Mean Sequential Organ Failure Assessment Research Articles

Epidemiology and outcome of acute kidney injury in patients presenting to emergency department – Our experience

Background: Compared to the developed world, the pattern of acute kidney injury (AKI) is different in tropics. The present study was undertaken to study the epidemiological profile and outcomes in AKI. Methods: This prospective observational study was conducted in a tertiary care teaching hospital in South India. Demographic details, detailed medical history, aetiological factors, comorbid conditions, prognostic factors and outcomes were studied. Acute physiology and chronic health evaluation II (APACHE II) and sequential organ failure assessment (SOFA) scores were calculated at admission for every patient to know the prognosis. Results: A total of 193 patients who fulfilled the inclusion criteria were enrolled in the study. Majority of the patients were in their sixth decade of life. The mean age was 52.1 ± 14.8 years (male:female = 1.7:1). Hypertension (41.5%; n = 80) and diabetes mellitus (33.7%; n = 65) were the most common comorbid illnesses in our patients. The average duration of hospital stay was 8 days. AKI was secondary to medical causes in 69.4% (134/193), surgical causes in 25.4% (49/193) and obstetric is 5.18% (10/193). Renal replacement therapy was required in 56.4% (n = 109) of the study population. The mortality rate observed in our study was 21.8% (n = 42). The mean APACHE II score and mean SOFA score were found to be significantly higher in the non survivors compared to the survivors. Conclusions: Patients with AKI who have higher APACHE II or SOFA score should be carefully monitored and aggressively treated to reduce mortality.

Relation between central venous pressure values and outcome in critically ill patients

Background Central venous pressure (CVP) was the most commonly used parameter to guide fluid responsiveness. However, recent studies showed that there is no correlation between CVP and circulating blood volume, and CVP more than 8 mmHg is independently associated with a higher mortality and increased risk of acute kidney injury in patients with sepsis and heart failure. Objective The aim of this study was to assess the effect of CVP over 7 days after ICU admission on clinical prognosis and mortality. Patients and methods The study was conducted on 218 patients in whom hemodynamic monitoring was required, and CVP was measured from the first day of ICU admission. Three values of CVP were selected to be measured (the values once inserted, the peak values, and the mean values of CVP) throughout the monitoring process over 7 days of ICU admission. Acute Physiology and Chronic Health Evaluation II score was calculated on admission, and Sequential Organ Failure Assessment (SOFA) score was calculated every other day. Length of ICU stay, mechanical ventilation days, and mortality at days 7 and 28 were recorded. Results Although the initial CVP values were only correlated with mean of SOFA scores, mean and peak CVP values were correlated with Acute Physiology and Chronic Health Evaluation II score, mean SOFA score, mechanical ventilation days, and mortality. Only peak CVP showed correlation with mean creatinine, and only mean CVP values were correlated with length of ICU stay. According to mean CVP values, patients were classified as low CVP ( 12 mmHg). The elevated mean CVP group was associated with increased 28-day mortality, and regarding further investigations such as renal function, duration of mechanical ventilation, and laboratory results related to organ dysfunction, it also demonstrated that higher mean CVP group was associated with poor ICU outcome for patients in ICU settings. Conclusion The study showed that for patients in ICU settings, elevated mean CVP load was associated with poor clinical outcome and prolonged treatment in ICU. Level and duration of elevated mean CVP should be evaluated, and more effort should be made to establish the cause and appropriate treatment for elevated mean CVP.

The early change of SOFA score as a prognostic marker of 28-day sepsis mortality: analysis through a derivation and a validation cohort

BackgroundSince the Sepsis-3 criteria, change in Sequential Organ Failure Assessment (SOFA) score has become a key component of sepsis identification. Thus, it could be argued that reversal of this change (ΔSOFA) may reflect sepsis response and could be used as measure of efficacy in interventional trials. We aimed to assess the predictive performance of ΔSOFA for 28-day mortality.MethodsData from two previously published randomized controlled trials were studied: the first reporting on patients with severe Gram-negative infections as a derivation cohort and the second reporting on patients with ventilator-associated pneumonia as a validation cohort. Only patients with sepsis according to the Sepsis-3 definition were included in this analysis. SOFA scores were calculated on days 1, 2, 3, 5, 7, 14, and 28.ResultsWe included 448 patients within the derivation cohort and 199 within the validation cohort. Mean SOFA scores on day 1 were 6.06 ± 4.07 and 7.84 ± 3.39, and 28 day mortality 22.8% and 29.6%, respectively. In the derivation cohort, the earliest time point where ΔSOFA score predicted mortality was day 7 (AUROC (95% CI) 0.84 (0.80–0.89); p < 0.001). The best tradeoff for prediction was found with 25% changes (78% sensitivity, 80% specificity); less than 25% decrease of admission SOFA was associated with increased mortality (odds ratio for death 14.87). This finding was confirmed in the validation cohort.ConclusionsΔSOFA on day 7 is a useful early prognostic marker of 28-day mortality and could serve as an endpoint in future sepsis trials alongside mortality.Trial registrationClinicalTrials.gov numbers NCT01223690 and NCT00297674

Ultrasound Assessment of Diaphragmatic Motion in Subjects With ARDS During Transpulmonary Pressure-Guided PEEP Titration.

We aimed to investigate the effects of incremental PEEP titration in patients with ARDS on regional diaphragmatic motion with bedside ultrasound. Dorsal diaphragmatic excursion (DDE) and ventral diaphragmatic excursion (VDE) were measured using anatomic M-mode ultrasonography of the right hemidiaphragm as PEEP was randomized to -6, -3, +3, and +6 cm H2O from baseline to achieve a positive transpulmonary pressure. Inter-operator variability of DDE was assessed in 10 separate subjects. A total of 14 subjects ventilated for ARDS were enrolled. Subjects had a mean age of 54 ± 12 y, mean PaO2 /FIO2 = 137 ± 54 mm Hg, and mean sequential organ failure assessment (SOFA) score = 14 ± 1). Transpulmonary pressure, DDE, and DDE/VDE ratio increased with incremental PEEP titration (-1.15 cm H2O vs 3.63 cm H2O, P < .001; 4.9 mm vs 8.2 mm, P < .001; and 62% vs 93%, P < .001, respectively). When transpulmonary pressure became positive, a visual increase in DDE and DDE/VDE ratio 0.60 to 0.93 was observed (from 0.48 cm to 0.82 cm, R2 = 0.87, P = .02; and R2 = 0.93, P = .006, respectively). There was high agreement in DDE measurements between 2 ultrasonographers (intra-class correlation 0.987, P < .001). DDE was affected by incremental PEEP titration toward a positive transpulmonary pressure. The ultrasound assessment using anatomic M-mode allowed for specific measurement of regional diaphragmatic excursion. This pattern of motion in the dependent regions of the diaphragm during PEEP titration in subjects with ARDS achieving a positive transpulmonary pressure may reflect a potential target for future studies in the bedside assessment for lung recruitment. (Clinical Trials.gov registration NCT02463773.).

The Epidemiology, Therapeutic Patterns, Outcome, and Challenges in Managing Septic Shock in a Sub-Saharan African Intensive Care Unit: A CrossSectional Study

Background: Septic shock (SS) is a health priority in sub-Saharan Africa. However, there is a dearth of data in this regard. Objective: This study aimed to determine the epidemiology, therapeutic patterns, outcome, and challenges in managing SS in a tertiary intensive care unit (ICU) of sub-Saharan Africa. Methods: The hospital files of 36 consecutive patients admitted to the ICU of the Douala General Hospital (DGH), Cameroon over the year 2018 were reviewed for SS. SS was diagnosed based on Sepsis-3 definition. Demographic and clinical characteristics, treatment details, and outcomes of patients with SS were reviewed. Data was analyzed using the chi-square or Fisher exact tests and Bonferroni correction. Results: SS accounted for 36 (9.4%) ICU admissions. The majority of patients were males (63.9%). The most common site of infection was the lungs. The mean age, average mean arterial pressure (MAP), and mean sequential organ failure assessment (SOFA) score of patients were 52.9±25.2 years, 52±18 mm Hg, and 9.2 ±2.3, respectively. Noradrenaline was the sole vasopressor used. Therapeutic challenges included the inability to have a specific antibiogram before a mean duration of 7 days. The mortality rate was 39% and associated with age ≤1 year, MAP ≤ 65 mm Hg, Glasgow Coma Score (GCS) ≤8, and mechanical ventilation, which were not attenuated after Bonferroni correction. Conclusion: SS is a frequent cause of ICU admission and is associated with a high mortality rate. SS mortality-related factors can be screened during SS management for more aggressive ICU management geared at preventing death.

ASSOCIATION OF MULTI-MORBIDITIES WITH SEPSIS IN ADULT PATIENTS ADMITTED IN A TERTIARY CARE HOSPITAL, KARACHI

Background: Multi-morbid chronic diseases are increasingly placing a greater burden on individuals, communities and health care services. With advancing medical facilities, a growing proportion of the population is surviving longer with multiple chronic diseases. Sepsis is a life threatening infection with multiple organ dysfunctions leading to very high morbidity and mortality. Treating patients with multi-morbidities have always been more difficult when compared to patients with no co-morbid conditions. Hence, data from this study will empower us in exhibiting effective plans in the management of multi-morbidities with sepsis in our region. The study is aimed to determine the association of multi-morbidities with sepsis in adult patients admitted in a tertiary care hospital. Methods: This is a case-control study conducted in the Medicine Wards and Intensive Care Unit of a tertiary care hospital in Karachi during the period of May 2018 to October 2018. Results: In this study, 52 patients were enrolled. The mean age of patients was 59.35 ± 6.17. Socioeconomic Status showed significant association (p-value 0.034). The mean Sequential Organ Failure Assessment (SOFA) Score was 2.13 ± 1.86. The odds ratio of having cancer [OR: 3.10 (0.10 – 80.1), p-value 0.50] and other multimorbidities like rheumatoid arthritis [OR: 3.30 (0.30 – 33.6), p-value 0.32] in cases of sepsis respectively were more than in controls but the data was not statistically significant. The mean length of hospital stay was 4.71 ± 2.08. Conclusion: Despite our study limitations, a strong association of socioeconomic status with cases and controls in admitted patients was seen and among them, the upper income groups were the most. Although, an association of cancers and multimorbidities like rheumatoid arthritis with cases and controls has been identified, it requires to be researched further. Consensus regarding the definition of multimorbidity should be made.

In-Hospital Post-Operative Infection after Heart Transplantation: Epidemiology, Clinical Management, and Outcome.

Background: Infection is a major cause of morbidity and mortality after heart transplantation (HT). Little information about its importance in the immediate post-operative period is available. The aim of this study was to analyze the characteristics, incidence, and outcomes of in-hospital post-operative infections after HT. Methods: We conducted an observational, single-center study based on 677 adults who underwent HT from 1991 to 2015 and who survived the surgical intervention. In-hospital post-operative infections were identified retrospectively according to the medical finding in the clinical records. Results: Over a mean hospital stay of 24.5 days, 239 patients (35.3%) developed 348 episodes of infection (2 episodes per 100 patient-days). The most common sources of infection were those related to invasive procedures (respiratory infections, 115 [33%]; urinary tract infections, 47 [13.5%]; bacteremia, 42 [12.1%]; surgical site infections, 25 [7.2%]), in addition to abdominal focus (33, 9.5%). Enterobacteriaceae (76, 21.8%) and gram-positive cocci (58, 16.7%) were the predominant germs, although opportunistic infections were not infrequent (69, 19.8%). Ninety-five septic episodes were detected with a mean Sequential Organ Failure Assessment Score of 9.5 ± 5.3 points, with hemodynamic failure being the most severe organ dysfunction and renal dysfunction the most frequent one. Management included broad-spectrum antibiotics in 48.8% of episodes and surgical management in 13.8%. The overall antimicrobial success rate was 96.3%. Higher in-hospital mortality was observed among infected patients (15.1% vs. 10.3%), but this difference was not statistically significant (p = 0.067). The one-year survival and events were not different between patients suffering from a post-operative infection and those who did not. Conclusions: In-hospital infections were frequent in the post-operative period after HT and were associated with a poor short-term outcome. Patients who survived sepsis had a similar one-year morbidity and mortality compared with patients who did not develop an infection.

Effects of a High Dose of Vitamin C along with Thiamine in Critically-ill Patients with Septic Shock: A Preliminary Study

Septic shock may occur in critically ill patients and despite antimicrobial treatment, it is associated with a high mortality rate. It is reasonable to look for new treatment modalities that might improve outcome. This is a randomized, double-blind control trial aiming at critically-ill septic patients in a tertiary hospital. Patients with quick sofa score of 2 and with organ dysfunction were included in this study. The intervention group received high doses of vitamin C at a dose of 50 mg/kg/four times daily along with thiamine at a dose of 200 mg/ twice daily) and the control group received normal saline for four days. The dose of vasopressors, procalcitonin and lactate clearance, and mean sequential organ failure assessment (SOFA) score were examined in the two groups. Patients were followed for 28 days. One hundred patients were allocated into two equal groups, and there was no difference between the two groups regarding baseline characteristics. Mean lactate concentration, SOFA score, days of antimicrobial therapy, and mortality at 28 days were similar between them. However, the mean procalcitonin concentration, and mean vasopressor treatment hours were significantly lower in the intervention group (p&lt;0.05). Although Days of ICU stay were lower in the intervention group, It did not reach statistical significance. The results of this study showed that treatment with high dose vitamin C Reduces the vasopressor requirement without any effects on other parameters. Further studies with larger sample size are required for more generalizable results.

Clinical epidemiology and mortality on patients with acute respiratory distress syndrome (ARDS) in Vietnam.

BackgroundThe clinical epidemiology and disease prognosis in patients with acute respiratory distress syndrome (ARDS) have not yet been fully elucidated in Vietnam.MethodsWe conducted a retrospective observational study at a national tertiary hospital in Hanoi, Vietnam. Participants were adult patients (age ≥18 years) who were admitted and diagnosed with ARDS during 2015–2017. Data on patients’ general and clinical conditions, radiographic findings, ventilator settings, gas exchange, and treatment methods were collected and compared between survivors and non-survivors. Risk factors for mortality were assessed using logistic regression analysis.ResultsAmong 126 eligible patients with ARDS admitted to the central tertiary hospital in Vietnam, we observed high mortality (57.1%). Of the total patients, 91.3% were transferred from local hospitals with a diagnosis of severe pneumonia and then diagnosed with ARDS at the central hospital. At the time of admission, 53.2% of patients had severe ARDS, 37.3% had moderate ARDS, and 9.5% had mild ARDS. The mean (standard deviation) sequential organ failure assessment (SOFA) score was 9.5 (3.4) in non-survivors and 7.4 (3.4) in survivors (p = 0.002). Although there was no significant difference in PaO2/FiO2 on admission between non-survivors and survivors, that on day 3 after admission was significantly different (p = 0.002). Logistic regression revealed that PaO2/FiO2 on day 3 [odds ratio (OR), 1.010; 95% confidence interval (CI), 1.003–1.017], length of stay in a local hospital before admission to the central hospital (OR, 1.122; 95% CI, 1.042–1.210) due to stable condition, and SOFA score on Day 1 (OR, 0.842; 95% CI, 0.708–1.002) were independent factors in patient survival.ConclusionsPatients with ARDS admitted the central tertiary hospital had severe illness and high mortality. Most patients were transferred from local hospitals. Improvements in human, medical, and sociological resources in local will contribute to reducing the mortality of ARDS in Vietnam.

Long-term Host Immune Response Trajectories Among Hospitalized Patients With Sepsis

Long-term immune sequelae after sepsis are poorly understood. To assess whether abnormalities in the host immune response during hospitalization for sepsis persist after discharge. This prospective, multicenter cohort study enrolled and followed up for 1 year adults who survived a hospitalization for sepsis from January 10, 2012, to May 25, 2017, at 12 US hospitals. Circulating levels of inflammation (interleukin 6 and high-sensitivity C-reactive protein [hs-CRP]), immunosuppression (soluble programmed death ligand 1 [sPD-L1]), hemostasis (plasminogen activator inhibitor 1 and D-dimer), endothelial dysfunction (E-selectin, intercellular adhesion molecule 1, and vascular cell adhesion molecule 1), and oxidative stress biomarkers were measured at 5 time points during and after hospitalization for sepsis for 1 year. Individual biomarker trajectories and patterns of trajectories across biomarkers (phenotypes) were identified. Outcomes were adjudicated centrally and included all-cause and cause-specific readmissions and mortality. A total of 483 patients (mean [SD] age, 60.5 [15.2] years; 265 [54.9%] male) who survived hospitalization for sepsis were included in the study. A total of 376 patients (77.8%) had at least 1 chronic disease, and their mean (SD) Sequential Organ Failure Assessment score was 4.2 (3.0). Readmissions were common (485 readmissions in 205 patients [42.5%]), and 43 patients (8.9%) died by 3 months, 56 patients (11.6%) died by 6 months, and 85 patients (17.6%) died by 12 months. Elevated hs-CRP levels were observed in 23 patients (25.8%) at 3 months, 26 patients (30.2%) at 6 months, and 23 patients (25.6%) at 12 months, and elevated sPD-L1 levels were observed in 45 patients (46.4%) at 3 months, 40 patients (44.9%) at 6 months, and 44 patients (49.4%) at 12 months. Two common phenotypes were identified based on hs-CRP and sPDL1 trajectories: high hs-CRP and sPDL1 levels (hyperinflammation and immunosuppression phenotype [326 of 477 (68.3%)]) and normal hs-CRP and sPDL1 levels (normal phenotype [143 of 477 (30.0%)]). These phenotypes had similar clinical characteristics and clinical course during hospitalization for sepsis. Compared with normal phenotype, those with the hyperinflammation and immunosuppression phenotype had higher 1-year mortality (odds ratio, 8.26; 95% CI, 3.45-21.69; P < .001), 6-month all-cause readmission or mortality (hazard ratio [HR], 1.53; 95% CI, 1.10-2.13; P = .01), and 6-month readmission or mortality attributable to cardiovascular disease (HR, 5.07; 95% CI, 1.18-21.84; P = .02) or cancer (HR, 5.15; 95% CI, 1.25-21.18; P = .02). These associations were adjusted for demographic characteristics, chronic diseases, illness severity, organ support, and infection site during sepsis hospitalization and were robust in sensitivity analyses. In this study, persistent elevation of inflammation and immunosuppression biomarkers occurred in two-thirds of patients who survived a hospitalization for sepsis and was associated with worse long-term outcomes.

Acinetobacter infections: a retrospective study to determine inhospital mortality rate and clinical factors associated with mortality

SummaryA retrospective case series of acinetobacter infections at a tertiary hospital in Nairobi was conducted to determine the mortality rate and factors associated with mortality. Over an eight-year period, 80 clinically significant infections were identified. The majority of infections were ventilator-associated pneumonia (40%) and bloodstream infections (30%). Eighty-six percent of the isolates were multi-drug resistant. The mortality rate in the study cohort was 45%. Twelve patients grew Acinetobacter spp. within 48 h of hospitalization, and three of these patients had no prior healthcare contact. The mean Sequential Organ Failure Assessment score was associated with mortality from acinetobacter infections.

Characteristics and outcomes of oncology unit patients requiring admission to an Australian intensive care unit.

Patients with advanced malignancies have historically been considered poor candidates for admission to the intensive care unit (ICU); however, prognosis is continually improving, and requirements for ICU access are increasing. To understand the characteristics and outcomes of oncology unit patients admitted to an Australian ICU and identify potential prognostic factors. A single-centre, retrospective, cohort study conducted at a tertiary public hospital with a quaternary ICU in Sydney, Australia. All patients admitted under the medical oncology team requiring ICU admission between June 2014 and June 2016 were evaluated. Clinical outcomes were determined including mortality, ICU requirements (ventilation, dialysis, vasopressors, infection) and prognostic scores (Acute Physiologic and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) score). There were 96 patients with mean age 61 years, 58% were male and 76% had metastatic disease. Most were receiving palliative treatment (89%), with recent chemotherapy (43%), immunotherapy (10%) and other therapies (5%). Of the 10 patients with recent immunotherapy, three (all with melanoma) required ICU admission due to immunotoxicity; 13% were admitted due to an oncological emergency. Mean APACHE II score was 17 (standard deviation (SD) 5.33), mean SOFA score was 3.99 (SD 2.70), ICU mortality was 5% and hospital mortality was 22%. Using multivariate logistic regression analysis, cancer stage, infection during ICU admission, intracranial mass effect on ICU admission and SOFA score were associated with 30-day mortality. Our patient population had good short-term survival outcomes despite most receiving palliative treatment. Cancer patients can achieve positive outcomes after ICU admission, and appropriate selection of patients is crucial.

Comparison of simplified acute physiology score iii and sequential organ failure assessment on detection prognosis of mortality in non-traumatic patients who admitted to the intensive care unit abstract

Background: There are different scoring systems to determine the mortality rate of patients to intensive care unit (ICU), the aim of this study was to compare the Simplified Acute Physiology Score (SAPS) III and Sequential Organ Failure Assessment (SOFA) tests in determining the degree of mortality in non-traumatic patients who admitted to the intensive care unit (ICU). Methods: In this retrospective cross-sectional study, mortality rate was assessed with using of SOFA and SAPS III scorings on 100 non traumatic patients who admitted to the ICU according to the inclusion and exclusion criteria. The patients were also divided into two groups based on mortality and were included survive and non-survive groups. Results: The mean SOFA score in survived and non-survived groups were 2.03 + 1.96 and 5.42 + 3.84 respectively, and for SAPS III, were 30.76 + 8.17 and 55.38 + 15.47 respectively. The SOFA and SAPS III scores in the non-survived group was significantly higher than survived group (P <0.0001 for both tests). The sensitivities, specificities, positive predictive value and negative predictive value were 79/75%, 85/71%, 95/5%, 52/9% for the SAPSII score, respectively and 91/14%, 57/14%, 88/9%, 63/2% for the SOFA Scoring system, respectively . Conclusion: SAPS III was a better prognostic score in determining of mortality.

Clinical Effects of Perioperative Selective Decontamination of the Digestive Tract (SDD) in Cardiac Surgery: A Propensity Score Matched Cohort Analysis

To determine the clinical effects of perioperative endotoxin reduction in the gut lumen in patients undergoing cardiac surgery with cardiopulmonary bypass. Retrospective cohort analysis with propensity score matching according to treatment group. Tertiary center for cardiopulmonary diseases and intensive care medicine. Included were patients who underwent cardiac surgery with cardiopulmonary bypass between 2008 and 2017. Excluded were readmitted patients. Endotoxin reduction in the gut lumen by ingestion of oral tobramycin 80 mg and polymyxin B 100 mg 4 times daily (TP) as part of selective digestive tract decontamination, which contains amphotericin B 500 mg as well. A total of 6,394 patients were included, of whom 2,044 patients were in the intervention group. A total of 835 patients received both pre- and postoperative TP (Pre+/Post+), and 1,165 patients received TP only postoperatively (Pre-/Post+). The control group, not treated with TP at any moment, consisted of 4,350 patients (Pre-/Post-). After matching, 652 Pre+/Post+ patients were compared with an equal number of controls (Pre-/Post-). Pre+/Post+ group did not do better for any clinical outcome. A total of 682 Pre+/Post+ patients matched with an equal number of Pre-/Post+ patients. The latter group had a 0.3 points higher mean Sequential Organ Failure Assessment score and in the regression analysis a significantly higher intensive care unit mortality but not hospital mortality. A significant reduction in length of stay and length of mechanical ventilation for the Pre+/Post+ group was shown compared with Pre-/Post+, but these differences can be explained by unbalanced differences in the severity of illness. Cardiosurgical patients who receive tobramycin and polymyxin orally preoperatively to reduce the gut endotoxin level do not expose convincing and relevant beneficial effects on clinical outcomes in this retrospective propensity score matching cohort study.

Effect of physostigmine on recovery from septic shock following intra-abdominal infection – Results from a randomized, double-blind, placebo-controlled, monocentric pilot trial (Anticholium® per Se)

PurposeThe cholinergic anti-inflammatory pathway has been shown to be accessible by physostigmine salicylate in animal models. However, the cholinesterase inhibitor is not approved for adjunctive therapy in sepsis, and tolerability and safety of high initial doses followed by continuous infusion have not been investigated. Materials and methodsIn this trial, 20 patients with perioperative septic shock due to intra-abdominal infection were eligible. The physostigmine group received an initial dose of 0.04 mg/kg physostigmine salicylate, followed by continuous infusion of 1 mg/h for 120 h; the placebo group was treated with 0.9% sodium chloride. Primary outcome was the mean Sequential Organ Failure Assessment (SOFA) score during treatment and up to 14 days. ResultsAdministration of physostigmine salicylate was well tolerated. Mean SOFA scores were 8.9 ± 2.5 and 11.3 ± 3.6 (mean ± SD) for physostigmine and placebo group, respectively. Adjusted for age, difference between means was not statistically significant (−2.37, 95% CI: −5.43 to 0.70, p = 0.121). Norepinephrine doses required only appeared lower in the physostigmine group (p = 0.064), along with a more rapid reduction from an elevated heart rate possibly indicating less hemodynamic instability. ConclusionsTreatment with physostigmine salicylate was feasible and safe. Further studies are justified to assess the effect on recovery from septic shock. Trial registrationEudraCT Number 2012-001650-26, ClinicalTrials.gov identifier NCT03013322.

Influence of age on the clinical efficacy of tigecycline in severely ill patients.

The aim of this study was to define the relationship between age and response to tigecycline among patients treated for complicated skin and soft-tissue infections (cSSTIs) and complicated intra-abdominal infections (cIAIs). Pooled data derived from five European observational studies on the use of tigecycline (July 2006-October 2011), either as monotherapy or in combination with other antibiotics, for the treatment of cSSTI or cIAI were used in the analysis. The total population (N=1782 patients) was divided into three age categories: <65 years (804 patients); 65-80 years (836 patients) and >80 years (139 patients) (data unknown/missing for 3 patients). The overall mean Acute Physiology and Chronic Health Evaluation (APACHE) II score for patients with cSSTI and cIAI was 15.0±7.9 and 16.9±7.6, respectively, and the overall mean Sequential Organ Failure Assessment (SOFA) score was 5.8±3.9 and 7.0±4.2, respectively. Overall, patients with cSSTI and cIAI in the three age groups showed a good response to tigecycline treatment (76.2-80.0% and 69.2-81.1%, respectively) with patients aged ≤80 years showing higher response rates. Patients with cIAI appeared to be at greater risk for all types of adverse events compared with those with cSSTI, particularly in the older age groups. In these real-life studies, tigecycline, either alone or in combination, achieved favourable clinical response rates in all age categories of patients with cSSTIs and cIAIs with a high severity of illness.

Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock

Abnormal peripheral perfusion after septic shock resuscitation has been associated with organ dysfunction and mortality. The potential role of the clinical assessment of peripheral perfusion as a target during resuscitation in early septic shock has not been established. To determine if a peripheral perfusion-targeted resuscitation during early septic shock in adults is more effective than a lactate level-targeted resuscitation for reducing mortality. Multicenter, randomized trial conducted at 28 intensive care units in 5 countries. Four-hundred twenty-four patients with septic shock were included between March 2017 and March 2018. The last date of follow-up was June 12, 2018. Patients were randomized to a step-by-step resuscitation protocol aimed at either normalizing capillary refill time (n = 212) or normalizing or decreasing lactate levels at rates greater than 20% per 2 hours (n = 212), during an 8-hour intervention period. The primary outcome was all-cause mortality at 28 days. Secondary outcomes were organ dysfunction at 72 hours after randomization, as assessed by Sequential Organ Failure Assessment (SOFA) score (range, 0 [best] to 24 [worst]); death within 90 days; mechanical ventilation-, renal replacement therapy-, and vasopressor-free days within 28 days; intensive care unit and hospital length of stay. Among 424 patients randomized (mean age, 63 years; 226 [53%] women), 416 (98%) completed the trial. By day 28, 74 patients (34.9%) in the peripheral perfusion group and 92 patients (43.4%) in the lactate group had died (hazard ratio, 0.75 [95% CI, 0.55 to 1.02]; P = .06; risk difference, -8.5% [95% CI, -18.2% to 1.2%]). Peripheral perfusion-targeted resuscitation was associated with less organ dysfunction at 72 hours (mean SOFA score, 5.6 [SD, 4.3] vs 6.6 [SD, 4.7]; mean difference, -1.00 [95% CI, -1.97 to -0.02]; P = .045). There were no significant differences in the other 6 secondary outcomes. No protocol-related serious adverse reactions were confirmed. Among patients with septic shock, a resuscitation strategy targeting normalization of capillary refill time, compared with a strategy targeting serum lactate levels, did not reduce all-cause 28-day mortality. ClinicalTrials.gov Identifier: NCT03078712.

Comparison of pressure-regulated volume control ventilation and pressure control ventilation in patients with abdominal compartment syndrome.

Mechanical ventilation support is commonly required in abdominal compartment syndrome (ACS). In the present study, pressure-regulated volume control ventilation (PRVCV) was compared to pressure control ventilation (PCV) in patients with ACS. The prospective study included 40 patients with ACS who were randomized into the PCV or PRVCV groups and subjected to the different modes of ventilation. After 6 h of ventilation, arterial blood gas, respiratory mechanics and hemodynamics parameters, as well as the intra-abdominal pressure (IAP) and Sequential Organ Failure Assessment (SOFA) scores were calculated. Compared to the PCV mode, mechanical ventilation with PRVCV lead to a significant decrease in the partial pressure of carbon dioxide, the peak inspiratory pressure, the mean inspiratory pressure, the central venous pressure, the heart rate and the extravascular lung water index. In addition, a marked improvement in pH, partial pressure of oxygen, oxygenation index and pulmonary static compliance was noted. However, no significant differences in airway resistance, mean arterial pressure, or IAP and SOFA scores were obtained. In conclusion, the PRVCV mode is better than the PCV mode in ventilation patients with ACS, and should therefore be used as a lung protective strategy. The present study was registered at Chictr.org (no. ChiCTR1800016869).

Audit of Antibiotic Practices: An Experience from a Tertiary Referral Center.

ABSTRACTAimsTo estimate the prevalence of antibiotic de-escalation at admission in patients referred to a tertiary hospital in India. The secondary outcomes were the adequacy of empirical antibiotic therapy and culture positivity rates in the de-escalated group.Materials and methodsA prospective observational study, in a 20-bedded intensive care unit (ICU) of tertiary care hospital. Patients >18 years, surviving > 48 hours, were included (June– December 2017). Demographic data, previous cultures, and antibiotics from other hospitals, laboratory parameters in the first 24 hours, and severity of illness were noted. Changes made in antibiotic therapy within 48 hours were recorded. Patients were analyzed into three groups: “No change”–empiric therapy was maintained, “Escalation”–switch to or addition of an antibiotic with a broader spectrum, and “De-escalation”–switch to or interruption of a drug class.ResultsThe total number of patients eligible was 75. The mean age of the population is 43.38 (SD + 3.4) and groups were comparable in terms of mean sequential organ failure assessment score (SOFA) and acute physiology, age, chronic health evaluation (APACHE) 2. The prevalence of de-escalation was 60% at admission. The escalation group consisted of 24%. Sixteen percent patients belonged to no change group. Results showed that 38% of patients were on carbapenems, dual gram negative was given to 26%, and empirical methicillin-resistant staphylococcus aureus (MRSA) coverage was 28% on admission.ConclusionOur study aims to provide data about actual practices in the Indian scenario. It highlights the generous use of high-end antibiotics in the community. Indian practices are far cry from theoretical teaching and western data. The need for antibiotic stewardship program in our country for both public and private health sectors is the need of the hour.How to cite this articleSingh R, Azim A, Gurjar M, Poddar B, Baronia AK. Audit of Antibiotic Practices: An Experience from a Tertiary Referral Center. Indian Journal of Critical Care Medicine, January 2019;23(1):7-10.

Babesiosis as a cause of acute respiratory distress syndrome: a series of eight cases

ABSTRACTObjectives: The characteristics of patients with Acute Respiratory Distress Syndrome (ARDS) as a complication of Babesia microti infection have not been systematically described.Methods: Adult patients admitted to the medical intensive care unit (MICU) of a tertiary care hospital in the Lower Hudson Valley of New York from 1/1/2008 to 8/1/2016 were evaluated for ARDS complicating babesiosis.Results: Of 22 patients with babesiosis in the MICU, eight (36.4%; 95% CI: 19.7–57.0%) had ARDS. Six patients (75%) developed ARDS following initiation of anti-babesia drug therapy; however, the mean duration of symptoms in these patients exceeded that of patients who developed ARDS prior to initiation of treatment (7.50 ± 3.83d vs. 4.50 ± 0.71d, p = 0.34). Three patients (37.5%; 95% CI: 13.7–69.4%) expired without recovery from ARDS. In comparison, the mortality rate for the 14 MICU babesiosis patients without ARDS was 14.3% (p = 0.31). There was a trend toward younger age in survivors relative to non-survivors (mean age 54.6 ± 13.8y vs. 74.0 ± 6.24y, p = 0.07). Three of the five survivors did not require mechanical ventilation. The mean sequential organ failure assessment score of non-survivors was significantly higher than that of survivors (12.3 ± 1.15 vs. 6.0 ± 1.4, p = 0.0006).Conclusion: Among 22 critically ill adult patients with B. microti infection, ARDS developed in eight (35.4%), and three (37.5%) expired without resolution of the ARDS. ARDS often followed the initiation of anti-babesia drug therapy, raising the question of whether the death of the parasite per se contributed to its development. However, this observation was confounded by the longer duration of symptoms preceding initiation of drug therapy.