Sepsis-related Organ Failure Assessment Score Research Articles

S105 The Quick Sepsis-Related Organ Failure Assessment Score Is Prognostic of Pancreatitis Severity in Patients With Alcohol-Induced Pancreatitis

Introduction: Multiple models already exist to prognosticate pancreatitis severity and mortality. However, most require invasive measurements and are cumbersome to use. The quick Sequential Organ Failure Assessment (SOFA) score (qSOFA) score is a bedside tool that may be useful in determining prognosis in patients with alcohol-induced acute pancreatitis (AAP). The goal of this study was to determine if the qSOFA and BISAP score assessed at admission is prognostic of severe clinical outcomes in AAP. Methods: This is a retrospective, single center, cohort review study of 147 patients admitted to a community academic hospital in Houston, Texas, USA with the diagnosis of AAP. IRB approval was granted by the University of Texas Health Science Center at Houston, Houston, Texas, USA. Patient records were obtained from an electronic medical record system between December 1st, 2014 to July 1st, 2020. Patients were included if they were >18 years of age, had a history of alcohol consumption and had acute pancreatitis based on the Atlanta criteria. Receiver operator characteristics (ROC) and area under the curve (AUC) analysis was used to assess the diagnostic accuracy of the qSOFA and BISAP score on admission. Logistic regression was used to assess the odds of developing severe pancreatitis based on the Atlanta criteria and need for ICU admission, intubation or vasopressors based on the BISAP and qSOFA scoring systems. Results: The qSOFA score ≥2 at admission to the hospital was found to be ≥94% specific and ≥33% sensitive while a BISAP score ≥3 at admission was found to be ≥96% specific and ≥20% sensitive for multiple clinical outcomes, including severe AAP and need for ICU admission, intubation or vasopressors. A qSOFA score ≥2 was prognostic of need for ICU admission by an adjusted odds ratio (aOR) of 48.5 (95% CI: 6.4-1,013.3; p< 0.001) and of severe AAP by an aOR of 35.3 (95% CI: 7.2-224.3; p< 0.001). A BISAP score ≥3 was prognostic of severe AAP by an aOR 7.1 (95% CI: 1.2-36.0; p< 0.05), need for ICU admission by an aOR 47.7 (95% CI: 6.9-487.1; p< 0.001), need for intubation by an aOR of 25.8 (95% CI: 3.5-238.4; p< 0.01) and need for vasopressors by an aOR of 14.2 (95% CI: 1.1-358.2; p< 0.05). Conclusion: At the time of admission, a BISAP score ≥3 or a qSOFA score ≥ 2 is highly specific and prognostic for multiple severe clinical outcomes of AAP. Since the qSOFA score has fewer variables than the BISAP score, it may be a more useful clinical tool to evaluate prognosis.Figure 1.: ROC-AUC curves showing the diagnostic accuracy of qSOFA score at admission (qSOFAADM) relative to the BISAP score at admission to diagnose clinical outcomes in alcoholic pancreatitis patients. (A) Overlayed ROC curves assessing severe pancreatitis. (B) Overlayed ROC curves assessing need for ICU admission. (C) Overlayed ROC curves assessing need for intubation. (D) Overlayed ROC curves assessing need for vasopressors.

The relationship between disease prognosis and serum calcium and corrected calcium levels in COVID-19 patients

Objectives: The present study aimed to evaluate whether low serum calcium (Ca) and corrected calcium (cCa) levels could predict disease prognosis and mortality in patients with COVID-19. Methods: In this study, we retrospectively enrolled 206 eligible patients with COVID-19, diagnosed at Turkey Kanuni Sultan Süleyman Training and Research Hospital between March 12, 2020 and June 15, 2020. Results: Serum Ca level was 8.8 ± 0.57 mg/dL and the serum cCa level was 8.99 ± 0.53 in all patients. The patients were divided into two groups, such as hypocalcemic and non-hypocalcemic patients. We observed that serum Ca levels of patients who died were significantly lower than that of surviving patients. A significant negative correlation was found between serum cCa level and albumin level. A significant positive correlation was found between serum cCa level and C-reactive protein, lactate dehydrogenase, ferritin, procalcitonin, troponin, CURB-65 score, and quick Sepsis-related Organ Failure Assessment (q-SOFA) score. Univariate logistic regression analysis revealed that age, respiratory rate, saturation, heart rate, lymphocyte, serum calcium, D-dimer, CURB-65 score, and q-SOFA score were independent predictors of high-risk group of mortality. Conclusions: This study confirms that the severity of COVID-19 is associated with lower concentrations of serum Ca. The cCa levels were associated with certain prognostic factors. Serum Ca and cCa levels could be an early and helpful marker to improve management of patients with COVID-19. We recommend evaluation of calcium in patients on initial presentation and serial monitoring during hospitalization in order to perform timely and appropriate corrective actions.

Important scoring systems for assessing the severity of COVID-19 based on COVID-19-related deaths in Wuhan, China.

Background:This study aimed to investigate the clinical characteristics of 21 deaths and evaluate potential factors affecting disease severity and mortality risk in patients with coronavirus disease (COVID-19).Methods:This retrospective analysis assessed clinical data of 21 patients who died owing to COVID-19. Disease severity and mortality risk were assessed using Acute Physiology and Chronic Health Evaluation II (APACHE II); Sepsis-related Organ Failure Assessment (SOFA); multilobular infiltration, hypo-lymphocytosis, bacterial coinfection, smoking history, hypertension and age (MuLBSTA); and pneumonia severity index (PSI) scores.Results:The mean age of the patients was 66 ± 14 years and 15 (71.4%) patients were men. Sixteen (76.2%) patients had chronic medical illnesses. Twelve (57.1%) patients were overweight. Decreased lymphocyte proportions were observed in 17 (81.0%) patients on admission. Elevated D-dimer levels were observed in 11 (52.4%) patients, and the levels significantly increased when pneumonia deteriorated. The initial APACHE II and SOFA scores demonstrated that 18 (85.7%) and 13 (61.9%) patients, respectively, were in the middle-risk level. MuLBSTA and PSI scores after admission were associated with higher risks of mortality in 13 (61.9%) patients. Most patients developed organ failure and subsequently died.Conclusions:Older, overweight, male patients with a history of chronic illnesses and continuously decreased lymphocyte proportions and increased D-dimer levels might have higher risks of death owing to COVID-19. The combination of general scoring (SOFA) and pneumonia-specific scoring (MuLBSTA and PSI) systems after admission might be sensitive in assessing the mortality risk of patients with COVID-19 who are in critical condition.

Out-of-hospital sepsis recognition by paramedics improves the course of disease and mortality: A single center retrospective study

Early recognition of sepsis and a prompt initiation of goal-directed therapy is important for sepsis survival. Little is known about the impact of early recognition of sepsis in the out-of-hospital setting when paramedics are the 1st medical professionals arriving on the scene. To characterize the impact of sepsis recognition by paramedics in the 1st out-of-hospital contact and to establish a predictive model by combining preclinical patient characteristics. In this retrospective single-center cohort study, we included a total of 263 patients diagnosed with sepsis after admission to the emergency department and correlated them to the emergency medical protocols of the paramedics who have seen the patient out-of-hospital. Only 25 patients were correctly diagnosed by paramedics out-of-hospital. If sepsis was diagnosed, the median time to antibiotic administration was significantly lower (136.50 min compared to 206.98 min, p = 0.0069) and mortality was reduced from 22.8% to 8% (p = 0.0292). We have identified predictors for prognosis and calculated a predictive model with a modified quick Sepsis-related Organ Failure Assessment (qSOFA) score, which fits the needs for out-of-hospital usage and results in a better discrimination of vitally threatened patients (receiver operating characteristic (ROC) area under curve (AUC) of 0.641 compared to 0.719), as compared to the standard qSOFA. Sepsis recognition by paramedics at the 1st out-of-hospital contact significantly reduces sepsis mortality. The qSOFA and modified qSOFA are suitable tools for sepsis recognition, and have an impact on mortality and disease management when used.

SEPSIS-3.0-Is intensive care medicine ready for ICD-11?

HintergrundIm Januar 2022 wird die 11. Revision der International Classification of Diseases (ICD-11) in Kraft treten. Unter anderem wird darin die SEPSIS-3-Definition implementiert sein, in der Sepsis als „lebensbedrohliche Organdysfunktion, hervorgerufen durch eine fehlregulierte Wirtsantwort auf eine Infektion“ definiert wird. Ziel der vorliegenden Sekundärauswertung einer Umfrage zum Thema „Sepsis-induzierte Koagulopathie“ war es zu evaluieren, ob die SEPSIS-3-Definition (engl. The Third International Consensus Definitions for Sepsis and Septic Shock) 4 Jahre nach ihrer internationalen Einführung im klinischen Alltag anästhesiologisch geführter Intensivstationen in Deutschland angekommen ist und so die Voraussetzungen für die Verwendung des ICD-11 gegeben sind.MethodenIm Rahmen einer deutschlandweiten Umfrage unter ärztlichen Leitern von Intensivstationen, die zwischen Oktober 2019 und Mai 2020 durchgeführt wurde, wurde in einem gesonderten Fragenblock nach der verwendeten Sepsisdefinition gefragt. Zusätzlich wurde gefragt, ob der quick-Sequential (Sepsis-related) Organ Failure Assessment (qSOFA) Score zum Screening auf Sepsis in dem Krankenhaus, zu dem die teilnehmende Intensivstation gehört, verwendet wird.ErgebnisseInsgesamt nahmen 50 ärztliche Leiter von anästhesiologisch geführten Intensivbereichen an der Umfrage teil. In Summe gaben die ausgewerteten Intensivstationen an, etwa 14,0 % der in Deutschland registrierten High-Care-Betten zu führen. An 78,9 % der Universitätsklinika und 84,0 % der teilnehmenden Lehrkrankenhäuser ist die SEPSIS-3-Definition im klinischen Alltag integriert. Im Gegensatz dazu wird der Screening-Test „qSOFA“ nur von 26,3 % der teilnehmenden Universitätsklinika, aber immerhin von 52,0 % der Lehrkrankenhäuser und 80,0 % der „sonstigen“ Krankenhäuser verwendet.SchlussfolgerungUnsere Daten zeigen, dass sowohl SEPSIS‑3 als auch qSOFA im klinischen Alltag deutscher Krankenhäuser angekommen sind. Die zurückhaltende Verwendung des qSOFA an Universitätsklinika bei gleichzeitiger breiter Akzeptanz der SEPSIS-3-Definition kann als Indiz interpretiert werden, dass die Suche nach einem geeigneten Screeningtest für Sepsis noch nicht abgeschlossen ist.

Characterization of the blood and neutrophil-specific microbiomes and exploration of potential bacterial biomarkers for sepsis in surgical patients.

IntroductionRecent studies have demonstrated the presence of a circulating microbiome in the blood of healthy subjects and chronic inflammatory patients. However, our knowledge regarding the blood microbiome and its potential roles in surgical patients remains very limited. The objective of this study was to determine the blood microbial landscape in surgical patients and to explore its potential associations with postoperative sepsis.Materials and Methods2825 patients who underwent surgical treatments were screened for enrollment and 204 cases were recruited in this study. The patients were sub‐grouped into noninfected, infected, sepsis, and septic shock according to postoperative clinical manifestations. A total of 222 blood samples were obtained for neutrophil isolation, DNA extraction and high‐throughput sequencing, quantitative proteomics analysis, and flow cytometric analyses.ResultsBlood and neutrophils in surgical patients and healthy controls contained highly diverse microbiomes, mainly comprising Proteobacteria, Actinobacteria, Firmicutes and Bacteroidetes. The majority (80.7%–91.5%) of the microbiomes were composed of gut‐associated bacteria. The microbiomes in septic patients were significantly distinct from those of healthy controls, and marked differences in microbiome composition were observed between sepsis and septic shock groups. Several specific bacterial genera, including Flavobacterium, Agrococcus, Polynucleobacter, and Acidovorax, could distinguish patients with septic shock from those with sepsis, with higher area under curve values. Moreover, Agrococcus, Polynucleobacter, and Acidovorax were positively associated with the sequential (sepsis‐related) organ failure assessment scores and/or acute physiology and chronic health examination scores in septic shock patients. The proteins involved in bactericidal activities of neutrophils were downregulated in septic patients.ConclusionsWe present evidence identifying significant changes of blood and neutrophil‐specific microbiomes across various stages of sepsis, which might be associated with the progression of sepsis after surgical treatments. Several certain bacterial genera in blood microbiome could have potential as microbial markers for early detection of sepsis.

Prognostic Value of Variations in Serum Biomarkers and Prognostic Scores Values Between Admission and Second Day in Intensive Care Unit Septic Patients.

ObjectiveTo determinate the prognostic value of procalcitonin (PCT) and C-reactive protein (CRP) changes during the first two days of admission to the ICU with sepsis and/or septic shock, and to compare it with changes in Acute Physiology And Chronic Health Evaluation II (APACHE-II) and Sepsis-related Organ Failure Assessment (SOFA) prognostic scores.MethodsA single-center prospective observational study was performed. Fifty consecutive patients admitted to the ICU, diagnosed of severe sepsis/septic shock were included. We considered risk factors for infection: diabetes mellitus, chronic obstructive pulmonary disease (COPD), previous antibiotic treatment, central intravascular catheter, bladder catheter, active neoplasia.ResultsMedian aged 67(52-75) years with median APACHE-II 19(14-25) points and SOFA scores 7(5-11) points on admission, and 28-day mortality of 42%. When we studied the relationship between mortality and the changes between the day of admission and the second day of the variables studied, we found that APACHE-II (p = 0.001) and SOFA (p = 0.002) between admission and second day raised significantly in no survivors, with no significant changes in CRP and PCT. Multivariate analysis showed that mortality was significantly associated to changes in SOFA score (odds ratio [OR], 2.13; 95% confidence interval [CI], 1.18-3.86) and to the presence of one or more risk factors for infection (OR, 6.01; 95% CI, 1.01-35.78) but not with PCT changes. Mortality was also related to the variations between the day of admission and the fifth day on APACHE-II (p = 0.002), SOFA (p < 0.001) and PCT (p = 0.012).ConclusionsChanges in SOFA and APACHE-II scores between admission and second day in ICU septic patients are more sensitive mortality predictors than the observed changes in CRP and PCT values. Changes in PCT levels between the day of ICU admission and the fifth day are significantly related to mortality and may be useful as an additional marker in patient outcome.

Extracorporeal Membrane Oxygenation Induces Early Alterations in Coagulation and Fibrinolysis Profiles in COVID-19 Patients with Acute Respiratory Distress Syndrome.

Hemostatic changes induced by extracorporeal membrane oxygenation (ECMO) support have been yet poorly documented in coronavirus-19 (COVID-19) patients who have a baseline complex hypercoagulable state. In this prospective monocentric study of patients with severe acute respiratory distress syndrome (ARDS) rescued by ECMO, we performed longitudinal measurements of coagulation and fibrinolysis markers throughout the course of ECMO support in 20 COVID-19 and 10 non-COVID-19 patients. Blood was sampled before and then 24 hours, 7, and 14 days after ECMO implantation. Clinical outcomes were prospectively assessed until discharge from the intensive care unit or death. The median age of participants was 47 (35-56) years, with a median body mass index of 30 (27-35) kg/m2, and a Sepsis-related Organ Failure Assessment score of 12 (8-16). Baseline levels of von Willebrand factor, fibrinogen, factor VIII, prothrombin F1 + 2, thrombin-antithrombin, D-dimer, and plasminogen activator inhibitor-1 (PAI-1) were elevated in both COVID-19 and non-COVID-19 ARDS patients, indicating that endothelial activation, endogenous thrombin generation, and fibrinolysis shutdown occur in all ARDS patients before ECMO implantation. From baseline to day 7, thrombin generation (prothrombin F1 + 2, p < 0.01) and fibrin formation markers (fibrin monomers, p < 0.001) significantly increased, further resulting in significant decreases in platelet count (p < 0.0001) and fibrinogen level (p < 0.001). PAI-1 levels significantly decreased from baseline to day 7 (p < 0.0001) in all ARDS patients. These changes were more marked in COVID-19 patients, resulting in 14 nonfatal and 3 fatal bleeding. Additional studies are warranted to determine whether monitoring of thrombin generation and fibrinolysis markers might help to early predict bleeding complications in COVID-19 patients supported by ECMO.

Clinical, radiological, and laboratory predictors of a positive urine lipoarabinomannan test in sputum-scarce and sputum-negative patients with HIV-associated tuberculosis in two Johannesburg hospitals.

BackgroundTuberculosis (TB) is a major cause of mortality in persons living with HIV (PLWH). Sputum-based diagnosis of TB in patients with low CD4 counts is hampered by paucibacillary disease and consequent sputum scarcity or negative sputum results. Urine lipoarabinomannan (LAM) has shown promise in the point-of-care detection of TB in this patient subset but lacks sensitivity, and its exact role in a diagnostic algorithm for TB in South Africa remains to be clarified.ObjectivesThe objective of this study was to better define the patient profile and the TB characteristics associated with a positive urine LAM (LAM+ve) test.MethodThis multicentre retrospective record review examined the clinical, radiological, and laboratory characteristics of hospitalised PLWH receiving urine LAM testing with sputum-scarce and/or negative sputum GeneXpert ® (mycobacterium tuberculosis/resistance to rifampicin [MTB/RIF]) results.ResultsMore than a third of patients, 121/342 (35%), were LAM+ve. The positive yield was greater in the sputum-scarce than the sputum-negative group, 66/156 (42%) versus 55/186 (30%), P = 0.0141, respectively. Patients who were LAM+ve were more likely to be confused (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 1.2–3.7, P = 0.0045), have a higher median heart rate (P = 0.0135) and an elevated quick sepsis-related organ failure assessment score (≥ 2), OR = 3.5, 95% CI = 1.6–7.6, P = 0.0014. A LAM+ve test was significantly associated with disseminated TB (dTB), P < 0.0001, TB-related immune reconstitution inflammatory syndrome (IRIS), P = 0.0035, and abdominal TB, P < 0.0001. Laboratory predictors of a LAM+ve status included renal dysfunction, P = 0.044, severe anaemia, P = 0.0116, and an elevated C-reactive protein, P = 0.0131. Of the 12 PLWH with disseminated non-TB mycobacteria cultured from the blood and/or bone marrow, n = 9 (75%) had a LAM+ve result (OR = 5.8, 95% CI = 1.6–20.8, P = 0.0053).ConclusionUrine LAM testing of hospitalised PLWH with suspected active TB had significant diagnostic utility in those that were sputum-scarce or sputum-negative. A LAM+ve result was associated with dTB, clinical and laboratory markers of severe illness, and TB-IRIS. Disseminated non-tuberculous mycobacterial infection of hospitalised PLWH may also yield urine LAM+ve results, and mycobacterial cultures must be checked in those non-responsive to conventional TB treatment. Selective use of the LAM test in the critically ill is likely to maximise the diagnostic yield, improve the test’s predictive value, and reduce the time to TB diagnosis and initiation of treatment.

Relation between inflammatory markers and sepsis in critically ill patients

Background Sepsis and septic shock is a serious complication in ICU patients. Early identification can help to improve the outcome. C-reactive protein (CRP) and neutrophil–lymphocyte ratio (NLR) are suggested markers for diagnosis. The aim of the work is to evaluate the relation between inflammatory markers and sepsis in critically ill patients. Patients and methods The study included 30 patients with different degrees of sepsis and septic shock in addition to age-matched and sex-matched healthy controls. All patients were subjected to full clinical examination. The clinical condition of the patients was further assessed using acute physiology age chronic health evaluation II score and Sequential (sepsis-related) Organ Failure Assessment score. The performed laboratory investigations included complete blood count, coagulation profile, erythrocyte sedimentation rate, CRP, renal function tests (blood urea, serum creatinine, sodium, and potassium), liver function tests (serum albumin and bilirubin), and pan-cultures. Results Among the studied patients, there were 16 (53.3%) patients with sepsis, seven (23.3%) patients with severe sepsis, and seven (23.3%) patients with septic shock. Six (20.0%) patients died at the end of the study. The patients had a significantly higher CRP (46.6±24.3 vs. 6.7±3.3 mg/dl, P Conclusions Use of CRP and NLR as early predictors of sepsis and septic shock development is reliable and convenient.

Prognostic value of SOFA score and SIRS criteria for ICU mortality in adult sepsis patients admitted to the ICU of a tertiary care Hospital of Bangladesh

Background: Sepsis is one of the most common admission-diagnosis in intensive care unit (ICU). It is associated with rapid organ dysfunction with increased mortality. Different scoring systems {e.g. Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score, systemic inflammatory response syndrome (SIRS) criteria} are commonly used to identify and predict prognosis of sepsis in ICU at present. The objective was to determine the prognostic value of SOFA score and SIRS criteria among sepsis patients.&#x0D; Methods: This was a prospective observational study, conducted in the department of Critical Care Medicine, BIRDEM General Hospital during the period of January, 2018 to July, 2019. Consecutive sampling was conducted in patients fulfilling the selection criteria. After admission of patients with sepsis from indoor or emergency department; SOFA score and SIRS criteria were calculated using physiological and laboratory parameters recorded within 24 hours of ICU admission. Standard criteria were applied, an increase of point of e” 2 in SOFA score, and/ or SIRS criteria was regarded as sepsis. Patients who were admitted in ICU other than sepsis., known cases of acute myocardial infarction (MI), trauma victims, acute stroke, pregnancy, end stage renal disease (ESRD), decompensated chronic liver disease (CLD), who developed sepsis after admission in ICU, readmitted cases were excluded. All patients were followed up daily. Outcome was measured in terms of ICU mortality.&#x0D; Results: A total 203 patients were analyzed. About one-third (29.6%) patients belonged to age group 61-70 years (mean age: 58.25 ± 15.03 years); with slightly male predominance (52.2%). Pneumonia (56%) was the most common on admission diagnosis followed by uro-sepsis (19.7%). SOFA score showed greater discrimination (AUROC, 0.900 [95% CI, 0.860-0.941]) (p value &lt;0.001) than SIRS criteria (AUROC,0.406 [95% CI, 0.327-0.486]).&#x0D; Conclusion: SOFA score had higher prognostic value than SIRS criteria regarding ICU mortality in sepsis.&#x0D; Birdem Med J 2021; 11(2): 84-89

Do Digital Handover Checklists Influence the Clinical Outcome Parameters of Intensive Care Unit Patients? A Randomized Controlled Pilot Study.

Background: Clinical handovers have been identified as high-risk situations for medical treatment errors. It has been shown that handover checklists lead to a reduced rate of medical errors and mortality. However, the influence of handover checklists on essential patient outcomes such as prevalence of sepsis, mortality, and length of hospitalization has not yet been investigated in a randomized controlled trial (RCT).Objectives: The aim of the present pilot study was to estimate the effect of two different handover checklists on the 48 h sepsis-related organ failure assessment (SOFA) score and the feasibility of a respective clinical RCT.Methods: Outcome parameters and feasibility were investigated implementing and comparing an intervention with a control checklist.Design: Single center two-armed cluster randomized prospective crossover pilot study.Setting: The study took place over three 1-month periods in an intensive care unit (ICU) setting at the University Hospital Aachen.Patients/Participants: Data from 1,882 patients on seven ICU wards were assessed, of which 1,038 were included in the analysis.Intervention: A digital standardized handover checklist (ISBAR3) was compared to a control checklist (VICUR).Main Outcome Measures: Primary outcome was the 2nd 24 h time window sepsis-related organ failure assessment (SOFA) score. Secondary outcomes were SOFA scores on the 3rd and 5th 24 h time window, mortality, reuptake, and length of stay; handover duration, degree of satisfaction, and compliance as feasibility-related outcomes.Results: Different sepsis scores were observed only for the 1st 24 h time window after admission to the ICU, with higher values for ISBAR3. With respect to the patient-centered outcomes, both checklists achieved similar results. Average handover duration was shorter for VICUR, whereas satisfaction and compliance were higher for ISBAR3. However, overall compliance was low (25.4% for ISBAR3 and 15.8% for VICUR).Conclusions: Based on the results, a stratified randomization procedure is recommended for following RCTs, in which medical treatment errors should also be investigated as an additional variable. The use of control checklists is discouraged due to lower acceptance and compliance among healthcare practitioners. Measures should be undertaken to increase compliance with the use of checklists. Clinical outcome parameters should be carefully selected.Trial Registration: ClinicalTrials.gov, Identifier [NCT03117088]. Registered April 14, 2017.

Critical carE Database for Advanced Research (CEDAR): An automated method to support intensive care units with electronic health record data

Patients treated in an intensive care unit (ICU) are critically ill and require life-sustaining organ failure support. Existing critical care data resources are limited to a select number of institutions, contain only ICU data, and do not enable the study of local changes in care patterns. To address these limitations, we developed the Critical carE Database for Advanced Research (CEDAR), a method for automating extraction and transformation of data from an electronic health record (EHR) system. Compared to an existing gold standard of manually collected data at our institution, CEDAR was statistically similar in most measures, including patient demographics and sepsis-related organ failure assessment (SOFA) scores. Additionally, CEDAR automated data extraction obviated the need for manual collection of 550 variables. Critically, during the spring 2020 COVID-19 surge in New York City, a modified version of CEDAR supported pandemic response efforts, including clinical operations and research. Other academic medical centers may find value in using the CEDAR method to automate data extraction from EHR systems to support ICU activities.

Recent advances in the pathophysiology and management of sepsis: a review

Sepsis is a syndrome consisting of physiological, pathological and biochemical anomalies caused by infectious agents. It causes clinical organ dysfunction, which is identified by an acute increase in the Sequential (sepsis-related) Organ Failure Assessment (SOFA) score of two or more points. SOFA score is a score of three components that can be easily used at the bedside to track the clinical status of a patient while on admission, and these are altered respiratory rate of ≥ 22 breaths/minute, altered mental status, and systolic blood pressure of ≤ 100 mmHg. A patient with SOFA score of ≥ 2 has an attributable 2 - 25-fold increased risk of mortality compared to a patient with SOFA score of ˂ 2. This present review provides information on the new definition of sepsis and septic shock, aetiology, pathophysiology, biochemical, pathological and haematological changes, morbidity and mortality parameters, management, andprognostic factors in patients with sepsis.&#x0D; Key words: Sepsis, septic shock, SOFA score, pathophysiology, management bundles

Can we learn from others? The Swedish intensive care unit database for COVID-19 cases.

Can we learn from others? The Swedish intensive care unit database for COVID-19 cases.

The prognostic value of myoglobin difference in sepsis related chronic critical illness

Objective: To investigate the predictive value of myoglobin (Mb) for the prognosis of sepsis related chronic critical illness (CCI). Methods: Retrospective study was conducted on septic patients with the length of ICU stay equal or greater than 14 days, and sepsis-related organ failure assessment (SOFA) score equal or greater than 2 on the 14th day in ICU in the First Department of Critical Care Medicine at the First Affiliated Hospital of Sun Yat-sen University from January 2017 to March 2020. Patients' clinical and laboratory data were collected on the 1st and 14th day in ICU. The survival on day 28 in ICU was recorded. According to the myoglobin levels on day 1 and day 14, all subjects were divided into myoglobin elevation group and decline group. Kaplan-Meier survival curve was used to compare the cumulative survival rate at day 28. Cox regression analysis was used to analyze the independent risk factors of mortality. Receiver operating characteristic (ROC) curve was used to analyze the prognostic value of myoglobin. Results: A total of 131 patients with sepsis related CCI were recruited, including 58 patients in the elevation group and 73 in the decline group. The Mb level in elevation group on day 1 was significantly lower than that in decline group [172.40(59.99, 430.53) μg/L vs. 413.60(184.40, 1 328.50) μg/L, Z=3.749, P=0.000], and the Mb level on day 14 was the opposite change in two groups [483.65(230.38, 1 471.75)μg/L in elevation group vs. 132.20(76.86, 274.35)μg/L in decline group, Z=5.595, P=0.000]. Kaplan-Meier survival curve analysis showed that the 28-day cumulative survival rate of the elevation group was significantly lower than that of decline group (χ²=7.051, P=0.008). Cox ratio regression analysis suggested that elevated myoglobin was an independent risk factor for 28-day mortality in septic patients with CCI (OR=2.534, 95%CI 1.212-5.295, P=0.013). ROC curve analysis suggested that the sensitivity of myoglobin elevation in predicting mortality related to CCI within 28 days was 64.5%, and the specificity was 32.0% with area under the curve(AUC) 0.661(95%CI 0.550-0.773,P=0.007) and Jorden Index was 0.325. Conclusion: Elevated myoglobin, an independent risk factor for mortality within 28 days in ICU, can predict the prognosis of sepsis related chronic critical illness.

Can mini-tracheostomy needle be safer for residency training in percutaneous dilatation tracheostomy applications in intensive care unit?

Aim&#x0D; The aim of study to evaluate the bedside percutaneous dilatation tracheostomy, performed with Fiberoptic bronchoscopy guided Griggs technique using a mini-tracheostomy needle, by residents in intensive care unit retrospectively.&#x0D; Materials and Methods&#x0D; Percutaneous dilatation tracheostomys performed in 20 intensive care unit patients using a mini-tracheostomy needle. All percutaneous dilatation tracheostomy procedures were performed by a resident who was currently undergoing intensive care unit residency training. Griggs technique was used in all procedures. All complications, the time from needle insertion to the insertion of the tracheostomy cannula was also noted. &#x0D; Results&#x0D; The average age of the patients was 69.8 ± 16.14 years. The mean Acute Physiology and Chronic Health Assessment (APACHE) II score of the patients was 23.05 ± 6.16, Glasgow Coma Scale (GCS) score was 10 ± 3.43, and Sepsis-Related Organ Failure Assessment (SOFA) score was 7.2 ± 2.11. The mean procedure time was 13 ± 1.68 minutes, and the day of tracheostomy application was 6.35 ± 4.59. Twelve (60%) patients were switched to home-type ventilators. Ten (50%) of the patients were transferred to the palliative ward with home-type ventilator. Mortality rate was 20% (4 patients) at 90 days. When patients were evaluated in terms of complications; none of the patients had pneumothorax, subcutaneous emphysema, posterior tracheal wall damage, or tracheoesophageal fistula. Minimal bleeding that required no intervention was observed in only one patient. &#x0D; Conclusion&#x0D; Using Mini-trach® needle in percutaneous dilatation tracheostomys performed via fiberoptic broncoscopy by less experienced residents may be safer to prevent complications.

One in four die from acute infectious illness in an emergency department in Eastern Cape Province, South Africa.

Despite the breadth of data supporting evidence-based practice for sepsis care in high-resource settings, there are relatively few data to guide the management of sepsis in low-resource settings, particularly in areas where HIV and tuberculosis (TB) are prevalent. Furthermore, few studies had broadened sepsis parameters to include all patients with acute infectious illness or followed patients up after hospital discharge. Understanding the epidemiology and outcomes of acute infections in a local context is the critical first step to developing locally informed targeted management strategies. To quantify and describe the incidence of and risk factors for mortality in a cohort of patients with undifferentiated acute infectious illnesses who presented to an emergency department (ED) in the Eastern Cape region of South Africa (SA). In this prospective cohort study, patients with suspected acute infectious illness were enrolled at a district casualty ward in Mthatha, SA, between 1 July and 1 September 2017. Demographic data, interventions, diagnostic studies and disposition were prospectively collected during the initial encounter and during the hospital stay. Follow-up was conducted both in hospital and via phone interviews 30days after the index visit. A total of 301 patients presented to the ED with acute infectious illness during the study period, of whom 54.8% had complete 30-day follow-up. Of the study population, only 5.7% had a complete set of vital signs (heart rate, respiratory rate, blood pressure and temperature) documented. Of the cohort, 51.8% had HIV and 32.9% active or treated TB; 25.2% of patients died within 30 days. Accounting for medical history, diagnosis and ED interventions, risk of mortality was independently associated with age (odds ratio (OR) 1.03; 95% confidence interval (CI) 1.00 - 1.06), HIV-positive status (OR 4.10; 95% CI 1.44 - 11.67) and Quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA) score (OR 1.90; 95% CI 1.14 - 3.19) in an adjusted model. No ED interventions were protective for mortality, with intravenous fluid administration associated with increased 30-day mortality in this cohort (OR 3.65; 95% CI 1.38 - 9.62). Among adults with suspected acute infectious illness in Mthatha, SA, 30-day mortality was concerningly high. Mortality was highest in patients with concomitant HIV infection. In particular, vital sign assessment to identify possible sepsis in this cohort is crucial, as it affects mortality to a meaningful extent, yet is often unavailable. Future research is needed on the management of sepsis in low-resource settings, particularly in HIV-positive individuals.

Underlying Diseases and in-Hospital Mortality of Acute Respiratory Failure Patients: Indonesian Prospective Cohort Study

Background: Epidemiologic data of acute respiratory failure (ARF) are limited. This study aims to investigate the underlying diseases and in-hospital mortality of patients with ARF in Indonesia. Materials and Methods: An observational prospective cohort study involving patients with ARF in six hospitals was conducted. Data were collected between January and December 2017. Data on the type of ARF, quick sepsis-related organ failure assessment (qSOFA) score, underlying diseases, and in-hospital mortality were documented. Proportions were compared using Chi-square or Fisher exact tests. Multivariable regression models with variable selection based on a stepwise backward elimination were run to analyze the risk factors for in-hospital mortality. Results: A total of 412 patients (median age: 56-years-old) were included. Most of the subjects were male (66.9%), hypoxemic (55.3%), and acute onset (86.4%). The most commonly encountered underlying diseases were pneumonia (58.7%), chronic obstructive pulmonary disease (25.5%), lung tuberculosis (25.2%), lung cancer (16.5%), noncystic fibrosis bronchiectasis (11.9%), congestive heart failure (10.2%), and chronic kidney disease (CKD) (3.2%). There were 65% of patients received only oxygen therapy, invasive mechanical ventilation was utilized for 30.8% of patients, and 4.1% of patients underwent noninvasive mechanical ventilation. There were 201 (48.79%) in-hospital mortality cases. The risk factors of in-hospital mortality were qSOFA ≥2 (odds ratio [OR]: 2.420, 95% confidence interval [CI] 1.599–3.662; P = 0.000) and CKD (OR: 3.871, 95% CI 1.024–14.631; P = 0.046). Conclusions: Most of the underlying diseases of ARF in Indonesia are communicable diseases. Patients with qSOFA ≥2 and CKD have a higher risk of death during hospitality.

Therapeutic Plasma Exchange Protects Patients with Sepsis-Associated Disseminated Intravascular Coagulation by Improving Endothelial Function.

The mortality rate of sepsis-associated disseminated intravascular coagulation (DIC) is high. This study aimed to explore the efficacy of therapeutic plasma exchange (TPE) in sepsis-associated DIC patients by improving endothelial function. A total of 112 sepsis-associated DIC patients were randomly divided into the TPE group (n = 40), the heparin (HP) group (n = 36), and the SHAM group (n = 36). The SHAM group received conventional treatment; the HP group was treated with HP based on conventional treatment; and the TPE group received conventional treatment plus TPE. The differences in thromboelastogram (TEG), platelet (PLT), coagulation function, and the endothelial cell (EC) injury biomarkers at 6 h, 24 h, 48 h, 72 h, and 7 days after TPE were compared among the three groups, and the three groups were compared in terms of Acute Physiology and Chronic Health Evaluation II (APACHE II) score, Sepsis-Related Organ Failure Assessment (SOFA) score, the length of intensive care unit (ICU) hospitalization, 28-day mortality rate, 28-day cumulative survival rate, the incidence of bleeding events, the incidence of acute kidney injury (AKI), and acute respiratory distress syndrome (ARDS). The efficacy of TPE is superior to the HP in increasing PLT, improving coagulation function, increasing the 28-day cumulative survival rate, and reducing the length of ICU hospitalization, 28-day mortality, and the incidence of bleeding events, AKI, and ARDS with statistically significant differences (P < .05). Moreover, the effect of TPE outperforms HP on the EC injury biomarkers with statistically significant differences (P < .05). Our results suggest that TPE may be more effective than HP in the treatment of patients with sepsis-associated DIC. The possible mechanism is via improving endothelial function.