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

Prospective study on time-to-tertiary care in alcohol-associated hepatitis: space-time coordinates as prognostic tool and therapeutic target

BACKGROUND AND AIMS

Alcohol-associated hepatitis (AH) frequently triggers acute decompensation (AD) in cirrhosis, with severe AH linked to high short-term mortality, especially in acute-on-chronic liver failure. Current corticosteroid treatments have limited efficacy, highlighting the need for new therapies. We hypothesized that severe AH outcomes are influenced by early specialized care; thus, we examined the impact of time-to-tertiary care (TTTc).

METHODS

Adults with cirrhosis or advanced chronic liver disease were enrolled (RH7, NCT04767945). AH was diagnosed using National Institute on Alcohol Abuse and Alcoholism criteria. Primary admission site, TTTc, and adverse outcomes (death or liver transplantation) were analyzed. Patients admitted directly to tertiary care were assigned a TTTc of zero.

RESULTS

Of 221 AD-AH patients, 107 were transferred from secondary care to tertiary care (TTTc >0) and 114 were admitted directly (TTTc = 0). TTTc >0 patients were younger (48.3 vs. 52 years, P = .008) and had more severe disease, as shown by model for end-stage liver disease scores (25.5 vs. 20.8, P < .001) and Maddrey's discriminant function (59.3 vs. 40.6, P < .001). Propensity-score matching yielded 49 case pairs. The Cox model showed that transfer from secondary care was not associated with increased risk, but delayed transfer (days, hazard ratio = 1.03, 95% confidence interval 1.01-1.05) independently predicted adverse outcomes.

CONCLUSIONS

Delayed initiation of specialized care adversely impacts outcomes in AD-AH. If validated, timely care bundles could improve AH survival, similar to sepsis or vascular syndromes.

HIGHLIGHTS

AD-AH is a common syndrome associated with high short-term mortality. There is an unmet need for new prognosis-modifying therapies for AH. Currently, in real-life hepatology, refining the existing bundle of care is the only practical option to improve the prognosis of AD-AH. Past experience with acute coronary syndromes, stroke, and sepsis, emphasizing symptoms-to-intervention duration, combined with the recent COVID-19 lockdown finding of increased mortality due to skewed access to specialized liver care indicates that focusing on timely specialized care might be key to improved outcome in certain liver conditions. In this line, we set out to track the number of days elapsing between admission to SC and referral to TC, coining this interval as "time-to-tertiary care" (TTTc). We examined TTTc as a potential compound surrogate that might influence the prognosis in AD-AH. After correcting for important baseline differences, we conclude that the delay of transfer to the tertiary care hospital was independently associated with a worse prognosis with each additional day in TTTc increasing adverse outcomes by nearly 3%.

Hospitalised older adults with community-acquired pneumonia and sepsis have dysregulated neutrophil function but preserved glycolysis

OBJECTIVE

Community-acquired pneumonia (CAP) is a leading cause of hospitalisation in older adults and is associated with a high likelihood of adverse outcomes. Given the ageing population and lack of therapeutic advances in CAP, new strategies to manage the burden of this disease are needed. Neutrophil dysfunction has been widely demonstrated in CAP and is associated with poor outcomes. We hypothesised that impaired glycolytic metabolism was driving neutrophil dysfunction in older adults with CAP.

METHODS

To investigate the mechanism underlying neutrophil dysfunction in CAP, we recruited older adults with CAP and sepsis, age-matched controls and healthy young adults to assess neutrophil function and glycolytic metabolism in peripheral blood neutrophils.

RESULTS

We demonstrate that neutrophils from older donors with CAP display a broad range of functional defects, including inaccurate migration to interleukin 8, impaired respiratory burst in response to phorbol 12-myristate 13-acetate and increased spontaneous degranulation compared with age-matched controls. Glycolysis (assessed by extracellular flux and RNA-sequencing) was not significantly altered between age-matched groups; however, basal rates of neutrophil glycolysis were significantly higher in patients with CAP and older adult controls compared with healthy young adults, and stimulated glycolysis was significantly higher in young adults compared with older adults with and without CAP.

CONCLUSIONS

Our findings suggest that neutrophil dysfunction in older adults with CAP may be implicated in poor outcomes, irrespective of glycolytic metabolism.

Clinical evaluation of a multiplex droplet digital PCR for diagnosing suspected bloodstream infections: a prospective study

Background

Though droplet digital PCR (ddPCR) has emerged as a promising tool for early pathogen detection in bloodstream infections (BSIs), more studies are needed to support its clinical application widely due to different ddPCR platforms with discrepant diagnostic performance. Additionally, there is still a lack of clinical data to reveal the association between pathogen loads detected by ddPCR and corresponding BSIs.

Methods

In this prospective study, 173 patients with suspected BSIs were enrolled. A multiplex ddPCR assay was used to detect 18 pathogens. The results of ddPCR testing were evaluated in comparison with blood cultures (BCs) and clinical diagnosis. Taking BC as the gold standard, receiver operating characteristic curve and Cohen's kappa agreement were used to investigate whether the pathogen load could predict a corresponding culture-proven BSI for the top five microorganisms detected by ddPCR.

Results

Of the 173 blood samples collected, BC and ddPCR were positive in 48 (27.7%) and 92 (53.2%) cases, respectively. Compared to BC, the aggregate sensitivity and specificity for ddPCR were 81.3% and 63.2%, respectively. After clinical adjudication, the sensitivity and specificity of ddPCR increased to 88.8% and 86.0%, respectively. There were 143 microorganisms detected by ddPCR. The DNA loads of these microorganisms ranged from 30.0 to 3.2×105 copies/mL (median level: 158.0 copies/mL), 72.7% (104/143) of which were below 1,000 copies/mL. Further, statistical analysis showed the DNA loads of Escherichia coli (AUC: 0.954, 95% CI: 0.898-1.000, κ=0.731, cut-off values: 93.0 copies/mL) and Klebsiella pneumoniae (AUC: 0.994, 95% CI: 0.986-1.000, κ=0.834, cut-off values: 196.5 copies/mL) were excellent predictors for the corresponding BSIs. The DNA loads of Pseudomonas aeruginosa (AUC: 0.816, 95% CI: 0.560-1.000, κ=0.167), Acinetobacter baumannii (AUC: 0.728, 95% CI: 0.195-1.000), and Enterococcus spp. (AUC: 0.282, 95% CI: 0.000-0.778) had little predictive value for the corresponding culture-proven BSIs.

Conclusion

Our results indicate that the multiplex ddPCR is a promising platform as a complementary add-on to conventional BC. The DNA loads of E. coli and K. pneumoniae present excellent predictive value for the corresponding BSIs. Further research is needed to explore the predictive potential of ddPCR for other microorganisms.

Urinary biomarkers for diagnosing acute kidney injury in sepsis in the emergency department

Background

Development of acute kidney injury (AKI) in patients with sepsis is associated with increased mortality, highlighting the importance of early detection and management. However, baseline creatinine or urine output measurements are required for AKI diagnosis, which can be challenging in emergency departments (EDs). We aimed to evaluate the association between urinary biomarkers and the AKI diagnosis or 30-day survival status in patients with sepsis in the ED.

Methods

This prospective observational study enrolled patients from a single ED. We enrolled adult patients presenting to the ED with symptoms suggestive of infection and an initial quick sequential organ failure assessment score ≥2. Initial urine samples were collected, and urinary biomarkers (dickkopf-3, soluble triggering receptor expressed on myeloid cells-1, kidney injury molecule-1, neutrophil gelatinase-associated lipocalin (NGAL), and tissue inhibitor of metalloproteinases-2 (TIMP-2), and insulin-like growth factor binding protein-7 (IGFBP-7), and TIMP-2 × IGFBP-7) were analyzed using an enzyme-linked immunosorbent assay kit. Multivariable logistic regression models were used to evaluate biomarker performance.

Results

Of 84 patients, 63 (75.0 %) were diagnosed with AKI and 16 (19.0 %) died within 30 days. None of the urinary biomarkers demonstrated significant differences between the survivors and non-survivors. NGAL (p = 0.014) and TIMP-2 × IGFBP-7 (p = 0.027) levels were different between the AKI and non-AKI groups. The multivariable logistic regression model suggested a higher area under the receiver operating characteristic curve for models, including TIMP-2 × IGFBP-7 (from 0.853 to 0.889, p = 0.018).

Conclusion

None of the urinary biomarkers in the initial urine sample demonstrated an independent association with AKI diagnosis or 30-day survival status in patients with sepsis presenting to the ED. Further studies with larger population are necessary to confirm its clinical utility and explore its role.

Systemic inflammatory response index improves prognostic predictive value in intensive care unit patients with sepsis

Sepsis is a severe infectious disease with high mortality. However, the indicators used to evaluate its severity and prognosis are relatively complicated. The systemic inflammatory response index (SIRI), a new inflammatory indicator, has shown good predictive value in chronic infection, stroke, and cancer. The purpose of this study was to investigate the connection between sepsis and SIRI and evaluate its predictive usefulness. A total of 401 patients with sepsis were included in this study. Multiple linear regression and logistic regression analyses were performed to evaluate the relationship between SIRI and sepsis. The restricted cubic spline (RCS) method was employed to illustrate the dose-response relationship. The area under the curve (AUC) and decision curve analysis (DCA) were used to evaluate the prognostic value of SIRI. Multiple linear regression analysis revealed a significant positive correlation between SIRI and both blood cell count and Sequential Organ Failure Assessment (SOFA) score. Additionally, higher SIRI levels were significantly linked to a higher risk of sepsis worsening, according to logistic regression analysis. The RCS curve demonstrated that the risk of poor prognosis rose with increasing SIRI, particularly when SIRI exceeded 6.1. Furthermore, AUC and DCA results showed that SIRI had superior predictive value compared to traditional indicators. A higher SIRI is linked to a worse prognosis and more severe sepsis. SIRI may serve as a novel prognostic indicator in sepsis, though further clinical studies are necessary to confirm these findings.

Critical reflection on the indication for computed tomography: an interdisciplinary survey of risk and benefit management in patients with sepsis

OBJECTIVES

To survey physicians' views on the risks and benefits of computed tomography (CT) in the management of septic patients and indications for and contraindications to contrast media use in searching for septic foci.

METHODS

A web-based questionnaire was administered to physicians at a large European university medical center in January 2022. A total of 371 questionnaires met the inclusion criteria and were analyzed with physicians' work experience, workplace, and medical specialty as independent variables. Chi-square tests were used for exploratory analysis.

RESULTS

While physicians with all levels of work experience were included, the largest group (35.0%, n = 130/371) had 3-7 years of experience. Most physicians agreed that the benefits of CT outweigh its potential adverse effects in septic patients (90.5%, n = 336/371). Responders saw the strongest indication for contrast media administration in septic patients for (1) CT examinations of the abdomen (92.7%, n = 333/359) and (2) combined CT examinations of the chest, abdomen, and pelvis (94.1%, n = 337/358). While radiologists were most likely to consider manifest hyperthyroidism an absolute contraindication to contrast media administration (43.8%, n = 14/32), most other groups of physicians opted for appropriate preparation before contrast media administration in this subset of septic patients.

CONCLUSION

In this survey, most participating physicians considered CT an essential diagnostic modality to detect an infectious focus in septic patients. Whereas the risk of ionizing radiation was regarded as justifiable by most physicians, different specialties varied in their assessment of the risks of contrast media administration.

KEY POINTS

Physicians recognize CT as a relevant imaging modality in the diagnostic management of patients with sepsis. There is an interdisciplinary consensus that the use of ionizing radiation is justified in septic patients. There is disagreement about indications for and contraindications to contrast media administration among physicians from different medical specialties.

To Hemoadsorb or Not to Hemoadsorb-Do We Have the Answer Yet? An Updated Meta-Analysis on the Use of CytoSorb in Sepsis and Septic Shock

Severe inflammation leading to organ dysfunction is the cornerstone of the pathophysiology of sepsis. Thus, from a theoretical point of view, rebalancing inflammation has the potential to improve patient outcomes.

METHODS

To better understand the clinical effectiveness of hemoadsorption in managing inflammation, we conducted an updated meta-analysis on the effects of CytoSorb in critically ill septic patients. Ten studies containing 715 patients (355 in the interventional group and 360 in the control group) have been included in the final analysis.

RESULTS

Statistical analysis demonstrated that the use of CytoSorb did not influence overall mortality (OR 0.95, 95% CI [0.58, 1.56], p = 0.85), but we observed a decreased mortality when comparing CytoSorb-treated patients with patients in the control group treated with continuous renal replacement therapy (CRRT) (OR 0.97, 95% CI [0.46, 0.98], p = 0.04). We also observed an increased mortality in patients in whom hemoadsorption was initiated earlier in the treatment course (OR 0.97, 95% CI [0.46, 0.98], p = 0.04). We did not observe any significant difference in either intensive care unit length of stay (p = 0.93) or between end-of-treatment severity scores in the two groups (p = 0.24).

CONCLUSIONS

Although it has a high risk of bias, current evidence does not support the routine use of CytoSorb in critically ill septic patients. The addition of CytoSorb to CRRT may be associated with decreased survival as compared to CRRT alone, but future studies are needed to draw a definitive conclusion.

Fever in the Trauma Bay: A Marker for Greater Risk of Adverse Outcomes

Purpose: Previous work identified a sub-group of trauma patients at risk for bacteremia who presented with signs of infection, including fever. A majority were older adult falls who had early onset bacteremia. Hypothesis: Fever in the trauma bay is associated with a greater risk of adverse outcomes and identifies patients who might benefit from early initiation of interventions for sepsis. Methods: Trauma patients ≥18 years, drawn from a system-wide electronic medical record (EMR) (2017-2020), were included. Fever+ patients (temperature >38°C) were compared with Fever- patients (36°C-38°C). Multi-variable logistic regressions assessed the association of fever status with outcomes. The interaction between fever, age, and outcomes was assessed. Results: A total of 140,647 patients were included from 89 centers. Eight hundred ninety (0.6%) were Fever+ and had worse unadjusted outcomes. After adjustment, Fever+ patients had significantly greater mortality (adjusted odds ratios [aOR], 95% confidence interval: 1.05 [1.04-1.07]), intensive care unit use (1.08 [1.04-1.11]), and ventilator use (1.11 [1.09-1.13]). Fever+ status was associated with a significantly larger aOR of severe sepsis in older versus younger patients (≥65 y: 1.12 [1.11-1.13]; <65 y: 1.04 [1.03-1.05]). Fever+ status was also associated with a significantly larger aOR of bacteremia in older versus younger patients (≥65 y: 1.09 [1.08-1.10]; <65 y: 1.04 [1.03-1.05]). Implications: Although uncommon, fever at presentation is an ominous sign for trauma patients and portends significantly greater risks for bacteremia, sepsis, and mortality. These risks increase with age. These findings suggest older adults who present with fever warrant early aggressive intervention and may sustain injury as a consequence of debility from systemic infection.

Post-mortem diagnosis of septic arthritis by Pasteurella multocida: a case report and literature review of fatal septic arthritis

The diagnosis of septic arthritis remains challenging in the clinical setting, often leading to a suspicion for medical liability. Our purpose is to describe an unusual case of a post-mortem diagnosis of P. multocida fatal septic arthritis, in a healthy 67-year-old woman presenting with pain in the right shoulder. Moreover, a literature review of cases of fatal septic arthritis is provided. The multidisciplinary approach consisted of a forensic autopsy and additional post-mortem analyses (microbiology, biochemical analyses, histopathology, and revision of radiological images) carried out during the prosecutor's investigation for medical liability. A systematic review of the literature was performed to collect cases of fatal septic arthritis and to understand its frequency and characteristics. No clear cause of death was determined after the autopsy, that only highlighted swelling and purulent exudation in the right glenohumeral joint. The microbiological swab performed on the shoulder tested positive for P. multocida, while histopathological and biochemical data were consistent with a sepsis. These results guided the interview with the woman's relatives, until a history of a previous contact with a stray cat emerged. The cause of death was deemed as fatal septic arthritis caused by P. multocida, occurred after cat scratches and bites and only diagnosed post-mortem. The review of the literature provided 15 articles about fatal septic arthritis, only 1 caused by P. multocida, and all with ante-mortem diagnosis. Given the nonspecific symptoms, usually including a localized pain, and the absence of a clear history, e.g. of animal contact, septic arthritis might represent an under-reported clinical and pathological diagnosis, leading to a judicial autopsy for the suspicion for medical liability. The post-mortem examination, following a multidisciplinary approach including integration of the clinical history, microbiological and histopathological analysis, could represent the only opportunity for the diagnosis of the cause of death.

Examining the effect of direct-from-blood bacterial testing on antibiotic administration and clinical outcomes: a protocol and statistical analysis plan for a pragmatic randomised trial

INTRODUCTION

Patients with suspected bacterial infection frequently receive empiric, broad-spectrum antibiotics prior to pathogen identification due to the time required for bacteria to grow in culture. Direct-from-blood diagnostics identifying the presence or absence of bacteria and/or resistance genes from whole blood samples within hours of collection could enable earlier antibiotic optimisation for patients suspected to have bacterial infections. However, few randomised trials have evaluated the effect of using direct-from-blood bacterial testing on antibiotic administration and clinical outcomes. This manuscript describes the protocol and statistical analysis plan for a randomised trial designed to evaluate the effect of blood cultures plus direct-from-blood bacterial testing results compared with blood culture results alone on antibiotic administration and clinical outcomes.

METHODS AND ANALYSIS

We are conducting a prospective, single-centre, parallel-group, non-blinded, pragmatic, randomised trial. The trial will enrol 500 adult patients presenting to the emergency department at Vanderbilt University Medical Center with suspected bacterial infection who have been initiated on empiric intravenous vancomycin. Eligible patients are randomised 1:1 to receive Food and Drug Administration-approved direct-from-blood bacterial testing in addition to blood cultures or blood cultures alone. The primary outcome is the time to the last dose of intravenous vancomycin within 14 days of randomisation. The secondary outcome is the time to the last dose of systemic antipseudomonal beta-lactam antibiotics within 14 days of randomisation. Additional outcomes include highest stage of acute kidney injury, lowest platelet count and receipt of kidney replacement therapy within 14 days of randomisation, as well as hospital-free days, intensive care unit-free-days and all-cause, in-hospital mortality within 28 days of randomisation. Enrolment began on 13 December 2023.

ETHICS AND DISSEMINATION

The trial involves human participants and was approved by the Vanderbilt University Medical Center institutional review board with a waiver of informed consent (IRB#231229). Results will be submitted in a peer-reviewed journal and presented at scientific conferences.

TRIAL REGISTRATION NUMBER

NCT06069206.

Klebsiella pneumoniae induces dose-dependent shock, organ dysfunction, and coagulopathy in a nonhuman primate critical care model

Nonhuman primate models that closely emulate the disease course, pathogenesis, and supportive care provided to human patients in the modern intensive care unit with bacterial sepsis are urgently needed to study pathogenesis and assess novel therapies. We therefore developed a non-human primate model of septic shock that includes supportive care akin to a modern intensive care unit. In this study, we characterized pathogen kinetics and evaluated the physiologic, immunologic, and pathologic responses in this model of septic shock induced by the clinically relevant pathogen Klebsiella pneumoniae across a three-log dose range. We observed dose-dependent bacteremia and circulating levels of Klebsiella pneumoniae DNA and endotoxin. Tachycardia and hypotension occurred in all animals and the study endpoint occurred in 8 of 12 animals that were euthanized. The infused bacterial dose was significantly associated with the severity of renal insufficiency and coagulopathy. Neutrophil activation evidenced by increased CD11b expression, decreased CD62L expression, and increased circulating levels of myeloperoxidase, lactoferrin, and neutrophil extracellular traps; monocyte activation evidenced by increased circulating levels of interleukin-6, tumor necrosis factor-alpha, granulocyte-macrophage colony-stimulating factor, and monocyte chemotactic protein-1; and endothelial activation evidenced by increased circulating levels of syndecan-1 and angiopoietin-II were all consistent with human sepsis. Our model provides an opportunity to study pathogenesis and investigate novel therapeutics for the treatment of bacterial sepsis in the setting of modern supportive care.IMPORTANCEThere is currently a disconnect between the efficacy of sepsis therapies in pre-clinical animal models and human clinical trials. Therefore, developing nonhuman primate models that closely mimic human sepsis pathogenesis to study novel host-targeted therapeutics is a priority. In this study, we developed a model of septic shock with a clinically relevant bacteria (Klebsiella pneumoniae) that provides standard supportive care including mechanical ventilation, invasive hemodynamic monitoring, volume resuscitation, vasopressors, antibiotics, and steroids. In a dose-dependent manner, we observed that this model closely emulates the hemodynamic, end-organ dysfunction, and cellular and soluble responses associated with human sepsis. This validated model provides a unique opportunity to study the pathogenesis of acute septic shock and evaluate host-directed therapeutics in a large animal model that closely emulates the modern-day intensive care unit and supportive critical care.

Transformer-based model for predicting length of stay in intensive care unit in sepsis patients

Introduction

Sepsis, a life-threatening condition with a high mortality rate, requires intensive care unit (ICU) admission. The increasing hospitalization rate for patients with sepsis has escalated medical costs due to the strain on ICU resources. Efficient management of ICU resources is critical to addressing this challenge.

Methods

This study utilized the dataset collected from 521 patients with sepsis at Chungbuk National University Hospital between July 2020 and August 2023. A transformer-based deep learning model was developed to predict ICU length of stay (LOS). The model incorporated global and local input data analysis through classification and feature-wise tokens, based on sequential organ failure assessment (SOFA) criteria. Model performance was evaluated using four-fold cross-validation.

Results

The proposed model achieved a mean absolute error (MAE) of 2.05 days for predicting ICU LOS. The result demonstrates the ability of the proposed model to provide accurate and reliable predictions.

Discussion

The proposed model offers valuable insights for healthcare resource management by optimizing ICU resource allocation and potentially reducing medical expenses. These findings highlight the applicability of the proposed model to efficient healthcare cost management.

Interpretable machine learning for predicting sepsis risk in emergency triage patients

The study aimed to develop and validate a sepsis prediction model using structured electronic medical records (sEMR) and machine learning (ML) methods in emergency triage. The goal was to enhance early sepsis screening by integrating comprehensive triage information beyond vital signs. This retrospective cohort study utilized data from the MIMIC-IV database. Two models were developed: Model 1 based on vital signs alone, and Model 2 incorporating vital signs, demographic characteristics, medical history, and chief complaints. Eight ML algorithms were employed, and model performance was evaluated using metrics such as AUC, F1 Score, and calibration curves. SHapley Additive exPlanations (SHAP) and Local Interpretable Model-agnostic Explanations (LIME) methods were used to enhance model interpretability. The study included 189,617 patients, with 5.95% diagnosed with sepsis. Model 2 consistently outperformed Model 1 across most algorithms. In Model 2, Gradient Boosting achieved the highest AUC of 0.83, followed by Extra Tree, Random Forest, and Support Vector Machine (all 0.82). The SHAP method provided more comprehensible explanations for the Gradient Boosting algorithm. Modeling with comprehensive triage information using sEMR and ML methods was more effective in predicting sepsis at triage compared to using vital signs alone. Interpretable ML enhanced model transparency and provided sepsis prediction probabilities, offering a feasible approach for early sepsis screening and aiding healthcare professionals in making informed decisions during the triage process.

Novel applications of metformin in the treatment of septic myocardial injury based on metabolomics and network pharmacology

BACKGROUND

While metformin has shown promise in treating septic myocardial injury (SMI), its underlying mechanisms and impact on metabolic disturbances remain poorly understood.

METHODS

This study employed an integrated approach of metabolomics and network pharmacology to identify key targets and pathways through which metformin may act against SMI. Findings were validated using a lipopolysaccharide (LPS)-induced mouse model.

RESULTS

Metformin was found to counter myocardial metabolic disruptions, indicated by the reversal of 49 metabolites primarily involved in purine metabolism, pantothenate and CoA biosynthesis, and histidine metabolism. In vivo, metformin significantly improved survival rates and cardiac function, reduced cardiomyocyte apoptosis, and inhibited inflammation and oxidative stress in LPS-induced mice. Integrated analyses identified 27 potential targets for metformin in SMI treatment. KEGG pathway analysis revealed significant enrichment in TNF, HIF-1, IL-17, and PI3K/AKT signaling pathways, while protein-protein interaction analysis pinpointed ten core targets, including IL6, IL1B, CCL2, CASP3, MMP9, HIF1A, IGF1, NOS3, MMP2, and LEP. Molecular docking and dynamics simulations demonstrated metformin's high affinity for these core targets. Further, RT-qPCR and Western blot analyses confirmed that metformin modulates core target expression to mitigate SMI. Notably, our data underscore the importance of PI3K/AKT and MMP2/MMP9 signaling pathways in SMI therapy.

CONCLUSION

This study elucidates the metabolic and molecular mechanisms of metformin in SMI treatment, supporting its potential repurposing for SMI.

Diagnostic uncertainties in patients with bacteraemia: impact on antibiotic prescriptions and outcome

OBJECTIVES

To establish a formal diagnosis in infectious disease is not an easy task. Our aim was to characterize diagnostic uncertainty (DU) in patients for whom blood cultures were positive (PBC) and to determine its impact on both the antibiotic therapy and the outcome.

METHODS

This was a prospective multicentre study including PBC for 6 months. The laboratory gave the PBC result to the infectious disease (ID) specialists in real time (24/7). The latter analysed all data from electronic patient charts and gave therapeutic advice to the physicians in charge of the patient to either initiate an antibiotic therapy, or to modify or to pursue continuing antimicrobial treatment. A DU was defined as no diagnosis of ID after thorough reading of the patient's chart, or more than two diagnoses despite two medical opinions obtained before PBC. An unfavourable outcome was defined by the occurrence of death during hospitalization.

RESULTS

One hundred and nighty-nine PBCs were communicated to ID specialists, including 93 DUs (47%). In multivariate analysis, DU was associated with hospitalization in medical wards: [adjusted odds ratio (AOR) (95% CI): 6.94 (3.41-14.28)], the advice to initiate an antibiotic treatment: [3.89 (1.56-9.70)] and piperacillin-tazobactam use [3.75 (1.56-9.00)]; ICU requirement at initiation of care was a protective factor [0.38 (0.17-0.84)]. An unfavourable outcome was observed in 22 cases, and in a second logistic regression showed that DU was associated with the latter [AOR (95% CI): 5.07 (1.60-16.12)].

CONCLUSION

DUs were frequent during infections proved by PBC, and were associated with admission in medical wards, broad-spectrum antibiotic use and a high rate of unfavourable outcomes.

Retrospective evaluation of dexamethasone for treatment of suspected critical illness-related corticosteroid insufficiency in dogs with septic shock (2017-2022): 60 cases

OBJECTIVE

To retrospectively compare and report vasopressor duration and mortality of septic dogs with hypotension refractory to vasopressor administration (presumed critical illness-related corticosteroid insufficiency [CIRCI]) treated with or without dexamethasone sodium phosphate (DxSP).

DESIGN

Retrospective study (2017-2022).

SETTING

Tertiary referral and teaching hospitals.

ANIMALS

Sixty client-owned dogs with confirmed or presumed sepsis and vasopressor-resistant hypotension. Hypotension was defined as systolic arterial pressure < 90 mm Hg or MAP < 65 mm Hg. Vasopressor resistance was defined as hypotension despite therapy with moderate- to high-dose vasopressors (> 0.5 µg/kg/min of norepinephrine IV).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twenty-six dogs received DxSP (DxSP group, 0.002-0.39 mg/kg IV, variable frequency), and 34 dogs did not receive a glucocorticoid (non-DxSP group). The median time to vasopressor discontinuation was 20 hours (interquartile range [IQR]: 21; n = 6) in the DxSP group and 27 hours (IQR: 11; n = 5) in the non-DxSP group. In the DxSP group, 23% (6/26) of dogs survived to discharge compared with 15% (5/34) of dogs in the non-DxSP group, which was not significantly different (relative risk: 0.90, 95% confidence interval: 0.70-1.16; P = 0.41). There was no significant difference between the 2 groups in time from vasopressor administration to weaning in dogs that survived to discharge (P = 0.43). The median time from steroid administration to vasopressor wean was 15 hours (IQR: 19; n = 6), and the median time from steroid administration to sustained normotension (a systolic blood pressure > 90 mm Hg or a MAP >65 mm Hg for at least 4 h) was 1 hour (IQR: 5; n = 11).

CONCLUSIONS

There was no association between DxSP therapy and survival, duration of vasopressor therapy, or time between steroid administration and discontinuation of vasopressor therapy in dogs being treated for sepsis, vasopressor resistance, and suspected CIRCI.

Identification of the Shared Gene Signatures of HCK, NOG, RNF125 and Biological Mechanism in Pediatric Acute Lymphoblastic Leukaemia and Pediatric Sepsis

The shared mechanisms between pediatric acute lymphoblastic leukaemia (ALL) and pediatric sepsis are currently unclear. This study was aimed to explore the shared key genes of pediatric ALL and pediatric sepsis. The datasets involved were downloaded from the Gene Expression Omnibus (GEO) database. Differentially expressed genes (DEGs) between disease and control samples in GSE13904 and GSE79533 were intersected. The least absolute shrinkage and selection operator (LASSO) and the boruta analyses were performed in GSE13904 and GSE79533 separately based on shared DEGs, and shared key genes were obtained by taking the intersection of sepsis-related key genes and ALL-related key genes. Three shared key genes (HCK, NOG, RNF125) were obtained, that have a good diagnostic value for both sepsis and ALL. The correlation between shared key genes and differentially expressed immune cells was higher in GSE13904 and conversely, the correlation of which was lower in GSE79533. Suggesting that the sharing key genes had a different impact on the immune environment in pediatric ALL and pediatric sepsis. We make the case that this study provides a new perspective to study the relationship between pediatric ALL and pediatric sepsis.

Understanding ICU Nursing Knowledge, Perceived Barriers, and Facilitators of Sepsis Recognition and Management: A Cross-Sectional Study

IMPORTANCE

Nursing workforce changes, knowledge translation gaps, and environmental/organizational barriers may impact sepsis recognition and management within the ICU.

OBJECTIVES

To: 1) evaluate current ICU nursing knowledge of sepsis recognition and management, 2) explore individual and environmental or organizational factors impacting nursing recognition and management of sepsis using the Theoretical Domains Framework (TDF), and 3) describe perceived barriers and facilitators to nursing recognition and management of patients with sepsis.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey was administered to nurses working in four general system ICUs between October 24, 2023, and January 30, 2024.

MAIN OUTCOMES AND MEASURES

Quantitative questions (single/multiple choice, true/false, and Likert-based questions eliciting agreement with a statement) were analyzed using descriptive statistics. Open-ended questions exploring barriers and facilitators to sepsis recognition and management were analyzed using qualitative content analysis.

RESULTS

A total of 101 completed survey responses were retained. Most nurses agreed early sepsis detection saves lives (n = 98, 97%, TDF domain Beliefs About Consequences) and that nursing care can improve patient outcomes (n = 97, 96%, TDF domain Optimism). Fewer nurses agreed it was easy to identify priority sepsis interventions based on order urgency (n = 53, 53%, TDF domain Memory, Attention, and Decision Processes). Reoccurring barriers and facilitators to sepsis recognition and management were commonly identified across the TDF domains of Knowledge, Skills, Environmental Context and Resources, and Social Influences, including competency deficit (with facilitators including support from colleagues), workload or staffing, and equipment or resource availability.

CONCLUSION AND RELEVANCE

ICU nursing sepsis recognition and management is impacted by numerous individual, environmental, and organizational factors. Recommendations include enhanced competency development or support, utilization of structured reinforcement measures (involving the interdisciplinary team and imploring the use of integrative technologies), and addressing equipment/resource-related gaps. Future research and improvement initiatives should use a theory-informed approach to overcome the pervasive, complex challenges impeding timely sepsis recognition and management.

Provider-to-provider telemedicine for sepsis is used less frequently in communities with high social vulnerability

PURPOSE

Sepsis disproportionately affects patients in rural and socially vulnerable communities. A promising strategy to address this disparity is provider-to-provider emergency department (ED)-based telehealth consultation (tele-ED). The objective of this study was to determine if county-level social vulnerability index (SVI) was associated with tele-ED use for sepsis and, if so, which SVI elements were most strongly associated.

METHODS

We used data from the TELEmedicine as a Virtual Intervention for Sepsis in Rural Emergency Department study. The primary exposures were SVI aggregate and component scores. We used multivariable generalized estimating equations to model the association between SVI and tele-ED use.

FINDINGS

Our study cohort included 1191 patients treated in 23 Midwestern rural EDs between August 2016 and June 2019, of whom 326 (27.4%) were treated with tele-ED. Providers in counties with a high SVI were less likely to use tele-ED (adjusted odds ratio [aOR] = 0.51, 95% confidence interval [CI] 0.31‒0.87), an effect principally attributable to the housing type and transportation component of SVI (aOR = 0.44, 95% CI 0.22-0.89). Providers who treated fewer sepsis patients (1‒10 vs. 31+ over study period) and therefore may have been less experienced in sepsis care, were more likely to activate tele-ED (aOR = 3.91, 95% CI 2.08‒7.38).

CONCLUSIONS

Tele-ED use for sepsis was lower in socially vulnerable counties and higher among providers who treated fewer sepsis patients. These findings suggest that while tele-ED increases access to specialized care, it may not completely ameliorate sepsis disparities due to its less frequent use in socially vulnerable communities.

Blood Pressure Targets for Adults with Vasodilatory Shock - An Individual Patient Data Meta-Analysis

BACKGROUND

We sought to estimate whether a lower mean arterial blood pressure target, compared with a higher mean arterial blood pressure target, reduced 90-day all-cause mortality among critically ill adult patients with vasodilatory shock.

METHODS

We conducted an individual patient data meta-analysis of randomized controlled trials that evaluated the effect of distinct thresholds of mean arterial blood pressure to guide vasopressor support among critically ill adults identified in a systematic literature search. The main exposure was a lower mean arterial pressure target compared with a higher mean arterial pressure target (including usual care). The primary outcome was 90-day all-cause mortality. We used a Bayesian random effects log-binomial model to estimate risk ratios with 95% credible intervals (CrIs).

RESULTS

Between 2010 and 2019, 3352 patients were randomly assigned in three trials (SEPSISPAM, OVATION pilot trial, and 65-Trial) across 103 hospitals from the United Kingdom, France, and Canada. When compared with a higher mean arterial blood pressure target or usual care, the risk ratio for 90-day all-cause mortality associated with a lower blood pressure target was 0.93 (95% CrI, 0.76 to 1.07; low certainty, posterior probability of benefit 87%). Results were consistent across multiple secondary and sensitivity analyses, including adjustment for prognostically important baseline covariates and alternative modeling techniques. Multiple approaches to evaluate the heterogeneity of treatment effect did not identify any subgroups that may potentially benefit from higher mean arterial blood pressure targets.

CONCLUSIONS

Targeting a lower mean arterial blood pressure for vasopressor therapy in critically ill patients with vasodilatory shock possibly reduced 90-day all-cause mortality. However, the certainty of evidence is low, and this analysis does not exclude the possibility that lower targets may cause harm overall.

Multicenter retrospective evaluation of norepinephrine extravasation in dogs and cats (2015-2021): 14 cases

OBJECTIVE

To document clinical complications and intervention options associated with norepinephrine (NE) extravasation in dogs and cats.

DESIGN

Cases were identified between 2015 and 2021. Because this is an uncommon complication, the findings are compiled as a descriptive retrospective study.

SETTING

Cases were provided from 4 universities and 2 private practice groups in the United States, Canada, and Australia.

ANIMALS

Fourteen patients (13 dogs, 1 cat) that experienced extravasation events (16 total).

INTERVENTIONS

Small animal patients were included where extravasation of a NE constant rate infusion (CRI) was documented. Records were reviewed for information, including suspected underlying condition, description of the interventions pursued after identification of extravasation, clinical signs after extravasation, and survival to discharge or reason for patient death or euthanasia. When available, information was collected pertaining to the NE dose, dilution, total duration of CRI, and duration of CRI before extravasation was recognized.

MEASUREMENTS AND MAIN RESULTS

The most commonly reported clinical signs after extravasation of NE were skin necrosis (n = 9 [64.3%]) and swelling (n = 6 [42.9%]). In 10 of 16 events (62.5%), discontinuation of the NE CRI and/or application of a warm compress to the extravasation site were performed; these were the most common nonpharmacological rescue measures. Two patients received subcutaneous phentolamine, and 1 patient underwent hyperbaric oxygen therapy. While surgical intervention was recommended for 4 dogs, 2 improved without surgical debridement. The overall survival rate from underlying disease processes was 57% (n = 8), with only 1 patient (7%) euthanized due to an injury from the extravasation.

CONCLUSIONS

Severe lesions can result from NE extravasation in dogs and cats, leading to euthanasia. Although phentolamine remains the treatment of choice, lesions may heal with alternative supportive measures.

Enhancing Sepsis Care at an Academic Emergency Department in a Resource-Constrained Setting: A Quality Improvement Initiative

OBJECTIVES

The early recognition of sepsis and septic shock is crucial for improved patient outcomes. Quality improvement programs have ameliorated processes and outcomes in the care of patients with sepsis and septic shock. This study aimed to improve the proportion of patients receiving antibiotics within 1 hour of triage and compliance with sepsis bundles.

METHODS

A multidisciplinary sepsis task force was created to monitor and improve sepsis care. The program lasted 24 months from January 1, 2018, to December 31, 2019. A unique screening criterion was created by combining items from the systemic inflammatory response syndrome, quick sequential organ failure assessment, and National Early Warning Score systems. Thereafter, a sepsis flowsheet was implemented in the emergency department for monitoring. The measures between the first 12 months and the last 12 months were compared.

RESULTS

The proportion of patients receiving antibiotics within 1 hour of triage improved from 44% to 84%, intravenous crystalloid administration within 3 hours improved from 62% to 94%, serum lactic acid measurement within 3 hours improved from 62% to 94%, and vasopressor initiation within 6 hours improved from 76% to 94%. The mortality rates decreased from 32% to 21% between the 2 study periods.

CONCLUSIONS

This program emphasizes the impact of a structured quality improvement program on the process and outcomes of care.

Mortality-associated plasma proteome dynamics in a prospective multicentre sepsis cohort

BACKGROUND

Sepsis remains a leading cause of mortality in intensive care units. Understanding the dynamics of the plasma proteome of patients with sepsis is critical for improving prognostic and therapeutic strategies.

METHODS

This prospective, multicentre observational cohort study included 363 patients with sepsis recruited from five university hospitals in Germany between March 2018 and April 2023. Plasma samples were collected on days 1 and 4 after sepsis diagnosis, and proteome analysis was performed using mass spectrometry. Classical statistical methods and machine learning (random forest) were employed to identify proteins associated with 30-day survival outcomes.

FINDINGS

Out of 363 patients, 224 (62%) survived, and 139 (38%) did not survive the 30-day period. Proteomic analysis revealed significant differences in 87 proteins on day 1 and 95 proteins on day 4 between survivors and non-survivors. Additionally, 63 proteins were differentially regulated between day 1 and day 4 in the two groups. The identified protein networks were primarily related to blood coagulation, immune response, and complement activation. The random forest classifier achieved an area under the receiver operating characteristic curve of 0.75 for predicting 30-day survival. The results were compared and partially validated with an external sepsis cohort.

INTERPRETATION

This study describes temporal changes in the plasma proteome associated with mortality in sepsis. These findings offer new insights into sepsis pathophysiology, emphasizing the innate immune system as an underexplored network, and may inform the development of targeted therapeutic strategies.

FUNDING

European Regional Development Fund of the European Union. The State of North Rhine-Westphalia, Germany.

National Analysis of Preexisting Immunosuppressive Conditions and Infection-Related Readmissions Among Sepsis Survivors

BACKGROUND

Recurrent episodes of infection and subsequent sepsis are a frequent cause of readmission after sepsis hospitalization. Although persistent immune dysregulation initiated during the sepsis episode may play a role, the impact of preexisting immune suppression (including HIV, organ transplantation, and cancer) and common chronic diseases associated with immune suppression (diabetes and chronic kidney disease) on the risk of recurrent infections after sepsis is unknown.

OBJECTIVES

To investigate the role of preexisting immune-suppressive conditions (PISCs) and other common chronic diseases on infection-related readmissions after a sepsis admission.

METHODS

Using the US 2015 Nationwide Readmissions Database, we identified a retrospective cohort of adult patients with an unplanned sepsis index admission from April to September, excluding patients with sepsis during the preceding 90 days. We followed all sepsis survivors for subsequent infection-related admissions for 90 days. We identified clinical conditions using International Classification of Diseases coding.

RESULTS

We identified 649 029 unique unplanned sepsis admissions over 6 months; 189 604 (29.2%) had sepsis with PISC, and 459 425 (70.8%) had sepsis without PISC. Overall, sepsis survivors were older (median age, 70 years), and 145 156 (22.4%) experienced at least 1 infection-related readmission within 90 days. The incidence of infection-related readmission among sepsis survivors with PISC was 26.1%, whereas it was 20.8% for those without PISC. The excess risk of infection-related readmissions attributed to PISC was 5.3%, whereas the excess risk attributed to diabetes and chronic kidney disease was 3.7% and 4.7%, respectively. The background risk attributed to new-onset sepsis among participants with none of these conditions was 16.3%. Multivariable regression analysis adjusting for age, gender, and acute illness factors indicated that odds of infection-related readmission were strongly associated with PISC (odds ratio 1.30; 95% confidence interval, 1.29-1.32), closely followed by chronic kidney disease (1.28 [1.27-1.32]) and diabetes (1.17 [1.16-1.19]).

CONCLUSION

The risk of subsequent infection is higher among patients with PISC, although chronic kidney disease and diabetes are also important risk factors for subsequent infection and sepsis readmissions.

The use of methylene blue in adult patients with septic shock: a systematic review and meta-analysis

OBJECTIVES

Methylene blue exerts its vasopressor properties by inhibiting nitric oxide-mediated vasodilation. Recent studies have advocated the use of methylene blue as a rescue therapy for patients with septic shock. The primary aim was to investigate the effect of methylene blue on the mean arterial pressure among adult patients with septic shock.

METHODS

Databases of MEDLINE, EMBASE, and CENTRAL were searched from their inception date until October 2023. Randomized Clinical Trials (RCT) comparing methylene blue and placebo in adults with septic shock were included.

RESULTS

Our systematic review included 5 studies (n = 257) for data analysis. As compared to the placebo, our pooled analysis showed that methylene blue significantly increased mean arterial pressure (MD: 1.34 mmHg, 95% CI 0.15 to 2.53, p = 0.03, level of evidence: very low). Patients who were given methylene blue were associated with statistically lower mortality rate (OR = 0.49, 95% CI 0.27 to 0.88, p = 0.02, level of evidence: low), reduced serum lactate levels (MD: -0.76 mmoL.L-1, 95% CI -1.22 to -0.31, p = 0.0009, level of evidence: low), reduced length of hospital stay (MD: -1.94 days, 95% CI -3.79 to -0.08, p = 0.04, level of evidence: low), and increased PaO2/FiO2 (MD: 34.78, 95% CI 8.94 to 60.61, p = 0.008, level of evidence: low).

CONCLUSIONS

This meta-analysis demonstrated that methylene blue administration was associated with an increased in mean arterial pressure and PaO2/FiO2 ratio, along with a reduction in mortality rates, serum lactate levels, and length of hospital stay. However, substantial degree of heterogeneity and inadequate number of studies with low level of evidence warrant future adequately powered RCTs to affirm our results.

Predicting survival in sepsis: The prognostic value of NLR and BAR ratios

BACKGROUND

Due to the high-risk nature of sepsis, emergency departments urgently need a simple evaluation method to assess the degree of inflammation and prognosis in sepsis patients, providing a reference for diagnosis and treatment.

OBJECTIVE

To investigate the prognostic value of the neutrophil-to-lymphocyte ratio (NLR) combined with the blood urea nitrogen-to-serum albumin ratio (BAR) in sepsis.

METHODS

A total of 377 sepsis patients admitted to Lishui People's Hospital from June 2022 to June 2023 were selected as the study subjects. Based on their prognosis, they were divided into a survival group (255 cases) and a death group (82 cases). The clinical data of the two groups were compared. Multivariate logistic analysis was used to identify factors influencing sepsis prognosis, and ROC curve analysis was used to assess the predictive efficacy of NLR, BAR, and their combination.

RESULTS

Compared with survivors, non-survivors had higher NLR and BAR, with statistically significant differences (p< 0.05). After adjusting for confounding factors, NLR (OR = 1.052) and BAR (OR = 1.095) were found to be independent prognostic factors for sepsis patients (both p< 0.05). The AUC of NLR combined with BAR was 0.798 (95% CI 0.745-0.850, p< 0.05), higher than the AUC of NLR alone (0.776) and BAR alone (0.701).

CONCLUSIONS

The combination of NLR and BAR has a high predictive value for the prognosis of sepsis patients. Its simple calculation makes it particularly suitable for use in emergency departments.

Health Equity in the Care of Adult Critical Illness Survivors

There is evidence that people who fare worse in recovery do so, not only because of their illness, but also because of social and structural determinants. For example, food insecurity and poor nutrition, unemployment, poverty, social isolation and loneliness, limited social support, and poor access to medical care represent marked obstacles to recovery. Those who experience social or structural disadvantage have a poor start to their critical illness journey and are more vulnerable to adverse material conditions that contribute to and worsen their health outcomes.

EZH2 contributes to sepsis-induced acute lung injury through regulating macrophage polarization

BACKGROUND

Zeste enhancer homolog 2 (EZH2) is a pivotal regulator of gene dynamics implicated in the progression of sepsis-induced acute lung injury (SALI). EZH2 regulates aberrant inflammatory and immune responses in macrophages via unconventional biochemical interactions. However, the mechanisms driving atypical behavior of EZH2 during sepsis remain elusive, and therapeutic strategies targeting EZH2 are currently underutilized.

PURPOSE

This study aimed to investigate how EZH2 regulates macrophage polarization through the AKT pathway to improve SALI and to explore therapeutic drugs targeting EZH2.

METHODS

We used Western blotting, hematoxylin-eosin stainin, immunofluorescence, flow cytometry, qRT-PCR, RNA sequencing, and chromatin immunoprecipitation sequencing methods to investigate regulation of macrophage immune response by EZH2 and explored its specific mechanism. These methods were also used to examine the protective effects of MS177 against SALI.

RESULTS

Specific deletion of EZH2 in macrophages reduced the level of AKTIP, downregulated the M1 macrophage markers CD86 and cytotoxic T cell marker CD8+, upregulated the M2 macrophage marker CD206 and regulatory T cell marker FOXP3+, decreased the levels of pro-inflammatory cytokines IL-6, TNF-α, and IL-β, and increased the level of anti-inflammatory cytokine IL-10. This ultimately improved lung injury and mortality in SALI mice. EZH2 promoted the M1 polarization of macrophages by activating AKT2 via direct binding to the promoter region of AKTIP in a SALI mouse model. Furthermore, MS177 alleviated SALI by degrading EZH2 both in vitro and in vivo.

CONCLUSION

EZH2 regulates macrophage polarization via the AKTIP-AKT2 pathway. Our findings suggest that MS177 is a promising therapeutic agent for EZH2-dependent SALI.

Shielding the Gut: Ghrelin and Ferrostatin-1's Protective Role Against Sepsis-Induced Intestinal Ferroptosis

Objective: This study investigates the therapeutic efficacy of ghrelin in alleviating sepsis-induced intestinal damage, focusing on its potential to inhibit ferroptosis and protect intestinal barrier integrity. Methods: This study evaluates the therapeutic efficacy of intraperitoneal ghrelin (80 μg/kg) and Ferrostatin-1 (5 mg/kg) using a cecal ligation and puncture (CLP) model in C57BL/6 mice to determine their potential in alleviating sepsis-induced intestinal damage. The investigation focuses on the impacts of ghrelin and Ferrostatin-1 on bacterial load, intestinal morphology, systemic inflammation, oxidative stress, and ferroptosis markers. Our comprehensive methodology encompasses histopathological evaluations, cytokine profiling, oxidative stress assays, and detailed analyses of ferroptosis indicators to thoroughly assess the interventions' efficacy. Results: Treatment with ghrelin significantly reduced bacterial proliferation, mitigated intestinal damage, and decreased systemic inflammation. Comparable outcomes were observed with Fer-1 treatment. Both interventions restored intestinal barrier functions, modulated inflammatory responses, and attenuated oxidative stress, indicating a suppression of the ferroptosis pathway. Conclusion: Ghrelin exhibits a protective role in sepsis-induced intestinal injury, likely through the inhibition of ferroptosis. This mechanism underscores ghrelin's therapeutic potential in sepsis management, suggesting avenues for further clinical exploration.

Mediating Role of Platelet Count Increase in Unfractionated Heparin Treatment for Sepsis Patients: A Retrospective Cohort Analysis

Aims/Background The role of heparin in sepsis therapy has been widely debated. The controversy surrounding heparin's use as an anticoagulant in sepsis may stem from differences in sepsis definitions, study designs, timing and dosage of drug administration, treatment duration, complications, and patient severity. In this study, we aimed to determine the optimal timing and dosage of heparin in patients with sepsis, identify specific subgroups that could benefit from heparin therapy, and explore laboratory markers to assess its efficacy. Methods This retrospective cohort study was conducted using the Medical Information Mart for Intensive Care-IV dataset. Data from patients with sepsis were extracted based on the Sepsis 3.0 criteria. Patients were categorized according to heparin use. The effectiveness of early and appropriate heparin administration was assessed, and a subgroup analysis was performed to identify patients most likely to benefit from heparin therapy. Additionally, factors mediating the improvement in sepsis prognosis following heparin treatment were analyzed. Results We recruited 4149 participants who met the inclusion criteria, with an overall 28-day mortality rate of 19.5%. There were 2192 individuals in the heparin group and 1957 in the non-heparin group. After propensity score matching, heparin therapy demonstrated a significantly greater effect on reducing both 28-day and 90-day mortality compared to the non-heparin treatment (18.1% vs. 10.7%, p < 0.001; 18.8% vs. 12.6%, p < 0.001). However, the heparin group had a higher incidence of major bleeding (10.9% vs. 6.3%, p = 0.001), increased use of mechanical ventilation (54.3% vs. 45.1%, p < 0.001), and a longer intensive care unit stay (3.6 vs. 2.5 days, p < 0.001) compared to the non-heparin group. Early administration of high-dose heparin improved 28-day survival. Early and adequate heparin administration was more effective than late and insufficient dosing (p < 0.01), except in patients with sepsis who had low white blood cell counts, alkalosis, or reduced platelet counts. The increase in platelet count had a significant mediating effect on the entire cohort (p < 0.001 for the causal mediation effect), with a mediation proportion of 14%. Conclusion Early and adequate heparin administration can significantly improve the prognosis of sepsis. An increase in platelet count may serve as a potential indicator of the effectiveness of heparin therapy in sepsis.

An essential component of antimicrobial stewardship during the COVID-19 pandemic in the intensive care unit: de-escalation

BACKGROUND

The antimicrobial de-escalation strategy (ADE) plays a crucial role in antimicrobial stewardship, reducing the likelihood of bacterial resistance. This study aims to evaluate how often the intensive care unit (ICU) used ADE for empirical treatment during COVID-19.

MATERIALS

Adult ICU patients receiving empirical antimicrobial therapy for bacterial infections were retrospectively studied from September 2020 to December 2021. ADE was defined as (1) discontinuation of an antimicrobial in case of empirical combination therapy or (2) replacement of the antimicrobial to narrow the antimicrobial spectrum within the first 3 days of therapy, according to the test results and clinical picture.

RESULTS

A total of 99 patients were included in the study. The number of patients who received empirical combined therapy (38.4%) was lower than those who received monotherapy (61.6%). The most preferred monotherapy (45.9%) was piperacillin-tazobactam, while the most preferred in combination treatment (22.7%) was meropenem. Within the first 3 days of admittance to the ICU, 3% of patients underwent ADE for their empirical antimicrobial therapy, 61.6% underwent no change, and 35.4% underwent change other than ADE. Procalcitonin levels were below 2 µg/L on the third day of treatment in 69.7% of the patients. Culture or culture-antibiogram results of 50.5% of the patients were obtained within the first 3 days of empirical therapy. There was no growth in the culture results of 21 patients (21.2%) during their ICU stay.

CONCLUSION

In this study, ADE practice was much lower than expected. In order to reduce the significant differences between theory and reality, clinical, laboratory, and organisational conditions must be objectively assessed along with patient characteristics.

Physical compatibility of ceftriaxone and cefepime in 0.45% sodium chloride, Ringer's lactate solution, and Plasma-Lyte A

OBJECTIVES

The compatibility of intravenous fluids with medications is of paramount concern to pharmacists and is an imperative component of ensuring patient safety. Data regarding the physical compatibility of medications with intravenous fluids has not been examined, or published with conflicting results or the concentrations studied were not consistent with current practice. Our objective was to determine the physical compatibility of ceftriaxone and cefepime in 0.45% sodium chloride, Ringer's lactate solution, and Plasma-Lyte A.

METHODS

An in vitro analysis of the physical compatibility of ceftriaxone and cefepime at 10 mg/mL, 20 mg/mL, and 40 mg/mL concentrations was conducted in 0.45% sodium chloride, Ringer's lactate solution, and Plasma-Lyte A. Admixtures were evaluated in triplicate at hours 0, 1, 5, 8, and 24. Physical compatibility was assessed by visual inspection, spectrophotometry, and pH analysis.

RESULTS

Ceftriaxone 40 mg/mL was found to be physically incompatible in 0.45% sodium chloride and Ringer's lactate solution beyond 5 hours and in Plasma-Lyte A beyond 8 hours. Cefepime was found to be physically incompatible with all fluids and in all concentrations beyond 1 hour.

CONCLUSIONS

This work contributes to the body of literature dedicated to the evaluation of intravenous drug and fluid physical compatibility by identifying demonstrable changes in admixtures containing 0.45% sodium chloride, Plasma-Lyte A, and Ringer's lactate solution. Ceftriaxone should not be administered with 0.45% sodium chloride, Ringer's lactated solution, or Plasma-Lyte A at selected concentrations and time points and cefepime is not considered to be physically compatible at 10 mg/mL, 20 mg/mL, or 40 mg/mL in any of the studied fluids beyond 1 hour.

Impact of Haemoadsorption Therapy on Short Term Mortality and Vasopressor Dependency in Severe Septic Shock with Acute Kidney Injury: A Retrospective Cohort Study

Background/Objectives: Sepsis, a life-threatening organ dysfunction caused by a dysregulated host response to infection, remains a major challenge in ICUs. This study evaluated whether combining haemoadsorption therapy with continuous renal replacement therapy (CRRT) reduces ICU and short-term mortality in patients with severe septic shock and acute kidney injury (AKI) requiring CRRT. Methods: A single-centre retrospective cohort study was conducted at Rambam Health Care Campus, Haifa, Israel, from January 2018 to February 2024. Data were collected from ICU patients with severe septic shock and AKI requiring CRRT. Patients were divided into two groups: those receiving haemoadsorption therapy with CRRT and those receiving CRRT alone. Primary and secondary endpoints included ICU, 30 and 60-day mortality, vasopressor dependency index (VDI), and lactate levels. Results: Out of 545 patients with septic shock, 133 developed AKI requiring CRRT, and 76 met the inclusion criteria. The haemoadsorption group (n = 47) showed significant reductions in blood lactate levels and VDI after 24 h compared to the CRRT alone group (n = 29). ICU mortality was significantly lower in the haemoadsorption group (34.0% vs. 65.5%, p = 0.008), as was 30 and 60-day mortality (34.0% vs. 62.1%, p = 0.02, and 48.9% vs. 75.9%, p = 0.002). Multivariate analysis confirmed haemoadsorption therapy as independently associated with lower ICU and 30-day but not 60-day mortality. Conclusions: Haemoadsorption therapy combined with CRRT in patients with severe septic shock and AKI requiring CRRT is associated with improved lactate clearance, reduced vasopressor requirements, and lower ICU and 30-day mortality. Further high-quality randomized controlled trials are needed to confirm these findings.

Impact on fluid balance of an optimized restrictive strategy targeting non-resuscitative fluids in intensive care patients with septic shock: a single-blind, multicenter, randomized, controlled, pilot study

BACKGROUND

In septic shock, the classic fluid resuscitation strategy can lead to a potentially harmful positive fluid balance. This multicenter, randomized, single-blind, parallel, controlled pilot study assessed the effectiveness of a restrictive fluid strategy aiming to limit daily volume.

METHODS

Patients 18-85 years' old admitted to the ICU department of three French hospitals were eligible for inclusion if they had septic shock and were in the first 24 h of vasopressor infusion. Exclusion criteria were acute kidney injury requiring renal replacement therapy, end stage chronic kidney disease, and severe malnutrition. Patients were electronically randomized 1:1 to either an optimized fluid restriction (reducing fluid intake as much as possible in terms of maintenance fluids and fluids for drug dilution during the first 7 days) or standard fluid strategy. The primary outcome was cumulative fluid balance (ml/kg) in the first 5 days. Patients and statisticians were blinded to group arm, but not clinicians.

RESULTS

Between September 2021 and February 2023, 1201 patients were screened and 50 included, with two in the control group withdrawing, thus 48 patients were analyzed (24 in each group). In the first 5 days, the optimized restrictive strategy and control groups received 89.7 (IQR 35; 128.9) and 114.3 (IQR 78.8; 168.5) ml/kg of fluid, respectively (mean difference: 35.9 ml/kg [0.0; 71.8], p = 0.0506). After 5 days, the median cumulative fluid balance was 6.9 (IQR - 13.7; 52.1) and 35.0 (IQR - 7.9; 40.2) ml/kg in the optimized restrictive strategy and control groups, respectively (absolute difference 13.2 [95%CI - 15.2; 41.6], p = 0.42). After 28 days, mortality and the numbers of days alive without life support were similar between groups. The main adverse events were severe hypernatremia in 1 and 2 patients in the fluid restriction strategy and control groups, respectively, and acute kidney injury KDIGO 3 in 4 and 7 patients in the fluid restriction strategy and control groups, respectively.

CONCLUSIONS

In ICU patients with septic shock, an optimized restrictive fluid strategy targeting hidden fluid intakes did not reduce the overall fluid balance at day 5. Trial registration ClinicalTrials.gov identifier NCT04947904, registered on 1 July 2021.

Social Determinants of Sepsis Mortality in the United States: A Retrospective, Epidemiologic Analysis

Objective

To determine whether neighborhood-level social determinants of health (SDoH) influence mortality following sepsis in the United States.

Study Setting and Design

Retrospective analysis of data from 4.4 million hospitalized patients diagnosed with sepsis, identified using International Classification of Diseases-10 codes, across the United States.

Data Sources and Analytic Sample

De-identified, aggregated data were sourced from the TriNetX Diamond Network. SDoH variables included income, housing cost burden, broadband access, park proximity, racial/ethnic diversity, and the Area Deprivation Index (ADI). The primary outcome was mortality, assessed using univariate and multivariate binomial generalized linear models. Predictors with high multicollinearity (Variance Inflation Factor > 5) were excluded to enhance model stability.

Principal Findings

Lower median income, higher ADI scores, limited park access, and lack of broadband connectivity were strongly associated with increased sepsis mortality. Unexpectedly, greater racial/ethnic diversity was negatively associated with mortality, possibly reflecting regional disparities in healthcare access and socioeconomic conditions. Multivariate analyses revealed that the inclusion of SDoH variables attenuated some effects observed in univariate models, highlighting their complex interplay. Random Forest analysis identified park access as the most important predictor of sepsis mortality, emphasizing its role as a potential proxy for broader neighborhood resources.

Conclusions

Neighborhood-level SDoH are critical for risk stratification in sepsis prognostic models and should be systematically integrated into predictive frameworks. These findings highlight the need for targeted public health interventions to address social vulnerabilities, enhance access to green spaces, and reduce disparities in sepsis outcomes across diverse populations.

Predictive accuracy of lactate albumin ratio for mortality in intensive care units: a nationwide cohort study

BACKGROUND

The lactate albumin ratio (LAR), a simple prognostic marker used in intensive care units (ICUs), combines lactate and serum albumin levels to predict patient outcomes. Despite its potential, the predictive accuracy of the LAR remains insufficiently explored. This study aimed to assess the usefulness of the LAR in predicting mortality among patients in the ICU.

METHODS

This retrospective study conducted a secondary analysis of prospectively obtained clinical data from the Japanese Intensive Care Patient Database. We included all patients admitted to ICUs between 2015 and 2021, excluding those under the age of 16 years. The main outcome was in-hospital mortality. The LAR predictive value for this outcome was assessed by examining the area under the receiver operating characteristic curve and comparing it against prognostic indicators such as age, lactate, albumin and Sequential Organ Failure Assessment score. LAR shape was assessed using unrestricted spline curves, and the optimal cut-off value was identified from sensitivity and negative likelihood ratio. Subgroup analysis was used to evaluate the predictive accuracy of the LAR across different patient attributes and clinical scenarios.

RESULTS

Of 2 34 774 cases analysed, in-hospital mortality was 8.8% (20 723 deaths). The LAR had an area under the curve of 0.761 (95%CI 0.757 to 0.765), indicating a fair predictive performance for in-hospital mortality. Unrestricted spline curves demonstrated that LAR can predict mortality through a monotonic positive dose-response relationship with 0.4 as the optimal cut-off value. In subgroup analysis, areas under the curve were significantly higher in subgroups defined by younger age, female sex, unplanned ICU admission, non-surgical patients, non-infectious patients, non-heart failure patients and lack of end-stage renal disease.

CONCLUSIONS

The LAR might be a useful predictor for screening mortality in ICU patients. However, further research to establish appropriate cut-off values for the LAR and identify the optimal target population is warranted.

Acute kidney injury in elderly patients receiving invasive mechanical ventilation: early versus late onset

BACKGROUND

Acute kidney injury (AKI) is a severe complication in critical patients receiving invasive mechanical ventilation (MV). However, AKI which occurs in the first 48 h after MV (early AKI) and thus likely associated with the MV settings is probably different from AKI occurring following 48 h (late AKI). This study is aimed at exploring the incidence of early and late AKI in elderly patients receiving MV and identifying their different risk factors and outcomes.

METHODS

This retrospective, observational, multicenter cohort study consecutively included 3271 elderly patients (≥ 75 years) receiving invasive MV at four medical centers of Chinese PLA General Hospital from 2008 to 2020. The diagnosis of AKI was made following the 2012 KDIGO criteria and categorized into early (≤ 48 h) or late (> 48 h-7 days) according to the time from MV.

RESULTS

There were totally 1292 cases enrolled for the final analysis. Among them, 376 patients (29.1%) developed early AKI versus 132 (10.2%) developed late AKI. The 28-day mortality rates of the non-AKI, early AKI, and late AKI patients were 14.4, 46.8, and 61.4%, respectively. After 90 days, mortality rates of three groups were 33.2, 60.6, and 72.7%, respectively. Risk factors for early AKI included PaO2/FIO2, serum creatinine, hemoglobin, and positive end-expiratory pressure at the beginning of MV, while those for late AKI were PaO2/FIO2, serum creatinine, and hemoglobin. In the multivariable adjusted analysis, both early AKI (HR = 4.035; 95% CI = 3.166-5.142; P < 0.001) and late AKI (HR = 6.272; 95% CI = 4.654-8.453; P < 0.001) were related to the increased 28-day mortality relative to non-AKI. AKI was significantly related to 90-day mortality: early AKI (HR = 2.569; 95% CI = 2.142-3.082; P < 0.001) and late AKI (HR = 3.692; 95% CI = 2.890-4.716; P < 0.001).

CONCLUSIONS

AKI mostly develops in the initial 48 h following MV, which is related to the health and MV settings; while AKI occurring following 48 h is not associated with MV settings. Therefore, a strategy for kidney protection in patients with MV should take these differences into consideration.

Employing artificial intelligence for optimising antibiotic dosages in sepsis on intensive care unit: a study protocol for a prospective observational study (KI.SEP)

INTRODUCTION

In sepsis treatment, achieving and maintaining effective antibiotic therapy is crucial. However, optimal antibiotic dosing faces challenges due to significant variability among patients with sepsis. Therapeutic drug monitoring (TDM), the current gold standard, lacks initial dosage adjustments and global availability. Even with daily TDM, antibiotic serum concentrations (ASCs) often deviate from the therapeutic range. This study addresses these challenges by developing machine learning (ML)-based ASC prediction models capable of handling variable data input and encompassing diverse clinical, laboratory, microbiological and proteomic parameters without the need for daily TDM.

METHODS

This prospective observational study is conducted in a German university hospital intensive care unit. Eligible sepsis patients receive continuous antibiotic therapy with piperacillin/tazobactam (n=100) or meropenem (n=100) within 24 hours. Exclusion criteria include refusal, pregnancy, lactation and severe anaemia (haemoglobin <8 g/dL). Blood samples for TDM are collected from patients, along with clinical and laboratory parameters on days 1-8 and day 30 or on discharge. ML models predicting ASC between day 1 and day 8 serve as primary and key secondary endpoints. We will use the collected data to develop multifaceted ML-based algorithms aimed at optimising antibiotic dosing in sepsis. Our two-way approach involves creating two distinct algorithms: the first focuses on predictive accuracy and generalisability using routine clinical parameters, while the second leverages an extended dataset including a plethora of factors currently insufficiently explored and not available in standard clinical practice but may help to enhance precision. Ultimately, these models are envisioned for integration into clinical decision support systems within patient data management systems, facilitating automated, personalised treatment recommendations for sepsis.

ETHICS AND DISSEMINATION

The study received approval from the Ethics Committee of the Medical Faculty of Ruhr-University Bochum (No. 23-7905). Findings will be disseminated through open-access publication in a peer-reviewed journal and social media channels.

TRIAL REGISTRATION NUMBER

DRKS00032970.

Association between lactate determined at emergency department arrival and the probability of inhospital mortality and intensive care admission in elderly patients

BACKGROUND AND IMPORTANCE

Elderly patients often have atypical clinical presentations. Lactate measurement on arrival at the Emergency Department (ED) could be useful to identify elderly patients with a bad prognosis.

OBJECTIVE

The study aimed to investigate the relationship between serum lactate determined at ED arrival and the probability of inhospital mortality and intensive care (ICU) admission in elderly patients.

DESIGN

Retrospective multipurpose registry. Secondary analysis of the EDEN cohort (Elderly Department and Elder Needs).

SETTINGS AND PARTICIPANTS

All patients ≥65 years attending 52 Spanish EDs during 2 week and in whom serum lactate was determined at ED arrival.

OUTCOME MEASURES AND ANALYSIS

The relationship between serum lactate values and the risk of inhospital all-cause death and transfer from the ED to the ICU was assessed by unadjusted and adjusted logistic regression assuming linearity and restricted cubic spline models assuming nonlinearity.

RESULTS

The cohort included 25 557 patients. The 3024 patients in whom lactate was measured were analyzed. The median age was 81 years (74-87), 1506 (27.2%) were women, 591 (19.5%) had serious comorbidities, 475 (15.7%) severe dependency, and 648 (21.4%) dementia. Death occurred during hospitalization in 217 patients (7.2%) and 53 patients (1.75%) were admitted to the ICU. Serum lactate values were nonlinear related to inhospital mortality and ICU admission. Serum lactate >3.1 mmol/L [odds ratio (OR): 1.60, 95% confidence interval (CI): 1.02-2.50] for inhospital mortality and 3.2 mmol/L (OR: 2.83, 95% CI: 1.03-6.79) for ICU admission were associated with significantly increased ORs in the adjusted models.

CONCLUSION

Serum lactate measured at ED arrival has a significant and exponential relationship with inhospital mortality and ICU admission in elderly patients.

Outcomes of adults hospitalized with COVID-19 at the University Teaching Hospital of Butare in Rwanda and validation of the Universal Vital Assessment (UVA) mortality risk score

There are few data regarding clinical outcomes from COVD-19 from low-income countries (LICs) including Rwanda. Accordingly, we aimed to determine 1) outcomes of patients admitted to hospital with COVID-19 in Rwanda, and 2) the ability of the Universal Vital Assessment (UVA) score to predict mortality in patients with COVID-19 compared to sequential organ failure assessment (SOFA) and quick (qSOFA) scores. We conducted a retrospective study of patients aged ≥18 years hospitalized with laboratory-confirmed COVID-19 at the University Teaching Hospital of Butare (CHUB), Rwanda, April 2021-January 2022. For each participant, we calculated UVA, SOFA, and qSOFA risk scores and determined their area under the receive operating characteristic curve (AUC). We used logistic regression to determine predictors of mortality. Of the 150 patients included, 83 (55%) were female and the median (IQR) age was 61 (43-73) years. The median (IQR) length of hospital stay was 6 (3-10) days. Respiratory failure occurred in 69 (46%) including 34 (23%) who had ARDS. The case fatality rate was 44%. Factors independently associated with mortality included acute kidney injury (adjusted odds ratio [aOR] 7.99, 95% confidence interval [CI] 1.47-43.22, p = 0.016), severe COVID-19 (aOR 3.42, 95% CI 1.06-11.01, p = 0.039), and a UVA score >4 (aOR 7.15, 95% CI 1.56-32.79, p = 0.011). The AUCs for UVA, qSOFA, and SOFA scores were 0.86 (95% CI 0.79-0.92), 0.81 (95% CI 0.74-0.88), and 0.84 (95% CI 0.78-0.91), respectively, which were not statistically significantly different from each other. At a UVA score cut-off of 4, the sensitivity, specificity, positive predictive value, and negative predictive value for mortality were 0.58, 0.93, 0.86, and 0.74, respectively. Patients hospitalized with COVID-19 in CHUB had high mortality, which was accurately predicted by the UVA score. Calculation of the UVA score in patients with COVID-19 in LICs may assist clinicians with triage and other management decisions.

Association of LVV-Hemorphin-7 with Sepsis and Shock: Roles of Cathepsin D and G in Hemoglobin Metabolism in a Prospective ICU Cohort Study

BACKGROUND

Sepsis is a leading cause of mortality in intensive care units (ICUs). Cell-free hemoglobin (CFH) released during sepsis interacts with lysosomal enzymes from neutrophils and macrophages. This study aims to examine the association of LVV-hemorphin-7 (LVV-H7), cathepsin D, and cathepsin G with sepsis and shock in ICU patients.

METHODS

A prospective observational cohort study was conducted in the medical ICU of a tertiary referral hospital in Taiwan. The patients with an acute increasing sequential organ failure assessment (SOFA) score ≥ 2 between 2022 and 2023. Blood samples from 40 healthy controls were obtained from the hospital biobank. CFH metabolites, including LVV-H7 and lysosomal enzyme cathepsin D and cathepsin G, were compared between the sepsis (definite and probable) and non-sepsis (possible sepsis) groups. Multivariate logistic regression analyzed factors associated with sepsis and shock.

RESULTS

Among 120 patients, 75 were classified as septic and 45 as non-septic. Significant differences were observed in CFH, cathepsin D, cathepsin G, and LVV-H7 levels between sepsis and non-sepsis groups. LVV-H7 was a significant predictor for sepsis (adjusted OR [aOR] 1.009, 95% CI 1.005-1.013; p < 0.001) and shock (aOR 1.005, 95% CI 1.002-1.008; p < 0.05). Cathepsin G predicted non-shock (aOR 0.917, 95% CI 0.848-0.991; p < 0.05), while cathepsin D predicted septic shock (aOR 1.001, 95% CI 1.000-1.002; p < 0.05).

CONCLUSIONS

LVV-H7, cathepsin D, and cathepsin G are associated with the classification of sepsis and shock episodes in critically ill patients with elevated SOFA scores.

Nonlinear relationship between Hemoglobin-to-Age Ratio and all-cause mortality in patients with septic shock: A retrospective cohort study in the MIMIC-IV database

BACKGROUND

Previous studies have shown that both age and hemoglobin are closely associated with the prognosis of septic shock. A recent study found that hemoglobin may change with age. Hemoglobin-to-Age Ratio (HAR) takes both age and hemoglobin into consideration as essential factors. So far, the effect of HAR on the prognosis of septic shock is still unclear. This research aimed to investigate the association between the HAR and the prognosis of patients with septic shock.

METHODS

Cox proportional hazards regression analysis, restricted cubic spline, Kaplan-Meier survivor analysis and stratified interaction analysis were used to elucidate the relationship between the HAR and prognosis of patients with septic shock.

RESULTS

There is a nonlinear association between the HAR and mortality within 28 days after intensive care unit admission. When the HAR was lower than 0.13, mortality within 28 days after ICU admission decreased significantly as the HAR increased. When the HAR was higher than 0.13, the HAR was not a protective factor for mortality within 28 days after ICU admission. In patients with septic shock, the HAR was more effective in reducing the risk of death in patients with atrial fibrillation than in patients without atrial fibrillation.

CONCLUSION

There is a nonlinear association between the HAR and mortality within 28 days after intensive care unit admission. When the HAR was at a low level, mortality within 28 days after ICU admission decreased significantly as the HAR increased. When the HAR was at high levels, the HAR might not be a protective factor for mortality within 28 days after ICU admission. In patients with septic shock, the HAR was more effective in reducing the risk of death in patients with atrial fibrillation than in patients without atrial fibrillation.

Critical Points of Risk in Registered Nurses' Use of a National Early Warning Score-Perceptions and Challenges

AIM

To explore Registered Nurses' experiences and perceptions of using the National Early Warning Score in the U.K. as part of the recognition and management of acute adult patient deterioration.

DESIGN

Hermeneutic Phenomenological design.

METHODS

Sixteen Registered Nurses from a U.K. NHS hospital were interviewed using an interpretative phenomenological approach (2019-2020).

RESULTS

Registered Nurses' use of NEWS highlighted 3 risk areas: delegation of vital sign monitoring to unregistered staff leading to uncertainty and delayed escalation, junior nurses' over-reliance on NEWS and deference to expertise, and senior nurses' self-management of deteriorating patients. The workplace culture revealed frequent compromises and limited learning opportunities.

CONCLUSION

When using NEWS, failure to recognise associated risks threatens patient safety. Wrong decisions at the three 'pinch points' may lead to missed chances in preventing deterioration. Incorrect judgements may lead to unrecognised patient deterioration or inappropriate management leading to preventable adverse events.

IMPLICATIONS FOR THE PROFESSION AND PATIENT CARE

The way in which NEWS is used by healthcare professionals brings inherent patient safety risks. Addressing education gaps and fostering a supportive culture in nursing, valuing and enhancing nurses' clinical judgement, is crucial for mitigating these risks and ensuring patient safety.

IMPACT

The study deepens understanding of nurses' use of NEWS and identifies components affecting the recognition of patient deterioration.

REPORTING METHOD

Adherence to the EQUATOR guidelines SRQR confirmed.

PATIENT OR PUBLIC CONTRIBUTION

Service user involvement was included within the design of the study and ethical approval.

A national survey of medication utilization for cardiac resuscitation in the emergency department: A survey of emergency medicine pharmacists

PURPOSE

Vasoactive medications are used during advanced cardiac life support (ACLS) to shunt oxygenated blood to vital organs and after return of spontaneous circulation (ROSC) to maintain hemodynamic goals. However, limited evidence exists to support vasoactive medication recommendations in such scenarios, and it is unknown how practices vary among emergency departments across the US.

METHODS

A survey questionnaire (15 questions) was electronically distributed to emergency medicine pharmacists (EMPs) in the US through various professional listservs. Demographic information, American Heart Association ACLS algorithm medication use, and use of continuous vasopressor infusions and adjunct medications following ROSC were assessed and are reported descriptively.

RESULTS

The survey was distributed to 764 EMPs, with a 23% response rate from a wide geographic distribution and 48% of respondents practicing in academic medical centers. Epinephrine dosing and administration during cardiac arrest were reported by most to be in accordance with ACLS cardiac arrest algorithms. Calcium, magnesium sulfate, and sodium bicarbonate were the most common adjunct intravenous medications given during cardiac arrest. Norepinephrine was the first-choice vasopressor (81%) for post-ROSC hypotension, while epinephrine was preferred less frequently (17%). Antibiotics and sodium bicarbonate were the most frequently administered post-ROSC adjunct medications.

CONCLUSION

This survey of a geographically diverse group of EMPs demonstrated high ACLS algorithm adherence for epinephrine during cardiac arrest with frequent additional administration of nonalgorithm medications. Sodium bicarbonate and calcium were the most frequently administered adjunct medications during cardiac arrest, while sodium bicarbonate and antibiotics were the most frequently used adjunct medications following ROSC. Norepinephrine was the most commonly used vasopressor following ROSC.

Longitudinal assessment of immunoglobulin response and disease progression in critically ill patients with community acquired pneumonia

BACKGROUND

Low endogenous immunoglobulin(Ig)-levels are common in critically ill patients with sepsis, but it is unknown whether low Ig-levels are associated with poor outcome, and in which patients Ig-replacement therapy (IgRT) improves outcome. Given the crucial role of immunoglobulins in eliminating certain encapsulated pathogens, we examined the relationship between serial Ig-levels and disease course in critically ill patients with community acquired pneumonia (sCAP) caused by encapsulated or other pathogens.

METHODS

We included a cohort of consecutive critically ill patients with CAP, and PaO2/FiO2-ratio < 200 with or without septic shock, from an existing biorepository where microbiological causes of infection had been adjudicated in a protocolized manner. We used generalized linear mixed models to assess the association between IgG and IgM (measured on admission days 1, 3 and 7) and disease course (Sequential Organ Failure Assessment (SOFA)-score on day 2, 4, and 8) for all-cause sCAP and for episodes caused by Streptococcus (S.) pneumoniae or Haemophilus (H.) influenzae.

RESULTS

We included 255 eligible patients admitted with CAP, of which 82 (32%) episodes were caused by S. pneumoniae or H. influenzae. 151 (59%) patients had low IgG (< 7.0 g/L), 77 (30%) had low IgM (< 0.4 g/L), and 56 (22%) had both. A lower IgG-level was related to a slightly higher SOFA-score at admission (β =  - 0.07 per 1 g/L IgG, p = 0.029), but an IgG-level decline over time was not associated with a SOFA-score increase (β =  - 0.04, p = 0.564). IgM-levels were not associated with changes in SOFA-score over time. Neither association was affected by the presence or absence of S. pneumoniae and H. influenzae.

CONCLUSION

In critically ill patients with CAP, IgG and IgM dynamics in the first week of ICU stay are not associated with clinically relevant changes in disease course, regardless of the causative pathogen.

Characteristics of a revised quick sequential organ failure assessment score (RqSOFA) to predict in-hospital mortality of patients visiting the emergency department via ambulance: an observational cohort study

The National Early Warning Score (NEWS), Quick Sequential Organ Failure Assessment (qSOFA), and modified qSOFA (MqSOFA) are scoring systems that rely on vital signs. However, NEWS is time-consuming, qSOFA has low sensitivity, and MqSOFA includes a difficult calculation. To address these issues, we developed the Revised qSOFA score (RqSOFA) that consists of percutaneous oxygen saturation, oxygen usage, Simple Shock Index, and the parameters of qSOFA. The predictability of RqSOFA was examined for in-hospital mortality among patients who were transported by ambulance. This observational cohort study included all patients transported via ambulance to an Emergency Department between 2019 and 2021. Patients who had prehospital cardiopulmonary arrest, were pregnant, were younger than 15 years old, arrived from another hospital, and had missing data were excluded. The Area Under the Receiver Operating Characteristic curve (AUROC) of RqSOFA, as well as its sensitivity and specificity at the optimal cut-off point, were determined and compared to those of qSOFA, NEWS and MqSOFA. Among 1849 included patients, 53 died in the hospital. The AUROC for RqSOFA was 0.867 and the optimal cut-off point was 2. The sensitivity and specificity were 0.849 and 0.802, respectively. The AUROC of RqSOFA was larger than qSOFA but had no significance with NEWS and MqSOFA. RqSOFA exhibited the same sensitivity and better specificity compared to NEWS. There were no differences in sensitivity and specificity between RqSOFA and MqSOFA. In conclusion, RqSOFA exhibited superior predictability for in-hospital mortality to qSOFA and NEWS, while offering similar predictability to MqSOFA despite relying only on simple measurements.

Homeostasis: understanding the effects of impaired mechanisms

This article focuses on homeostasis and offers a pathophysiological perspective. The dynamic mechanisms responsible for maintaining internal balance and disruptive processes will be analysed through the lens of key systems including the nervous, endocrine and renal systems. The environmental factors and their potential impact on homeostasis have been considered. A clinical case study will contextualise homeostasis in clinical practice.

Influence of underlying condition and performance of sepsis bundle in very old patients with sepsis: a nationwide cohort study

BACKGROUND

Sepsis is a life-threatening condition that affects individuals of all ages; however, it presents unique challenges in very old patients due to their complex medical histories and potentially compromised immune systems. This study aimed to investigate the influence of underlying conditions and the performance of sepsis bundle protocols in very old patients with sepsis.

METHODS

We conducted a nationwide cohort study of adult patients with sepsis prospectively collected from the Korean Sepsis Alliance Database. Underlying conditions, prognosis, and their association with sepsis bundle compliance in patients with sepsis aged ≥ 80 years were analyzed.

RESULTS

Among the 11,981 patients with sepsis, 3,733 (31.2%) were very old patients aged ≥ 80 years. In-hospital survivors (69.8%) were younger, less likely male, with higher BMI, lower Charlson Comorbidity Index, lower Clinical Frailty Scale, and lower Sequential Organ Failure Assessment (SOFA) scores. The in-hospital survivor group had lower lactate measurement but higher fluid therapy and vasopressor usage within the 1-h bundle. Similar trends were seen in the 3-h and 6-h bundles. Furthermore, in-hospital survivors were more likely to receive appropriate empiric antibiotics within 24 h. In-hospital mortality was associated with age, Clinical Frailty Scale, SOFA score, comorbidities, Life sustaining treatment issue, interventions in the ICU and vasopressor use in the 1-h sepsis bundle.

CONCLUSIONS

Addressing underlying conditions and enhancing sepsis bundle adherence is crucial for better outcomes in very old patients with sepsis. Personalized approaches and increased awareness are essential. Further research should explore interventions to optimize sepsis care in this population.