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.

Osteoarticular Lesions of the Shoulder Girdle by Hippopotamus Bite: Highly Septic Lesion

Hippopotamus bites are rare in medical consultations, despite several studies exposing their aggressive character. A case of a hippopotamus bite on the shoulder of a fisherman has been reported. In addition to the osteoarticular aspect representing a therapeutic problem, the infectious aspect was marked by sepsis, with a death in less than 48 hours. Based on this observation, a protocol for the initial management of large animal bites was submitted.

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.

Native and prosthetic septic arthritis in a university hospital in Saudi Arabia:A retrospective study

BACKGROUND Septic arthritis,whether native or prosthetic,poses a significant challenge in clinical practice due to its potentially devastating consequences.Despite its clinical importance,there remains a dearth of comprehensive studies and standardized diagnostic criteria,particularly in the Kingdom of Saudi Arabia.AIM To investigate the epidemiology,microbiological profiles,and clinical characteristics of native and prosthetic septic joints in the Saudi Arabian population.METHODS Medical records of patients diagnosed with septic arthritis between January 1,2015,and December 31,2022,were retrospectively reviewed.Data regarding patient demographics,clinical presentation,microbiological cultures,treatment modalities,and outcomes were analyzed.RESULTS In a retrospective review of 52 cases of septic arthritis,a balanced gender distribution was observed(1:1 ratio),with the knee being the most commonly affected joint(80.8%).Methicillin-resistant Staphylococcus aureus predominated in native joints(24.2%),while Brucella spp.was more prevalent in prosthetic joints(21.1%).Joint preservation was achieved in most cases(84.6%),with no significant difference in clinical features between native and prosthetic joints.However,certain comorbidities were more common in native joint cases,including renal impairment(P=0.002),hemodialysis(P=0.004),heart disease(P=0.013),and chronic liver disease(P=0.048).At the same time,osteoarthritis was more prevalent in prosthetic joint cases(P=0.013).Vancomycin was the most frequently used antibiotic(26.9%),and most patients received antibiotics before joint aspiration(57.7%).Surgical intervention,predominantly arthrotomy,was required in most cases(32.7%).Notably,a significant association was found between joint type and mortality(odds ratio=0.587,P=0.048),as well as the Charlson comorbidity index and mortality(P=0.001).CONCLUSION This study highlighted distinctive microbiological profiles and etiological factors in septic arthritis cases in the Saudi Arabian population.

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.

Bedside emergency surgical decompression and venoarterial extra-corporeal membrane oxygenation for obstructive uropathy with uroseptic cardiomyopathy-induced arrest:A case report

Background:Septic shock combined with septic cardiomyopathy greatly increases the risk of mortality in elderly patients.Patients with a rapid deteriorating state unresponsive to standard resuscitation may benefit from extra-corporeal membrane oxygenation(ECMO).In cases where obstructive uropathies lead to urosepsis,emergent decompression with double-J(D-J)stenting may be necessitated. Case Presentation:We report the case of a 72-year-old woman who arrived at the emergency department and rapidly deteriorated into a state of shock.During the process of resuscitation,emergent biochemical and ultrasound results suggested septicemia and septic cardiomyopathy due to urinary tract infection caused by ureteric stone obstruction.She was transferred to the intensive care unit to be put on venoarterial ECMO after failed resuscitation.Given the suspected diagnosis,it was decided that an emergent bedside digital disposable flexible ureteroscopy(ddFURS)and D-J catheterization to be performed as rescue decompression procedure.The patient was suc-cessfully stabilized with received antibiotic and continuous renal replace-ment therapy(CRRT)before being transferred to the cardiology department to correct her arrhythmia.She was weaned off CRRT and was able to walk without the need of aids upon discharge. Conclusion:Uroseptic cardiomyopathy can rapidly progress to renal and cardiac failure.Emergent decompression with ddFURS and D-J stenting can be performed effectively even in a patient with venoarterial ECMO for res-cuing uroseptic cardiomyopathy-induced arrest secondary to obstructive uropathy.Short-term outcomes were favorable.However,long-term prog-nosis remains to be elucidated.

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.

Theoretical Analysis of Biogas Production from Septic Tanks: The Case of the City of Kinshasa

As many think that respect for the environment, is not only a question intended for industrialists but has all the sectors of life, in particular sanitary also. In this regard, our article brings alternative management of human waste (excrement) to solve the problems that plague our dear beautiful capital, namely: 1) Lack of latrines that meet the standards;2) Emptying of septic tanks directly into the gutters and;3) Water pollution by sewage csompanies. In order to carry out the cartographic analysis of the study area, we used Shapefile data from the OpenStreetMap, Diva-Gis. These different data allowed us, analyzed, to categorize with the software ArArcGIS 0.8.1 to produce different zones according to the cases incurred in the city of Kinshasa. To do this, the analytical method uses the Buswell equation to determine the amount of gas contained in human excrement. Focusing on the analysis of the excrements produced by the population of age superior to 10 years, for 2023, we obtained: 138355.7283 m3/day of CH4 (885476.66 kWh/day or 885.476 MWh/day), which, energy can light: 138,355 lamps of 60 to 100 W for six hours or nearly 70,000 lamps of 60 to 100 W for 12 hours. Considering the last one which offers the lowest access rate, i.e. 3% of the district population to these latrines, we have: a) In Tshangu, we produce: 1618.762 3>/day (10360.07 kWh/day or 10.36 MWh/day) which can light nearly 1600 lamps from 60 to 100 W for six hours or nearly 800 lamps from 60 to 100 W for twelve hours. b) Mont-Amba, we produce 1402.927 3>/day (8978.73 kWh/day or 8.97 MWh/day) which can light nearly 1400 lamps from 60 to 100 W for six hours or nearly 700 lamps from 60 to 100 W for twelve hours;c) In Lukunga, we produce: 946.35 3>/day (6056.66 kWh/day or 6.056 MWh/day) which can light nearly 900 lamps from 60 to 100 W for six hours or nearly 450 lamps from 60 to 100 W for twelve hours. d) Funa, we produce: 182.629 3>/day (1168.83 kWh/day or 1.17 MWh/day) which can light almost 180 lamps from 60 to 100 W for six hours or almost 90 lamps from 60 to 100 W for twelve hours.

Septic Hip Arthritis at CHU Gabriel TOURE: Therapeutic and Evolutionary Aspects

Introduction: Septic hip arthritis involves the functional prognosis of the hip in case of joint destruction. The aim of this work was to evaluate the hospital frequency, to determine the therapeutic and evolutionary aspects of septic arthritis of the hip at the trauma orthopedic department of CHU Gabriel TOURE Bamako. Methods: This was a descriptive, monocentric, cross-sectional study of patients with septic hip arthritis, managed from January 2010 to December 2019. Results: We collected 48 patients. Gender male was represented 58.3% with a sex ratio of 1.4. The average age of our patients was 17.02, with extremes of 7 and 80. Septic hip arthritis was observed in a chronic mode in 87.5% (more than 3 weeks). Diagnosis was based on clinical, bacteriological and imaging. Trauma was incriminated in 5 cases (10.4%). The radiographic assessment at the time of the consultation was normal in 66.7% of cases. Staphylococcus aureus was the most common germ with 47.9%, and the culture was sterile in 10.4%. Septic hip arthritis was complicated in 18.75% of cases. Antibiotic therapy was probabilistic with the combination of ciprofloxacin and metronidazole in 24 cases (50%). Watson Jones antero-lateral arthrotomy was performed in 35.71%. We observed 66.6% complications. After an average decrease of 41.6 months, functional results were good in 58.3%. Conclusion: Septic hip arthritis is a serious condition of the child and adolescent. Diagnosis must be early;management must also be early, multidisciplinary and adapted to minimize sequelae.

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.

New classification for septic arthritis of the hand

The severity of septic arthritis of the hand and the prospects for restoration of joint function are determined by a complex of factors. Among them, the leading role belongs to local changes in tissue structures. This includes the destruction of articular cartilage and bone tissue with the development of osteomyelitis, the involvement of paraarticular soft tissues in the purulent process, and the destruction of the flexor/extensor tendons of the fingers. The currently missing specialized classification of septic arthritis could help in systematizing the diseases, determining treatment tactics, and predicting the results of treatment.The classification of septic arthritis of the hand proposed for discussion is based on the following principle: Joint-Wound-Tendon(Jx Wx Tx);Jx characterizes damage to the osteochondral structures of the joint, Wx is the presence of paraarticular purulent wounds or fistulas, and Tx is destruction of the flexor/extensor tendons of the finger. The classification of the diagnosis makes it possible to assess the nature and severity of damage to the structures of the joint and may also be useful when comparing the results of treatment of septic arthritis of the hand.

Continuous renal replacement therapy with oXiris®in patients with hematologically malignant septic shock:A retrospective study

BACKGROUND The mortality rate from septic shock in patients with hematological malignancies(HMs)remains significantly higher than that in patients without HMs.A longer resuscitation time would definitely be harmful because of the irreversibly immunocompromised status of the patients.Shortening the resuscitation time through continuous renal replacement therapy(CRRT)with oXiris^(■)would be an attractive strategy in managing such patients.AIM To explore the effects of CRRT and oXiris^(■)in shortening the resuscitation time and modifying the host response by reducing inflammation mediator levels.METHODS Forty-five patients with HM were diagnosed with septic shock and underwent CRRT between 2018 and 2022.Patients were divided into two groups based on the hemofilter used for CRRT(oXiris^(■)group,n=26;M150 group,n=19).We compared the number of days of negative and total fluid balance after 7 d of CRRT between the groups.The heart rate,norepinephrine dose,Sequential Organ Failure Assessment(SOFA)score,and blood lactic acid levels at different time points in the two groups were also compared.Blood levels of inflammatory mediators in the 26 patients in the oXiris^(■)group were measured to further infer the possible mechanism.RESULTS The average total fluid balance after 7 d of CRRT in the oXiris^(■)group was significantly lower than that of patients in the M150 hemofilter group.The SOFA scores of patients after CRRT with oXiris^(■)therapy were significantly lower than those before treatment on day 1(d1),d3 and d7 after CRRT;these parameters were also significantly lower than those of the control group on d7.The lac level after oXiris^(■)therapy was significantly lower than that before treatment on d3 and d7 after CRRT.There were no significant differences in the above parameters between the two groups at the other time points.In the oXiris^(■)group,procalcitonin levels decreased on d7,whereas interleukin-6 and tumor necrosis factor levels decreased significantly on d3 and d7 after treatment.CONCLUSION CRRT with oXiris^(■)hemofilter may improve hemodynamics by reducing inflammatory mediators and playing a role in shortening the resuscitation period and decreasing total fluid balance in the resuscitation phases.

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.

Diagnostic use of superb microvascular imaging in evaluating septic arthritis of the manubriosternal joint:A case report

BACKGROUND Septic arthritis of the manubriosternal joint is a diagnostic challenge due to its rarity and anatomical characteristic.Conventional ultrasound,plain radiographs,and computed tomography are not able to confirm or even suspect arthritis early.Superb microvascular imaging is a new advanced Doppler technique in evaluating low-flow microvascular patterns.The higher sensitivity for increased perisynovial vascularity helps to suspect septic arthritis and forms a methodical approach to using magnetic resonance imaging(MRI).CASE SUMMARY A 34-year-old immunocompetent woman presented with a fever and a dull ache in the chest radiating to the right arm.Traumatic injury and the most common respiratory and cardiac disorders were ruled out.Blood cultures came back positive for Staphylococcus aureus,and sepsis was confirmed.A small lump was noted on the chest during the first week of hospitalization.Superb microvascular imaging was performed and septic arthritis of the manubriosternal joint was detected.MRI confirmed the diagnosis and showed septic arthritis of the manubriosternal joint with several localized abscesses behind the sternum.The patient was treated for three weeks with intravenous antibiotics and the outcome was favorable:Inflammatory markers became normal,and the lump disappeared.Three months later,the patient was examined for a new episode of mild pain in the sternum and was diagnosed with persistent perichondritis by ultrasound in comparison with MRI.CONCLUSION Superb microvascular imaging is a useful tool for the early diagnosis of septic arthritis of the manubriosternal joint and following-up.

Should we initiate vasopressors earlier in patients with septic shock: A mini systemic review

Septic shock treatment remains a major challenge for intensive care units,despite the recent prominent advances in both management and outcomes.Vasopressors serve as a cornerstone of septic shock therapy,but there is still controversy over the timing of administration.Specifically,it remains unclear whether vasopressors should be used early in the course of treatment.Here,we provide a systematic review of the literature on the timing of vasopressor administration.Research was systematically identified through PubMed,Embase and Cochrane searching according to PRISMA guidelines.Fourteen studies met the eligibility criteria and were included in the review.The pathophysiological basis for early vasopressor use was classified,with the exploration on indications for the early administration of mono-vasopressors or their combination with vasopressin or angiotensinII.We found that mortality was 28.1%-47.7%in the early vasopressors group,and 33.6%-54.5%in the control group.We also investigated the issue of vasopressor responsiveness.Furthermore,we acknowledged the subsequent challenge of administration of high-dose norepinephrine via peripheral veins with early vasopressor use.Based on the literature review,we propose a possible protocol for the early initiation of vasopressors in septic shock resuscitation.

Factors associated with subsequent surgery after septic arthritis of the knee in children

BACKGROUND Septic arthritis of the knee in children is a challenging problem.Surgical debridement is an established treatment,but there is a paucity of literature on long-term prognosis.AIM To determine the rates and factors associated with return to surgery(RTS)and readmission after index surgical debridement for septic arthritis of the knee in children.METHODS This is a retrospective cohort study that utilizes data from the Healthcare Cost and Utilization Project(HCUP).We included patients between ages 0 to 18 years that underwent surgical debridement for septic arthritis of the knee between 2005 and 2017.Demographic data included age,gender,race,hospital type and insurance type.Clinical data including index admission length of stay(LOS)and Charlson Comorbidity Index(CCI)were available from the HCUP database.Descriptive statistics were used to summarize the data and univariate and multivariate analyses were performed.RESULTS Nine-hundred thirty-two cases of pediatric septic knee were included.This cohort was 62.3%male,with mean age of 9.0(±6.1)years.Approximately 46%of patients were white and approximately half had Medicaid insurance.Thirty-six patients(3.6%)required RTS at a minimum of 2 year after index surgery,and 172 patients(18.5%)were readmitted at any point.The mean readmission LOS was 11.6(±11.3)d.Higher CCI was associated with RTS(P=0.041).There were no significant associations in age,gender,race,insurance type,or type of hospital to which patients presented.Multivariate analysis showed that both increased CCI(P=0.008)and shorter LOS(P=0.019)were predictive of RTS.CONCLUSION Septic arthritis of the knee is an important condition in children.The CCI was associated with RTS at a minimum of 2 years after index procedure.No association was found with age,gender,race,insurance type,or hospital type.Shorter LOS and CCI were associated with RTS in multivariate analysis.Overall,risk of subsequent surgery and readmission after pediatric septic knee arthritis is low,and CCI and shorter LOS are predictive of RTS.

SEPTIC技术快速检测结核分枝杆菌

目的评价SEPTIC（sensing of phage—triggered ion cascade）技术在结核分枝杆菌快速检测中的应用价值。方法制备纳米阱微芯片，用于检测噬菌体感染细菌时导致细胞内离子释放发生的微范围内的电位变化。调整大肠杆菌、结核分枝杆菌、耻垢分枝杆菌及其相应噬菌体的浓度。将细菌和噬菌体等体积混合，37℃孵育1min。取5μl混合液滴于探针上，30S后开始采集数据，每2min采集一个数据文件，共采集10min，计算机分析采集结果。结果当结核分枝杆菌与分枝杆菌噬菌体D29混合反应时，在0—8min内显示了非常明确的1／f功率谱特征。而且功率谱强度明显高于阴性反应的功率谱，并出现了明确的电压超出±4盯范围的波形，持续约0．2S的时间，可认为发生了一次细菌被噬菌体感染的事件，表明探针明确地捕获了细菌被噬菌体感染的事件。结论SEPTIC技术能在较短时间内检测、鉴定出活菌的存在，有可能为结核分枝杆菌的检测提供一种简便、快捷的方法。

Caval replacement with parietal peritoneum tube graft for septic thrombophlebitis after hepatectomy: A case report

BACKGROUND Caval vein thrombosis after hepatectomy is rare, although it increases mortality and morbidity. The evolution of this thrombosis into a septic thrombophlebitis responsible for persistent septicaemia after a hepatectomy has not been reported to date in the literature. We here report the management of a 54-year-old woman operated for a peripheral cholangiocarcinoma who developed a suppurated thrombophlebitis of the vena cava following a hepatectomy.CASE SUMMARY This patient was operated by left lobectomy extended to segment V with bile duct resection and Roux-en-Y hepaticojejunostomy. After the surgery, she developed Streptococcus anginosus, Escherichia coli, and Enterococcus faecium bacteraemias, as well as Candida albicans fungemia. A computed tomography scan revealed a bilioma which was percutaneously drained. Despite adequate antibiotic therapy,the patient's condition remained septic. A diagnosis of septic thrombophlebitis of the vena cava was made on post-operative day 25. The patient was then operated again for a surgical thrombectomy and complete caval reconstruction with a parietal peritoneum tube graft. Use of the peritoneum as a vascular graft is an inexpensive technique, it is readily and rapidly available, and it allows caval replacement in a septic area. Septic thrombophlebitis of the vena cava after hepatectomy has not been described previously and it warrants being added to the spectrum of potential complications of this procedure.CONCLUSION Septic thrombophlebitis of the vena cava was successfully treated with antibiotic and anticoagulation treatments, prompt surgical thrombectomy and caval reconstruction.

Septic encephalopathy: When cytokines interact with acetylcholine in the brain

Sepsis-associated encephalopathy(SAE) is a brain dysfunction that occurs secondary to infection in the bo characterized by alteration of consciousness, ranging from delirium to coma, seizure or focal neurological signs. S involves a number of mechanisms, including neuroinflammation, in which the interaction between cytokines a acetylcholine results in neuronal loss and alterations in cholinergic signaling. Moreover, the interaction also occurs the periphery, accelerating a type of immunosuppressive state. Although its diagnosis is not specific in biochemis and imaging tests, it could potentiate severe outcomes, including increased mortality, cognitive decline, progress immunosuppression, cholinergic anti-inflammatory deficiency, and even metabolic and hydroelectrolyte imbalan Therefore, the bilateral communication between SAE and the multiple peripheral organs and especially the immu system should be emphasized in sepsis management.