Glucocorticoids in the treatment of severe sepsis and septic shock

A systematic review and meta-analysis of the efficacy and safety of glucocorticoids in the treatment of severe pneumonia

OBJECTIVES

To systematically evaluate the efficacy and superiority of glucocorticoids in the treatment of severe pneumonia.

METHOD

Randomized Controlled Trials (RCTs) on glucocorticoids in the treatment of severe pneumonia were retrieved from CNKI, CBM, China Science and Technology Journal Database (VIP), Wanfang Database, and PubMed as of January 1, 2017. The literature was independently and objectively screened, extracted, and evaluated by two researchers, and a meta-analysis of the extracted data was performed using Revman 5.3 software.

RESULTS

Ten studies that met the inclusion criteria were included, with a cumulative total of 1120 cases. The meta-analysis results confirmed that the observation group was superior to the control group in terms of efficacy rate, temperature recovery time, cough relief time, rale disappearance time, and serum CRP level. There was no statistically significant difference in terms of the incidence of adverse reactions, mortality rate, and reinfection rate between the two groups.

CONCLUSIONS

Glucocorticoids showed an obvious clinical efficacy in patients with severe pneumonia. However, due to the small number of included studies and the ambiguity of numerous bias risk assessments, high-quality and large-sample RCTs are still needed to provide corroborating evidence.

Physiologic effects of stress dose corticosteroids in in-hospital cardiac arrest (CORTICA): A randomized clinical trial

Aim

Postresuscitation hemodynamics are associated with hospital mortality/functional outcome. We sought to determine whether low-dose steroids started during and continued after cardiopulmonary resuscitation (CPR) affect postresuscitation hemodynamics and other physiological variables in vasopressor-requiring, in-hospital cardiac arrest.

Methods

We conducted a two-center, randomized, double-blind trial of patients with adrenaline (epinephrine)-requiring cardiac arrest. Patients were randomized to receive either methylprednisolone 40 mg (steroids group) or normal saline-placebo (control group) during the first CPR cycle post-enrollment. Postresuscitation shock was treated with hydrocortisone 240 mg daily for 7 days maximum and gradual taper (steroids group), or saline-placebo (control group). Primary outcomes were arterial pressure and central-venous oxygen saturation (ScvO₂) within 72 hours post-ROSC.

Results

Eighty nine of 98 controls and 80 of 86 steroids group patients with ROSC were treated as randomized. Primary outcome data were collected from 100 patients with ROSC (control, n = 54; steroids, n = 46). In intention-to-treat mixed-model analyses, there was no significant effect of group on arterial pressure, marginal mean (95% confidence interval) for mean arterial pressure, steroids vs. control: 74 (68–80) vs. 72 (66–79) mmHg] and ScvO₂ [71 (68–75)% vs. 69 (65–73)%], cardiac index [2.8 (2.5–3.1) vs. 2.9 (2.5–3.2) L/min/m²], and serum cytokine concentrations [e.g. interleukin-6, 89.1 (42.8–133.9) vs. 75.7 (52.1–152.3) pg/mL] determined within 72 hours post-ROSC (P = 0.12–0.86). There was no between-group difference in body temperature, echocardiographic variables, prefrontal blood flow index/cerebral autoregulation, organ failure-free days, and hazard for poor in-hospital/functional outcome, and adverse events (P = 0.08–>0.99).

Conclusions

Our results do not support the use of low-dose corticosteroids in in-hospital cardiac arrest.

Trial Registration:ClinicalTrials.gov number: NCT02790788 (https://www.clinicaltrials.gov).

Effect of adjunctive corticosteroid on 28-day mortality in neutropenic patients with septic shock

The role of adjunctive corticosteroid in septic shock remains debatable, and its role has not been assessed in neutropenic patients. We evaluated whether hydrocortisone reduces 28-day mortality in neutropenic patients with septic shock. We conducted a retrospective cohort study between January 2012 and May 2017 at a tertiary care center in South Korea. Patients who developed septic shock treated with at least one vasopressor and whose absolute neutrophil count was < 1000 cells/μL were included. Patients were classified into a steroid and a no-steroid group. The primary outcome of the study was 28-day mortality. Propensity score matching was used to adjust baseline characteristics and disease severity between the groups. Of the 287 patients analyzed, 189 were classified in the no-steroid group and 98 in the steroid group. Fifty propensity score-matched pairs were compared for the study outcomes. We found no significant difference in 28-day mortality between patients treated with and without steroid after propensity score matching (38.0% and 42.0%, respectively; p = 0.838). Incidences of pneumonia and gastrointestinal bleeding were more frequent in the steroid group, but it was not statistically significant after matching. In conclusion, adjunctive hydrocortisone was not associated with reduced 28-day mortality in neutropenic patients with septic shock.

Adjunctive Corticosteroid Treatment in Septic Shock

Two recent randomized controlled trials have provided new data to inform opinion on the use of corticosteroids in septic shock. This article discusses the background and rationale for corticosteroid use, compares the findings and methodologies of the new trials, and provides suggestions for practice.

Sepsis: mechanisms of bacterial injury to the patient

In bacteremia the majority of bacterial species are killed by oxidation on the surface of erythrocytes and digested by local phagocytes in the liver and the spleen. Sepsis-causing bacteria overcome this mechanism of human innate immunity by versatile respiration, production of antioxidant enzymes, hemolysins, exo- and endotoxins, exopolymers and other factors that suppress host defense and provide bacterial survival. Entering the bloodstream in different forms (planktonic, encapsulated, L-form, biofilm fragments), they cause different types of sepsis (fulminant, acute, subacute, chronic, etc.). Sepsis treatment includes antibacterial therapy, support of host vital functions and restore of homeostasis. A bacterium killing is only one of numerous aspects of antibacterial therapy. The latter should inhibit the production of bacterial antioxidant enzymes and hemolysins, neutralize bacterial toxins, modulate bacterial respiration, increase host tolerance to bacterial products, facilitate host bactericidal mechanism and disperse bacterial capsule and biofilm.

Treatment of AECHB and Severe Hepatitis (Liver Failure)

This chapter describes the general treatment and immune principles and internal management for AECHB and HBV ACLF, including ICU monitoring, general supportive medications/nutrition/nursing, immune therapy, artificial liver supportive systems, hepatocyte/stem cell, and liver transplant, management for special populations, frequently clinical complications and the utilization of Chinese traditional medicines.

Early clinical indicators of severe hepatitis B include acratia, gastrointestinal symptoms, a daily increase in serum bilirubin >1 mg/dL, toxic intestinal paralysis, bleeding tendency and mild mind anomaly or character change, and the presence of other diseases inducing severe hepatitis. Laboratory indicators include T-Bil, PTA, cholinesterase, pre-albumin and albumin. The roles of immune indicators (such as IL-6, TNF-α, and fgl2), gene polymorphisms, HBV genotypes, and gene mutations as early clinical indicators.

Intensive Care Unit monitor patients with severe hepatitis include intracranial pressure, infection, blood dynamics, respiratory function, renal function, blood coagulation function, nutritional status and blood purification process. Nursing care should not only include routine care, but psychological and special care (complications).

Nutrition support and nursing care should be maintained throughout treatment for severe hepatitis. Common methods of evaluating nutritional status include direct human body measurement, creatinine height index (CHI) and subject global assessment of nutrition (SGA). Malnourished patients should receive enteral or parenteral nutrition support.

Immune therapies for severe hepatitis include promoting hepatocyte regeneration (e.g. with glucagon, hepatocyte growth factor and prostaglandin E1), glucocorticoid suppressive therapy, and targeting molecular blocking. Corticosteroid treatment should be early and sufficient, and adverse drug reactions monitored. Treatments currently being investigated are those targeting Toll-like receptors, NK cell/NK cell receptors, macrophage/immune coagulation system, CTLA-4/PD-1 and stem cell transplantation.

In addition to conventional drugs and radioiodine, corticosteroids and artificial liver treatment can also be considered for severe hepatitis patients with hyperthyreosis. Patients with gestational severe hepatitis require preventive therapy for fetal growth restriction, and it is necessary to choose the timing and method of fetal delivery. For patients with both diabetes and severe hepatitis, insulin is preferred to oral antidiabetic agents to control blood glucose concentration. Liver toxicity of corticosteroids and immune suppressors should be monitored during treatment for severe hepatitis in patients with connective tissue diseases including SLE, RA and sicca syndrome. Patient with connective tissue diseases should preferably be started after the antiviral treatment with nucleos(t)ide analogues.

An artificial liver can improve patients’ liver function; remove endotoxins, blood ammonia and other toxins; correct amino acid metabolism and coagulation disorders; and reverse internal environment imbalances. Non-bioartificial livers are suitable for patients with early and middle stage severe hepatitis; for late-stage patients waiting for liver transplantation; and for transplanted patients with rejection reaction or transplant failure. The type of artificial liver should be determined by each patient’s condition and previous treatment purpose, and patients should be closely monitored for adverse reactions and complications. Bio- and hybrid artificial livers are still under development.

MELD score is the international standard for choosing liver transplantation. Surgical methods mainly include the in situ classic type and the piggyback type; transplantation includes no liver prophase, no liver phase or new liver phase. Preoperative preparation, management of intraoperative and postoperative complications and postoperative long-term treatment are keys to success.

Severe hepatitis belongs to the categories of “acute jaundice”, “scourge jaundice”, and “hot liver” in traditional Chinese medicine. Treatment methods include Chinese traditional medicines, acupuncture and acupoint injection, external application of drugs, umbilical compress therapy, drip, blow nose therapy, earpins, and clysis. Dietary care is also an important part of traditional Chinese medicine treatment.

Exposure to Stress-Dose Steroids and Lethal Septic Shock After In-Hospital Cardiac Arrest: Individual Patient Data Reanalysis of Two Prior Randomized Clinical Trials that Evaluated the Vasopressin-Steroids-Epinephrine Combination Versus Epinephrine Alone

PURPOSE

Low-dose steroids may reduce the mortality of severely ill patients with septic shock. We sought to determine whether exposure to stress-dose steroids during and/or after cardiopulmonary resuscitation is associated with reduced risk of death due to postresuscitation septic shock.

METHODS

We analyzed pooled, individual patient data from two prior, randomized clinical trials (RCTs). RCTs evaluated vasopressin, steroids, and epinephrine (VSE) during resuscitation and stress-dose steroids after resuscitation in vasopressor-requiring, in-hospital cardiac arrest. In the second RCT, 15 control group patients received open-label, stress-dose steroids. Patients with postresuscitation shock were assigned to a Steroids (n = 118) or No Steroids (n = 73) group according to an "as-treated" principle. We used cumulative incidence competing risks Cox regression to determine cause-specific hazard ratios (CSHRs) for pre-specified predictors of lethal septic shock (primary outcome). In sensitivity analyses, data were analyzed according to the intention-to-treat (ITT) principle (VSE group, n = 103; control group, n = 88).

RESULTS

Lethal septic shock was less likely in Steroids versus No Steroids group, CSHR, 0.40, 95% confidence interval (CI), 0.20-0.82; p = 0.012. ITT analysis yielded similar results: VSE versus Control, CSHR, 0.44, 95% CI, 0.23-0.87; p = 0.019. Adjustment for significant, between-group baseline differences in composite cardiac arrest causes such as "hypotension and/or myocardial ischemia" did not appreciably affect the aforementioned CSHRs.

CONCLUSIONS

In this reanalysis, exposure to stress-dose steroids (primarily in the context of a combined VSE intervention) was associated with lower risk of postresuscitation lethal septic shock.

Low-dose corticosteroids for adult patients with septic shock: a systematic review with meta-analysis and trial sequential analysis

PURPOSE

To assess the effect of low dose corticosteroids on outcomes in adults with septic shock.

METHODS

We systematically reviewed randomised clinical trials (RCTs) comparing low-dose corticosteroids to placebo in adults with septic shock. Trial selection, data abstraction and risk of bias assessment were performed in duplicate. The primary outcome was short-term mortality. Secondary and tertiary outcomes included longer-term mortality, adverse events, quality of life, and duration of shock, mechanical ventilation and ICU stay.

RESULTS

There were 22 RCTs, including 7297 participants, providing data on short-term mortality. In two low risk of bias trials, the relative risk (RR) of short-term mortality with corticosteroid versus placebo was 0.98 [95% confidence interval (CI) 0.89-1.08, p = 0.71]. Sensitivity analysis including all trials was similar (RR 0.96; 95% CI 0.91-1.02, p = 0.21) as was analysis of longer-term mortality (RR 0.96; 95% CI 0.90-1.02, p = 0.18). In low risk of bias trials, the risk of experiencing any adverse event was higher with corticosteroids; however, there was substantial heterogeneity (RR 1.66; 95% CI 1.03-2.70, p = 0.04, I2 = 78%). No trials reported quality of life outcomes. Duration of shock [mean difference (MD) -1.52 days; 95% CI -1.71 to -1.32, p < 0.0001], duration of mechanical ventilation (MD -1.38 days; 95% CI -1.96 to -0.80, p < 0.0001), and ICU stay (MD -0.75 days; 95% CI -1.34 to -0.17, p = 0.01) were shorter with corticosteroids versus placebo.

CONCLUSIONS

In adults with septic shock treated with low dose corticosteroids, short- and longer-term mortality are unaffected, adverse events increase, but duration of shock, mechanical ventilation and ICU stay are reduced. PROSPERO registration no. CRD42017084037.

Adjunctive Glucocorticoid Therapy in Patients with Septic Shock

BACKGROUND

Whether hydrocortisone reduces mortality among patients with septic shock is unclear.

METHODS

We randomly assigned patients with septic shock who were undergoing mechanical ventilation to receive hydrocortisone (at a dose of 200 mg per day) or placebo for 7 days or until death or discharge from the intensive care unit (ICU), whichever came first. The primary outcome was death from any cause at 90 days.

RESULTS

From March 2013 through April 2017, a total of 3800 patients underwent randomization. Status with respect to the primary outcome was ascertained in 3658 patients (1832 of whom had been assigned to the hydrocortisone group and 1826 to the placebo group). At 90 days, 511 patients (27.9%) in the hydrocortisone group and 526 (28.8%) in the placebo group had died (odds ratio, 0.95; 95% confidence interval [CI], 0.82 to 1.10; P=0.50). The effect of the trial regimen was similar in six prespecified subgroups. Patients who had been assigned to receive hydrocortisone had faster resolution of shock than those assigned to the placebo group (median duration, 3 days [interquartile range, 2 to 5] vs. 4 days [interquartile range, 2 to 9]; hazard ratio, 1.32; 95% CI, 1.23 to 1.41; P<0.001). Patients in the hydrocortisone group had a shorter duration of the initial episode of mechanical ventilation than those in the placebo group (median, 6 days [interquartile range, 3 to 18] vs. 7 days [interquartile range, 3 to 24]; hazard ratio, 1.13; 95% CI, 1.05 to 1.22; P<0.001), but taking into account episodes of recurrence of ventilation, there were no significant differences in the number of days alive and free from mechanical ventilation. Fewer patients in the hydrocortisone group than in the placebo group received a blood transfusion (37.0% vs. 41.7%; odds ratio, 0.82; 95% CI, 0.72 to 0.94; P=0.004). There were no significant between-group differences with respect to mortality at 28 days, the rate of recurrence of shock, the number of days alive and out of the ICU, the number of days alive and out of the hospital, the recurrence of mechanical ventilation, the rate of renal-replacement therapy, and the incidence of new-onset bacteremia or fungemia.

CONCLUSIONS

Among patients with septic shock undergoing mechanical ventilation, a continuous infusion of hydrocortisone did not result in lower 90-day mortality than placebo. (Funded by the National Health and Medical Research Council of Australia and others; ADRENAL ClinicalTrials.gov number, NCT01448109 .).

Hydrocortisone and Ascorbic Acid Synergistically Prevent and Repair Lipopolysaccharide-Induced Pulmonary Endothelial Barrier Dysfunction

BACKGROUND

Sepsis refers to the dysregulated host immune response elicited by microbial infections resulting in life-threatening organ dysfunction. Sepsis represents a medical challenge, since it is associated with a rate of death as high as 60%. Septic shock is strongly associated with vascular dysfunction and elevated pulmonary capillary permeability. We recently reported that the combination of hydrocortisone (HC), ascorbic acid (vitC), and thiamine dramatically improves outcomes and reduces mortality in patients with sepsis. In the present study, we provide experimental evidence in support of the hypothesis that the combination of HC and vitC enhances endothelial barrier function.

METHODS

Human lung microvascular endothelial cells were exposed to lipopolysaccharide (LPS) in the absence or presence of HC and vitC.

RESULTS

LPS alone induced profound hyperpermeability, as reflected in decreased values of transendothelial electrical resistance. vitC alone did not exhibit barrier enhancement properties nor did it affect the LPS-induced hyperpermeability. Similarly, HC alone exhibited only a minor barrier-enhancing and protective effect. Conversely, the combination of HC and vitC, either as before or after treatment, dramatically reversed the LPS-induced barrier dysfunction. The barrier-protective effects of HC and vitC were associated with reversal of LPS-induced p53 and phosphorylated cofilin downregulation and LPS-induced RhoA activation and myosin light chain phosphorylation.

CONCLUSIONS

These data provide a novel mechanism of endothelial barrier protection and suggest one possible pathway that may contribute to the therapeutic effects of HC and vitC in patients with sepsis.

Effects of Cellular 11β-hydroxysteroid Dehydrogenase 1 on LPS-induced Inflammatory Responses in Synovial Cell Line, SW982

11β-hydroxysteroid dehydrogenase 1 (11β-HSD1) catalyzes the conversion of inactive cortisone into active cortisol, which has pleiotropic roles in various biological conditions, such as immunological and metabolic homeostasis. Cortisol is mainly produced in the adrenal gland, but can be locally regenerated in the liver, fat, and muscle. Its diverse actions are primarily mediated by binding to the glucocorticoid receptor. SW982, a human synovial cell line, expresses 11β-HSD type 1, but not type 2, that catalyzes the conversion of cortisone to cortisol. In this study, therefore, we investigated the control of lipopolysaccharide (LPS)-induced inflammatory responses by prereceptor regulation-mediated maintenance of cortisol levels. Preliminarily, cell seeding density and incubation period were optimized for analyzing the catalytic activity of SW982. Additionally, cellular 11β-HSD1 still remained active irrespective of monolayer or spheroid culture conditions. Inflammatory stimulants, such as interleukin (IL)-1β, tumor necrosis factor (TNF)α, and LPS, did not affect the catalytic activity of 11β-HSD1, although a high dose of LPS significantly decreased its activity. Additionally, autocrine effects of cortisol on inflammatory responses were investigated in LPS-stimulated SW982 cells. LPS upregulated pro-inflammatory cytokines, including IL-6 and IL-1β, in SW982 cells, while cortisol production, catalyzed by cellular 11β-HSD1, downregulated LPS-stimulated cytokines. Furthermore, suppression of NFκB activation-mediated pro-inflammatory responses by cortisol was revealed. In conclusion, the activity of cellular 11β-HSD1 was closely correlated with suppression of LPS-induced inflammation. Therefore, these results partly support the notion that prereceptor regulation of locally regenerated cortisol could be taken into consideration for treatment of inflammation-associated diseases, including arthritis.

Controversies in diagnosis and management of community-acquired pneumonia

Community-acquired pneumonia (CAP) is a common condition; however, it appears to be overdiagnosed. Diagnosing CAP too frequently may be adding to the problems of overuse of antibiotics, such as bacterial resistance in the community and greater costs and complications in individuals. Data support that most patients with non-severe CAP can be treated for 3-5 days; however, most patients with CAP are receiving much longer courses of therapy. Macrolides such as azithromycin have the potential to prolong the QT interval, although large population studies show that this does not appear to result in excess cardiac mortality. CAP is associated with an increase in a variety of cardiac complications, most notably infarctions and worsening cardiac failure, so clinicians should be vigilant for signs and symptoms of these complications, particularly in patients with a history of ischaemic cardiac disease or the presence of cardiac risk factors. Cardiac risk factors should be assessed and managed in patients with CAP over 40 years of age, although there are yet to be data to show that this approach reduces deaths. Corticosteroids may have a slight effect on reducing deaths in patients with severe CAP, but this must be balanced against the significant potential for side effects.

Sepsis and septic shock: Pathogenesis and treatment perspectives

The majority of bacteremias do not develop to sepsis: bacteria are cleared from the bloodstream. Oxygen released from erythrocytes and humoral immunity kill bacteria in the bloodstream. Sepsis develops if bacteria are resistant to oxidation and proliferate in erythrocytes. Bacteria provoke oxygen release from erythrocytes to arterial blood. Abundant release of oxygen to the plasma triggers a cascade of events that cause: 1. oxygen delivery failure to cells; 2. oxidation of plasma components that impairs humoral regulation and inactivates immune complexes; 3. disseminated intravascular coagulation and multiple organs' failure. Bacterial reservoir inside erythrocytes provides the long-term survival of bacteria and is the cause of ineffectiveness of antibiotics and host immune reactions. Treatment perspectives that include different aspects of sepsis development are discussed.

Endothelial Response to Glucocorticoids in Inflammatory Diseases

The endothelium plays a crucial role in inflammation. A balanced control of inflammation requires the action of glucocorticoids (GCs), steroidal hormones with potent cell-specific anti-inflammatory properties. Besides the classic anti-inflammatory effects of GCs on leukocytes, recent studies confirm that endothelial cells also represent an important target for GCs. GCs regulate different aspects of endothelial physiology including expression of adhesion molecules, production of pro-inflammatory cytokines and chemokines, and maintenance of endothelial barrier integrity. However, the regulation of endothelial GC sensitivity remains incompletely understood. In this review, we specifically examine the endothelial response to GCs in various inflammatory diseases ranging from multiple sclerosis, stroke, sepsis, and vasculitis to atherosclerosis. Shedding more light on the cross talk between GCs and endothelium will help to improve existing therapeutic strategies and develop new therapies better tailored to the needs of patients.

Protective effect of Xuebijing injection on paraquat-induced pulmonary injury via down-regulating the expression of p38 MAPK in rats

Background

Exposure to paraquat results in acute lung injury. A systemic inflammatory response has been widely established as a contributor to paraquat-induced acute lung injury. Recent studies have reported that consumption of Xuebijing prevents inflammatory response-induced diseases. This study investigated whether consumption of Xuebijing protected rats against paraquat-induced acute lung injury.

Methods

Adult male Sprague Dawley rats were randomly divided into four groups: control group; paraquat group; paraquat + Xuebijing group; and paraquat + dexamethasone group. Rats in the paraquat, paraquat + Xuebijing and paraquat + dexamethasone groups were intraperitoneally injected with paraquat (30 mg/kg) or administered paraquat and Xuebijing at 8 mL/kg or dexamethasone at 5 mg/kg, respectively, via an injection into the tail vein. Lung p38 MAPK, NF-κB65, IkB, p-IκB-α, HIF-1α, Nrf2 and TGF-β1 expression were essayed using western blotting. IL-6, TNF-α, IL-1β, IL-10, TGF-β1 and PIIIP were measured using ELISA. ROS, oxidised glutathione and glutathione activity were measured.

Results

After inducing acute lung injury with paraquat for 24 h, Xuebijing was observed to block lung p-p38 MAPK, NF-κB65, HIF-1α, p-IκB-α and TGF-β1 expression, and increased Nrf2 and IkB expression. The numbers of neutrophils and lymphocytes and total number of cells were significantly lower in the Xuebijing group compared with the control group. IL-6, TNF-α, IL-1β, TGF-β1 and PIIIP levels were significantly decreased in the Xuebijing group. ROS and oxidised glutathione activity were markedly inhibited by Xuebijing. Histological evaluation showed attenuation of the effects of Xuebijing on paraquat-induced lung injury. Compared with the paraquat + dexamethasone group, the Xuebijing + paraquat group showed no significant differences.

Conclusions

Inhibiting the expression of p38 MAPK and NF-κB65 was crucial for the protective effects of Xuebijing on paraquat-induced acute lung injury. The findings suggest that Xuebijing could effectively ameliorate paraquat-induced acute lung injury in rats. Xuebijing was as effective as dexamethasone at improving paraquat-induced lung injury by regulating lung inflammation, lung function and oxidative stress responses.

Microbiology of hidradenitis suppurativa (acne inversa): a histological study of 27 patients

Hidradenitis suppurativa (acne inverse) (HS) is a chronic skin disease primarily affecting hair follicles. The aetiology of HS is unknown, but infection is believed to play some role. This retrospective study investigated the microbial colonization directly in skin appendices in HS skin samples. Archival samples from 27 patients with HS were screened by immunofluorescence labelling with monoclonal and polyclonal antibodies against Gram-positive bacteria, Propionibacterium acnes and Propionibacterium granulosum. Fluorescence in situ hybridization was used for further species identification of Staphylococcus spp. Overall, 17 patients (63%) were found positive for bacterial colonization. Of these, 15 showed colonization in hair follicles and/or sinus tracts. The most commonly identified bacteria were DAPI labelled coccoids that were seen in 71% of the positive patients in the form of biofilms and microcolonies. P. acnes was found as biofilms in hair follicles of two patients. Staphylococcus aureus and coagulase-negative staphylococci were not detected in any sample. The results of this study indicate a common bacterial presence in HS skin lesions. Bacterial biofilms are not uncommon and their pathogenic role needs further evaluation.

ISG12 is a critical modulator of innate immune responses in murine models of sepsis

Sepsis is still a major burden for our society with high incidence of morbidity and mortality each year. Molecular mechanisms underlying the systemic inflammatory response syndrome (SIRS) associated with sepsis are still ill defined and most therapies developed to target the acute inflammatory component of the disease are insufficient. Recently the role of nuclear receptors (NRs) became a major topic of interest in transcriptional regulation of inflammatory processes. Nuclear receptors, such as the peroxisome proliferators-activated receptors (PPARs), have been demonstrated to exert anti-inflammatory properties by interfering with the NFκB pathway. We identified the nuclear envelope protein, interferon stimulated gene 12 (ISG12), which directly interacts with NRs. ISG12 is a co-factor stimulating nuclear export of NRs, thereby reducing the anti-inflammatory potential of NRs such as NR4A1. To examine the role of ISG12 in acute inflammatory processes we used recently generated ISG12 deficient mice. We can clearly demonstrate that lack of ISG12 prolongs survival in experimental sepsis and endotoxemia. Furthermore we can show that several acute inflammatory parameters, such as systemic IL6 cytokine levels, are downregulated in septic ISG12-/- animals. Consistently, similar results were obtained in in vitro experiments in peritoneal macrophages derived from ISG12 deficient mice. In contrast, mice deficient for the nuclear receptor NR4A1 exhibited an exacerbated innate immune response, and showed a significantly higher mortality after lethal endotoxemic challenge. This dramatic phenotype could be restored in ISG12/NR4A1 double deficient mice. We conclude from our data in vitro and in vivo that ISG12 is a novel modulator of innate immune responses regulating anti-inflammatory nuclear receptors such as NR4A1.

Physiologic responses to severe hemorrhagic shock and the genesis of cardiovascular collapse: can irreversibility be anticipated?

BACKGROUND

The causes of cardiovascular collapse (CC) during hemorrhagic shock (HS) are unknown. We hypothesized that vascular tone loss characterizes CC, and that arterial pulse pressure/stroke volume index ratio or vascular tone index (VTI) would identify CC.

METHODS

Fourteen Yorkshire-Durock pigs were bled to 30 mmHg mean arterial pressure and held there by repetitive bleeding until rendered unable to compensate (CC) or for 90 min (NoCC). They were then resuscitated in equal parts to shed volume and observed for 2 h. CC was defined as a MAP < 30 mmHg for 10 min or <20 mmHg for 10 s. Study variables were recorded at baseline (B0), 30, 60, 90 min after bleeding and at resuscitation (R0), 30, and 60 min afterward.

RESULTS

Swine were bled to 32% ± 9% of total blood volume. Epinephrine (Epi) and VTI were low and did not change in NoCC after bleeding compared with CC swine, in which both increased (0.97 ± 0.22 to 2.57 ± 1.42 mcg/dL, and 173 ± 181 to 939 ± 474 mmHg/mL, respectively), despite no differences in bled volume. Lactate increase rate (LIR) increased with hemorrhage and was higher at R0 for CC, but did not vary in NoCC. VTI identified CC from NoCC and survivors from non-survivors before CC. A large increase in LIR was coincident with VTI decrement before CC occurred.

CONCLUSIONS

Vasodilatation immediately prior to CC in severe HS occurs at the same time as an increase in LIR, suggesting loss of tone as the mechanism causing CC, and energy failure as its probable cause.

Validation of a low-dose ACTH stimulation test in healthy adult horses

OBJECTIVE

To determine the lowest ACTH dose that would induce a maximum increase in serum cortisol concentration in healthy adult horses and identify the time to peak cortisol concentration.

DESIGN

Evaluation study.

ANIMALS

8 healthy adult horses.

PROCEDURES

Saline (0.9% NaCl) solution or 1 of 4 doses (0.02, 0.1, 0.25, and 0.5 μg/kg [0.009, 0.045, 0.114, and 0.227 μg/lb]) of cosyntropin (synthetic ACTH) were administered IV (5 treatments/horse). Serum cortisol concentrations were measured before and 30, 60, 90, 120, 180, and 240 minutes after injection of cosyntropin or saline solution; CBCs were performed before and 30, 60, 120, and 240 minutes after injection.

RESULTS

For all 4 doses, serum cortisol concentration was significantly increased, compared with the baseline value, by 30 minutes after administration of cosyntropin; no significant differences were detected among maximum serum cortisol concentrations obtained in response to administration of doses of 0.1, 0.25, and 0.5 μg/kg. Serum cortisol concentration peaked 30 minutes after administration of cosyntropin at a dose of 0.02 or 0.1 μg/kg, with peak concentrations 1.5 and 1.9 times, respectively, the baseline concentration. Serum cortisol concentration peaked 90 minutes after administration of cosyntropin at a dose of 0.25 or 0.5 μg/kg, with peak concentrations 2.0 and 2.3 times, respectively, the baseline concentration. Cosyntropin administration significantly affected WBC, neutrophil, and eosinophil counts and the neutrophil-to-lymphocyte ratio.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that in healthy horses, administration of cosyntropin at a dose of 0.1 μg/kg resulted in maximum adrenal stimulation, with peak cortisol concentration 30 minutes after cosyntropin administration.

Adrenocortical (dys)function in septic shock - a sick euadrenal state

A central feature of the endocrine pathophysiology of septic shock is thought to be the existence of adrenal dysfunction. Based on changes in glucocorticoid secretion and responsiveness, protein binding, and activity. These changes have been described by the terms "Relative Adrenal Insufficiency" (RAI), or "Critical Illness Related Corticosteroid Insufficiency" (CIRCI), and form part of the rationale for trials of glucocorticoid treatment in septic shock. Diagnostic criteria for these conditions have been based on plasma cortisol profiles and have proven notoriously difficult to establish. The uncertainty in this area arises from the inability of current tests to clearly identify who is truly glucocorticoid "deficient" at a cellular level, and hence who requires supplemental glucocorticoid administration. Emerging data suggest that there may be abnormalities in the tissue activity of glucocorticoids in patients with severe sepsis and plasma profiles may not be reliable indicators of tissue glucocorticoid activity, We put forward an alternative point of view, that is the spectrum of adrenocortical dysfunction in sepsis - plasma and tissue, can be grouped under the umbrella of a "sick euadrenal syndrome" rather than an adrenocortical insufficiency.

Sepsis-associated encephalopathy and its differential diagnosis

Sepsis-associated encephalopathy (SAE) is defined as a diffuse cerebral dysfunction resulting from the systemic inflammatory response to an infection without direct infestation of the CNS. Although the pathophysiology of SAE is as yet unknown, some mechanisms have been suggested that involve BBB disruption as a consequence of proinflammatory mediators’ effects on endothelial cells. This leads to an increased passage of neurotoxic and proinflammatory mediators into the brain parenchyma, as well as an impairment of the movements of oxygen and metabolites through the BBB. Both neurons and glial cells are affected, resulting in neural functioning and neurotransmission impairment. The clinical translation of this process is an alteration of consciousness and awareness. SAE is a frequent condition in septic patients. Despite being considered reversible, SAE appears to be associated with long-term cognitive impairment. Detection and diagnosis can be challenging; it requires daily neurological assessment with the assistance of clinical scores. Use of biomarkers and neurophysiological testing is discussed. The aim of this article is to provide practical tools for detection of SAE, as well as an updated overview of its pathophysiology and therapeutic perspectives.

Adjunct therapy for sepsis: how early?

Sepsis is a leading cause of death worldwide. The management of patients is primarily based on curing the infectious process with anti-infective drugs and/or surgical drainage. Simultaneously, treatment includes optimization of oxygen use by tissues via appropriate oxygen therapy and respiratory and hemodynamic management. At best, initiating appropriate anti-infective and symptomatic treatments should lead to patient improvement within a few hours. Activated protein C and hydrocortisone are the only two available adjunct therapies for sepsis. These treatments should optimally be started within 24 hours of the onset of shock. They should be initiated in those patients who did not adequately respond after 6 hours of optimal anti-infective and symptomatic treatments.

Critical care management of patients before liver transplantation

The critical care management of patients before liver transplantation is aimed at optimizing hepatic and extrahepatic organ function before the transplant operation, with a goal to favorably influence perioperative and postoperative graft and patient outcomes. Critical illness in liver disease can present in the context of acute liver failure or acute on chronic liver failure. The differing pathophysiologic processes underlying these 2 types of liver failure necessitate specific approaches to their intensive care management. In their extreme presentations, both types of liver failure present as multiorgan system failure; and therefore, the critical care management of these entities requires a systematic multiorgan system approach to address hepatic and extrahepatic organ dysfunction. This review provides a multiorgan system-based description of critical care management of acute liver failure and acute on chronic liver failure before liver transplantation.

Relationship of basal heart rate variability to in vivo cytokine responses after endotoxin exposure

Autonomic inputs from the sympathetic and parasympathetic nervous systems, as measured by heart rate variability (HRV), have been reported to correlate to the severity injury and responses to infectious challenge among critically ill patients. In addition, parasympathetic/vagal activity has been shown experimentally to exert anti-inflammatory effects via attenuation of splanchnic tissue TNF-alpha production. We sought to define the influence of gender on HRV responses to in vivo endotoxin challenge in healthy humans and to determine if baseline HRV parameters correlated with endotoxin-mediated circulating cytokine responses. Young (<30 years of age), healthy subjects (n = 30) received endotoxin (2 ng/kg), and HRV and blood samples were obtained serially thereafter. Plasma cytokines were measured by enzyme-linked immunosorbent assay, and HRV parameters were determined by analysis of serial 5-min epochs of heart rate monitoring. In addition, calculation of multiscale entropy deriving from cardiac monitoring data was performed. The influence of factors such as gender, body mass index, and resting heart rate on HRV after endotoxin exposure was assessed. We found that gender, body mass index, or resting heart rate did not significantly alter the HRV response after endotoxin exposure. Using entropy analysis, we observed that females had significantly higher entropy values at 24 h after endotoxin exposure. Using a serially sampling protocol for cytokine determination, we found a significant correlation of several baseline HRV parameters (percentage of interval differences of successive interbeat intervals more than 50 ms, r = 0.42, P < 0.05; high-frequency variability, r = 0.4, P < 0.05; and low-frequency/high-frequency ratio, r = -0.43, P < 0.05) on TNF-alpha release after endotoxin exposure.

Time-dependent inhibitory effect of lipopolysaccharide injection on Per1 and Per2 gene expression in the mouse heart and liver

Lipopolysaccharide (LPS) is a pathogen-associated large molecule responsible for sepsis-related endotoxic shock, and the heart is one of the most common organs adversely affected. LPS is reported to increase serum TNFalpha levels and reduce Per1 and Per2 gene expression. Therefore, in this experiment, we determined the time-dependent effects of LPS on heart rate (HR) and circadian gene expression in the mouse heart and liver. HR of the LPS group was significantly elevated 2 and 8 h after injection compared to the control group. A significant percent increase in HR was observed at ZT6, 12, and 18. LPS increased Tnfalpha mRNA expression in the heart and liver at ZT6, 18, and 24. A time-dependent effect of LPS on reduction of Per1 and Per2 gene expression was also observed in the heart and liver. In order to examine the effect of LPS on cell damage, we examined apoptosis-related gene expression after LPS injection. Bax mRNA expression level of the LPS group was higher than that of the control group 8 and 26 h after injection. On the other hand, Bcl2 mRNA expression level of the LPS group was lower than that of the control group 2 and 26 h after injection. Dexamethasone strongly attenuated the LPS-induced increase of serum TNFalpha without significant change in Per1 and Per2 gene expression in the heart. In conclusion, the present results demonstrated that LPS exerts a time-dependent inhibitory effect on Per1 and Per2 gene expression in the heart and liver. The chronopharmacological lethal effect of LPS may be related to the time-dependent increase of serum TNFalpha level and simultaneously high level of Per2 gene expression in the heart and liver between ZT12-18. Taken together, chronopharmacological effect of LPS may be related to not only sickness behavior syndrome and mortality, but also circadian rhythm systems.

Therapeutic strategies targeting the endothelial glycocalyx: acute deficits, but great potential

Damage of the endothelial glycocalyx, which ranges from 200 to 2000 nm in thickness, decreases vascular barrier function and leads to protein extravasation and tissue oedema, loss of nutritional blood flow, and an increase in platelet and leucocyte adhesion. Thus, its protection or the restoration of an already damaged glycocalyx seems to be a promising therapeutic target both in an acute critical care setting and in the treatment of chronic vascular disease. Drugs that can specifically increase the synthesis of glycocalyx components, refurbish it, or selectively prevent its enzymatic degradation do not seem to be available. Pharmacological blockers of radical production may be useful to diminish the oxygen radical stress on the glycocalyx. Tenable options are the application of hydrocortisone (inhibiting mast-cell degranulation), use of antithrombin III (lowering susceptibility to enzymatic attack), direct inhibition of the cytokine tumour necrosis factor-alpha, and avoidance of the liberation of natriuretic peptides (as in volume loading and heart surgery). Infusion of human plasma albumin (to maintain mechanical and chemical stability of the endothelial surface layer) seems the easiest treatment to implement.

Combined immunosuppressive and antibiotic therapy improves bacterial clearance and survival of polymicrobial septic peritonitis

Effective immunosuppressive therapy is essential to prevent transplant rejection but renders patients vulnerable to opportunistic infections. The present study investigates the effects of common immunosuppressive drugs on the course of septic peritonitis in an experimental mouse model. We show that treatment with a combination of tacrolimus, mycophenolate mofetil, and methylprednisolone resulted in highly elevated lethality of septic peritonitis. When immunosuppressive drugs were combined with antibiotic therapy, however, mice were almost completely protected. The combination of mycophenolate mofetil and methylprednisolone was shown to be required and sufficient to improve outcome of septic peritonitis in the presence of antibiotic therapy. Combined immunosuppressive and antibiotic therapy, but not antibiotic therapy alone, resulted in enhanced bacterial clearance. These beneficial effects were linked to an elevated expression of activation markers and an increased production of reactive oxygen metabolites by peritoneal neutrophils and correlated with a reduced messenger RNA expression of the inhibitory cytokine IL-22. In contrast, systemic or peritoneal levels of IL-10, IL-12, TNF-alpha, keratinocyte chemoattractant, and monocyte chemoattractant protein 1, and splenic messenger RNA levels of IFN-gamma were not influenced by the immunosuppressive therapy. These results therefore suggest that combined immunosuppressive and antibiotic therapy may improve bacterial clearance and survival of septic peritonitis by a mechanism that involves enhanced activation and antimicrobial activity of neutrophils and reduced production of IL-22.

Selective iNOS inhibition for the treatment of sepsis-induced acute kidney injury

The incidence and mortality of sepsis and the associated development of acute kidney injury (AKI) remain high, despite intense research into potential treatments. Targeting the inflammatory response and/or sepsis-induced alterations in the (micro)circulation are two therapeutic strategies. Another approach could involve modulating the downstream mechanisms that are responsible for organ system dysfunction. Activation of inducible nitric oxide (NO) synthase (iNOS) during sepsis leads to elevated NO levels that influence renal hemodynamics and cause peroxynitrite-related tubular injury through the local generation of reactive nitrogen species. In many organs iNOS is not constitutively expressed; however, it is constitutively expressed in the kidney and, in humans, a relationship between the upregulation of renal iNOS and proximal tubular injury during systemic inflammation has been demonstrated. For these reasons, the selective inhibition of renal iNOS might have important implications for the treatment of sepsis-induced AKI. Various animal studies have demonstrated that selective iNOS inhibition-in contrast to nonselective NOS inhibition-attenuates sepsis-induced renal dysfunction and improves survival, a finding that warrants investigation in clinical trials. In this Review, the selective inhibition of iNOS as a potential novel treatment for sepsis-induced AKI is discussed.

Extra-adrenal glucocorticoid synthesis in the intestinal epithelium: more than a drop in the ocean?

Glucocorticoids (GC) are lipophilic hormones commonly used as therapeutics in acute and chronic inflammatory disorders such as inflammatory bowel disease due to their attributed anti-inflammatory and immunosuppressive actions. Although the adrenal glands are the major source of endogenous GC, there is increasing evidence for the production of extra-adrenal GC in the brain, thymus, skin, vasculature, and the intestine. However, the physiological relevance of extra-adrenal-produced GC remains still ambiguous. Therefore, this review attracts attention to discuss possible biological benefits of extra-adrenal-synthesized GC, especially focusing on the impact of locally synthesized GC in the regulation of intestinal immune responses.

Immunomodulation in the critically ill

Immunotherapy in the critically ill is an appealing notion because of the apparent abnormal immune and inflammatory responses seen in so many patients. The administration of a medication that could alter immune responses and decrease mortality in patients with sepsis could represent a ‘magic bullet’. Various approaches have been tried over the last 20 yr: steroids; anti-endotoxin or anti-cytokine antibodies; cytokine receptor antagonists; and other agents with immune-modulating side-effects. However, in some respects, research along these lines has been unsuccessful or disappointing at best. The current state of knowledge is summarized with particular reference to sepsis and the acute respiratory distress syndrome.

The role of MAP kinase phosphatase-1 in the protective mechanism of dexamethasone against endotoxemia

AIMS

We have previously shown that glucocorticoids induce the expression of MAP kinase phosphatase (Mkp)(a)-1 in innate immune cells. Since Mkp-1 is a critical negative regulator of the innate immune response, we hypothesize that Mkp-1 plays a significant role in the anti-inflammatory action of glucocorticoids. The specific aim of the present study is to understand the role of Mkp-1 in the anti-inflammatory function of glucocorticoids.

MAIN METHODS

Wild-type and Mkp-1(-/-) mice were treated with different doses of dexamethasone and then challenged with different doses of lipopolysaccharide (LPS). The survival and blood cytokines were assessed. The effects of dexamethasone on cytokine production in wild-type and Mkp-1(-/-) primary macrophages ex vivo were also examined.

KEY FINDINGS

We found that dexamethasone induced the expression of Mkp-1 in vivo. Dexamethasone treatment completely protected wild-type mice from the mortality caused by a relatively high dose of LPS. However, dexamethasone treatment offered only a partial protection to Mkp-1(-/-) mice. Dexamethasone attenuated TNF-alpha production in both wild-type and Mkp-1(-/-) mice challenged with LPS, although TNF-alpha production in Mkp-1(-/-) mice was significantly more robust than that in wild-type mice. Dexamethasone pretreatment shortened the duration of p38 and JNK activation in LPS-stimulated wild-type macrophages, but had little effect on p38 or JNK activation in similarly treated Mkp-1(-/-) macrophages.

SIGNIFICANCE

Our results indicate that the inhibition of p38 and JNK activities by glucocorticoids is mediated by enhanced Mkp-1 expression. These results demonstrate that dexamethasone exerts its anti-inflammatory effects through both Mkp-1-dependent and Mkp-1-indepent mechanisms.

Methylene blue in the treatment of vasoplegia following severe burns

Vasoplegia resulting from severe burns may persist despite adequate fluid resuscitation and treatment with norepinephrine (NE), vasopressin (VP), and steroids. The adenylate cyclase inhibitor methylene blue (MB), currently used in the burn patient to treat methemoglobinemia, has been used to treat vasoplegia after cardiopulmonary bypass. We report the case of MB infusion in two burn patients refractory to NE. The patients had severe burns, 95 and 80% TBSA not responding to conventional treatment. Fluid requirements were estimated according to Parkland formula and then to maintain a urinary output of 30-50 ml/hr. Patient #1, 95% TBSA, was adrenally insufficient and was receiving steroids according to the Annane protocol, as well as VP at 0.2 U/min. His NE requirements were 55 mcg/kg/min. Patient #2, 80% TBSA, was receiving 20 mcg/kg/min of NE. Circulatory failure was defined as inability to maintain mean arterial pressure >70 mm Hg. Hemodynamic and physiologic parameters were measured before and after infusion of a single dose of 2 mg/kg of MB. Both patients showed dramatic improvements in their shock after MB. Patient #1 had an initial reaction within 30 minutes and reached peak effect at 1 hour. His NE requirements decreased to 0.2 mcg/kg/min and VP decreased to 0.04 U/min. Patient #2 showed effects within 15 minutes of the infusion and by 2 hours the NE was stopped. No adverse side effects were noted in either of the two patients. The fact that MB successfully reversed refractory vasoplegia after severe burns suggests a new tool for treating a small subgroup of patients who exhibit persistent vasoplegia from their burn injury. A controlled randomized trial is needed to test its effects on a large number of patients and graft survival.

Is steroid therapy ever of benefit to patients in the intensive care unit going into septic shock

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, is steroid therapy ever of benefit to patients in the intensive care unit going into septic shock? Using the reported search 1505 papers were identified. Fourteen papers represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. Recent guidelines from the Surviving Sepsis Campaign recommend using stress doses of corticosteroids for septic shock regardless of adrenal function. All patients undergoing cardiothoracic surgery are at risk of developing septic shock. The 14 papers demonstrated that 28-day mortality is unaffected by hydrocortisone, however, the time to shock reversal is significantly reduced. Steroids reduced inflammatory mediators (IL-6, IL-8 and CRP) and neutrophil activation whilst maintaining neutrophil phagocytic functions. Haemodynamically, they increased systemic vascular resistance (SVR) and mean arterial pressure (MAP) and reduced heart rate (HR) and glomerular permeability. We conclude that steroids have no effect on mortality but shorten time to shock reversal, therefore they have a limited capacity in septic shock patients. Their immunological and haemodynamic effects cannot be discounted and could benefit patients in severe septic shock with adrenal insufficiency.

Adrenal insufficiency in critical illness

One of the more controversial areas in critical care in recent decades relates to the issue of adrenal insufficiency and its treatment in critically ill patients. There is no consensus on which patients to test for adrenal insufficiency, which tests to use and how to interpret them, whether to use corticosteroids, and, if so, who to treat and with what dose. This review illustrates the complexity and diversity of pathophysiological changes in glucocorticoid secretion, metabolism, and action and how these are affected by various types of illness. It will review adrenal function testing and give guidance on corticosteroid replacement regimens based on current published literature. There remain inherent difficulties in interpreting the effects of glucocorticoid replacement during critical illness because of the diversity of effects of glucocorticoids on various tissues. Investigation and treatment will depend on whether the likely cause of corticosteroid insufficiency is adrenal or central in origin.

Vascular biology in sepsis: pathophysiological and therapeutic significance of vascular dysfunction

Sepsis is the leading cause of mortality in critically ill patients. In this pathological syndrome, septic shock and sequential multiple organ failure correlate with poor outcome. The pathophysiology of sepsis with acute organ dysfunction involves a highly complex, integrated response that includes activation of number of cell types, inflammatory mediators, and the hemostatic system. Central to this process may be alterations in vascular functions. This review article provides a growing body of evidence for the potential impact of vascular dysfunction on sepsis pathophysiology with a major emphasis on the endothelium. Furthermore, the role of apoptotic signaling molecules in the mechanisms underlying endothelial cell injury and death during sepsis and its potential value as a target for sepsis therapy will be discussed, which may help in the assessment of ongoing therapeutic strategies.

Adrenal insufficiency in early phase of pediatric acute lung injury/acute respiratory distress syndrome

INTRODUCTION

Adequate adrenal function is essential to survive critical illness. Several recent articles have reported the significant effect of adrenal insufficiency (AI) in patients with sepsis. However, the prevalence of AI in pediatric acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is so far still scanty. Thus, we elected to study its prevalence and its clinical outcome.

METHODS

This is a cross-sectional observational study. We enrolled eligible infants and children aged between 1 month and 15 years who were admitted to our tertiary pediatric intensive care unit from February 1, 2005, to December 31, 2005, with ALI or ARDS diagnosed by the American-European Consensus criteria. A short corticotropin stimulation test (250 microg) was done within 24 hours of enrollment, and all clinical data were also recorded. Cortisol levels were measured at baseline, 30 minutes, and 60 minutes posttest. Adrenal insufficiency was defined as a baseline cortisol level of less than 15.1 microg/dL or an increment of cortisol level of less than 9 microg/dL after the adrenocorticotropic hormone stimulation test.

RESULTS

Of 507 patients admitted to the pediatric intensive care unit, there were 20 diagnosed with ALI/ARDS. Of 20 children, 16 met the inclusion criteria and had none of the exclusion criteria. Of 16, there were 9 (56%) with ARDS, and 7 (44%) of 12 had ALI. The prevalence of AI was observed in 37.5% (6/16), diagnosed by baseline level criteria in 25% (4/16) and by incremental criteria in 12.5% (2/16). The Baseline level of the adrenocorticotropic hormone was 7.8 +/- 5 (nmol/L). The median age in the AI group was 2 months. Of 6 children, 5 (83.3%) were in the ARDS group. Pediatric Risk of Mortality III score was significantly higher in the AI group compared with that in the non-AI (P < .05). Initial Pao(2)/fraction of inspired oxygen ratio tended to be lower in the AI group (123.2 +/- 62.2) compared with that in the non-AI group (183.8 +/- 79.1), although not statistically significant (P = .1). The mortality was also not statistically different between the AI (1/6, 16.7%) and the non-AI groups (1/10, 10%).

CONCLUSIONS

Our study demonstrated that the prevalence of AI was common in pediatric ALI/ARDS. These results would be an initial step to further study the impact of AI on clinical outcomes of these children in a larger scale.

Corticosteroid treatment of severe community-acquired pneumonia

OBJECTIVE

To assess the evidence for adjunctive corticosteroids for severe community-acquired pneumonia (CAP).

DATA SOURCES

MEDLINE (1966-February 2007) and EMBASE (1980-February 2007) were searched to identify English- and French-language publications that evaluated the use of corticosteroids for CAP in adults. Major search terms included community-acquired pneumonia, intensive care unit, steroids, glucocorticoids, and adrenal cortex hormones.

STUDY SELECTION AND DATA EXTRACTION

Clinical studies that evaluated the use of corticosteroids for CAP in adults were included. Clinical and surrogate markers of pneumonia were evaluated.

DATA SYNTHESIS

Severe CAP is associated with an increase in pulmonary and circulatory cytokines such as interleukin-6 and tumor necrosis factor-alpha that may be associated with higher mortality. Corticosteroids suppress inflammatory reactions and prevent migration of inflammatory cells from the circulation to tissues by suppressing the synthesis of chemokines and cytokines. One observational comparative study and 2 randomized, controlled studies examined the effects of corticosteroid therapy at various doses on endpoints of pulmonary and systemic inflammation and clinical outcomes. One small observational pilot study revealed that methylprednisolone blunted some of the pulmonary and systemic markers of inflammation. One small, randomized, placebo-controlled study revealed that hydrocortisone had no significant effects on markers of pulmonary and systemic inflammation or clinical outcomes. Another small, randomized, placebo-controlled preliminary study with methodological limitations revealed improvements in oxygenation, organ dysfunction score, and markers of inflammation favoring hydrocortisone over placebo.

CONCLUSIONS

Given the lack of proven benefit on clinically meaningful endpoints and adverse events, corticosteroids cannot be recommended for adjunctive treatment of severe CAP.

Therapeutic and prognostic considerations in catastrophic antiphospholipid syndrome

Catastrophic antiphospholipid syndrome (CAPS) is a rapidly progressive life-threatening disease that causes multiple organ thromboses in the presence of antiphospholipid antibodies. High index of clinical suspicion and careful investigation are required to make an early diagnosis so that treatment with anticoagulation, corticosteroids, and plasma exchange or intravenous immunoglobulins can be initiated. Despite this multi-modal treatment, CAPS is associated with high mortality; evidence-based management recommendations do not exist due to the rarity of the condition and the lack of controlled studies. This article reviews the therapeutic and prognostic controversies that were addressed during the 1st International Symposium on CAPS.

Low-dose hydrocortisone during severe sepsis: effects on microalbuminuria

OBJECTIVE

The aim of this study was to investigate the effect of low-dose hydrocortisone on glomerular permeability measured by the microalbuminuria to creatinine ratio (MACR) and on other markers of sepsis in severe septic patients.

DESIGN

Randomized prospective study.

SETTING

University intensive care unit.

PATIENTS

The study involved 40 patients with severe sepsis randomized into the hydrocortisone group (n = 20) and the standard therapy group (n = 20).

INTERVENTIONS

The hydrocortisone group received standard therapy plus a continuous infusion of hydrocortisone for 6 days, whereas the standard therapy group received only standard therapy.

MEASUREMENTS AND MAIN RESULTS

MACR, serum C-reactive protein, and procalcitonin concentrations were recorded every day from the day before the steroid therapy (T(0)) until the 6 days after (T(1), T(2), T(3), T(4), T(5), and T(6)). Concentrations in the hydrocortisone group and the standard therapy group were compared using Mann-Whitney test at each time. We also compared with Wilcoxon signed rank test the values determined in each group at T(0) with those at each subsequent time. Median MACR decreased from T(0) to T(6) in both patient groups; however, values were significantly lower in the hydrocortisone group from T(3) through to T(6). Median serum C-reactive protein also decreased from T(0) in both patient groups, with significantly lower values in the hydrocortisone group from T(3) through to T(6). There were no significant differences in procalcitonin between groups compared with baseline values or at any individual time point.

CONCLUSIONS

Low-dose hydrocortisone seems to reduce MACR and serum C-reactive protein but not procalcitonin in patients with severe sepsis. Further studies are needed to confirm these results and to understand the underlying molecular mechanisms.