Onset Of Organ Failure Research Articles

Minimally invasive surgery compared to endoscopic intervention for treating infected pancreatic necrosis. A meta-analysis.

The current study aimed to compare the outcomes of endoscopic and minimally invasive surgical treatment for infected necrotizing pancreatitis. A meta-analysis of clinical studies on minimally invasive operations for necrotic infection was conducted. A systematic review and study inclusion were done on multiple databases. English-language prospective comparison studies were included. Random design was used to analyze research with continuous and dichotomous variables. Ten studies were included in the current study. When compared to minimally invasive surgery, endoscopic procedures showed significant beneficial outcomes regarding low post-operative complication rates (p = 0.006), new onset organ failure (p < 0.001), and pancreatic fistula (p < 0.001). However, there was no significant difference between the two interventions regarding hospital stay, postoperative bleeding, incisional hernia, endocrine insufficiency, and perforation of a visceral organ. Endoscopic therapy appears to have potential advantages over minimally invasive surgery. However, there is no difference between interventions regarding several parameters.

Endoscopic versus minimally invasive surgical approach for infected necrotizing pancreatitis: a systematic review and meta-analysis of randomized controlled trials

Background/Aims Acute pancreatitis is a common condition of the digestive system, but sometimes it develops into severe cases. In about 10–20% of patients, necrosis of the pancreas or its periphery occurs. Although most have aseptic necrosis, 30% of cases will develop infectious necrotizing pancreatitis. Infected necrotizing pancreatitis (INP) requires a critical treatment approach. Minimally invasive surgical approach (MIS) and endoscopy are the management methods. This meta-analysis compares the outcomes of MIS and endoscopic treatments. Methods We searched a medical database until December 2022 to compare the results of endoscopic and MIS procedures for INP. We selected eligible randomized controlled trials (RCTs) that reported treatment complications for the meta-analysis. Results Five RCTs comparing a total of 284 patients were included in the meta-analysis. Among them, 139 patients underwent MIS, while 145 underwent endoscopic procedures. The results showed significant differences (p < 0.05) in the risk ratios (RRs) for major complications (RR: 0.69, 95% confidence interval (CI): 0.49–0.97), new onset of organ failure (RR: 0.29, 95% CI: 0.11–0.82), surgical site infection (RR: 0.26, 95% CI: 0.07–0.92), fistula or perforation (RR: 0.27, 95% CI: 0.12–0.64), and pancreatic fistula (RR: 0.14, 95% CI: 0.05–0.45). The hospital stay was significantly shorter for the endoscopic group compared to the MIS group, with a mean difference of 6.74 days (95% CI: −12.94 to −0.54). There were no significant differences (p > 0.05) in the RR for death, bleeding, incisional hernia, percutaneous drainage, pancreatic endocrine deficiency, pancreatic exocrine deficiency, or the need for enzyme use. Conclusions Endoscopic management of INP performs better compared to surgical treatment due to its lower complication rate and higher patient life quality.

Impact of endoprosthesis type on inflammatory response in patients undergoing endoscopic drainage of pancreatic fluid collections.

To study the impact of endoprosthesis type on inflammatory response in patients undergoing endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFC). Patients undergoing EUS-guided PFC drainage and treated using lumen-apposing metal stents (LAMS) or plastic endoprostheses constituted the study cohort. The primary outcome was the presence of systemic inflammatory response syndrome (SIRS) after index intervention. Secondary outcomes were persistent organ failure, new onset organ failure, duration of hospitalization, and treatment success. In all, 303 patients were treated using LAMS (n = 247) or plastic stents (n = 56). At 48 h postintervention, the presence of SIRS (25.0 vs. 14.2%, P = 0.047), new onset SIRS (10.0 vs. 1.8%, P = 0.017), and new organ failure (5.4 vs. 0.4%, P = 0.003) were significantly higher in the plastic stent cohort compared to LAMS. On multivariable logistic regression analysis, the use of plastic stents (odds ratio [OR] 2.7, 95% confidence interval [CI] 1.2-6.0, P = 0.014), patients receiving high-acuity care (OR 5.1, 95% CI 2.5-10.4, P < 0.001) and the presence of ≥33% of necrosis (OR 4.5, 95% CI 2.0-10.0, P < 0.001) were significantly associated with the presence of SIRS or new organ failure. While there was no significant difference in treatment success (96.4 vs. 95.5%, P = 0.77), duration of hospitalization was significantly longer for the plastic stent cohort (mean [standard deviation] 12.5 [17.8] vs. 7.9 [10.1] days, P = 0.009). Use of plastic stents as compared to LAMS was associated with a higher proportion of SIRS and new organ failure that prolonged hospital stay. Therefore, placement of LAMS is recommended in sick patients and those with ≥33% necrosis to minimize inflammatory response.

Outcome of patients with newly diagnosed AML admitted to the ICU, including preemptive admission - a multi-center study.

Acute myeloid leukemia (AML) can lead to life-threatening complications that may require intensive care unit (ICU) management. It has been advocated that early preemptive (ePE) ICU admission, before the onset of organ failure, could benefit some high-risk patients such as those with hyperleukocytosis. The aim of this study was to retrospectively analyze the outcome of newly diagnosed AML patients who required ICU admission in five academic centers with a special focus on patients with an ePE admission strategy, i.e., those transferred to the ICU without any organ failure (modified SOFA score ≤ 2 [omitting thrombocytopenia] and no life-sustaining intervention in the first 24h following ICU admission) before the start of induction therapy. Between January 2017 and December 2019, 428 patients were included among which 101 were admitted to the ICU. Among patients requiring life-sustaining interventions (n = 83), 18 (22%) died while in the ICU but ICU survivors had the same survival as those not admitted to the ICU. Patients with an ePE admission (n = 18) had more comorbidities and high-risk disease features such as hyperleukocytosis but required no life-sustaining interventions while in the ICU. In a subgroup analysis of patients with hyperleukocytosis ≥ 50 G/l at diagnosis (n = 85), patients not admitted to the ICU and those admitted with an ePE strategy had similar outcomes. This study provides encouraging results about ICU outcome in AML patients during induction therapy but the potential benefit of an ePE strategy must be confirmed prospectively.

456: A CHALLENGING CASE OF RAPID-ONSET MULTISYSTEM ORGAN FAILURE IN A BURN PATIENT

Introduction: Burns are significant injuries that cause a cascade of inflammatory responses. Patients with large burns and inhalation injury often experience respiratory failure, renal failure, liver dysfunction, and sepsis. The COVID-19 virus has added a unique challenge as a current or recent COVID-19 infection seems to lend to worse outcomes, However, we do not yet have enough data to understand the full implication of COVID-19 on burn patients. Description: A 41-year-old man with no remarkable medical history was admitted to the Burn Intensive Care Unit (BICU) with 58% body surface area burns with smoke inhalation. He was given appropriate burn resuscitation and placed on the volumetric diffusive respirator (VDR). Admission COVID-19 PCR was negative, and COVID-19 Spike IgG was 12 IU/mL. Both labs and vital signs remained stable and he went to the OR on hospital day 4 for excision and grafting and the first 24 hours post-op were unremarkable. On post-op day 1, he had an abrupt rise in lactate with worsening acidosis. Sepsis guidelines were followed and he required initiation of renal replacement therapy (CRRT) along with bedside laparotomy with no significant findings. Repeat lab work showed a COVID-19 Spike IgG level >800. Patient’s conditioned worsened despite maximal medical intervention, and he died on hospital day 8. Since the sudden, rapid decline in patient’s condition at this point in his hospitalization is somewhat atypical, we theorize that patient was either admitted with COVID-19 infection that was undetectable, or this was a nosocomial infection. Though he had no significant comorbidities, it certainly seems that this new infection unduly stressed his immune system, leading to multi-system organ failure and death. Discussion: Large burn injuries are often challenging to manage, but improved therapies and treatments have led to increasingly good outcomes. The addition of current or recent COVID-19 infection adds a new challenge which needs further study as we learn more about the inflammatory and long-term implications of this disease on lung function and immune systems. Our experience of rapid onset organ failure and death in a burn patient with likely new COVID-19 infection presented a unique burn and critical care management challenge that needs further study.

Perforation and Fistula of the Gastrointestinal Tract in Patients With Necrotizing Pancreatitis: A Nationwide Prospective Cohort.

The aim of this study was to explore the incidence, risk factors, clinical course and treatment of perforation and fistula of the gastrointestinal (GI) tract in a large unselected cohort of patients with necrotizing pancreatitis. Perforation and fistula of the GI tract may occur in necrotizing pancreatitis. Data from large unselected patient populations on the incidence, risk factors, clinical outcomes, and treatment are lacking. We performed a post hoc analysis of a nationwide prospective database of 896 patients with necrotizing pancreatitis. GI tract perforation and fistula were defined as spontaneous or iatrogenic discontinuation of the GI wall. Multivariable logistic regression was used to explore risk factors and to adjust for confounders to explore associations of the GI tract perforation and fistula on the clinical course. A perforation or fistula of the GI tract was identified in 139 (16%) patients, located in the stomach in 23 (14%), duodenum in 56 (35%), jejunum or ileum in 18 (11%), and colon in 64 (40%). Risk factors were high C-reactive protein within 48 hours after admission [odds ratio (OR): 1.19; 95% confidence interval (CI): 1.01-1.39] and early organ failure (OR: 2.76; 95% CI: 1.78-4.29). Prior invasive intervention was a risk factor for developing a perforation or fistula of the lower GI tract (OR: 2.60; 95% CI: 1.04-6.60). While perforation or fistula of the upper GI tract appeared to be protective for persistent intensive care unit-admission (OR: 0.11, 95% CI: 0.02-0.44) and persistent organ failure (OR: 0.15; 95% CI: 0.02-0.58), perforation or fistula of the lower GI tract was associated with a higher rate of new onset organ failure (OR: 2.47; 95% CI: 1.23-4.84). When the stomach or duodenum was affected, treatment was mostly conservative (n=54, 68%). Treatment was mostly surgical when the colon was affected (n=38, 59%). Perforation and fistula of the GI tract occurred in one out of six patients with necrotizing pancreatitis. Risk factors were high C-reactive protein within 48 hours and early organ failure. Prior intervention was identified as a risk factor for perforation or fistula of the lower GI tract. The clinical course was mostly affected by involvement of the lower GI tract.

Drainage of pancreatic fluid collections in acute pancreatitis: A comprehensive overview

Moderately severe and severe acute pancreatitis is characterized by local and systemic complications. Systemic complications predominate the early phase of acute pancreatitis while local complications are important in the late phase of the disease. Necrotic fluid collections represent the most important local complication. Drainage of these collections is indicated in the setting of infection, persistent or new onset organ failure, compressive or pressure symptoms, and intraabdominal hypertension. Percutaneous, endoscopic, and minimally invasive surgical drainage represents the various methods of drainage with each having its own advantages and disadvantages. These methods are often complementary. In this minireview, we discuss the indications, timing, and techniques of drainage of pancreatic fluid collections with focus on percutaneous catheter drainage. We also discuss the novel methods and techniques to improve the outcomes of percutaneous catheter drainage.

Intra-Abdominal Hypertension: A Systemic Complication of Severe Acute Pancreatitis.

Patients with severe acute pancreatitis (SAP) present complications and organ failure, which require treatment in critical care units. These extrapancreatic complications determine the clinical outcome of the disease. Intra-abdominal hypertension (IAH) deteriorates the prognosis of SAP. In this paper, relevant recent literature was reviewed, as well as the authors’ own experiences, concerning the clinical importance of IAH and its treatment in SAP. The principal observations confirmed that IAH is a frequent consequence of SAP but is practically absent in mild disease. Common manifestations of AP such as pain, abdominal distension, and paralytic ileus contribute to increased abdominal pressure, as well as fluid loss in third space and aggressive fluid replacement therapy. A severe increase in IAP can evolve to abdominal compartment syndrome and new onset organ failure. Conservative measures are useful, but invasive interventions are necessary in several cases. Percutaneous drainage of major collections is preferred when possible, but open decompressive laparotomy is the final possibility in some cases in order to definitively reduce abdominal pressure. Intra-abdominal pressure should be measured in all SAP cases that worsen despite adequate treatment in critical care units. Conservative measures must be introduced to treat IAH, including negative fluid balance, digestive decompression by gastric–rectal tube, and prokinetics, including neostigmine. In the case of insufficient responses to these measures, minimally invasive interventions should be preferred.

The importance of α1AMP-activated protein kinase (α1AMPK) in hemostatic dysfunctions induced by sepsis

Sepsis is a pathological circumstance whose outcome is associated with organ dysfunction and death. Vascular hyperpermeability and hemostasis impairment both play a key role in the onset of organ failure. Our previous work highlighted the protective role of α1AMPK against sepsis-induced hyperpermeability. However, the impact of α1AMPK on hemostasis has never been investigated in this condition. This study aims to characterize the interaction of α1AMPK with hemostasis in sepsis. α1AMPK wild type (WT) and knockout (KO) mice were challenged with intraperitoneal injection of lipopolysaccharide (LPS) from Escherichia coli O55B5 (10 mg/kg) during 6 and 18 hours. Plasmatic markers of coagulation, NETosis and platelet activation were measured by ELISA. To identify cell type responsible for the dysregulation, same analyses were conducted on endothelial-, leucocyte- or platelet- specific α1AMPK knockout mouse models. Hemostasis was altered at 6 hours and 18 hours after LPS administration, in both α1AMPK WT and KO mice. Thrombin generation, reflected by thrombin-antithrombin complex formation, was significantly increased in α1AMPK KO mice compared to WT mice, after 18 hours of treatment with LPS. In contrast, fibrinolysis was more inhibited in α1AMPK KO than in WT mice, with a higher level of plasminogen activator inhibitor-1 measured at 6 and 18 hours, while tissue plasminogen activator was not different. This exacerbated procoagulant phenotype in α1AMPK KO mice was associated with an increase of sCD62P in plasma, reflecting an overactivation of platelets under septic conditions. Septic α1AMPK KO mice also showed an increase of Neutrophil Elastase and plasma DNA with no variation of MPO-DNA complexes, suggesting that NETosis was not altered but that exacerbated cellular damages occurred in these mice compared to WT animals. Platelet- and leucocyte- specific α1AMPK knockout mouse models did not recapitulate the phenotype observed in total α1AMPK knockout mice after LPS administration. However, endothelial specific α1AMPK knockout mice showed an increase of thrombin generation with a tendency to higher platelet activation. Altogether, these results demonstrate that α1AMPK plays a crucial role in the regulation of hemostasis disturbances during sepsis. While α1AMPK from platelets and leucocytes does not contribute to the septic damage, endothelialα1AMPK might be a brake for hemostatic dysregulation.

The importance of alpha-1 AMP-activated protein kinase (α1AMPK) in hemostatic dysfunctions induced by sepsis

Sepsis is a pathological circumstance whose outcome is associated with organ dysfunction and death. Vascular hyperpermeability and hemostasis impairment, both play a key role in the onset of organ failure. Our previous work highlighted the protective role of α1AMPK against sepsis-induced hyperpermeability. However, the impact of α1AMPK on hemostasis has never been investigated in this condition. This study aims to characterize the interaction of α1AMPK with hemostasis in sepsis. α1AMPK wild type (WT) and knockout (KO) mice were challenged with intraperitoneal injection of lipopolysaccharide (LPS) from Escherichia coli O55B5 (10 mg.kg) during 6 and 18 hours. Plasmatic markers of coagulation, NETosis and platelet activation were measured by ELISA. In order to identify the origin of the dysregulation, same analyses were conducted on endothelial, leucocyte or platelet specific deletion model. In both α1AMPK WT and KO mice, hemostasis was altered at 6 hours and 18 hours after LPS administration. Thrombin generation, reflected by thrombin-antithrombin complex formation, was significantly increased in α1AMPK KO mice compared with WT mice, after 18 hours of treatment by LPS. In contrast, fibrinolysis was more inhibited in α1AMPK KO than in WT mice, with a higher level of plasminogen activator inhibitor-1 measured at 6 and 18 hours, while tissue plasminogen activator was not different. This exacerbated procoagulant phenotype in α1AMPK KO mice was associated with an increase in sCD62P in plasma, showing an overactivation of platelets under septic conditions. Septic α1AMPK KO mice showed an increase of Neutrophil Elastase and plasmatic DNA with no variation of MPO-DNA complex suggesting a stronger cellular damage than WT mice with no increase of NETosis. Platelet and leucocyte specific models did not have the phenotype observed in the total deletion model after LPS administration. However, endothelial specific model showed an increase of thrombin generation with a tendency of more platelet activation. Altogether, these results demonstrate that α1AMPK plays an important role in the regulation of hemostasis disturbances during sepsis. Specific model showed that α1AMPK from platelet and leucocyte does not contribute directly to the septic damage but endothelial α1AMPK seems to be important to contain hemostasis dysregulation.

Early initiation of norepinephrine in patients with septic shock: A propensity score-based analysis.

The use of vasopressors is vital in septic shock. However, the optimal timing of treatment remains unclear. Therefore, we aimed to explore the impact of early norepinephrine initiation on the survival of patients with septic shock. We selected 4253 patients from the Medical Information Mart for Intensive Care IV database between 2008 and 2019. The primary outcome was 28-day mortality. Propensity score matching (PSM) was applied to minimize between-group imbalances, and a restricted mean survival time was used to quantify the beneficial impact of early norepinephrine treatment on survival. Sensitivity analyses were conducted to test the robustness of the study results in multiple cohorts. In the PSM cohort, 2862 patients were equally assigned to early (receiving norepinephrine within the first 3 h) and delayed (> 3 h) norepinephrine initiation groups. Patients in the early norepinephrine initiation group received significantly less fluid therapy (0 vs. 79 mL/kg), had lower 28-day mortality (30.0% vs. 37.8%), longer survival days (21.89 vs. 20.37 days), shorter duration of intensive care unit (4.9 vs. 7.2 days) and hospital stays (12.4 vs. 13.6 days), shorter duration of supportive norepinephrine and invasive mechanical ventilation, lower incidence of organ failure progression (64.4% vs. 79.2%) within 24 h after shock onset, and higher mean arterial pressure within 6 and 24 h after shock onset than patients in the delayed norepinephrine initiation group (p < 0.05). Norepinephrine initiation within the first 3 h, regardless of preload dependency, was associated with longer survival time and shorter duration of supportive norepinephrine and invasive mechanical ventilation and may delay or partially reverse rapid onset organ failure.

Critical Illness and the Gastrointestinal System.

Critical illness can sometimes develop within the gastrointestinal (GI) system. This symposium series describes GI illnesses and phenomena seen within the organs of the GI system in hospitalized adults, particularly those who require critical care. The articles present state-of-the-science information for critical care and advanced practice nurses in the area of GI illnesses and their management, including providing nutrition to the critically ill. These topics are covered with a focus on pathophysiology, advanced assessment and evidence-based interventions, and cutting-edge therapies to allow nurses to innovate and strategize the care of patients with these difficult conditions.Patients of all ages can develop liver disease as a result of various illnesses; this liver disease can take the form of acute liver disease, end-stage liver disease (ESLD), or hepatocellular carcinoma. All of these disorders have significant and life-threatening aspects that require advanced knowledge of the disease processes and the application of interventions to thwart progression of the disease. Pryzbyl et al provide a timely update on the newest therapies to treat and, in some cases cure, the chronic form of liver disease and also analyze cutting-edge strategies to manage acute and acute-on-chronic hepatic failure. They review medical management, including when medical management fails and patients with life-threatening ESLD or acute liver failure undergo liver transplantation. Finally, they describe the most up-to-date preoperative and postoperative management strategies and therapies for transplant patients and examine the evidence on trends in liver transplantation, including methods to expand the donor pool as well as guidance and updates on recipient (candidate) selection.1Bloom and Seckel provide an update on the often-controversial topic of feeding tube insertion and care. They present detailed evidence about methods of insertion and recommendations on how to ensure that tubes are correctly placed and safely maintained. This is important information for acute and critical care nurses, as studies have shown a lack of standardization of clinical practice in feeding tube placement verification,2 checking gastric residuals, holding feedings, and other practices related to enteral nutrition management. Bloom and Seckel discuss best practices for enteral nasogastric feeding tube placement and care, with a focus on preventing the complications associated with this intervention.Finally, in the third article of the series, I describe the physiologic response to the infectious and inflammatory conditions of severe acute pancreatitis and fulminant colitis caused by Clostridium difficile. Patients hospitalized in acute care settings carry risk factors for developing either of these conditions, presenting critical care and advanced practice nurses with significant challenges to their identification and treatment. Severe sequelae of these diseases, including sepsis and systemic inflammatory response syndrome, correlate with the onset of organ failure and poor outcomes.3 The few interventions available to treat severe acute pancreatitis and fulminant colitis caused by C difficile are, for the most part, supportive in nature, but there are some evidence-based strategies described that may improve outcomes in patients experiencing the most severe form of these diseases and for whom there are few effective solutions. Although some of these strategies are still under investigation, they may prove valuable in improving the care available for these patients.Diseases of the GI tract and of the auxiliary organs of the GI system are highly prevalent, and patients with these diseases are seen in adult acute and critical care units. Despite their prevalence, GI system illnesses are often challenging to recognize. These diseases may be chronic in nature, such as with ESLD or acute-on-chronic liver disease, or may develop rapidly, as with acute liver failure or acute infectious/inflammatory conditions of organs of the GI tract. Critical care and advanced practice nurses are at the forefront in identifying and managing these complex disorders with the most state-of-the science strategies available, many of which are presented in this symposium. In addition, there is a clear need for knowledge and experience in nutrition in critical care and in the safe insertion of feeding tubes and their management. This is another area in which advanced practice nurses can be instrumental in forging needed change and updated standards.

Comparison of Intra-abdominal pressure monitoring vs APACHE-II and Ranson’s scoring in predicting the outcome of Acute Pancreatitis

Introduction: Intra-abdominal pressure is important risk factor for predicting mortality and morbidity in the early phase of acute pancreatitis. World Society on the abdominal compartment syndrome defines Intra-abdominal hypertension as a sustained increase in pressure above 12 mm of Hg and abdominal compartment syndrome is a sustained increase in intra-abdominal pressure above 20 mm of Hg with new onset organ failure. However, even values of lower than 15 mm of Hg may cause organ dysfunction. Material and Methods: Intra-abdominal pressure was indirectly determined by measuring urinary bladder pressure with a 16 gauge Foley’s catheter in situ. The bladder was drained completely and the tubing of the collecting bag was clamped and then the catheter will be connected to a saline manometer. Intra-abdominal pressure was measured on day 1st, 3rd, 7th and 14th after controlling the severe pain by analgesics. Result: In our study 50 patient of acute pancreatitis was taken. Patient was categorized in low risk and high risk group according to Ranson’s, APACHE and IAP criteria. It was observed that there is a positive correlation between IAP with APACHE and Ranson’s score, positive predictive value for assessment of mortality (4%), Ranson’s (4%), APACHE scoring (4%). It was observed that as the grade of Ranson’s and APACHE increases in patients of acute pancreatitis, IAP also increases. Similarly for morbidity most of the local complication occurs in moderate to severe grade of IAP 1st day (&gt;15 mm), severe grade of APACHE score (&gt;13) and severe grade of Ranson’s score (&gt;3). Common systemic complication were gastrointestinal (98%), circulatory (52%), respiratory (68%), metabolic (56%), renal (24%), MODS (10%), ARDS (8%), DIC (4%). Most of the systemic complication occurs in moderate to severe grade of IAP 1st day (&gt;15), severe grade of APACHE score (&gt;8) and severe grade of Ranson’s score (&gt;3). Conclusion: IAP measurement is cheap, easy, bedside, minimally invasive prognostic modality, cheaper alternative to Ranson’s and APACHE scoring. Early IAP monitoring can be very useful in assessment of mild to severe acute pancreatitis, hospital stay, determines local and systemic complication.

Necrotising Pancreatitis- A Cross-sectional Study on Surgical Outcomes of Pancreatic Necrosectomy

Introduction: Necrotising Pancreatitis (NP) is the severe form of acute pancreatitis accounting for significant mortality (15- 40%), morbidity (~25%) and has significant health costs. The traditional management of infected necrosis has centered on open surgical debridement which is accompanied by significant risk of stress, organ failure and complications. Short-term and long-term functional outcomes after operative treatment of NP have not been studied extensively. Aim: To evaluate the short-term and long-term surgical outcomes in patients undergoing surgery for NP. Materials and Methods: This was a cross-sectional study of patients who underwent surgery for NP conducted at Manipal Hospital, Bangalore between June 2009 to March 2016. The electronic records pertaining to such patients were retrieved. Various surgeries done were grouped. Surgical complications and short-term outcomes like new onset organ failure, Surgical Site Infection (SSIs), haemorrhage, bowel fistula, re-explorations, and requirement of additional procedures, hospital stay and the mortality were studied by hospital data. Long-term outcomes like endocrine/exocrine insufficiency, weight loss, recurrent pancreatitis, incision hernia were studied by prospective data collected from telephonic interview; questionnaires in addition to data collected as and when patient gets admitted and in Outpatient Department (OPD) during follow-up. A comparison with different surgical techniques like laparoscopy, open necrosectomy, Video assisted necrosectomy was made. Statistical analyses were performed by STATA 11.2 (College Station TX USA). Mann-Whitney test were used to find the significance difference between the length of stay and Intensive Care Unit (ICU) stay with the groups and it is expressed as mean and standard deviation, Chi-square test has been used to measure the association between different clinical variables. p&lt;0.05 was considered as statistically significance. Results: Forty six patients underwent surgical treatment during the study period. Patients’ age ranged from 25 to 75 years (median age- 44 years). Median postoperative ICU stay was 12 days (range of 01- 32 days). The mean follow-up was 3.5 years. The overall mortality rate was 26% (12 patients). The mortality rates between laparatomy (33%) and minimally invasive necrosectomy (23%) groups were not significantly different (p=0.436). Secondary diabetes mellitus was observed in 18 (40%) and exocrine insufficiency in 8 (18%) of patients. The other long-term complications were recurrent pancreatitis in 7 (15%), biliary stricture 3 (6%) and incisional hernia in 3 (6%). Conclusion: Mortality rate, organ failure rates and median ICU admission rate were similar across all surgical techniques though there was a trend of overall reduced complication rate. A long-term and close follow-up is advised in these patients for the late complications to be identified and treated.

The role of α1AMP-activated protein kinase (α1AMPK) in vascular dysfunctions induced by sepsis

Sepsis is a pathological circumstance whose outcome is associated with organ dysfunction and death. Vascular hyperpermeability and haemostasis impairment, both play a key role in the onset of organ failure. Our previous work highlighted the protective role of α1AMPK against sepsis-induced hyperpermeability. However, the impact of α1AMPK on haemostasis has never been investigated in this condition. This study aims to characterize the interaction of α1AMPK with hemostasis in sepsis. C57BL6 J mice and α1AMPK wild-type (WT) and knock-out (KO) mice were challenged with intraperitoneal injection of lipopolysaccharide (LPS) from Escherichia coli O55B5 (10 mg.kg-1) during 6 hours. Plasmatic markers of coagulation, platelet and NETosis activation were measured by ELISA and membrane markers of platelet activation were analysed by flow cytometry. The dsDNA analysis of NETosis was performed by fluorometry. Ex vivo platelets activation was assessed by flow cytometry on platelets α1AMPK WT and KO, incubated in a medium with 5 μg/mL of LPS. In C57BL6 J mice, haemostasis was activated 6 hours after LPS administration, as reflected by the increase in fibrinogen, plasminogen activator inhibitor and tissue plasminogen activator. In addition, platelets isolated from LPS-treated mice were activated as demonstrated by the increased exposure of CD62P and αIIbβIII on platelet surface and soluble CD62P detection in plasma. Finally, we measured a significant increase in myeloperoxidase, neutrophil elastase and plasmatic dsDNA, all markers of NETosis. Same parameters were measured in α1AMPK WT and KO mice. We brought out an increase of fibrinolysis impairment and heightened a trend of NETosis in α1AMPK undergoing sepsis. Furthermore, platelets of α1AMPK KO mice exhibited a more important activation ex vivo, in response to LPS. These results suggest that α1AMPK is involved in the regulation of hemostasis disturbances following sepsis.

TRANSCUTANEOUS MINI INVASIVE INTERVENTIONS IN TREATMENT OF PURULENT SEPTIC COMPLICATIONS OF ACUTE NECROTIZING PANCREATITIS

Aim. To estimate efficacy of mini invasive transcutaneous interventions in treatment of purulent septic complications of acute necrotizing pancreatitis. Material and methods. We analyzed results of treatment of 85 patients with purulent septic complications of acute necrotizing pancreatitis in whom mini invasive transcutaneous interventions were applied during 2014-2019. New onset of organ failure after operation, duration of intensive care treatment, postoperative complications and mortality rates have been studied. Results and discussion. Transcutaneous punctions and drainages were definitive methods of treatment at 74.1 % of patients with infectioned pathological lesions, at 25.9 % of patients – as a stage for preparation for open necrosequestrectomy that promoted to reduce postoperative mortality to 4.5 %. Conclusion. Transcutaneous mini invasive interventions are effective methods of step-up treatment of purulent septic complications of acute necrotizing pancreatitis, reduce necessary for wide laparotomic necrosectomies and reduce level of postoperative mortality.

Sepsis Six implementation on a general surgical ward. More work to be done

Background: Sepsis can lead to significant morbidity and mortality if not recognised and managed early. On the basis of national mortality reports, Irish guidelines recommend that patients at risk of neutropenia, patients with sepsis or those with a systemic inflammatory response (SIRS) with one plus co-morbidity should receive Sepsis Six. We assessed the implementation of the Sepsis Six on a surgical ward in our institution. Methods: All inpatients on a surgical ward in July 2018 were prospectively assessed for the presence of infection and sepsis. If the Sepsis Six was required, implementation of each of the Sepsis Six elements was recorded. Results: Of 164 patients, 40.2% (66/164) developed an infection of whom 47% (31/66), met the criteria for requiring Sepsis Six. Of these, 7.3% (12/164) patients had sepsis, with 3% (5/164) developing septic shock. Patients required Sepsis Six for the following reasons: ³1 co-morbidity and ³2 SIRS criteria(n=19); new onset organ failure (n=12) and neutropenic risk(n=0).Only 12.9% (4/31) patients received all of the Sepsis Six elements within one hour; 77.4% (24/31) received some and 9.67% (3/31) did not receive any elements. Blood cultures were taken in 54.8% (17/31) of cases but only 32.3% (10/31) patients had their lactate level checked. Conclusion: Further research action is required to better understand and improve Sepsis Six implementation. This should facilitate improved sepsis recognition and enhance patient care.

Safety and efficacy of omega-3 fatty acids in acute pancreatitis and in sepsis: A systematic review and meta-analysis

Background: Reducing the pro-inflammatory response in acute pancreatitis and sepsis has the potential to reduce the systemic inflammatory response syndrome (SIRS), prevent (multiple) organ failure and ultimately reduce mortality. Early intravenous or oral supplementation of omega-3 fatty acids (FA) has been suggested to reduce SIRS via anti-inflammatory pathways. A systematic review to evaluate safety and efficacy of omega-3 FA in acute pancreatitis is lacking. Material & Methods: A systematic literature review and meta-analysis was performed using the PubMed, Embase, and Cochrane databases. Three authors screened the literature, two authors extracted the data and assessed study quality using the Cochrane risk of bias tool. Only randomized trials were included to reduce possible selection bias. The primary outcome was mortality as assessed by calculating odds ratios and 95% confidence intervals (CI). This study was registered with PROSPERO (CRD42016048261). Results: After screening 1186 studies, five randomized trials with 229 patients suffering from acute pancreatitis were included. In patients receiving omega-3 FA, compared to controls, a non-significant reduction of mortality was seen (OR 0∙50, 95% CI 0∙13 – 1∙99, p=0∙33). Based on two studies (n=85), omega-3 FA reduced the risk of new onset of organ failure (OR 0∙33, 95% CI 0∙12 – 0∙93, p=0∙04). Nine randomized trials with 312 patients suffering from sepsis (no pancreatitis) were assessed for the same outcomes. A significant reduction of mortality was seen (OR 0∙52, 95%CI 0∙28 – 0∙97, p=0·04). None of these 14 randomized trials reported safety concerns. Conclusion: Supplementation of omega-3 FA as early modulator of systemic inflammatory response in acute pancreatitis and in sepsis appears safe and reduced the risk of new-organ failure in patients with acute pancreatitis and mortality in patients with sepsis. To show the clinical benefit of omega-3 FA in acute pancreatitis, additional research is needed.

Are omega-3 fatty acids safe and effective in acute pancreatitis or sepsis? A systematic review and meta-analysis.

Acute pancreatitis (AP) is marked by a strong pro-inflammatory response, which may cause a systemic inflammatory response syndrome (SIRS), organ failure, and death. Early administration of omega-3 fatty acids (FA) may reduce the pro-inflammatory response and improve outcome in AP. A systematic review focusing on the safety and efficacy of omega-3 FA in AP is lacking. Evaluate the safety and efficacy of an intervention with omega-3 FA in acute pancreatitis and additionally in sepsis. A systematic review and meta-analysis was performed using the PubMed, Embase, and Cochrane databases including only randomized controlled trials in AP and, for safety endpoints, in sepsis investigating intervention including omega-3 FA without other active components (e.g. addition of glutamine to the intervention). The primary outcome was mortality. After screening 1186 studies, five randomized trials (n=229) with omega-3 FA in AP were included. In AP patients treated with omega-3 FA within 48h after hospitalization, a non-significant reduction of mortality was seen (OR 0∙50, 95%CI 0∙13-1∙99, p=0∙33), compared to controls. In two studies (n=85), omega-3 FA reduced the risk of new onset of organ failure (OR 0∙33, 95%CI 0∙12-0∙93, p=0∙04). Nine randomized trials with 312 patients suffering from sepsis (not pancreatitis related) demonstrated a reduced mortality (OR 0∙52, 95%CI 0∙28-0∙97, p=0·04). None of these 14 randomized trials reported safety concerns. Administration of omega-3 FA could reduce the risk of new-organ failure in patients with AP. There were no safety issues reported of the early administration of omega-3 FA in any of the included studies. To show the real clinical benefit of omega-3 FA in AP, a large and pragmatic randomized controlled trial is needed.

Lavage through percutaneous catheter drains in severe acute pancreatitis: Does it help?A randomized control trial

AimsThere is no study comparing large volume lavage through image guided percutaneously placed drains in severe acute pancreatitis. MethodsOf the 114 randomized patients, 60 eligible candidates were randomly allocated to – Lavage Treatment (LT) group (28 patients) and Dependent Drainage (DD) group (32 patients). Primary end point was reversal of pre-existing organ failure, development of new onset organ failure, need for surgery, mortality and hospital stay. ResultsBoth the groups were comparable in terms of demographic data, onset and severity of pancreatitis. LT group had higher infected pancreatic necrosis (75% vs 50%,p = 0.047). On intention to treat analysis, lavage treatment group showed a significant reversal of persistent organ failure (84% vs 50%, p = 0.23), reduction in APACHEII scores (3.5 ± 3.405 vs 1.16 ± 3.811 p = 0.012), as measured at the time of placement of PCD to cessation of intervention. There was no difference in development of new onset organ failure in the two groups (25% vs37.5% p=.290). 75% in LT group and 69% in DD group improved with PCD alone. There was no difference in the catheter related complications and number of catheters used. The need for surgical intervention was comparable in two groups (18.8% vs 14.3% p=.737). There was a trend toward decreased mortality in group A (18.8% vs 28.8% p=.370). ConclusionLarge volume lavage trough PCD improves organ failure and this translates into trend towards reduced mortality.