Incidence Of Organ Dysfunction Research Articles

\u201cOne-step\u201d approach versus \u201cStep-up\u201d approach minimally invasive treatment for infected pancreatic necrosis: a study protocol for a single-center, prospective, randomized controlled trial

BackgroundCurrently, the minimally invasive “Step-up” surgical strategy is still the main treatment for infected pancreatic necrosis (IPN). However, indiscriminate implementation of the “Step-up” strategy can lead to increased numbers of operations and prolonged hospital stay. The “Step-up” approach is not appropriate for some patients due to unavailabilty of a safe puncture path. Therefore, we developed the “One-step” surgical approach to treat IPN, which is safety. However, there is still a lack of comparison of the short and long-term efficacy between the “One-step” and “Step-up” approach. Consequently, we are conducting this clinical trial to provide a reference for IPN treatment.MethodsThis is an ongoing, single-center, randomized controlled trial of patients with IPN. The total sample size required for the trial (May 2021–December 2023) is approximately 128 patients. Patients will be randomly assigned to either an experimental group (One-step) or a control group (Step-up) at a ratio of 1:1 using the block randomization method. We used the case report forms and electronic data capture systems to obtain demographic information, preoperative laboratory examination, auxiliary examination results, surgery data, postoperative recovery outcomes, and follow-up outcomes. The patients will be followed up for 2 years after surgery. The primary endpoint is a composite endpoint, consisting of mortality and severe complications. The secondary endpoints include the incidence of organ dysfunction, the number of surgical procedures, mortality (the incidence of death in hospital and deaths within 30 days of discharge), hospital stay, intensive care unit stay, hospitalization costs, perioperative inflammatory marker changes, and short-and long-term complications.DiscussionCompared with the “Step-up,” the “One-step” minimally invasive surgery can significantly reduce the number of operations, reduce the length of hospital stay and hospitalization costs without increasing the incidence of composite endpoint events, and has better short- and long-term efficacy and safety. Additionally, there was no statistically significant difference in perioperative complications and mortality between “Step-up” and “One-step”. This study will assist with the formulation of an effective and scientific “One-step” minimally invasive treatment strategy for IPN, and an understanding of this technique will facilitate clinical decision-making for IPN.Trial Registration ChiCTR2100044348. Trial status: Ongoing.

Оксидативний стрес у хворих на гострий панкреатит: асоціації із синдромом системної запальної відповіді та органною дисфункцією

Обстежено 129 хворих на гострий панкреатит. Досліджено показники інтенсивності вільнорадикального окислення, перекисного окислення ліпідів, антиоксидантної активності плазми крові, тяжкість проявів синдрому системної запальної відповіді та органної дисфункції/недостатності залежно від наявності в комплексі інтенсивної терапії препаратів з антиоксидантною та антигіпоксантною активністю. Виявлено, що зростання тяжкості синдрому системної запальної відповіді асоціюється з підвищенням вмісту маркерів оксидативного стресу в сироватці крові. Включення антиоксидантів (мексидол, аскорбінова кислота) в інтенсивну терапію пацієнтів із гострим панкреатитом дозволяє знизити ступінь проявів оксидативного стресу, сприяє зменшенню проявів синдрому системної запальної відповіді та частоти органних дисфункцій.

Efficacy and safety of abdominal paracentesis drainage on patients with acute pancreatitis: a systematic review and meta-analysis

ObjectivesTo conduct a systematic review and meta-analysis of the efficacy and safety of abdominal paracentesis drainage (APD) in patients with acute pancreatitis (AP) when compared with conventional ‘step-up’ strategy based...

Driving pressure-guided ventilation versus protective lung ventilation in ARDS patients: A prospective randomized controlled study

ABSTRACT Background: Secondary analyses of randomized controlled trials found that driving pressure (DP) ≤ 14 cm H2O may be associated with improved clinical outcomes in acute respiratory distress syndrome (ARDS) patients. Therefore, the aim of this study was to evaluate the effect of DP-guided ventilation compared to conventional protective lung ventilation (PLV) on clinical outcomes in ARDS patients. Methods: In this prospective, controlled trial, 110 patients with ARDS were randomly assigned according to ventilatory strategy into conventional PLV group and DP-guided ventilation group (by maintaining DP value ≤ 14 cm H2O). Clinical outcomes were incidence of mortality at 28th day (primary outcome), PaO2/FiO2, static compliance (Cstat), organ(s) dysfunction, mechanical ventilation (MV) duration, and length of ICU stay. Results: Incidence of mortality at 28th day was reduced in DP-guided ventilation group compared to PLV group (20% vs. 5.45%); the hazard ratio was 0.26)95% CI: 0.09 to 0.73). The PaO2/FiO2, C stat and MV-free days were higher in in DP-guided ventilation group compared to PLV group. Organ dysfunction, duration of MV and length of ICU stay were significantly lower DP-guided ventilation group compared to PLV group. Conclusions: In patients with ARDS, DP-guided ventilation showed improved survival, Cstat and oxygenation and lower incidence of organ dysfunction, duration of MV and length of ICU stay compared to PLV.

Ninety days transplant free survival with high volume plasma exchange in Wilson disease presenting as acute liver failure.

To study the efficacy and safety of high volume plasma exchange (HVPE) in Wilson disease presenting as acute liver failure (WD-ALF). An analysis of prospectively collected data of consecutively admitted WD-ALF cases was done and patients were divided into two groups: (i) high volume plasma exchange (HVPE) group- who received HVPE + standard medical therapy (SMT), and (ii) SMT group- received only SMT. Outcome measure was transplant free survival (TFS) at 90 days post enrollment, change in biochemical, hemodynamic parameters & incidence of organ dysfunction in HVPE as compared to SMT group, and HVPE related complications. Out of the total 43 cases of WD-ALF reported in the study period, 37 were enrolled (median age 9 years, 62.2% males). All biochemical parameters and prognostic indices except blood ammonia and serum creatinine improved significantly at 72 to 96 hours after enrollment in the HVPE group. Overall, TFS at 90 days was present in 9/19 (47.3%) in HVPE group vs 3/18 (16.6%) in the SMT group (OR 2.84, 95% CI 0.91-8.8, P = .049). Kaplan Meier survival analysis revealed that HVPE group had significantly higher cumulative survival as per the Log Rank test (P = .027); median days of survival was 38 days (IQR 12-63) in HVPE group vs 14 (IQR 5-22) days in SMT group. The present study indicates that in children with WD-ALF, HVPE not only acts as a bridging therapy to LT but may also improve proportion of the cases with TFS.

Mapping the Steroid Response to Major Trauma From Injury to Recovery: A Prospective Cohort Study.

ContextSurvival rates after severe injury are improving, but complication rates and outcomes are variable.ObjectiveThis cohort study addressed the lack of longitudinal data on the steroid response to major trauma and during recovery.DesignWe undertook a prospective, observational cohort study from time of injury to 6 months postinjury at a major UK trauma centre and a military rehabilitation unit, studying patients within 24 hours of major trauma (estimated New Injury Severity Score (NISS) > 15).Main outcome measuresWe measured adrenal and gonadal steroids in serum and 24-hour urine by mass spectrometry, assessed muscle loss by ultrasound and nitrogen excretion, and recorded clinical outcomes (ventilator days, length of hospital stay, opioid use, incidence of organ dysfunction, and sepsis); results were analyzed by generalized mixed-effect linear models.FindingsWe screened 996 multiple injured adults, approached 106, and recruited 95 eligible patients; 87 survived. We analyzed all male survivors <50 years not treated with steroids (N = 60; median age 27 [interquartile range 24–31] years; median NISS 34 [29–44]). Urinary nitrogen excretion and muscle loss peaked after 1 and 6 weeks, respectively. Serum testosterone, dehydroepiandrosterone, and dehydroepiandrosterone sulfate decreased immediately after trauma and took 2, 4, and more than 6 months, respectively, to recover; opioid treatment delayed dehydroepiandrosterone recovery in a dose-dependent fashion. Androgens and precursors correlated with SOFA score and probability of sepsis.ConclusionThe catabolic response to severe injury was accompanied by acute and sustained androgen suppression. Whether androgen supplementation improves health outcomes after major trauma requires further investigation.

PC170. Impact of National Adoption of Endovascular Revascularization on a Regional Referral Center Specializing in Management of Chronic Mesenteric Ischemia

A dramatic increase in the national rates of endovascular revascularization (ER) for chronic mesenteric ischemia (CMI) has occurred; however, the incidence of open mesenteric bypass (OMB) has remained largely unchanged. The impact of ER adoption on referral hospitals specializing in CMI management that may be disproportionately affected by features precluding ability to use ER remains poorly defined. The purpose of this analysis was to determine the temporal variation in management and outcomes within a center with regional specialization for CMI management. A single, large tertiary academic referral institution’s prospectively collected database was queried retrospectively to identify all patients treated for CMI (2002-2018). The primary end point was temporal change in revascularization strategy (ER vs OMB; eras for analysis: 2002-2007, 2008-2013, 2014-2018). Secondary end points included temporal change in complications, reintervention, and survival. Life tables were used to estimate end points. The incidence of organ dysfunction (hepatic, renal, pulmonary, coagulopathy) was examined, and its relationship to outcomes was determined. There were 189 patients identified (OMB, n = 109 [antegrade, 91%; retrograde, 8%]; ER, n = 80 [mesenteric stent, 91%; angioplasty alone, 9%]. There was a significant difference in use of ER and OMB (most recent era, 84% OMB; P < .0001). For either ER or OMB, incidence of in-hospital complications or 30-day mortality was similar over time. OMB patients were significantly younger (66 ± 11 years vs ER, 71 ± 11 years; P = .006) and more likely to have undergone prior ER (OMB, 36%; ER, 17%; P = .005). No significant difference in presenting symptoms (postprandial pain > unintentional weight loss) or comorbidities was present. Major complications were more frequent with OMB (OMB, 54%; ER, 20%; P < .0001); however, 30-day mortality was similar (OMB, 6% [n = 6]; ER, 1% [n = 1]; P = .012). ER had a negligible incidence of postoperative organ dysfunction, whereas OMB was associated with a 75% incidence (threefold or higher transaminitis, 72%; thrombocytopenia [platelet count <40,000], 35%; renal injury, 9%; respiratory failure, 13%). Two-year symptom resolution overall was 69%; however, there was greater frequency of restenosis or recurrent symptoms after ER (50% vs OMB, 9%; P < .0001). Five-year freedom from reintervention or restenosis was significantly higher for OMB (77% ± 7% vs ER, 33% ± 6%; log-rank, P < .0001). There was a nonsignificant trend toward improved 5-year survival after OMB (70% ± 5% vs ER, 60% ± 6%; Cox model, P = .06; Fig). Centers focused on CMI management may not reflect national trends in revascularization strategies as evidenced by the increasing use of OMB. This selection pressure is predominantly due to a significant proportion of prior mesenteric revascularization failures or nonanatomic suitability for ER. Despite specialization and a high-volume referral pattern, complication rates, including frequency of postoperative organ dysfunction, remained similar over time, probably reflecting a cohort of complex patients with significant comorbidities. These findings highlight the significant challenges and resource utilization faced by regional referral centers and provide contemporary benchmarks for outcomes, especially when elective OMB occurs.

Utility of sequential organ failure assessment score in predicting outcome for patients with peritoneal sepsis

Background: Severe complicated intra-abdominal sepsis (SCIAS) is a worldwide challenge with increasing incidence. The sequential organ failure assessment (SOFA) score numerically quantifies the number and severity of failed organs. We examined the utility of the SOFA score for assessing outcome of patients with severe peritoneal sepsis.Methods: This is a prospective observational study. A total of 100 patients who presented to emergency department of Victoria hospital with features suggestive of peritoneal sepsis from January 2018 to August 2018 were included in the study. The presence of organ dysfunction was assessed using a sequential organ failure assessment (SOFA). Clinical, microbiologic, and laboratory factors were considered for assessing the outcome.Results: Forty-two patients had two or more sites of infection on admission. Bacteraemia was confirmed in 20 patients. 88 patients were surgical. The median age of patients was 69 years. Males being more commonly affected than females. Twenty-eight days survival rate was 41%. The incidence of organ dysfunction on day 1 was noted more frequently for renal, cardiovascular, and neurological systems. SOFA score on day 1 and day 3 were significantly higher in non-survivors than those in survivors. Patients with three and higher number of organ systems with dysfunction had a lower survival rate than the subgroups of patients with one or two organ systems with dysfunction.Conclusions: The SOFA score provides potentially valuable prognostic information on in hospital survival when applied to patients with severe peritoneal sepsis.

Effect of conservative and conventional oxygen therapy on the prognosis of critically ill patients: a Meta-analysis

To compare the efficacy and safety of conservative and conventional oxygen therapy in critically ill patients. Relevant literature and randomized controlled trials (RCTs) about the effect of conservative oxygen therapy and conventional oxygen therapy on the prognosis of intensive care unit (ICU) critically ill patients was searched from CNKI, VIP, Wanfang Data, Chinese Clinical Trial Registry, PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov by using the keywords "critically ill patients, conservative oxygen therapy, liberal oxygen therapy, conventional oxygen therapy, mortality" until October 30th in 2018. The main outcome indicators were short-term mortality (28-day mortality or ICU mortality); secondary indicators were 90-day mortality, duration of mechanical ventilation, the length of ICU stay, total hospitalization time, new infection rate in ICU and incidence of new organ dysfunction in ICU. In the conservative oxygen therapy group, the aim of pulse oxygen saturation (SpO2) was 0.90-0.92 or the arterial partial oxygen pressure (PaO2) was 70-100 mmHg (1 mmHg = 0.133 kPa), while in conventional oxygen therapy group SpO2 > 0.96 or PaO2 > 150 mmHg. Literature search, quality evaluation and data extraction was conducted independently by the two authors. The quality of these study was evaluated using Cochrane risk deviation assessment tool, and the relevant data were analyzed using RevMan 5.3 software. Four studies were included in the analysis, these studies were assessed as moderate to high quality studies. A total of 1 076 patients were enrolled, with 539 in the conservative oxygen therapy group and 537 in the conventional oxygen therapy group. Compared with conventional oxygen therapy group, short-term mortality [odds ratio (OR) = 0.66, 95% confidence interval (95%CI) = 0.50-0.87, P = 0.003] and the incidence of new organ dysfunction in ICU (OR = 0.64, 95%CI = 0.41-0.99, P = 0.04) were significantly decreased in conservative oxygen therapy group, duration of mechanical ventilation was significantly prolonged [standardized mean difference (SMD) = 17.17, 95%CI = 7.14-27.21, P = 0.000 8]. But there was no significantly difference in 90-day mortality (OR = 0.83, 95%CI = 0.59-1.17, P = 0.28), new infection rate in ICU (OR = 0.90, 95%CI = 0.66-1.21, P = 0.47), the length of ICU stay (SMD = -0.22, 95%CI = -1.02-0.59, P = 0.60) and total hospitalization time (SMD = 1.44, 95%CI = -1.43-4.31, P = 0.32) between the two groups. Compared with conventional oxygen therapy, conservative oxygen therapy can reduce short-term mortality and the incidence of organ dysfunction in critically ill patients, but cannot decrease the length of ICU stay and total hospitalization time.

Clinical Treatment Efficacy of Percutaneous Coronary Intervention Therapy on Acute Myocardial Infarction Complicated with Multiple Organ Dysfunction Syndrome

Objective: This study aims to evaluate the clinical efficacy of the percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) complicated by multiple organ dysfunction syndrome (MODS). Methods: 216 patients with AMI complicated by MODS hospitalized in the Department of Cardiology of our hospital from January 2011 to March 2013 were divided into a PCI group (n=98) and a drug treatment group (n=118). The basic clinical data, the incidence rate of each dysfunction organ, the number of dysfunction organs and the mortality were compared between the two groups. Results: The rate of patients with ST-segment elevation AMI in the PCI group was higher than in the drug treatment group, and the rate of patients with non-ST-segment elevation AMI was lower than in the drug treatment group (P 0.05). The recanalization rate in PCI group was much higher than that in the drug treatment group (P<0.05). The two groups had similar rates in the incidence of organ dysfunction in the heart, lungs, kidneys, stomach and intestine, etc. and the PCI group had lower organ dysfunction incidence rate in the liver, brain and hematological system than the drug treatment group (P<0.05). The dysfunction incidence rate of 2 organs was higher in PCI group than in drug treatment group (P<0.05), the dysfunction incidence rate of 3 organs was similar between the two groups, and the dysfunction incidence rate of 3 organs or more was significantly lower in PCI group than in drug treatment group (P<0.05). Conclusion: Despite the high risk and high mortality in the patients with AMI complicated by MODS, satisfactory clinical efficacy can still be achieved as long as positive and effective PCI therapy is applied.

Therapeutic effects of percutaneous coronary intervention on acute myocardial infarction complicated with multiple organ dysfunction syndrome.

Objective:To evaluate the clinical efficacy of percutaneous coronary intervention (PCI) on patients with acute myocardial infarction (AMI) complicated with multiple organ dysfunction syndrome (MODS).Methods:A total of 216 patients with AMI complicated with MODS enrolled from January 2016 to March 2018 were divided into a PCI group (n=98) and a drug treatment group (n=118). The baseline clinical data, the incidence of each dysfunction organ, the number of dysfunctional organs and the mortality were compared between the two groups.Results:The number of patients with ST-segment elevation AMI in the PCI group was higher than in the drug treatment group, and the rate of patients with non-ST-segment elevation AMI was lower than in the drug treatment group (P<0.05). The use of temporary pacemakers and IABP was similar between the two groups (P>0.05). The recanalization rate in PCI group was much higher than that in the drug treatment group (P<0.05). The two groups had similar incidence of organ dysfunction in the heart, lungs, kidneys, stomach and intestine, etc. and the PCI group had lower organ dysfunction incidence in the liver, brain and hematological system than the drug treatment group (P<0.05). The dysfunction incidence rate of two organs was higher in PCI group than in drug treatment group (P<0.05), the dysfunction incidence rate of 3 organs was similar between the two groups, and the dysfunction incidence rate of three organs or more was significantly lower in PCI group than in drug treatment group (P<0.05).Conclusion:Despite the high risk and high mortality of patients with AMI plus MODS, clinical improvement can still be achieved when effective PCI is performed.

The Adverse Consequences of Initial Watchful Waiting for Patients With Follicular Lymphoma

BackgroundPatients with low tumor burden follicular lymphoma (FL) are commonly managed with watchful waiting (WW). The incidence of organ dysfunction and/or transformation at disease progression, and subsequent impact on outcomes is poorly understood. Patients and MethodsPatients managed with WW during 1994 to 2011 were identified through the Alberta Lymphoma Database. Individuals receiving immediate rituximab (R)-chemotherapy were identified as a comparator group to those on WW who received R-chemotherapy at progression. Endpoints included transformation, organ dysfunction, time to progression, time to next treatment, progression-free survival (PFS) after chemotherapy, and overall survival (OS). ResultsWe identified 238 patients managed with WW (28.9% of registry patients) during this 17-year period. The median follow up was 8.2 years. At a median of 29.9 months, 58 (24.4%) of these patients developed organ dysfunction and/or transformation. Of 169 (71%) patients who required therapy, 10-year OS was inferior for those with transformation (hazard ratio, 2.88; P = .002) and organ dysfunction (hazard ratio, 2.10; P = .028). PFS after R-chemotherapy and OS in patients without organ dysfunction and/or transformation was not affected by the initial WW period, compared with immediate R-chemotherapy. WW resulted in increased high risk FL International Prognostic Index scores at initiation of R-chemotherapy (45% vs. 20%), and more frequent transformation at progression (5-year risk, 17.8% vs. 3.5%; P < .001). Baseline characteristics did not predict organ dysfunction. ConclusionPatients with FL accepting initial WW should be aware of the 1 in 4 risk of organ dysfunction and/or transformation, and subsequent inferior OS. Physicians should consider surveillance for progression to consider early therapy.

Analyzing intra-abdominal pressures and outcomes in patients undergoing laparotomy

Background: Despite the abundance of knowledge, IAH still remains strangely under-diagnosed. A national postal questionnaire in United Kingdom reported that despite widespread awareness of IAH and the ACS, many intensive care units never measure the IAP. The aim was to evaluate the effects of intra-abdominal hypertension and to assess whether intra-abdominal pressure is a predictor of morbidity and mortality in patients undergoing laparotomy. Methods: This was a prospective observational study conducted in Department of General Surgery, Kamineni Hospitals, L. B. Nagar, Hyderabad, India on patients undergoing emergency and elective laparotomy, over a period of 2 years from October 2012 to October 2014. The study included 51 patients who underwent laparotomy. IAP was measured preoperatively and then post-operatively at 0, 6, 24, 48 and 72 hours. If IAP remained below 12 mmHg, measurement was discontinued after 24 hours. Duration of ICU and hospital stay, occurrence of burst abdomen, new organ function damage, need for ventilatory support and mortality in patients undergoing laparotomy were noted as outcomes. Results: At admission, an overall 65% incidence of intra-abdominal hypertension (IAH) was observed. In this group of 33 patients, CVS dysfunction was seen in 11 patients (33.3%), Respiratory dysfunction was seen in 9 patients (27.2%) and renal dysfunction was seen in 11 patients (33.3%). At 24 hours improvement was seen in all organ dysfunctions. Number of patients with CVS, respiratory and renal dysfunction in this group of 33 patients at 24 hours was 5 (15%), 4 (12%) and 6 (18%) respectively. This signifies that along with decrease in incidence of IAH, there is concomitant decrease in incidence of organ dysfunctions and morbidity. Conclusions: Raised intra-abdominal pressure (IAP) is associated with higher morbidity and mortality in patients undergoing laparotomy. Intra-abdominal hypertension (IAH) has detrimental effect on various organ systems and decompression leads to improvement in all the parameters.

The incidences of organ dysfunction in the early resuscitation of severe sepsis and septic shock patients:a retrospective analysis

To investigate the potential risk factors of organ dysfunction and mortality in the early resuscitation of severe sepsis and septic shock patients. Data were retrospectively analyzed from patients with severe sepsis and septic shock receiving non-cardiac operation and admitted to Department of Critical Care Medicine of the Second Affiliated Hospital of Kunming Medical University from January 1st,2013 to December 31st,2015.The patients were divided into the senior group (≥ 65 years old) and the younger group (＜ 65 years old),the high-procalcitonin (PCT) group (PCT ＞ 100 μg/L) and the control group (PCT ≤ 100 μg/L).The stage of early resuscitation was set to the first 6 hours. The diagnostic time and the incidence of acute respiratory distress syndrome (ARDS),acute kidney injury (AKI),and cardiac insufficiency were observed, which also included the usage of continuous renal replacement therapy (CRRT).The total fluid volume and the time of vasopressor usage during the first 6 hours of early goal-directed therapy (EGDT) were also recorded, which aslo included the 28-day mortality. 512 patients with severe sepsis and septic shock receiving non-cardiac operation were treated according to the guidelines of "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock:2012".EGDT was used during the early resuscitation. The incidence of ARDS, AKI, and cardiac insufficiency was 80.9％ (414/512),71.3％ (365/512),and 61.9％ (317/512) respectively. There were 205 senior patients and 307 younger, as well as 154in high-PCT group and 358 in control group. The 28-day mortality was 30.3％ (155 died).90.8％ of patients (376/414)combined with ARDS were diagnosed before EGDT.95.1％ of patients (347/365) combined with AKI were diagnosed before EGDT, among whom 14.0％ (51/365) were treated with CRRT.153 senior patients combined with cardiac insufficiency were diagnosed no longer than 12 hours after EGDT. Compared with the younger group, the incidences of ARDS and cardiac insufficiency were higher in the senior group [85.9％ (176/205) vs.77.5％ (238/307),82.9％(170/205) vs.32.9％ (147/307),both P ＜ 0.05],so were the time of vasopressor usage during EGDT (hours:5.81 ±0.28vs.5.68 ± 0.52,P ＜ 0.05) was prolonged markedly and the 28-day mortality [42.9％ (88/205) vs.21.8％ (67/307),P ＜0.05] was increased significantly. But the incidence of AKI and the total fluid volume during EGDT were not significantly different between the senior group and the younger group [incidence of AKI:74.1％ (152/205) vs.69.4％ (213/307),total fluid volume (mL):2 769 ± 1 589 vs.2 804± 1 611,both P ＞ 0.05].Compared with the control group, the incidence of ARDS was higher in the high-PCT group [86.4％ (133/154) vs.78.5％ (281/358),P ＜ 0.05].But the incidences of AKI and cardiac insufficiency were not significantly differentiated between the high-PCT group and the control group [77.9％ (120/154) vs.68.4％ (245/358),58.4％ (90/154) vs.63.4％ (227/358),both P ＞ 0.05].Multiple logistic regression analysis showed that the risk factors of increase in mortality in patients with severe sepsis and septic shock included old age [odds ratio (OR) =1.782,95％ confidence interval (95％CI) =1.173-2.708,P =0.007],ARDS (OR =1.786,95％CI =1.028-3.102,P =0.040),AKI (OR =1.878,95％CI =1.145-3.079,P =0.012),and cardiac insufficiency (OR =4.177,95％CI =2.505-6.966,P =0.000),except for gender (OR =1.112,95％CI =0.736-1.680,P =0.614). In the senior postoperative patients with severe sepsis or septic shock, the incidence of ARDS and cardiac insufficiency, and the mortality were increased. The incidence of ARDS was correlated to the severity of infection.Old age, surgery, and EGDT could be the potential risk factors of cardiac insufficiency.

Myocardial Ischemia Induces SDF-1α Release in Cardiac Surgery Patients.

In the present observational study, we measured serum levels of the chemokine stromal cell-derived factor-1α (SDF-1α) in 100 patients undergoing cardiac surgery with cardiopulmonary bypass at seven distinct time points including preoperative values, myocardial ischemia, reperfusion, and the postoperative course. Myocardial ischemia triggered a marked increase of SDF-1α serum levels whereas cardiac reperfusion had no significant influence. Perioperative SDF-1α serum levels were influenced by patients' characteristics (e.g., age, gender, aspirin intake). In an explorative analysis, we observed an inverse association between SDF-1α serum levels and the incidence of organ dysfunction. In conclusion, time of myocardial ischemia was identified as the key stimulus for a significant upregulation of SDF-1α, indicating its role as a marker of myocardial injury. The inverse association between SDF-1α levels and organ dysfunction association encourages further studies to evaluate its organoprotective properties in cardiac surgery patients.

STATA- Strategy of Transfusion in Trauma Patients: A Randomized Trial

Background: Trauma is a leading cause of death worldwide and massive bleeding is the main cause of death in the first 24 hours after injury. Patients with large blood volume loss should undergo the massive transfusion protocol to quickly restore the blood volume and the clotting factors that were lost during bleeding. There are two common strategies regarding transfusion therapy for multiple trauma patients with severe bleeding. The fixed ratio strategy is based on the proportional transfusion of packed red blood cells, fresh frozen plasma and platelets (fixed ratio 1:1:1). The thromboelastometry guide approach is based on the physiopathology of the trauma coagulopathy is a phenomenon that occurs in the early stages of trauma, with hyperfibrinolysis and fibrinogen consumption. Blood products are given based on viscoelastic tests. Methods/design: This study is a prospective, single-center, open-label, randomized trial. Males and females between 18 and 80 years old, with severe trauma and a high Injury Severity Score (ISS- greater or equal than 15) admitted to trauma emergency room are included. To be included, patients require is bleeding actively, with inclusion criteria’s to massive transfusion protocol. Patients are randomly allocated to one of the two strategies for massive transfusion (Group A- fixed ratio 1:1:1 or group B- thromboelastometry guided). The primary outcome is the incidence of organ dysfunction on the first, 5th, and 7th day until 28 days post. The secondary outcome are the consumption of blood products within 48 hours, the length of stay in the hospital, days without mechanical ventilation and the financial costs in both groups. Discussion: This trial was proposed to answer questions about the outcomes related to these two strategies of transfusion. This study is important because there is a lack of prospective studies with the subject proposed. Trial registration: Clinical Trial NCT02416817

Abstract 16602: The Clinical Significance of Mif, Mif-2 and Mif Genotype in Patients Exhibited to Myocardial Ischemia/reperfusion Injury

Background: Cardiac surgery is increasingly been performed on an aging patient population with increased numbers of comorbid conditions. These patients are frequently exposed to myocardial ischemia/reperfusion with deleterious consequences and development of organ dysfunctions. The pleiotropic cytokine macrophage migration inhibitory factor (MIF) is an upstream regulator of the immune response and rapidly released from pre-formed cytoplasmatic pools in response to activating stimuli such as hypoxia, infection or inflammation. Yet, its interaction with related mediators such as its homolog, D-dopachrome tautomerase (MIF-2) is largely unknown. Therefore, we aimed to investigate the interaction and clinical significance of MIF and MIF-2 in patients undergoing cardiac surgery with myocardial ischemia/reperfusion. Methods and Results: Circulating levels of MIF and MIF-2 were measured peri-operatively in 100 patients that underwent elective cardiac surgery and showed a rapid increase upon myocardial ischemia. Intra-operative MIF levels reached maximum during myocardial reperfusion and were independently associated with a reduced risk for the development of AF in the post-operative period (odds ratio 0.99 (0.98-1.00); p=0.007), whereas circulating levels of MIF-2 were associated with an increased frequency of organ dysfunction and predicted the occurrence of atrial fibrillation (area under the curve (AUC)=0.663;p=0.041) and pneumonia (AUC=0.708;p=0.040). Known functional MIF allelic variants were analyzed and patients with high-expression MIF-genotype exhibited reduced incidence of organ dysfunction (3 vs. 25; p=0.042). Conclusion: Our findings present the first description of the kinetics and potential clinical relevance of the MIF, MIF-2 and MIF genotype in myocardial ischemia/reperfusion (I/R) in the setting of cardiac surgery. The present study demonstrated that increased intra-operative MIF levels may provide organoprotective effects, whereas elevated serum levels of MIF-2 were associated with the development of organ dysfunctions in patients after cardiac surgery. Patients with a high-expression MIF genotype experienced a significantly lower incidence of organ dysfunctions.

The prognostic and risk-stratified value of heart-type fatty acid–binding protein in septic patients in the emergency department

PurposeTo evaluate the prognostic and risk-stratified ability of heart-type fatty acid–binding protein (H-FABP) in septic patients in the emergency department (ED). Materials and MethodsFrom August to November 2012, 295 consecutive septic patients were enrolled. Circulating H-FABP was measured. The predictive value of H-FABP for 28-day mortality, organ dysfunction on ED arrival, and requirement for mechanical ventilation or a vasopressor within 6 hours after ED arrival was assessed by the receiver operating characteristic curve and logistic regression and was compared with Acute Physiology and Chronic Health Evaluation (APACHE) II score, Mortality in Emergency Department Sepsis (MEDS) score, and Sequential Organ Failure Assessment score. ResultsThe 28-day mortality, APACHE II, MEDS, and Sequential Organ Failure Assessment scores were much higher in H-FABP–positive patients. The incidence of organ dysfunction at ED arrival and requirement for mechanical ventilation or a vasopressor within 6 hours after ED arrival was higher in H-FABP–positive patients. Heart-type fatty acid–binding protein was an independent predictor of 28-day mortality and organ dysfunction. The area under the receiver operating characteristic curve for H-FABP predicting 28-day mortality and organ dysfunction was 0.784 and 0.755, respectively. Combination of H-FABP and MEDS improved the performance of MEDS in predicting organ dysfunction, and the difference of AUC was statistically significant (P < .05). The combinations of H-FABP and MEDS or H-FABP and APACHE II also improved the prognostic value of MEDS and APACHE II, but the areas under the curve were not statistically different. ConclusionsHeart-type fatty acid–binding protein was helpful for prognosis and risk stratification of septic patients in the ED.

Oral Feeding in Necrotizing Pancreatitis

Background: Restoration of gastrointestinal function is a crucial determinant of favorable outcome in severe acute pancreatitis (SAP). The purpose of this study was to retrospectively review our experience with early oral feeding in patients with the necrotizing form of SAP. Over the last 10 years, we have routinely gradually increased oral feeds in order to restore gastrointestinal function.Methods: Early low volume oral (ELVO) feeds containing 248–330 kcal/daily were routinely provided for all patients to help stimulate gastrointestinal function. Patients who received ELVO feeding within 72 hours of admission were allocated to Group I; those who received ELVO feeds after 72 hours were allocated to Group II. The volume and calories of the feed, magnitude of systemic inflammation, levels of C-reactive protein (CRP) and lipase, incidence of organ dysfunction, main outcomes, and complications were analyzed.Results: In total, 129 patients received ELVO feedings. The mean CRP level on day 7 was 160 ± 77.6 mg/l in Group I compared to 200.2 ± 103.2 mg/l in Group II, p = 0.043. Normalization of CRP below 100 mg/l was observed on day 14 in both groups. The rate of infection and the need for surgical intervention (46.8% vs. 26%) were significantly higher in Group II (p = 0.026). Group II also had longer ICU/hospital stays (p = 0.039/p = 0.002). Overall mortality was 10%. Conclusions: ELVO feeding provides physiologic stimulation and promotes recovery of bowel function, preparing the gastrointestinal tract for low-fat hospital food in patients with necrotizing SAP. The majority of patients required no additional nutritional support.

Evaluation of hemostatic biomarker abnormalities that precede platelet count decline in critically ill patients with sepsis

PurposeThe hemostatic biomarkers for early diagnosis of sepsis-associated coagulopathy have not been identified. The purpose of this study was to evaluate hemostatic biomarker abnormalities preceding a decrease in platelet count, which is a surrogate indicator of overt coagulopathy in sepsis. Materials and MethodsSeventy-five septic patients with a platelet count more than 80 × 103/μL were retrospectively analyzed. Hemostatic biomarkers at intensive care unit admission were compared between patients with and patients without a subsequent decrease in platelet count (≥30% within 5 days), and the ability of biomarkers to predict a decrease in platelet count was evaluated. ResultsForty-two patients (56.0%) developed a subsequent decrease in platelet count. Severity of illness, incidence of organ dysfunction, and 28-day mortality rate were higher in patients with a subsequent decrease in platelet count. There were significant differences between patients with and patients without a subsequent decrease in platelet count in prothrombin time–international normalized ratio, fibrinogen, thrombin-antithrombin complex, antithrombin, protein C (PC), plasminogen, and α2-plasmin inhibitor (α2-PI). Receiver operating characteristic curve analysis showed that PC (area under the curve, 0.869; 95% confidence interval, 0.699-0.951) and α2-PI (area under the curve, 0.885; 95% confidence interval, 0.714-0.959) were strong predictors of a subsequent decrease in platelet count. ConclusionsDecreased PC and α2-PI activity preceded a decrease in platelet count in intensive care unit patients with sepsis.