Multiorgan Failure In Patients Research Articles

Management of alcoholic hepatitis: A clinical perspective.

Alcohol-associated liver disease is the primary cause of liver-related mortality worldwide and one of the most common indications for liver transplantation. Alcoholic hepatitis represents the most acute and severe manifestation of alcohol-associated liver disease and is characterized by a rapid onset of jaundice with progressive inflammatory liver injury, worsening of portal hypertension, and an increased risk for multiorgan failure in patients with excessive alcohol consumption. Severe alcoholic hepatitis is associated with a poor prognosis and high short-term mortality. During the COVID-19 pandemic, rates of alcohol-associated hepatitis have increased significantly, underscoring that it is a serious and growing health problem. However, adequate management of alcohol-associated hepatitis and its complications in everyday clinical practice remains a major challenge. Currently, pharmacotherapy is limited to corticosteroids, although these have only a moderate effect on reducing short-term mortality. In recent years, translational studies deciphering key mechanisms of disease development and progression have led to important advances in the understanding of the pathogenesis of alcoholic hepatitis. Emerging pathophysiology-based therapeutic approaches include anti-inflammatory agents, modifications of the gut-liver axis and intestinal dysbiosis, epigenetic modulation, antioxidants, and drugs targeting liver regeneration. Concurrently, evidence is increasing that early liver transplantation is a safe treatment option with important survival benefits in selected patients with severe alcoholic hepatitis not responding to medical treatment. This narrative review describes current pathophysiology and management concepts of alcoholic hepatitis, provides an update on emerging treatment options, and focuses on the need for holistic and patient-centred treatment approaches to improve prognosis.

Multiorgan failure in patients after out of hospital resuscitation: a retrospective single center study.

Information on extracerebral system dysfunction is important for assessing the needs of critically ill patients after cardiac arrest. To describe the prevalence of organ dysfunction and patient severity after out of hospital cardiac arrest (OHCA) using scores commonly used in intensive care and the association between these and mortality. Retrospective analysis of observational data collected in real time in a tertiary medical center where care withdrawal is mostly illegal. Adult patients after nontraumatic OHCA with ROSC who survived for more than two hours were included. Primary outcome-prevalence of organ failure, based on common definitions for organ dysfunction, in the 1days of hospitalization. Secondary outcomes-rates of survival to hospital discharge and survival with a good neurological outcome (CPC 1 or 2), and associations between organ dysfunction SOFA and APACHE-II scores and outcomes. Associations were assessed using fisher's exact test for categorical variables and Mann-Whitney and T test for continuous variables. Multivariable models were also constructed for all measurements showing associations in previous tests. For severity scores compatibility, we used receiver-operating curve (ROC). Overall 369 patients (median age 75years, 65% male) were included. Most arrests (64%) were witnessed, bystander CPR was provided in 15%. Median call to arrival time was 4min. The presenting rhythm was asystole in 48% and VT/VF in 22%. Cardiovascular causes of arrest predominated (48%, n = 178). The median length of hospitalization was 5days. Overall 28% of the patients (n = 98) survived to hospital discharge, mostly with a good neurological status (18.7%, n = 57). The rates of organ dysfunction were: hemodynamic instability 65% (n = 247), respiratory dysfunction 94% (n = 296), kidney dysfunction 70% (n = 259), hepatic dysfunction 14% (n = 50). The median SOFA score on day 1 was 9 and the median APACHE II score was 34. Modeling was limited by missing data. Neurological dysfunction (i.e. GCS and seizures) and kidney injury were consistently correlated with the outcomes in the multivariable models. Severity of critical illness assessed by above scoring systems correlated with mortality (all ROC curves had an AUC ranging between 0.728 and 0.849). Multiorgan failure is common after ROSC (1-4). Therefore, the management of patients after ROSC may require advanced multidisciplinary care. Scores describing the severity of critical illness should be routinely reported in resuscitation research. Our unique setting where withdrawal of care is illegal, allows assessment of extremely ill patients and may assist in defining margins for futility.

The Role of Serum and Peritoneal Biomarkers in Predicting Sepsis and Septic Multiorgan Failure in Patients With Secondary Peritonitis.

Purpose Secondary peritonitis is still one of the most important causes of severe sepsis in the world; therefore, it is of utmost importance to identify biomarkersthat could be employed for the purpose of selecting patients at high risk for developing life-threatening complications after emergency surgery. In view of this quest, our study seeks to reveal the possible role for serum and peritoneal concentrations of selected biomarkers, specifically presepsin, procalcitonin, monocyte chemoattractant protein-1 (MCP-1), high mobility group box 1 protein (HMGB-1) and interleukins (IL-6, -8, -10), in early prediction of sepsis and septic multiorgan failure for patients with secondary peritonitis. Methods We prospectively observed 32 selected patients with secondary peritonitis that underwent emergency surgery. Blood and peritoneal fluid samples were drawn at the time of surgery (T0), and after that, blood samples were taken at 24 (T1) and 48 (T2) hours postoperatively. Cytokines concentrations were determined using a sandwich enzyme-linked immunosorbent assay (ELISA), a non-competitive variant, both in peritoneal fluid and serum. For determining whole blood concentration of presepsin and procalcitonin, PATHFAST™ assays (Polymedco, Cortlandt, New York) were used, based on the principle of non-competitive chemiluminescent enzyme immune-assay (CLEIA). The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Ethics Committee of University Emergency Hospital Bucharest (no. 40325/6 April 2023). Results We found significant elevations in the peritoneal concentrations of interleukins 6, 8, 10, HMGB-1, and MCP-1 in all patients with secondary peritonitis at the moment of surgery; however, no clear correlation could be made based on this data with patient evolution. With regards to blood concentrations of the aforementioned serum cytokines and presepsin, procalcitonin (as already established markers of sepsis), our results showed good predictive value of presepsin for developing sepsis and septic multiorgan failure from the first hoursin this patient category. All other biomarkers, despite having higher concentrations than baseline, in particular at 24-48 hours after surgery, had unpredictable dynamics that couldn't be correlated with the severity of the disease. Conclusion Cytokine production is the mainstay in developing sepsis and septic multiorgan failure in patients with secondary peritonitis; therefore, studying the dynamics of said cytokines seems of interest in finding tools to predict the development of sepsis or sepsis-related mortality. However, at the time, there seemed to be no clear correlation between the values of these cytokines and the development of complications.

Associated Risk Factors and Impact in Clinical Outcomes of Multiorgan Failure in Patients with TBI.

Individual extracerebral organ dysfunction is common after severe traumatic brain injury (TBI) and impacts outcomes. However, multiorgan failure (MOF) has received less attention in patients with isolated TBI. Our objective was to analyze the risk factors associated with the development of MOF and its impact in clinical outcomes in patients with TBI. This was an observational, prospective, multicenter study using data from a nationwide registry that currently includes 52 intensive care units (ICUs) in Spain (RETRAUCI). Isolated significant TBI was defined as Abbreviated Injury Scale (AIS) ≥ 3 in the head area with no AIS ≥ 3 in any other anatomical area. Multiorgan failure was defined using the Sequential-related Organ Failure Assessment as the alteration of two or more organs with a score of ≥ 3. We analyzed the contribution of MOF to crude and adjusted mortality (age and AIS head) by using logistic regression analysis. A multiple logistic regression analysis was performed to analyze the risk factors associated with the development of MOF in patients with isolated TBI. A total of 9790 patients with trauma were admitted to the participating ICUs. Of them, 2964 (30.2%) had AIS head ≥ 3 and no AIS ≥ 3 in any other anatomical area, and these patients constituted the study cohort. Mean age was 54.7 (19.5) years, 76% of patients were men, and ground-level falls were the main mechanism of injury (49.1%). In-hospital mortality was 22.2%. Up to 185 patients with TBI (6.2%) developed MOF during their ICU stay. Crude and adjusted (age and AIS head) mortality was higher in patients who developed MOF (odds ratio 6.28 [95% confidence interval 4.58-8.60] and odds ratio 5.20 [95% confidence interval 3.53-7.45]), respectively. The logistic regression analysis showed that age, hemodynamic instability, the need of packed red blood cells concentrates in the initial 24h, the severity of brain injury, and the need for invasive neuromonitoring were significantly associated with MOF development. MOF occurred in 6.2% of patients with TBI admitted to the ICU and was associated with increased mortality. MOF was associated with age, hemodynamic instability, the need of packed red blood cells concentrates in the initial 24h, the severity of brain injury, and the need for invasive neuromonitoring.

Effects of airway pressure release ventilation on multi-organ injuries in severe acute respiratory distress syndrome pig models

BackgroundExtra-pulmonary multi-organ failure in patients with severe acute respiratory distress syndrome (ARDS) is a major cause of high mortality. Our purpose is to assess whether airway pressure release ventilation (APRV) causes more multi-organ damage than low tidal volume ventilation (LTV).MethodsTwenty one pigs were randomized into control group (n = 3), ARDS group (n = 3), LTV group (n = 8) and APRV group (n = 7). Severe ARDS model was induced by repeated bronchial saline lavages. Pigs were ventilated and monitored continuously for 48 h. Respiratory data, hemodynamic data, serum inflammatory cytokines were collected throughout the study. Histological injury and apoptosis were assessed by two pathologists.ResultsAfter severe ARDS modeling, pigs in ARDS, LTV and APRV groups experienced significant hypoxemia and reduced lung static compliance (Cstat). Oxygenation recovered progressively after 16 h mechanical ventilation (MV) in LTV and APRV group. The results of the repeated measures ANOVA showed no statistical difference in the PaO2/FiO2 ratio between the APRV and LTV groups (p = 0.54). The Cstat showed a considerable improvement in APRV group with statistical significance (p < 0.01), which was significantly higher than in the LTV group since 16 h (p = 0.04). Histological injury scores showed a significantly lower injury score in the middle and lower lobes of the right lung in the APRV group compared to LTV (pmiddle = 0.04, plower = 0.01), and no significant increase in injury scores for extra-pulmonary organs, including kidney (p = 0.10), small intestine (p = 1.0), liver (p = 0.14, p = 0.13) and heart (p = 0.20). There were no significant differences in serum inflammatory cytokines between the two groups.ConclusionIn conclusion, in the experimental pig models of severe ARDS induced by repetitive saline lavage, APRV improved lung compliance with reduced lung injury of middle and lower lobes, and did not demonstrate more extra-pulmonary organ injuries as compared with LTV.

COMPARISON OF INFLAMMATORY MARKERS BETWEEN COVID VACCINATED POPULATION AND NATURALLY INFECTED POPULATION

The 2019 coronavirus disease (COVID-19) pandemic poses formidable obstacles in the fields of medicine, science, and public health. SARS-CoV-2 is a coronavirus that causes severe acute respiratory syndrome and may spread fast, with potentially fatal consequences. Establishing reliable laboratory biomarkers capable of risk-based patient classification is crucial for ensuring timely therapy. The study focuses on the problems of the COVID‐19 vaccine and multisystem inflammatory syndrome. Multi-organ failure in patients with severe COVID-19 consequences is mostly caused by systemic vasculitis and cytokine-mediated coagulation abnormalities, as shown by a review of recently published data. In addition, the study examines biomarkers associated with COVID-19 disease progression. Lastly, the study focuses on Pro-Inflammatory Cytokines (Il-1 and Il-6) And Lung Inflammation by Coronavirus-19 and its Anti-Inflammatory Strategies.

Coronary Artery Calcifications Are Associated With More Severe Multiorgan Failure in Patients With Severe Coronavirus Disease 2019 Infection: Longitudinal Results of the Maastricht Intensive Care COVID Cohort.

Purpose:Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is regarded as a multisystemic disease. Patients with preexisting cardiovascular disease have an increased risk for a more severe disease course. This study aimed to investigate if a higher degree of coronary artery calcifications (CAC) on a standard chest computed tomography (CT) scan in mechanically ventilated patients was associated with a more severe multiorgan failure over time.Materials and Methods:All mechanically ventilated intensive care unit patients with SARS-CoV-2 infection who underwent a chest CT were prospectively included. CT was used to establish the extent of CAC using a semiquantitative grading system. We categorized patients into 3 sex-specific tertiles of CAC: lowest, intermediate, and highest CAC score. Daily, the Sequential Organ Failure Assessment (SOFA) scores were collected to evaluate organ failure over time. Linear mixed-effects regression was used to investigate differences in SOFA scores between tertiles. The models were adjusted for age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, cardiovascular risk factors, and chronic liver, lung, and renal disease.Results:In all, 71 patients were included. Patients in the highest CAC tertile had, on average, over time, 1.8 (0.5-3.1) points higher SOFA score, compared with the lowest CAC tertile (P=0.005). This association remained significant after adjustment for age, sex, and APACHE II score (1.4 [0.1-2.7], P=0.042) and clinically relevant after adjustment for cardiovascular risk factors (1.3 [0.0-2.7], P=0.06) and chronic diseases (1.3 [−0.2 to 2.7], P=0.085).Conclusion:A greater extent of CAC is associated with a more severe multiorgan failure in mechanically ventilated coronavirus disease 2019 patients.

Interleukin-6 in SARS-CoV-2 induced disease: Interactions and therapeutic applications.

Interleukin-6 (IL-6) is a multi-tasking cytokine that represents high activity in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and cancer. High concentration of this pleiotropic cytokine accounts for hyperinflammation and cytokine storm, and is related to multi-organ failure in patients with SARS-CoV-2 induced disease. IL-6 promotes lymphopenia and increases C-reactive protein (CRP) in such cases. However, blockade of IL-6 is not a full-proof of complete response. Hypoxia, hypoxemia, aberrant angiogenesis and chronic inflammation are inter-related events occurring as a response to the SARS-CoV-2 stimulatory effect on high IL-6 activity. Taking both pro- and anti-inflammatory activities will make complex targeting IL-6 in patient with SARS-CoV-2 induced disease. The aim of this review was to discuss about interactions occurring within the body of patients with SARS-CoV-2 induced disease who are representing high IL-6 levels, and to determine whether IL-6 inhibition therapy is effective for such patients or not. We also address the interactions and targeted therapies in cancer patients who also have SARS-CoV-2 induced disease.

Therapeutic application of estrogen for COVID-19: Attenuation of SARS-CoV-2 spike protein and IL-6 stimulated, ACE2-dependent NOX2 activation, ROS production and MCP-1 upregulation in endothelial cells

The outbreak of COVID-19 has remained uncontained with urgent need for robust therapeutics. We have previously reported sex difference of COVID-19 for the first time indicating male predisposition. Males are more susceptible than females, and more often to develop into severe cases with higher mortality. This predisposition is potentially linked to higher prevalence of cigarette smoking. Nonetheless, we found for the first time that cigarette smoking extract (CSE) had no effect on angiotensin converting enzyme 2 (ACE2) and transmembrane protease serine 2 (TMPRSS2) expression in endothelial cells. The otherwise observed worse outcomes in smokers is likely linked to baseline respiratory diseases associated with chronic smoking. Instead, we hypothesized that estrogen mediated protection might underlie lower morbidity, severity and mortality of COVID-19 in females. Of note, endothelial inflammation and barrier dysfunction are major mediators of disease progression, and development of acute respiratory distress syndrome (ARDS) and multi-organ failure in patients with COVID-19. Therefore, we investigated potential protective effects of estrogen on endothelial cells against oxidative stress induced by interleukin-6 (IL-6) and SARS-CoV-2 spike protein (S protein). Indeed, 17β-estradiol completely reversed S protein-induced selective activation of NADPH oxidase isoform 2 (NOX2) and reactive oxygen species (ROS) production that are ACE2-dependent, as well as ACE2 upregulation and induction of pro-inflammatory gene monocyte chemoattractant protein-1 (MCP-1) in endothelial cells to effectively attenuate endothelial dysfunction. Effects of IL-6 on activating NOX2-dependent ROS production and upregulation of MCP-1 were also completely attenuated by 17β-estradiol. Of note, co-treatment with CSE had no additional effects on S protein stimulated endothelial oxidative stress, confirming that current smoking status is likely unrelated to more severe disease in chronic smokers. These data indicate that estrogen can serve as a novel therapy for patients with COVID-19 via inhibition of initial viral responses and attenuation of cytokine storm induced endothelial dysfunction, to substantially alleviate morbidity, severity and mortality of the disease, especially in men and post-menopause women. Short-term administration of estrogen can therefore be readily applied to the clinical management of COVID-19 as a robust therapeutic option.

Therapeutic plasma-exchange improves systemic inflammation and survival in acute-on-chronic liver failure: A propensity-score matched study from AARC.

Plasma-exchange (PE) has improved survival in acute liver failure by ameliorating systemic inflammatory response syndrome (SIRS). We evaluated PE and compared it to Fractional Plasma Separation and Adsorption (FPSA) and standard medical treatment (SMT) in a large multinational cohort of ACLF patients. Data were prospectively collected from the AARC database and analysed. Matching by propensity risk score (PRS) was performed. Competing risk survival analysis was done to identify deaths because of multiorgan failure (MOF). In a subset of 10 patients, we also evaluated the mechanistic basis of response to PE. ACLF patients (n=1866, mean age 44.3±12.3 yrs, 93% males, 65% alcoholics) received either artificial liver support (ALS) (n=162); [PE (n=131), FPSA (n=31)] or were continued on standard medical therapy (SMT) (n=1704). In the PRS-matched cohort (n=208, [ALS-119; PE-94, FPSA-25)], SMT-89). ALS therapies were associated with a significantly higher resolution of SIRS (Odd's ratio 9.23,3.42-24.8), lower and delayed development of MOF (Hazard ratio 7.1, 4.5-11.1), and lower liver-failure-related deaths as compared to FPSA and SMT (P<.05). PE cleared inflammatory cytokines, damage-associated molecular patterns, and endotoxin in all patients. Responders improved monocyte phagocytic function and mitochondrial respiration and increased the anti-inflammatory cytokine interleukin-1 receptor antagonist (IL-1RA) compared to non-responders. PE was associated with lesser adverse effects as compared to FPSA. PE improves systemic inflammation and lowers the development of MOF in patients with ACLF. Plasma-exchange provides significant survival benefit over FPSA and could be a preferred modality of liver support for ACLF patients.

Diagnostic and Prognostic Value of Plasma Gelsolin in Multiorgan Failure in Patients with Sepsis

AIM: The aim of this work is to investigate the clinical value of gelsolin plasma concentration in the diagnosis of sepsis and investigate the relationship between gelsolin plasma concentration and the severity of organ dysfunction assessed by the acute physiology and chronic health evaluation (APACHE II) and SOFA scores, and to study the mortality predictive power of gelsolin plasma concentration.&#x0D; METHODS: We analyzed data of patients admitted with sepsis (n = 46) for 5 days. Age- and sex-matched non-specific intensive care unit (ICU) patients (n = 18) served as controls. Septic patients were then divided according to severity of disease to patients with sepsis, severe sepsis, and septic shock. Besides plasma gelsolin (pGSN) classical laboratory parameters and clinical scores (APACHE II and SOFA) were also assessed.&#x0D; RESULTS: Septic patients showed significantly decreased 1st-day GSN levels (170.9 ± 74.3 mg/l) compared to non-septic critically ill patients (225.9 ± 84.5 mg/l, p &lt; 0.05). Furthermore, patients with septic shock had lower gelsolin plasma concentration than with severe sepsis and with sepsis (p &lt; 0.05); furthermore, non-survivors had significantly lower GSN levels compared to survivors (p &lt; 0.05). Septic patients had higher APACHE II and SOFA scores. Lower GSN level was significantly correlated with the development of multiple organ dysfunction syndrome and fatal outcome, also, patients with lower GSN level had longer ICU stay, APACHE II, and SOFA scores. APACHE II score has shown best ability to predict mortality with AUC 0.913 followed by PCT with AUC 0.828. pGSN was the least in the ability to predict mortality with AUC only 0.378 despite significant difference between pGSN levels between survivals and non-survivals.&#x0D; CONCLUSIONS: pGSN might serve as efficient complementary marker in sepsis. However, the prognostic role of pGSN in mortality requires further investigation in larger studies.

Myocardial Injury in Adults Hospitalized With COVID-19.

Myocardial Injury in Adults Hospitalized With COVID-19.

Duration and Mortality Characteristics of Patients with Cerebral Tumors Treated in the Intensive Care Unit of Sanglah General Hospital from January to December 2017

BACKGROUND: The incidence and survival rates of cerebral tumor patients are increasing, along with advances in medical technology. Severe complications, such as multiorgan failure in patients, cause the need for intensive care to improve. The effectiveness of intensive care in tumor patients is still controversial, considering that patients included in low and vulnerable performance status. Patients with cerebral tumors also require intensive care either before or after effective action. The controversy of economic and ethical issues still places aggressive action in intensive care on oncology patients. It is necessary to identify and know the characteristics of tumor patients that are useful in intensive management.&#x0D; AIM: The purpose of this study was to determine the demographic characteristics, length of stay, complications, and mortality rates of cerebral tumor patients undergoing intensive care at Sanglah Hospital Denpasar, the period January–December 2017.&#x0D; METHODS: This study is a cross-sectional descriptive where all sample data collection is secondarily based on existing medical records. The sample population in this study were cerebral tumor patients treated in the intensive care ward Sanglah period January–December 2017 who met the inclusion criteria.&#x0D; RESULTS: In the study, it found that 54 patients with the highest number of cerebral tumors treated in the intense sex with women (64.85%) and middle-aged adults (41–60 years) were 31 patients (57.4%). Most diagnoses of cerebral tumors were 39 non-glioma tumors (72.2%) followed by glioma tumors (20.4%) and tumor metastases (7.4%). Non-glioma tumors noted were meningiomas of around 48.1%, followed by glioblastoma multiforme tumors of 9.3%, tumors at the cerebellopontine angle and tumor metastases of 7.4%, respectively. All patients were treated intensively after receiving surgical therapy with a Karnofsky 50 score of about 29 patients (53.7%). All patients came out alive, and there were no recorded complications during treatment with the maximum length of stay of patients in the intensive care unit for up to 3 days by 45 patients (83.3%).&#x0D; CONCLUSION: The most brain tumor cases are meningioma, which occurred in women, middle-aged adults with no mortality and complications within 3 days during treatment intensive care.

PECULIARITIES OF THE COURSE OF ACUTE SEVERE PANCREATITIS COMPLICATED WITH ASCITES AND PERITONITIS

Acute pancreatitis is one of the most common diseases of the digestive system that often requires urgent admission to the hospital. Ascites and peritonitis in acute severe pancreatitis is a rather common complication of the early period of the disease. The evacuation of fluid rich in potentially toxic mediators from the abdominal cavity is advocated in a number of reports as an efficient measure to alleviate the burden of disease for patients in emergency condition. The purpose of the work was to analyze the effect of enzymatic ascites and peritonitis and drainage interventions performed on the course of acute pancreatitis. The study was based on the analysis of 44 case histories of inpatients with acute pancreatitis complicated with ascites and peritonitis who took the course of treatment at the surgical department of the M.V. Sklifosovsky Poltava Regional Clinical Hospital for 2013 – 2017. The patients were divided into two groups: the first group included individuals who were performed on surgical interventions for enzymatic ascites and peritonitis in the early period of the disease; the second group included he patients who only had a comprehensive conservative treatment according to the protocols for the treatment of acute pancreatitis. The obtained results confirm that resolving enzymatic ascites enables to avoid mortality in the early period of the disease associated with the increase of organ and multiorgan failure in patients with severe and extremely severe course of acute pancreatitis, and in some cases contributes to regression of the disease. Once the damage is in progression, to some extent it can provoke a more severe course of post-operative drainage due to the number of factors as a surgical trauma, or drainage as an entrance gate for infection.

Middle East Respiratory Syndrome: Emergence of a Pathogenic Human Coronavirus.

In 2012, a zoonotic coronavirus was identified as the causative agent of Middle East respiratory syndrome and was named MERS coronavirus (MERS-CoV). As of August 11, 2016, the virus has infected 1,791 patients, with a mortality rate of 35.6%. Although MERS-CoV generally causes subclinical or mild disease, infection can result in serious outcomes, including acute respiratory distress syndrome and multi-organ failure in patients with comorbidities. The virus is endemic in camels in the Arabian Peninsula and Africa and thus poses a consistent threat of frequent reintroduction into human populations. Disease prevalence will increase substantially if the virus mutates to increase human-to-human transmissibility. No therapeutics or vaccines are approved for MERS; thus, development of novel therapies is needed. Further, since many MERS cases are acquired in healthcare settings, public health measures and scrupulous attention to infection control are required to prevent additional MERS outbreaks.

Risk factors for multiorgan failure and mortality in severe sepsis patients who need intensive care unit follow-up.

Multiorgan failure (MOF) is a primary cause of morbidity and mortality in sepsis patients in intensive care units (ICU). Finding risk factors and solving preventable problems of MOF in patients who have sepsis can be a favourable step for decreasing mortality. We aimed to examine multiorgan failure and mortality related risk factors in intensive care unit patients who have sepsis. A retrospective data collection and prognostic cohort study was performed. Between January 2009-March 2010, patients accepted to the 22-bed pulmonary intensive care unit with the diagnosis of sepsis were enrolled. Patients' demographic data, ICU severity scores, application of mechanical ventilation, causative agent of sepsis, number of ICU days and presence of mortality were recorded. Logistic regression analysis was carried out for risk factors. 347 patients with sepsis were involved in the study. 43 of the patients (12.4%) developed MOF and overall mortality rate was 14.9% (n= 52). Presence of resistant pathogen, presence of shock, application of TPN and high APACHE II score were found to be risk factors for MOF [p= 0.015 Odds ratio (OR) 3.47 confidence interval (CI): 1.27 - 9.47, p= 0.001, OR: 30.8 CI: 11.41 - 83-49, p= 0.028, OR: 3.08, CI: 1.13 - 8.39, p= 0.003, OR: 1.10, CI: 1.04-1.18, respectively]. Risk factors for overall mortality were presence of nosocomial infection, high 3rd day SOFA score, presence of shock, application of TPN and sedation (p= 0.005, OR: 3.39, CI: 1.45 - 7.93; p= 0.001, OR: 1.51, CI: 1.27 - 1.81; p= 0.014, OR: 3.24, CI: 1.27 - 8.25; p= 0.003, OR: 3.64. CI: 1.54 - 8.58; p= 0.001, OR: 3.38, CI: 1.51 - 7.57, respectively). In sepsis patients who need ICU follow up, presence of resistant pathogen, presence of shock, application of TPN and high APACHE II scores are risk factors for developing MOF. Thus, rational use of antibiotics, reducing the use of TPN, application of infection control programmes and prevention of shock will further reduce multiorgan failure and mortality.

Transfusion of 1 and 2 units of red blood cells does not increase mortality and organ failure in patients undergoing isolated coronary artery bypass grafting.

In cardiac surgery, the association between red blood cell (RBC) transfusion and clinical outcome is elusive. We investigated in a large cohort of patients who underwent isolated coronary artery bypass grafting (CABG) the effect of transfusion of 1-2 units of leucocyte-depleted RBCs on mortality and multiorgan failure. The investigation included all patients from July 2009 to June 2014 who underwent CABG at our institution and received no (n = 1478) or 1-2 units of RBCs (n = 1528). The primary end-point was 30-day mortality; secondary end-points were major organ dysfunction. A subgroup analysis assessed the effect of the duration of RBC storage on patient outcome. Statistical analysis was performed using propensity score (PS) adjustment. The 30-day mortality rate was 0.3% in the RBC- group and 0.2% in the RBC+ group. Compared with the RBC- group, PS-adjusted odds ratio (OR) of 30-day mortality in the RBC+ group was 0.29 [95% confidence interval (CI): 0.06-1.50; P = 0.14]. PS-adjusted OR of a 'prolonged intensive care unit (ICU) stay' (>48 h) was significantly higher in the RBC+ group than in the RBC- group [OR 1.49 (95% CI: 1.14-1.95); P = 0.004], but major clinical complications such as low cardiac output syndrome, stroke, haemofiltration, wound infection and prolonged mechanical ventilator support (>24 h) did not differ significantly between groups. Duration of blood storage was not independently associated with clinical outcome. Our data do not indicate a transfusion-related increase in mortality and multiorgan failure in patients undergoing isolated CABG.

Antiphospholipid syndrome

The antiphospholipid syndrome (APS) is defined by venous or arterial thrombosis and/or pregnancy morbidity in patients with persistent presence of antiphospholipid antibodies (aPLs). Catastrophic APS is the most severe form of APS, which is associated with rapid development of microvascular thrombosis resulting in multiorgan failure in patients with aPLs. Patients with APS and catastrophic APS are recognized to have a high risk of recurrent thrombosis that can occur despite anticoagulant therapy. Although antithrombotic therapy remains the mainstay of treatment, bleeding manifestations can complicate management and contribute to increased morbidity. Patients with persistently elevated aPL levels, particularly those who exhibit positive testing for lupus anticoagulant, anticardiolipin antibodies, and anti-β2GPI antibodies (triple positivity), appear to be at increased risk for thrombosis and pregnancy complications, whereas isolated positivity for aPLs appears to be associated with low risk. Recognizing that patients with APS have different thrombotic risk profiles may assist clinicians in assessing the risks and benefits of anticoagulation. The optimal type, intensity, and duration of anticoagulation in the treatment of APS remain controversial, particularly for arterial thrombosis and recurrent thrombosis. Future studies that delineate thrombotic risk in APS and evaluate current and novel anticoagulants as well as nonanticoagulant therapies are required.

Noninvasive Measurement of Intestinal Inflammation After Burn Injury

Intestinal inflammation has been linked with multiorgan failure in patients with burn and other traumatic injuries. We hypothesized that markers of intestinal inflammation are detectible noninvasively. Fecal samples were collected from seven severely burned patients and 15 control patients for the measurement of inflammatory cytokines using a multiplex assay kit. In addition, fecal levels of myeloperoxidase (MPO) and elastase were measured using standard procedures. Compared with a control group, levels of inflammatory cytokines were significantly increased in the burn group. Interleukin (IL)-6 increased to a mean (± SEM) of 2.16 ± 0.61 to 3.81 ± 0.49 pg/mg (P < .05), as did IL-8 (3.32 ± 0.76 to 20.51 ± 6.65 pg/mg; P < .05), IL-12 (6.23±0.98 to 8.11±0.95pg/mg; P=0.01), IL-13 (3.86 ± 0.32 to 11.83 ± 1.47 pg/mg; P < .05), monocyte chemoattractant protein-1 (2.78 ± 2.61 to 6.5 ± 3.97 pg/mg; P < .05), MPO (13.41 ± 1.40 to 24.52 ± 4.31 units/mg protein; P < .05), and elastase (2.46 ± 0.38 to 5.08 ± 0.72 pg/mL; P < .05). Our results suggest that markers of intestinal inflammation are measurable by noninvasive means and are increased after burn injury compared with controls. Of note, increased IL-8 correlated with increased MPO and elastase activity, suggesting a role for neutrophil activation in burn-mediated intestinal inflammation. Thus, these inflammatory cytokine profiles may be valuable biomarkers of intestinal inflammation after burn injury.

Invasive Burn Wound Infection

Dear Editor, I read the article by Pattanshetti et al. [1] with great interest. The authors randomized 30 consecutive adult patients with burn injury (involving <60% of total body surface area) to receive tube feeds of either glutamine-enriched isonitrogenous diet or non-glutamine-enriched isonitrogenous diet. All patients were admitted to a single institution and received enteral feeds till the wounds healed “completely” or received a skin graft. The primary outcomes measured were incidence of “wound infection” detected by “wound culture” and incidence of “bacteremia” detected by “blood culture” [1]. The secondary outcomes measured were duration of hospital stay and mortality. The authors found statistically significant reduction in “wound infection” rates and duration of hospital stay but no statistically significant reduction in the incidence of “bacteremia” or mortality in patients receiving glutamine supplementation. The authors conclude that administration of glutamine in their patients prevented translocation of luminal gut bacteria and hence reduced incidence of burn wound infection [1]. I would like the authors and the editors of the Indian Journal of Surgery to clarify certain issues regarding the article. Firstly, the authors mention that “wound cultures” were performed weekly to diagnose “wound infection” in all patients [1]. Detection of bacteria on a wound surface swab can confirm bacterial colonization of the wound. It does not diagnose invasive wound infection. A wound biopsy is required to confirm bacterial invasion of sub-eschar viable tissue [2]. This invasive wound infection can lead to bacteremia and sepsis in a burn patient. Secondly, the authors mention that “most of the bacteria cultured from the wound were of gut origin. Thus, wound infection in patients with burns is not always due to contamination from hospital environment, it could be due to endogenous bacteria” [1]. It is a well known fact that translocated gut bacteria can cause bacteremia, sepsis and multi-organ failure in patients with extensive deep dermal and full thickness burns [3]. Translocated bacteria however, do not cause invasive burn wound infection. Fecal contamination of burn wounds can logically explain the authors’ findings. Thirdly, the authors state that “the depth of burn wound has not got any role in the initial management of patients with burns” [1]. The management of superficial and deep dermal burns are completely different. The issue of burn wound infection and mortality from sepsis are issues in the management of patients with deep dermal and full thickness burns [4]. These are non-issues in patients with epidermal or superficial dermal burns. Fourthly, the authors mention that “The glutamine supplementation or the isonitrogenous mixture was given until the end of the study” [1]. However, the authors do not mention how many patients tolerated their tube feeds and how many patients needed their tube feeds to be stopped due to ileus. It is important to know if the intended nutritional supplement actually reached the patient’s intestine. Fifthly, the authors do not mention their source of funding for conducting the study. Nor do they disclose any conflict of interest. However, finding images of commercially available glutamine packets (Glutammune, Claris Lifesciences Limited, Ahmedabad, India) in the article makes one wonder if a conflict of interest actually exists. Lastly, the results and discussion sections in this article have been amalgamated into one. I would like to appeal to the editor that a standard format for all published articles be maintained. In conclusion, I would like to add that the peer-reviewers of a submitted article should ask the authors pertinent questions before an article is deemed fit for publication. Accepting the drawbacks of a study does not show the author(s) in poor light. On the contrary, it improves the quality of published articles and provides a clear message to the reader. It is probably time that editors of our esteemed journal enforce the principles they espouse [5].