS 23.0. Results Compared with control group, effective rate of the observation group was 86.05%, and the difference had statistical significance (P 0.05) , but SvO2 and CI increased significantly in T1 and T2, and the differences were statistically significant (P 0.05) . The SvO2 and CI in the observation group were higher than those of the control group in time of T1 and T2, and the differences were statistically significant (P 0.05) . After intervention, the CRP in the observation group (5.14±1.23) mg/L was lower than that in the control group (7.56±1.35) mg/L (P<0.05) . Conclusions Comprehensive nursing measures can relatively improve the prognosis of patients with septic shock in ICU ward, improve the level of CRP, and have less influence on the hemodynamics. Key words: Nursing care; Intensive care units; Shock, septic; Resuscitation

Stratification of Gut Microbial Communities for ICU Septic Patients and Correlation with Septic Shock

Background: Disruption of gut microbiota correlated with various diseases. Previous research showed gut microbiota of septic patients altered. However, whether the alteration correlated with the occurrence of septic shock remains unclear. Methods: Patients diagnosed with sepsis or septic shock were enrolled. Clinical data including lab results, enteral nutrition (EN), antibiotic treatments and Sequential Organ Failure Assessment (SOFA) score were obtained daily. Fresh fecal samples were obtained during the patients' first week in ICU. 16S rRNA gene sequencing was used to analyze gut microbiota. Stratification and biomarkers analysis of ICU-enterotypes was analyzed using R language and linear discriminate analysis effect size (LEfSe). Multivariate logistic regression was utilized to explore associations between enterotypes and septic shock, as well as duration of EN and antibiotics. Results: Seventy-two ICU septic patients were enrolled. Two different stratified clusters (ICU-enterotype) were identified. Cluster1 was characterized with higher relative abundance of Firmicutes (Lactobacillales-Enterococcaceae-Enterococcus in particular), and Actinobacteria (Bifidobacteriales-Bifidobacterium in particular). Cluster2 was characterized with higher relative abundance of Bacteroides, Enterobacteriaceae, and Parabacteroides. ICU-enterotype correlated with septic shock (p=0.036) adjusting for lactate, SOFA score, age and sex. Patients with Cluster2 had increased risk of septic shock compared with Cluster1. EN duration influenced ICU-enterotype (p=0.047) adjusting for antibiotics, age, sex and BMI. Patients with longer EN duration were more likely to have Cluster1. Conclusions: Gut microbiota of ICU septic patients could be stratified into two enterotypes, Cluster1 and Cluster2. Cluster2 is an independent risk factor of septic shock. Patients with longer period of EN are more likely to have Cluster1. Funding: None Declaration of interests: The authors declared no conflicts of interests. Ethical Approval Statement: Ethical approval was received from the Medical Ethics Committee of PUMCH, and all research was conducted in accordance with the declaration of Helsinki.

An acid-base disorders analysis with the use of the Stewart approach in patients with sepsis treated in an intensive care unit.

Patients with sepsis admitted to the intensive care unit often present with acid-base disorders. As the traditional interpretation might be clinically misleading, an alternative approach described by Stewart may allow one to quantify the individual components of acid-base abnormalities and provide an insight into their pathogenesis. The aim of our study was to compare the traditional and Stewart approaches in the analysis of acid-base disturbance. We analyzed arterial blood gases (ABG) taken from 43 ICU septic patients from admission to discharge categorising them according to SBE values. The traditional concept analysis was compared with the physicochemical approach using the Stewart equations. 990 ABGs were analysed. In the SBE < -2 mEq L⁻¹ group, hyperlactatemia was observed in 34.7% ABG, hypoalbuminemia in 100% and SIG acidosis in 42% ABG. Moreover, a Cl/Na ratio > 0.75 was present in 96.9% ABG. In the normal range SBE group, elevated lactates were present in 21.3% ABG, SIG acidosis in 14.9%, elevated Cl/Na ratio in 98.4% and hypoalbuminemia in all 324 ABG. In the metabolic alkalosis group (SBE > +2 mEq L⁻¹), hyperlactatemia was observed in 18.4% ABG, SIG acidosis in 5% ABG, Cl/Na ratio> 0.75 in 88.8%, while 99.1% samples revealed hypoalbuminemia. The use of the Stewart model may improve our understanding of the underlying pathophysiological mechanism and the true etiology of the derangements of acid-base disorders. Indeed, it proves that patients may suffer from mixed arterial blood gas disorders hidden under normal values of SBE and pH.

Prognostic significance of EEG abnormalities in acute septic patients in ICU: A study about 110 patients

Background It is known that sepsis is associated with increased mortality, delirium and long-term cognitive impairment in ICU patients. EEG abnormalities occurring at acute stage of sepsis may correlate with outcome. Predictive value of early standard EEG abnormalities for mortality in ICU septic patients remains to be assessed. Methods In this prospective, single center, observational study, standard EEG was performed, analyzed and classified according to both Synek and Young EEG scales, in consecutive patients acutely admitted in ICU for sepsis. Delirium, coma and the level of sedation were assessed at the time of EEG recording; and duration of sedation, occurrence of in-ICU delirium or death were assessed during follow-up. Adjusted analyses were carried out using multiple logistic regression. Results One hundred ten patients were included, mean age 63.8 ± 18.1 years, median Simplified Acute Physiology Score (SAPS-II): 38 (29–55). At the time of EEG recording, 46 patients (42%) were sedated and 22 (20%) suffered from delirium. Overall, 54 patients (49%) developed delirium, of which 32 (29%) in the days after EEG. Twenty-three (21%) patients died in the ICU. Absence of EEG reactivity was observed in 27 patients (25%), periodic epileptiform discharges (PEDs) in 21 (19%) and electrographic seizures (ESZ) in 17 (15%). ICU mortality was independently associated with absence of EEG reactivity (OR: 4.44; 95% CI [1.37–14.3], Synek Grade ≥ 3 (OR: 5.35; 95% CI [1.66–17.2]) and Young Grade ≥ 1 (OR: 3.44; 95% CI [1.09–10.8]), after adjustment to SAPS-II at admission and level of sedation. Delirium at the time of EEG was associated with ESZ in non-sedated patients (32% vs 10%, P = 0.037) and occurrence of delirium in the days after EEG was associated with absence of EEG reactivity (39% vs 10%, P = 0.003). Conclusions In this prospective cohort of 110 septic ICU patients, early standard EEG was significantly disturbed. Absence of EEG reactivity, Synek grade ≥ 3 and Young grade ≥ 1 at day 1 to 3 following admission were independent predictors of ICU mortality and associated with prevalence of delirium.

Association between systemic hemodynamics and septic acute kidney injury in critically ill patients: a retrospective observational study

IntroductionThe role of systemic hemodynamics in the pathogenesis of septic acute kidney injury (AKI) has received little attention. The purpose of this study was to investigate the association between systemic hemodynamics and new or persistent of AKI in severe sepsis.MethodsA retrospective study between 2006 and 2010 was performed in a surgical ICU in a teaching hospital. AKI was defined as development (new AKI) or persistent AKI during the five days following admission based on the Acute Kidney Injury Network (AKIN) criteria. We studied the association between the following hemodynamic targets within 24 hours of admission and AKI: central venous pressure (CVP), cardiac output (CO), mean arterial pressure (MAP), diastolic arterial pressure (DAP), central venous oxygen saturation (ScvO2) or mixed venous oxygen saturation (SvO2).ResultsThis study included 137 ICU septic patients. Of these, 69 had new or persistent AKI. AKI patients had a higher Simplified Acute Physiology Score (SAPS II) (57 (46 to 67) vs. 45 (33 to 52), P < 0.001) and higher mortality (38% vs. 15%, P = 0.003) than those with no AKI or improving AKI. MAP, ScvO2 and CO were not significantly different between groups. Patients with AKI had lower DAP and higher CVP (P = 0.0003). The CVP value was associated with the risk of developing new or persistent AKI even after adjustment for fluid balance and positive end-expiratory pressure (PEEP) level (OR = 1.22 (1.08 to 1.39), P = 0.002). A linear relationship between CVP and the risk of new or persistent AKI was observed.ConclusionsWe observed no association between most systemic hemodynamic parameters and AKI in septic patients. Association between elevated CVP and AKI suggests a role of venous congestion in the development of AKI. The paradigm that targeting high CVP may reduce occurrence of AKI should probably be revised. Furthermore, DAP should be considered as a potential important hemodynamic target for the kidney.

Multi-stage modeling using fuzzy multi-criteria feature selection to improve survival prediction of ICU septic shock patients

In many binary medical classification problems, the cost of misclassifying one category is higher than the other, and in these applications it is desirable to employ a classifier with selective sensitivity or specificity. This work explores the utility of a fuzzy multi–criteria function for performance evaluation during knowledge–based medical classification and prediction. The method presented here uses fuzzy optimization to combine the sensitivity, specificity, and accuracy of classification as goals in a single objective function. This approach is used to assign flexible goals, which can be used to maximize the outcome in terms of each one of the goals. The proposed approach significantly increases the sensitivity and the specificity while maintaining or increasing accuracy. The versatility of the method is further exploited in a multi-model approach, using individual structures of multi-objective optimization of sensitivity and specificity separately, and then combining their outcomes through a decision-making module. Among various medical benefits derived from applying this technique, the divergent feature sets selected by high sensitivity and specificity models lend insight into factors more integrally connected to what causes risk of death for patients.

Sepsis and AKI in ICU Patients: The Role of Plasma Biomarkers

Given the higher mortality rate of ICU patients with sepsis and AKI, we decided to investigate the possible correlation between serum biomarkers of organ damage, and endotoxin activity in ICU septic patients. Ninety-eight consecutive adult patients were enrolled in this study. Patients were divided in two groups depending on the presence of sepsis. Fifty-six patients had sepsis, while forty-two patients were nonseptic. Among septic patients, twenty-four subjects developed AKI, while thirty-two did not. AKI occurred in fourteen patients without sepsis as well. The levels of NGAL, BNP, and AOPP were significantly higher among septic patients compared with nonseptic subjects (P < 0.001). Among septic patients, subjects who developed AKI showed significant higher levels of NGAL and AOPP (P = 0.0425) and BNP (P = 0.0327). Among patients who developed AKI, a significant difference was found only in terms of AOPP levels between septic and nonseptic patients. The correlation between endotoxin activity and BNP in septic patients and the increase in the levels of NGAL, BNP, and AOPP in case of sepsis and AKI, in particular if they are associated, indicate a multiorgan involvement in these two conditions.

Mixed fibers diet in surgical ICU septic patients.

Diarrhea commonly occurs in surgical critically ill patients, especially septic patients and fiber formulas have been reported to improve diarrhea. Most reports have used soluble or insoluble fiber exclusively, while the effects of a mixed fiber diet remain unclear. This study compares diarrhea scores between mixed-fiber and non-fiber diets in surgical septic patients receiving broad spectrum antibiotics. We conducted a prospective randomized control double blind study in a general surgical ICU. Patients who received broad spectrum antibiotics and no contraindication to enteral feeding were randomly allocated to a fiber or non-fiber diet for up to 14 days. Nutritional delivery and diarrhea scores were recorded daily. Intention to treat analysis was performed. Thirty-four patients were enrolled in the study, 17 in the fiber group and 17 in non-fiber group. These two patients groups were similar in demographics, disease severity, nutritional status, cause of sepsis and total feeding per day. The proportion of patients with diarrhea score ≥12 was higher in the non-fiber group than in the fiber group, but the difference was not statistically significant [8/17 (47.06%) vs. 4/17(23.53%); p=0.15]. However, the fiber group had a lower mean diarrhea score (fiber vs. non-fiber = 3.6 ± 2.3 vs. 6.3 ± 3.6; p=0.005), as well as a lower global diarrhea score from the generalized estimation equation model for repeated measurement [Coefficient -3.03 (95%CI= -5.03 to -0.92); p=0.005]. In summary, a mixed fiber diet formula can reduce the diarrhea score in surgical critically ill septic patients who received broad spectrum antibiotics.