Prognostic impact of hypernatremia for septic shock patients in the intensive care unit

BACKGROUND Hypernatremia represents a significant electrolyte imbalance associated with numerous adverse outcomes,particularly in cases of intensive care unit(ICU)-acquired hypernatremia(IAH).Nevertheless,its relevance in patients with septic shock remains uncertain.AIM To identify independent risk factors and their predictive efficacy for IAH to improve outcomes in patients with septic shock.METHODS In the present retrospective single-center study,a cohort of 157 septic shock patients with concurrent hypernatremia in the ICU at The First Affiliated Hospital of Soochow University,between August 1,2018,and May 31,2023,were analyzed.Patients were categorized based on the timing of hypernatremia occurrence into the IAH group(n=62),the non-IAH group(n=41),and the normonatremia group(n=54).RESULTS In the present study,there was a significant association between the high serum sodium concentrations,excessive persistent inflammation,immunosuppression and catabolism syndrome and chronic critical illness,while rapid recovery had an apparent association with normonatremia.Moreover,multivariable analyses revealed the following independent risk factors for IAH:Total urinary output over the preceding three days[odds ratio(OR)=1.09;95%CI:1.02–1.17;P=0.014],enteral nutrition(EN)sodium content of 500 mg(OR=2.93;95%CI:1.13–7.60;P=0.027),and EN sodium content of 670 mg(OR=6.19;95%CI:1.75–21.98;P=0.005)were positively correlated with the development of IAH.Notably,the area under the curve for total urinary output over the preceding three days was 0.800(95%CI:0.678–0.922,P=0.001).Furthermore,maximum serum sodium levels,the duration of hypernatremia,and varying sodium correction rates were significantly associated with 28-day in-hospital mortality in septic shock patients(P<0.05).CONCLUSION The present findings illustrate that elevated serum sodium level was significantly associated with a poor prognosis in septic shock patients in the ICU.It is highly recommended that hypernatremia be considered a potentially important prognostic indicator for the outcome of septic shock.

Septic shock due to cytomegalovirus colitis associated with rituximab use:A case report

BACKGROUND Cytomegalovirus(CMV)infections can cause significant morbidity and mortality in immunocompromised individuals.CMV targets dysfunctional lymphocytes.Chronic rituximab(RTX)therapy can cause B-lymphocyte dysfunction,increasing CMV risk.Rarely,CMV infections present with critical illness such as septic shock.CASE SUMMARY A 64-year-old African American woman presented with generalized weakness and non-bloody watery diarrhea of 4-6 weeks duration.She did not have nausea,vomiting or,abdominal pain.She had been on monthly RTX infusions for neuromyelitis optica.She was admitted for septic shock due to pancolitis.Blood investigations suggested pancytopenia and serology detected significantly elevated CMV DNA.Valganciclovir treatment led to disease resolution.CONCLUSION This case illustrates an extremely rare case of CMV colitis associated with RTX use presenting with septic shock.High suspicion for rare opportunistic infections is imperative in individuals with long-term RTX use.

Early peripheral perfusion index predicts 28-day outcome in patients with septic shock

BACKGROUND:To investigate the prognostic value of the peripheral perfusion index(PPI)in patients with septic shock.METHODS:This prospective cohort study,conducted at the emergency intensive care unit of Peking University People's Hospital,recruited 200 patients with septic shock between January 2023 and August 2023.These patients were divided into survival(n=84)and death(n=116)groups based on 28-day outcomes.Clinical evaluations included laboratory tests and clinical scores,with lactate and PPI values assessed upon admission to the emergency room and at 6 h and 12 h after admission.Risk factors associated with mortality were analyzed using univariate and multivariate Cox regression analyses.Receiver operator characteristic(ROC)curve was used to assess predictive performance.Mortality rates were compared,and Kaplan-Meier survival plots were created.RESULTS:Compared to the survival group,patients in the death group were older and had more severe liver damage and coagulation dysfunction,necessitating higher norepinephrine doses and increased fl uid replacement.Higher lactate levels and lower PPI levels at 0 h,6 h,and 12 h were observed in the death group.Multivariate Cox regression identifi ed prolonged prothrombin time(PT),decreased 6-h PPI and 12-h PPI as independent risk factors for death.The area under the curves for 6-h PPI and 12-h PPI were 0.802(95%CI 0.742-0.863,P<0.001)and 0.945(95%CI 0.915-0.974,P<0.001),respectively,which were superior to Glasgow Coma Scale(GCS),Sequential Organ Failure Assessment(SOFA)scores(0.864 and 0.928).Cumulative mortality in the low PPI groups at 6 h and 12 h was signifi cantly higher than in the high PPI groups(6-h PPI:77.52%vs.22.54%;12-h PPI:92.04%vs.13.79%,P<0.001).CONCLUSION:PPI may have value in predicting 28-day mortality in patients with septic shock.

Systematic review with expert consensus on use of extracorporeal hemoadsorption in septic shock:An Indian perspective

BACKGROUND Septic shock is a severe form of sepsis characterised by deterioration in circulatory and cellular-metabolic parameters.Despite standard therapy,the outcomes are poor.Newer adjuvant therapy,such as CytoSorb®extracorporeal haemoadsorption device,has been investigated and shown promising outcome.However,there is a lack of some guidance to make clinical decisions on the use of CytoSorb®haemoadsorption as an adjuvant therapy in septic shock in Indian Setting.Therefore,this expert consensus was formulated.AIM To formulate/establish specific consensus statements on the use of CytoSorb®haemoadsorption treatment based on the best available evidence and contextualised to the Indian scenario.METHODS We performed a comprehensive literature on CytoSorb®haemoadsorption in sepsis,septic shock in PubMed selecting papers published between January 2011 and March 20232021 in English language.The statements for a consensus document were developed based on the summarised literature analysis and identification of knowledge gaps.Using a modified Delphi approach combining evidence appraisal and expert opinion,the following topics related to CytoSorb®in septic shock were addressed:need for adjuvant therapy,initiation timeline,need for Interleukin-6 levels,duration of therapy,change of adsorbers,safety,prerequisite condition,efficacy endpoints and management flowchart.Eleven expert members from critical care,emergency medicine,and the intensive care participated and voted on nine statements and one open-ended question.RESULTS Eleven expert members from critical care,emergency medicine,and the intensive care participated and voted on nine statements and one open-ended question.All 11 experts in the consensus group(100%)participated in the first,second and third round of voting.After three iterative voting rounds and adapting two statements,consensus was achieved on nine statements out of nine statements.The consensus expert panel also recognised the necessity to form an association or society that can keep a registry regarding the use of CytoSorb®for all indications in the open-ended question(Q10)focusing on“future recommendations for CytoSorb®therapy”.CONCLUSION This Indian perspective consensus statement supports and provides guidance on the use of CytoSorb®haemoadsorption as an adjuvant treatment in patients with septic shock to achieve optimal outcomes.

Dose-related effects of dexmedetomidine on immunomodulation and mortality to septic shock in rats

BACKGROUND: Dexmedetomidine has already been used in septic patients as a new sedative agent, few studies have examined its effects on immunomodulation. Therefore, the authors have designed a controlled experimental study to characterize the immunomodulation effects of dexmedetomidine in the cecal ligation and puncture(CLP) model in rats. METHODS: After CLP, 48 Wistar rats were randomly allocated into four groups:(1) CLP group;(2) small-dose treatment group(2.5 g·kg^(-1)·h^(-1));(3) medium-dose treatment group(5.0 g·kg^(-1)·h^(-1)); and(4) large-dose treatment group(10.0 g·kg^(-1)·h^(-1)). HLA-DR and plasma cytokine(IL-4, IL-6, IL-10 and TNF-α) levels were measured, and the mean arterial blood pressure(MAP), heart rate(HR), arterial blood gases, lactate concentrations and mortality were also documented. RESULTS: The HLA-DR level, inflammatory mediator levels, MAP and HR had no obvious changes among Dexmedetomidine treatment groups(DEX groups). Compared with the CLP group, the DEX groups exhibited decreased HLA-DR levels(P_(group)=0.0202) and increased IL-6 production, which was increased at 3 h(P= 0.0113) and was then attenuated at 5 h; additionally, the DEX groups exhibited decreased HR(P<0.001) while maintaining MAP(P_(group)=0.1238), and remarkably improving lactate(P<0.0001). All of these factors led to a significant decrease in the mortality, with observed rates of 91.7%, 66.7%, 25% and 18% for the CLP, DEX2.5, DEX5.0, DEX10.0 groups, respectively.CONCLUSION: Dexmedetomidine treatment in the setting of a CLP sepsis rat model has partially induced immunomodulation that was initiated within 5 h, causing a decreased HR while maintaining MAP, remarkably improving metabolic acidosis and improving mortality dosedependently.

Use of venous-to-arterial carbon dioxide tension difference to guide resuscitation therapy in septic shock

The mixed venous-to-arterial carbon dioxide(CO_2)tension difference[P(v-a) CO_2]is the difference between carbon dioxide tension(PCO_2) in mixed venous blood(sampled from a pulmonary artery catheter) and the PCO_2 in arterial blood.P(v-a) CO_2 depends on the cardiac output and the global CO_2 production,and on the complex relationship between PCO_2 and CO_2 content.Experimental and clinical studies support the evidence that P(v-a) CO_2 cannot serve as an indicator of tissue hypoxia,and should be regarded as an indicator of the adequacy of venous blood to wash out the total CO_2generated by the peripheral tissues.P(v-a) CO_2 can be replaced by the central venous-to-arterial CO_2 difference(△PCO_2),which is calculated from simultaneous sampling of central venous blood from a central vein catheter and arterial blood and,therefore,more easy to obtain at the bedside.Determining the △PCO_2 during the resuscitation of septic shock patients might be useful when deciding when to continue resuscitation despite a central venous oxygen saturation(SCVO_2) > 70%associated with elevated blood lactate levels.Because high blood lactate levels is not a discriminatory factor in determining the source of that stress,an increased △PCO_2(> 6 mmHg)could be used to identify patients who still remain inadequately resuscitated.Monitoring the △PCO_2 from the beginning of the reanimation of septic shock patients might be a valuable means to evaluate the adequacy of cardiac output in tissue perfusion and,thus,guiding the therapy.In this respect,it can aid to titrate inotropes to adjust oxygen delivery to CO_2 production,or to choose between hemoglobin correction or fluid/inotrope infusion in patients with a too low ScvO_2 related to metabolic demand.The combination of P(v-a) CO_2 or △PCO_2 with oxygen-derived parameters through the calculation of the P(v-a) CO_2 or △PCO_2/arteriovenous oxygen content difference ratio can detect the presence of global anaerobic metabolism.

Speckle-tracking echocardiography for detecting myocardial dysfunction in sepsis and septic shock patients:A single emergency department study

BACKGROUND:Septic cardiomyopathy(SCM)occurs in the early stage of sepsis and septic shock,which has implications for treatment strategies and prognosis.Additionally,myocardial involvement in the early stages of sepsis is difficult to identify.Here,we assess subclinical myocardial function using laboratory tests and speckle-tracking echocardiography(STE).METHODS:Emergency department patients diagnosed with sepsis or septic shock were included for analysis.Those with other causes of acute or pre-existing cardiac dysfunction were excluded.Transthoracic echocardiography(TTE),including conventional echocardiography and STE,were performed for all patients three hours after initial resuscitation.Samples for laboratory tests were taken around the time of TTE.RESULTS:Left ventricular functions of 60 patients were analyzed,including 21 septic shock patients and 39 sepsis patients.There was no significant difference in global longitudinal strain(GLS),global circumferential strain(GCS),or global radical strain(GRS)between patients with sepsis and septic shock(all with P>0.05).However,GLS and GCS were significantly less negative in patients with abnormal troponin levels or in patients with abnormal left ventricular ejection fraction(LVEF)values(all with P<0.05).There were also moderate correlations between GLS and levels of cTnI(r=0.40,P=0.002)or N-terminal pro-B-type natriuretic peptide(NT-proBNP)(r=0.44,P=0.001)in sepsis and septic shock patients.CONCLUSION:Myocardial dysfunction,e.g.,lower LVEF or less negative GLS in patients with sepsis or septic shock,is more affected by myocardial injury.GLS could be incorporated into mainstream clinical practice as a supplementary LVEF parameter,especially for those with elevated troponin levels.

Effect of early goal directed therapy on tissue perfusion in patients with septic shock

BACKGROUND:This study aimed to observe the effect of early goal directed therapy(EGDT)on tissue perfusion,microcirculation and tissue oxygenation in patients with septic shock.METHODS:Patients with early septic shock(<24 hours) who had been admitted to the ICU of Zhongda Hospital Affiliated to Southeast University from September 2009 through May 2011 were enrolled(research time:12 months),and they didn't meet the criteria of EGDT.Patients who had one of the following were excluded:stroke,brain injury,other types of shock,severe heart failure,acute myocardial infarction,age below 18 years,pregnancy,end-stage disease,cardiac arrest,extensive burns,oral bleeding,difficulty in opening the mouth,and the onset of septic shock beyond 24 hours.Patients treated with the standard protocol of EGDT were included.Transcutaneous pressure of oxygen and carbon dioxide(PtcO_2,PtcCO_2) were monitored and hemodynamic measurements were obtained.Side-stream dark field(SDF) imaging device was applied to obtain sublingual microcirculation.Hemodynamics,tissue oxygen,and sublingual microcirculation were compared before and after EGDT.If the variable meets the normal distribution,Student's t test was applied.Otherwise,Wilcoxon's rank-sum test was used.Correlation between variables was analyzed with Pearson's product-moment correlation coefficient method.RESULTS:Twenty patients were involved,but one patient wasn't analyzed because he didn't meet the EGDT criteria.PtcO_2 and PtcCO_2 were monitored in 19 patients,of whom sublingual microcirculation was obtained.After EGDT,PtcO_2 increased from 62.7+24.0 mmHg to 78.0±30.9mmHg(P<0.05) and tissue oxygenation index(PtcO_2/FiO_2) was 110.7+60.4 mmHg before EGDT and 141.6±78.2 mmHg after EGDT(P<0.05).The difference between PtcCO_2 and PCO_2 decreased significantly after EGDT(P<0.05).The density of perfused small vessels(PPV) and microcirculatory flow index of small vessels(MFI) tended to increase,but there were no significant differences between them(P>0.05).PtcO_2,PtcO_2/FiO_2,and PtcCO_2 were not linearly related to central venous saturation,lactate,oxygen delivery,and oxygen consumption(P>0.05).CONCLUSION:Peripheral perfusion was improved after EGDT in patients with septic shock,and it was not exactly reflected by the index of systemic perfusion.

Timing, method and discontinuation of hydrocortisone administration for septic shock patients

AIM To characterize the prescribing patterns for hydrocortisone for patients with septic shock and perform an exploratory analysis in order to identify the variables associated with better outcomes.METHODS This prospective cohort study included 59 patients with septic shock who received stress-dose hydrocortisone.It was performed at 2 critical care units in academic hospitals from June 1st, 2015, to July 31 st, 2016. Demographic data, comorbidities, medical management details, adverse effects related to corticosteroids, and outcomes were collected after the critical care physician indicated initiation of hydrocortisone. Univariate comparison between continuous and bolus administration of hydrocortisone was performed, including multivariate analysis, as well as Kaplan-Meier analysis to compare the proportion of shock reversal at 7 d after presentation. Receiver operating characteristic(ROC) curves determined the best cut-off criteria for initiation of hydrocortisone associated with the highest probability of shock reversal. We addressed the effects of the taper strategy for discontinuation of hydrocortisone, noting risk of shock relapse and adverse effects.RESULTS All-cause 30-d mortality was 42%. Hydrocortisone was administered as a continuous infusion in 54.2% of patients; time to reversal of shock was 49 h longer in patients who were given a bolus administration [59 h(range, 47.5-90.5) vs 108 h(range, 63.2-189); P = 0.001]. The maximal dose of norepinephrine after initiation of hydrocortisone was lower in patients on continuous infusion [0.19 μg/kg per minute(range, 0.11-0.28 μg)] compared with patients who were given bolus [0.34 μg/kg per minute(range, 0.16-0.49); P = 0.004]. Kaplan-Meier analysis revealed a higher proportion of shock reversal at 7 d in patients with continuous infusion compared to those given bolus(83% vs 63%; P = 0.004). There was a good correlation between time to initiation of hydrocortisone and time to reversal of shock(r = 0.80; P < 0.0001); ROC curve analysis revealed that the best criteria for prediction of shock reversal was a time to initiation of hydrocortisone of ≤ 13 h after administration of norepinephrine, with an area under the curve of 0.81(P < 0.001). The maximal dose of norepinephrine at initiation of hydrocortisone with the highest association with shock reversal was ≤ 0.28 μg/kg per minute, with an area under the curve of 0.75(P = 0.0002). On a logistic regression model, hydrocortisone taper was not associated with a lower risk of shock relapse(RR = 1.29; P = 0.17) but was related to a higher probability of hyperglycemia [odds ratio(OR), 5.3; P = 0.04] and hypokalemia(OR = 10.6; P = 0.01). CONCLUSION Continuous infusion of hydrocortisone could hasten the resolution of septic shock compared to bolus administration. Earlier initiation corresponds with a higher probability of shock reversal. Tapering strategy is unnecessary.

Knowledge,management,and complications of sepsis and septic shock:A significant therapeutic challenge in the intensive care unit

Sepsis and septic shock are life-threatening conditions that are globally responsible for almost 20%of mortality,especially in low and middle-income countries.This review was conducted on PubMed and Google Scholar databases with keywords sepsis,septic shock,sepsis management,and sepsis complications.Articles published up to July 2023 in English were included.Diagnosis and management should be carried out without unnecessary delay.Cooperation between various medical specialties including intensive care doctors,neurologists,hepatologists,cardiologists,and pediatric doctors is needed if a child is affected.New strategies have to be implemented in low and middle-income countries to decrease the sepsis incidence and reduce mortality in the population.

Development of septic shock and prognostic assessment in critically ill patients with coronavirus disease outside Wuhan, China

BACKGROUND: The study aims to illustrate the clinical characteristics and development of septic shock in intensive care unit(ICU) patients confirmed with severe acute respiratory syndrome coronavirus 2(SARS-Co V-2) infection, and to perform a comprehensive analysis of the association between septic shock and clinical outcomes in critically ill patients with coronavirus disease(COVID-19).METHODS: Patients confirmed with SARS-Co V-2 infection, who were admitted to the ICU of the Third People's Hospital of Shenzhen from January 1 to February 7, 2020, were enrolled. Clinical characteristics and outcomes were compared between patients with and without septic shock.RESULTS: In this study, 35 critically ill patients with COVID-19 were included. Among them, the median age was 64 years(interquartile range [IQR] 59-67 years), and 10(28.4%) patients were female. The median ICU length of stay was 16 days(IQR 8-23 days). Three(8.6%) patients died during hospitalization. Nine(25.7%) patients developed septic shock in the ICU, and these patients had a significantly higher incidence of organ dysfunction and a worse prognosis than patients without septic shock.CONCLUSIONS: Septic shock is associated with a poor outcome in critically ill COVID-19 patients and is one of the hallmarks of the severity of patients receiving ICU care. A dysregulated immune response, uncontrolled infl ammation, and coagulation disorders are strongly associated with the development and progression of COVID-19-related septic shock.

Machine learning in data abstraction: A computable phenotype for sepsis and septic shock diagnosis in the intensive care unit

BACKGROUND With the recent change in the definition(Sepsis-3 Definition)of sepsis and septic shock,an electronic search algorithm was required to identify the cases for data automation.This supervised machine learning method would help screen a large amount of electronic medical records(EMR)for efficient research purposes.AIM To develop and validate a computable phenotype via supervised machine learning method for retrospectively identifying sepsis and septic shock in critical care patients.METHODS A supervised machine learning method was developed based on culture orders,Sequential Organ Failure Assessment(SOFA)scores,serum lactate levels and vasopressor use in the intensive care units(ICUs).The computable phenotype was derived from a retrospective analysis of a random cohort of 100 patients admitted to the medical ICU.This was then validated in an independent cohort of 100 patients.We compared the results from computable phenotype to a gold standard by manual review of EMR by 2 blinded reviewers.Disagreement was resolved by a critical care clinician.A SOFA score≥2 during the ICU stay with a culture 72 h before or after the time of admission was identified.Sepsis versions as V1 was defined as blood cultures with SOFA≥2 and Sepsis V2 was defined as any culture with SOFA score≥2.A serum lactate level≥2 mmol/L from 24 h before admission till their stay in the ICU and vasopressor use with Sepsis-1 and-2 were identified as Septic Shock-V1 and-V2 respectively.RESULTS In the derivation subset of 100 random patients,the final machine learning strategy achieved a sensitivity-specificity of 100%and 84%for Sepsis-1,100%and 95%for Sepsis-2,78%and 80%for Septic Shock-1,and 80%and 90%for Septic Shock-2.An overall percent of agreement between two blinded reviewers had a k=0.86 and 0.90 for Sepsis 2 and Septic shock 2 respectively.In validation of the algorithm through a separate 100 random patient subset,the reported sensitivity and specificity for all 4 diagnoses were 100%-100%each.CONCLUSION Supervised machine learning for identification of sepsis and septic shock is reliable and an efficient alternative to manual chart review.

Predictive value of serum lactate dehydrogenase in diagnosis of septic shock in critical pediatric patients:A cross-sectional study

Objectives:To determine the predictive value of lactate dehydrogenase(LDH)in the diagnosis of septic shock and its association with other prognostic scores in critical pediatric patients.Methods:A cross-sectional study was performed at Children’s Hospital of Cairo University between June 2019 and December 2019.A total of 200 pediatric patients were divided into the septic shock group[100 critically ill patients with septic shock from the pediatric intensive care unit(PICU)]and the control group(100 patients with only sepsis).LDH was determined in the first 24 hours of admission.The sensitivity and specificity of LDH in diagnosis of septic shock were assessed;the levels of related indicators of patients with different etiologies were compared;correlations between LDH,Paediatric Index of MortalityⅡ,and Pediatric Sequential Organ Failure Assessment(pSOFA)were analyzed.Results:Median LDH was 512μL(406.50-663.00)in the septic shock group and was significantly higher than that[190μL(160.00-264.50)]in the control group(P<0.001).Besides,median LDH in children with chest infecion was higher than that in children with other diagnoses(P=0.047).A good positive correlation was found between pSOFA and LDH(r=0.503,P<0.001).Conclusions:LDH could be a potential inflammatory marker in the diagnosis of septic shock and is valuable for PICU admission decisions.

Septic shock due to Granulicatella adiacens after endoscopic ultrasound-guided biopsy of a splenic mass:A case report

BACKGROUND Endoscopic ultrasound-guided fine needle aspiration or biopsy(EUS-FNA or FNB)has become a popular method for diagnosing various lesions of the gastrointestinal tract and surrounding tissue due to the accuracy and safety.To the best of our knowledge,no case report of severe infection after EUS-FNB of a solid lesion in the spleen has been described.Herein,we report a rare case of septic shock after EUS-FNB of a splenic mass.CASE SUMMARY A 45-year-old male patient presented to the outpatient clinic due to an incidentally detected splenic mass.A definitive diagnosis could not be established based on the abdominal magnetic resonance imaging.EUS of the spleen showed a 6 cm-sized,relatively well-demarcated,heterogeneous mass,and EUS-FNB with a 22G needle was performed.Ten days after the procedure patient developed septic shock and a splenic abscess was identified.Blood culture revealed growth of Granulicatella adiacens.After the treatment with antibiotics the patient underwent surgical resection,and the pathological examination showed diffuse large B-cell lymphoma.The patient received chemotherapy and he is in complete remission.CONCLUSION Infection of a splenic mass after EUS-FNB is a rare complication and prophylactic antibiotics might be considered.

Low T3 vs low T3T4 euthyroid sick syndrome in septic shock patients:A prospective observational cohort study

BACKGROUND Both phases of euthyroid sick syndrome(ESS)are associated with worse prognosis in septic shock patients.Although there are still no indications for supplementation therapy,there is no evidence that both phases(initial and prolonged)are adaptive or that only prolonged is maladaptive and requires supplementation.AIM To analyze clinical,hemodynamic and laboratory differences in two groups of septic shock patients with ESS.METHODS A total of 47 septic shock patients with ESS were divided according to values of their thyroid hormones into low T3 and low T3T4 groups.The analysis included demographic data,mortality scores,intensive care unit stay,mechanical ventilation length and 28-day survival and laboratory with hemodynamics.RESULTS The Simplified Acute Physiology Score II score(P=0.029),dobutamine(P=0.003)and epinephrine requirement(P=0.000)and the incidence of renal failure and multiple organ failure(MOF)(P=0.000)were significantly higher for the low T3T4.Hypoalbuminemia(P=0.047),neutrophilia(P=0.038),lymphopenia(P=0.013)and lactatemia(P=0.013)were more pronounced on T2 for the low T3T4 group compared to the low T3 group.Diastolic blood pressure at T0(P=0.017)and T1(P=0.007),as well as mean arterial pressure at T0(P=0.037)and T2(P=0.033)was higher for the low T3 group.CONCLUSION The low T3T4 population is associated with higher frequency of renal insufficiency and MOF,with worse laboratory and hemodynamic parameters.These findings suggest potentially maladaptive changes in the chronic phase of septic shock.

A case report of iodine-125 seed placement during operation for the treatment of advanced gallbladder carcinoma with septic shock

This case report describes a patient with advanced gallbladder cancer who developed septic shock associated with iodine-125(^(125)I)seed implantation.The treatment process is described to provide a clinical reference for similar cases.A 52-year-old woman with recurrence of advanced gallbladder cancer underwent ^(125)I seed implantation and developed postoperative sepsis with septic shock.The blood culture suggested infection with Aeromonas caviae and Enterococcus faecalis.Vancomycin and imipenem were immediately administered according to the drug sensitivity results,along with immunoglobulin therapy and vasoactive drugs.The patient’s condition gradually stabilized after comprehensive treatment.Sepsis with septic shock is a rare but potentially fatal complication of ^(125)I seed implantation.Timely administration of broad-spectrum antibiotics,immunoglobulin therapy,and vasoactive drugs is very important to stabilize the patient’s condition.Our treatment of this patient can serve as a reference for clinicians to manage this complication in similar cases.

Precision medicine in sepsis and septic shock:From omics to clinical tools

Sepsis is a heterogeneous disease with variable clinical course and several clinical phenotypes.As it is associated with an increased risk of death,patients with this condition are candidates for receipt of a very well-structured and protocolized treatment.All patients should receive the fundamental pillars of sepsis management,which are infection control,initial resuscitation,and multiorgan support.However,specific subgroups of patients may benefit from a personalized approach with interventions targeted towards specific pathophysiological mechanisms.Herein,we will review the framework for identifying subpopulations of patients with sepsis,septic shock,and multiorgan dysfunction who may benefit from specific therapies.Some of these approaches are still in the early stages of research,while others are already in routine use in clinical practice,but together will help in the effective generation and safe implementation of precision medicine in sepsis.

Efficacy and safety of ulinastatin in the treatment of septic shock:a systematic review and meta-analysis

Background:Septic shock is a common systemic inflammatory response syndrome for critical patients in the intensive care unit.Ulinastatin is currently used for the treatment of septic shock.Our study sought to evaluate the efficacy and safety of ulinastatin in the treatment of septic shock patients.Methods:Three English databases(Embase,Medline,and Cochrane Library)and four Chinese databases(China National Knowledge Infrastructure,Wanfang data,SinoMed,and VIP)were searched for published randomized controlled trials.Stata 16.0 software was used to conduct the meta-analysis.Results:A total of 48 articles were included(Chinese article 47,1 in English).The results show that the treatment of ulinastatin could reduce mortality(risk ratio=0.63,95%confidence interval(CI)(0.55,0.72)),multiple organ dysfunction syndrome(risk ratio=0.6,95%CI(0.53,0.68)),length of intensive care unit stay(mean difference(MD)=-3.92,95%CI(-4.65,-3.18)),length of hospital stay(MD=-4.39,95%CI(-6.63,-2.15))and decrease Acute Physiology and Chronic Health Evaluation II score(MD=-4.55,95%CI(-5.63,-3.47))and Sequential Organ Failure Assessment score(MD=-2.02,95%CI(-2.59,-1.44))with P<0.001.Moreover,it lowers TNF-α(standardized mean difference(SMD)=-1.78,95%CI(-2.24,-1.32)),Interleukin-6(SMD=-1.17,95%CI(-1.55,-0.8)),C reactive protein(SMD=-1.49,95%CI(-1.99,-0.99)),hypersensitive C-reactive protein(SMD=-1.9,95%CI(-2.87,-0.94))and procalcitonin(SMD=-0.89,95%CI(-1.12,-0.67))levels in the body.Conclusions:Available evidence shows that ulinastatin reduces case mortality rate,multiple organ dysfunction syndrome,length of intensive care unit stay,and length of hospital stay and decreases Acute Physiology and Chronic Health Evaluation II score and Sequential Organ Failure Assessment score.Moreover,it also lowers TNF-α,Interleukin-6,C reactive protein,hypersensitive C-reactive protein,and procalcitonin levels in the body.

Hypoperfusion context as a predictor of 28-d all-cause mortality in septic shock patients:A comparative observational study

BACKGROUND As per the latest Surviving Sepsis Campaign guidelines,fluid resuscitation should be guided by repeated measurements of blood lactate levels until normalization.Nevertheless,raised lactate levels should be interpreted in the clinical context,as there may be other causes of elevated lactate levels.Thus,it may not be the best tool for real-time assessment of the effect of hemodynamic resuscitation,and exploring alternative resuscitation targets should be an essential research priority in sepsis.AIM To compare the 28-d mortality in two clinical patterns of septic shock:hyperlactatemic patients with hypoperfusion context and hyperlactatemic patients without hypoperfusion context.METHODS This prospective comparative observational study carried out on 135 adult patients with septic shock that met Sepsis-3 definitions compared patients with hyperlactatemia in a hypoperfusion context(Group 1,n=95)and patients with hyperlactatemia in a non-hypoperfusion context(Group 2,n=40).Hypoperfusion context was defined by a central venous saturation less than 70%,central venousarterial PCO_(2)gradient[P(cv-a)CO_(2)]≥6 mmHg,and capillary refilling time(CRT)≥4 s.The patients were observed for various macro and micro hemodynamic parameters at regular intervals of 0 h,3 h,and 6 h.All-cause 28-d mortality and all other secondary objective parameters were observed at specified intervals.Nominal categorical data were compared using theχ^(2)or Fisher’s exact test.Nonnormally distributed continuous variables were compared using the Mann-Whitney U test.Receiver operating characteristic curve analysis with the Youden index determined the cutoff values of lactate,CRT,and metabolic perfusion parameters to predict the 28-d all-cause mortality.A P value of<0.05 was considered significant.RESULTS Patient demographics,comorbidities,baseline laboratory,vital parameters,source of infection,baseline lactate levels,and lactate clearance at 3 h and 6 h,Sequential Organ Failure scores,need for invasive mechanical ventilation,days on mechanical ventilation,and renal replacement therapy-free days within 28 d,duration of intensive care unit stay,and hospital stay were comparable between the two groups.The stratification of patients into hypoperfusion and nonhypoperfusion context did not result in a significantly different 28-d mortality(24%vs 15%,respectively;P=0.234).However,the patients within the hypoperfusion context with high P(cva)CO_(2)and CRT(P=0.022)at baseline had significantly higher mortality than Group 2.The norepinephrine dose was higher in Group 1 but did not achieve statistical significance with a P>0.05 at all measured intervals.Group 1 had a higher proportion of patients requiring vasopressin and the mean vasopressor-free days out of the total 28 d were lower in patients with hypoperfusion(18.88±9.04 vs 21.08±8.76;P=0.011).The mean lactate levels and lactate clearance at 3 h and 6 h,CRT,P(cv-a)CO_(2)at 0 h,3 h,and 6 h were found to be associated with 28-d mortality in patients with septic shock,with lactate levels at 6 h having the best predictive value(area under the curve lactate at 6 h:0.845).CONCLUSION Septic shock patients fulfilling the hypoperfusion and non-hypoperfusion context exhibited similar 28-d all-cause hospital mortality,although patients with hypoperfusion displayed a more severe circulatory dysfunction.Lactate levels at 6 h had a better predictive value in predicting 28-d mortality than other parameters.Persistently high P(cv-a)CO_(2)(>6 mmHg)or increased CRT(>4 s)at 3 h and 6 h during early resuscitation can be a valuable additional aid for prognostication of septic shock patients.

Application and Nursing of Pulse Index Continuous Cardiac Output (PiCCO) Volume Monitoring in Early Fluid Resuscitation in Patients with Septic Shock

Background: Septic shock is a rapidly changing and fatal syndrome that can cause comprehensive deterioration of cardiopulmonary and renal function and multiple organ failure. At the same time, septic shock has the complex clinical manifestations and hemodynamics. PiCCO can accurately monitor blood flow, physical and volume indicators, and active and effective fluid resuscitation are important measures to reduce the fatality rate of septic shock and improve the prognosis of patients. Objectives: To explore the application and nursing of PiCCO in early fluid resuscitation in patients with septic shock. Methods: This was a retrospective observational study. The observation group and the control group each had 30 cases. The observation group used PiCCO to guide fluid resuscitation;the control group used conventional methods to guide fluid resuscitation. The changes in CVP, HR, MAP, and urine volume per hour were observed in the two groups. The changes of various indicators before and after fluid resuscitation, the length of stay in ICU and the mortality rate were compared between the two groups. All the outcomes were collected from the electronic medical case system after patients’ discharge from the hospital. Results: APACHE II, CVP, HR, MAP were compared between the observation group and the control group, and the differences were statistically significant (P < 0.05). The blood volume of patients in the observation group was significantly improved after fluid supplementation (P < 0.05). Compared with the control group, the length of stay in ICU in the observation group was significantly shorter, and the mortality rate was also significantly reduced (P < 0.05). Conclusion: PiCCO can be better used in early fluid resuscitation of patients with septic shock.