Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021

Adrenal insufficiency in cirrhosis

Hypothalamus-pituitary-adrenal axis assessment in patients with cirrhosis is challenging. The phenotype of fatigue, hypotension, electrolyte disarray, and abdominal pain characterizing primary adrenal insufficiency (AI) overlaps significantly with decompensated liver disease. Reliance on total cortisol assays in hypoproteinemic states is problematic, yet abnormal stimulated levels in cirrhosis are associated with poor clinical outcomes. Alternative measures including free plasma or salivary cortisol levels have theoretical merit but are limited by unclear prognostic significance and undefined cirrhosis-specific reference ranges. Further complicating matters is that AI in cirrhosis represents a spectrum of impairment. Although absolute cortisol deficiency can occur, this represents a minority of cases. Instead, there is an emerging concept that cirrhosis, with or without critical illness, may induce a “relative” cortisol deficiency during times of stress. In addition, the limitations posed by decreased synthesis of binding globulins in cirrhosis necessitate re-evaluation of traditional AI diagnostic thresholds.

Sepsis affects kidney graft function and one-year mortality of the recipients in contrast with systemic inflammatory response

Background

Infections remain a major cause of morbidity and mortality after kidney transplantation. The aim of our study was to determine the effect of sepsis on kidney graft function and recipient mortality.

Methods

A prospective, observational, single-center study was performed. Selected clinical and biochemical parameters were recorded and compared between an experimental group (with sepsis, n = 34) and a control group (with systemic inflammatory response syndrome, n = 31) comprising kidney allograft recipients.

Results

Sepsis worsened both patient (HR = 14.77, p = 0.007) and graft survival (HR = 15.07, p = 0.007). Overall one-year mortality was associated with age (HR = 1.08, p = 0.048), APACHE II score (HR = 1.13, p = 0.035), and combination immunosuppression therapy (HR = 0.1, p = 0.006), while graft survival was associated with APACHE II (HR = 1.25, p = 0.004) and immunosuppression. In sepsis patients, mortality correlated with the maximal dose of noradrenalin (HR = 100.96, p = 0.008), fungal infection (HR = 5.64, p = 0.024), SAPS II score (HR = 1.06, p = 0.033), and mechanical ventilation (HR = 5.97, p = 0.033), while graft survival was influenced by renal replacement therapy (HR = 21.16, p = 0.005), APACHE II (HR = 1.19, p = 0.035), and duration of mechanical ventilation (HR = 1.01, p = 0.015).

Conclusion

In contrast with systemic inflammatory response syndrome, septic kidney allograft injury is associated with early graft loss and may represent a significant risk of mortality.

Clinical decision support improves blood culture collection before intravenous antibiotic administration in the emergency department

OBJECTIVE

Surviving Sepsis guidelines recommend blood cultures before administration of intravenous (IV) antibiotics for patients with sepsis or moderate to high risk of bacteremia. Clinical decision support (CDS) that reminds emergency department (ED) providers to obtain blood cultures when ordering IV antibiotics may lead to improvements in this process measure.

METHODS

This was a multicenter causal impact analysis comparing timely blood culture collections prior to IV antibiotics for adult ED patients 1 year before and after a CDS intervention implementation in the electronic health record. A Bayesian structured time-series model compared daily timely blood cultures collected compared to a forecasted synthetic control. Mixed effects models evaluated the impact of the intervention controlling for confounders.

RESULTS

The analysis included 54 538 patients over 2 years. In the baseline phase, 46.1% had blood cultures prior to IV antibiotics, compared to 58.8% after the intervention. Causal impact analysis determined an absolute increase of 13.1% (95% CI 10.4-15.7%) of timely blood culture collections overall, although the difference in patients with a sepsis diagnosis or who met CDC Adult Sepsis Event criteria was not significant, absolute difference 8.0% (95% CI -0.2 to 15.8). Blood culture positivity increased in the intervention phase, and contamination rates were similar in both study phases.

DISCUSSION

CDS improved blood culture collection before IV antibiotics in the ED, without increasing overutilization.

CONCLUSION

A simple CDS alert increased timely blood culture collections in ED patients for whom concern for infection was high enough to warrant IV antibiotics.

Effectiveness of automated alerting system compared to usual care for the management of sepsis

There is a large body of evidence showing that delayed initiation of sepsis bundle is associated with adverse clinical outcomes in patients with sepsis. However, it is controversial whether electronic automated alerts can help improve clinical outcomes of sepsis. Electronic databases are searched from inception to December 2021 for comparative effectiveness studies comparing automated alerts versus usual care for the management of sepsis. A total of 36 studies are eligible for analysis, including 6 randomized controlled trials and 30 non-randomized studies. There is significant heterogeneity in these studies concerning the study setting, design, and alerting methods. The Bayesian meta-analysis by using pooled effects of non-randomized studies as priors shows a beneficial effect of the alerting system (relative risk [RR]: 0.71; 95% credible interval: 0.62 to 0.81) in reducing mortality. The automated alerting system shows less beneficial effects in the intensive care unit (RR: 0.90; 95% CI: 0.73-1.11) than that in the emergency department (RR: 0.68; 95% CI: 0.51-0.90) and ward (RR: 0.71; 95% CI: 0.61-0.82). Furthermore, machine learning-based prediction methods can reduce mortality by a larger magnitude (RR: 0.56; 95% CI: 0.39-0.80) than rule-based methods (RR: 0.73; 95% CI: 0.63-0.85). The study shows a statistically significant beneficial effect of using the automated alerting system in the management of sepsis. Interestingly, machine learning monitoring systems coupled with better early interventions show promise, especially for patients outside of the intensive care unit.

Changes in Biomarkers and Hemodynamics According to Antibiotic Susceptibility in a Model of Bacteremia

Proper selection of susceptible antibiotics in drug-resistant bacteria is critical to treat bloodstream infection. Although biomarkers that guide antibiotic therapy have been extensively evaluated, little is known about host biomarkers targeting in vivo antibiotic susceptibility. Therefore, we aimed to evaluate the trends of hemodynamics and biomarkers in a porcine bacteremia model treated with insusceptible antibiotics compared to those in susceptible models. Extended-spectrum β-lactamase (ESBL)-producing Escherichia coli (E. coli, 5.0 * 10^9 CFU) was intravenously administered to 11 male pigs. One hour after bacterial infusion, pigs were assigned to two groups of antibiotics, ceftriaxone (n = 6) or ertapenem (n = 5). Pigs were monitored up to 7 h after bacterial injection with fluid and vasopressor support to maintain the mean arterial blood pressure over 65 mmHg. Blood sampling for blood culture and plasma acquisition was performed before and every predefined hour after E. coli injection. Cytokine (tumor necrosis factor-α, interleukin [IL]-1β, IL-6, IL-8, IL-10, C-reactive protein, procalcitonin, presepsin, heparan sulfate, syndecan, and soluble triggering receptor expressed on myeloid cells-1 [sTREM-1]) levels in plasma were analyzed using enzyme-linked immunosorbent assays. Bacteremia developed after intravenous injection of E. coli, and negative conversion was confirmed only in the ertapenem group. While trends of other biomarkers failed to show differences, the trend of sTREM-1 was significantly different between the two groups (P = 0.0001, two-way repeated measures analysis of variance). Among hemodynamics and biomarkers, the sTREM-1 level at post 2 h after antibiotics administration represented a significant difference depending on susceptibility, which can be suggested as a biomarker candidate of in vivo antibiotics susceptibility. Further clinical studies are warranted for validation.

IMPORTANCE Early and appropriate antibiotic treatment is a keystone in treating patients with sepsis. Despite its importance, blood culture which requires a few days remains as a pillar of diagnostic method for microorganisms and their antibiotic susceptibility. Whether changes in biomarkers and hemodynamics indicate treatment response of susceptible antibiotic compared to resistant one is not well understood to date. In this study using extended-spectrum β-lactamase -producing E. coli bacteremia porcine model, we have demonstrated the comprehensive cardiovascular hemodynamics and trends of plasma biomarkers in sepsis and compared them between two groups with susceptible and resistant antibiotics. While other hemodynamics and biomarkers have failed to differ, we have identified that levels of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) significantly differed between the two groups over time. Based on the data in this study, trends of sTREM-1 obtained before the antibiotics and 2~4 h after the antibiotics could be a novel host biomarker that triggers the step-up choice of antibiotics.

Apixaban-Induced Pseudo-Ludwig’s Angina

Ludwig’s angina describes fulminant cellulitis involving the oro- and hypopharynx, which typically stems from bacterial pathogens, whereas “pseudo-Ludwig’s angina” is ascribed to sublingual swelling due to noninfectious causes. There is a paucity of case reports implicating warfarin as the culprit for sublingual hematoma mimicking Ludwig’s angina; however, we describe a novel case of apixaban-induced pseudo-Ludwig’s angina, which was successfully managed with urgent surgical intervention and supportive care with antibiotic and glucocorticoid therapy.

Evaluation of quick sequential organ failure scores in dogs with severe sepsis and septic shock

OBJECTIVES

To evaluate the prognostic utility of the quick sequential organ failure assessment score in dogs with severe sepsis and septic shock presenting to an emergency service, and evaluate the clinical value of the quick sequential organ failure assessment score to predict severe sepsis and septic shock.

MATERIALS AND METHODS

The quick sequential organ failure assessment score was calculated by evaluating respiratory rate (>22 breaths per minute), arterial systolic blood pressure (≤100 mmHg) and altered mentation. The quick sequential organ failure assessment scores with respiratory rate cut-offs of greater than 22, greater than 30 and greater than 40 were compared. Cases were defined as dogs presented to the emergency room and met at least 2 systemic inflammatory response syndrome criteria, had documented infection, and at least one organ dysfunction. A control population of dogs included animals with non-infectious systemic inflammatory response syndrome.

RESULTS

Forty-five dogs with severe sepsis and septic shock and 45 dogs with non-infectious systemic inflammatory response syndrome were included in the final analysis. The quick sequential organ failure assessment provided poor discrimination between survivors and non-survivors for severe sepsis and septic shock (area under receiving operating characteristic curve, 0.51; 95% confidence interval, 0.35 to 0.67). Discrimination remained poor when quick sequential organ failure assessment greater than 30 and quick sequential organ failure assessment greater than 40 scores were calculated (area under receiving operating characteristic curve, 0.56; 95% confidence interval, 0.39 to 0.72, and 0.54; 95% confidence interval, 0.36 to 0.71). The quick sequential organ failure assessment of at least 2, quick sequential organ failure assessment greater than 30 of at least 2 and quick sequential organ failure assessment greater than 40 of at least 2 produced sensitivity and specificity to detect severe sepsis and septic shock of 66.7% and 64.5%, 62.2% and 71.1%, 44.4% and 80%, respectively.

CONCLUSION AND CLINICAL SIGNIFICANCE

Scoring systems utilised in emergency rooms should have high sensitivity to reduce missed sepsis cases and treatment delays. The use of the quick sequential organ failure assessment for severe sepsis and septic shock demonstrated poor mortality prediction and low sensitivity to detect canine patients with severe sepsis and septic shock and should not be used alone when screening for sepsis.

Effects of Early Initiation of High-Dose Dexamethasone Therapy on Pro-Inflammatory Cytokines and Mortality in LPS-Challenged Mice

This study aims to explore the effects of early dexamethasone therapy at low to high doses on the survival and inflammatory responses in lipopolysaccharide (LPS)-challenged mice. We performed two-series experiments to explore the impact of early dexamethasone therapy at different doses (0.5 mg/kg, 1.5 mg/kg, and 5 mg/kg; PO) on pro-inflammatory cytokine levels, including tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6), as well as survival in LPS-treated mice (10 mg/kg, IP). Dexamethasone was administered daily from 24 h before and 5 days after LPS challenge. Dose-dependent improved survival was demonstrated with dexamethasone (p < 0.05). Body weight was significantly decreased within 24 h of LPS injection, with significantly greater weight loss in the dexamethasone groups (p < 0.05). Weight changes were significantly associated with the days after LPS administration (p < 0.01), but not with the dexamethasone dose (p > 0.05). Mice treated with high-dose dexamethasone (5 mg/kg) had a significantly lowered serum TNF-α (134.41 ± 15.83 vs. 408.83 ± 18.32) and IL-6 (22.08 ± 4.34 vs. 91.27 ± 8.56) compared with those without dexamethasone. This study provides essential insights that the suppression of early-phase hyperactivation of pro-inflammatory activities through the early initiation of high-dose dexamethasone therapy increases sepsis-related prognosis.

Relationship Between the Use of Preprinted Physician Orders for Hospital-Acquired Fever and Time to Blood Culture Collection: A Single-Center Retrospective Cross-Sectional Study

Purpose

Fever is relatively common in patients admitted to general wards. There is no standardized approach, and little is known about how physicians respond to fever. Additionally, preprinted physician orders are routinely used clinically in hospital medicine, and it is not clear how preprinted physician orders for fever affect the care of patients with fever. Therefore, we aimed to determine whether preprinted physician orders for inpatients have an effect on the time from fever measurement to blood culture collection.

Patients and Methods

This was a single-center, retrospective, cross-sectional study of patients with bacteremia. Between January 1, 2015 and December 31, 2019, 137 hospitalized febrile patients diagnosed with bacteremia by blood culture prepared from blood collected 72 h after hospitalization were included.

Results

Preprinted physician orders with instructions to call the physician if the patient has a fever were present for 59 patients. For preprinted physician orders with instructions to notify the physician about fever onset, 62.7% of the blood cultures were collected within 1 h of fever observation; when preprinted orders were not used, only 23.1% met the 1-h collection criterion. Multivariate analysis showed that preprinted physician orders were significantly associated with blood culture collection within 1 h from the reporting of fever (odds ratio, 4.94; 95% confidence interval, 2.27–10.70).

Conclusion

Preprinted physician orders with instructions to notify the physician about fever onset were present for only 40% of our sample, and this was related to the time of blood culture collection.

Acutely ill hematology/oncology patients with central-line associated bloodstream infections and the impact of timing of catheter removal on outcomes

BACKGROUND

Hematology/oncology patients are at risk for central line-associated bloodstream infections (CLABSI). The purpose was to determine if infection-related mortality, persistent bacteremia, and recurrent bacteremia were decreased with early central venous catheter (CVC) removal.

METHODS

A case-matched, retrospective cohort study was conducted comparing patients with early catheter removal (≤12 hours) to late catheter removal (>12 hours) in hematology/oncology patients with CLABSI from June 1, 2015 to May 31, 2018. Patients were case-matched based on intensive care unit admission and presence of shock to control for severity of illness.

RESULTS/DISCUSSION

Of 148 patients meeting study inclusion, 128 (86.5%), had their CVC removed during hospitalization (median 11.8 hours). The majority had a hematologic malignancy (90.5%). Following case-matching, 48 patients remained in each group. The primary outcome of infection-related mortality, persistent bacteremia, or recurrent bacteremia occurred more frequently in the late catheter removal group compared to the early catheter removal group although this was not statistically significant (18.8% vs 8.3%, P = .136).

CONCLUSIONS

A lower incidence of infection-related mortality, persistent bacteremia, and recurrent bacteremia was found in patients early catheter removal; however the sample size was not adequate to detect statistical differences. Investigators should continue to evaluate if early catheter removal confers a benefit in a larger patient population.

Top Myths of Diagnosis and Management of Infectious Diseases in Hospital Medicine

Antimicrobial agents are among the most frequently prescribed medications during hospitalization. However, approximately 30% to 50% or more of inpatient antimicrobial use is unnecessary or suboptimal. Herein, we describe 10 common myths of diagnosis and management that often occur in the hospital setting. Further, we discuss supporting data to dispel each of these myths. This analysis will provide hospitalists and other clinicians with a foundation for rational decision-making about antimicrobial use and support antimicrobial stewardship efforts at both the patient and institutional levels.

[Therapeutic drug monitoring and pharmacokinetic models as a strategy for rational antibiotic therapy in intensive care patients]

BACKGROUND AND OBJECTIVE

Antibiotic dosing in intensive care patients is complex due to pharmacokinetic (PK) alterations. The aim of this article is to illustrate the role of therapeutic drug monitoring (TDM) and PK models to individualize antibiotic dosing.

MATERIAL AND METHODS

Guidelines and recommendations are discussed in the context of clinical practice and the prerequisites for routine TDM of different antibiotics are presented. In addition, the benefits and limitations of TDM are discussed. The advantages and disadvantages of TDM and PK models are described and the resulting future options are presented.

RESULTS

In the clinical routine, the peak or trough concentrations of antibiotics in blood are measured depending on the antibiotic class. Prerequisites for a purposeful TDM are a coordinated blood sampling and a prompt reporting of findings. As target ranges are not uniformly defined following rules, dosage adjustments are difficult. The PK models offer a valid possibility to individualize the antibiotic therapy of intensive care patients. Areas of application are the calculation of the loading dose and the combination with TDM for treatment control. For whom and how often TDM is necessary and how it can best be combined with PK models or even replace them should be investigated in the future, in addition to evaluation of the optimal target area.

CONCLUSION

The routine use of TDM for antibiotics in intensive care patients is only effective under the abovementioned conditions. By combination with PK models the treatment could be optimized in the future.

Shock

Shock is a life-threatening condition of circulatory failure that causes an imbalance between cellular oxygen supply and demand resulting in organ dysfunction. It is important to recognize promptly as it is reversible in earlier stages but will transition to an irreversible phase if left untreated. This will result in multiorgan failure and subsequent death. The clinician should therefore consider shock in the differential for all patients with new organ failure. This article will review the pathophysiology, classification, evaluation, and management of shock.

Nursing Implications of the Updated 2021 Surviving Sepsis Campaign Guidelines

Sepsis is a life-threatening illness that affects millions of people worldwide. Early recognition and timely treatment are essential for decreasing mortality from sepsis. The Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021, the fifth iteration of the guidelines, was released in October 2021 and includes 93 recommendations for the management of sepsis. The evidence-based guidelines include recommendations and rationales for screening and early treatment, initial resuscitation, mean arterial pressure targets, admission to intensive care, management of infection, hemodynamic monitoring, ventilation, and additional therapies. A new section addresses long-term outcomes and goals of care. This article presents several recommendations, changes, and updates in the 2021 guidelines and highlights the important contributions nurses have in delivering timely and evidence-based care to patients with sepsis. Recommendations may be for or against an intervention, according to the evidence. Although many recommendations are unchanged, several new recommendations directly affect nursing care and may require specialized training (eg, venovenous extracorporeal membrane oxygenation). The newest section, long-term outcomes and goals of care, is aimed at using available resources to provide care that is aligned with the patient and the patient's family through goals-of-care discussions and shared decision-making. Interventions aimed at improving recovery across the continuum of care should include attention to long-term outcomes. Nurses are essential in identifying patients with sepsis, administering and assessing response to treatment, supporting the patient and family, and limiting sequelae from sepsis. This article highlights the 2021 recommendations that influence nursing care for patients with sepsis.

Surviving Sepsis Guideline–Directed Fluid Resuscitation: An Assessment of Practice Patterns and Impact on Patient Outcomes

IMPORTANCE:

Aggressive fluid resuscitation remains a cornerstone of the Surviving Sepsis Campaign (SSC) guidelines, but there is growing controversy regarding the recommended 30 mL/kg IV fluid dosage. It is contended that, in selected patients, this volume confers an increased risk of volume overload without either concomitant benefit or strong evidence in support of the recommended IV fluid dosage.

OBJECTIVES:

Assessment of practice patterns and their impact on patient outcomes following the surviving sepsis guidelines for fluid resuscitation.

DESIGN:

Large, multisite retrospective cohort study.

SETTING AND PARTICIPANTS:

The retrospective study included all adult patients who presented to the emergency department at one of 19 different Mayo Clinic sites throughout the Midwest, Southeast, and Southwest from August 2018 to November 2020 with suspected sepsis.

MAIN OUTCOMES AND MEASURES:

Eight-thousand four-hundred fourteen patients suspected to have sepsis were assessed regarding fluid resuscitation and outcomes among patients receiving 30 mL/kg IV fluid dosing compared with patients who did not. Patient demographics and clinical information were collected via electronic health records. Patients were divided into two cohorts: those who received 0–29.9 mL/kg of IV fluid and those who received 30.0+ mL/kg of IV fluid. Statistical analyses were performed to evaluate the impact of fluid dose on in-hospital death, 30-day mortality, ICU admission after diagnosis, dialysis initiation after diagnosis, ventilator use, vasopressor use, as well as ICU and hospital length of stay.

RESULTS:

We observed lower in-hospital mortality and 30-day mortality risk in the 30+ mL/kg dosing group. Increased fluid dosage did, however, carry a much greater chance of ICU admission. Most patients (72% after propensity score weighting) in our population received less than 30 mL/kg fluid (based on ideal body weight).

CONCLUSIONS AND RELEVANCE:

IV fluid dosing for sepsis resuscitation greater than 30 mL/kg was associated with decreased risk of in-hospital mortality, 30-day mortality, and reduced risk of requiring mechanical ventilation. Our data does ultimately seem to support the SSC recommendation.

Vasopressor Administration via Peripheral Intravenous Access for Emergency Department Stabilization in Septic Shock Patients

Background

Septic shock is commonly treated in the emergency department (ED) with vasopressors. Prior data have shown that vasopressor administration through a peripheral intravenous line (PIV) is feasible.

Objectives

To characterize vasopressor administration for patients presenting to an academic ED in septic shock.

Materials and methods

Retrospective observational cohort study evaluating initial vasopressor administration for septic shock. ED patients from June 2018 to May 2019 were screened. Exclusion criteria included other shock states, hospital transfers, or heart failure history. Patient demographics, vasopressor data, and length of stay (LOS) were collected. Cases were grouped by initiation site: PIV, ED placed central line (ED-CVL), or tunneled port/indwelling central line (Prior-CVL).

Results

Of the 136 patients identified, 69 were included. Vasopressors were initiated via PIV in 49%, ED-CVL in 25%, and prior-CVL in 26%. The time to initiation was 214.8 minutes in PIV and 294.7 minutes in ED-CVL (p = 0.240). Norepinephrine predominated all groups. No extravasation or ischemic complications were identified with PIV vasopressor administration. Twenty-eight-day mortality was 20.6% for PIV, 17.6% for ED-CVL, and 61.1% for prior-CVL. Of 28-day survivors, ICU LOS was 4.44 for PIV and 4.86 for ED-CVL (p = 0.687), while vasopressor days were 2.26 for PIV and 3.14 for ED-CVL (p = 0.050).

Conclusion

Vasopressors are being administered via PIVs for ED septic shock patients. Norepinephrine comprised the majority of initial PIV vasopressor administration. There were no documented episodes of extravasation or ischemia. Further studies should look at the duration of PIV administration with potential avoidance of central venous cannulation altogether in appropriate patients.

How to cite this article

Kilian S, Surrey A, McCarron W, Mueller K, Wessman BT. Vasopressor Administration via Peripheral Intravenous Access for Emergency Department Stabilization in Septic Shock Patients. Indian J Crit Care Med 2022;26(7):811-815.

Sepsis and the Heart: More to Learn

How to cite this article: Samavedam S. Sepsis and the Heart: More to Learn. Indian J Crit Care Med 2022;26(7):775-777.

Safety and risk of febrile recurrence after early antibiotic discontinuation in high-risk neutropenic patients with haematological malignancies: a multicentre observational study

BACKGROUND

Early antibiotic discontinuation according to the Fourth European Conference on Infections in Leukaemia (ECIL-4) recommendations is not systematically applied in high-risk neutropenic patients with haematological malignancies.

METHODS

A retrospective multicentre observational study was conducted over 2 years to evaluate the safety of early antibiotic discontinuation for fever of unknown origin (FUO) during neutropenia after induction chemotherapy or HSCT, in comparison with a historical cohort. We used Cox proportional hazards models, censored on neutropenia resolution, to analyse factors associated with febrile recurrence.

RESULTS

Among 147 included patients in the ECIL-4 cohort, mainly diagnosed with acute leukaemia (n = 104, 71%), antibiotics were discontinued during 170 post-chemotherapy neutropenic episodes. In comparison with the historical cohort of 178 episodes of neutropenia without antibiotic discontinuation, no significant differences were observed regarding febrile recurrences [71.2% (121/170) versus 71.3% (127/178), P = 0.97], admission in ICUs [6.5% (11/170) versus 11.2% (20/178), P = 0.17], septic shock [0.6% (1/170) versus 3.9% (7/178), P = 0.07] and 30 day mortality [1.4% (2/147) versus 2.7% (4/150), P = 0.084]. In the ECIL-4 cohort, the rate of bacteraemia in case of febrile recurrence was higher [27.1% (46/170) versus 11.8% (21/178), P < 0.01] and antibiotic consumption was significantly lower (15.5 versus 19.9 days, P < 0.001). After early antibiotic discontinuation according to ECIL-4 recommendations, enterocolitis was associated with febrile recurrence [HR = 2.31 (95% CI = 1.4-3.8), P < 0.001] and stage III-IV oral mucositis with bacteraemia [HR = 2.26 (95% CI = 1.22-4.2), P = 0.01].

CONCLUSIONS

After an FUO episode in high-risk neutropenia, compliance with ECIL-4 recommendations for early antibiotic discontinuation appears to be safe and mucosal damage was associated with febrile recurrence and bacteraemia. Prospective interventional studies are warranted to assess this strategy in high-risk neutropenic patients.

Chasing the Ghost: Hyperinflammation Does Not Cause Sepsis

Sepsis is infection sufficient to cause illness in the infected host, and more severe forms of sepsis can result in organ malfunction or death. Severe forms of Coronavirus disease-2019 (COVID-19), or disease following infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are examples of sepsis. Following infection, sepsis is thought to result from excessive inflammation generated in the infected host, also referred to as a cytokine storm. Sepsis can result in organ malfunction or death. Since COVID-19 is an example of sepsis, the hyperinflammation concept has influenced scientific investigation and treatment approaches to COVID-19. However, decades of laboratory study and more than 100 clinical trials designed to quell inflammation have failed to reduce sepsis mortality. We examine theoretical support underlying widespread belief that hyperinflammation or cytokine storm causes sepsis. Our analysis shows substantial weakness of the hyperinflammation approach to sepsis that includes conceptual confusion and failure to establish a cause-and-effect relationship between hyperinflammation and sepsis. We conclude that anti-inflammation approaches to sepsis therapy have little chance of future success. Therefore, anti-inflammation approaches to treat COVID-19 are likewise at high risk for failure. We find persistence of the cytokine storm concept in sepsis perplexing. Although treatment approaches based on the hyperinflammation concept of pathogenesis have failed, the concept has shown remarkable resilience and appears to be unfalsifiable. An approach to understanding this resilience is to consider the hyperinflammation or cytokine storm concept an example of a scientific paradigm. Thomas Kuhn developed the idea that paradigms generate rules of investigation that both shape and restrict scientific progress. Intrinsic features of scientific paradigms include resistance to falsification in the face of contradictory data and inability of experimentation to generate alternatives to a failing paradigm. We call for rejection of the concept that hyperinflammation or cytokine storm causes sepsis. Using the hyperinflammation or cytokine storm paradigm to guide COVID-19 treatments is likewise unlikely to provide progress. Resources should be redirected to more promising avenues of investigation and treatment.

Treatment of Hyperlactatemia in Acute Circulatory Failure Based on CO2-O2-Derived Indices: Study Protocol for a Prospective, Multicentric, Single, Blind, Randomized, Superiority Study (The LACTEL Study)

Background

Hyperlactatemia is a biological marker of tissue hypoperfusion with well-known diagnostic, prognostic, and therapeutic implications in shock states. In daily clinical practice, it is difficult to find out the exact mechanism underlying hyperlactatemia. Central venous to arterial CO₂ difference (pCO₂ gap) is a better parameter of tissue hypoperfusion than the usual ones (clinical examination and mixed venous saturation). Furthermore, the ratio between the pCO₂ gap and p(v–a)CO₂/C(a–v)O₂ may be a promising indicator of anaerobic metabolism, allowing for the identification of different causes of tissue hypoxia and hyperlactatemia. The main aim of the study is to demonstrate that initial hemodynamic resuscitation based on an algorithm integrating the pCO₂ gap and p(v–a)CO₂/C(a–v)O₂ ratio vs. usual clinical practice in acute circulatory failure improves lactate clearance.

Methods

LACTEL is a randomized, prospective, multicentric, controlled study. It compares the treatment of hyperlactatemia using an algorithm based on the pCO₂ gap and P(v–a)CO₂/C(a–v)O₂ ratio vs. usual clinical practice in acute circulatory failure. A total of 90 patients were enrolled in each treatment group. The primary endpoint is the number of patients with a lactate clearance of more than 10% 2 h after inclusion. Lactate levels were monitored during the first 48 h of treatment as hemodynamic parameters, biological markers of organ failure, and 28-day mortality.

Discussion

pCO₂ derivate indices may be of better interest than routine clinical indices to differentiate causes of hyperlactatemia and diagnose anaerobiosis. LACTEL results will provide clinical insights into the role of these indices in the early hemodynamic management of acute circulatory failure in the ICU.

Clinical Trial Registration

www.clinicaltrials.gov; identifier: NCT05032521.

Is Prehospital Assessment of qSOFA Parameters Associated with Earlier Targeted Sepsis Therapy? A Retrospective Cohort Study

BACKGROUND

This study aimed to determine whether prehospital qSOFA (quick sequential organ failure assessment) assessment was associated with a shortened 'time to antibiotics' and 'time to intravenous fluid resuscitation' compared with standard assessment.

METHODS

This retrospective study included patients who were referred to our Emergency Department between 2014 and 2018 by emergency medical services, in whom sepsis was diagnosed during hospitalization. Two multivariable regression models were fitted, with and without qSOFA parameters, for 'time to antibiotics' (primary endpoint) and 'time to intravenous fluid resuscitation'.

RESULTS

In total, 702 patients were included. Multiple linear regression analysis showed that antibiotics and intravenous fluids were initiated earlier if infections were suspected and emergency medical services involved emergency physicians. A heart rate above 90/min was associated with a shortened time to antibiotics. If qSOFA parameters were added to the models, a respiratory rate ≥ 22/min and altered mentation were independent predictors for earlier antibiotics. A systolic blood pressure ≤ 100 mmHg and altered mentation were independent predictors for earlier fluids. When qSOFA parameters were added, the explained variability of the model increased by 24% and 38%, respectively (adjusted R² 0.106 versus 0.131 for antibiotics and 0.117 versus 0.162 for fluids).

CONCLUSION

Prehospital assessment of qSOFA parameters was associated with a shortened time to a targeted sepsis therapy.

Extracorporeal immune cell therapy of sepsis: ex vivo results

BACKGROUND

Immune cell dysfunction plays a central role in sepsis-associated immune paralysis. The transfusion of healthy donor immune cells, i.e., granulocyte concentrates (GC) potentially induces tissue damage via local effects of neutrophils. Initial clinical trials using standard donor GC in a strictly extracorporeal bioreactor system for treatment of septic shock patients already provided evidence for beneficial effects with fewer side effects, by separating patient and donor immune cells using plasma filters. In this ex vivo study, we demonstrate the functional characteristics of a simplified extracorporeal therapy system using purified granulocyte preparations.

METHODS

Purified GC were used in an immune cell perfusion model prefilled with human donor plasma simulating a 6-h treatment. The extracorporeal circuit consisted of a blood circuit and a plasma circuit with 3 plasma filters (PF). PF1 is separating the plasma from the patient's blood. Plasma is then perfused through PF2 containing donor immune cells and used in a dead-end mode. The filtrated plasma is finally retransfused to the blood circuit. PF3 is included in the plasma backflow as a redundant safety measure. The donor immune cells are retained in the extracorporeal system and discarded after treatment. Phagocytosis activity, oxidative burst and cell viability as well as cytokine release and metabolic parameters of purified GCs were assessed.

RESULTS

Cells were viable throughout the study period and exhibited well-preserved functionality and efficient metabolic activity. Course of lactate dehydrogenase and free hemoglobin concentration yielded no indication of cell impairment. The capability of the cells to secret various cytokines was preserved. Of particular interest is equivalence in performance of the cells on day 1 and day 3, demonstrating the sustained shelf life and performance of the immune cells in the purified GCs.

CONCLUSION

Results demonstrate the suitability of a simplified extracorporeal system. Furthermore, granulocytes remain viable and highly active during a 6-h treatment even after storage for 3 days supporting the treatment of septic patients with this system in advanced clinical trials.

First-line Vasopressor Use in Septic Shock and Route of Administration: An Epidemiologic Study

RATIONALE

Norepinephrine is a first-line agent for treatment of hypotension in septic shock. However, its frequency of use, and potential barriers to its use are unclear.

OBJECTIVES

To evaluate the frequency of use of norepinephrine in septic shock, to identify potential barriers to its use, and to evaluate trends in use of vasopressors over time.

METHODS

Retrospective population-based cohort study of patients with septic shock in Alberta, Canada between July 1, 2012 and December 31, 2018. The primary outcome was receipt of a first-line vasopressor other than norepinephrine ("non-norepinephrine vasopressor"). Predictors of receiving a non-norepinephrine vasopressor were assessed using a multivariable-adjusted, multilevel logistic regression model with intensive care unit (ICU) as a random effect.

RESULTS

Among 6343 patients with septic shock, the proportion of patients receiving non-norepinephrine vasopressors as first-line treatment decreased steadily from 11.5% in 2012 to 3.0% in 2018. Two factors most strongly associated with their receipt were having peripheral intravenous access only (adjusted odds ratio (aOR) 6.15, 95% confidence interval (CI) 4.58-8.26, p<0.001) and year of admission (aOR 0.74 per year after 2012, 95% CI 0.69-0.80, p<0.001). Other factors that had associations after adjustment included admission to a non-teaching hospital (aOR 2.19, 95% CI 1.23-3.89, p=0.007), admission to a coronary care unit (aOR 2.56, 95% CI 1.001-6.54, p=0.05), SOFA score (aOR 0.92 per unit increase, 95% CI 0.88-0.96, p<0.001) and heart rate (aOR 0.92 per 10 beat per minute increase, 95% CI 0.87-0.97, p=0.002).

CONCLUSIONS

In a large cohort of patients in Alberta, Canada, we found a steady decrease in use of first-line vasopressors other than norepinephrine in septic shock. The strongest factor associated with their use was the presence of only peripheral venous access, suggesting this may still be considered a barrier to administration of norepinephrine.

Association between Type of Fluid Received Prior to Enrollment, Type of Admission, and Effect of Balanced Crystalloid in Critically Ill Adults: A Secondary Exploratory Analysis of the BaSICS Clinical Trial

Rationale: The effects of balanced crystalloid versus saline on clinical outcomes for ICU patients may be modified by the type of fluid that patients received for initial resuscitation and by the type of admission. Objectives: To assess whether the results of a randomized controlled trial could be affected by fluid use before enrollment and admission type. Methods: Secondary post hoc analysis of the BaSICS (Balanced Solution in Intensive Care Study) trial, which compared a balanced solution (Plasma-Lyte 148) with 0.9% saline in the ICU. Patients were categorized according to fluid use in the 24 hours before enrollment in four groups (balanced solutions only, 0.9% saline only, a mix of both, and no fluid before enrollment) and according to admission type (planned, unplanned with sepsis, and unplanned without sepsis). The association between 90-day mortality and the randomization group was assessed using a hierarchical logistic Bayesian model. Measurements and Main Results: A total of 10,520 patients were included. There was a low probability that the balanced solution was associated with improved 90-day mortality in the whole trial population (odds ratio [OR], 0.95; 89% credible interval [CrI], 0.66-10.51; probability of benefit, 0.58); however, probability of benefit was high for patients who received only balanced solutions before enrollment (regardless of admission type, OR, 0.78; 89% CrI, 0.56-1.03; probability of benefit, 0.92), mostly because of a benefit in unplanned admissions due to sepsis (OR, 0.70; 89% CrI, 0.50-0.97; probability of benefit, 0.96) and planned admissions (OR, 0.79; 89% CrI, 0.65-0.97; probability of benefit, 0.97). Conclusions: There is a high probability that balanced solution use in the ICU reduces 90-day mortality in patients who exclusively received balanced fluids before trial enrollment. Clinical trial registered with www.clinicaltrials.gov (NCT02875873).

Regulation and Dysregulation of Endothelial Permeability during Systemic Inflammation

Systemic inflammation can be triggered by infection, surgery, trauma or burns. During systemic inflammation, an overshooting immune response induces tissue damage resulting in organ dysfunction and mortality. Endothelial cells make up the inner lining of all blood vessels and are critically involved in maintaining organ integrity by regulating tissue perfusion. Permeability of the endothelial monolayer is strictly controlled and highly organ-specific, forming continuous, fenestrated and discontinuous capillaries that orchestrate the extravasation of fluids, proteins and solutes to maintain organ homeostasis. In the physiological state, the endothelial barrier is maintained by the glycocalyx, extracellular matrix and intercellular junctions including adherens and tight junctions. As endothelial cells are constantly sensing and responding to the extracellular environment, their activation by inflammatory stimuli promotes a loss of endothelial barrier function, which has been identified as a hallmark of systemic inflammation, leading to tissue edema formation and hypotension and thus, is a key contributor to lethal outcomes. In this review, we provide a comprehensive summary of the major players, such as the angiopoietin-Tie2 signaling axis, adrenomedullin and vascular endothelial (VE-) cadherin, that substantially contribute to the regulation and dysregulation of endothelial permeability during systemic inflammation and elucidate treatment strategies targeting the preservation of vascular integrity.

Development of Machine-Learning Model to Predict COVID-19 Mortality: Application of Ensemble Model and Regarding Feature Impacts

This study was designed to develop machine-learning models to predict COVID-19 mortality and identify its key features based on clinical characteristics and laboratory tests. For this, deep-learning (DL) and machine-learning (ML) models were developed using receiver operating characteristic (ROC) area under the curve (AUC) and F1 score optimization of 87 parameters. Of the two, the DL model exhibited better performance (AUC 0.8721, accuracy 0.84, and F1 score 0.76). However, we also blended DL with ML, and the ensemble model performed the best (AUC 0.8811, accuracy 0.85, and F1 score 0.77). The DL model is generally unable to extract feature importance; however, we succeeded by using the Shapley Additive exPlanations method for each model. This study demonstrated both the applicability of DL and ML models for classifying COVID-19 mortality using hospital-structured data and that the ensemble model had the best predictive ability.

Why So Salty? Transient Diabetes Insipidus After Discontinuation of Vasopressin

In recent years, vasopressin has been increasingly used as an early treatment of vasopressor-refractory septic shock. In this article, we describe 2 episodes of transient diabetes insipidus after vasopressin for the treatment of septic shock was discontinued, which adds to a modest number of case studies reporting the same phenomenon. With the anticipated continued use of vasopressin in intensive care units, it can be expected that this adverse effect will occur with some frequency. Awareness and early recognition of this phenomenon can lead to prompt diagnosis and treatment.

Effect of fixed-dose hydrocortisone on vasopressor dose and mean arterial pressure in obese and nonobese patients with septic shock

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Several studies have shown hydrocortisone to be beneficial in the treatment of vasopressor-refractory septic shock, but there are minimal data evaluating the efficacy of this fixed dosing regimen in overweight and obese patients. The purpose of this study was to compare the effects of fixed-dose hydrocortisone on vasopressor dose and mean arterial pressure in obese and nonobese patients with septic shock refractory to adequate fluid resuscitation and vasopressor administration.

METHODS

In this multicenter, retrospective study, we included adult patients with a confirmed or suspected diagnosis of septic shock who received hydrocortisone (200 mg/day). Patients were divided into 4 study groups based on admission body mass index (BMI; defined as BMI of <25 kg/m 2, 25-29.9 kg/m 2, 30-34.9 kg/m 2, and ≥35 kg/m 2). The primary outcomes analyzed were change in norepinephrine equivalent dose requirements and mean arterial pressure (MAP) at 6, 12, and 24 hours after initiating hydrocortisone.

RESULTS

Between October 1, 2017, and September 30, 2020, 431 patients were screened of whom 219 met inclusion criteria. Baseline characteristics were comparable among the groups. Mean vasopressor requirements (in ΀g/min) at 6, 12, and 24 hours were as follows: BMI of <25 kg/m 2:  28.8, 24.8, and 20; BMI of 25-29.9 kg/m 2: 34.1, 33.5, and 24.8; BMI of 30-34.9 kg/m 2: 29.5, 33.5, and 24.8; and BMI of ≥35≥kg/m 2: 32, 25.7 and, 21.2 (P = 0.75, 0.41, and 0.61, respectively). Mean MAP (in mm Hg) at 6, 12, and 24 hours was as follows: BMI of <25 kg/m 2:  73.5, 73.6, and 74; BMI of 25-29.9 kg/m 2: 71.6, 73.8, and 71.9; BMI of 30-34.9 kg/m 2: 72.2, 70, and 72.7; and BMI of ≥35 kg/m 2: 70.7, 73.5, and 71.4 (P = 0.56, 0.15, and 0.62, respectively).

CONCLUSION

BMI does not appear to impact the effects of fixed-dose hydrocortisone on vasopressor dose or blood pressure in patients with septic shock. Fixed-dose hydrocortisone should continue to be used for vasopressor-refractory septic shock in obese patients.

Endothelial Activation and Microcirculatory Disorders in Sepsis

The vascular endothelium is crucial for the maintenance of vascular homeostasis. Moreover, in sepsis, endothelial cells can acquire new properties and actively participate in the host's response. If endothelial activation is mostly necessary and efficient in eliminating a pathogen, an exaggerated and maladaptive reaction leads to severe microcirculatory damage. The microcirculatory disorders in sepsis are well known to be associated with poor outcome. Better recognition of microcirculatory alteration is therefore essential to identify patients with the worse outcomes and to guide therapeutic interventions. In this review, we will discuss the main features of endothelial activation and dysfunction in sepsis, its assessment at the bedside, and the main advances in microcirculatory resuscitation.

Improving transitions and outcomes of sepsis survivors (I-TRANSFER): a type 1 hybrid protocol

BACKGROUND

This protocol is based on home health care (HHC) best practice evidence showing the value of coupling timely post-acute care visits by registered nurses and early outpatient provider follow-up for sepsis survivors. We found that 30-day rehospitalization rates were 7 percentage points lower (a 41% relative reduction) when sepsis survivors received a HHC nursing visit within 2 days of hospital discharge, at least 1 more nursing visit the first week, and an outpatient provider follow-up visit within 7 days compared to those without timely follow-up. However, nationwide, only 28% of sepsis survivors who transitioned to HHC received this timely visit protocol. The opportunity exists for many more sepsis survivors to benefit from timely home care and outpatient services. This protocol aims to achieve this goal.  METHODS: Guided by the Consolidated Framework for Implementation Research, this Type 1 hybrid pragmatic study will test the effectiveness of the Improving Transitions and Outcomes of Sepsis Survivors (I-TRANSFER) intervention compared to usual care on 30-day rehospitalization and emergency department use among sepsis survivors receiving HHC. The study design includes a baseline period with no intervention, a six-month start-up period followed by a one-year intervention period in partnership with five dyads of acute and HHC sites. In addition to the usual care/control periods from the dyad sites, additional survivors from national data will serve as control observations for comparison, weighted to produce covariate balance. The hypotheses will be tested using generalized mixed models with covariates guided by the Andersen Behavioral Model of Health Services. We will produce insights and generalizable knowledge regarding the context, processes, strategies, and determinants of I-TRANSFER implementation.

DISCUSSION

As the largest HHC study of its kind and the first to transform this novel evidence through implementation science, this study has the potential to produce new knowledge about the impact of timely attention in HHC to alleviate symptoms and support sepsis survivor's recovery at home. If effective, the impact of this intervention could be widespread, improving the quality of life and health outcomes for a growing, vulnerable population of sepsis survivors. A national advisory group will assist with widespread results dissemination.

Selepressin in Septic Shock

ABSTRACT

Sepsis and septic shock usually show a high mortality rate and frequently need of intensive care unit admissions. After fluid resuscitation, norepinephrine (NE) is the first-choice vasopressor in septic shock patients. However, high-NE doses are associated with increased rates of adverse effects and mortality. In this perspective, many authors have proposed the administration of non-adrenergic vasopressors (NAV). Selepressin is a selective vasopressin type 1A (V1A) receptor agonist and may be a valid option in this field, because it can decrease NE requirements and also limit the deleterious effects induced by high doses of catecholamines. Only few clinical data actually support selepressin administration in this setting. Here, we review the current literature on this topic analyzing some pathophysiological aspects, the rationale about the use of NAV, the possible use of selepressin differentiating animal, and human studies. Various issues remain unresolved and future trials should be focused on early interventions based on a multimodal activation of the vasopressive pathways using both alpha and V1A receptors pathways.

Population pharmacokinetics of ciprofloxacin in critically ill patients receiving extracorporeal membrane oxygenation (an ASAP ECMO study)

INTRODUCTION

This study aimed to describe the pharmacokinetics (PK) of ciprofloxacin in critically ill patients receiving ECMO and recommend a dosing regimen that provides adequate drug exposure.

METHODS

Serial blood samples were taken from ECMO patients receiving ciprofloxacin. Total ciprofloxacin concentrations were measured by chromatographic assay and analysed using a population PK approach with Pmetrics®. Dosing simulations were performed to ascertain the probability of target attainment (PTA) represented by the area under the curve to minimum inhibitory concentration ratio (AUC_0-24/MIC) ≥ 125.

RESULTS

Eight patients were enrolled, of which three received concurrent continuous venovenous haemodiafiltration (CVVHDF). Ciprofloxacin was best described in a two-compartment model with total body weight and creatinine clearance (CrCL) included as significant predictors of PK. Patients not requiring renal replacement therapy generated a mean clearance of 11.08 L/h while patients receiving CVVHDF had a mean clearance of 1.51 L/h. Central and peripheral volume of distribution was 77.31 L and 90.71 L, respectively. ECMO variables were not found to be significant predictors of ciprofloxacin PK. Dosing simulations reported that a 400 mg 8 -hly regimen achieved > 72% PTA in all simulated patients with CrCL of 30 mL/min, 50 mL/min and 100 mL/min and total body weights of 60 kg and 100 kg at a MIC of 0.5 mg/L.

CONCLUSION

Our study reports that established dosing recommendations for critically ill patients not on ECMO provides sufficient drug exposure for maximal ciprofloxacin activity for ECMO patients. In line with non-ECMO critically ill adult PK studies, higher doses and therapeutic drug monitoring may be required for critically ill adult patients on ECMO.

Timely renal replacement therapy linked to better outcome in patients with sepsis-associated acute kidney injury

Background

Recent studies suggest that acute kidney injury (AKI) can be treated with renal replacement therapy (RRT). However, its benefits to patients with sepsis-associated AKI (SA-AKI), which is linked to high mortality and morbidity rates, remain under debate. The aim of this study was to compare the outcomes of different RRT strategies for patients with SA-AKI.

Methods

This retrospective study evaluated patients who were admitted to the hospital with sepsis and developed SA-AKI during hospitalization from 1st January 2014 to 31st January 2019. Mortality, renal recovery, and systemic organ function at 90 days following admission were compared between the RRT group (RG) and non-RRT group (NRG), as well as the early-RRT group (EG) and delayed-RRT group (DG). The groups were defined according to the time from admission to RRT initiation (criterion 1, EG1 and DG1) and Kidney Disease Improving Global Outcomes (KDIGO) classification (criterion 2, EG2 and DG2). Categorical and continuous variables were compared using the chi-squared test or Fisher's exact test and Student's t-test or Wilcoxon test. Kaplan-Meier curves were constructed to determine the unadjusted survival rates for the different subgroups.

Results

A total of 116 patients were included in this study; of those, 38 received RRT and 46 expired within 90 days. Among different strategies of RRT, there were no significant differences found in 90-day mortality (RG vs. NRG: χ²=0.610, P=0.435; EG1 vs. DG1: χ² =0.835, P=0.360; EG2 vs. DG2: χ²=0.022, P=0.899) and renal recovery. However, the values of change in sequential organ failure assessment (ΔSOFA)_max-min of patients in the EG and RG were significantly higher than those recorded in the NRG (ΔSOFA_RG=7.0, ΔSOFA_NRG=3.60, ΔSOFA_EG1=9.00, ΔSOFA_EG2=6.30; P<0.050). Also, the 90-day renal recovery in the EG was better than that noted in the DG with criterion 1 (87.5% vs. 38.5%, respectively, χ²=10.425, P=0.032), suggesting that RRT (especially timely RRT) may be beneficial to the restoration of systemic organ function in patients with SA-AKI.

Conclusion

RRT did not reduce the 90-day mortality among patients with SA-AKI. However, timely RRT may benefit the restoration of systemic organ function, thereby improving the quality of life of patients.

Machine learning to predict vasopressin responsiveness in patients with septic shock

STUDY OBJECTIVES

The objective of this study was to develop and externally validate a model to predict adjunctive vasopressin response in patients with septic shock being treated with norepinephrine for bedside use in the intensive care unit.

DESIGN

This was a retrospective analysis of two adult tertiary intensive care unit septic shock populations.

SETTING

Barnes-Jewish Hospital (BJH) from 2010 to 2017 and Beth Israel Deaconess Medical Center (BIDMC) from 2001 to 2012.

PATIENTS

Two septic shock populations (548 BJH patients and 464 BIDMC patients) that received vasopressin as second-line vasopressor.

INTERVENTION

Patients who were vasopressin responsive were compared with those who were nonresponsive. Vasopressin response was defined as survival with at least a 20% decrease in maximum daily norepinephrine requirements by one calendar day after vasopressin initiation, without a third-line vasopressor.

MEASUREMENTS

Two supervised machine learning models (gradient-boosting machine [XGBoost] and elastic net penalized logistic regression [EN]) were trained in 1000 bootstrap replications of the BJH data and externally validated in the BIDMC data to predict vasopressin responsiveness.

MAIN RESULTS

Vasopressin responsiveness was similar among each cohort (BJH 45% and BIDMC 39%). Mortality was lower for vasopressin responders compared with nonresponders in the BJH (51% vs. 73%) and BIDMC (45% vs. 83%) cohorts, respectively. Both models demonstrated modest discrimination in the training (XGBoost area under receiver operator curve [AUROC] 0.61 [95% confidence interval (CI) 0.61-0.61], EN 0.59 [95% CI 0.58-0.59]) and external validation (XGBoost 0.68 [95% CI 0.63-0.73], EN 0.64 [95% CI 0.59-0.69]) datasets.

CONCLUSION

Vasopressin nonresponsiveness is common and associated with increased mortality. The models' modest performances highlight the complexity of septic shock and indicate that more research will be required before clinical decision support tools can aid in anticipating patient-specific responsiveness to vasopressin.

Guidelines for the choice of intravenous fluids for vascular filling in critically ill patients, 2021

PURPOSE

To provide recommendations for the appropriate choice of fluid therapy for resuscitation of critically ill patients.

DESIGN

A consensus committee of 24 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Emergency Medicine (Société française de médecine d'urgence, SFMU) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Some recommendations were left ungraded.

METHODS

Four fields were defined: patients with sepsis or septic shock, patients with haemorrhagic shock, patients with acute brain failure, and patients during the peripartum period. For each field, the panel focused on two questions: (1) Does the use of colloids, as compared to crystalloids, reduce morbidity and mortality, and (2) Does the use of some specific crystalloids effectively reduce morbidity and mortality. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. The analysis of the literature and the recommendations were then conducted according to the GRADE methodology.

RESULTS

The SFAR/SFMU guideline panel provided nine statements on the appropriate choice of fluid therapy for resuscitation of critically ill patients. After two rounds of rating and various amendments, strong agreement was reached for 100% of the recommendations. Out of these recommendations, two have a high level of evidence (Grade 1 +/-), six have a moderate level of evidence (Grade 2 +/-), and one is based on expert opinion. Finally, no recommendation was formulated for two questions.

CONCLUSIONS

Substantial agreement among experts has been obtained to provide a sizable number of recommendations aimed at optimising the choice of fluid therapy for resuscitation of critically ill patients.

Timing of vasoactive agents and corticosteroid initiation in septic shock

Septic shock remains a health care concern associated with significant morbidity and mortality. The Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock recommend early fluid resuscitation and antimicrobials. Beyond initial management, the guidelines do not provide clear recommendations on appropriate time to initiate vasoactive therapies and corticosteroids in patients who develop shock. This review summarizes the literature regarding time of initiation of these interventions. Clinical data regarding time of initiation of these therapies in relation to shock onset, sequence of treatments with regard to each other, and clinical markers evaluated to guide initiation are summarized. Early-high vasopressor initiation within first 6 h of shock onset is associated with lower mortality. Following norepinephrine initiation, the exact dose and timing of escalation to adjunctive vasopressor agents are not well elucidated in the literature. However, recent data indicate that timing may be an important factor in initiating vasopressors and adjunctive therapies, such as corticosteroids. Norepinephrine-equivalent dose and lactate concentration can aid in determining when to initiate vasopressin and angiotensin II in patients with septic shock. Future guidelines with clear recommendations on the time of initiation of septic shock therapies are warranted.

Adjusting vasopressin availability and formulation: A cost-savings initiative

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

The increase in vasopressin price has required many healthcare systems to consider cost-saving strategies. To combat rising medication costs, our institution changed formulations from 50 units/250 mL to 20 units/100 mL and removed vasopressin from automated dispensing cabinets (ADCs).

Methods

This retrospective review occurred at a 545-bed academic medical center with 97 adult intensive care unit beds. Adult patients receiving a continuous vasopressin infusion were included with no exclusion criteria. A 1-month period was assessed before and after changing the formulation (pre and post groups, respectively). Duplicate bags compounded by pharmacy and bedside teams were also assessed in the pre group. The primary outcome was the estimated annual cost savings due to formulation change with a secondary outcome of estimated annual cost savings due to removal of vasopressin from ADCs. Each 20-unit vial of vasopressin cost $183.21 (wholesale acquisition cost) at the time of the study.

Results

In the pre group, 39 patients requiring a vasopressin infusion were allocated an average of 2 bags each costing $1,099.26 per patient. In the post group, 41 patients required an average of 4 bags each costing $732.84 per patient. With respect to the primary outcome, a savings of $366.42 per patient and an average of 40 patients per month would lead to an annual cost savings of $175,881.60. Secondary outcome analysis identified 9 duplicate bags prepared in the pre group; therefore, removal of vasopressin from ADCs is estimated to provide additional cost savings of $59,360.04. The estimated annual cost savings from both initiatives is $235,241.64.

Conclusion

Changing the vasopressin formulation and removing it from ADCs resulted in a significant cost savings to the health system.

Usefulness of lung ultrasound for early detection of hospital-acquired pneumonia in cardiac critically ill patients on venoarterial extracorporeal membrane oxygenation

Background

Hospital-acquired pneumonia (HAP) is the most common and severe complication in patients treated with venoarterial extracorporeal membrane oxygenation (VA ECMO) and its diagnosis remains challenging. Nothing is known about the usefulness of lung ultrasound (LUS) in early detection of HAP in patients treated with VA ECMO. Also, LUS and chest radiography were performed when HAP was suspected in cardiac critically ill adult VA ECMO presenting with acute respiratory failure. The sonographic features of HAP in VA ECMO patients were determined and we assessed the performance of the lung ultrasound simplified clinical pulmonary score (LUS-sCPIS), the sCPIS and bioclinical parameters or chest radiography alone for early diagnosis of HAP.

Results

We included 70 patients, of which 44 (63%) were independently diagnosed with HAP. LUS examination revealed that color Doppler intrapulmonary flow (P = 0.0000043) and dynamic air bronchogram (P = 0.00024) were the most frequent HAP-related signs. The LUS-sCPIS (area under the curve = 0.77) yielded significantly better results than the sCPIS (area under the curve = 0.65; P = 0.004), while leukocyte count, temperature and chest radiography were not discriminating for HAP diagnosis.

Discussion

Diagnosis of HAP is a daily challenge for the clinician managing patients on venoarterial ECMO. Lung ultrasound can be a valuable tool as the initial imaging modality for the diagnosis of pneumonia. Color Doppler intrapulmonary flow and dynamic air bronchogram appear to be particularly insightful for the diagnosis of HAP.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01013-9.

Blood culture utilization and epidemiology of antimicrobial-resistant bloodstream infections before and during the COVID-19 pandemic in the Indonesian national referral hospital

BACKGROUND

There is a paucity of data regarding blood culture utilization and antimicrobial-resistant (AMR) infections in low and middle-income countries (LMICs). In addition, there has been a concern for increasing AMR infections among COVID-19 cases in LMICs. Here, we investigated epidemiology of AMR bloodstream infections (BSI) before and during the COVID-19 pandemic in the Indonesian national referral hospital.

METHODS

We evaluated blood culture utilization rate, and proportion and incidence rate of AMR-BSI caused by WHO-defined priority bacteria using routine hospital databases from 2019 to 2020. A patient was classified as a COVID-19 case if their SARS-CoV-2 RT-PCR result was positive. The proportion of resistance was defined as the ratio of the number of patients having a positive blood culture for a WHO global priority resistant pathogen per the total number of patients having a positive blood culture for the given pathogen. Poisson regression models were used to assess changes in rate over time.

RESULTS

Of 60,228 in-hospital patients, 8,175 had at least one blood culture taken (total 17,819 blood cultures), giving a blood culture utilization rate of 30.6 per 1,000 patient-days. A total of 1,311 patients were COVID-19 cases. Blood culture utilization rate had been increasing before and during the COVID-19 pandemic (both p < 0.001), and was higher among COVID-19 cases than non-COVID-19 cases (43.5 vs. 30.2 per 1,000 patient-days, p < 0.001). The most common pathogens identified were K. pneumoniae (23.3%), Acinetobacter spp. (13.9%) and E. coli (13.1%). The proportion of resistance for each bacterial pathogen was similar between COVID-19 and non-COVID-19 cases (all p > 0.10). Incidence rate of hospital-origin AMR-BSI increased from 130.1 cases per 100,000 patient-days in 2019 to 165.5 in 2020 (incidence rate ratio 1.016 per month, 95%CI:1.016-1.017, p < 0.001), and was not associated with COVID-19 (p = 0.96).

CONCLUSIONS

In our setting, AMR-BSI incidence and etiology were similar between COVID-19 and non-COVID-19 cases. Incidence rates of hospital-origin AMR-BSI increased in 2020, which was likely due to increased blood culture utilization. We recommend increasing blood culture utilization and generating AMR surveillance reports in LMICs to inform local health care providers and policy makers.