Worsening Organ Failure Research Articles

ACUTE PULMONARY HYPERTENSION AFTER BORTEZOMIB THERAPY

ACUTE PULMONARY HYPERTENSION AFTER BORTEZOMIB THERAPY

Methemoglobin Level May Not Predict Organ Failure in Sepsis

Objective: To evaluate the sensitivity, specificity, and area under receiver operating characteristics (AUROC) of methemoglobin levels to predict worsening sequential organ failure assessment (SOFA) scores at 72 hours in sepsis and septic shock in the intensive care setting. Materials and Methods: The authors conducted a prospective pilot study in a single university hospital. The present study subjects were adults aged more than 19 years, sepsis and septic shock patients admitted to intensive care units, with an arterial line in place. All patients’ arterial blood samples were collected and sent to the central laboratory to analyze for methemoglobin levels at the enrolment time, then 12 and 24 hours later. Patient’s characteristics, SOFA scores and other related parameters at enrolment, 12, 24, and 72 hours later were extracted through electronic medical records. Higher SOFA score at 72 hours, comparing to the enrolment value, was considered as a reference standard. Results: Among 30 patients, seven had worsening SOFA scores. Initial methemoglobin level had an AUROC of 0.5404 (95% confidence interval 0.2603 to 0.8204). Using Youden’s index, the determined cut-off value was 0.75%. The sensitivity of this cut-off value was 71.4% (95% confidence interval 29 to 96.3) and the specificity was 52% (95% confidence interval 30.6 to 73.2). Conclusion: Initial Methemoglobin level had an insufficient AUROC of 0.5404 to predict worsening organ failure in critically ill patients with sepsis. As the present study is a pilot study, a larger scale study may be required. Keywords: Sepsis; Methemoglobin; Organ Failure; SOFA; Septic shock

High Mortality of HLH in ICU Regardless Etiology or Treatment.

Background: Adult hemophagocytic lymphohistiocytosis (HLH) is highly lethal in the ICU. The diagnostic and therapeutic emergency that HLH represents is compounded by its unknown pathophysiological mechanisms. Here, we report on a large cohort of adult HLH in the ICU (ICU-HLH). We analyzed prognostic factors associated with mortality to define the diagnostic and therapeutic challenges in this specific population.Methods: This retrospective study included adult patients diagnosed with HLH in four ICUs in Marseille, France between 2010 and 2020. Patients who fulfilled the HLH-2004 criteria (≥ 4/8) and/or had an HScore ≥ 169 were diagnosed with HLH. HLH was categorized into four groups according to etiology: sepsis-associated HLH, intracellular infection-associated HLH, malignancy-associated HLH, and idiopathic HLH.Results: Two hundred and sixty patients were included: 121 sepsis-associated HLH (47%), 84 intracellular infection-associated HLH (32%), 28 malignancy-associated HLH (11%), and 27 idiopathic HLH (10%). The ICU mortality rate reached 57% (n = 147/260) without a statistical difference between etiological groups. Independent factors associated with mortality in multivariate analysis included age (OR (5 years) = 1.31 [1.16–1.48], p < 0.0001), SOFA score at ICU admission (OR = 1.37 [1.21–1.56], p < 0.0001), degradation of the SOFA score between ICU arrival and HLH diagnosis (Delta SOFA) (OR = 1.47 [1.28–1.70], p < 0.0001), the presence of bone-marrow hemophagocytosis (OR = 5.27 [1.11–24.97], p = 0.04), highly severe anemia (OR = 1.44 [1.09–1.91], p = 0.01), and hypofibrinogenemia (OR = 1.21 [1.04–1.41], p = 0.02).Conclusions: In this large retrospective cohort study of critically ill patients, ICU-HLH in adults was associated with a 57% mortality rate, regardless of HLH etiology or specific treatment. Factors independently associated with prognosis included age, presence of hemophagocytosis in bone-marrow aspirates, organ failure at admission, and worsening organ failure during the ICU stay. Whether a rapid diagnosis and the efficacy of specific therapy improve outcome is yet to be prospectively investigated.

Effect of Low-Normal vs High-Normal Oxygenation Targets on Organ Dysfunction in Critically Ill Patients

Hyperoxemia may increase organ dysfunction in critically ill patients, but optimal oxygenation targets are unknown. To determine whether a low-normal Pao2 target compared with a high-normal target reduces organ dysfunction in critically ill patients with systemic inflammatory response syndrome (SIRS). Multicenter randomized clinical trial in 4 intensive care units in the Netherlands. Enrollment was from February 2015 to October 2018, with end of follow-up to January 2019, and included adult patients admitted with 2 or more SIRS criteria and expected stay of longer than 48 hours. A total of 9925 patients were screened for eligibility, of whom 574 fulfilled the enrollment criteria and were randomized. Target Pao2 ranges were 8 to 12 kPa (low-normal, n = 205) and 14 to 18 kPa (high-normal, n = 195). An inspired oxygen fraction greater than 0.60 was applied only when clinically indicated. Primary end point was SOFARANK, a ranked outcome of nonrespiratory organ failure quantified by the nonrespiratory components of the Sequential Organ Failure Assessment (SOFA) score, summed over the first 14 study days. Participants were ranked from fastest organ failure improvement (lowest scores) to worsening organ failure or death (highest scores). Secondary end points were duration of mechanical ventilation, in-hospital mortality, and hypoxemic measurements. Among the 574 patients who were randomized, 400 (70%) were enrolled within 24 hours (median age, 68 years; 140 women [35%]), all of whom completed the trial. The median Pao2 difference between the groups was -1.93 kPa (95% CI, -2.12 to -1.74; P < .001). The median SOFARANK score was -35 points in the low-normal Pao2 group vs -40 in the high-normal Pao2 group (median difference, 10 [95% CI, 0 to 21]; P = .06). There was no significant difference in median duration of mechanical ventilation (3.4 vs 3.1 days; median difference, -0.15 [95% CI, -0.88 to 0.47]; P = .59) and in-hospital mortality (32% vs 31%; odds ratio, 1.04 [95% CI, 0.67 to 1.63]; P = .91). Mild hypoxemic measurements occurred more often in the low-normal group (1.9% vs 1.2%; median difference, 0.73 [95% CI, 0.30 to 1.20]; P < .001). Acute kidney failure developed in 20 patients (10%) in the low-normal Pao2 group and 21 patients (11%) in the high-normal Pao2 group, and acute myocardial infarction in 6 patients (2.9%) in the low-normal Pao2 group and 7 patients (3.6%) in the high-normal Pao2 group. Among critically ill patients with 2 or more SIRS criteria, treatment with a low-normal Pao2 target compared with a high-normal Pao2 target did not result in a statistically significant reduction in organ dysfunction. However, the study may have had limited power to detect a smaller treatment effect than was hypothesized. ClinicalTrials.gov Identifier: NCT02321072.

Platelet-to-red blood cell ratio and mortality in bleeding trauma patients: A systematic review and meta-analysis.

BackgroundIn traumatic bleeding, transfusion practice has shifted toward higher doses of platelets and plasma transfusion. The aim of this systematic review was to investigate whether a higher platelet‐to‐red blood cell (RBC) transfusion ratio improves mortality without worsening organ failure when compared with a lower ratio of platelet‐to‐RBC.MethodsPubmed, Medline, and Embase were screened for randomized controlled trials (RCTs) in bleeding trauma patients (age ≥16 years) receiving platelet transfusion between 1946 until October 2020. High platelet:RBC ratio was defined as being the highest ratio within an included study. Primary outcome was 24 hour mortality. Secondary outcomes were 30‐day mortality, thromboembolic events, organ failure, and correction of coagulopathy.ResultsIn total five RCTs (n = 1757 patients) were included. A high platelet:RBC compared with a low platelet:RBC ratio significantly improved 24 hour mortality (odds ratio [OR] 0.69 [0.53–0.89]) and 30‐ day mortality (OR 0.78 [0.63–0.98]). There was no difference between platelet:RBC ratio groups in thromboembolic events and organ failure. Correction of coagulopathy was reported in five studies, in which platelet dose had no impact on trauma‐induced coagulopathy.ConclusionsIn traumatic bleeding, a high platelet:RBC improves mortality as compared to low platelet:RBC ratio. The high platelet:RBC ratio does not influence thromboembolic or organ failure event rates.

Ascites in Acute Pancreatitis: Clinical Implications and Management

Clinically significant ascites in acute pancreatitis (AP) is rarely encountered and is a result of multifactorial pathogenesis. Early reactionary ascites in AP usually does not require any treatment and resolves spontaneously in majority of patients. A diagnostic analysis should be performed in case of ascites developing in the latter stages with increasing pain or worsening organ failure. Low serum albumin-ascites gradient ascites with amylase > 1000U/l is highly suggestive of pancreatic ascites that is usually associated with duct disruption. A combination of nasojejunal feeding, subcutaneous octreotide, endoscopic drainage and rarely, surgery are employed in managing this difficult to treat condition. There is a need of further studies to better understand the clinical role of ascites as well as contribution of other factors like hypoalbuminemia and portal hypertension to its development in AP.

Early on-demand drainage or standard management for acute pancreatitis patients with acute necrotic collections and persistent organ failure: A pilot randomized controlled trial.

The current standard care for acute pancreatitis with acute necrotic collections (ANC) is to postpone invasive intervention for 4 weeks when indicated. However, in patients with persistent organ failure (POF), this delayed approach may prolong organ failure. In this study, we aimed to assess the feasibility and safety of earlier drainage for acute pancreatitis patients with ANC and POF. A single-center, randomized controlled trial was conducted. Eligible patients were randomly assigned to either the early on-demand (EOD) group or the standard management (SM) group. Within 21days of randomization, early drainage was triggered by unremitted or worsening organ failure in the EOD group. The primary endpoint was a composite of major complications/death during 90-days follow-up. Thirty patients were randomized. Within 21days of randomization, eight of the 15 patients (53%) in the EOD group underwent percutaneous drainage compared to four of the 15 patients (27%) in the SM group (P=0.26). The primary outcome occurred in three of the 15 (20%) patients in the EOD group and seven of the 15(46.7%) in the controls (P=0.25, relative risk 0.43, 95%CI 0.14 to 1.35). Although the EOD approach did not result in significant differences between groups, the primary outcome assessed in this trial demonstrated the potential for clinical benefits favoring early drainage.

S3428 Septic Shock Causing Black Esophagus

INTRODUCTION: Sepsis has the potential to change perfusion throughout the body. If sepsis is not appropriately managed it leads to significant end organ damage with shock. Often times when multiple organs are affected the mortality rates are exceptionally high. Multiple studies have shown early management with antibiotics, vasopressors, and source control lead to better outcomes for patients with septic shock [1]. Hemodynamic stability must be balanced with organ perfusion. A common manifestation of septic shock is often end organ ischemia. CASE DESCRIPTION/METHODS: A 65 year old male with a history of atrial fibrillation and recent right sided stroke presented for altered mental status and acute hypoxic respiratory failure. The patient was placed on a mechanical ventilator. Chest X-ray showed signs of aspiration pneumonia. He was admitted to intensive care with shock requiring vasopressors. He was placed on broad spectrum antibiotics for presumed sepsis. A NG tube was placed for enteral feeding. X-ray imaging confirmed placement of feeding tube. Despite aggressive care the patient’s vasopressor requirements kept worsening with deteriorating lactic acidosis. Renal and hepatic failure continued to worsen along with the patient’s acidosis. CT chest was performed to better visualize the pneumonia. Incidentally it revealed that the feeding tube had perforated through the distal esophagus at the level of the GE junction. Imaging was positive for extensive pneumomediastinum. The patient was taken for immediate EGD for endoscopic evaluation of his esophageal perforation. During endoscopy, it was noted that patient had circumferential esophageal ischemia and necrosis. His mucosa was noted be sloughing off into his intraluminal space. The patient continued to decline with worsening organ failure. An esophagectomy could not be performed. Instead, family opted to allow patient to pass with comfort measures. DISCUSSION: This patient presented with a rare complication of septic shock – acute esophageal necrosis (AEN). At times referred to as “black esophagus,” AEN is noted to have a mortality rate between 30-50% [3]. It often occurs at the distal portion towards the GE junction [4]. This is the same region at which our nasogastric tube perforated through this patient’s esophagus. Unfortunately when AEN is associated with perforation it has higher mortality. Perforations occur only about 7% of the time in AEN [5]. This case shows the rare complication of septic shock resulting in AEN with subsequent esophageal perforation.Figure 1.: Hydrothorax, Pneumothorax, Pneumomediastinum, & Air Surrounding Esophagus.Figure 2.: NG Tube Perforating GE Junction.Figure 3.: G Tube Terminating Outside GI Tract.

Time to vasopressor initiation and organ failure progression in early septic shock.

ObjectiveResearch evaluating the relationship between vasopressor initiation timing and clinical outcomes is limited and conflicting. We investigated the association between time to vasopressors, worsening organ failure, and mortality in patients with septic shock.MethodsThis was a retrospective study of patients with septic shock (2013–2016) within 24 hours of emergency department (ED) presentation. The primary outcome was worsening organ failure, defined as an increase in Sequential Organ Failure Assessment (SOFA) score ≥2 at 48 hours compared to baseline, or death within 48 hours. The secondary outcome was 28‐day mortality. Time to vasopressor initiation was categorized into 6, 4‐hour intervals from time of ED triage. Multiple logistic regression was used to identify predictors of worsening organ failure.ResultsWe analyzed data from 428 patients with septic shock. There were 152 patients with the composite primary outcome (SOFA increase ≥2 or death at 48 hours). Of these, 77 patients died in the first 48 hours and 75 patients had a SOFA increase ≥2. Compared to the patients who received vasopressors in the first 4 hours, those with the longest time to vasopressors (20–24 hours) had increased odds of developing worsening organ failure (odds ratios [OR] = 4.34, 95% confidence intervals [CI] = 1.47–12.79, P = 0.008). For all others, the association between vasopressor timing and worsening organ failure was non‐significant. There was no association between time to vasopressor initiation and 28‐day mortality.ConclusionsIncreased time to vasopressor initiation is an independent predictor of worsening organ failure for patients with vasopressor initiation delays >20 hours.

Multi-Compartment Profiling of Bacterial and Host Metabolites Identifies Intestinal Dysbiosis and Its Functional Consequences in the Critically Ill Child.

Adverse physiology and antibiotic exposure devastate the intestinal microbiome in critical illness. Time and cost implications limit the immediate clinical potential of microbial sequencing to identify or treat intestinal dysbiosis. Here, we examined whether metabolic profiling is a feasible method of monitoring intestinal dysbiosis in critically ill children. Prospective multicenter cohort study. Three U.K.-based PICUs. Mechanically ventilated critically ill (n = 60) and age-matched healthy children (n = 55). Collection of urine and fecal samples in children admitted to the PICU. A single fecal and urine sample was collected in healthy controls. Untargeted and targeted metabolic profiling using 1H-nuclear magnetic resonance spectroscopy and liquid chromatography-mass spectrometry or urine and fecal samples. This was integrated with analysis of fecal bacterial 16S ribosomal RNA profiles and clinical disease severity indicators. We observed separation of global urinary and fecal metabolic profiles in critically ill compared with healthy children. Urinary excretion of mammalian-microbial co-metabolites hippurate, 4-cresol sulphate, and formate were reduced in critical illness compared with healthy children. Reduced fecal excretion of short-chain fatty acids (including butyrate, propionate, and acetate) were observed in the patient cohort, demonstrating that these metabolites also distinguished between critical illness and health. Dysregulation of intestinal bile metabolism was evidenced by increased primary and reduced secondary fecal bile acid excretion. Fecal butyrate correlated with days free of intensive care at 30 days (r = 0.38; p = 0.03), while urinary formate correlated inversely with vasopressor requirement (r = -0.2; p = 0.037). Disruption to the functional activity of the intestinal microbiome may result in worsening organ failure in the critically ill child. Profiling of bacterial metabolites in fecal and urine samples may support identification and treatment of intestinal dysbiosis in critical illness.

Impaired vascular reactivity in sepsis – a systematic review with meta-analysis

IntroductionVascular dysfunction due to reduced nitric oxide bioavailability plays an important role in the pathogenesis of sepsis. This meta-analysis examines evidence from published literature to evaluate whether in the adult population the presence/severity of sepsis is associated with impaired vasoreactivity.Material and methodsWe performed a search of the Medline, Scopus, and EMBASE databases to identify observational studies using measurement of reactive hyperaemia in adult patients with sepsis. After data extraction using predefined protocol, qualitative synthesis of findings was performed regarding consistency of findings between methods, evidence of association between vascular reactivity and severity of sepsis, multiple organ failure, and death. A meta-analyses of standardised mean differences in vasoreactivity between groups was performed, in which data were available for relevant outcomes.ResultsEighteen studies using four methods to measure vascular reactivity from a total of 466 were included in the analysis. The pooled standardised mean difference estimate showed that septic patients had less reactive hyperaemia than controls (–2.59, 95% CI: –3.46 to –1.72; p < 0.00001), and peak hyperaemic blood flow was lower in patients with sepsis than in the control group (SMD = –1.42, 95% CI: –2.14 to –0.70; p = 0.0001). The combined SMD between non survivors and survivors was –0.36 (95% CI: –0.67 to –0.06; p = 0.02) for reactive hyperaemia and –0.70 (95% CI: –1.13 to –0.27; p = 0.001) for peak hyperaemic blood flow.ConclusionsSeptic patients have attenuated vascular reactivity when compared to healthy volunteers. There are insufficient data indicating that these changes can identify patients at risk of worsening organ failure or death.

Percutaneous Interventions in Acute Necrotizing Pancreatitis.

Acute pancreatitis (AP) is a disease of varying severity with acute necrotizing pancreatitis (ANP) being the severe form of AP. ANP needs multidisciplinary management and is associated with significant mortality and morbidity. Local complications of ANP viz. acute necrotic collections (ANC) and walled off pancreatic necrosis (WOPN) need intervention if they are associated with symptoms, sepsis or worsening organ failure. As surgery is associated with higher morbidity and mortality, there is paradigm shift in the management of these local complications with an increased emphasis on conservative and minimally invasive treatment approach. Image-guided percutaneous drainage (PCD) is a minimally invasive intervention that helps in drainage of infected collections, temporizes sepsis and improves outcomes in these patients. The present review discusses the utility of various percutaneous interventions in management of variety of pancreatic collections occurring in ANP. The available evidence, technical details and complications and emerging innovations in the field are also summarized.

Impaired heart rate variability predicts clinical deterioration and progressive organ failure in emergency department sepsis patients

Emergency department (ED) sepsis patients without overt shock have a high incidence of clinical deterioration after admission. Heart rate variability (HRV) is decreased in severe sepsis. The objective was to determine the ability of a panel of HRV indices to identify physiologically stable ED sepsis patients who will develop worsening organ failure. We hypothesized that patients meeting the outcome of progressive organ failure will have decreased HRV on initial presentation.

Prognosis of patients with haematological malignancies admitted to the intensive care unit: Sequential Organ Failure Assessment (SOFA) trend is a powerful predictor of mortality

Background The prognosis of patients with haematological malignancies who are admitted to the ICU is generally poor. In order to optimize care, it is important to be able to determine which patients are most likely to benefit from continuation of treatment after ICU admission. Methods Data of 86 patients with a haematological malignancy consecutively admitted to the ICU of Maastricht University Medical Centre were examined in a retrospective cohort study in order to identify clinically useful prognostic parameters. Results ICU mortality was 56% and in-hospital mortality was 65%. Non-survivors had higher APACHE-II and SOFA scores compared with survivors (32 ± 8.0 versus 25 ± 6.5 and 11.5 ± 3.1 versus 8.5 ± 3.0, respectively). The mortality rate was significantly higher in patients with an increasing SOFA score (≥ 2 points) compared with patients with an unchanged or decreasing SOFA score (72% versus 58% and 21%, respectively). Mortality was also higher in patients requiring invasive mechanical ventilation or inotropic/vasopressor therapy. Conclusion The mortality rate among patients with haematological malignancies who are admitted to the ICU is high and mainly associated with the severity of illness, as reflected by more severe and worsening organ failure and a need for mechanical ventilation or inotropic/vasopressor therapy. Several factors appear to be associated with a poor outcome, but no absolute predictors of mortality could be identified, although the results suggest that changes in the SOFA score during the stay in the ICU can be helpful in the decision making about the continuation or discontinuation of treatment.

The prognostic value of the subjective assessment of peripheral perfusion in critically ill patients

The physical examination of peripheral perfusion based on touching the skin or measuring capillary refill time has been related to the prognosis of patients with circulatory shock. It is unclear, however, whether monitoring peripheral perfusion after initial resuscitation still provides information on morbidity in critically ill patients. Therefore, we investigated whether subjective assessment of peripheral perfusion could help identify critically ill patients with a more severe organ or metabolic dysfunction using the Sequential Organ Failure Assessment (SOFA) score and lactate levels. : Prospective observational study. Multidisciplinary intensive care unit in a university hospital. Fifty consecutive adult patients admitted to the intensive care unit. None. Patients were considered to have abnormal peripheral perfusion if the examined extremity had an increase in capillary refill time (>4.5 seconds) or it was cool to the examiner hands. To address reliability of subjective inspection and palpation of peripheral perfusion, we also measured forearm-to-fingertip skin-temperature gradient (Tskin-diff), central-to-toe temperature difference (Tc-toe), and peripheral flow index. The measurements were taken within 24 hours of admission to the intensive care after hemodynamic stability was obtained (mean arterial pressure >65 mm Hg). Changes in SOFA score during the first 48 hours were analyzed (delta-SOFA). Individual SOFA score was significantly higher in patients with abnormal peripheral perfusion than in those with normal peripheral perfusion (9 +/- 3 vs. 7 +/- 2, p < 0.05). Tskin-diff, Tc-toe, and peripheral flow index were congruent with the subjective assessment of peripheral perfusion. The proportion of patients with delta-SOFA score >0 was significantly higher in patients with abnormal peripheral perfusion (77% vs. 23%, p < 0.05). The logistic regression analysis showed that the odds of unfavorable evolution are 7.4 (95% confidence interval 2-19; p < 0.05) times higher for a patient with abnormal peripheral perfusion. The proportion of hyperlactatemia was significantly different between patients with abnormal and normal peripheral perfusion (67% vs. 33%, p < 0.05). The odds of hyperlactatemia by logistic regression analysis are 4.6 (95% confidence interval 1.4-15; p < 0.05) times higher for a patient with abnormal peripheral perfusion. Subjective assessment of peripheral perfusion with physical examination following initial hemodynamic resuscitation in the first 24 hours of admission could identify hemodynamically stable patients with a more severe organ dysfunction and higher lactate levels. Patients with abnormal peripheral perfusion had significantly higher odds of worsening organ failure than did patients with normal peripheral perfusion following initial resuscitation.

Glucose control, organ failure, and mortality in pediatric intensive care*

In ventilated children, to determine the prevalence of hyperglycemia, establish whether it is associated with organ failure, and document glycemic control practices in Australasian pediatric intensive care units (PICUs). Prospective inception cohort study. All nine specialist PICUs in Australia and New Zealand. Children ventilated > 12 hrs excluding those with diabetic ketoacidosis, on home ventilation, undergoing active cardiopulmonary resuscitation on admission, or with do-not-resuscitate orders. None. All blood glucose measurements for up to 14 days, clinical and laboratory values needed to calculate Paediatric Logistic Organ Dysfunction (PELOD) scores, and insulin use were recorded in 409 patients. Fifty percent of glucose measurements were > 6.1 mmol/L, with 89% of patients having peak values > 6.1 mmol/L. The median time to peak blood glucose was 7 hrs. Hyperglycemia was defined by area under the glucose-time curve > 6.1 mmol/L above the sample median. Thirteen percent of hyperglycemic subjects died vs. 3% of nonhyperglycemic subjects. There was an independent association between hyperglycemia and a PELOD score > or = 10 (odds ratio 3.41, 95% confidence interval 1.91-6.10) and death (odds ratio 3.31, 95% confidence interval 1.26-7.7). Early hyperglycemia, defined using only glucose data in the first 48 hrs, was also associated with these outcomes but not with PELOD > or = 10 after day 2 or with worsening PELOD after day 1. Five percent of patients received insulin. Hyperglycemia is common in PICUs, occurs early, and is independently associated with organ failure and death. However, early hyperglycemia is not associated with later or worsening organ failure. Australasian PICUs seldom use insulin.

Prognostic value of a simple evolving disseminated intravascular coagulation score in patients with severe sepsis*

We postulated that the coagulopathy initiated by the inflammatory response to severe sepsis would be reflected by changes in the platelet count and prothrombin time that convey prognostic information. To examine this hypothesis, we looked at the utility of a simple evolving disseminated intravascular coagulation (DIC) score that awarded 1 point for each of the following: a) an absolute platelet count <100 x 10/L; b) a prothrombin time >15.0 secs; c) a 20% decrease in platelets; and d) a >0.3-sec increase in prothrombin time in predicting outcome in patients with severe sepsis. Prospective observational study. Intensive care units of university medical center. Patients were 163 critically ill severe sepsis patients. None. Patients were clinically classified as having capillary leak syndrome (n = 24), multiple organ failure with death from sepsis (n = 37), or multiple organ failure with recovery (n = 57) or as well (n = 45) if they showed rapid improvement in their modified Multiple Organ Dysfunction Syndrome (MODS) score (which did not score for thrombocytopenia). Patients with capillary leak syndrome had the highest Acute Physiology and Chronic Health Evaluation II score, modified MODS, and prothrombin time and the lowest platelet counts, whereas well patients had the most normal values. The simple evolving DIC score increased with worsening clinical class and was associated with worsening organ failure (increased modified MODS). Mortality rate increased from 10% for a simple evolving score of 0 to 73% for a score of 4 (p < .01). Overall, 86% of those with a score < or =1 survived, whereas 85% of those with a score of > or =2 developed multiple organ failure and half of them died from sepsis. The simple evolving DIC score calculated in the first 48 hrs from two readily available global coagulation markers appears to reflect the severity of the underlying disorder. It can be easily calculated at the bedside and provides useful prognostic information for the patient with severe sepsis.

Pneumonia: Cause or symptom of postinjury multiple organ failure?

Recent studies have shown that selective gut decontamination can reduce the incidence of pneumonia, but this does not decrease multiple organ failure (MOF) or mortality. These findings have prompted the hypothesis that pneumonia is an inconsequential symptom of MOF. To test this, we prospectively evaluated 123 high-risk trauma patients (mean Injury Severity Score = 36.2 +/- 1.5). Organ dysfunction, scored daily according to a 12-point scale, ultimately developed in 28 (23%) patients. Major infections were diagnosed, based on strict criteria, in 59 patients (48%), and pneumonia developed in 52 patients (43%). Pneumonia was significantly associated with MOF (82% of patients with MOF versus 30% of patients without MOF, p < 0.0001). In 14 (50%) of the patients with MOF, pneumonia preceded a significant rise (greater than or equal to 3) in serial MOF scoring. Of note, 10 (71%) of these patients died. Among the remaining 14 patients with MOF, 10 developed pneumonia, but this was associated with a minimal increase (less than or equal to 2) in MOF scoring (3 patients died). These data, by temporal association with MOF scoring, implicate pneumonia in precipitating or significantly worsening organ failure in 50% of the patients who developed MOF.

Exploratory laparotomy for potential abdominal sepsis in patients with multiple-organ failure.

We studied 29 patients with multiple-organ failure (MOF) who underwent exploratory laparotomy because of suspected intra-abdominal sepsis. The purpose was to identify predictors of continuing abdominal sepsis and to assess outcome of operation in these severely ill patients. The strongest predictor of continuing intra-abdominal sepsis was development of unexplained single-organ failure, which occurred in 17 patients. Physical findings were not a totally reliable indicator of abdominal sepsis since only 15 of 29 patients had acute abdominal findings. The main clue to sepsis in patients without acute abdominal findings was worsening organ failure. Fifteen of 29 patients died of continuing MOF. Only one patient older than 50 years survived. We suggest that earlier operation is indicated in certain patients with organ failure. Particularly aggressive operative therapy seems justified in young patients with unexplained single-organ failure or worsening MOF.