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.

Predictive value of thrombocytopenia for bloodstream infection in patients with sepsis and septic shock

BACKGROUND Thrombocytopenia is common in patients with sepsis and septic shock.AIM To analyse the decrease in the number of platelets for predicting bloodstream infection in patients with sepsis and septic shock in the intensive care unit.METHODS A retrospective analysis of patients admitted with sepsis and septic shock in Xingtai People Hospital was revisited.Patient population characteristics and laboratory data were collected for analysis.RESULTS The study group consisted of 85(39%)inpatients with bloodstream infection,and the control group consisted of 133(61%)with negative results or contamination.The percentage decline in platelet counts(PPCs)in patients positive for pathogens[57.1(41.3-74.6)]was distinctly higher than that in the control group[18.2(5.1–43.1)](P<0.001),whereas the PPCs were not significantly different among those with gram-positive bacteraemia,gram-negative bacteraemia,and fungal infection.Using receiver operating characteristic curves,the area under the curve of the platelet drop rate was 0.839(95%CI:0.783-0.895).CONCLUSION The percentage decline in platelet counts is sensitive in predicting bloodstream infection in patients with sepsis and septic shock.However,it cannot identify gram-positive bacteraemia,gram-negative bacteraemia,and fungal infection.

Comparing 11 early warning scores and three shock indices in early sepsis prediction in the emergency department

BACKGROUND:This study aimed to evaluate the discriminatory performance of 11 vital sign-based early warning scores(EWSs)and three shock indices in early sepsis prediction in the emergency department(ED).METHODS:We performed a retrospective study on consecutive adult patients with an infection over 3 months in a public ED in Hong Kong.The primary outcome was sepsis(Sepsis-3 definition)within 48 h of ED presentation.Using c-statistics and the DeLong test,we compared 11 EWSs,including the National Early Warning Score 2(NEWS2),Modified Early Warning Score,and Worthing Physiological Scoring System(WPS),etc.,and three shock indices(the shock index[SI],modified shock index[MSI],and diastolic shock index[DSI]),with Systemic Inflammatory Response Syndrome(SIRS)and quick Sequential Organ Failure Assessment(qSOFA)in predicting the primary outcome,intensive care unit admission,and mortality at different time points.RESULTS:We analyzed 601 patients,of whom 166(27.6%)developed sepsis.NEWS2 had the highest point estimate(area under the receiver operating characteristic curve[AUROC]0.75,95%CI 0.70-0.79)and was significantly better than SIRS,qSOFA,other EWSs and shock indices,except WPS,at predicting the primary outcome.However,the pooled sensitivity and specificity of NEWS2≥5 for the prediction of sepsis were 0.45(95%CI 0.37-0.52)and 0.88(95%CI 0.85-0.91),respectively.The discriminatory performance of all EWSs and shock indices declined when used to predict mortality at a more remote time point.CONCLUSION:NEWS2 compared favorably with other EWSs and shock indices in early sepsis prediction but its low sensitivity at the usual cut-off point requires further modification for sepsis screening.

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.

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.

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.

Influence of the Pre-shock State on the Prognosis of Medical Patients with Sepsis: A Retrospective Cohort Study

Objective To investigate the effects of the pre-shock state on the mortality of patients with sepsis.Methods We enrolled patients with sepsis admitted to the medical intensive care unit of a tertiary care university hospital. These patients were then classified into three groups: sepsis, pre-shock state,and septic shock. The primary outcome was the 28-day mortality rate. The secondary outcomes were the 90-day, 180-day, and 1-year mortality rates.Results A total of 303 patients(groups: sepsis 135 [44.6%]), pre-shock state(93 [30.7%]), and septic shock(75 [24.8%]) completed the 1-year follow-up. The mortality rates at 28 days, 90 days, and 180days and 1 year were significantly higher in the pre-shock state group than those of the sepsis group,but significantly lower than those in the septic shock group, especially among older patients. When compared with the pre-shock state group, the sepsis group had significantly lower mortality risks at 28days, 90 days, and 180 days and 1 year, whereas the sepsis shock group had higher mortality risks at these time points.Conclusion The mortality rates of patients in the pre-shock state were notably different from those of patients with sepsis or septic shock. The introduction of a modified sepsis severity classification, which includes sepsis, pre-shock state, and septic shock, could offer valuable additional prognostic information.

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.

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.

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.

Adjuvant Administration of Vitamin C Improves Mortality of Patients with Sepsis and Septic Shock: A Systems Review and Meta-Analysis

The aim of this study was to examine whether vitamin C reduced mortality when adjutant therapy of patients with septic shock and severe sepsis compared with placebo by meta-analysis. Eligible trials were identified from Pubmed, Embase, Ovid, and the Cochrane database. Four randomized controlled trials (RCT) and two retrospective studies were published between 2000 and 2017 met the inclusion criteria and suitable for meta-analysis. The data were analyzed with randomized-effects or fixed-effects models using Review Manager Version 5.3. Four randomized studies with a total of 109 participants were suitable for meta-analysis. The heterogeneity was assessed by calculating the Q and I2 methods. A random-effects approach instead of a fixed-effects analysis was undertaken if I2 > 50%. Adjuvant vitamin C did not associate with a reduction in mortality as compared with placebo, it is occurred similarly in both RCT studies and retrospective studies. However, high doses of vitamin C (>50 mg/kg/day) significant reduced the mortality rate of severe sepsis patients. And administration of high doses of vitamin C to therapy severe sepsis did not significantly reduce the ICU length of stay. The results suggested a trend toward reducing mortality in severe sepsis and septic shock patients’ adjuvant with vitamin C. Further multicenter large randomized controlled trials are necessary to determine the potential benefits of vitamin C in patients with severe sepsis and septic shock.

Septic shock 3.0 criteria application in severe COVID-19 patients:An unattended sepsis population with high mortality risk

BACKGROUND Coronavirus disease 2019(COVID-19)can be associated with life-threatening organ dysfunction due to septic shock,frequently requiring intensive care unit(ICU)admission,respi-ratory and vasopressor support.There-fore,clear clinical criteria are pivotal for early recognition of patients more likely to need prompt organ support.Although most patients with severe COVID-19 meet the Sepsis-3.0 criteria for septic shock,it has been increasingly recognized that hyperlactatemia is frequently absent,possibly leading to an underestimation of illness severity and mortality risk.AIM To identify the proportion of severe COVID-19 patients with vasopressor support requirements,with and without hyperlactatemia,and describe their clinical outcomes and mortality METHODS We performed a single-center prospective cohort study.All adult patients admitted to the ICU with COVID-19 were included in the analysis and were further divided into three groups:Sepsis group,without both criteria;Vasoplegic Shock group,with persistent hypotension and vasopressor support without hyperlactatemia;and Septic Shock 3.0 group,with both criteria.COVID-19 was diagnosed using clinical and radiologic criteria with a severe acute respiratory syndrome coronavirus 2(SARS-CoV-2)positive RT-PCR test.RESULTS 118 patients(mean age 63 years,87%males)were included in the analysis(n=51 Sepsis group,n=26 Vasoplegic Shock group,and n=41 Septic Shock 3.0 group).SOFA score at ICU admission and ICU length of stay were different between the groups(P<0.001).Mortality was significantly higher in the Vasoplegic Shock and Septic Shock 3.0 groups when compared with the Sepsis group(P<0.001)without a significant difference between the former two groups(P=0.713).The log rank tests of Kaplan-Meier survival curves were also different(P=0.007).Ventilator-free days and vasopressor-free days were different between the Sepsis vs Vasoplegic Shock and Septic Shock 3.0 groups(both P<0.001),and similar in the last two groups(P=0.128 and P=0.133,respectively).Logistic regression identified the maximum dose of vasopressor therapy used(AOR 1.046;95%CI:1.012-1.082,P=0.008)and serum lactate level(AOR 1.542;95%CI:1.055-2.255,P=0.02)as the major explanatory variables of mortality rates(R20.79).CONCLUSION In severe COVID-19 patients,the Sepsis 3.0 criteria of septic shock may exclude approximately one third of patients with a similarly high risk of a poor outcome and mortality rate,which should be equally addressed.

Combining Serum Procalcitonin Level,Thromboelastography,and Platelet Count to Predict Short-term Development of Septic Shock in Intensive Care Unit

Objective Despite the recent advances in diagnosis and treatment,sepsis continues to lead to high morbidity and mortality.Early diagnosis and prompt treatment are essential to save lives.However,most biomarkers can only help to diagnose sepsis,but cannot predict the development of septic shock in high-risk patients.The present study determined whether the combined measurement of procalcitonin(PCT),thromboelastography(TEG)and platelet(PLT)count can predict the development of septic shock.Methods A retrospective study was conducted on 175 septic patients who were admitted to the intensive care unit between January 2017 and February 2021.These patients were divided into two groups:73 patients who developed septic shock were assigned to the septic shock group,while the remaining 102 patients were assigned to the sepsis group.Then,the demographic,clinical and laboratory data were recorded,and the predictive values of PCT,TEG and PLT count for the development of septic shock were analyzed.Results Compared to the sepsis group,the septic shock group had statistically lower PLT count and TEG measurements in the R value,K value,αangle,maximum amplitude,and coagulation index,but had longer prothrombin time(DT),longer activated partial thromboplastin time(APTT),and higher PCT levels.Furthermore,the Sequential Organ Failure Assessment(SOFA)score was higher in the septic shock group.The multivariate logistic regression analysis revealed that PCT,TEG and PLT count were associated with the development of septic shock.The area under the curve analysis revealed that the combined measurement of PCT,TEG and PLT count can be used to predict the development of septic shock with higher accuracy,when compared to individual measurements.Conclusion The combined measurement of PCT,TEG and PLT count is a novel approach to predict the development of septic shock in high-risk patients.

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.

Impact of heart failure on outcomes in patients with sepsis:A systematic review and meta-analysis

BACKGROUND Heart failure(HF)often affects the progress of sepsis patients,although its impact on outcomes is inconsistent and inconclusive.AIM To conduct a systematic review and meta-analysis of the impact of HF on mortality in patients with sepsis.METHODS PubMed,Embase,Web of Science,and the Cochrane Library databases were searched to compare the outcomes of sepsis patients with HF.A random effect model was used to summarize the mortality data,and the odds ratio(OR)and 95%confidence interval(CI)were calculated as effect indicators.RESULTS Among 18001 records retrieved in the literature search,35712 patients from 10 separate studies were included.The results showed that sepsis patients with HF were associated with increased total mortality(OR=1.80,95%CI:1.34-2.43;I2=92.1%),with high heterogeneity between studies.Significant subgroup differences according to age,geographical location,and HF patient sample were observed.HF did not increase the 1-year mortality of patients(OR=1.11,95%CI:0.75-1.62;I2=93.2%),and the mortality of patients with isolated right ventricular dysfunction(OR=2.32,95%CI:1.29-4.14;I2=91.5%)increased significantly.CONCLUSION In patients with sepsis,HF is often associated with adverse outcomes and mortality.Our results call for more high-quality research and strategies to improve outcomes for sepsis patients with HF.

Meta-analysis effects of levosimendan on mortality and hemodynamics in patients with sepsis

Objective:To investigate the effect of levosimendan on 28-day mortality in patients with sepsis.Methods:The English databases including Embase,PubMed,Web of Science,Cochrane Library and Chinese databasesincluding China National Knowledge Infrastructure(NKI),Wan fang Data,VIP,CBM were searched with levosimendan,sepsis and septic shock is as search terms.The published clinical randomized controlled trials of levosimendan injection were searched and the primary outcome measures of 28-day and 30-day mortality were included.Secondary outcome measures were left ventricular ejection fraction,left ventricular work index,cardiac index,and lactic acid.The literature retrieved is from the establishment of the database to October 2022.Stata 14.0 software was used for all data consolidation,publication bias monitoring and sensitivity analysis.Results:A total of 15 studies with 1337 patients were included in this meta-analysis.The results showed that at the 28-day mortality of patients with sepsis in the levosimendan group was not statistically superior to the 28-day mortality in the control group[RR=0.91,95%CI(0.78~1.06),Z=1.24,P=0.22].However,levosimendan can increase left ventricular ejection fraction,decrease left ventricular function index,increase cardiac index and decrease lactic acid in patients with sepsis.Conclusion:There is insufficient evidence to support a reduction in 28-day mortality in sepsis patients with levosimendan.However,levosimendan showed positive results on hemodynamic parameters,and more clinical trials are needed to verify the application of levosimendan in hemodynamic parameters of sepsis.

Fatal hemophagocytic lymphohistiocytosis-induced multiorgan dysfunction secondary to Burkholderia pseudomallei sepsis: A case report

BACKGROUND Burkholderia pseudomallei(B.pseudomallei)is a short,straight,medium-sized Gramnegative bacterium that mostly exists alone,without a capsule or spores,has more than three flagella at one end,and actively moves.B.pseudomallei confers high morbidity and mortality,with frequent granulocytopenia in B.pseudomallei sepsisrelated deaths.However,mortality may be related to hemophagocytic lymphohistiocytosis(HLH)secondary to B.pseudomallei infection.CASE SUMMARY A 12-year-old female was referred from a local hospital to the pediatric intensive care unit with suspected septic shock and fever,cough,dyspnea,and malaise.After admission,supportive symptomatic treatments including fluid resuscitation,anti-infective therapy,mechanical ventilation,and a vasoactive drug maintenance cycle were carefully initiated.The patient became unconscious,her blood pressure could not be maintained even under the exposure of vasoactive drugs,and she experienced cardiorespiratory arrest.The patient died due to ineffective high-quality in-hospital cardiopulmonary resuscitation.A subsequent bone marrow smear examination revealed extensive phagocytosis,and the blood culture was positive for B.pseudomallei.Family history revealed a sibling death from B.pseudomallei sepsis 5 years earlier.CONCLUSION The higher mortality rate in patients with B.pseudomallei sepsis may be related to secondary HLH after infection,wherein multiorgan dysfunction syndrome may be directly related to infection or immune damage caused by secondary HLH.Patients with B.pseudomallei can be asymptomatic and can become an infective source.

Emerging concepts in the care of patients with cirrhosis and septic shock

Septic shock impacts approximately 6% of hospitalized patients with cirrhosis and is associated with high rates of morbidity and mortality. Although a number of landmark clinical trials have paved the way for incremental improvements in the diagnosis and management of septic shock in the general population, patients with cirrhosis have largely been excluded from these studies and critical knowledge gaps continue to impact the care of these individuals. In this review,we discuss nuances in the care of patients with cirrhosis and septic shock using a pathophysiology-based approach. We illustrate that septic shock may be challenging to diagnose in this population in the context of factors such as chronic hypotension, impaired lactate metabolism, and concomitant hepatic encephalopathy. Furthermore, we demonstrate that the application of routine interventions such as intravenous fluids, vasopressors, antibiotics, and steroids should be carefully considered among those with decompensated cirrhosis in light of hemodynamic, metabolic, hormonal, and immunologic disturbances. We propose that future research should include and characterize patients with cirrhosis in a systematic manner, and clinical practice guidelines may need to be refined accordingly.

The Slippery Slope of Sepsis

Mortality, morbidity, early recognition, and treatment of sepsis remain a diagnostic dilemma for clinicians, in addition, the timely diagnosis of sepsis represents an ongoing clinical challenge. This review looks at the challenges of early recognition, the scope of the problem, the immunologic basis of the sepsis cascade, new frontiers related to interventions, and the role of antibiotics in an era of antimicrobial resistance. In Figure 1, once a patient is on the slippery slope of sepsis, the ability to reverse the momentum is challenging;hoping antibiotics, fluid resuscitation, vasopressors may buy time for the immunologic cascade to equilibrate to its homeostatic balance. While the development of septic shock is much more complex than pathogen proliferation, our understanding of the pathogenesis and ability to therapeutically intervene is in its infancy. Patients with sepsis frequently present for urgent medical care with undifferentiated infection and nonspecific symptoms. As 80% of patients with sepsis are initially treated in an Emergency Department, the burden of early recognition and intervention falls squarely on the shoulders of Emergency Department Clinicians. [1] This is an entity that occurs in all age groups, without regard to race, geography, or health status. Survival and mortality related to this clinical entity are poorly understood. Our understanding of sepsis needs to expand beyond the downstream effects and collateral damage of multiorgan dysfunction and failure. Immunologically, the antigenic triggers, be it invasive infection, severe injury, and systemic inflammation without concomitant infection, elicit similar pattern recognition receptors and innate host responses. If you are lucky enough to have survived an acute episode of sepsis, patients with sepsis often develop new adverse sequelae after treatment, a concept called persistent critical illness or post sepsis syndrome, characterized by long-term disability, and worsening chronic health conditions requiring re-hospitalization. [2]