Septic Shock Conditions Research Articles

Extensive Fournier’s Gangrene Due to Delayed Management of Perianal Abscess in Uncontrolled Diabetes: A Case Report

Abstract Fournier’s gangrene is a rapidly spreading gangrene predominantly affecting the genital and perianal region. It has the highest mortality and is more common in immunocompromised and diabetic patients. Poorly controlled diabetes is one of the common risk factors for Fournier’s gangrene. Delayed diagnosis and treatment increase mortality by nearly 100%. In our case, the patient was initially managed for a perianal abscess and later progressed to Fournier’s gangrene. A 48-year-old male diabetic presented with erythematous swelling in the right-side scrotal region for one-week duration. He had a recent perianal abscess and underwent incision and drainage at another hospital He also reported fever with chills and rigors for the past two days. The patient is now in a state of septic shock. He has a history of irregular medication for type 2 diabetes mellitus. Clinical examination confirmed Fournier’s gangrene resulting from a perianal abscess in the context of uncontrolled diabetes. The patient underwent an emergency wound debridement under spinal anesthesia. Extensive wound debridement was performed on the right hemiscrotum. Necrotic tissue was debrided on the right perianal region. The patient was initiated on empirical antibiotics, receiving a calculated dose of cefoperazone with sulbactam and metronidazole. Additionally, the patient underwent sitz baths and received regular wound dressing. Following wound debridement and glycemic control with insulin, the patient showed signs of improvement. Four weeks post-debridement, the patient underwent split-skin grafting for the raw area on the scrotum, while the fistula site was allowed to heal by secondary intention. The cornerstone in managing perianal abscess with Fournier’s gangrene in diabetic patients is extensive wound debridement, antibiotic coverage, and proper management of diabetes. Early diagnosis and prompt surgery of perianal abscess can reduce the risk of developing Fournier’s gangrene in diabetic patients. Post-surgical raw areas can be effectively managed with split-skin grafts.

The concomitant occurrence of hidradenitis suppurativa and Fournier’s gangrene

Background: Fournier’s gangrene represents a life-threatening necrotising infection affecting the perineal region, while hidradenitis suppurativa is characterised by a chronic inflammatory skin condition. The simultaneous occurrence of both conditions is exceedingly rare. Case description: A 42-year-old female with a documented history of severe untreated hidradenitis suppurativa presented for shortness of breath, fever and lethargy, along with extensive wounds and skin breakdown involving the left axilla, perineum, lower back, lumbosacral region and bilateral gluteal areas, extending to the perineum. Upon presentation, the patient was in a state of septic shock, and a diagnosis of actively manifesting Fournier’s gangrene was established at the site of the pre-existing hidradenitis suppurativa lesions. Despite the implementation of an aggressive multidisciplinary approach incorporating surgical interventions, antibiotic therapy and intensive care measures, the patient’s condition deteriorated, culminating in septic shock, multi-organ failure and eventual demise. In this report, we discuss both clinical entities, their similarities and differences, and the possible mechanisms by which they may have co-occurred. Conclusion: The co-existence of hidradenitis suppurativa and Fournier’s gangrene poses unique challenges, given the rapid progression of Fournier’s gangrene within the context of hidradenitis suppurativa, potentially suggesting the latter as a predisposing factor. This case underscores the importance of vigilant screening and management of hidradenitis suppurativa.

Efferent methods of therapy for critical illness

Extracorporeal blood purification is intended to eliminate dysregulation of the immune system. The concept of extracorporeal therapy is based on the nonspecific clearance of inflammatory mediators and triggers, which attenuates the systemic expression of inflammatory mediators. The main types of extracorporeal therapy are hemoadsorption and plasma exchange. Hemoadsorption is used primarily as an adjuvant treatment for septic shock and other severe inflammatory conditions, including severe forms of COVID-19 with cytokine storm.
 Reliable data demonstrating the benefit of hemoadsorption in critically ill patientsis is limited. Recommendations for the use of hemoadsorption devices are often based on incomplete data or questionable interpretations of available data. Given the lack of evidence for the benefit of hemoadsorption in the treatment of severe inflammation, sepsis, liver failure and rhabdomyolysis, its routine use in clinical practice is not justified until the mechanisms underlying these findings are fully elucidated.
 Plasma replacement is a potentially life-saving invasive extracorporeal blood purification procedure that replaces plasma with a substitute fluid (saline, albumin solution, fresh frozen plasma, or a combination of these) with the risk of side effects and complications. There is still uncertainty regarding the timing, type of plasma exchange, volume and frequency of plasma filtration. Although plasma replacement is considered to be relatively safe, there is still insufficient evidence to support its inclusion in sepsis treatment protocols.
 Reports of the use of extracorporeal methods in the treatment of patients with severe refractory systemic inflammation provide evidence of decreased levels of inflammatory biomarkers, improved hemodynamic parameters, and decreased organ failure. However, according to the results of randomized clinical trials, extracorporeal therapy does not affect clinical outcomes, and in some even increases mortality. To clarify the effectiveness of extracorporeal therapy, it is necessary to study the mechanisms of interaction of the devices used with target and non-target blood components and large-scale randomized controlled trials assessing the ability of this therapy to improve clinical outcomes.

Lactate Albumin Ratio as Predictor of 28 Days Mortality in Septic Shock Patients and its Correlation to SOFA Score for Assessment of Organ Dysfunction: A Prospective Observational Study

Background: Sepsis and septic shock are leading cause of mortality in ICU patients. Prognostication and early intervention forms most integral part of management of septic shock. There many validated score to assess the critical state of septic shock patients. APACHE2 and SOFA scores are widely used world over. Multiple parameters used in the score and complexity involved have lead researchers to search for more convenient and simple markers. Lactate albumin Ratio (L/A ratio) turns out to be one such marker, combining two easily available parameters and abbreviating fallacies associated with both parameters when assessed individually. We aimed to assess L/A ratio as predictor of all cause 28 days’ mortality in septic shock patients and correlated L/A ratio to the SOFA score to assess organ dysfunction.
 Methods: It was a prospective observational study. 130 patients admitted in the state of septic shock were studied. L/A ratio was obtained at 24 hours after admission in the ICU. SOFA score was also calculated at 24 hours. ROC curve was plotted for L/A ratio to evaluate diagnostic accuracy, as predictor of 28 days’ mortality. Multivariable analysis of L/A ratio with other significant parameters was performed. Spearman rank correlation coefficient was used for correlation of L/A ratio with SOFA score.
 Results: L/A ratio at 24 hours (AUC 0.99; 95% CI: 0.95 to 0.99), p value =0.0001, was significant predictor of mortality at 28 days, at cut off point of >1.15. Significant positive correlation was found between L/A ratio and SOFA score at 24 hours, with correlation coefficient of 0.828, p value=0.0001.
 Conclusion: L/A ratio was found to be independent predictor of 28 days’ Mortality in Septic Shock Patients. Also strong correlation was obtained of L/A ratio to SOFA score to assess organ dysfunction in septic shock patients.

A State of Septic Shock Revealing a Pyomyoma as An Exceptional Complication Post Abortum

Pyomyoma is a pyogenous infection of a leiomyoma and occurs when a leiomyoma under goes infarction and subsequent infection. It is a rare, yet potentially fatal complication of uterine leiomyoma. We report the case of a 42-year-old tunisian woman,20 weeks of gestation, who presented with rupture of membrane. In her ultrasonography, in 20 weeks of gestation, she had 18 cm × 16 cm sub-mucosal to intramural myoma and a normal fetus. a cesarean section was performed for suspected chorioamniotitis with a failed induction. Seven days later, she presented with fever and lower abdominalpain. In physical examination, she had blood pressure:100/70mmHg, pulse rate: 110 beats per minute and temperature:39.5°C. She had tenderness on uterus and uterine height was 24 weeks. Ultrasonography showed a hetero-echoic mass (18 cm × 16 cm × 12 cm) in posterior side of uterus and endometrial thickness was 8 mm. With diagnosis of endometritis or infected myoma, she was admitted and received intravenous.

Vasopressin in Sepsis and Other Shock States: State of the Art.

This review of the use of vasopressin aims to be comprehensive and highly practical, based on the available scientific evidence and our extensive clinical experience with the drug. It summarizes controversies about vasopressin use in septic shock and other vasodilatory states. Vasopressin is a natural hormone with powerful vasoconstrictive effects and is responsible for the regulation of plasma osmolality by maintaining fluid homeostasis. Septic shock is defined by the need for vasopressors to correct hypotension and lactic acidosis secondary to infection, with a high mortality rate. The Surviving Sepsis Campaign guidelines recommend vasopressin as a second-line vasopressor, added to norepinephrine. However, these guidelines do not address specific debates surrounding the use of vasopressin in real-world clinical practice.

Monoclonal antibodies neutralizing alpha-hemolysin, bicomponent leukocidins, and clumping factor A protected against Staphylococcus aureus-induced acute circulatory failure in a mechanically ventilated rabbit model of hyperdynamic septic shock.

Patients with septic shock caused by Staphylococcus aureus have mortality rates exceeding 50%, despite appropriate antibiotic therapy. Our objectives were to establish a rabbit model of S. aureus septic shock and to determine whether a novel immunotherapy can prevent or halt its natural disease progression. Anesthetized rabbits were ventilated with lung-protective low-tidal volume, instrumented for advanced hemodynamic monitoring, and characterized for longitudinal changes in acute myocardial dysfunction by echocardiography and sepsis-associated biomarkers after S. aureus intravenous challenge. To demonstrate the potential utility of this hyperdynamic septic shock model for preclinical drug development, rabbits were randomized for prophylaxis with anti-Hla/Luk/ClfA monoclonal antibody combination that neutralizes alpha-hemolysin (Hla), the bicomponent pore-forming leukocidins (Luk) including Panton-Valentine leukocidin, leukocidin ED, and gamma-hemolysin, and clumping factor A (ClfA), or an irrelevant isotype-matched control IgG (c-IgG), and then challenged with S. aureus. Rabbits challenged with S. aureus, but not those with saline, developed a hyperdynamic state of septic shock characterized by elevated cardiac output (CO), increased stroke volume (SV) and reduced systemic vascular resistance (SVR), which was followed by a lethal hypodynamic state characterized by rapid decline in mean arterial pressure (MAP), increased central venous pressure, reduced CO, reduced SV, elevated SVR, and reduced left-ventricular ejection fraction, thereby reproducing the hallmark clinical features of human staphylococcal septic shock. In this model, rabbits pretreated with anti-Hla/Luk/ClfA mAb combination had 69% reduction in mortality when compared to those pretreated with c-IgG (P<0.001). USA300-induced acute circulatory failure-defined as >70% decreased in MAP from pre-infection baseline-occurred in only 20% (2/10) of rabbits pretreated with anti-Hla/Luk/ClfA mAb combination compared to 100% (9/9) of those pretreated with c-IgG. Prophylaxis with anti-Hla/Luk/ClfA mAb combination halted progression to lethal hypodynamic shock, as evidenced by significant protection against the development of hyperlactatemia, hypocapnia, hyperkalemia, leukopenia, neutropenia, monocytopenia, lymphopenia, as well as biomarkers associated with acute myocardial injury. These results demonstrate the potential utility of a mechanically ventilated rabbit model that reproduced hallmark clinical features of hyperdynamic septic shock and the translational potential of immunotherapy targeting S. aureus virulence factors for the prevention of staphylococcal septic shock.

Emphysematous pyelonephritis complicated by septic shock treated with antibiotic therapy alone: a case report.

We present a case of a 64-year-old female patient with type 2 diabetes under insulin and hypertension under amlodipine, who was admitted to the intensive care unit for a state of septic shock on EPN. The patient received resuscitation measures and antibiotic therapy, and the evolution was favorable. The patient was transferred to the urology unit after 10 days of hospitalization in the intensive care unit. EPN is frequently caused by gram-negative cocci and generally develops in diabetics. The clinical signs of EPN are not very specific and are essentially based on the signs of acute pyelonephritis, which responds badly to treatment. It is essential to take preventive measures in diabetic patients to avoid this complication. Early diagnosis allows for avoiding surgery by preserving the kidney.

Impact of β3-adrenergic receptor modulation on vascular function during experimental septic shock

Dysautonomia is an adverse event in septic shock (SC) associated with loss of cardiovascular variability. Modulation by β1-blockers is associated with cardiovascular benefits. Unlike β1-adrenergic (AR) receptors, β3-ARs are widely expressed on vascular level and, when stimulated, cause vasorelaxation. We hypothesize that during SC, vascular function could also be mediated by β3-ARs. The aim of the study is to assess the impact of β3-ARs modulation at the level of endothelial cells on vascular function during SC. We developed an inflammatory model using commercial human aortic endothelial cells (HAEC) stimulated with lipopolysaccharides (LPS, 10 μg/mL) to mimic SC conditions. These HAECs were treated 6 h for the transcriptional evaluations (PCR) and 24 h for the protein evaluations (WB). Then, the β3-AR was modulated with an agonist (CL316243, 1 μM) and antagonist (SR59230A, 1 μM) and its impact on different markers was assessed as inflammatory markers (VCAM-1, ICAM-1), expression of other β-ARs, NO synthases (eNOS, iNOS) and cell permeability. Finally, the expression of β3-AR was evaluated using murine vascular tissue samples (thoracic aorta and mesenteric arteries) lysed for PCR and WB detection. The expression of endothelial surface inflammatory markers (VCAM-1, ICAM-1) and the activation of NFκB were increased in LPS condition, validating the inflammatory model. Additionally, LPS induced a decreased transcriptional expression of β1 and 2-AR. In LPS condition, eNOS was decreased, while iNOS as well as cell permeability were increased. However, β3-AR expression was not demonstrated on HEACs, and the addition of agonist or antagonist had not induced any change on the above mentioned markers. Although, we demonstrated the expression of β3-AR in mouse aortic and mesenteric vessels at the genetic and protein level, allowing the study of the modulation of this receptor in vivo. The concept of decatecholamines emerged in order to minimize the use of catecholamines in SC management. Blockade of β-AR is a therapeutic approach aimed at downregulating adrenergic stimulation during SC. While β1-ARs have been widely studied, there are no data on β3-ARs, so characterization of the β3-AR is required and could play a significant role in septic vascular dysfunction.

Concurrent infection by Clostridium perfringens type A, Clostridium septicum, and Clostridium sordelli in mouflon (Ovis aries musimon) - A case report

A female mouflon, weighing 40 kilograms, was submitted to the diagnostic laboratory of the Institute of Veterinary Medicine of Serbia for determining the potential cause of death. Necropsy revealed massive hemorrhages in subcutaneous and intermuscular tissue and on papillary muscle. Petechiae and ecchymoses were found on the omentum, mesentery and adipose tissue of heart, kidney and costal pleura. Haemorrhagic-necrotic enteritis in duodenum and jejunum was characterized by catarrhal hemorrhagic inflammation with the presence of mucous and bloody content, whereas gas bubbles in the submucosa have also been confirmed. Bacterial cultures from sampled organs were identified as Clostridium perfringens type A, Clostridium septicum, and Clostridium sordelli. Based on the established pathological and histological changes and the results of the bacteriological, biochemical, and molecular examination, the state of septic shock and toxemia with disseminated massive bleeding was the immediate cause of mouflon death. The septic condition is a consequence of enterotoxemia caused by Clostridium perfringens type A, Clostridium septicum, and Clostridium sordelli infection.

Management of an Elderly Patient Via Trans-Catheter Approach for a Post-Cardiac Surgery Aortic Pseudoaneurysm: A Case Report

Pseudoaneurysm of the ascending aorta is a rare but dreadful complication following cardiac surgery and it has more chances of rupturing in elderly females. It occurs as a result of lengthy cardiopulmonary bypass time and associated degenerative changes in old patients. Due to the poor prognosis, early diagnosis and management of this complication is essential. Our case is of a 68-year old female who developed a 44 mm large ascending aortic pseudoaneurysm 7 days after undergoing (coronary artery bypass grafting) CABG for long-standing. (Triple vessel coronary artery disease) TVCAD. The location of the pseudoaneurysm was found to be just above the vein graft to the RCA on (computerized tomography) CT-Aortogram. 2D-Echocardiography showed an Ejection Fraction of 45% and a 22 mm neck of the aneurysmal sac. Trans-catheter device closure was planned and the neck was successfully closed with no residual leak seen on (computerized tomography) CT-Aortogram performed after 3 days. However, she developed cardiac arrest during the device closure and even after successful resuscitation she went into a state of septic shock in the following weeks that did not respond to maximum medical treatment which unfortunately led to her death. A review of 3 similar cases of post-cardiac surgery aortic pseudoaneurysms which were successfully managed via trans-catheter device closure is also discussed. Early diagnosis and interventional treatment of post-cardiac surgery aortic pseudoaneurysms in elderly patients is necessary alongside very careful surgical technique while performing cardiac surgery to minimize the risk of aneurysm formation.

OPEN CHOLECYSTECTOMY UNDER THORACIC ANESTHESIA IN A PATIENT WHO HAS CHRONIC OPSTRACTIVE PULMONARY DISEASE WITH HEART FAILURE AND DEVELOPED RESPIRATORY DISTRESS-A CASE REPORT

For decades, the management of symptomatic cholelithiasis in high surgical risk patients has remained contentious. Cholecystectomy has become firmly established as a procedure of choice in the management of symptomatic cholelithiasis. The procedure usually necessitates general anesthesia and endotracheal intubation to prevent aspiration and respiratory embarrassment secondary to the induction of pneumoperitoneum. Open cholecystectomy (OC) usually necessitates general anesthesia and endotracheal intubation to prevent aspiration and respiratory embarrassment. We report our preliminary experience with open cholecystectomy using thoracic anesthesia in patients with cardiac failure and with previous history of smoking. A 78-year-old mal (weight 81 kg, height 176 cm) with abdominal pain applied to the emergency department. After general surgery and infectious disease consultations, he was admitted to the intensive care unit because of high infection parameters and general condition disorder. He had a history of frequent pain at the right hypochondriac region with ultrasonography documented calculi in the gallbladder for two years and heart failure. With the patient at the right lateral decubitus position, EA was performed with a 18-G thoracic catheter inserted 4cm towards the cephalad-direction from T7/T8 successfully. After completion of the surgical procedure, the thoracic catheter was removed, and the patient was shifted to the post-anesthesia care unit (PACU) for further observation. The patient remained hemodynamically stable and comfortable during the 1 hour at PACU. In this case report, we wanted to demonstrate the management of an emergency case with epidemic anesthesia, with a general condition of poor heart failure and septic shock.

Audit of General Intensive Care Unit of Sir Salimullah Medical College, Mitford, Dhaka

Background: Intensive care units provide care to patients with severe or life-threatening illnesses and injuries, which require constant support, close supervision from life support equipment and medication in order to ensure normal bodily functions. It is staffed by highly trained physicians, nurses and respiratory therapists who specialize in caring for critically ill patients. ICUs are also different from general hospital wards by a higher staff-to-patient ratio and access to advanced medical resources and equipment that is not routinely available somewhere else. Common conditions include acute respiratory distress syndrome, septic shock, and other life-threatening conditions that are treated within ICUs. Aim of the study: The aim of the study was to assess the operational power, existing facilities, bed requirement, patients source and follow up and to determine and analyze the mortality in the ICU of this institution. Methods: It was a retrospective study conducted in the General Intensive Care Unit of Sir Salimullah Medical College and Mitford Hospital, Dhaka, Bangladesh from January 2019 to December 2019. A total of 607 patients who had been taken admission in General ICU unit of the hospital was recruited as study population. According to the criteria of analysis already informed, data were collected from admission register and mortality record books. We divided the total number of patients into 4 age groups, 10-30 years, 31-45 years, 46-65 years and above 65 years. We calculated patients’ mortality and male female ratio. We also considered patients coming from different specialties those who were referred to the ICU. We observed the relationship of mortality with number of organ failure too. We categorized the patients as single, double or more organs involvement and its relationship with mortality. Duration of stay in the ICU was defined as the number of days between the admission in ICU and discharge with a minimum stay of one day and also more. Relationship with mortality and number of staying days was noticed. All data were collected within data collection sheets. Result: Hospital ICU mortality in an average was 45%. Patients with long ICU stay have higher mortality than shorter stay. Nonsurvivors were older than survivors. Patients from outside have a higher mortality (85%) than those from ward, postoperative and emergency (35%).25% of patients were in the intensive care unit for more than 3 days and shared 80% of bed occupancy. Much mortality was due to inappropriate early discharge, lack of meticulous attention before admission and inadequate care after discharge. Conclusion: So strengthening of facilities may be provided by appropriate transport system and acute medicine service at emergency and also by step down units or high dependency unit in ICU surroundings. Resources and study should be directed towards the low probable mortalities to improve the ICU outcome and to decrease the mortality percentage. Continuous advice and follow up should be provided to the patients after transferring to the ward, cabin or home.

Emergency transanal total mesorectal excision for perforated rectal cancer: a two-case series

BackgroundSurgery for perforated rectal cancer is technically difficult because of paralytic dilatation due to generalized fecal peritonitis, the presence of a bulky tumor, and fecal retention due to obstruction. Transanal total mesorectal excision (TaTME) is the latest minimally invasive transanal technique pioneered to facilitate difficult pelvic dissections. It can provide a good surgical field linearly from the perineal side and reduce manipulations from the intraabdominal side. Here, we present two cases of emergency TaTME performed for perforated rectal cancer.Case presentationThe patients were a 38-year-old female and a 75-year-old male. They were diagnosed with perforated rectal cancer and were in a state of septic shock. Emergency Hartmann’s procedure was performed in both cases. Intraoperative findings showed fecal contamination of the entire abdomen and dilated intestines and bulky tumors with perforation. The female patient had multiple uterine fibroids, and the male patient had an enlarged prostate. For both patients, dissection of the mesorectum to the anal side of the tumor and transection of the rectum on the anal side of the tumor via a linear stapler were considered difficult because of the insufficient surgical field of view into the pelvis. Therefore, a two-team approach with TaTME was adopted. En bloc resection of the rectum was completed by collaboration of the abdominal team and the transanal team, and the autonomic nerves were successfully preserved. Finally, the specimens were resected, and the anal edge of the rectum was closed with a purse-string suture by the transanal team. Although these two cases were emergency surgeries in difficult situations, the cancer lesions were successfully and safely removed without involvement of the resection margin.ConclusionsThis is the first report of emergency TaTME. Although these cases were emergency operations in a situation where it was difficult to pursue radical resection—and often times in these situations, the operation may end with only stoma creation—the specimens were safely resected. Emergency TaTME is a useful procedure for treatment of perforated rectal cancer.

MO232: Amyloidosis AL in Nephrology

Abstract BACKGROUND AND AIMS Systemic AL amyloidosis is a rare pathology associated with the precipitation of monoclonal immunoglobulin light chains in the form of fibrils in various organs. Clinical presentations are extremely variable and diagnosis is often delayed. The two most affected organs are the kidney and the heart. The treatment is based on chemotherapy to eliminate the medullary clone that produces the monoclonal light chain. However, the outcome is still poor. The aim of our study was to describe the demographic, clinicobiological, histological, therapeutic and evolutionary characteristics of AL amyloidosis in our population. METHOD We carried out a single-center retrospective descriptive trial of patients who were diagnosed with histologically confirmed AL amyloidosis in our Nephrology Department during the period from 2014 to 2021. RESULTS We enrolled 12 patients with a mean age of 61.25 ± 8.17years. The sex ratio (M/F) was 3. The histological confirmation of AL amyloidosis was based on biopsies: kidney (n = 7) and salivary glands (n = 5). The immunoglobulin type was Ig G Lambda in 75% of cases (n = 9), IgG kappa in 16.6% of cases (n = 2) and IgM in 8.3% of cases (n = 1). The cause of amyloidosis was multiple myeloma in 66.6% of cases (n = 8) and Waldenström disease in 8.3% of cases (n = 1). The mean creatinine at diagnosis was 441.33 ± 334.47 umol/L, i.e. a median creatinine clearance (MDRD) of 36.67 ± 46.77 mL/min. At the time of diagnosis, 50% of the patients (n = 6) had end-stage renal disease and 25% (n = 3) had reached it after a few more months. The mean proteinuria was 6.33 g/24 h within 83.3% of cases (n = 10) with the presence of a nephrotic syndrome. The cardiac involvement was found in 58% of the patients (n = 7) at the time of diagnosis with a Mayo Clinic prognostic score of III. The neurological involvement was observed in 8.3% of cases (n = 1) and was confirmed by spinal MRI as polyradiculoneuritis. As for the therapeutical management, 75% of the patients (n = 9) received first-line treatment with Bortezomib Cyclophosphamide Dexamethasone, and 16.6 of the patients (n = 2) were treated with corticosteroids and Melphalan (the 12th patient died early). The outcome was fatal in 41.5% (n = 5) and the cause of death was a state of septic shock, and the rest of the patients are alive with a mean follow-up of 1 year. CONCLUSION AL Amyloidosis is one of the most severe complications of monoclonal lymphocyte proliferation. This overgrowth is most frequently related to myeloma, and rarely to another malignant B-cell disease. The prognosis is related to cardiac and renal impairment. It requires urgent management to improve its outcome and to reduce mortality.

The use of a hemoperfusion column that removes endotoxin and cytokines in the complex therapy of widespread peritonitis complicated by septic shock

А clinical case of septic shock treatment with new approved for clinical use hemoperfusion columns Efferon LPS of multi-purpose action, which are capable of removing LPS and cytokines from the blood, is presented. A 75-year-old patient 8 hours after surgery for widespread peritonitis, which developed due to obturation intestinal obstruction and rupture of the cecum, in a state of septic shock (SOFA 10, sympathomimetic support with norepinephrine 0.56 μg/kg per minute) underwent in addition to the treatment 2 sessions of hemoperfusion (120 minutes each) with an interval of two days. The next day after the first session of hemoperfusion, blood pressure returned to normal. Over the next 5 days, impaired organ functions gradually recovered (SOFA dynamics from 10 to 1 point) and the level of procalcitonin in the blood decreased from 98 to 5 ng/ml. A decrease in the concentration of IL-6 in the blood was noted: from 1686 to 1388 pg/ml after the first session, from 692 to 411 pg/ml after the second and up to 350 pg/ml on the following days. The content of CD14+ blood monocytes also decreased: from 0.13·109/l to 0.03·109/l after the first session and from 0.30·109/l to 0.18·109/l after the second. The patient was in intensive care for 8 days and was discharged from the hospital after 24 days. The use of hemoperfusion column for the adsorption of cytokines and LPS in an extremely severe patient with septic shock was safe. One of the effects of using the column was the removal of LPS-activated CD14+ monocytes and CD14+ granulocytes from the blood, which helped to reduce systemic inflammation and the severity of multiple organ disorders.

The Effects of Hemoadsorption on the Kinetics of Antibacterial and Antifungal Agents.

The extracorporeal elimination of a pathogen or damage-associated molecular pattern via blood purification techniques is increasingly being used in patients with septic shock and other clinical conditions characterized by a life-threatening inflammatory response. The removal of these substances can be accomoplished by means of ultrafiltration or hemoadsorption. Independently from the blood putification technique used, they could also affect the clearance of antibacterial and antifungal agents with a potentially significant clinical impact. In our review, we describe the basic principles of ultrafiltration and hemoadsorption, the available devices for this latter and the existing experimental and clinical studies; the final paragraph is dedicated to practical considerations that can help clinicians to consider the clearance of antibiotics and antifungals attributable to these techniques to minimize the risk of a iatrogenic underdosage.

The role of direct peritoneal resuscitation in the treatment of hemorrhagic shock after trauma and in emergency acute care surgery: a systematic review.

Direct peritoneal resuscitation (DPR) has been used to help preserve microcirculation by reversing vasoconstriction and hypoperfusion associated with the pathophysiological process of shock, which can occur despite appropriate intravenous resuscitation. This approach depends on infusing a hyperosmolar solution intraperitoneally via a percutaneous catheter with the tip ending near the pelvis or the root of the mesentery. The abdomen is usually left open with a negative pressure abdominal dressing to continuously evacuate the infused dialysate. Hypertonicity of the solution triggers visceral vasodilation to help maintain blood flow, even during shock, and is also associated with reduced local inflammatory cytokines and other mediators, preservation of endothelial cell function, and mitigation of organ edema and necrosis. It also has a direct effect on liver perfusion and edema, more rapidly corrects electrolyte abnormalities compared to intravenous resuscitation alone, and may requireless intravenous fluid to stabilize blood pressure, all of which shortens the time required to close patients' abdomen. An online query using the search term "direct peritoneal resuscitation" was carried out in PubMed, MEDLINE and SciELO, limited to publications indexed from January 2014 to June 2020. Of the 20 articles returned, full text was able to be obtained for 19. A manual review of included articles' references was resulted in the addition of 1 article, for a total of 20 included articles. The 20 articles were comprised of 15 animal studies, 4 clinical studies,and 1 expert opinion. The benefits include both local and possibly systemic effects on perfusion, hypoxia, acidosis, and inflammation, and are associated with improved outcomes and reduced complications. DPR shows promise in patients with hemorrhagic shock, septic shock, and other conditions resulting in an open abdomen after damage control laparotomy.

The Concentration of Large Extracellular Vesicles Differentiates Early Septic Shock From Infection

Septic shock represents a subset of sepsis with severe physiological aberrations and a higher mortality rate than sepsis alone. Currently, the laboratory tools which can be used to identify the state of septic shock are limited. In pre-clinical studies, extracellular vesicles (EVs), especially large EVs (lEVs), have been demonstrated a role as functional inflammatory mediators of sepsis. However, its longitudinal trend during the disease course has not been explored. In this study, the quantities and subtypes of plasma-derived lEVs were longitudinally compared between patients with septic shock (n = 21) and non-sepsis infection (n = 9), who presented within 48 h of their symptom onset. Blood specimens were collected for seven consecutive days after hospital admission. lEVs quantification and subtyping were performed using an imaging flow cytometer. The experiments revealed a higher lEVs concentration in septic shock patients than infected patients at the onset of the disease. In septic shock patients, lEVs concentration decreased over time as opposed to infected patients whose lEVs concentration is relatively static throughout the study period. The major contributors of lEVs in both septic shock and infected patients were of non-leukocyte origins; platelets, erythrocytes, and endothelial cells released approximately 40, 25, and 15% of lEVs, respectively. Among lEVs of leukocyte origins, neutrophils produced the highest number of EVs. Nevertheless, the proportion of each subtype of lEVs among the given amount of lEVs produced was similar between septic shock and infected patients. These findings raise the possibility of employing lEVs enumeration as a septic shock identifying tool, although larger studies with a more diverse group of participants are warranted to extrapolate the findings to a general population.

STUDY OF SURGICAL MANAGEMENT OF INTESTINAL OBSTRUCTION FROM CENTRAL INDIA: A CROSS SECTIONAL STUDY

Intestinal obstruction is a common surgical emergency with high mortality and morbidity rates. About 15% of all emergency room visits for acute abdominal pain are due to intestinal obstruction. Acute intestinal obstruction may manifest in a variety of ways, from a relatively normal appearance with only minor abdominal pain and distension to a condition of hypovolemic or septic shock (or both) that necessitates an emergency procedure. In present study we aimed to evaluate surgical management of intestinal obstruction at our tertiary hospital. The current research included patients aged 21 to 80 who had an acute intestinal obstruction that was surgically treated. After initial resuscitation, patients with strong signs and symptoms of acute obstruction were treated with an appropriate surgical procedure. All of the information was recorded in a preformat and analysed using descriptive statistics. 144 patients had surgery for acute intestinal obstruction during the study period. 51 to 60 years old was the most common age group (26 %), followed by 41 to 50 years old (21 %). In a ratio of 2.8:1, male patients were more frequently affected than female patients. Previous abdominal surgery (56 %), diabetes (31 %), smoking (25 %), hypertension (24 %), and bronchial asthma/ COPD (15 %) were all found to be common comorbidities in this research. Postoperative adhesions (47 %), malignancy (15 %), obstructed hernia (11 %), and Koch's abdomen were the most common causes of intestinal obstruction in this report (8 %). Adhesiolysis (47 %), resection and anastomosis (22 %), diversion colostomy (13 %), and hernioplasty were the most common surgical procedures in this study (11 %). The most common post-operative complications were fever (15%) and wound infection (11%) respectively. The post-operative mortality rate was 13%. (9 patients). Complications such as septicaemia, peritonitis, and respiratory infection account for the majority of deaths. Intestinal obstruction is often caused by postoperative adhesions. Early operative procedures, in combination with clinical diagnosis and radiological findings, may enhance the outcome of acute intestinal obstruction.