Systemic Inflammatory Response Criteria Research Articles

Bacteremia From a Presumed Urinary Source in Hospitalized Adults With Asymptomatic Bacteriuria

Guidelines recommend withholding antibiotics in asymptomatic bacteriuria (ASB), including among patients with altered mental status (AMS) and no systemic signs of infection. However, ASB treatment remains common. To determine prevalence and factors associated with bacteremia from a presumed urinary source in inpatients with ASB with or without AMS and estimate antibiotics avoided if a 2% risk of bacteremia were used as a threshold to prompt empiric antibiotic treatment of ASB. This cohort study assessed patients hospitalized to nonintensive care with ASB (no immune compromise or concomitant infections) in 68 Michigan hospitals from July 1, 2017, to June 30, 2022. Data were analyzed from August 2022 to January 2023. The primary outcome was prevalence of bacteremia from a presumed urinary source (ie, positive blood culture with matching organisms within 3 days of urine culture). To determine factors associated with bacteremia, we used multivariable logistic regression models. We estimated each patient's risk of bacteremia and determined what percentage of patients empirically treated with antibiotics had less than 2% estimated risk of bacteremia. Of 11 590 hospitalized patients with ASB (median [IQR] age, 78.2 [67.7-86.6] years; 8595 female patients [74.2%]; 2235 African American or Black patients [19.3%], 184 Hispanic patients [1.6%], and 8897 White patients [76.8%]), 8364 (72.2%) received antimicrobial treatment for UTI, and 161 (1.4%) had bacteremia from a presumed urinary source. Only 17 of 2126 patients with AMS but no systemic signs of infection (0.7%) developed bacteremia. On multivariable analysis, male sex (adjusted odds ratio [aOR], 1.45; 95% CI, 1.02-2.05), hypotension (aOR, 1.86; 95% CI, 1.18-2.93), 2 or more systemic inflammatory response criteria (aOR, 1.72; 95% CI, 1.21-2.46), urinary retention (aOR, 1.87; 95% CI, 1.18-2.96), fatigue (aOR, 1.53; 95% CI, 1.08-2.17), log of serum leukocytosis (aOR, 3.38; 95% CI, 2.48-4.61), and pyuria (aOR, 3.31; 95% CI, 2.10-5.21) were associated with bacteremia. No single factor was associated with more than 2% risk of bacteremia. If 2% or higher risk of bacteremia were used as a cutoff for empiric antibiotics, antibiotic exposure would have been avoided in 78.4% (6323 of 8064) of empirically treated patients with low risk of bacteremia. In patients with ASB, bacteremia from a presumed urinary source was rare, occurring in less than 1% of patients with AMS. A personalized, risk-based approach to empiric therapy could decrease unnecessary ASB treatment.

Evaluating Clinical Prediction Rules for Bacteremia Detection in the Emergency Department: A Retrospective Review

BackgroundBacteremia is a major cause of morbidity. Blood cultures are the gold standard for diagnosing bacteremia. ObjectiveTo compare previously published clinical decision rules for predicting a true positive blood culture (bacteremia) in the emergency department. MethodsRetrospective analysis of medical records of patients who had a blood culture performed in a tertiary hospital emergency department in 2020 (12 months). Positive blood cultures were compared with randomly selected negative blood cultures (1:4 ratio). Blood cultures were analyzed per patient presentation. Clinical data from patient presentations were extracted and appraised against the modified-Shapiro (mShapiro) rule and systemic inflammatory response syndrome (SIRS) criteria to calculate diagnostic accuracy to detect bacteremia. ResultsDuring the study period, 3870 blood cultures were taken from 2921 patients: 476 (12.3%) cultures were positive for bacterial growth, from 421 individual patient presentations (10 excluded as incomplete data). Of included patients, 338 were true positives and 73 contaminates, these were compared with 1446 patients with negative blood culture presentations. Evaluating mShapiro's rule and SIRS criteria to detect bacteremia vs. no bacteremia (negative + contaminated cultures) had a sensitivity of 94.4% (95% confidence interval [CI] 91.4–96.4%) and 84.9% (95% CI 80.7–88.3%), respectively, and a specificity of 37.9% (95% CI 35.5–40.1%) and 33.8% (95% CI 31.5–36.3%), respectively. Both had a high negative predictive value for bacteremia of 96.8% (95% CI 95.1–98.0) and 91.0% (95% CI 88.3–93.1) for mShapiro's rule and SIRS criteria, respectively. ConclusionsIn this cohort, mShapiro's rule performed better than the SIRS criteria at predicting bacteremia.

Prognostic accuracy of SOFA and qSOFA for mortality among children with infection: a meta-analysis.

Age-adjusted Sequential Organ Failure Assessment (SOFA) and age-adjusted quick SOFA (qSOFA) scores have been developed to predict poor outcomes in children with infection. We investigated the prognostic performance of age-adjusted SOFA and age-adjusted qSOFA scores and compared them with the systemic inflammatory response syndrome (SIRS) criteria for predicting mortality in children with infection. A bivariate random-effects regression model was used for synthesis of diagnostic test data. A total of 14 studies invoing 70,194 participants were included. The pooled sensitivity for age-adjusted SOFA, age-adjusted qSOFA, and SIRS were 0.82 (95% CI, 0.74-0.88), 0.46 (95% CI, 0.22-0.71), and 0.79 (95% CI, 0.66-0.88), respectively. The pooled specificity for age-adjusted SOFA, age-adjusted qSOFA, and SIRS were 0.62 (95% CI, 0.45-0.77), 0.90 (95% CI, 0.66-0.98), and 0.39 (95% CI, 0.26-0.54), respectively. The area under the summary receiver operating characteristic curve (AUSROC) for age-adjusted SOFA, age-adjusted qSOFA, and SIRS were 0.82 (95% CI, 0.79-0.85), 0.66 (95% CI, 0.62-0.70), and 0.64 (95% CI, 0.60-0.68), respectively. Different baseline populations, different SOFA adaptation methods and different cut-offs used for age-adjusted SOFA may be potential sources of heterogeneity. Age adjusted SOFA score is a useful tool for predicting mortality in children with sepsis/suspected sepsis. First study to investigate the prognostic performance of age-adjusted sequential organ failure assessment (SOFA) and age adjusted quick SOFA (qSOFA) scores in comparison to the systemic inflammatory response criteria (SIRS) for the prediction of mortality in children with sepsis. The age-adjusted SOFA score predicts poor outcomes with high sensitivity in children with sepsis Low sensitivity limits the utility of age-adjusted qSOFA as a simple predictive tool for adverse outcomes. Developing another enhanced or modified bedside tool with higher sensitivity may be necessary.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Measurement of Sepsis in a National Cohort Using Three Different Methods to Define Baseline Organ Function.

Rationale: In 2017, the U.S. Centers for Disease Control and Prevention (CDC) developed a new surveillance definition of sepsis, the adult sepsis event (ASE), to better track sepsis epidemiology. The ASE requires evidence of acute organ dysfunction and defines baseline organ function pragmatically as the best in-hospital value. This approach may undercount sepsis if new organ dysfunction does not resolve by discharge.Objectives: To understand how sepsis identification and outcomes differ when using the best laboratory values during hospitalization versus methods that use historical lookbacks to define baseline organ function.Methods: We identified all patients hospitalized at 138 Veterans Affairs hospitals (2013-2018) admitted via the emergency department with two or more systemic inflammatory response criteria, were treated with antibiotics within 48 hours (i.e., had potential infection), and completed 4+ days of antibiotics (i.e., had suspected infection). We considered the following three approaches to defining baseline renal, hematologic, and liver function: the best values during hospitalization (as in the Centers for Disease Control and Prevention's ASE), the best values during hospitalization plus the prior 90 days (3-mo baseline), and the best values during hospitalization plus the prior 180 days (6-mo baseline). We determined how many patients met the criteria for sepsis by each approach, and then compared characteristics and outcomes of sepsis hospitalizations between the three approaches.Results: Among 608,128 hospitalizations with potential infection, 72.1%, 68.5%, and 58.4% had creatinine, platelet, and total bilirubin measured, respectively, in the prior 3 months. A total of 86.0%, 82.6%, and 74.8%, respectively, had these labs in the prior 6 months. Using the hospital baseline, 100,568 hospitalizations met criteria for community-acquired sepsis. By contrast, 111,983 and 117,435 met criteria for sepsis using the 3- and 6-month baselines, for a relative increase of 11% and 17%, respectively. Patient characteristics were similar across the three approaches. In-hospital mortality was 7.2%, 7.0%, and 6.8% for sepsis hospitalizations identified using the hospital, 3-month baseline, and 6-month baseline. The 30-day mortality was 12.5%, 12.7%, and 12.5%, respectively.Conclusions: Among veterans hospitalized with potential infection, the majority had laboratory values in the prior 6 months. Using 3- and 6-month lookbacks to define baseline organ function resulted in an 11% and 17% relative increase, respectively, in the number of sepsis hospitalizations identified.

IT'S ABOUT TIME: IMPROVING COMPLIANCE IN THE ONE-HOUR SEPSIS BUNDLE USING A MODIFIED ELECTRONIC MEDICAL RECORD ALERT PROMPTING A NURSING DRIVEN PROTOCOL

SESSION TITLE: Education, Research, and Quality Improvement Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Sepsis and septic shock are life-threatening illnesses that affect more than 20 million patients. Early recognition of sepsis is vital for reducing morbidity and mortality as each hour of delay in antibiotics increases mortality by 8%. We implemented a simplified computerized alert system triggering a nursing driven protocol aimed at timely intervention, which we hypothesized would improve the speed of resuscitation and compliance with the 1-hour sepsis bundle. METHODS: A modified algorithm was built into our existing electronic medical record (EMR) system firing a systemic inflammatory response (SIRS) alert if 3 of the following criteria were met: heart rate ≥ 91 bpm, respiratory rate ≥ 21 bpm, temperature < 36 C or ≥38.4 C, or WBC <4k or ≥12.1k. A SEPSIS alert would fire if 2 SIRS criteria plus 1 of the following signs of organ dysfunction were met: lactate ≥ 2.1 mmol/L, systolic blood pressure < 90mmHg or mean arterial pressure < 65mmHg, bilirubin ≥ 2.1 mg/dL, platelet count < 100,000, INR > 1.5 (not on Coumadin), or creatinine ≥ 2 mg/dL without known chronic kidney disease. Once an alert was fired and infection was suspected, the nursing staff was electronically prompted to draw a lactic acid level, initiate a 500ml crystalloid bolus, and collect blood cultures. These nursing interventions were initiated autonomously before the evaluation of an emergency department (ED) provider. Pediatric (<age 18), trauma, or obstetric patients were excluded. We analyzed data from April through October 2019 for all the SIRS/Sepsis alerts. Full compliance of the 1-hour sepsis bundle meant obtaining blood cultures, drawing a lactate level, and initiating antibiotics and intravenous fluids within 1 hour of the EMR trigger. Monthly comparisons were analyzed using a two-sample t-Test. RESULTS: Of the 1900 alerts, 587 patients met the inclusion criteria. Compliance with the sepsis bundle at 1-hour was evaluated by comparing alerts from April 2019 through October 2019. In April, the 1-hour sepsis bundle was met in 25.5% of the patients. In October, the 1-hour sepsis bundle was met in 69.8% of the patients. This represents a compliance improvement of 44.3% (P=<0.01). Length of stay was also reduced by 1 day (P=0.5). The major improvement was observed in the timely administrations of intravenous fluids with a reduction of 83 minutes (P=0.003) and antibiotic administration with a reduction of 73 minutes (P=0.001). CONCLUSIONS: Our hospital compliance with the 1-hour sepsis bundle has steadily improved each month since the introduction of the EMR alert and with reinforcement of the nursing driven protocol. A concerted effort between the nursing staff, pharmacy, ED providers and prompt the recognition of sepsis have been the key in improving the 1-hour sepsis bundle. Given our success, we plan on expanding this project beyond the ED to all adult hospital units. CLINICAL IMPLICATIONS: This resident champion quality improvement project has helped steadily improve our hospital compliance in the 1-hour sepsis bundle since the introduction of the EMR alert and with reinforcement of the nursing driven protocol aimed at improving timely sepsis resuscitation. DISCLOSURES: No relevant relationships by Marium Asad, source=Web Response No relevant relationships by Kristine Galang, source=Web Response No relevant relationships by Mohsen Saadat, source=Web Response No relevant relationships by Kimberley Stephania Yescas Garibay, source=Web Response

Frailty: A key concept to improve older person care.

Frailty is associated with increased hospitalization, hospital length of stay, intensive care unit admission, ED re-presentations, discharge to long-term care, mortality, and healthcare costs The CFS demonstrated higher sensitivity for predicting mortality and, when used in combination with systemic inflammatory response criteria and the Quick Sequential Organ Failure Assessment, improved prognostication than any individual score alone Fernando SM, Guo KH, Lukasik M, Frailty and associated prognosis among older emergency department patients with suspected infection: a prospective, observational cohort study

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

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

Distinct Biomarker Profiles Distinguish Malawian Children with Malarial and Non-malarial Sepsis.

Presently, it is difficult to accurately diagnose sepsis, a common cause of childhood death in sub-Saharan Africa, in malaria-endemic areas, given the clinical and pathophysiological overlap between malarial and non-malarial sepsis. Host biomarkers can distinguish sepsis from uncomplicated fever, but are often abnormal in malaria in the absence of sepsis. To identify biomarkers that predict sepsis in a malaria-endemic setting, we retrospectively analyzed data and sera from a case-control study of febrile Malawian children (aged 6-60 months) with and without malaria who presented to a community health center in Blantyre (January-August 2016). We characterized biomarkers for 29 children with uncomplicated malaria without sepsis, 25 without malaria or sepsis, 17 with malaria and sepsis, and 16 without malaria but with sepsis. Sepsis was defined using systemic inflammatory response criteria; biomarkers (interleukin-6 [IL-6], tumor necrosis factor receptor-1, interleukin-1 β [IL-1β], interleukin-10 [IL-10], von Willebrand factor antigen-2, intercellular adhesion molecule-1, and angiopoietin-2 [Ang-2]) were measured with multiplex magnetic bead assays. IL-6, IL-1β, and IL-10 were elevated, and Ang-2 was decreased in children with malaria compared with non-malarial fever. Children with non-malarial sepsis had greatly increased IL-1β compared with the other subgroups. IL-1β best predicted sepsis, with an area under the receiver operating characteristic (AUROC) of 0.71 (95% CI: 0.57-0.85); a combined biomarker-clinical characteristics model improved prediction (AUROC of 0.77, 95% CI: 0.67-0.85). We identified a distinct biomarker profile for non-malarial sepsis and developed a sepsis prediction model. Additional clinical and biological data are necessary to further explore sepsis pathophysiology in malaria-endemic regions.

Elevated Syndecan-1 after Trauma and Risk of Sepsis: A Secondary Analysis of Patients from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial

Endotheliopathy of trauma is characterized by breakdown of the endothelial glycocalyx. Elevated biomarkers of endotheliopathy, such as serum syndecan-1 (Synd-1) ≥ 40 ng/mL, have been associated with increased need for transfusions, complications, and mortality. We hypothesized that severely injured trauma patients who exhibit elevated Synd-1 levels shortly after admission have an increased likelihood of developing sepsis. We analyzed a subset of patients from the Pragmatic, Randomized Optimal Platelet and Plasma Ratios (PROPPR) trial who survived at least 72 hours after hospital admission, and we determined elevated Synd-1 levels (≥ 40 ng/mL) 4 hours after hospital arrival. Sepsis was defined a priori as meeting systemic inflammatory response criteria and having a known or suspected infection. Univariate analysis was performed to identify variables associated with elevated Synd-1 levels and sepsis. Significant variables at a value of p < 0.2 in the univariate analysis were chosen by purposeful selection and analyzed in a mixed effects multivariate logistic regression model to account for the 12 different study sites. We included 512 patients. Of these, 402 (79%) had elevated Synd-1 levels, and 180 (35%) developed sepsis. Median Synd-1 levels at 4 hours after admission were 70 ng/dL (interquartile range [IQR] 36 to 157 ng/dL) in patients who did not develop sepsis, and 165ng/dL [IQR 67 to 336 ng/dL] in those who did (p < 0.001). Adjusting for treatment arm and site, multivariable analyses revealed that elevated Synd-1 status, Injury Severity Score (ISS), and total blood transfused were significantly associated with an increased likelihood of developing sepsis. Elevated Synd-1 levels 4 hours after admission in severely injured adult trauma patients who survived the initial 72 hours after hospital admission are associated with subsequent sepsis.

Abstract PCCLB-26: INSIGHTS INTO MALARIAL AND NON-MALARIAL SEPSIS: BIOMARKER PROFILES IN MALAWIAN CHILDREN

Aims & Objectives: Sepsis is a complex interplay between the infectious agent and host response. Biomarker analyses can elucidate this dynamic relationship, but little is known about pediatric biomarker profiles in sub-Saharan Africa (SSA). We aimed to characterize the biomarker profile of 1) children with and without sepsis and 2) with malarial and non-malarial sepsis (NMS) in Malawi. Methods This is a cohort study of children (aged 6–60 mo) at a community health center in Blantyre (January-August 2016). We measured serum pro-inflammatory (interleukin-6 [IL], tumor necrosis factor receptor-1 [TNF R1]), anti-inflammatory (IL-10, IL-1β) and endothelial injury (vonWillebrand factor antigen-2 [vWFA2], intercellular adhesion molecule-1 [ICAM-1], angiopoietin-2 [Ang-2]) biomarkers at presentation. We used StataMP 14.2 for data analysis; a probability <0.05 was considered statistically significant. Results We compared 33 patients with sepsis (by systemic inflammatory response criteria) to 54 children with simple fever and 36 afebrile controls. Patient characteristics and presenting symptoms were similar between subgroups. IL-6, TNF R1, IL-10, IL-1β, and Ang-2 were elevated in children with sepsis as compared to children without sepsis (Table 1). Children with malarial sepsis compared to NMS had significantly elevated IL-6 and IL-10 and decreased IL-1β (Table 2). IL-10 predicted sepsis the best with an area under the receiver operator characteristic of 0.67. Conclusions Sepsis is a heterogeneous clinical entity. Septic children in Malawi had a distinct biomarker profile compared to controls and sepsis etiology influenced the host response. Regional clinical and biological data from SSA are necessary to explore sepsis pathophysiology in this population.

Clinical epidemiology of carbapenem-resistant gram-negative sepsis among hospitalized patients: Shifting burden of disease?

Infections caused by carbapenem-resistant gram-negative bacilli are an emerging public health threat. However, there is a paucity of data examining comparative incidence rates, risk factors, and outcomes in this population. This single-center retrospective cohort study was conducted at an urban tertiary-care academic medical center. We included patients admitted from 2012 to 2015 who met the following criteria: i) age ≥ 18 years; and ii) culture positive for carbapenem-resistant Enterobacteriaceae (CRE) or carbapenem-resistant non-Enterobacteriaceae (CRNE) from any site. Exclusion criteria were: i) < 2 systemic inflammatory response criteria; ii) cystic fibrosis; and iii) no targeted treatment. We evaluated hospital survival by Cox regression and year-by-year differences in the distribution of cases by the Cochran-Armitage test. 448 patients were analyzed (CRE, n = 111 [24.8%]; CRNE, n = 337 [75.2%]). CRE sepsis cases increased significantly over the study period (P <.001), driven primarily by increasing incidence of Enterobacter spp. infection (P = .004). No difference was observed in hospital survival between patients with CRE versus CRNE sepsis (hazard ratio [HR], 1.29; 95% confidence interval [CI], 0.83-2.02; P = .285), even after adjusting for confounding factors (adjusted HR, 1.08; 95% CI, 0.62-1.87; P = .799). Clinical outcomes did not differ between patients with CRE versus CRNE sepsis. Dramatic increases in CRE, particularly Enterobacter spp., appear to be causing a shift in the burden of clinically significant carbapenem-resistant gram-negative infection.

Algoritm for diagnostics of appendicitis in childhood and SIRS

The specific purpose of this study was to describe and characterize the systemic inflammatory response to appendicitis in childhood. The clinical symptoms of SIRS are present in a large proportion of patients . A study of high-risk patients showed that over a given period of time, 44-68% of the patients met the criteria for this condition, while at the same time they had proven infection up to 50%.The incidence of SIRS is even higher in the post-operative period and in trauma regardless of the presence or absence of infection. On the other hand, between 10% and 43% of patients with proven sepsis do not meet the SIRS criteria.The inclusion of a number of biological markers (C-reactive protein, procalcitonin, cytokines) aims to help differentiate SIRS with infectious and noninfectious etiology. Sixty six patients were studied, divided into four groups from onset of symptoms to diagnosis. The primary outcome measure was to determine the systemic inflammatory response to appendicitis according to the established groups of time intervals. The secondary outcome measure was the analysis of C-reactive protein for the same purpose. The variables of the systemic inflammatory response, according to diagnostic intervals, showed non-significant differences in white blood cell count. The temperature rose constantly after 48 h, reaching its peak after 72 h (p = 0.001), and the respiratory rate rose after 72 h (p &lt; 0.0001). After 73 h, most patients had three or four systemic inflammatory response criteria (p &lt; 0.0001). C-reactive protein levels rose progressively, showing higher levels after 48 h (p = 0.005). The inflammatory response to appendicitis is progressive, being more marked along the timeline from onset of symptoms to diagnosis. Key words: appendicitis, diagnostic SIRS, children, algoritm.

Patterns and Outcomes Associated With Timeliness of Initial Crystalloid Resuscitation in a Prospective Sepsis and Septic Shock Cohort.

The objectives of this study were to 1) assess patterns of early crystalloid resuscitation provided to sepsis and septic shock patients at initial presentation and 2) determine the association between time to initial crystalloid resuscitation with hospital mortality, mechanical ventilation, ICU utilization, and length of stay. Consecutive-sample observational cohort. Nine tertiary and community hospitals over 1.5 years. Adult sepsis and septic shock patients captured in a prospective quality improvement database inclusion criteria: suspected or confirmed infection, greater than or equal to two systemic inflammatory response criteria, greater than or equal to one organ-dysfunction criteria. The primary exposure was crystalloid initiation within 30 minutes or lesser, 31-120 minutes, or more than 120 minutes from sepsis identification. We identified 11,182 patients. Crystalloid initiation was faster for emergency department patients (β, -141 min; CI, -159 to -125; p < 0.001), baseline hypotension (β, -39 min; CI, -48 to -32; p < 0.001), fever, urinary or skin/soft-tissue source of infection. Initiation was slower with heart failure (β, 20 min; CI, 14-25; p < 0.001), and renal failure (β, 16 min; CI, 10-22; p < 0.001). Five thousand three hundred thirty-six patients (48%) had crystalloid initiated in 30 minutes or lesser versus 2,388 (21%) in 31-120 minutes, and 3,458 (31%) in more than 120 minutes. The patients receiving fluids within 30 minutes had lowest mortality (949 [17.8%]) versus 31-120 minutes (446 [18.7%]) and more than 120 minutes (846 [24.5%]). Compared with more than 120 minutes, the adjusted odds ratio for mortality was 0.76 (CI, 0.64-0.90; p = 0.002) for 30 minutes or lesser and 0.76 (CI, 0.62-0.92; p = 0.004) for 31-120 minutes. When assessed continuously, mortality odds increased by 1.09 with each hour to initiation (CI, 1.03-1.16; p = 0.002). We observed similar patterns for mechanical ventilation, ICU utilization, and length of stay. We did not observe significant interaction for mortality risk between initiation time and baseline heart failure, renal failure, hypotension, acute kidney injury, altered gas exchange, or emergency department (vs inpatient) presentation. Crystalloid was initiated significantly later with comorbid heart failure and renal failure, with absence of fever or hypotension, and in inpatient-presenting sepsis. Earlier crystalloid initiation was associated with decreased mortality. Comorbidities and severity did not modify this effect.

Systemic Inflammatory Response Syndrome is an Independent Predictor of One-Year Mortality in Patients with Acute Myocardial Infarction.

Convincing evidence suggests that inflammatory biomarkers are associated with an increased risk among patients with acute myocardial infarction (AMI). However, the impact of systemic inflammatory response (SIRS) on one-year clinical outcomes remains uncertain. Herein we investigated the impact of SIRS on one-year mortality and major adverse cardiovascular events (MACE) in patients with AMI. We conducted a retrospective study that enrolled patients admitted due to AMI and who received coronary artery intervention from January 2012 to June 2014. SIRS was defined according to standard criteria as having two or more of the following: (1) body temperature < 36 or > 38 °C, (2) heart rate > 90 beats per minute, (3) respiratory rate > 20, or (4) white blood cell count < 4000/mm3 or > 12,000/mm3. The primary endpoint was one-year mortality. The secondary endpoint was a one-year MACE, including revascularization, AMI, and stroke. A total of 330 AMI patients were enrolled in the study, and 121 study subjects (36.6%) met the SIRS criteria. AMI patients with SIRS on admission had significantly increased one-year all-cause mortality (control vs. SIRS: 21.1% vs. 33.1%, p = 0.026) and one-year MACE (35.9% vs. 53.7%, p = 0.022). Patients with SIRS had a higher incidence of one-year non-fatal myocardial infarction, but not non-fatal stroke. After multivariable adjustment, SIRS [hazard ratio (HR) = 1.773, 95% confidence interval (CI) = 1.097-2.886, p = 0.019] and age (HR = 1.038, 95% CI = 1.018-1.058, p < 0.001) were associated with enhanced risk of one-year mortality. This study revealed that AMI patients with SIRS on initial admission were associated with increased risk of one-year all-cause mortality.

BET 1: SIRS criteria as a way of predicting mortality in acute pancreatitis

A shortcut review was carried out to establish whether the presence of systemic inflammatory response criteria in emergency department patients with pancreatitis is predictive of the risk of death. Eight...

Heat Injury

Heat injuries present on a spectrum from mild (eg, miliaria rubra) to severe and life-threatening (heat stroke). The two main classifications of heat injury are exertional, which affects mainly young to middle-age individuals undergoing physical activity in hot environments, and classic, which typically affects young children and the elderly and results from an inability to dissipate heat. This review details the assessment and stabilization, diagnosis, treatments, disposition, and outcomes for patients with heat injury. Figures show the four mechanisms of passive heat transfer, physiologic responses to heat, the spectrum of heat injuries, risk factors for exertional versus classic heat stroke, a clinical algorithm to provide guidance in the diagnosis and management of heat stroke, the general pattern of organ dysfunction, and two evidence-based methods of rapid cooling for patients with heat stroke. Tables list factors affecting the efficiency of the mechanisms of passive heat transfer; minor to moderate heat injuries; exertional versus classic heat stroke; predisposing medical conditions, medications, and drugs for heat stroke; systemic inflammatory response criteria; key historical questions and physical examination items for heat stroke and differential diagnosis; signs, symptoms, and spectrum of pathology in heat stroke; comparison of pathology in exertional versus classic heat stroke; differential diagnosis for heat stroke; comparison of methods of cooling heat stroke patients; mortality data for heat stroke; and biologic variable prognostic indicators of mortality. This review contains 7 highly rendered figures, 14 tables, and 193 references.

The Systemic Inflammatory Response in Patients with Appendicitis: a Progressive Phenomenon.

The systemic inflammatory response has been described in patients with appendicitis. However, its progression from onset of symptoms to diagnosis has not been characterized. The specific purpose of this study was to describe and characterize the systemic inflammatory response to appendicitis. A descriptive cross-sectional study was conducted. One hundred eighty-three patients were studied, divided into four groups from onset of symptoms to diagnosis. The primary outcome measure was to determine the systemic inflammatory response to appendicitis according to the established groups of time intervals. The secondary outcome measure was the analysis of C-reactive protein for the same purpose. The variables of the systemic inflammatory response, according to diagnostic intervals, showed non-significant differences in white blood cell count. The temperature rose constantly after 48h, reaching its peak after 72h (p = 0.001), and the respiratory rate rose after 73h (p < 0.0001). After 73h, most patients had three or four systemic inflammatory response criteria (p < 0.0001). C-reactive protein levels rose progressively, showing higher levels after 48h (p = 0.005). The inflammatory response to appendicitis is progressive, being more marked along the timeline from onset of symptoms to diagnosis.

Characteristics and Outcomes of Patients With Vasoplegic Versus Tissue Dysoxic Septic Shock

The current consensus definition of septic shock requires hypotension after adequate fluid challenge or vasopressor requirement. Some patients with septic shock present with hypotension and hyperlactatemia greater than 2 mmol/L (tissue dysoxic shock), whereas others have hypotension alone with normal lactate (vasoplegic shock). The objective of this study was to determine differences in outcomes of patients with tissue dysoxic versus vasoplegic septic shock. This was a secondary analysis of a large, multicenter randomized controlled trial. Inclusion criteria were suspected infection, two or more systemic inflammatory response criteria, and systolic blood pressure less than 90 mmHg after a fluid bolus. Patients were categorized by presence of vasoplegic or tissue dysoxic shock. Demographics and Sequential Organ Failure Assessment scores were evaluated between the groups. The primary outcome was in-hospital mortality. A total of 247 patients were included, 90 patients with vasoplegic shock and 157 with tissue dysoxic shock. There were no significant differences in age, race, or sex between the vasoplegic and tissue dysoxic shock groups. The group with vasoplegic shock had a lower initial Sequential Organ Failure Assessment score than did the group with tissue dysoxic shock (5.5 vs. 7.0 points; P = 0.0002). The primary outcome of in-hospital mortality occurred in 8 (9%) of 90 patients with vasoplegic shock compared with 41 (26%) of 157 in the group with tissue dysoxic shock (proportion difference, 17%; 95% confidence interval, 7%-26%; P < 0.0001; log-rank test P = 0.02). After adjusting for confounders, tissue dysoxic shock remained an independent predictor of in-hospital mortality. In this analysis of patients with septic shock, we found a significant difference in in-hospital mortality between patients with vasoplegic versus tissue dysoxic septic shock. These findings suggest a need to consider these differences when designing future studies of septic shock therapies.

Plasma Levels of Mitochondrial DNA in Patients Presenting to the Emergency Department With Sepsis

Elevated levels of plasma mitochondrial DNA (mtDNA) have been reported in trauma patients and may contribute to the systemic immune response. We sought to determine the plasma levels of mtDNA in emergency department (ED) patients with and without sepsis and evaluate their association with severity of illness. This was a prospective observational study of patients presenting to one of three large, urban, tertiary care EDs. Patients were enrolled into one of three cohorts: (i) sepsis defined as suspected infection and two or more systemic inflammatory response criteria without hypotension, (ii) septic shock defined as sepsis plus hypotension despite an adequate fluid challenge, and (iii) control defined as noninfected ED patients without systemic inflammatory response/hypotension. Plasma levels of three mtDNAs were measured using real-time quantitative polymerase chain reaction. Levels of mtDNAs were compared among the three cohorts, and linear regression was used to assess the association between mtDNAs, interleukin 6, interleukin 10, and Sequential Organ Failure Assessment (SOFA) scores in patients with sepsis. We enrolled 93 patients: 24 control subjects, 29 patients with sepsis, and 40 patients with septic shock. As expected, comorbidities and SOFA score increased across categories. We found no difference in mtDNA levels between the three groups (P = 0.14-0.30). Among patients with sepsis, we found a small but significant negative association between mtDNA level and SOFA score, most clearly with cytochrome b (P = 0.03). We found no difference in mtDNA levels between control subjects and patients with sepsis. Mitochondrial DNA levels were negatively associated with organ dysfunction, suggesting that plasma mtDNA does not significantly contribute to the pathophysiology of sepsis.