Multiple Organ Dysfunction Syndrome Score Research Articles

To Study Correlation between MOD Score and Biomarker Values for Early Prediction of MODS in Suspected Cases of Sepsis Cases in Hospital

Background: Utility of biomarkers in early prediction of multiple organ dysfunction syndrome (MODS) in suspected cases of sepsis presenting to the Emergency Department (ED). Aim and Objectives: To correlate the biomarker values (Pro-calcitonin (PCT), C-reactive protein (CRP), NT-pro BNP and Neutrophil gelatinase associated lipocalin (NGAL) with multiple organ dysfunction (MOD) score and to evaluate their role in early prediction of MODS in suspected sepsis patients presenting to ED. Methods: This is a prospective observational study conducted on 65 patients with suspected sepsis. Patients of 18-65 years presented in the ED with triage complaints of fever, respiratory, urinary and abdominal infections, who were sepsis screen positive on arrival and admitted, were enrolled in the study. They were categorized into two groups: Group 1 (MODS score Positive at 48 or 72 hours) and Group 2 (MOD score Negative). Biomarker values in both the groups and its correlation with MOD score was analyzed. Results: At 48 hours, 40 (61.5%) patients were MODS positive with PCT (Sensitivity 100%, OR-12.6, CI-0.6-255.04, p=0.098), CRP (Sensitivity 100%, OR-27.0, CI-1.44-504.0, p=0.027), NTpro BNP (Sensitivity 82.5%, OR-7.07, CI-2.55-22.16, p=0.0008) and NGAL (Sensitivity 77.5%, OR-82.9, CI-9.7-698.16, p=0.0001) with PPV of NGAL (96.88%) and NT-pro BNP (76.74%) and 100% NPV for PCT and CRP. Conclusion: This study established a good correlation of NT-pro BNP and NGAL with positive MODS score suggestive of and highly predictive of developing MODS in suspected cases of sepsis. The normal value of PCT and CRP on arrival in patients with suspected sepsis rules out MODS even at 72 hours during their hospital stay.

The effect of anemia on the severity and prognosis of patients with acute pancreatitis: A single-center retrospective study

Anemia was a risk factor for a worse prognosis of many diseases. This study aims to investigate the relationship between anemia and the severity and prognosis of acute pancreatitis (AP). Inpatients hospitalized at the First Affiliated Hospital of Guangdong Pharmaceutical University with a primary diagnosis of AP between 1st July 2016 to 31st December 2020 were enrolled. Subsequently, disease severity, the incidence of complications, and the prognosis of patients with AP were compared between the anemic group and the non-anemic group. A total of 282 patients with acute pancreatitis were enrolled; 68.43% of them were also diagnosed with anemia. Notably, these patients had more severe disease (higher RANSON, acute physiologic assessment and chronic health evaluation-II, bedside index for severity in acute pancreatitis, and multiple organ dysfunction syndrome scores); higher incidence of organ failure (acute kidney injury [AKI] and acute heart failure); worse prognosis (higher incidence of vasoactive and diuretic agent use, longer hospital stays, and higher hospital costs) compared to that of patients without anemia (all P < .05). After adjusting for potential confounders, acute physiologic assessment and chronic health evaluation-II, bedside index for severity in acute pancreatitis, multiple organ dysfunction syndrome scores, hospital stay, and hospital costs in anemic patients were higher than those in non-anemic patients; besides, the incidence of AKI and using a diuretic agent in anemic patients was 6.645 and 4.053 times that of non-anemic patients in AP, respectively (all P < .05). Acute pancreatitis patients with anemia have more disease severity, higher incidence of AKI, and worse prognosis compared to those without anemia.

Electroacupuncture in Treatment of Acute Gastrointestinal Injury in Patients with Severe Traumatic Brain Injury: A Multicenter Randomized Controlled Trial.

To evaluate whether electroacupuncture (EA) would improve gastrointestinal function and clinical prognosis in patients with severe traumatic brain injury (TBI) complicocted by acute gastrointestinal injury (AGI). This multicenter, single-blind trial included patients with TBI and AGI admitted to 5 Chinese hospitals from September 2018 to December 2019. A total of 500 patients were randomized to the control or acupuncture groups using a random number table, 250 cases in each group. Patients in the control group received conventional treatment, including mannitol, nutritional support, epilepsy and infection prevention, and maintenance of water, electrolytes, and acid-base balance. While patients in the acupuncture group received EA intervention at bilateral Zusanli (ST 36), Shangjuxu (ST 37), Xiajuxu (ST 39), Tianshu (ST 25), and Zhongwan (RN 12) acupoints in addition to the conventional treatment, 30 min per time, twice daily, for 7 d. The primary endpoint was 28-d mortality. The secondary endpoints were serum levels of D-lactic acid (D-lac), diamine oxidase (DAO), lipopolysaccharide (LPS), motilin (MTL) and gastrin (GAS), intra-abdominal pressure (IAP), bowel sounds, abdominal circumference, AGI grade, scores of gastrointestinal failure (GIF), Glasgow Coma Scale (GCS), Acute Physiology and Chronic Health Evaluation (APACHE II), Sequential Organ Failure Assessment (SOFA), and Multiple Organ Dysfunction Syndrome (MODS), mechanical ventilation time, intense care unit (ICU) stay, and the incidence of hospital-acquired pneumonia. The 28-d mortality in the acupuncture group was lower than that in the control group (22.80% vs. 33.20%, P<0.05). Compared with the control group, the acupuncture group at 7 d showed lower GIF, APACHE II, SOFA, MODS scores, D-lac, DAO, LPS, IAP, and abdominal circumference and higher GCS score, MTL, GAS, and bowel sound frequency (all P<0.05). In addition, the above indices showed simillar changes at 7 d compared with days 1 and 3 (all P<0.05) in the EA group. Early EA can improve gastrointestinal function and clinical prognosis in patients with severe TBI complicated by AGI. (Registration No. ChiCTR2000032276).

Prospective study of etiology, intervention, morbidity and mortality associated with sirs and mods following intra-abdominal infection and trauma

Multiple organ failure is a major cause of morbidity and mortality in the critically ill patient. The syndrome involves the progressive dysfunction of the physiological system in the presence of Major injuries and operations for intra abdominal sepsis. This study was aimed at studying the incidence of systemic inflammatory response syndrome (SIRS) and multiple-organ dysfunction syndrome (MODS) in intraabdominal infections due to various causes, traumatic and non traumatic, mortality and morbidity associated and various interventions done for the patients. This study followed 200 patients in over 3 years. The incidence of SIRS and MODS in intraabdominal infection was found to be 11% and it accounts for 36.8% for all trauma admission. Mortality rate associated with SIRS and MODS appears to be 22%. There was a stronger correlation between observed and predicted mortality rate in SIRS and MODS score, there by indicating their greater usefulness in predicting the outcome.

The role of antimicrobial resistance on long-term mortality and quality of life in critically ill patients: a prospective longitudinal 2-year study

BackgroundIn the recent era, antimicrobial resistance has been identified as one of the most important threats to human health worldwide. The rapid emergence of antibiotic-resistant pathogens (ABRP) in the modern intensive care unit (ICU) also represents a “nightmare scenario” with unknown clinical consequences. In the Greek ICU, in particular, gram negative ABRPs are now considered endemic. However, the possible longitudinal impact of ABRPs on long-term outcomes of ICU patients has not yet been determined.MethodsIn this two-year (January 2014-December 2015) single-centre observational longitudinal study, 351 non-neurocritical ICU patients ≥ 18 year-old were enrolled. Patients’ demographic, clinical and outcome data were prospectively collected. Quality-adjusted life years (QALY) were calculated at 6, 12, 18 and 24 months after ICU admission.ResultsFifty-eight patients developed infections due to ABRP (ABRP group), 57 due to non-ABRP (non-ABRP group), and 236 demonstrated no infection (no-infection group) while in ICU. Multiple regression analysis revealed that multiple organ dysfunction syndrome score (OR: 0.676, 95%CI 0.584–0.782; P < 0.001) and continuous renal replacement therapy (OR: 4.453, 95%CI 1.805–10.982; P = 0.001) were the only independent determinants for ABRP infections in ICU. Intra-ICU, 90-day and 2-year mortality was 27.9%, 52.4% and 61.5%, respectively. Compared to the non-ABRP and no-infection group, the ABRP group demonstrated increased intra-ICU, 90-day and 2-year mortality (P ≤ 0.022), worse 2-year survival rates in ICU patients overall and ICU survivor subset (Log-rank test, P ≤ 0.046), and poorer progress over time in 2-year QALY kinetics in ICU population overall, ICU survivor and 2-year survivor subgroups (P ≤ 0.013). ABRP group was further divided into multi-drug and extensively-drug resistant subgroups [MDR (n = 34) / XDR (n = 24), respectively]. Compared to MDR subgroup, the XDR subgroup demonstrated increased ICU, 90-day and 2-year mortality (P ≤ 0.031), but similar 90-day and 2-year QALYs (P ≥ 0.549). ABRP infections overall (HR = 1.778, 95% CI 1.166–2.711; P = 0.008), as well as XDR [HR = 1.889, 95% CI 1.075–3.320; P = 0.027) but not MDR pathogens, were independently associated with 2-year mortality, after adjusting for several covariates of critical illness.ConclusionsThe present study may suggest a significant association between ABRP (especially XDR) infections in ICU and increased mortality and inability rates for a prolonged period post-discharge that requires further attention in larger-scale studies.

P0635 / #1815: A PROSPECTIVE COHORT STUDY ON THE EVOLUTION OF INFECTION MARKERS IN CHILDREN WITH SEVERE BACTERIAL INFECTIONS TREATED WITH ANTIBIOTICS

Aims & Objectives: Inflammatory biomarkers have been used to guide antibiotic duration in adults and neonates, but their utility in children admitted to pediatric intensive care units (PICUs) is unknown. Our objective was thus to characterize the temporal behaviour of biomarkers (C-reactive protein [CRP], procalcitonin, and white blood cell [WBC] count) in children with severe bacterial infections. Methods: Ongoing prospective cohort study in 7 Canadian PICUs including patients 1 month to 18 years old admitted with suspected or proven severe bacterial infection (sepsis, pneumonia, and central nervous system and intrabdominal infections) and who were prescribed ≥1 antimicrobial. We measure biomarker levels from days 1 to 7 and day 10 of antibiotic treatment. We used Pearson’s correlation coefficient and multivariable linear regressions. Results: We have enrolled 208 patients. Median age was 56.0 months (interquartile range [IQR] 14.8 – 103.0). Median antibiotic duration was 9.5 days (IQR 6.0 – 14.0). Absolute levels of CRP and procalcitonin were highest on day 1 and descended over the course of treatment. By day 5, 82% and 43% of patients had ≥80% drop in procalcitonin and CRP levels, respectively. Patients with ≥50% drop in CRP from days 1 to 3 had a shorter hospital stay (-6.4 days, 95% confidence interval [CI] -12.2, -0.8). There was a strong correlation between mean daily values of multiple organ dysfunction syndrome scores with mean daily CRP (0.93, 95%CI 0.66, 0.99) and procalcitonin values (0.98, 95%CI 0.88, 0.99).Conclusions: Preliminary data suggest that CRP and procalcitonin may be good candidate biomarkers to personalize antibiotic treatment duration in children.

Evaluation of the usefulness of red blood cell distribution width in critically ill pediatric patients.

Red blood cell distribution width (RDW) is a component of routine complete blood count, which reflects variability in the size of circulating erythrocytes. Recently, there have been many reports about RDW as a strong prognostic marker in various disease conditions in the adult population. However, only a few studies have been performed in children. This study aimed to investigate the association between RDW and pediatric intensive care unit (PICU) mortality in critically ill children. This study includes 960 patients admitted to the PICU from November 2012 to May 2018. We evaluated the associations between RDW and clinical parameters including PICU mortality outcomes. The median age of the study population was 15.5 (interquartile range, 4.8–54.5) months. The mean RDW was 15.6% ± 3.3%. The overall PICU mortality was 8.8%. As we categorized patients into 3 groups with respect to RDW values (Group 1: ≤14.5%; Group 2: 14.5%–16.5%; and Group 3: >16.5%) and compared clinical parameters, the higher RDW groups (Groups 2 and 3) showed more use of vasoactive-inotropic drugs, mechanical ventilator support, higher severity scores, including pediatric risk of mortality III, pediatric sequential organ failure assessment, pediatric logistic organ dysfunction-2 (PELOD-2), and pediatric multiple organ dysfunction syndrome scores, and higher PICU mortality than the lower RDW group (Group 1) (P < .05). Based on multivariate logistic regression analysis adjusted for age and sex, higher RDW value (≥14.5%) was an independent risk factor of PICU mortality. Moreover, adding RDW improved the performance of the PELOD-2 score in predicting PICU mortality (category-free net reclassification index 0.357, 95% confidence interval 0.153–0.562, P = .001). In conclusion, higher RDW value was significantly associated with worse clinical parameters including PICU mortality. RDW was an independent risk factor of PICU mortality and the addition of RDW significantly improved the performance of PELOD-2 score in predicting PICU mortality. Thus, RDW could be a promising prognostic factor with advantages of simple and easy measurement in critically ill pediatric patients.

Effect of sub-hypothermia blood purification technique in cardiac shock after valvular disease surgery.

To observe the effect of sub-hypothermia (HT) blood purification technique in the treatment of cardiac shock after heart valve disease.The patients were randomly divided into normothermic (NT) continuous blood purification (CBP) group (NT group) and HT CBP group (HT group). Observe the cardiac index (CI), the oxygen delivery (DO2) and oxygen consumption (VO2) ratio, Acute Physiology and Chronic Health Evaluation III(APACHE III) score, multiple organ dysfunction syndrome (MODS) score, dynamic monitoring of electrocardiograph, blood loss with or without muscle tremors, intensive care unit stay, mechanical ventilation time, CBP time, and the cases of infection and mortality at 0 day, 1 day, 2 day, 3 day; all above indicators were compared between 2 groups.Ninety-five patients were randomly assigned into HT group (48 cases) and NT group (47 cases); there were no significant differences between the 2 groups for age, gender, pre-operative cardiac function, cardiothoracic ratio, and type of valve replacement (P > .05). There were no significant differences among the 1 day, 2 day, 3 day after recruited for CI, DO2/VO2 ratio, APACHE III score, MODS score (P > .05). But in HT group, DO2/VO2 ratio had been significantly improved after treatment for 1 day (2.5 ± 0.7 vs 1.8 ± 0.4, P = .024), and CI (3.0 ± 0.5 vs 1.9 ± 0.7, P = .004), APACHE III score (50.6 ± 6.2 vs 77.5 ± 5.5 P = .022), MODS score (6.0 ± 1.5 vs 9.3 ± 3.4, P = .013) also had been significantly improved after treatment for 3 days. In clinical outcomes, there were no significant differences between 2 groups for blood loss (617.0 ± 60.7 ml vs 550.9 ± 85.2 ml, P = .203), infection ratio (54.17% vs 53.19%, P = .341), the incidence of ventricular arrhythmia (31.25% vs 36.17%, P = .237), and muscle tremors (14.58% vs 8.51%, P = .346), while there were significant differences between 2 groups for intensive care unit stay (6.9 ± 3.4 days vs 12.5 ± 3.5 days, P = .017,), mechanical ventilation time (4.2 ± 1.3 days vs 7.5 ± 2.7 days, P = .034,), CBP time (4.6 ± 1.4 days vs 10.5 ± 4.0 days, P = .019), mortality (12.50% vs 23.40%, P = .024). But the incidence of bradycardia in HT group was much higher than the NT group (29.16% vs 14.89%, P = .029).HT blood purification is a safer and more effective treatment than NT blood purification for patients who suffered from cardiac shock after valve surgery.

Predictive Value of Osteoprotegerin and Neutrophil Gelatinase-associated Lipocalin on Multiple Organ Failure in Multiple Trauma.

Multiple organ dysfunction syndrome (MODS) is the leading cause of late posttraumatic mortality. This study analyzed the prognostic values of osteoprotegerin (OPG) and neutrophil gelatinase-associated lipocalin (NGAL/lipocalin 2) compared to interleukin-6 (IL-6) in multiply injured patients. A retrospective observational cohort study on multiply injured patients with an injury severity score (ISS) of ≥16 was performed. OPG, NGAL and IL-6 blood concentrations were measured. Statistical analysis comprised receiver-operating-characteristic (ROC) analysis with the corresponding area under the curve (AUC). Thirty-nine patients with a mean ISS of 34±11 were included. Fourteen patients (36%) developed MODS and 8 patients (21%) died. Plasma levels of NGAL, OPG, and IL-6 were significantly elevated in the MODS+ group. Each biomarker positively correlated with MODS score and diagnosis of MODS. NGAL and OPG might be indicative of MODS and could have the potential to be biomarkers in the early detection of patients at risk of posttraumatic MODS.

Impact of timing of antibiotic bundle therapy on outcomes in septic shock patients: a multicenter retrospective investigation

The clinical data of 372 patients with septic shock admitted in departments of critical care medicine of three Grade A tertiary hospitals from January 2013 to December 2015 were retrospectively reviewed, including 211 survival cases and 161 fatal cases. According to septic shock early goal-directed therapy implementation, 117 patients received bundle therapy (bundle group), including 30 cases with bundle goal-fully achieved, and 87 cases with bundle goal-partly achieved; and 255 cases received conventional treatment (non-bundle group). Multiple logistic regression analysis showed that the multiple organ dysfunction syndrome score, length of ICU stay and first time using of antibiotics were independent risk factors for prognosis of septic shock (P 0.05), while the fatality in bundle goal-fully achieved group(20.0%)was significantly lower than that of goal-partly achieved group (55.2%) and non-bundle group (42.0%) (P<0.05). Survival curve analysis showed that the medial survival time in bundle goal-fully achieved group was significantly higher than that in non-bundle group(19.4 vs. 10.5 days, P<0.05) and that in control group plus goal-partly achieved group(19.4 vs. 12.9 days, P<0.05). Multiple Logistic regression analysis showed that central venous oxygen saturation and antibiotics using within one hour were protective factors for prognosis of septic shock (P<0.05). The results indicate that antibiotic bundle treatment of all indicators up to standards could significantly reduce the mortality of septic patients and early antibiotics is important in bundle treatment. Key words: Shock, septic; Combined modality therapy; Anti-bacterial agents; Hospital mortality

Safety and efficacy of regional citrate anticoagulation in continuous blood purification treatment of patients with multiple organ dysfunction syndrome.

The aim of this study was to discuss the safety and efficacy of regional citrate anticoagulation (RCA) on continuous blood purification (CBP) during the treatment of multiple organ dysfunction syndrome (MODS). Thirty-five patients with MODS were divided into two groups: the local citrate anticoagulation (RCA) group, and the heparin-free blood purification (hfBP) group. The MODS severity was assessed according to Marshall’s MODS score criteria. Blood coagulation indicators, blood pressure, filter lifespan, filter replacement frequency, anticoagulation indicators, and main metabolic and electrolyte indicators were analyzed and compared between RCA and hfBP groups. RCA resulted in lower blood pressure than hfBP. The filter efficacy in RCA treatment was longer than in the hfBP group. The blood clearance of creatine, blood urea nitrogen and uric acid was better in the RCA group. RCA also led to higher pH than hfBP. Neither treatment resulted in severe bleeding events. In addition, MODS score was positively correlated with prothrombin time and activated partial thromboplastin time but negatively correlated with platelet concentration. RCA is a safer and more effective method in CBP treatment; however, it could also lead to low blood pressure and blood alkalosis.

High-volume hemofiltration in adult burn patients with septic shock and acute kidney injury: a multicenter randomized controlled trial

BackgroundSepsis and septic shock occur commonly in severe burns. Acute kidney injury (AKI) is also common and often results as a consequence of sepsis. Mortality is unacceptably high in burn patients who develop AKI requiring renal replacement therapy and is presumed to be even higher when combined with septic shock. We hypothesized that high-volume hemofiltration (HVHF) as a blood purification technique would be beneficial in this population.MethodsWe conducted a multicenter, prospective, randomized, controlled clinical trial to evaluate the impact of HVHF on the hemodynamic profile of burn patients with septic shock and AKI involving seven burn centers in the United States. Subjects randomized to the HVHF were prescribed a dose of 70 ml/kg/hour for 48 hours while control subjects were managed in standard fashion in accordance with local practices.ResultsDuring a 4-year period, a total of nine subjects were enrolled for the intervention during the ramp-in phase and 28 subjects were randomized, 14 each into the control and HVHF arms respectively. The study was terminated due to slow enrollment. Ramp-in subjects were included along with those randomized in the final analysis. Our primary endpoint, the vasopressor dependency index, decreased significantly at 48 hours compared to baseline in the HVHF group (p = 0.007) while it remained no different in the control arm. At 14 days, the multiple organ dysfunction syndrome score decreased significantly in the HVHF group when compared to the day of treatment initiation (p = 0.02). No changes in inflammatory markers were detected during the 48-hour intervention period. No significant difference in survival was detected. No differences in adverse events were noted between the groups.ConclusionsHVHF was effective in reversing shock and improving organ function in burn patients with septic shock and AKI, and appears safe. Whether reversal of shock in these patients can improve survival is yet to be determined.Trial registrationClinicaltrials.gov NCT01213914. Registered 30 September 2010.

Clinical relevance of peroxisome proliferator-activated receptor-γ gene polymorphisms with sepsis.

Peroxisome proliferator-activated receptor-γ (PPARγ) is a regulator of inflammation. This study aimed to explore associations between PPARγ gene single-nucleotide polymorphisms (SNPs) and susceptibility to and clinical outcome of sepsis in the North China Han population. This study included 303 patients with sepsis and 303 controls. We conducted genetic typing for 13 common PPARγ gene SNPs (improved multiplex ligation detection reaction), linkage disequilibrium mapping, and haplotype inference. Associations between SNP genotypes/haplotypes and sepsis susceptibility and outcome (septic shock, organ dysfunction, or death) were assessed using unconditional logistic regression analysis. For rs2972164, patients with genotypes CT/CT+TT had higher risk of sepsis than genotype CC (odds ratio [95% CI]: 1.74 [1.05-2.86], P=.03 and 1.72 [1.06-2.80], P=.026, respectively); the T allele was associated with increased sepsis risk compared with the C allele (1.64 [1.04-2.58], P=.033). For rs1801282, genotypes CG/CG+GG had lower risk of sepsis than genotype CC (0.55 [0.33-0.92], P=.024 and 0.57 [0.35-0.95], P=.03, respectively); the G allele was associated with decreased sepsis risk compared with the C allele (0.62 [0.39-1.01], P=.055). For rs4135275, genotypes AG/AG+GG had higher risk of severe organ dysfunction (multiple organ dysfunction syndrome score >8) than genotype AA (2.66 [1.16-6.09], P=.038 and 2.21 [1.00-4.85], P=.042, respectively). Haplotype TAT (rs2972164, rs4684846, and rs17036188) was associated with increased sepsis risk (1.66 [1.03-2.67], P=.038). No mutation was correlated with septic shock or death. PPARγ gene polymorphisms may play a role in the occurrence and progression of sepsis in the North China Han population.

An observational study of incidence, risk factors & outcome of systemic inflammatory response & organ dysfunction following major trauma.

Background & objectives:Trauma is known to lead to systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), which is often a cause of late deaths after injury. SIRS and MODS have been objectively measured using scoring systems. This prospective observational study was carried out in a tertiary care hospital in India to evaluate SIRS and MODS following trauma in terms of their incidence, the associated risk factors and the effect on the outcome.Methods:All adult patients with major life- and limb-threatening trauma were included. Patients who died within 24 h, those with severe head injury, known comorbidity, immunocompromised state, on immunosuppressants or pregnancy were excluded. SIRS and MODS scores were recorded after initial management (baseline score), on days 3 and 6 of admission. SIRS was defined as SIRS score of ≥2 and MODS was defined as MODS score of ≥1.Results:Two hundred patients were enrolled. SIRS was noted in 156 patients (78%). MODS was noted in 145 (72.5%) patients. Overall mortality was 39 (19.5%). Both SIRS and MODS scores were significantly associated with age >60 yr, blunt injury, (lower) revised trauma score hypotension on admission and (higher) injury severity score, but not with gender, pre-hospital time or operative treatment.Interpretation & conclusions:Both SIRS and MODS scores were associated with longer Intensive Care Unit (ICU) stay, more ICU interventions and higher mortality. Incidence of MODS was significantly higher in patients with SIRS. Both scores showed rising trend with time in non-survivors and a decreasing trend in survivors. The serial assessment of scores can help prognosticate outcome and also allocate appropriate critical care resources to patients with rising scores.

Construction and evaluation of models for early diagnosis and prognosis assessment of trauma sepsis risks

Objective To investigate the value of multiple inflammatory cells and clinical score in early diagnosis and prognosis assessment of trauma sepsis risks. Methods This retrospective control study enrolled 209 severe trauma patients admitted from January 2010 and May 2016. White blood cell count, lymphocyte count and percentage, monocyte count and percentage, neutrophil count and percentage, ratio of neutrophil to lymphocyte count (N/L), acute physiology and chronic health evaluation (APACHE) Ⅱ score, sequential organ failure assessment (SOFA), improved early warning score (MEWS), Glasgow coma score (GCS), multiple organ dysfunction syndrome (MODS) score and lactic acid (LAC) were collected on the day of admission and 3, 5, 7 days after trauma. These data were applied to construct weighted and biological score models for early diagnosis and prognosis of traumatic sepsis. Receiver operating characteristic curve (ROC) was performed and area under the curve (AUC) was calculated to measure the value of the two models in early diagnosis and prognosis of sepsis. Results AUC of the weighted model combined by APACHE Ⅱ score, SOFA score and MEWS was 0.729 on the day of admission. AUC of the weighted model combined by inflammatory cells was 0.680 and AUC of the biological score model was 0.800 3 days after trauma (P 0.05). AUC of the biological score model had significant difference 3 days and 5 days after trauma (P<0.05). Of the weighted model combined by APACHE Ⅱ score, MODS score, GCS and LAC to evaluate the prognosis of sepsis, the AUC showed significant difference on the day of admission (0.838), 3 days after trauma (0.878), 5 days after trauma (0.947) and 7 days after trauma (0.936) (P<0.05). Conclusions Biological score possesses better effect on early diagnosis of sepsis 3 days after trauma. Weighted model combined by APACHE Ⅱ score, MODS score, GCS and LAC can effectively predict the prognosis of sepsis 5 days after trauma. Key words: Sepsis; Diagnosis, differential; Prognosis

Scoring System for Multiple Organ Dysfunction in Adult Horses with Acute Surgical Gastrointestinal Disease.

BackgroundThe prevalence of multiple organ dysfunction syndrome (MODS) in horses with acute surgical gastrointestinal (GI) disease is unknown. Currently, there are no validated criteria to confirm MODS in adult horses.ObjectivesTo develop criteria for a MODS score for horses with acute surgical colic (MODS SGI) and evaluate the association with 6‐month survival. To compare the MODS SGI score with a MODS score extrapolated from criteria used in people (MODS EQ).AnimalsAdult horses that required exploratory laparotomy (n = 62) for colic. Healthy adult horses undergoing elective surgical procedures (n = 12) established the reference range of some variables.MethodsProspectively, a MODS SGI score was developed based on organ‐specific criteria established from a literature review, data collection, and clinical judgment. Data for scoring each horse were collected on Days 1 and 2 postoperatively. Horses were scored retrospectively using both scoring criteria. The prognostic performance of the MODS SGI score and its overall performance compared with the MODS EQ score were assessed with receiver operating characteristic (ROC) curve analysis.ResultsThe MODS SGI score had excellent performance for predicting 6‐month survival with an area under the ROC curve (AUC) of 0.95 (95% CI: 0.87–0.99). The AUC for the MODS SGI score was significantly higher than the MODS EQ (AUC: 0.76; 0.63–0.86).Conclusions and Clinical ImportanceThe MODS SGI score predicts 6‐month survival from discharge in horses with acute surgical colic. The MODS SGI score performed better than a score extrapolated from human scoring systems.

The organ protective effects and timing of continuous blood purification in the treatment of severe sepsis：a double-blind randomized controlled trial

To investigate the organ protective effects and the timing of continuous blood purification (CBP) in the treatment of severe sepsis. A double-blind randomized controlled trial was conducted. Seventy-four patients with severe sepsis aged between 35 years and 80 years with acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) scores over 20 admitted to Department of Critical Care Medicine of the First Hospital of Wuhan from January 2013 to January 2015 were enrolled. They were divided into control group (n = 37) and treatment group (n = 37) by random number table method. All patients in these two groups received conventional therapy following the guidelines for management of severe sepsis in 2012. In addition the patients in treatment group received continuous veno-venous hemofiltration (CVVH). The critical score, liver and kidney function indexes, etc., levels of pro-inflammatory cytokines in plasma and ultra filtrate before and 24, 48, and 72 hours after treatment, and the clinical picture 2 weeks after treatment in two groups were observed. APACHE Ⅱ scores, multiple organ dysfunction syndrome (MODS) scores, Murray scores of acute lung injury, and systemic inflammatory response syndrome (SIRS) scores of the patients of the above two groups were gradually declined after the treatment. The levels of white blood cell count (WBC), procalcitonin (PCT), lactate (Lac), tumor necrosis factor-α (TNF-α), interleukins (IL-6 and IL-8), and endotoxin gradually lowered. Levels of blood urea nitrogen (BUN), serum creatinine (SCr), alanine transaminase (ALT) and the oxygenation index (PaO2/FiO2) showed a tendency of lowering. There were statistically significant differences in scores of critical illness, WBC, PCT, Lac, pro-inflammatory cytokine, liver and kidney function indexes, etc. between treatment group and control group 48 hours after treatment (APACHE Ⅱ score: 15.5±4.7 vs. 20.3±5.3, MODS score: 4.6±1.4 vs. 7.3±2.2, Murray score: 1.4±0.5 vs. 1.7±0.6, SIRS score: 2.9±0.8 vs. 3.7±1.0, WBC (×109/L): 1.1±0.5 vs. 1.6±0.5, PCT (μg/L): 26.7±12.0 vs. 32.4±14.1, Lac (mmol/L): 7.6±2.2 vs. 9.3±2.8, TNF-α (μg/L): 96.3±17.4 vs. 153.4±24.2, IL-6 (μg/L): 146.8±20.6 vs. 213.8±29.2, IL-8 (μg/L): 287.1±43.6 vs. 354.5±56.2, endotoxin (kEU/L): 1.4±0.5 vs. 2.6±0.8, BUN (mmol/L): 8.7±3.6 vs. 18.5±6.4, SCr (μmol/L): 143±39 vs. 197±42, ALT (U/L): 141±27 vs. 183±34, PaO2/FiO2 (mmHg, 1 mmHg = 0.133 kPa): 150.3±45.4 vs. 124.7±32.1, all P < 0.05], and the difference was significant up to 72 hours. In the treatment group, TNF-α, IL-6, IL-8, and endotoxin could be decreased in the filtrate 24 hours and 48 hours after treatment and they correlated with the lowering tendency of their plasma levels. Compared with the control group, CVVH based on conventional treatment of severe sepsis could significantly reduce the incidence of MODS (10.8% vs. 29.7%, χ2 = 4.423, P = 0.038) and mortality (5.4% vs. 13.5%, χ2 = 4.674, P = 0.032), and remarkably shortened the duration of mechanical ventilation (days: 3.1±0.6 vs. 5.3±1.7, t = 2.103, P = 0.045), and the length of intensive care unit (ICU) stay (days: 8.5±1.7 vs. 13.2±2.4, t = 2.245, P = 0.042). Early CBP can decrease the level of pro-inflammatory cytokines, prevent MODS, and remarkably improve the prognosis of patients with severe sepsis.

The value of determination of serum cholinesterase levels in judgment of severity and prognosis in patients with severe pneumonia

To investigate the value of serum cholinesterase (S-ChE) levels in judgment of severity and prognosis in patients with severe pneumonia. The clinical data of patients with severe pneumonia, who were admitted to the Department of Internal Medicine in the First Affiliated Hospital of Sun Yat-sen University, or the Department of Neurology in the Third People's Hospital of Foshan from May 2011 to May 2015, whose hospital time was longer than 24 hours, were retrospectively analyzed. They were divided into survival group and death group according to the final outcome. Lab data, acute physiology and chronic health evaluation II (APACHE II) score, multiple organ dysfunction syndrome (MODS) score, the improved pneumonia score of British Thoracic Society (confusion, uremia, respiratory, blood pressure, age 65 years, CURB-65), and S-ChE levels of all patients were collected after they were hospitalized into the intensive care unit (ICU) within 24 hours. Independent risk factors for prognosis were analyzed by binary logistic regression analysis, and receiver operating characteristic curve (ROC) was plotted. Best truncation point analysis was used to compare their estimated value for prognosis of patients with severe pneumonia. Eighty-six patients with severe pneumonia were studied. Among them 46 patients survived, and 40 patients died. By the single factor analysis, the following lab data in the death group were found significantly lower than those in the survival group: S-ChE levels (kU/L: 2.748±0.826 vs. 4.489±1.360, t' = 7.274, P = 0.000), arterial partial pressure of oxygen [PaO2 (mmHg, 1 mmHg = 0.133 kPa): 52.55±18.29 vs. 60.83±16.65, t = 2.196, P = 0.031], oxygenation index (mmHg: 114.20±48.01 vs. 167.10±69.68, t' = 4.229, P = 0.000), and carbon dioxide combining power [CO2-CP (mmol/L): 22.85±5.44 vs. 26.00±7.63, t' = 2.225, P = 0.029]. The following clinical data were significantly higher in the death group than those in the survival group, namely body temperature (centigrade: 38.67±1.18 vs. 37.74±1.18, t = -3.627, P = 0.000), pulse (bpm: 130.65±15.72 vs. 107.26±19.61, t' = -6.133, P = 0.000), the ratio of concomitant chronic lung disease [45.0% (18/40) vs. 13.0% (6/46), χ(2) = 10.860, P = 0.001], fraction of inspired oxygen [FiO2: 0.495 (0.410, 0.600) vs. 0.380 (0.290, 0.500), Z = -3.265, P = 0.001], APACHE II score (25.80±5.07 vs. 16.39±5.12, t =-8.540, P = 0.000), CURB-65 score [3 (3, 4) vs. 2 (1, 2), Z = -5.562, P = 0.000], MODS score (8.15±2.49 vs. 4.35±2.01, t = -7.832, P = 0.000), international normalized ratio [INR: 1.22 (1.08, 1.31) vs. 1.07 (1.00, 1.10), Z = -4.231, P = 0.000], and activated partial thromboplastin time [APTT (s): 33.80 (32.13, 38.75) vs. 28.50 (25.70, 36.00), Z = -3.482, P = 0.000]. Binary logistic regression analysis showed that, S-ChE levels, APACHE II score and MODS score were found to be the independent risk factors for prognosis in the patients with severe pneumonia, respectively [S-ChE: odds ratio (OR) = 0.084, 95% confidence interval (95%CI) = 0.017-0.424, P = 0.003; APACHE II score: OR = 1.675, 95%CI = 1.098-2.556, P = 0.017; MODS score: OR = 2.189, 95%CI = 1.262-3.800, P = 0.005]. The area under ROC (AUC) for S-ChE levels, APACHE II score and MODS score were 0.874±0.036, 0.889±0.033 and 0.884±0.035, respectively (all P > 0.05 as compared between any two means). At the best truncation points of S-ChE levels, APACHE II score and MODS score were 3.372 kU/L, 19.5 score, and 6.5 score respectively. The sensitivity, specificity, positive predictive value and negative predictive value in predicting death risk in patients with severe pneumonia were (80.0%, 78.0%, 76.19% and 81.82%), (95.0%, 70.0%, 73.08% and 94.12%) and (70.0%, 91.0%, 87.50%, 77.78%), respectively. If S-ChE levels was combined with APACHE II score or combined with MODS score, the sensitivity, specificity, positive predictive value and negative predictive value [S-ChE levels combined APACHE II score: 100%, 92.0%, 93.75% and 100%; S-ChE levels combined MODS score: all 100%] were higher than single power of S-ChE levels, APACHE II score or MODS score. S-ChE levels can be considered as an effective and practical index to estimate the severity and prognosis in patients with severe pneumonia. The combined application of S-ChE levels and APACHE II score or MODS score can obviously improve the prognostic power in patients with severe pneumonia.

Clinical significance of vascular endothelial growth factor levels in bronchoalveolar lavage fluid of patients with acute lung injury

Objective To test the levels of vascular endothelial growth factor (VEGF) in bronchoalveolar lavage fluid (BALF) during acute lung injury (ALI)/ acute respiratory distress syndome (ARDS) after the interference with anticoagulation and fibrinolytic in an attempt to find a possible treatment plan for ALI/ARDS. Methods Oleic acid-induced ALI models were used in this study. A total of 96 rats were randomly assigned oleic acid group, salvianolate group, urokinase group, and saline group according to the random number table, with 24 animals per group. In oleic acid group, oleic acid (0.2 ml/kg, caudally) was administered alone. In addition to the oleic acid, the rats in salvianolate and urokinase groups received caudal injection with 10 ml/kg of 0.06% salvianolate and 5, 000 U/kg of urokinase respectively. In saline group, saline solution with an equal volume of oleic acid was caudally administered alone. Effect of the early use of salvianolate and urokinase on levels of VEGF in BALF was measured. Clinically, patients with ALI/ARDS composing survivor and death groups were enrolled and assessed by acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score and multiple organ dysfunction syndrome (MODS) score. Besides, healthy population was included as the controls to comparatively analyze the levels of VEGF in BALF in ALI/ARDS group. Results Of the rat models of ALI, early use of salvianolate or urokinase was associated with elevated level of VEGF in BALF(P<0.05), which subsequently attenuated the lung injury. In the clinical research, it was found that the level of VEGF in BALF in ALI/ARDS group was much lower than that in control group [(45.9±5.7)pg/ml vs (60.6±4.5)pg/ml] (P<0.01). The level of VEGF in BALF was negatively correlated with APACHEⅡor MODS scores(r=-0.542, -0.659, P<0.01). Moreover, patients in death group appeared lower VEGF level in BALF than those in survivor group(t=2.68, P<0.05). Conclusion VEGF level in BALF can be taken as an indicator of patient condition and outcome. Early use of anticoagulation or thrombolytic drugs may play a positive role on patients with ALI/ARDS. Key words: Acute lung injury; Vascular endothelial growth factors; Salvia miltiorrhiza; Urokinase

Prognostic value of natriuretic peptides in severe trauma patients with multiple organ dysfunction syndrome.

The aim of the present study was to evaluate the prognostic values of the N-terminal peptide of pro-atrial natriuretic peptide (NT-proANP) and the N-terminal fragment of B-type natriuretic peptide (NT-proBNP) in severe trauma patients developing multiple organ dysfunction syndrome (MODS). Out of the 126 severe trauma patients that were admitted to the Emergency Intensive Care Unit of the General Hospital of Shenyang Military Region between January 2009 and December 2011, 26 patients with multiple injuries and an injury severity score (ISS) of >16 points were included in the study. The MODS score was calculated on admission as well as 24, 48 and 72 h after the injury. Patients were divided into two groups: Group A consisted of patients with minor signs of organ dysfunction (MODS score, ≤4 points) and group B of patients with major organ dysfunction (MODS score, >4 points). Venous blood (5 ml) was extracted from the patients on admission and 6, 12, 24, 48 and 72 h after the injury. The Elecsys proBNP® and proANP® assays were used to determine the NT-proBNP and NT-proANP levels, respectively. The changes in the levels of C-reactive protein, white blood cells and neutrophils were detected and analyzed on admission. Acute physiology and chronic health evaluation II scores and ISSs were collected 72 h after the injury. The hemodynamic monitoring of cardiac index (CI) was performed using The Pulse index Continuous Cardiac Output system. The serum NT-proANP and NT-proBNP concentrations were elevated in all 26 patients. Upon admission, the serum NT-proANP and NT-proBNP values were 637.3±8.9 and 137.3±8.9 pmol/l, respectively, in group A and 1,185.0±7.2 and 185.0±7.2 pmol/l, respectively, in group B. The NT-proANP and NT-proBNP levels in group A were significantly lower than those in group B at all subsequent time-points (P<0.001). By contrast, the CI in group A was significantly higher than that in group B at all time-points (P<0.001). An inverse correlation was observed between the NT-proANP or NT-proBNP concentration and CI at 24, 48 and 72 h after the injury (r=-0.679 and -0.772, respectively; P<0.001). In conclusion, the serum NT-proANP and NT-proBNP concentrations following multiple injuries have been found to be significantly correlated with the clinical signs of MODS, and a distinct correlation has been observed between the levels of serums NT-proANP and NT-proBNP and decreased CI. The data of this pilot study suggest that NT-proANP and NT-proBNP levels may be of value in the diagnosis of post-traumatic cardiac impairment.