Non-shock Patients Research Articles

Abstract 15474: Factors Associated With Shock at Presentation for Patients With Kawasaki Disease versus Multisystem Inflammatory Syndrome in Children Associated With COVID-19

Background: Comparisons between Kawasaki disease (KD) and Multisystem Inflammatory Syndrome in Children (MIS-C) have been critiqued, with suggestions that KD Shock Syndrome (KDSS) patients may be a more valid comparison. We compared contemporaneous KD and MIS-C patients, both with and without shock at presentation. Methods: The International KD Registry enrolled 2144 patients with either KD (site diagnosis confirmed by AHA criteria) or MIS-C (site diagnosis confirmed by CDC criteria) from 40 sites in 7 countries from 01/2020 to 01/2023. Data collected included demographics, clinical features and presentation, management, laboratory values, and outcomes, and diagnosis/shock groups were compared. Results: Shock at presentation was noted for 19 of 672 (2.8%) KD patients and 653 of 1472 (38%; p<0.001) MIS-C patients. For both groups, shock patients were significantly more likely to be admitted to ICU, receive inotropes, and have cardiac arrest or arrhythmia. Groups did not differ by sex, but MIS-C patients and shock patients were older. While MIS-C shock patients were less likely to be White, KD shock and MIS-C shock patients more likely to be Black. For inflammatory markers, while shock patients in both groups had higher CRP and ferritin compared to non-shock patients, ESR was similar in both groups to non-shock patients, and higher WBC was only noted for MIS-C shock versus MIS-C non-shock patients. KD shock patients had similar values to MIS-C shock patients, with the exception of lower ferritin. Shock patients had higher NTproBNP (both diagnoses) and Troponin I (MIS-C only). Shock patients had lower LV ejection fraction, more so for MIS-C patients ( Figure A ). KD shock patients had higher max coronary artery Z scores versus MIS-C patients ( Figure B ). Conclusions: KD shock patients are more similar to MIS-C patients, particularly those with shock. Shock was associated with worse coronary artery involvement for KD patients, and worse LV dysfunction for both MIS-C and KD.

Plasma Nitric Oxide Consumption Is Elevated and Associated With Adverse Outcomes in Critically Ill Patients.

Impaired nitric oxide (NO) bioavailability may contribute to microvascular dysfunction in sepsis. Excessive plasma NO consumption has been attributed to scavenging by circulating cell-free hemoglobin. This may be a mechanism for NO deficiency in sepsis and critical illness. We hypothesized that plasma NO consumption is high in critically ill patients, particularly those with sepsis, acute respiratory distress syndrome (ARDS), shock, and in hospital nonsurvivors. We further hypothesized that plasma NO consumption is correlated with plasma cell-free hemoglobin concentration. Retrospective cohort study. Adult ICUs of an academic medical center. Three hundred sixty-two critically ill patients and 46 healthy control subjects. None. Plasma NO consumption was measured using reductive chemiluminescence and cell-free hemoglobin was measured with a colorimetric assay. Mean (95% CI) plasma NO consumption (µM) was higher in critically ill patients versus healthy control subjects (3.9 [3.7-4.1] vs 2.1 [1.8-2.5]), septic versus nonseptic patients (4.1 [3.8-4.3] vs 3.6 [3.3-3.8]), ARDS versus non-ARDS patients (4.4 [4.0-4.9] vs 3.7 [3.6-3.9]), shock vs nonshock patients (4.4 [4.0-4.8] vs 3.6 [3.4-3.8]), and hospital nonsurvivors versus survivors (5.3 [4.4-6.4] vs 3.7 [3.6-3.9]). These relationships remained significant in multivariable analyses. Plasma cell-free hemoglobin was weakly correlated with plasma NO consumption. Plasma NO consumption is elevated in critically ill patients and independently associated with sepsis, ARDS, shock, and hospital death. These data suggest that excessive intravascular NO scavenging characterizes sepsis and adverse outcomes of critical illness.

Effect of selected cardiovascular factors on mortality in patients with ST-segment elevation myocardial infarction treated with primary coronary intervention.

This work was aimed at analyzing in-hospital, 30-day and 1-year mortality rates, impact of selected cardiovascular factors on mortality of patients with ST-segment elevation myocardial infarction (STEMI) manifested on electrocardiogram (ECG) and treated by the percutaneous coronary intervention (PCI) at our cardiac center, comparing the subgroup of non-shock (survivors and deceased) patients after STEMI and evaluating how these patients differ from each other. In total, 270 patients with STEMI manifested on ECG and treated by PCI were enrolled between April 1, 2018, and March 31, 2019, at our cardiologic center. Our study sought to determine the risk of death after acute myocardial infarction with carefully selected factors and parameters such as the presence of cardiogenic shock, ischemic time, left ventricular ejection fraction (LVEF), post‑PCI TIMI (thrombolysis in myocardial infarction) flow and serum levels of cardio‑specific markers, namely troponin T, creatine kinase and N-terminal pro-brain natriuretic peptide (NT-proBNP). Further evaluation included in-hospital, 30-day and 1-year mortality rates in shock and non-shock patients and determination of factors that influence the survival separately in each subgroup. The follow-up was carried out for 12 months after the myocardial infarction in form of outpatient examinations. After 12 months of follow-up, the collected data were statistically evaluated. Shock and non-shock patients differed in mortality and several other parameters including NT-proBNP values, ischemic time, TIMI flow defect and LVEF. In all outcomes (in-hospital, 30-day and 1-year mortality rates) the shock patients did worse than non-shock patients (p < 0.001). In addition, age, gender, LVEF, NT-proBNP and post‑PCI TIMI flow less than 3 were found to be important factors influencing the overall survival. In shock patients, the survival was associated with age, LVEF and TIMI flow, while in non-shock patients, the factors predicting survival were age, LVEF, level of NT-proBNP and troponin levels. Shock patients differed in terms of mortality in post-PCI TIMI flow, while non-shock patients varied in troponin and NT-proBNP levels. Despite early intervention, certain risk factors might affect the clinical outcome and prognosis of patients with STEMI treated by PCI (Tab. 5, Fig. 1, Ref. 30). Text in PDF www.elis.sk Keywords: myocardial infarction, primary coronary intervention, shock, mortality, cardio‑specific markers.

Association of Septic Shock with Mortality in Hospitalized COVID-19 Patients in Wuhan, China.

Purpose Septic shock is a severe complication of COVID-19 patients. We aim to identify risk factors associated with septic shock and mortality among COVID-19 patients. Methods A total of 212 COVID-19 confirmed patients in Wuhan were included in this retrospective study. Clinical outcomes were designated as nonseptic shock and septic shock. Log-rank test was conducted to determine any association with clinical progression. A prediction model was established using random forest. Results The mortality of septic shock and nonshock patients with COVID-19 was 96.7% (29/30) and 3.8% (7/182). Patients taking hypnotics had a much lower chance to develop septic shock (HR = 0.096, p=0.0014). By univariate logistic regression analysis, 40 risk factors were significantly associated with septic shock. Based on multiple regression analysis, eight risk factors were shown to be independent risk factors and these factors were then selected to build a model to predict septic shock with AUC = 0.956. These eight factors included disease severity (HR = 15, p < 0.001), age > 65 years (HR = 2.6, p=0.012), temperature > 39.1°C (HR = 2.9, p=0.047), white blood cell count > 10 × 10⁹ (HR = 6.9, p < 0.001), neutrophil count > 75 × 10⁹ (HR = 2.4, p=0.022), creatine kinase > 5 U/L (HR = 1.8, p=0.042), glucose > 6.1 mmol/L (HR = 7, p < 0.001), and lactate > 2 mmol/L (HR = 22, p < 0.001). Conclusions We found 40 risk factors were significantly associated with septic shock. The model contained eight independent factors that can accurately predict septic shock. The administration of hypnotics could potentially reduce the incidence of septic shock in COVID-19 patients.

Increase in the Complement Activation Product C4d and the Terminal Complement Complex sC5b-9 Is Associated with Disease Severity and a Fatal Outcome in Necrotizing Soft-Tissue Infection

The hyperinflammatory burden is immense in necrotizing soft-tissue infection (NSTI). The complement system is a key during the innate immune response and may be a promising target to reduce the inflammatory response, potentially improving the clinical outcome. However, complement activation and its association to disease severity and survival remain unknown in NSTI. Therefore, we prospectively enrolled patients with NSTI and sampled blood at admission and once daily for the following 3 days. Plasma C4c, C4d, C3bc, and C3dg and the terminal complement complex (TCC) were evaluated using ELISA techniques. In total, 242 patients were included with a median age of 62 years, with a 60% male predominance. All-cause 30-day mortality was 17% (95% confidence interval [CI] 13–23) with a follow-up of >98%. C4c and C3dg were negatively correlated with Simplified Acute Physiology Score II (Rho −0.22, p < 0.001 and Rho −0.17, p = 0.01). Patients with septic shock (n = 114, 47%) had higher levels of baseline TCC than those in non-shock patients (18 vs. 14, p < 0.001). TCC correlated with the Sequential Organ Failure Assessment (SOFA) score (Rho 0.19, p = 0.004). In multivariate Cox regression analysis (adjusted for age, sex, comorbidity, and SOFA score), high baseline C4d (>20 ng/mL) and the combination of high C4d and TCC (>31 arbitrary units/mL) were associated with increased 30-day mortality (hazard ratio [HR] 3.26, 95% CI 1.56–6.81 and HR 5.12, 95% CI 2.15–12.23, respectively). High levels of both C4d and TCC demonstrated a negative predictive value of 0.87. In conclusion, we found that in patients with NSTI, complement activation correlated with the severity of the disease. High baseline C4d and combination of high C4d and TCC are associated with increased 30-day mortality. Low baseline C4d or TCC indicates a higher probability of survival.

EARLY ANTIBIOTICS CAN BOTH PREVENT AND MITIGATE SEPTIC SHOCK IN ED PATIENTS WITH SUSPECTED INFECTION

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Certain medical societies have publicly questioned the use of early antibiotics in patients with sepsis without septic shock. However, we recently demonstrated that among emergency department patients with suspected infection, antibiotic delay was associated with development of shock, and that for those patients who developed shock in spite of early antibiotics, mortality was unexpectedly low. The purpose of our study was to determine if early antimicrobial administration in patients with suspected infection but not septic shock affects risk of mortality if septic shock does develop. METHODS: This was a single center retrospective cohort study from March 2007 to March 2020. All adults presenting to the emergency department with suspected infection and first antimicrobial administered < 24 hours from triage were included. Septic shock at presentation was defined by receiving vasopressors within 3 hours of triage. We performed univariate and multivariate logistic regressions predicting progression to septic shock and mortality. We also compared mortality in patients who presented with shock compared with patients who developed shock after treatment was initiated. RESULTS: 74,655 patients were included in the study. Of these, 541 (0.7%) patients were characterized as having septic shock on presentation. 5,510 (7.4%) patients did not have septic shock on presentation but progressed to septic shock after treatment initiation. For patients in the latter group, in-hospital mortality was 10.7%. For patients with septic shock on presentation, in-hospital mortality was 23% (p<0.001). Median time to antibiotics for the septic shock on presentation group was 0.35 hours, and 97% of these patients received their antimicrobials within 5 hours of triage. In a multivariate logistic regression model including only patients without septic shock on presentation, time to first antimicrobial had OR of 1.03 [95% CI: 1.02-1.04; p<0.001] for progression to septic shock and 1.02 [95% CI: 0.98-1.04; p = 0.090] for in-hospital mortality. In a multivariate logistic model including only patients with septic shock on presentation, time to first antimicrobial had an OR of 1.25 [95% CI: 1.05-1.48; p = 0.010] for in-hospital mortality. CONCLUSIONS: Delays in first antimicrobial administration in patients with suspected infection or septic shock are associated with increased likelihood of disease progression and in-hospital mortality. However, early administration of antibiotics in non-shock patients with suspected infection is associated with decreased mortality rate by half, even if shock does subsequently develop. CLINICAL IMPLICATIONS: Antibiotics administered before the onset of shock may mitigate the mortality associated with septic shock. DISCLOSURES: No relevant relationships by Roshan Bisarya, source=Web Response No relevant relationships by Mei Liu, source=Web Response No relevant relationships by Anurag Patel, source=Web Response No relevant relationships by John Salle, source=Web Response No relevant relationships by Steven Simpson, source=Web Response No relevant relationships by Xing Song, source=Web Response

The relationship between vitamin C or thiamine levels and outcomes for severe sepsis patients admitted to the ICU

Preliminary data have produced conflicting results regarding whether initial vitamin C levels in patients with severe sepsis correlate with mortality outcomes. We hypothesized that low plasma ascorbic acid or thiamine levels in severe sepsis patients admitted from the Emergency Department (ED) to the Intensive Care Unit (ICU) would be associated with increased mortality and an increased incidence of shock. Retrospective analysis of a prospective database of severe sepsis patients admitted to the ICU at an urban, academic medical center. Ascorbic acid and thiamine levels were analyzed in relation to survivors vs. non-survivors and shock vs. non-shock patients. 235 patients were included; mean age, 59.4 years ± 16.8 years; male, 128 (54.5%); in-hospital mortality, 16.6% (39/235); mean APACHE3 score, 61.8 ± 22.8; mean ascorbic acid level (reference range 0.40–2.10 mg/dL), 0.23 mg/dL (95% CI 0.07–4.02); and the mean thiamine level (reference range 14.6–29.5 nmol/L), 6.0 nmol/L (95% CI 4.0–9.5). When survivors were compared to non-survivors, survivors were more likely to be male (57.7% [113/196] vs. 38.5% [15/39]) and have lower APACHE3 scores (58.2 ± 22.6 vs. 79.9 ± 16.0). For the total cohort of 235 patients, there was no statistically significant relationship between a patient’s initial ascorbic acid or thiamine level and either survival or development of shock. In this analysis of early plasma samples from patients with severe sepsis admitted from the ED to the ICU, we found that mean ascorbic acid and thiamine levels were lower than normal range but that there was no relationship between these levels and outcomes, including 28 day mortality and development of shock.

Prognostic value of hemodynamic indices in patients with sepsis after fluid resuscitation.

BACKGROUNDSepsis usually causes hemodynamic abnormalities. Hemodynamic index is one of the factors to identify the severity of sepsis and an important parameter to guide the procedure of fluid resuscitation. The present study investigated whether the assessment of hemodynamic indices can predict the outcomes of septic patients undergoing resuscitation therapy.AIMTo evaluate the prognostic value of hemodynamic indices in patients with sepsis after fluid resuscitation.METHODSA retrospective study was conducted in 120 patients with sepsis at Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University between October 2016 and October 2019. All patients were treated with sodium chloride combined with dextran glucose injection for fluid resuscitation. Patients’ hemodynamic parameters were monitored, including heart rate (HR), cardiac index (CI), systemic vascular resistance index (SVRI), mean arterial pressure (MAP), central venous pressure (CVP), and central venous oxygen saturation. The prognostic value of hemodynamic indices was determined based on the prognosis status.RESULTSDuring fluid resuscitation, 86 patients developed septic shock and 34 did not. Ninety-nine patients survived and 21 patients died at 28 d after the treatment. Heart rate, CI, mean arterial pressure, SVRI, and CVP were higher in patients with septic shock and patients who died from septic shock than in non-shock patients and patients who survived, and central venous oxygen saturation was lower in patients with shock and patients who died than in non-shock patients and the survivors (P < 0.05). When prognosis was considered as a dependent variable and hemodynamic parameters was considered as independent variables, the results of a logistic regression analysis showed that CI, SVRI, and CVP were independent risk factors for septic shock, and CI was an independent risk factor for 28-d mortality (P < 0.05).CONCLUSIONHemodynamic indices can be used to evaluate the prognosis of septic patients after fluid resuscitation.

Hyperbaric oxygen treatment is associated with a decrease in cytokine levels in patients with necrotizing soft‐tissue infection

BackgroundThe pathophysiological understanding of the inflammatory response in necrotizing soft‐tissue infection (NSTI) and its impact on clinical progression and outcomes are not resolved. Hyperbaric oxygen (HBO2) treatment serves as an adjunctive treatment; however, its immunomodulatory effects in the treatment of NSTI remains unknown. Accordingly, we evaluated fluctuations in inflammatory markers during courses of HBO2 treatment and assessed the overall inflammatory response during the first 3 days after admission.MethodsIn 242 patients with NSTI, we measured plasma TNF‐α, IL‐1β, IL‐6, IL‐10, and granulocyte colony‐stimulating factor (G‐CSF) upon admission and daily for three days, and before/after HBO2 in the 209 patients recieving HBO2. We assessed the severity of disease by Simplified Acute Physiology Score (SAPS) II, SOFA score, and blood lactate.ResultsIn paired analyses, HBO2 treatment was associated with a decrease in IL‐6 in patients with Group A‐Streptococcus NSTI (first HBO2 treatment, median difference −29.5 pg/ml; second HBO2 treatment, median difference −7.6 pg/ml), and overall a decrease in G‐CSF (first HBO2 treatment, median difference −22.5 pg/ml; 2− HBO2 treatment, median difference −20.4 pg/ml). Patients presenting with shock had significantly higher baseline cytokines values compared to non‐shock patients (TNF‐α: 51.9 vs. 23.6, IL‐1β: 1.39 vs 0.61, IL‐6: 542.9 vs. 57.5, IL‐10: 21.7 vs. 3.3 and G‐CSF: 246.3 vs. 11.8 pg/ml; all p < 0.001). Longitudinal analyses demonstrated higher concentrations in septic shock patients and those receiving renal‐replacement therapy. All cytokines were significantly correlated to SAPS II, SOFA score, and blood lactate. In adjusted analysis, high baseline G‐CSF was associated with 30‐day mortality (OR 2.83, 95% CI: 1.01–8.00, p = 0.047).ConclusionIn patients with NSTI, HBO2 treatment may induce immunomodulatory effects by decreasing plasma G‐CSF and IL‐6. High levels of inflammatory markers were associated with disease severity, whereas high baseline G‐CSF was associated with increased 30‐day mortality.

Impact of left-ventricular end-diastolic pressure as a predictor of periprocedural hemodynamic deterioration in patients undergoing Impella supported high-risk percutaneous coronary interventions

BackgroundAn increasing number of high-risk percutaneous coronary interventions (PCI) are performed with mechanical circulatory support (MCS) to minimize the risk of periprocedural hemodynamic compromise. Prior studies have demonstrated that an elevated left-ventricular end-diastolic pressure (LVEDP) is associated with worse outcome after acute myocardial infarction or cardiac surgery. Although LVEDP is frequently measured, little is known about the usefulness for predicting periprocedural hemodynamic deterioration in high-risk PCI. The objective of this study is to assess the impact of preprocedural measured LVEDP in non-shock patients undergoing high-risk PCI with MCS on periprocedural hemodynamic deterioration. Methods and ResultsWe reviewed the PCI protocol and the Automated Impella Controller in a consecutive series of 64 patients (mean age 73 years, 80% male), who underwent high-risk PCI with Impella MCS (period 01/2017–12/2018). LVEDP (17 ± 8 mm Hg) was measured in all cases before Impella insertion and start of PCI. Periprocedural hemodynamic deterioration was defined as: systolic blood pressure (SBP) drop (decrease ≥20 mm Hg or ≤90 mm Hg), or transient loss of arterial pressure pulsatility. Hemodynamic deterioration occurred in 33% (n = 21) of all patients but did not lead to a hemodynamic compromise due to the Impella support. Regression analysis of LVEDP for periprocedural hemodynamic deterioration or in-hospital major adverse cardiac and cerebrovascular events (MACCE) showed no significant results. ConclusionLVEDP was not associated with periprocedural hemodynamic deterioration or a higher rate of in-hospital MACCE. Our data propose that LVEDP may not be used as a risk stratification variable for MCS usage in non-shock patients undergoing high-risk PCI.

Percutaneous edge-to-edge mitral valve repair may rescue select patients in cardiogenic shock: Findings from a single center case series.

Patients with severe mitral regurgitation (MR) and cardiogenic shock are typically too high risk for immediate surgery; however, percutaneous edge-to-edge mitral valve repair (pMVr) may be reasonable in select patients. Describe characteristics and outcomes of patients who underwent pMVr with and without shock at a single center. Chart review of all patients who underwent non-investigational pMVr from November 2013 to October 2018. Shock was defined as dependence on an intravenous (IV) inotrope, IV afterload reduction, and/or temporary mechanical circulatory support immediately preceding pMVr. There were 135 patients. Mean age was 80 ± 12 years and 56 (41%) were female. Twelve (8.9%) had shock. All patients had 3+ or 4+ MR at baseline. Post-procedure, all shock patients had 2+ or less MR. Two (17%) shock patients and 4 (3%) non-shock patients died within 30 days of pMVr (P = 0.03). Six (50%) shock patients had resolution of shock and discharged home (primary outcome). Five shock patients had acute MI, four of whom met the primary outcome. Four shock patients had chronic MR (>21 days), three of whom did not meet the primary outcome. Overall, follow-up time for mortality was median (IQR) 198 (42-379) days. Shock patients who survived to 30 days post-procedure had significantly shorter time from diagnosis of MR to pMVr compared to those who died (35 ± 68 vs. 374 ± 111 days; P = 0.0001). Percutaneous edge-to-edge MVr may be reasonable in shock patients with acute MR and/or acute MI. This case series should guide larger studies designed to improve selection of shock patients for pMVr.

Gestalt for shock and mortality in the emergency department: A prospective study

ObjectiveThe diagnosis of shock in patients presenting to the emergency department (ED) is often challenging. We aimed to compare the accuracy of experienced emergency physician gestalt against Li's pragmatic shock (LiPS) tool for predicting the likelihood of shock in the emergency department, using 30-day mortality as an objective standard. MethodIn a prospective observational study conducted in an urban, academic ED in Hong Kong, adult patients aged 18years or older admitted to the resuscitation room or high dependency unit were recruited. Eligible patients had a standard ED workup for shock. The emergency physician treating the patient was asked whether he or she considered shock to be probable, and this was compared with LiPS. The proxy ‘gold’ or reference standard was 30-day mortality. The area under the receiver operating curve (AUROC) was used to predict prognosis. The primary outcome measure was 30-day mortality. ResultsA total of 220 patients fulfilled the inclusion criteria and were included in the analysis. The AUROC for LiPS (0.722; sensitivity=0.733, specificity=0.711, P<0.0001) was greater than emergency physician gestalt (0.620, sensitivity=0.467, specificity=0.774, P=0.0137) for diagnosing shock using 30-day mortality as a proxy (difference P=0.0229). LiPS shock patients were 6.750 times (95%CI=2.834–16.076, P<0.0001) more likely to die within 30-days compared with non-shock patients. Patients diagnosed by emergency physicians were 2.991 times (95%CI=1.353–6.615, P=0.007) more likely to die compared with the same reference. ConclusionsLiPS has a higher diagnostic accuracy than emergency physician gestalt for shock when compared against an outcome of 30-day mortality.

Primary percutaneous coronary intervention for acute ST elevation myocardial infarction: Outcomes and determinants of outcomes: A tertiary care center study from North India

BackgroundPrimary percutaneous coronary intervention (PCI) is the current standard of care for acute ST elevation myocardial infarction (STEMI). Most of the data on primary PCI in acute STEMI is from western countries. We studied the outcomes of primary PCI for acute STEMI at a tertiary care center in North India. MethodsConsecutive patients undergoing primary PCI for STEMI were prospectively studied during the period from February 2103 to May 2015. The outcomes assessed were all cause in hospital mortality, factors associated with mortality, major adverse cardiac and cerebrovascular event rate (composite of all cause in hospital mortality, non-fatal re infarction and stroke) and procedural complications. Results371 patients underwent primary PCI during the study period. The mean age was 54 years and 82.7% were males. The mean total ischemia time and door to balloon times were 6.8h and 51min respectively. 96.4% patients underwent successful primary PCI. The total in hospital mortality was 12.9%. Mortality with cardiogenic shock at presentation was 66.7% while non-shock mortality was 2.6%. In hospital MACCE rate was 13.5%. Factors significantly associated with mortality were KILLIP class (OR: 8.4), door to balloon time (OR 1.02), final TIMI flow (OR 0.44) and severe LV dysfunction (OR 22.0). Procedure related adverse events were rare and there was no non-CABG associated major TIMI bleeding. ConclusionPrimary PCI for acute STEMI is feasible in our setup and associated with high success rate, low mortality in non-shock patients and low complication rates.

Pentraxin-3 as a marker of disease severity and risk of death in patients with necrotizing soft tissue infections: a nationwide, prospective, observational study.

BackgroundNew biomarkers are needed to assess the severity of necrotizing soft tissue infection (NSTI) at an early stage and to individualize treatment strategies. We assessed pentraxin-3 (PTX3) as a marker of disease severity and risk of death in patients with NSTI.MethodsWe conducted a prospective, observational study in the intensive care unit at Copenhagen University Hospital, where treatment of NSTI is centralized at a national level. We compared PTX3, procalcitonin and C-reactive protein in septic shock versus nonshock patients and in amputated versus nonamputated patients using the Mann-Whitney U test. The prognostic value of the markers for 180-day mortality was assessed using Cox regression analyses.ResultsPatients with NSTI (n = 135) were included over 25 months with up to 2.5-year follow-up; 71 % had septic shock, amputation was undertaken in 20 % and the 180-day mortality was 27 %. Baseline plasma PTX3 level was significantly higher in patients with septic shock (67.3 versus 24.6 ng/mL, p < 0.0001) and in patients who underwent amputation (118.6 versus 43.6 ng/mL, p = 0.019). No significant differences in baseline procalcitonin or C-reactive protein levels were found according to amputation (25.2 versus 7.0 μg/L, p = 0.060 and 202 versus 225 mg/L, p = 0.123), respectively. Baseline PTX3 level above the median was associated with death (p = 0.009, log-rank test) and the univariate Cox regression analysis revealed a significant association between PTX3 level upon admission and 180-day mortality (hazard ratio 2.60 (95 % confidence interval 1.28–5.29), p = 0.008). When adjusted for age, sex, chronic disease and Simplified Acute Physiology Score II, no significant association was found.ConclusionsHigh PTX3 level is associated with septic shock, amputation and risk of death in patients with NSTI, but it is not an independent predictor of 180-day mortality in this patient group.Trial registrationClinicalTrials.gov Identifier: NCT02180906. Date of registration: June 29, 2014.

Post-Hospital Outcomes of Patients With Acute Myocardial Infarction With Cardiogenic Shock: Findings From the NCDR

BackgroundMany patients with acute myocardial infarction (AMI) and cardiogenic shock survive hospitalization; little is known about their subsequent prognosis. ObjectivesThis study sought to evaluate the associations between cardiogenic shock and post-discharge mortality and all-cause hospitalization among hospital survivors. MethodsWe included patients ≥65 years of age with AMI from the ACTION Registry–GWTG (Acute Coronary Treatment and Intervention Outcomes Network Registry–Get With The Guidelines) who survived hospitalization and linked these patients with Medicare claims data. We used proportional hazards models to test the association between cardiogenic shock and outcomes, adjusting for patient and hospital characteristics. Hazard ratios (HRs) are reported for early (1 to 60 days) and late (61 to 365 days) post-discharge time periods. ResultsAmong 112,668 AMI survivors, 5% had cardiogenic shock during hospitalization. The rate of death was significantly higher among patients with cardiogenic shock at 60 days (9.6% vs. 5.5%) and 1 year (22.4% vs. 16.7%). After accounting for baseline characteristics, the risk of death remained higher for cardiogenic shock patients in the first 60 days after discharge (adjusted HR: 1.62; 95% confidence interval [CI]: 1.46 to 1.80), but was similar to nonshock patients thereafter (adjusted HR: 1.08 for days 61 to 365; 95% CI: 1.00 to 1.18). The rate of all-cause hospitalization or death was significantly higher among shock patients at 60 days (33.9% vs. 24.9%) and 1 year (59.1% vs. 52.3%). After adjustment, the risk of this outcome was also clustered in the first 60 days (adjusted HR: 1.28; 95% CI: 1.21 to 1.35) and was similar thereafter (adjusted HR: 0.95 for days 61 to 365; 95% CI: 0.89 to 1.01). ConclusionsHospital survivors of AMI who had cardiogenic shock have a higher risk of death and/or hospitalization during the first year after discharge. The risk is time-dependent and is clustered in the early post-discharge period, after which the prognosis is similar in patients with and without cardiogenic shock.

Bicarbonate versus lactate solutions for acute peritoneal dialysis.

The high mortality rate among critically ill patients with acute kidney injury (AKI) remains an unsolved problem in intensive care medicine, despite the use of renal replacement therapy (RRT). Increasing evidence from clinical studies in adults and children suggests that the new peritoneal dialysis (PD) fluids may allow for better long-term preservation of peritoneal morphology and function. Formation of glucose degradation products (GDPs) can be reduced and even avoided with the use of newer "biocompatible" solutions. However, it is still unclear if there are any differences in using conventional (lactate) solutions compared with low GDP (bicarbonate) solutions for acute PD. To look at the benefits and harms of bicarbonate versus lactate solutions in acute PD. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (from 1966), EMBASE (from 1980), Latin American and Caribbean Health Sciences Literature Database LILACS (from 1982), and reference lists of articles.Date of last search: 6 May 2014. Randomised controlled trials (RCTs) comparing bicarbonate to lactate solution for acute PD. Two authors independently assess the methodological quality of studies. One author abstracted data onto a standard form, and a second author checked data extraction. We used the random-effects model and expressed the results as relative risk (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI). We included one study (20 patients) in this review. In shock patients, bicarbonate did not differ from lactate with respect to mortality (RR 0.50, 95% CI 0.06 to 3.91); however there were significant differences in blood lactate (MD -1.60 mmol/L, 95% CI -2.04 to -1.16), serum bicarbonate (MD 5.00 mmol/L, 95% CI 3.26 to 6.74) and blood pH (MD 0.12, 95% CI 0.06 to 0.18). In non-shock patients there was a significance difference in blood lactate (MD -0.60 mmol/L, 95% CI -0.85 to -0.35) but not in serum bicarbonate (MD 1.10 mmol/L, 95% CI -0.27 to 2.47) or blood pH (MD -0.02, 95% CI -0.02 to -0.06). Other outcomes could not be analysed because of the limited data available. There is no strong evidence that any clinical advantage for patients requiring acute PD for AKI when comparing conventional (lactate) with low GDP dialysis solutions (bicarbonate).

The initial success rate of cardiopulmonary resuscitation and its associated factors in patients with cardiac arrest within 24 hours after anesthesia for an emergency surgery

PurposeTo determine the initial success rate and its associated factors on cardiopulmonary resuscitation (CPR) in patients with cardiac arrest within 24 hours after receiving anesthesia for an emergency surgery.Patients and methodsAfter the hospital ethical committee gave approval for this study, the anesthesia providers recorded all relevant data regarding CPR in patients with cardiac arrest within 24 hours after anesthesia for emergency surgery at Maharaj Nakorn Chiang Mai Hospital, a university hospital in Northern Thailand. Only data from the cardiac arrest patients who received the first CPR attempt were included in the analysis. The end point of the initial success of CPR was return of spontaneous circulation (ROSC). Factors related to ROSC were determined by univariate analyses and multiple logistic regression analysis. The odds ratios (OR) and 95% confidence intervals (CI) were used to calculate the strength of the factors associated with the ROSC.ResultsOf the 96 cardiac arrest patients, 44 patients (45.8%) achieved ROSC. Factors associated with ROSC were electrocardiogram monitoring for detected cardiac arrest (OR =4.03; 95% CI =1.16–14.01; P=0.029), non-shock patients before arrest (OR =8.54; 95% CI =2.13–34.32; P=0.003), timing to response of activated CPR team within 1 minute (OR =9.37; 95% CI =2.55–34.39; P<0.001), having trained CPR teams (OR =8.76; 95% CI =2.50–30.72; P<0.001), and administration of more than one dose of epinephrine (OR =5.62; 95% CI =1.32–23.88; P<0.019).ConclusionPatients undergoing anesthesia for an emergency surgery are at risk for perioperative cardiac arrest with high mortality which requires immediate CPR. Our results have confirmed that early detection of cardiac arrest by vigilant electrocardiogram monitoring and prompt management with a qualified team are important factors in improving the success of CPR. Emergency surgical patients at risk for cardiac arrest should be promptly managed, with facilities available not only during the operation but also during the pre- to postoperative period.

Abstract 338: Therapeutic Hypothermia for Patients With Post-Resuscitation Shock After Out-of-Hospital Cardiac Arrest

Background: Animal data have suggested a beneficial effect of therapeutic hypothermia following return of spontaneous circulation (ROSC) (post-ROSC cooling) in cardiogenic shock, but there are few human studies of patients with post-resuscitation shock who were treated with post-ROSC cooling. METHODS: From the J-PULSE HYPO registry, a multi-center registry in Japan, we selected the patients who met the following inclusion criteria: bystander-witnessed cardiac arrest due to ventricular fibrillation (VF), target core temperature of 32-34°C, and cooling duration of 12-72 hours. Study patients were divided into two groups based on hemodynamic status. The post-resuscitation shock group consisted of patients with systolic blood pressure &lt; 90 mmHg and/or mechanical circulation support. The remaining patients constituted the non-shock group. The primary endpoint was favorable neurological outcome at 30 days after cardiac arrest. Results: Of the 452 adult patients treated with post-ROSC cooling, 292 met the inclusion criteria; 149 (51%) were post-resuscitation shock and 143 (49%) were non-shock. No significant difference was observed between the two groups in the frequency of 30-day favorable neurological outcome (63% [94/149] post-resuscitation shock group vs. 68% [97/143] non-shock group; p=0.39). However, the median collapse-to-ROSC interval was significantly longer in the post-resuscitation shock group than in the non-shock group (27 minutes vs. 20 minutes, p&lt;0.001). In the quartiles of collapse-to-ROSC interval and 30-day favorable neurological outcome, both groups exhibited high frequencies of 30-day favorable neurological outcome in Quartile 1, in which the collapse to ROSC interval was 15 minutes or less (93% post-resuscitation shock group vs. 87% non-shock group, p=0.40), and a significant decrease in 30-day favorable neurological outcome was found in each group as the quartile value of collapse-to-ROSC interval increased (p&lt;0.001, respectively). The 30-day favorable neurological outcome in each Quartile 2, 3 and 4 did not differ between the two groups. Conclusion: Due to the effects of post-ROSC cooling, post-resuscitation shock patients were able to achieve the same level of neurological benefit as non-shock patients.

Shock State

Some patients with drug reaction with eosinophilia and systemic symptoms (DRESS) are probably admitted in intensive care unit (ICU), but data concerning their clinical features at admission are scarce. Therefore, in the present study, we used a clinical network of French intensivists to study the clinical features and evolution of DRESS patients hospitalized in ICU. A national, retrospective, multicenter study collected DRESS cases hospitalized in ICU for DRESS from 2000 to end of 2011. All files were analyzed through the RegiSCAR scoring system as "no," "possible," "probable," or "definite" DRESS. Patients were included only if they had a probable or definite DRESS. Demographic, hemodynamic, biological, and infectious data were recorded. Twenty-one patients were included. Hospital mortality was 10 (47%) of 21, and 16 of 21 patients had on admission a shock state necessitating vasopressor agents. Echocardiographic ejection fraction in shock patients was depressed (47% ± 13%). Mechanical ventilation was required in 13 of 21 cases. Hepatic failure was observed in 11 of 21 cases, acute renal failure in 18 of 20 cases, and lactic acidosis in 12 of 20 patients. Initial bacteriology was negative in all patients. Human herpesvirus reactivations were found in five of 15 cases. In conclusion, shock without bacteriological documentation associated with multiple organ failure is the most common presentation of DRESS at admission in ICU and is associated with a higher mortality than previously described.

Development of a Geriatric Resuscitation Protocol, Utilization Compliance, and Outcomes

Inconsistent application of trauma service resources and underevaluation of risk and resuscitation status in elderly trauma patients are problematic. We describe a geriatric protocol that includes initial lactate determination and trauma surgery admission. Protocol compliance rates were initial lactate determination, 67.9%; trauma service admission for overt or compensated (elevated lactate) shock, 73.6%; and trauma service consultation for nonshock patients, 67.8%. Implementation of this protocol resulted in a trend toward reduced mortality and reduced potentially preventable deaths.