Survival In Septic Shock Patients Research Articles

Efficacy of Adjunct Hemoperfusion Compared to Standard Medical Therapy on 28-Day Mortality in Leptospirosis Patients with Renal Failure and Shock: A Single-Center Randomized Controlled Trial.

Hemoperfusion is a novel adjunct therapy that targets the dysregulated inflammatory events in severe sepsis. Previous studies have reported conflicting results on its efficacy and safety. This study was designed to assess the efficacy and safety of hemoperfusion among leptospirosis patients in septic shock and renal failure in terms of improvement in 28-day mortality, SOFA score, level of inflammatory markers, hemodynamics, and renal and pulmonary function. A total of 37 severe leptospirosis patients were enrolled and randomized into either standard medical therapy (SMT) alone, n = 20, or with hemoperfusion (HP), n = 17. Vital signs, urine output, vasopressor dose, PaO2/FiO2 (P/F) ratio, and biochemical parameters of patients from each treatment arm were compared. The hemoperfusion group showed a 36.84% (p = 0.017) risk reduction in 28-day mortality. Levels of procalcitonin, IL6, and lactate significantly decreased from baseline to day 7 in both groups. Statistically significant improvements in serum creatinine (p = 0.04) and PF ratio (p = 0.045) were observed in the hemoperfusion cohort. Intention-to-treat and per-protocol approaches showed that hemoperfusion increased the survival rate and decreased the mortality risk. This benefit for survival persisted even when patients were also receiving extracorporeal membrane oxygenation (ECMO), showing that hemoperfusion's benefits are independent of ECMO use. Hemoperfusion is a safe and effective adjunct therapy for managing severe sepsis. It promotes earlier renal and pulmonary function recovery and improves the survival of septic shock patients.

#3436 EFFICACY OF ADJUNCT HEMOPERFUSION VERSUS STANDARD MEDICAL THERAPY ON 28-DAY MORTALITY IN LEPTOSPIROSIS PATIENTS WITH RENAL FAILURE AND SHOCK

Abstract Background and Aims Leptospirosis, a ubiquitous zoonotic infection in the Philippines, is a classic representation of sepsis-induced multi-organ dysfunction with its life-threatening complications: pulmonary hemorrhage, renal and liver failure. Despite pre-established treatment guidelines, leptospirosis- induced morbidity and mortality continue to rise. Hemoperfusion with HA 330 is a promising adjunct therapy as it removes rogue cytokines responsible for the dysregulated inflammatory response in severe sepsis. However, studies on its survival benefit have yielded conflicting results, so far. This study was designed to assess the efficacy and safety of hemoperfusion among leptospirosis patients in septic shock and renal failure, in terms of improvement in 28-day mortality, SOFA score, level of inflammatory markers, hemodynamics, renal and pulmonary function. Method This is an open-label randomized controlled trial which enrolled a total of 37 adult presumptive leptospirosis patients with early signs of septic shock and acute renal failure. The study participants were randomized into either of the two treatment arms: 1. standard medical therapy (SMT) alone or 2. SMT + HA330 Hemoperfusion (HP). All patients were managed based on the NKTI Leptospirosis treatment protocol (hydration, antibiotics, three-day steroid pulsing, single cyclophosphamide dose and respective organ support) and were placed on daily intermittent hemodialysis. Subjects randomized to the HP group received three hemoperfusion sessions (on top of SMT). Vital signs, urine output, vasopressor dose, P/F ratio and biochemical parameters (including level of inflammatory markers) of patients from each treatment arm were measured at baseline, day 3 and day 7 and compared subsequently. Monitoring of participants continued until 28 days post-randomization. Descriptive statistics was used to summarize the general and clinical characteristics of the participants. Independent Sample T-test, Mann-Whitney U test, and Fisher's Exact/Chi-square test was used to determine the difference of mean, median and frequency between hemoperfusion group and control group, respectively. Mean, median, or risk difference and their corresponding 95% confidence intervals were calculated. Friedman test or Wilcoxon's signed-rank test were used to determine whether differences between groups were significant over time. Intention to treat and per protocol analyses were performed. Null hypothesis was rejected at 0.05α-level of significance. Stata 15.0 (StataCorp LLC, TX) was used for data analysis. Results Hemoperfusion conferred a 36.84% (p = 0.017) risk reduction in 28-day mortality. Serial monitoring of inflammatory markers and SOFA score of patients showed significant improvement in sepsis score (p = 0.018 HP, 0.002 SMT) and levels of procalcitonin (p = 0.013 HP, 0.003 SMT), IL6 (p = 0.033 HP, 0.020 SMT) and lactate (p< 0.001 HP, 0.021 SMT) in both treatment arms, from baseline to Day 7. There is, however, no statistically significant difference in the change in SOFA (p = 0.965) and inflammatory marker levels if we compare HP versus SMT (p = 0.997, 0.451, 0.858, 0.052 for hsCRP, procalcitonin, IL6 and lactate, respectively). Statistically significant improvement in serum creatinine (p = 0.04) and PF ratio (p = 0.045) were observed in the hemoperfusion cohort as early as Day 3. Vasopressor dose did not differ significantly between two groups (p = 0.792). No adverse events were observed in both treatment arms. Conclusion Hemoperfusion is a safe and effective adjunct therapy in managing severe sepsis. It promotes earlier renal and pulmonary function recovery and, in doing so, improves survival of septic shock patients.

Veno‐venous extracorporeal membrane oxygenation for septic shock patients with pulmonary infection: A propensity score matching‐based retrospective study

To evaluate whether septic shock patients with pulmonary infection and life-threatening hypoxemia can benefit from V-V ECMO. Retrospective clinical data analysis on patients who suffered septic shock with pulmonary infection, categorized into V-V ECMO and control groups. The propensity score matching (PSM) method was used to screen patients matched for age, gender, and disease severity. The primary outcome was 30- and 90-day mortality after diagnosis of septic shock. After PSM, 31 pairs of patients were enrolled in this study, and there were no significant differences between the two groups in terms of gender, age, chronic disease, acute physiological and chronic health evaluation II (APACHE II) score, and sequential organ failure assessment (SOFA) score. Within 28 days after the diagnosis of septic shock, the median time of renal replacement therapy-free days was longer in the V-V ECMO group than in the control group (27 days vs. 9 days; p=0.044). Kaplan-Meier analysis showed that 30-day mortality was lower in the V-V ECMO group than in the control group (38.7% vs. 61.3%; HR 0.488; 95% CI 0.240-0.992; p=0.043, by log-rank test); 90-day mortality was not significantly different between the two groups (51.6% vs. 67.7%, p=0.097). Patients receiving V-V ECMO support had lower 30-day mortality and faster recovery of renal function within 28 days compared with those receiving conventional therapy. However, V-V ECMO did not improve 90-day survival in septic shock patients with pulmonary infection.

Norepinephrine may improve survival of septic shock patients in a low-resource setting: a proof-of-concept study on feasibility and efficacy outside the Intensive Care Unit

ABSTRACT Septic shock treatment in sub-Saharan African hospitals is challenging due to limited availability of ICUs, central venous catheters, vasopressors, and trained staff. We designed this proof-of-concept study to determine efficacy, safety, and feasibility of norepinephrine (NE) use in a non-intensive setting in a low-resource country, consisting in a peripheral infusion via a mechanical drop counter. Septic shock patients accessing a rural hospital in Uganda were included: the 2020 group (N = 12) was prospectively enrolled (Jan–Mar 2020) when NE was available; the 2019 group (N = 11) was retrospectively enrolled (Oct–Dec 2019). Enrollment was continuous to reduce selection bias. Basic clinical endpoints (noninvasive blood pressure, tissue perfusion, diuresis) defined shock control and the prognostic endpoint was survival at hospital discharge. Shock control at 6 and 12 hours was higher in the 2020 group (p = 0.012 for both). Survival at hospital discharge was 75% and 27.3%, respectively (p = 0.039). NE infusion was associated with a Hazard Ratio of 0.23 (p = 0.041) in a multivariate Cox model. No NE-induced adverse effects were detected. These preliminary results suggest that implementing NE infusion in a low-resource setting without ICU could be a safe and effective strategy in managing septic shock and that this approach could lead to a lower mortality rate.

Effect of heart rate control with amiodarone infusion on hemodynamic and clinical outcomes in septic shock patients with tachycardia: a prospective, single-arm clinical study

BackgroundKeeping the heart rate within the normal range has improved the survival of septic shock patients. Amiodarone could target the underlying pathophysiology of sepsis-induced tachycardia. This study aimed to determine whether amiodarone is effective in controlling the heart rate in critically ill patients with septic shock and sustained tachycardia who were receiving vasopressor.MethodsIn this prospective, single-arm cohort study, 46 patients with septic shock and tachycardia were enrolled to receive a loading dose of amiodarone 150 mg, then continuous infusion of 1 mg/min. The primary outcome was the ability of amiodarone in rate control lower than 95 beats per minute (BPM) and maintaining it during 24-h study period. We also recorded the effect of amiodarone on hemodynamic indices as the secondary outcomes.ResultsThe results of the present study indicated a significant decrease in HR in septic shock patients for amiodarone, from 121.0 (116.5, 140.0) at baseline to 91.5(89.3, 108.0) at the end of the study period (p < 0.001). During the study period, a total of 26 (56.52%) of patients achieved the target heart rate lower than 95 BPM and maintained it during study period. Amiodarone decreased HR by 22.8 ± 13.7. While receiving amiodarone infusion, the values for heart rate, mean arterial pressure, cardiac index, norepinephrine infusion rate, and stroke volume index changed significantly between amiodarone initiation and 24-h follow-up (P < 0.001). Amiodarone was well tolerated, because this anti-arrhythmic agent did not increase the need for vasopressor and none of the patients experienced episodes of refractory hypotension.ConclusionThis study showed that amiodarone infusion successfully reduced the heart rate in sepsis-induced tachycardia. The patients had improved hemodynamic state as indicated by an increase in cardiac index and SVI.

Impact of Prehospital Antibiotic Therapy on Septic Shock Mortality

Background Septic shock (SS) is associated with high morbidity and mortality rate. Early antibiotic therapy administration in septic patients was shown to reduce mortality but its impact on mortality in a prehospital setting is still under debate. To clarify this point, we performed a retrospective analysis on patients with septic shock who received antibiotics in a prehospital setting. Methods From April 15th, 2017 to March 1st, 2020, patients with septic shock requiring Mobile Intensive Care Unit (MICU) intervention were retrospectively analyzed to assess the impact of prehospital antibiotic therapy administration on a 30-day mortality. Results Three-hundred-eight patients with septic shock requiring MICU intervention in the prehospital setting were analyzed. The mean age of the study population was 70 ± 15 years. Presumed origin of SS was mainly pulmonary (44%), digestive (21%) or urinary (19%) infection. Overall 30-day mortality was 29%. Ninety-eight (32%) patients received antibiotic therapy. Using Cox regression analysis, we showed that prehospital antibiotic therapy significantly reduces 30-day mortality for patients with septic shock (hazard ratio = 0.56, 95%CI [0.35-0.89], p = 0.016). Conclusion In this retrospective study, prehospital antibiotic therapy reduces 30-day mortality of septic shock patients cared for by MICU. Further studies will be needed to confirm the beneficial effect of prehospital antibiotic therapy in association or not with prehospital hemodynamic optimization to improve the survival of septic shock patients.

Circulating Complement C3-Alpha Chain Levels Predict Survival of Septic Shock Patients.

Circulating complement C3 fragments released during septic shock might contribute to the development of complications such as profound hypotension and disseminated intravascular coagulation. The role of C3 in the course of septic shock varies in the literature, possibly because circulating C3 exists in different forms indistinguishable via traditional ELISA-based methods. We sought to test the relationship between C3 forms, measured by Western blotting with its associated protein size differentiation feature, and clinical outcomes. Secondary analysis of two prospective cohorts of patients with septic shock: a discovery cohort of 24 patents and a validation cohort of 181 patients. C3 levels were measured by Western blotting in both cohorts using blood obtained at enrollment. Differences between survivors and non-survivors were compared, and the independent prognostic values of C3 forms were assessed. In both cohorts there were significantly lower levels of the C3-alpha chain in non-survivors than in survivors, and persisted after controlling for sequential organ failure assessment score. Area under the receiver operating characteristics to predict survival was 0.65 (95% confidence interval: 0.56-0.75). At a best cutoff value (Youden) of 970.6 μg/mL, the test demonstrated a sensitivity of 68.5% and specificity of 61.5%. At this cutoff point, Kaplan-Meier survival analysis showed that patients with lower levels of C3-alpha chain had significantly lower survival than those with higher levels (P < 0.001). Circulating C3-alpha chain levels is a significant independent predictor of survival in septic shock patients.

Influence of Timing of Initiation and Volume of Processed Plasma on the Outcome of Septic Shock Patients Treated with Coupled Plasma Filtration and Adsorption

Background: The extracorporeal removal of mediators is a rescue strategy for septic shock patients, which is still under investigation. Several techniques are available: coupled plasma filtration and adsorption (CPFA) combines plasma processing with renal replacement therapy. Methods: The study aimed to elucidate the role of both timing of initiation and intensity of treatment on the outcome, for which we retrospectively studied 52 patients. We collected the overall pre-CPFA time interval, starting from the first episode of hypotension in the wards and the volume of processed plasma (Vp), which we used as a proxy for intensity of treatment. Results: Timing of initiation did not significantly differ between survivors and non-survivors (25 vs. 27 h), while the Vp did (0.25 vs. 0.17 L/kg/session, p < 0.05). The significance of Vp was confirmed by a multiple logistic regression model. Conclusion: Our study confirms that intensity of CPFA, but not its timing of initiation, correlates with survival of septic shock patients.

Timing of antibiotic administration and lactate measurement in septic shock patients: a comparison between hospital wards and the emergency department.

BackgroundThe timing of intravenous antibiotic administration and lactate measurement is associated with survival of septic shock patients. Septic shock patients were admitted to the medical intensive care unit (MICU) from 2 major sources: hospital ward and emergency department (ED). This study aimed to compare the timing of antibiotic administration and lactate measurement between hospital wards and the ED.Patients and methodsMedical data were collected from adult patients admitted to the MICU with septic shock from January 2015 to December 2016. “Time Zero” was defined as the time of diagnosis of sepsis. The associations between the times and risk-adjusted 28-day mortality were assessed.ResultsIn total, 150 septic shock patients were admitted to the MICU. The median time interval (hour [h] interquartile range [IQR]) from time zero to antibiotic administration was higher in patients from the hospital wards compared to those from the ED (4.84 [3.5–8.11] vs 2.04 [1.37–3.54], P<0.01), but the lactate level measurement time interval (h [IQR]) from time zero was not different between the hospital wards and the ED (1.6 [0.2–2.7] vs 1.6 [0.9–3.0], P=0.85). In multivariate analysis, higher risk-adjusted 28-day mortality was associated with antibiotic monotherapy (odds ratio [OR]: 19.3, 95% confidence interval [CI]: 2.4–153.1, P<0.01) and admission during the weekends (OR: 24.4, 95% CI: 2.9–199.8, P<0.01).ConclusionAntibiotic administration in septic shock patients from the hospital wards took longer, and there was also less appropriate antibiotic prescriptions seen in this group compared with those admitted from the ED. However, neither the timing of antibiotic administration nor lactate measurement was associated with mortality.

Disturbed fluid responsiveness and lactate/pyruvate ratio as predictors for mortality of septic shock patients

ObjectivesEvaluation of fluid responsiveness of septic shock patients admitted to surgical ICU and the predictability of non-invasive monitoring and estimated lactate/pyruvate (L/P) ratio for survival of these patients.Patients and methodsThe study included 58 septic shocked patients admitted and managed at surgical ICU. After non-invasive determination of baseline hemodynamic data and calculation of shock index (SI-0) and Pleth variability index (PVI-0), all patients received intravenous colloid infusion followed 15-min later by non-invasive re-evaluation for SI-15 and PVI-15. Blood samples were obtained for estimation of blood lactate and pyruvate levels at admission (BLL-0 and BPL-0) and 12-h after fluid resuscitation (BLL-12 and BPL-12) and L/P ratio was calculated. All patients were managed according to the Surviving Sepsis Campaign guidelines and followed up for ICU mortality rate (MR).ResultsICU stay MR was 20.7%. Survival showed negative significant correlation with PVI, L/P ratio and BLL, while it showed positive significant correlation with BPL. Receiver Operating Characteristic (ROC) curve analysis defined baseline and persistently low PVI, high BLL and L/P ratio as significant sensitive predictors for MR, while elevated BPL-12 as significant specific predictor for survival. Regression analysis defined persistently elevated L/P ratio as the highly significant specific predictor, while persistently disturbed SI and PVI could predict mortality as screening tests. Odds ratio for mortality at BLL-0 of >2 mmol/L was 0.0321 (95% CI: 0.0037–0.2755), while it was 4.1111 (95% CI: 1.0702–15.792) at BLL-0 >4 mmol/L.ConclusionAfter fluid resuscitation and hemodynamic stability, persistently elevated BLL could predict mortality, while elevated BPL could predict survival of septic shock patients. Continuous non-invasive evaluation of fluid responsiveness judged by PVI and SI could provide sensitive screening for survival outcome of shocked patients. Wider scale comparative studies are mandatory for establishment of discriminative PVI and BLL cutoff points for prediction of survival of shocked patients.

Effects of antibiotic administration delay and inadequacy upon the survival of septic shock patients

ObjectiveTo assess how antibiotic administration delay and inadequacy influence survival in septic shock patients. DesignA prospective, observational cohort study was carried out between September 2005 and September 2010. ScopePatients admitted to the ICU of a third level hospital. PatientsA total of 342 septic shock patients. InterventionsNone. Variables of interestThe time to antibiotic administration (difference between septic shock presentation and first administered dose of antibiotic) and its adequacy (in vitro susceptibility testing of isolated pathogens) were determined. ResultsICU and hospital mortality were 26.4% and 33.5%, respectively. The median delay to administration of the first antibiotic dose was 1.7h. Deceased patients received antibiotics significantly later than survivors (1.3±14.5h vs. 5.8±18.02h; p=0.001). Percentage drug inadequacy was 12%. Those patients who received inadequate antibiotics had significantly higher mortality rates (33.8% vs. 51.2%; p=0.03). The coexistence of treatment delay and inadequacy was associated to lower survival rates. ConclusionsBoth antibiotic administration delay and inadequacy exert deleterious effects upon the survival of septic shock patients, independently of their characteristics or severity.

TNFAIP2 Inhibits Early TNFa-Induced NF-κB Signaling and Decreases Survival in Septic Shock Patients

During septic shock, tumor necrosis factor alpha (TNFa) is an early response gene and induces a plethora of genes and signaling pathways. To identify robust signals in genes reliably upregulated by TNFa, we first measured microarray gene expression in vitro and searched methodologically comparable, publicly available data sets to identify concordant signals. Using tag single-nucleotide polymorphisms in the genes common to all data sets, we identified a genetic variant of the TNFAIP2 gene, rs8126, associated with decreased 28-day survival and increased organ dysfunction in an adult cohort in the Vasopressin and Septic Shock Trial. Similar to this cohort, we found that an association with rs8126 and increased organ dysfunction is replicated in a second cohort of septic shock patients in the St. Paul's Hospital Intensive Care Unit. We found that TNFAIP2 inhibits NF-κB activity, impacting the downstream cytokine interleukin (IL)-8. The minor G allele of TNFAIP2 rs8126 resulted in greater TNFAIP2 expression, decreased IL-8 production and was associated with decreased survival in patients experiencing septic shock. These data suggest that TNFAIP2 is a novel inhibitor of NF-κB that acts as an autoinhibitor of the TNFa response during septic shock.

Efectos del retraso y la inadecuación del tratamiento antibiótico en la supervivencia de los pacientes en shock séptico

ObjectiveTo assess how antibiotic administration delay and inadequacy influence survival in septic shock patients. DesignA prospective, observational cohort study was carried out between September 2005 and September 2010. ScopePatients admitted to the ICU of a third level hospital. PatientsA total of 342 septic shock patients InterventionsNone Variables of interestThe time to antibiotic administration (difference between septic shock presentation and first administered dose of antibiotic) and its adequacy (in vitro susceptibility testing of isolated pathogens) were determined. ResultsICU and hospital mortality were 26.4% and 33.5%, respectively. The median delay to administration of the first antibiotic dose was 1.7h. Deceased patients received antibiotics significantly later than survivors (1.3±14.5h vs. 5.8±18.02h; P=.001). Percentage drug inadequacy was 12%. Those patients who received inadequate antibiotics had significantly higher mortality rates (33.8% vs. 51.2%; P=.03). The coexistence of treatment delay and inadequacy was associated to lower survival rates. ConclusionsBoth antibiotic administration delay and inadequacy exert deleterious effects upon the survival of septic shock patients, independently of their characteristics or severity

Protein C zymogen in adults with severe sepsis or septic shock

IntroductionActivated protein C is associated with a risk of bleeding and its effects on survival in septic shock patients are questionable. Protein C zymogen has no risk of bleeding and improves the outcome of patients with septic shock. We hereby describe the largest published case series of adult patients receiving protein C zymogen. Design, setting and participantsA prospective study on 23 adult patients with severe sepsis or septic shock, two or more organ failures and at high risk for bleeding, treated with protein C zymogen (50IU/kg bolus followed by continuous infusion of 3IU/kg/h for 72h). ResultsThe Z-test evidenced a significant reduction between the expected mortality (53%) and the observed mortality 30% (Z value=1.99, p=0.046) in our sample population. Protein C levels increased from 34±18% to 66±22% at 6h after PC bolus (p<0.001), and kept on increasing during 72h of administration (p<0.001 to baseline). Sequential Organ Failure Assessment (SOFA), score of organ dysfunction, decreased from baseline to 7 days after administration of protein C from 14±2 to 7±4 (p<0.001). No adverse event drug related was noted. ConclusionProtein C zymogen administration is safe and its use in septic patients should be investigated through a randomized controlled trial.

Protein C zymogen in adults with severe sepsis or septic shock

IntroductionActivated protein C is associated with a risk of bleeding and its effects on survival in septic shock patients are questionable. Protein C zymogen has no risk of bleeding and improves the outcome of patients with septic shock. We hereby describe the largest published case series of adult patients receiving protein C zymogen. Design, setting and participantsA prospective study on 23 adult patients with severe sepsis or septic shock, two or more organ failures and at high risk for bleeding, treated with protein C zymogen (50IU/kg bolus followed by continuous infusion of 3IU/kg/h for 72h). ResultsThe Z-test evidenced a significant reduction between the expected mortality (53%) and the observed mortality 30% (Z value=1.99, p=0.046) in our sample population. Protein C levels increased from 34±18% to 66±22% at 6h after PC bolus (p<0.001), and kept on increasing during 72h of administration (p<0.001 to baseline). Sequential Organ Failure Assessment (SOFA), score of organ dysfunction, decreased from baseline to 7 days after administration of protein C from 14±2 to 7±4 (p<0.001). No adverse event drug related was noted. ConclusionProtein C zymogen administration is safe and its use in septic patients should be investigated through a randomized controlled trial.

Statins and hemoperfusion improve 28-day survival in septic shock patients

Abstract Uncontrolled inflammation and endotoxin play a central role in septic shock. Statins may possess anti-inflammatory properties, and removal of endotoxin by hemoperfusion with polymyxin B-immobilized fiber (PMX-F) could have favorable effects on sepsis. We examined retrospectively whether pre-existing statin and hemoperfusion with PMX-F at the time of admission were separately and independently associated with decreased overall 28-day mortality in septic shock patients. Consecutive 173 patients with septic shock (71.2±10.7 years old, 115 male and 58 female) were included in the present study. All patients underwent a complete history and physical examination, determination of blood chemistries. Multiple stepwise regression analysis revealed that albumin, creatinine (inversely), statin use, hemoperfusion with PMX-F and HDL-cholesterol were independently correlated to 28-day survival in septic shock patients (R2=0.464). Our present study suggests that pre-existing statin use and hemoperfusion with PMX-F may separately and independently contribute to blunt the process of septic shock.

Impact of case volume on survival of septic shock in patients with malignancies*

Septic shock is a frequent and severe complication in the course of malignancies. In a large multicenter cohort of septic shock patients with hematologic malignancies and solid tumors, we assessed the temporal trend in survival and the prognostic factors, with particular emphasis on case volume. A 12-yr multicenter retrospective cohort study of prospectively collected data. Cancer patients with septic shock were selected over a 12-yr period (1997-2008) from a French regional database (CUB-Réa). The following variables were extracted: demographic characteristics, type of malignancy, characteristics of infection, severity-of-illness score (Simplified Acute Physiology Score II), organ failure supports, and vital status. For each unit, a running mean annual volume of admissions was calculated for the purpose of categorization into volume tertiles. Prognostic factors were analyzed by a conditional multivariate logistic model after matching on a propensity score of being admitted to a high-volume unit and on the year of admission. None. A total of 3,437 patients were included in the study. The intensive care unit mortality rate dramatically dropped over time (from 70.4% in 1997 to 52.5% in 2008, relative decrease 25.4%, p < .001). Participating units were distributed into low-volume (< five patients per year), medium-volume (five to 12 patients per year), and high-volume (≥ 13 patients per year) tertiles. A medical cause for intensive care unit admission, Simplified Acute Physiology Score II, invasive mechanical ventilation, renal replacement therapy, fungal infections, and unknown microorganism were identified as poor prognostic factors. Case volume demonstrated a strong influence on survival, admission in a high-volume unit being associated with a marked decrease in mortality as compared to low-volume units (adjusted odds ratio 0.63; 95% confidence interval [0.46-0.87], p = .002). Survival of septic shock patients with malignancies markedly increased over the recent years. Furthermore, we identified case volume as a major prognostic factor in this setting.

Dynamic Change of Procalcitonin, Rather Than Concentration Itself, Is Predictive of Survival in Septic Shock Patients When Beyond 10 ng/mL

Procalcitonin (PCT) concentration of greater than 10 ng/mL is compatible for septic shock. Its predictive value for survival is not well established, mainly because of much overlap and variation of PCT in this condition. We hypothesized that dynamic change of PCT, rather than PCT itself, is predictive of hospital survival when greater than 10 ng/mL. Thirty-seven septic shock patients with PCT concentration of greater than 10 ng/mL were enrolled in this prospective cohort study. Patients were divided into survivors (n = 25) and nonsurvivors (n = 12) based on 28-day hospital outcome. Subsequent PCT measurements were taken 5 days after enrollment. Sequential Organ Failure Assessment (SOFA) scores were recorded simultaneously. Dynamic changes of the PCT and SOFA score were defined as the difference between the subsequent and initial measurement. There were no significant differences between survivors and nonsurvivors in age, sex, initial measurement of PCT, and SOFA. All survivors had a decrease in PCT concentration; median decrease was 9.73 ng/mL. All nonsurvivors had an increase in PCT concentration; median increase was 5.95 ng/mL. Significant decrease in PCT concentration (>25%) was observed in all the 25 survivors, whereas there was none in 12 nonsurvivors. Procalcitonin of initial, subsequent measurements, and dynamics significantly correlated with their counterparts of SOFA score. In conclusion, significant decrease in PCT concentration, rather than PCT concentration itself, may be a useful indicator of survival in septic shock patients when PCT concentration is greater than 10 ng/mL. Procalcitonin concentration highly correlated with the SOFA score in septic shock patients even when the PCT concentration is greater than 10 ng/mL.

What’s New in Shock, December 2011?

What’s New in Shock, December 2011?

Low‐dose hydrocortisone treatment for patients with septic shock: A pilot study comparing 3 days with 7 days

Although there is controversy regarding the benefit of low-dose corticosteroid therapy in patients with septic shock, the Surviving Sepsis Campaign has advocated that low-dose intravenous hydrocortisone be used to treat adult septic shock patients. This study investigated the effect of the duration of a stress dose of hydrocortisone on survival of septic shock patients with relative adrenal insufficiency. One hundred and thirty consecutive patients who met the American College of Chest Physicians/Society of Critical Care Medicine criteria for septic shock were included in the study. An additional inclusion criterion was vasopressor support after fluid resuscitation. The primary end-point was 28-day mortality, and the secondary end-points were shock reversal and mortality in the intensive care unit and hospital. All eligible patients were prospectively randomized to receive hydrocortisone treatment for 3 or 7days. Hydrocortisone treatment was started at a dose of 50mg every 6h. Baseline data at recruitment did not differ between the two groups. After 28days, mortality did not differ between the 3- and 7-day treatment groups (33.8% vs 36.9%, P=0.629). Mortality rates in the intensive care unit and hospital did not differ significantly between the two groups. The median time to withdrawal of vasopressor therapy was 5.0days in the 3-day treatment group and 6.4days in the 7-day treatment group (P=0.102). This pilot study showed that in patients with septic shock and relative adrenal insufficiency, 28-day mortality did not differ between those treated with low-dose hydrocortisone for 3 or 7days.