Multiple Organ Dysfunction Score Research Articles

Multiple Organ Dysfunction Syndrome

The concept of and approach to multiple organ dysfunction syndrome (MODS), also known as progressive systems failure, multiple organ failure, and multiple system organ failure, have evolved over the last decade. Characterized by progressive but potentially reversible tissue damage and dysfunction of two or more organ systems that arise after a significant physiologic insult and its subsequent management, MODS evolves in the wake of a profound disruption of systemic homeostasis. Pre-existing illness, nutritional status, hospital course, and genetic variation all lead to the development of organ dysfunction in patients exposed to these risk factors. The ultimate outcome from MODS is influenced not only by a patient’s genetic and biological predisposition but also by specific management principles practiced by intensivists. This review details the clinical definitions, quantification, prevention, evaluation, support, and outcomes of organ dysfunction. A figure shows the increasing severity of organ dysfunction correlated with increasing intensive care unit mortality, and an algorithm details the approach to MODS. Tables list risk factors and prognosis for MODS, the multiple organ dysfunction (MOD) score, the sequential organ failure assessment (SOFA) score, intensive care unit interventions that reduce mortality or attenuate organ dysfunction along with unproven or disproven ICU interventions, and the temporal evolution of MODS. This review contains 1 figure, 7 tables, and 159 references.

Age-related mortality in blunt traumatic hemorrhagic shock: the killers and the life savers

BackgroundThere are sparse data on the association between age and mortality in hemorrhagic shock (HS). We examined this association in this study. Materials and methodsThe Glue Grant database was analyzed. Patients aged ≥16 y with blunt traumatic HS were stratified into eight age groups (16–24, 25–34, 35–44, 45–54, 55–64, 65–74, 75–84, and ≥85 y) to identify the mortality inflection point. Subsequently, patients were restratified into young age (16–44 y), middle age (45–64 y), and elderly (≥65 y). Multivariate analysis was used to determine predictors of mortality by group. ResultsA total of 1976 patients were included, with mortality of 16%. Mortality by initial age group is as follows: 16–24 (13.0%), 25–34 (11.9%), 35–44 (11.9%), 45–54 (15.6%), 55–64 (15.7%), 65–74 (20.3%), 75–84 (38.2%), and ≥85 y (51.6%), delineating 65 y as the mortality inflection point. Overall, 55% were young, 30% middle age, and 15% elderly. Predictors of mortality in the young include multiple-organ dysfunction score (MODS; odds ratio [OR]: 1.93, confidence interval [CI]: 1.62–2.30), emergency room lactate (OR: 1.14, CI: 1.02–1.27), injury severity score (OR: 1.06, CI: 1.03–1.09), and cardiac arrest (OR: 10.60, CI: 3.05–36.86). Predictors of mortality in the middle age include MODS (OR: 1.38, CI: 1.24–1.53), cardiac arrest (OR: 12.24, CI: 5.38–27.81), craniotomy (OR: 5.62, CI: 1.93–16.37), and thoracotomy (OR: 2.76, CI: 1.28–5.98). In the elderly, predictors of mortality were age (OR: 1.07, CI: 1.02–1.13), MODS (OR: 1.47, CI: 1.26–1.72), laparotomy (OR: 2.04, CI: 1.02–4.08), and cardiac arrest (OR: 11.61, CI: 4.35–30.98). Open fixation of nonfemoral fractures was protective against mortality in all age groups. ConclusionsIn blunt HS, mortality parallels increasing age, with the inflection point at 65 y. MODS and cardiac arrest uniformly predict mortality across all age groups. Craniotomy and thoracotomy are associated with mortality in the middle age, whereas laparotomy is associated with mortality in the elderly.

Effects of Red-Cell Storage Duration on Patients Undergoing Cardiac Surgery

BackgroundSome observational studies have reported that transfusion of red-cell units that have been stored for more than 2 to 3 weeks is associated with serious, even fatal, adverse events. Patients undergoingcardiac surgery may be especially vulnerable to the adverse effects of transfusion.MethodsWe conducted a randomized trial at multiple sites from 2010 to 2014. Participants 12 years of age or older who were undergoing complex cardiac surgery and were likely to undergo transfusion of red cells were randomly assigned to receive leukocyte-reduced red cells stored for 10 days or less (shorter-term storage group) or for 21 days or more (longer-term storage group) for all intraoperative and postoperative transfusions. The primary outcome was the change in Multiple Organ Dysfunction Score (MODS; range, 0 to 24, with higher scores indicating more severe organ dysfunction) from the preoperative score to the highest composite score through day 7 or the time of death or discharge.ResultsThe median storage time of red-cell units provided to the 1098 participants who received red-cell transfusion was 7 days in the shorter-term storage group and 28 days in the longer-term storage group. The mean change in MODS was an increase of 8.5 and 8.7 points, respectively (95% confidence interval for the difference, −0.6 to 0.3; P=0.44). The 7-day mortality was 2.8% in the shorter-term storage group and 2.0% in the longer-term storage group (P=0.43); 28-day mortality was 4.4% and 5.3%, respectively (P=0.57). Adverse events did not differ significantly between groups except that hyperbilirubinemia was more common in the longer-term storage group.ConclusionsThe duration of red-cell storage was not associated with significant differences in the change in MODS. We did not find that the transfusion of red cells stored for 10 days or less was superior to the transfusion of red cells stored for 21 days or more among patients 12 years of age or older who were undergoing complex cardiac surgery. (Funded by the National Heart, Lung, and Blood Institute; RECESS ClinicalTrials.gov number, NCT00991341.)

Angiotensin Inhibition Is Associated with Preservation of T-Cell and Monocyte Function and Decreases Multiple Organ Failure in Obese Trauma Patients

Obese patients are more prone to post-injury multiple organ failure (MOF). Obesity pathophysiology includes an adipose-tissue-derived, renin-angiotensin-aldosterone system affecting inflammatory responses via leukocyte angiotensin receptors. We hypothesized that obese patients receiving pre-injury angiotensin-converting enzyme inhibitor (ACE) or angiotensin receptor blocker (ARB) therapy would have decreased MOF and differences in immune cell frequencies. We analyzed the Inflammation and the Host Response to Injury trauma-related database. Patients receiving pre-injury ACE or ARB were stratified as obese (BMI >30 kg/m(2)) or nonobese (BMI <30 kg/m(2)). Groups were age, sex, and Injury Severity Score matched against patients not receiving this therapy. Primary end points were Marshall Multiple Organ Dysfunction Score, Denver-2 Postinjury MOF Score, leukocyte markers on T cells, and monocytes measured by flow cytometry. We evaluated 1,932 patients. One hundred and ten were receiving pre-injury ACE/ARB; 94 patients had data available to calculate BMI. Obese patients receiving ACE/ARB showed maximum Marshall (5.83 ± 2.87) and Denver-2 (2.45 ± 2.32) scores similar to nonobese patients receiving or not receiving ACE/ARB, and obese patients not receiving ACE/ARB had significantly higher Marshall (6.49 ± 2.57; p = 0.009) and Denver-2 (3.33 ± 2.21; p = 0.006) scores. Leukocyte analysis suggested improved T-cell function and monocyte maturation in obese patients on ACE/ARB. Obese patients receiving preinjury ACE/ARB therapy demonstrate post-injury MOF scores similar to nonobese patients; obese patients not receiving these medications have greater post-injury MOF. Leukocyte analysis demonstrates improved immune regulation. Modulation of the renin-angiotensin-aldosterone system pathway might represent a novel therapeutic target in severely injured obese patients.

The early evolving sex hormone environment is associated with significant outcome and inflammatory response differences after injury.

Clinical research characterizing the mechanisms responsible for sex-based outcome differences after injury remains conflicting. Currently lacking is an understanding of the early sex hormone milieu of the injured patient and the effects these early hormone differences have on clinical outcomes and the innate immune response following injury. A prospective cohort study was performed over a 20-month period. Blunt injury patients requiring intensive care unit admission were enrolled. Samples were collected within 6 hours and at 24 hours after injury and were analyzed for total testosterone (TT) and estradiol concentrations. Outcomes of interest included multiple-organ failure (MOF; Marshall Multiple Organ Dysfunction Score [MODScore] > 5), nosocomial infection (NI), mortality, and serial cytokine/chemokine measurements. Multivariate logistic regression was used to determine the independent risks associated with early sex hormone measurements. In 288 prospectively enrolled patients, 69% were male, with a median Injury Severity Score (ISS) of 16 (interquartile range 10-21). Elevated TT levels at 6 hours were associated with elevated interleukin 6 levels and cytokine/chemokine measurements (18 of 24 measured). Rising TT levels were significantly associated with more than a fivefold and twofold higher independent risk of MOF and NI, respectively (odds ratio [OR], 5.2; p = 0.02; 95% confidence interval [CI], 1.2-22.3; and OR, 2.1; p = 0.03; 95% CI, 1.02-4.2). At 24 hours, TT levels were no longer associated with poor outcome, while estradiol levels were significantly associated with nearly a fourfold higher independent risk of MOF (OR, 3.9; p = 0.04, 95% CI, 1.05-13). Early elevations and increasing testosterone levels over initial 24 hours after injury are associated with an exaggerated inflammatory response and a significantly greater risk of MOF and NI. High estrogen levels at 24 hours are independently associated with an increased risk of MOF. The current analysis suggests that an early evolving testosterone to estrogen hormonal environment is associated with a significantly higher independent risk of poor outcome following traumatic injury. Prognostic/epidemiologic study, level II.

Patterns of multiorgan dysfunction after pediatric drowning

AimsTo evaluate patterns of multiorgan dysfunction and neurologic outcome in children with respiratory and cardiac arrest after drowning. MethodsSingle center retrospective chart review of children aged 0–21 years admitted between January 2001 and January 2012 to the pediatric intensive care unit at Children's Hospital of Pittsburgh with a diagnosis of drowning/submersion/immersion. Organ dysfunction scores were calculated for first 24h of admission as defined by the Pediatric Logistic Organ Dysfunction Score-1 (PELOD-1) and Pediatric Multiple Organ Dysfunction Score (P-MODS). Neurologic outcome at hospital discharge was assigned Pediatric Cerebral and Overall Performance Category Scale scores. ResultsWe identified 60 cases of pediatric drowning in which 21 children experienced cardiorespiratory arrest (CA) and 39 had respiratory arrest (RA). All children with CA had multiorgan failure and 81% had a poor neurologic outcome at hospital discharge while 49% of children with RA had multiorgan failure and none had an unfavorable neurological outcome (p<0.001). The most common organ failures in both CA and RA groups within the first 24h of admission were respiratory, followed by neurologic, cardiovascular, gastrointestinal, hematological, and least commonly, renal. ConclusionPatterns of organ failure differ in children with CA and RA due to drowning. The contribution of multiorgan failure to poor outcome and evaluation of the impact of augmenting cerebral resuscitation with MOF-targeting therapies after drowning deserves to be explored.

Clinical Profile and Prognostic Indicators in Adults Hospitalized with Severe Malaria Caused by Different Plasmodium Species.

INTRODUCTIONSevere malaria remains a major cause of death and morbidity among adults in the Asiatic tropics. This study was planned to evaluate clinical profile and prognostic indicators of severe malaria in adults so as to improve insight into this highly prevalent disease.MATERIALS AND METHODSThis prospective observational study was conducted on 60 confirmed cases of malaria. Cases were divided into two groups: (a) study group: suffering from severe malaria and (b) control group: no severe manifestations. All cases were thoroughly studied for clinical features, laboratory evaluation, and outcome. Prognostic evaluation was also done by different score systems.RESULTSIn all, 40 cases suffer from severe malaria (study group), while 20 cases belong to the control group. The majority of our cases were males of age 21–40 years. The most common species of malaria in the study group was vivax (52.5%), followed by falciparum (25%) and mixed malaria species (22.5%). The clinical predictors for severe malaria were rural habitat, longer duration of fever, marked chills, tiredness, giddiness, nausea, vomiting, decreased urine output, jaundice, and altered sensorium. Extreme weakness (80%), jaundice (55%), renal failure (50%), and severe anemia (27.5%) were the most common presenting features in severe malaria. Two patients died of severe mixed malaria. The mortality rate was significantly associated with lower hemoglobin level (P = 0.002); higher total leukocyte count (P = 0.006), blood urea (P < 0.001), serum creatinine (P < 0.001), SGOT (P = 0.001), SGPT (P < 0.007), serum bilirubin (P = 0.003), and parasite density (P = 0.033); lower platelet count (P = 0.043); and those who had more APACHE II score (P = 0.003), SOFA score (P = 0.04), and Multiple Organ Dysfunction Score (P < 0.001) and lower Glasgow Coma Scale (P < 0.001).CONCLUSIONSManifestations of severe malaria is becoming increasingly more prevalent specifically in vivax and mixed malaria cases. Our study proposes that there are certain clinical predictors and prognostic indicators that should be kept in mind for better management of severe malaria.

Association of low non-invasive near-infrared spectroscopic measurements during initial trauma resuscitation with future development of multiple organ dysfunction.

Near-infrared spectroscopy (NIRS) non-invasively monitors muscle tissue oxygen saturation (StO2). It may provide a continuous noninvasive measurement to identify occult hypoperfusion, guide resuscitation, and predict the development of multiple organ dysfunction (MOD) after severe trauma. We evaluated the correlation between initial StO2 and the development of MOD in multi-trauma patients. Patients presenting to our urban, academic, Level I Trauma Center/Emergency Department and meeting standardized trauma-team activation criteria were enrolled in this prospective trial. NIRS monitoring was initiated immediately on arrival with collection of StO2 at the thenar eminence and continued up to 24 hours for those admitted to the Trauma Intensive Care Unit (TICU). Standardized resuscitation laboratory measures and clinical evaluation tools were collected. The primary outcome was the association between initial StO2 and the development of MOD within the first 24 hours based on a MOD score of 6 or greater. Descriptive statistical analyses were performed; numeric means, multivariate regression and rank sum comparisons were utilized. Clinicians were blinded from the StO2 values. Over a 14 month period, 78 patients were enrolled. Mean age was 40.9 years (SD 18.2), 84.4% were male, 76.9% had a blunt trauma mechanism and mean injury severity score (ISS) was 18.5 (SD 12.9). Of the 78 patients, 26 (33.3%) developed MOD within the first 24 hours. The MOD patients had mean initial StO2 values of 53.3 (SD 10.3), significantly lower than those of non-MOD patients 61.1 (SD 10.0); P=0.002. The mean ISS among MOD patients was 29.9 (SD 11.5), significantly higher than that of non-MODS patients, 12.1 (SD 9.1) (P<0.0001). The mean shock index (SI) among MOD patients was 0.92 (SD 0.28), also significantly higher than that of non-MODS patients, 0.73 (SD 0.19) (P=0.0007). Lactate values were not significantly different between groups. Non-invasive, continuous StO2 near-infrared spectroscopy values during initial trauma resuscitation correlate with the later development of multiple organ dysfunction in this patient population.

Prognostic value of different scoring models in patients with multiple organ dysfunction syndrome associated with acute COPD exacerbation.

Chronic obstructive pulmonary disease (COPD) represents an increasing healthcare concern as a leading cause of morbidity and mortality worldwide. Our objective was to predict the outcome of COPD patients associated with multiple organ dysfunction syndrome (MODS) by scoring models. A retrospective study was performed on severe COPD patients within 24 hours of the onset of MODS. The Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, Multiple Organ Dysfunction Score (MODS), Simplified Acute Physiology Score II (SAPS II), and Sepsis-related Organ Failure Assessment (SOFA) scores were calculated for patients. A total of 153 elderly patients were recruited. Compared to 30-day survivors, the number of failing organs and all of the scoring models were significantly higher in 30-day non-survivors. The SOFA showed the highest sensitivity and area under the curve (AUC) for predicting the prognosis of patients with MODS induced by acute exacerbation of COPD. The results of logistic regression indicated that factors that were correlated with the prognosis of COPD included the exacerbation history, SOFA score, number of failing organs, and duration of ICU stay. The value of exacerbation frequency for predicting the outcome of COPD was excellent (AUC: 0.892), with a sensitivity of 0.851 and a specificity of 0.797. The SOFA score, determined at the onset of MODS in elderly patients with COPD, was a reliable predictor of the prognosis. The exacerbation frequency, number of failing organs, and the SOFA score were risk factors of a poor prognosis, and the exacerbation frequency could also effectively predict the outcome of COPD.

Survival Predictors in Acute Respiratory Distress Syndrome With Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) can be used as a salvage therapy, but the effectiveness is controversial. The aim of this study was to investigate the predictors of mortality and the influence of organ dysfunction scores in severe acute respiratory distress syndrome (ARDS) patients treated with ECMO. The records of adult severe ARDS patients receiving ECMO support from May 2006 to December 2011 at Chang Gung Memorial Hospital were retrospectively analyzed. The records of 65 patients with severe ARDS who received venovenous ECMO were analyzed. The hospital survival rate was 47.7%. Survivors were younger than nonsurvivors (41.4 ± 15.4 versus 54.1 ± 16.9 years, respectively; p = 0.002) and had shorter duration of mechanical ventilation before ECMO (52.7 ± 51.1 versus 112.1 ± 101.0 hours, respectively; p = 0.01). Before ECMO, Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, and Multiple Organ Dysfunction scores were significantly lower for survivors than for nonsurvivors. Mortality rate increased with rising predictive score. During 7 days of ECMO use, organ dysfunction scores were significantly lower for survivors than nonsurvivors. Severe ARDS patients who are younger, have shorter duration of mechanical ventilation, and lower organ dysfunction scores before ECMO initiation have more favorable survival outcome. Early application of ECMO, especially if predictive score is below 2, may improve survival. Organ dysfunction scores before and during ECMO support are correlated with survival.

Multi-scale symbolic entropy analysis provides prognostic prediction in patients receiving extracorporeal life support.

IntroductionExtracorporeal life support (ECLS) can temporarily support cardiopulmonary function, and is occasionally used in resuscitation. Multi-scale entropy (MSE) derived from heart rate variability (HRV) is a powerful tool in outcome prediction of patients with cardiovascular diseases. Multi-scale symbolic entropy analysis (MSsE), a new method derived from MSE, mitigates the effect of arrhythmia on analysis. The objective is to evaluate the prognostic value of MSsE in patients receiving ECLS. The primary outcome is death or urgent transplantation during the index admission.MethodsFifty-seven patients receiving ECLS less than 24 hours and 23 control subjects were enrolled. Digital 24-hour Holter electrocardiograms were recorded and three MSsE parameters (slope 5, Area 6–20, Area 6–40) associated with the multiscale correlation and complexity of heart beat fluctuation were calculated.ResultsPatients receiving ECLS had significantly lower value of slope 5, area 6 to 20, and area 6 to 40 than control subjects. During the follow-up period, 29 patients met primary outcome. Age, slope 5, Area 6 to 20, Area 6 to 40, acute physiology and chronic health evaluation II score, multiple organ dysfunction score (MODS), logistic organ dysfunction score (LODS), and myocardial infarction history were significantly associated with primary outcome. Slope 5 showed the greatest discriminatory power. In a net reclassification improvement model, slope 5 significantly improved the predictive power of LODS; Area 6 to 20 and Area 6 to 40 significantly improved the predictive power in MODS. In an integrated discrimination improvement model, slope 5 added significantly to the prediction power of each clinical parameter. Area 6 to 20 and Area 6 to 40 significantly improved the predictive power in sequential organ failure assessment.ConclusionsMSsE provides additional prognostic information in patients receiving ECLS.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0548-3) contains supplementary material, which is available to authorized users.

Pilot investigation of the association between serum stress neuropeptide levels and lymphocyte expression of fas and fas ligand in critical illness.

In critical illness, apoptotic loss of immunocytes is associated with immunosuppression. To explore expression of Fas/Fas ligand (FasL) on B and T cells from critically ill patients without sepsis compared to matched controls and associations with disease severity and neuropeptide Y (NPY), cortisol, adrenocorticotropic hormone (ACTH), and prolactin (PRL) levels. Repeated-measures correlational design with 36 critically ill patients (14-day follow-up) and 36 controls. Disease severity was assessed using the Multiple Organ Dysfunction Score (MODS) and Multi Organ Failure scale. Fas/FasL values were standardized for viable cell counts. An enzyme-linked immunosorbent assay (NPY) and electrochemiluminescence immunoassay (cortisol, ACTH, and PRL) were employed. Fas and FasL expression on T-helper (p < .0001-.03) and T-cytotoxic cells (p < .0001-.002) and Fas expression on B cells (p < .0001-.03) were higher in patients. MODS severity was associated with FasL expression on cytotoxic T cells (r = .752-.902, p = .023-.037). There was an inverse association between Day 1 NPY levels and Fas expression on T-helper cells (r = -.447, p = .019). On the day of maximum severity, we report for the first time an inverse association between NPY levels and FasL expression on helper (r = -.733, p = .016) and cytotoxic (r = -.862, p = .003) T cells. Cortisol levels were positively associated with counts of FasL-positive helper (r = .828) and cytotoxic (r = .544, p < .05) T cells. Results suggest a potential role for stress neuropeptides in lymphocyte survival and activation in critical illness.

The EUPHRATES trial (Evaluating the Use of Polymyxin B Hemoperfusion in a Randomized controlled trial of Adults Treated for Endotoxemia and Septic shock): study protocol for a randomized controlled trial.

BackgroundSeptic shock is common and has unacceptably high morbidity, mortality, and associated cost with numerous failed attempts at developing effective therapies. Endotoxin, one of the most potent mediators of sepsis, is found in high levels in approximately 50% of patients with septic shock. Polymyxin B (PMX) hemoperfusion has been shown in numerous studies to successfully remove endotoxin and potentially improve outcomes. EUPHRATES (Evaluating the Use of Polymyxin B Hemoperfusion in a Randomized controlled trial of Adults Treated for Endotoxemia and Septic shock) is a theragnostic trial (matching blood measurement to treatment capability) of PMX hemoperfusion in patients with septic shock and confirmed endotoxemia as measured by the endotoxin activity assay (EAA).MethodsEUPHRATES is a pivotal regulatory trial that is multi-centered, placebo-controlled and blinded. The trial is being conducted in fifty ICUs in the United States and Canada and is powered to enroll 360 patients. Patients with persistent septic shock despite adequate fluid resuscitation on vasopressors for more than 2 and less than 30 hours are eligible for measurement of the EAA. Those with EAA ≥0.60 are eligible to be randomized to treatment with two sessions of PMX hemoperfusion 24 hours apart. The primary endpoint for the trial is 28-day all-cause mortality.DiscussionUnique features of the trial include absence of systemic inflammatory response (SIRS) criteria as a requirement for inclusion, use of the EAA to confirm endotoxemia as a requisite for treatment, and use of a detailed “façade” hemoperfusion event as a blinding mechanism. The outcomes of the second interim analysis included a resizing of the trial to 650 patients and the addition of an exclusion criterion of subjects with multiple organ dysfunction score (MODS) ≤ 9. Results are anticipated in 2016.Trial registrationClinicaltrials.gov identifier: NCT01046669. Registered: January 8, 2010.

Bacterial species-specific hospital mortality rate for intra-abdominal infections.

Intra-abdominal infections (IAIs) are a major cause of morbidity and death. We hypothesized that the involvement of specific organisms would predict death independently. All patients with IAIs treated at an academic tertiary-care facility over eight years (June 1999-June 2007) were included. The data collected were demographics, co-morbidities, source of infection, intra-abdominal culture results, type of infection (community-acquired vs. nosocomial), type of intervention (operative vs. percutaneous drainage), and outcome. The Charlson Comorbidity Index and multiple organ dysfunction score (MODS) were used in the analysis. A total of 389 patients were admitted for 452 infection episodes (IEs) during the study period. None of the 129 patients with appendiceal-related infections died, and these patients were excluded from further analysis. Thus, 323 non-appendiceal IEs were evaluated. The overall mortality rate was 8.7%. The mean age of the patients was 54 y, and 50% of them were male. Intra-abdominal cultures were obtained from 303 IEs (93.8%). The most common cause of IAI was post-operative infection (44%). There were 49 distinct species isolated. The most common were Enterococcus (105), Escherichia coli (75), Streptococcus (62), Staphylococcus (51), and Bacteroides (46). Bivariable analysis revealed multiple risk factors associated with death. Logistic regression demonstrated that independent risk factors for death were age ≥65 years (odds ratio [OR] 3.92), cardiac event (OR=8.17), catheter-related blood stream infection (OR=6.16), and growth of Clostridium (OR=13.03). The growth of Streptococcus was predictive of survival. The C statistic was 0.89. In addition to age and intrinsic patient factors, the presence of specific bacterial organisms independently predicts death in patients with non-appendiceal IAI.

Therapeutic effectiveness analysis of Xuebijing, Xiyanping combined with naloxone in the treatment of acute coagulation disorders during severe thoracoabdominal injuries

Objective To observe the therapeutic effectiveness of the early intervention of Xuebijing (XBJ) Xiyanping and Naloxone (NX) in acute coagulation disorders during severe thoracoabdominal injuries.Methods Severe thoracoabdominal injury patients with trauma index (TI) ≥ 17 points except the ones associated craniocerebral injuries and died in emergency department were randomly divided into two groups:a intervention group (n=82) and a control group (n=47); The patients were all collected at 253th Hosptital of PLA between January 2009 and June 2012.The intervention group was tested at the time of arriving at the emergency department and the time of leaving the emergency department to the inpatient department for platelet count (PLT),D-dimer (D-D),activated partial thromboplastin (APPT),prothrombin time (PT),thromboplastin time (TT),tumor necrosis factor-α (TNF-α),lipopolysaccharide (LPS),interleukin-6 (IL-6),phospholipase A2 (PLA2) and platelet-activating factor (PAF).The control group was just tested at the time of leaving the emergency department for the same items.Results At the time of arriving at the emergency department,PLT was (83.44±38.52) 109/L,D-D was (1 823.89±608.02) U/L,APTT was (68.24±24.12) s,PT was (28.42± 10.83) s,TT was (58.27 ± 12.44) s,PLA2 (41.35 ± 14.26) ng/ml,PAF (15 765.31 ± 4431.65) ng/L; At the time of leaving the emergency department,PLT was (127.59±27.18) 109/L,D-D was (769.42± 106.34)U/L,APTT was (49.11 ±12.76) s,PT was (19.51 ±8.23) s,TT was (31.44±9.17) s,PLA2 (19.16±7.11)ng/ml,PAF (6 722.56± 1 049.34)ng/L;At the time of leaving the emergency department the records of the control group of severe thoracoabdominal injury patients,PLT was (89.22±31.27) 109/L,D-D was (1 814.45±643.18) U/L,APTT was (63.48±28.27) s,PT was (27.79 ± 11.94) s,TT was (60.51 ± 14.23) s,PLA2 (44.71 ± 16.52) ng/ml、PAF (15 933.07 ± 4573.19) ng/L.After the intervention the records of PLT were higher,the ones of D-D、APTT、PT、TT were lower; the records of TNF-α、LPS、IL-6、PLA2 and PAF were significantly lower than the time before intervention and the control group (all P＜0.01).Conclusion XBJ,Xiyanping and NX can significantly improve the acute coagulation disorders during severe thoracoabdominal injuries which have important significance in reducing incidence rate of complication,preventing multiple organ dysfunction score (MODS),improving prognosis and increasomg survival rate. Key words: Severe thoraco-abdominal injuries; Acute coagulation disorders; Xuebijing; Xiyanping; Naloxone; Treatment effectiveness analysis

Determination of protein phosphatase type 2A in monocytes from multiple trauma patients: a potential biomarker for sepsis

BackgroundProtein phosphatase type 2A (PP2A) can downregulate c-Jun N-terminal kinase (JNK) expression in monocytes stimulated by lipopolysaccharide. However, this effect has not been evaluated in patients with sepsis. We sought to determine whether PP2A/JNK pathway is involved in sepsis and whether PP2A expression can be associated with patient outcome. Materials and methodsWe measured PP2A, c-Jun, and JNK protein as well as PP2A and c-Jun messenger RNA in monocytes from trauma patients with (n = 24) or without (n = 22) sepsis 1 and 7 d after major trauma and from healthy volunteers (n = 15) by Western blotting and quantitative real-time polymerase chain reaction. Patient outcomes, including intensive care unit length of stay, Sequential Organ Failure Assessment score, and Multiple Organ Dysfunction score were compared between groups. Correlations between PP2A and c-Jun/JNK expression as well as patient outcomes were analyzed. Receiver operating characteristic analysis was performed to determine the diagnostic efficiency of PP2A for sepsis. ResultsPP2A protein and messenger RNA expression were significantly higher in septic patients compared with nonseptic patients or healthy volunteers. Conversely, the expressions of JNK and c-Jun were significantly reduced in septic patients and correlated inversely with PP2A expression. Furthermore, PP2A expression was positively associated with LOS, Sequential Organ Failure Assessment and Multiple Organ Dysfunction score at day 1 and day 7. Receiver operating characteristic curve yielded a high sensitivity (87.5%) of PP2A in discriminating septic versus nonseptic patients. ConclusionsPP2A may serve as a negative regulator of the JNK pathway and a biomarker for sepsis.

Survival in Fully Manifest Multiple Organ Dysfunction Syndrome

Multiple organ dysfunction syndrome (MODS) is the leading cause of death in intensive care units throughout the world. Several composite clinical scores, such as the Multiple Organ Dysfunction (MOD) score and Sequential Organ Failure Assessment (SOFA) score, have been developed to assess the severity of critical illness and predict mortality. Survival in fully manifest MODS is nearly unprecedented. Case report and review of the relevant literature. A 55-year-old male was admitted to the neurologic intensive care unit with left lateral medullary syndrome, and access for permanent enteral feeding was indicated. On day 7 of the patient's hospitalization an attempt was made to place a gastrostomy tube in the patient, but the procedure was aborted after unexplained intra-operative hemodynamic instability. Eight days later the patient developed florid MODS of unclear etiology. His daily MOD and SOFA scores peaked at 16 and 20, respectively, and his cumulative MOD and SOFA scores peaked at 19 and 22, respectively, portending 100% mortality. Over the next 6 wks the patient gradually recovered nearly all organ function, until both his MOD and SOFA scores decreased to 1. He was discharged to a sub-acute rehabilitation facility. This patient is the oldest patient reported to have survived fully manifest MODS. Whereas scoring systems such as the MOD and SOFA systems can be useful tools, they have several limitations and their results must be interpreted with caution.

An Evidence-Based Proposal for Predicting Organ Failure in Severe Acute Pancreatitis

Early, efficient, and accurate evaluation for organ failure is an important step for improving outcome in severe acute pancreatitis (SAP). We aim to develop a method that can early, efficiently, and accurately evaluate the in-hospital organ failure in patients with SAP. Using multivariate logistic regression analysis, the associative factors for in-hospital organ failure were evaluated retrospectively from conventional data obtained from 393 patients with SAP from 2000 to 2012. In classification and regression tree analysis, a new clinical scoring system was developed for the evaluation of in-hospital organ failure in SAP. We also compared the accuracy of our new scoring system with multiple organ dysfunction score and Acute Physiology and Chronic Health Examination II score by the receiver operating characteristic curve. Laboratory results revealed serum calcium level greater than or equal to 1.84 mmol/L, serum creatinine level greater than or equal to 110 µmol/L, age greater than or equal to 72 years, activated partial thromboplastin time less than or equal to 30.95 seconds, and Balthazar computed tomography score greater than or equal to 7 (CCAAB) score system, each contributed 1 point for the prediction of organ failure. The area under the curve of the CCAAB score system was similar to multiple organ dysfunction scores and Acute Physiology and Chronic Health Examination II scores. The new scoring system CCAAB is an efficient and accurate method for the early evaluation of patients with SAP for in-hospital organ failure.

Plasma copeptin levels are associated with prognosis of severe acute pancreatitis

Copeptin reflects the individual stress level, and is correlated with outcomes of critical illness. This study was designed to evaluate its relationship with disease severity, local complications, organ failure and mortality of severe acute pancreatitis (SAP). Seventy-eight SAP patients and 78 sex- and age-matched healthy individuals were recruited. Plasma samples were obtained on admission from SAP patients and at study entry from healthy individuals. Copeptin concentration was determined using enzyme-linked immunosorbent assay. Plasma copeptin level was obviously higher in patients than in healthy individuals, was identified as an independent predictor of local complications, organ failure and in-hospital mortality, was highly associated with traditional predictors of disease severity and mortality including the Acute Physiology and Chronic Health Care Evaluation II score, Ranson score, multiple organ dysfunction score, sequential organ failure assessment score, and predicted local complications, organ failure, and in-hospital mortality of SAP patients with high areas under receiver operating characteristic curve. Furthermore, its predictive value was similar to the traditional predictors’. However, it could not improve these traditional predictors’ predictive values. Therefore, increased plasma copeptin level is associated with disease severity and identified as a novel prognostic marker of local complications, organ failure and mortality after SAP.

Assessment of the severity of acute destructive pancreatitis for proper treatment selection

The review covers the most common integrated scales used for the assessment of severity of acute destructive pancreatitis. The use of those scales in the surgical in-patient department is discussed. Different views of Russian and foreign pancreatologists on the use of integrated scales to predict the disease outcome according to various criteria (clinical, laboratory, and special examination methods) are presented. Because of the acute pancreatitis morphological forms variety at admission for urgent surgery, there is a need for a comprehensive assessment of the disease severity in such patients. First stage of assessment is based on clinical data obtained at admission; correlation with systemic organ failure is also taken into account. This approach helps to distinguish mild, moderate and severe clinical course of disease. The use of multiple integral scales used for clinical assessment, with the number of possible options exceeding 20, is widely applied when the patient is admitted. The surgeon’s selection of a scale for assessment of the disease severity depends on the available equipment and the time for evaluation. Currently, the multi-parameter prognostic scales Ranson (1972), APACHE II (Acute Physiology And Chronic Health Evaluation, 1990), Glasgow-Imrie (1984), SAPS (Simplified acute physiology score, 1984), MODS (Multiple Organ Dysfunction Score, 1995), SOFA (Sepsis-related Organ Failure. 1996) are considered to be most objective. The use of these scales allows improving the prediction of outcome and necrotic complications by several times.