Management of sepsis in a cirrhotic patient admitted to the intensive care unit:A systematic literature review

BACKGROUND Sepsis is a severe medical condition that occurs when the body's immune system overreacts to an infection,leading to life-threatening organ dysfunction.The"Third international consensus definitions for sepsis and septic shock(Sepsis-3)"defines sepsis as an increase in sequential organ failure assessment score of 2 points or more,with a mortality rate above 10%.Sepsis is a leading cause of intensive care unit(ICU)admissions,and patients with underlying conditions such as cirrhosis have a higher risk of poor outcomes.Therefore,it is critical to recognize and manage sepsis promptly by administering fluids,vasopressors,steroids,and antibiotics,and identifying and treating the source of infection.AIM To conduct a systematic review and meta-analysis of existing literature on the management of sepsis in cirrhotic patients admitted to the ICU and compare the management of sepsis between cirrhotic and non-cirrhotic patients in the ICU.METHODS This study is a systematic literature review that followed the PRISMA statement's standardized search method.The search for relevant studies was conducted across multiple databases,including PubMed,Embase,Base,and Cochrane,using predefined search terms.One reviewer conducted the initial search,and the eligibility criteria were applied to the titles and abstracts of the retrieved articles.The selected articles were then evaluated based on the research objectives to ensure relevance to the study's aims.RESULTS The study findings indicate that cirrhotic patients are more susceptible to infections,resulting in higher mortality rates ranging from 18%to 60%.Early identification of the infection source followed by timely administration of antibiotics,vasopressors,and corticosteroids has been shown to improve patient outcomes.Procalcitonin is a useful biomarker for diagnosing infections in cirrhotic patients.Moreover,presepsin and resistin have been found to be reliable markers of bacterial infection in patients with decompensated liver cirrhosis,with similar diagnostic performance compared to procalcitonin.CONCLUSION This review highlights the importance of early detection and management of infections in cirrhosis patients to reduce mortality.Therefore,early detection of infection using procalcitonin test and other biomarker as presepsin and resistin,associated with early management with antibiotics,fluids,vasopressors and low dose corticosteroids might reduce the mortality associated with sepsis in cirrhotic patients.

Effect of continuous positive airway pressure treatment on serum adiponectin level and mean arterial pressure in male patients with obstructive sleep apnea syndrome

Background Recent research suggested that obstructive sleep apnea syndrome （OSAS） might be independently associated with hypoadiponectinemia, which was linked to some complications of OSAS, such as hypertension, diabetes etc. This study was conducted to investigate the effect of continuous positive airway pressure （CPAP） treatment on changes of both serum adiponectin levels and mean arterial pressure and their possible links in male OSAS patients. Methods Twenty-three adult male patients with moderate-to-severe OSAS but without obesity, coronary heart disease and diabetes were recruited. Their blood samples were collected and morning mean arterial pressure （MAP） was measured before CPAP treatment and on day 3, 7, 14 of CPAP treatment respectively. The serum adiponectin concentration was tested with radioimmunoassay. Results Compared with the serum adiponectin level before CPAP treatment, no significant change was found in OSAS patients on day 3 and day 7 of CPAP treatment （P〉0.05）. It was not until day 14 of CPAP treatment did a significant elevation in serum adiponectin level occur （P〈0.01）. Meanwhile, the MAP showed no statistically significant difference among its levels before CPAP, on day 3 and day 7 of CPAP treatment （P〉0.05）. However, on day 14 of CPAP treatment, a significantly lower MAP than that obtained before treatment was observed （P〈0.05）. Conclusions CPAP treatment can gradually reverse hypoadiponectinemia and reduce MAP in OSAS patients. Hypoadiponectinemia might be involved in the pathogenesis of OSAS-mediated hypertension.

H_1 and H_2 receptors in the locus ceruleus are involved in the intracere-broventricular histamine-induced carotid sinus baroreceptor reflex reset-ting in rats

Objective To investigate the role of H1 and H2 receptors in the locus ceruleus （LC） in carotid sinus baroreceptor reflex （CSR） resetting induced by intracerebroventricular （i.c.v.） injection of histamine （HA）. Methods The left and right carotid sinus regions were isolated from the systemic circulation in 18 male Sprague-Dawley rats anesthetized with pentobarbital sodium. The intracarotid sinus pressure （ISP） was altered in a stepwise manner in vivo. ISP-mean arterial pressure （MAP） relationship curve and its characteristic parameters were constructed by fitting to the logistic function with five parameters. The changes in CSR performance induced by i.c.v. HA and the effects of pretreatment with H1 or H2 receptors selective antagonist, chlorpheniramine （CHL） or cimetidine （CIM） into the LC, on the responses of CSR to HA were examined. Results I.c.v. HA （100 ng in 5 μl） significantly shifted the ISP-MAP relationship curve upwards （P 〈 0.05） and obviously decreased the value of the reflex parameters such as MAP range and maximum gain （P 〈 0.05）, but increased the threshold pressure, saturation pressure and ISP at maximum gain （P 〈 0.05）. The pretreatment with CHL （0.5 μg in 1 μl） or CIM （1.5 μg in 1 μl） into the LC could obviously attenuate the changes mentioned above in CSR performance induced by HA, but the alleviative effect of CIM was less remarkable than that of CHL （P 〈 0.05）. Respective microinjection of CHL or CIM alone into the LC with the corresponding dose and volume did not change CSR performance significantly （P 〉 0.05）. Conclusion Intracerebroventricular administration of HA results in a rapid resetting of CSR and a decrease in reflex sensitivity, and the responses of CSR to HA may be mediated, at least in part, by H1 and H2 receptors activities in the LC, especially by H1 receptors. Moreover, the effects of the central HA on CSR might be related to a histaminergic descending pathway from the hypothalamus to LC.

Role of Nuclear Transcription Factor-кB in Endotoxin induced Shock in Rats

Summary: To investigate the role of NF-κB in endotoxic shock in rats, the model of endotoxin-shock rats was induced by intravenous infusion of lipopolysaccharide (LPS). 1 h, 2 h, 4 h and 6 h after LPS injection, the activation of NF-κB in blood mononuclear cells and the content of TNF-α and IL-6 in plasma was detected by enzyme-linked immunoadsordent assay (ELISA). The level of mean arterial pressure (MAP) and the histopathological changes of lung and liver were also observed. The activation of NF-κB in mononuclear cells increased 1 h after LPS injection and reached its peak 2 h after the injection, and its level was higher than that of normal group. The level of TNF-α was increased 1 h after the infusion and peaked 2 h after the injection, and its level was higher than that of normal group after LPS infusion. The content of IL-6 increased gradually with time, the IL-6 level was higher than that of normal group after LPS injection. MAP was decreased gradually with time and its level was lower than that of normal group after LPS injection. Pathological examination showed that endotoxic shock could cause pulmonary alveolar hemorrhage, edema and infiltration of inflammatory cell in lung tissue and congestion, edema, capillary dilation and inflammatory cell infiltration in liver tissue. It is concluded that NF-κB can up-regulate the expression of TNF-α and IL-6 in plasma and play an important role in endotoxin-induced shock in rats.

Perioperative risk factors associated with delayed graft function following deceased donor kidney transplantation:A retrospective,single center study

BACKGROUND There is an abundant need to increase the availability of deceased donor kidney transplantation(DDKT)to address the high incidence of kidney failure.Challenges exist in the utilization of higher risk donor organs into what appears to be increasingly complex recipients;thus the identification of modifiable risk factors associated with poor outcomes is paramount.AIM To identify risk factors associated with delayed graft function(DGF).METHODS Consecutive adults undergoing DDKT between January 2016 and July 2017 were identified with a study population of 294 patients.The primary outcome was the occurrence of DGF.RESULTS The incidence of DGF was 27%.Under logistic regression,eight independent risk factors for DGF were identified including recipient body mass index≥30 kg/m^(2),baseline mean arterial pressure<110 mmHg,intraoperative phenylephrine administration,cold storage time≥16 h,donation after cardiac death,donor history of coronary artery disease,donor terminal creatinine≥1.9 mg/dL,and a hypothermic machine perfusion(HMP)pump resistance≥0.23 mmHg/mL/min.CONCLUSION We delineate the association between DGF and recipient characteristics of preinduction mean arterial pressure below 110 mmHg,metabolic syndrome,donorspecific risk factors,HMP pump parameters,and intraoperative use of phenylephrine.

Prognostic value of hemodynamic indices in patients with sepsis after fluid resuscitation

BACKGROUND Sepsis usually causes hemodynamic abnormalities.Hemodynamic index is one of the factors to identify the severity of sepsis and an important parameter to guide the procedure of fluid resuscitation.The present study investigated whether the assessment of hemodynamic indices can predict the outcomes of septic patients undergoing resuscitation therapy.AIM To evaluate the prognostic value of hemodynamic indices in patients with sepsis after fluid resuscitation.METHODS A retrospective study was conducted in 120 patients with sepsis at Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University between October 2016 and October 2019.All patients were treated with sodium chloride combined with dextran glucose injection for fluid resuscitation.Patients’hemodynamic parameters were monitored,including heart rate(HR),cardiac index(CI),systemic vascular resistance index(SVRI),mean arterial pressure(MAP),central venous pressure(CVP),and central venous oxygen saturation.The prognostic value of hemodynamic indices was determined based on the prognosis status.RESULTS During fluid resuscitation,86 patients developed septic shock and 34 did not.Ninety-nine patients survived and 21 patients died at 28 d after the treatment.Heart rate,CI,mean arterial pressure,SVRI,and CVP were higher in patients with septic shock and patients who died from septic shock than in non-shock patients and patients who survived,and central venous oxygen saturation was lower in patients with shock and patients who died than in non-shock patients and thesurvivors (P < 0.05). When prognosis was considered as a dependent variable andhemodynamic parameters was considered as independent variables, the results ofa logistic regression analysis showed that CI, SVRI, and CVP were independentrisk factors for septic shock, and CI was an independent risk factor for 28-dmortality (P < 0.05).CONCLUSIONHemodynamic indices can be used to evaluate the prognosis of septic patientsafter fluid resuscitation.

PLASMA SODIUM AND NaCl-SENSITIVE HYPERTENSION

Objective To test the following three hypotheses: ①plasma sodium concentration displays a 24-hour rhythm; ②the circadian rhythm of plasma sodium is disrupted in SHR fed a basal NaCl diet; ③high NaCl diet elevates plasma sodium concentration and may lead to an increase in mean arterial pressure (MAP) of SHR. Methods After having been instrumented with arterial catheter at 9 weeks of age, all rats (Spontaneously Hypertensive Rat, SHR; Wistar-Kyoto Rat, WKY) experienced two experimental protocols, the mean arterial pressure and heart rate were monitored and the blood samples also been analysed for sodium contents. Results On basal NaCl diet, plasma sodium concentrations in SHR were significantly higher than those of WKY at almost every time point measured and the plasma sodium concentration and MAP rhythms were in nearly opposite phases; on high NaCl diet, the MAP and plasma sodium rhythms were essentially opposite in WKY. In SHR, the plasma sodium rhythm was inversely related to the MAP rhythm. Conclusion Plasma sodium displays a significant circadian rhythm in rats. The high NaCl diet disrupts the normal plasma sodium circadian rhythm only in SHR.

Screening and Prevention of Preeclampsia

Preeclampsia(PE)is a multisystem disorder of pregnancy classically characterized by hypertension with significant proteinuria after 20 weeks'gestation.This disorder is one of the leading causes of maternal and perinatal morbidity and mortality.PE can be subdivided into preterm PE(with delivery at<37 weeks'gestation)and term PE(with delivery at≥37 weeks'gestation).Preterm PE is associated with a higher risk of adverse maternal and perinatal outcomes than term PE.Traditional method of screening as recommended by professional guidelines has limited predictive performance and therefore should be updated to reflect recent scientific evidence that the target of screening should be preterm PE,the best way to identify the high-risk group is the Bayes-based method that combines maternal risk factors and biomarkers,the threshold should be set at screen positive rate of 10%,aspirin should be started before 16 weeks'gestation,and the daily dose should be higher than 100mg.