Decreasing Magnitude of Multiple Organ Dysfunction Syndrome Despite Increasingly Severe Critical Surgical Illness: A 17-Year Longitudinal Study

Continuous blood purification ameliorates clinical signs and corrects the plasma phospholipid levels of patients with multiple organ dysfunction syndromes

BACKGROUND

Multiple organ dysfunction syndromes (MODS) is reported as a leading cause of mortality in intensive care units. Recently, continuous blood purification (CBP) has been mostly applied for MODS treatment. Thus, the purpose of this study was to investigate the effects of CBP on plasma phospholipid level in patients with MODS.

METHODS

A total of 126 patients with MODS and 120 healthy people were collected. The serum cytokine levels, blood biochemical parameters, and blood gas indexes were detected, and the correlation among phospholipid compounds with serum cytokine levels, blood biochemical parameters, and blood gas indexes was analyzed.

RESULTS

Before CBP, levels of body temperature, RR, HR, CVP, IL-6, IL-10, TNF-α, BUN, SCr, PaCO₂ , SM747, and LPC540 were obviously higher, and pH, HCO_3- , PaO₂ , SaO₂ , PE750, PI885, PC792, PC826, PC830, PC854, PC802, and PG747 were lower in the MODS group than those in the control group. During CBP, the MODS group had gradually declined RR, CVP, levels of IL-6, IL-10 and TNF-α, BUN, SCr, PaCO₂ , SM747, and LPC540 and increased HCO_3- , PaO₂ and SaO₂ , PE750, PI885, PC792, PC826, PC830, PC854, PC802, and PG747. Besides, levels of PE750, PI885, PC792, PC826, PC830, PC854, PC802, and PG747 had an obvious negative correlation with levels of TNF-α, IL-10, IL-6, BUN, SCr, and PaCO₂ , and a significant positive correlation with levels of HCO_3- , PaO₂ , and SaO₂ .

CONCLUSION

CBP could effectively ameliorate clinical signs of patients with MODS and correct the plasma phospholipid levels.

Outcomes of Surgical Sepsis

BACKGROUND

Discussion of outcomes of surgical sepsis is no longer straightforward. Definitions of sepsis have changed recently and updated data are scant. Surgical patient populations are often heterogeneous; the patient population being considered must be described with precision. Traditional 30-d operative mortality may not be the most relevant outcome to consider. What should change or be the emphasis going forward?

METHODS

Review and synthesis of pertinent English-language literature.

RESULTS

Epidemiologic data are abundant for short-term outcomes of sepsis in general, but despite the fact that approximately 30% of patients with sepsis are surgical patients, sepsis outcome data for surgical patients are scant, especially for durations longer than 30 d, and essentially non-existent for patients defined under the new Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria. Interpretability of extant data is hampered by non-standard and changing definitions.

CONCLUSIONS

Sepsis and organ dysfunction may be decreasing in prevalence and magnitude among surgical patients, but terminology must be standardized to enhance the interpretability of data generated in the future. It behooves journal editors, reviewers, and authors to insist upon standardized definitions and rigorous study design and data interpretation. Longer term data (e.g., 90-d mortality as opposed to in-hospital or traditional 30-d mortality) will be needed to justify to payers the complex, expensive care that these patients require. There is an urgent need to redefine the research agenda for surgical infections.

Scoring System for Multiple Organ Dysfunction in Adult Horses with Acute Surgical Gastrointestinal Disease

Background

The prevalence of multiple organ dysfunction syndrome (MODS) in horses with acute surgical gastrointestinal (GI) disease is unknown. Currently, there are no validated criteria to confirm MODS in adult horses.

Objectives

To develop criteria for a MODS score for horses with acute surgical colic (MODS SGI) and evaluate the association with 6‐month survival. To compare the MODS SGI score with a MODS score extrapolated from criteria used in people (MODS EQ).

Animals

Adult horses that required exploratory laparotomy (n = 62) for colic. Healthy adult horses undergoing elective surgical procedures (n = 12) established the reference range of some variables.

Methods

Prospectively, a MODS SGI score was developed based on organ‐specific criteria established from a literature review, data collection, and clinical judgment. Data for scoring each horse were collected on Days 1 and 2 postoperatively. Horses were scored retrospectively using both scoring criteria. The prognostic performance of the MODS SGI score and its overall performance compared with the MODS EQ score were assessed with receiver operating characteristic (ROC) curve analysis.

Results

The MODS SGI score had excellent performance for predicting 6‐month survival with an area under the ROC curve (AUC) of 0.95 (95% CI: 0.87–0.99). The AUC for the MODS SGI score was significantly higher than the MODS EQ (AUC: 0.76; 0.63–0.86).

Conclusions and Clinical Importance

The MODS SGI score predicts 6‐month survival from discharge in horses with acute surgical colic. The MODS SGI score performed better than a score extrapolated from human scoring systems.

Survival in fully manifest multiple organ dysfunction syndrome

BACKGROUND

Multiple organ dysfunction syndrome (MODS) is the leading cause of death in intensive care units throughout the world. Several composite clinical scores, such as the Multiple Organ Dysfunction (MOD) score and Sequential Organ Failure Assessment (SOFA) score, have been developed to assess the severity of critical illness and predict mortality. Survival in fully manifest MODS is nearly unprecedented.

METHODS

Case report and review of the relevant literature.

CASE REPORT

A 55-year-old male was admitted to the neurologic intensive care unit with left lateral medullary syndrome, and access for permanent enteral feeding was indicated. On day 7 of the patient's hospitalization an attempt was made to place a gastrostomy tube in the patient, but the procedure was aborted after unexplained intra-operative hemodynamic instability. Eight days later the patient developed florid MODS of unclear etiology. His daily MOD and SOFA scores peaked at 16 and 20, respectively, and his cumulative MOD and SOFA scores peaked at 19 and 22, respectively, portending 100% mortality. Over the next 6 wks the patient gradually recovered nearly all organ function, until both his MOD and SOFA scores decreased to 1. He was discharged to a sub-acute rehabilitation facility.

CONCLUSIONS

This patient is the oldest patient reported to have survived fully manifest MODS. Whereas scoring systems such as the MOD and SOFA systems can be useful tools, they have several limitations and their results must be interpreted with caution.

Treatment with Fms-like tyrosine kinase 3 ligand reverses lung dendritic cell immunoparalysis and ameliorates zymosan-induced secondary lung injury in mice

Depletion and dysfunction of dendritic cells in the lung can induce local immunoparalysis, which often leads to multiple organ dysfunction syndrome (MODS)-associated mortality. A therapeutic strategy that reverses this immunoparalysis is required. In the present study, we examined the effects of in vivo Fms-like tyrosine kinase 3 ligand (Flt3L) treatment on zymosan (zym)-induced secondary lung injury and dendritic cell (DC) immunoparalysis. BALBc mice were divided randomly into four groups (20/group): (1) sham [intraperitoneal (i.p.) saline] + vehicle [subcutaneous (s.c.) 0·01% mouse serum albumin]; (2) sham + Flt3L (s.c.); (3) zym (i.p.) + vehicle; and (4) zym + Flt3L. Injections were for 9 consecutive days; 12 days later we examined: survival rate (monitored for 12 days); lung tissue histopathology (haematoxylin and eosin staining); plasma indices of lung function (pH, PaO(2) , PaCO(2) , HCO(3) (-) ); DC subsets in lung tissue; and lung DCs production of interleukin (IL)-12p70 and IL-10. Zym administration resulted in increased mortality associated with significant lung histopathological changes and abnormal blood gas indices; however, these pathological changes were ameliorated by Flt3L treatment. Zym injections also resulted in significant reductions in DC subsets recovered from lungs [CD11c(+) major histocompatibility complex (MHC)-II/I-A(d+) , CD11c(+) CD11b(+) and CD11c(+) B220(+) ]. Importantly, in-vivo Flt3L treatment reversed these trends for DC immunoparalysis by increasing the percentages of recovered DC subsets concomitant with increased DC production of IL-12 p70 and decreased IL-10 production. These results suggest that Flt3L may have therapeutic potential for reversing DC immunoparalysis and ameliorating lung injury secondary to MODS.

Antibiotic heterogeneity optimizes antimicrobial prescription and enables resistant pathogen control in the intensive care unit

BACKGROUND

Multi-drug-resistant organisms (MDRO) complicate care increasingly on the general ward and in the emergency department, operating room, and intensive care unit (ICU). Whereas barrier precautions are important in limiting transmission of MDRO between patients, few tactics have been defined that reduce the genesis of MDRO.

METHOD

Review of pertinent English-language literature.

RESULTS

Antibiotic heterogeneity practices, as part of an overall antimicrobial drug stewardship program, offer one readily deployable means to reduce selection pressure for MDRO development in the ICU. The data underpinning this approach and data derived from its use indicate that, especially in surgical ICUs, heterogeneity of antibiotic prescribing can preserve or restore microbial ecology, reduce the prevalence of MDRO and the incidence of infections caused thereby, and facilitate the implementation and effectiveness of other antibiotic-sparing tactics, such as de-escalation.

CONCLUSION

Heterogeneity of antibiotic prescribing is effective in preventing the dissemination of MDRO pathogens.