Primary sepsis in a university hospital in northern Sweden: a retrospective study

The Patient's Gender Influencing the Accuracy of Diagnosis and Proposed Sepsis Treatment in Constructed Cases

Background

Male sex is an independent risk factor for sepsis development. In addition to immunological gender differences, women less often receive sepsis treatment once diagnosed. Gender differences have also been described in other medical conditions, such as acute coronary syndrome.

Aim

To study whether the gender of patients influenced physicians' tendency to suspect sepsis and propose correct initial sepsis treatment in constructed cases.

Method

Four cases were constructed to fulfil the sepsis-3 criteria as well as raise clinical suspicions of other common medical differential diagnoses. Two of the cases were drafted in two versions, only differing in the gender of the patient. The two versions were randomly distributed to all clinical physicians in a medical region in Sweden. The responding physicians were asked to state the three most important diagnoses and the three most important initial treatments for each case. If sepsis were among the stated diagnoses together with fluids and antibiotics, the case was considered as correctly identified and initially treated sepsis.

Results

120 hospital physicians answered the cases. In the case the patient was a female, the respondents correctly identified and treated sepsis significantly more often than if the patient was of the male sex (Case 1: 12/58 vs 2/62, p < 0.01 and Case 2: 25/62 vs 13/58, p < 0.05).

Conclusion

A low proportion of Swedish physicians identified and proposed treatment for sepsis in four constructed cases. In the case the patient strongly mimicked other diagnoses common in the male sex, the male cases were less often correctly identified and treated for sepsis.

Effects of propolis and melatonin on oxidative stress, inflammation, and clinical status in patients with primary sepsis: Study protocol and review on previous studies

BACKGROUND

Previous studies have explored the anti-inflammatory, anti-infection and oxidative stress reduction effects of propolis and melatonin in experimental studies. However, there are no studies at present exploring the effects of propolis and melatonin in patients with primary sepsis. The present study aims to evaluate the potential effects of propolis and melatonin as a pharmaceutical agent in patients with primary sepsis.

METHODS/DESIGN

The study will be conducted as a randomized controlled clinical trial at the Imamreza hospital. Patients with primary sepsis, in four equal groups, will be recruited for the study. The treatment drugs are propolis and melatonin and the placebo. The following primary and secondary outcome measures will be evaluated: APACHE II Score, SOFA score, NUTRIC score, inflammatory factors, and oxidative stress markers.

DISCUSSION

We describe the protocol for a clinical trial design evaluating the effects of simultaneous administration of propolis and melatonin in patients with primary sepsis. The result of the present study, positive or negative, should provide a step change in the evidence guiding current and future policies regarding the use of propolis and melatonin as an auxiliary treatment in patients with primary sepsis.

TRIAL REGISTRATION

Iranian Registry of Clinical Trials: IRCT20181025041460N1. Registered on 6 November 2018.

The impact of acute organ dysfunction on patients' mortality with severe sepsis

Background:

Severe sepsis leads to organ failure and results in high mortality. Organ dysfunction is an independent prognostic factor for intensive care unit (ICU) mortality. The objective of the present study was to determine the effect of acute organ dysfunction for ICU mortality in patients with severe sepsis using administrative data.

Materials and Methods:

A multicenter cross-sectional study was performed in 2008. The study was conducted in 112 teaching hospitals in Japan. All cases with severe sepsis in ICU were identified from administrative data.

Results:

Administrative data acquired for 4196 severe septic cases of 75,069 cases entered in the ICU were used to assess patient outcomes. Cardiovascular dysfunction was identified as the most major organ dysfunction (73.0%), and the followings were respiratory dysfunction (69.4%) and renal dysfunction (39.0%), respectively. The ICU mortality and 28-day means 28-day from ICU entry. were 18.8% and 27.7%, respectively. After adjustment for age, gender, and severity of illness, the hazard ratio of 2, 3, and ≥4, the organ dysfunctions for one organ failure on ICU mortality was 1.6, 2.0, and 2.7, respectively.

Conclusions:

We showed that the number of organ dysfunction was a useful indicator for ICU mortality on administrative data. The hepatic dysfunction was the highest mortality among organ dysfunctions. The hazard ratio of ICU death in severe septic patients with multiple organ dysfunctions was average 2.2 times higher than severe septic patients with single organ dysfunction.

Economic evaluation in critical care: a focus on severe sepsis in oncology

Hospital care, physician and clinical services, and prescription drugs continue to drive healthcare expenditures across healthcare systems and nations. The critical-care setting, owing to the complexity and intensity of care, is a high user of the resources that drive healthcare spending. Information regarding the cost and effectiveness of critical-care therapies is necessary to properly guide care and policies for this unique population. Many challenges exist for conducting and comparing economic evaluation in critical care. Recently, recommendations on cost and cost-effectiveness analysis in critical care have been developed that will guide future research. A focus area, severe sepsis in oncology, is reviewed to highlight the challenges and opportunities of economic evaluation in this setting.

Risk assessment in sepsis: a new prognostication rule by APACHE II score and serum soluble urokinase plasminogen activator receptor

INTRODUCTION

Early risk assessment is the mainstay of management of patients with sepsis. APACHE II is the gold standard prognostic stratification system. A prediction rule that aimed to improve prognostication by APACHE II with the application of serum suPAR (soluble urokinase plasminogen activator receptor) is developed.

METHODS

A prospective study cohort enrolled 1914 patients with sepsis including 62.2% with sepsis and 37.8% with severe sepsis/septic shock. Serum suPAR was measured in samples drawn after diagnosis by an enzyme-immunoabsorbent assay; in 367 patients sequential measurements were performed. After ROC analysis and multivariate logistic regression analysis a prediction rule for risk was developed. The rule was validated in a double-blind fashion by an independent confirmation cohort of 196 sepsis patients, predominantly severe sepsis/septic shock patients, from Sweden.

RESULTS

Serum suPAR remained stable within survivors and non-survivors for 10 days. Regression analysis showed that APACHE II ≥ 17 and suPAR ≥ 12 ng/ml were independently associated with unfavorable outcome. Four strata of risk were identified: i) APACHE II <17 and suPAR <12 ng/ml with mortality 5.5%; ii) APACHE II < 17 and suPAR ≥ 12 ng/ml with mortality 17.4%; iii) APACHE II ≥ 17 and suPAR <12 ng/ml with mortality 37.4%; and iv) APACHE II ≥ 17 and suPAR ≥ 12 ng/ml with mortality 51.7%. This prediction rule was confirmed by the Swedish cohort.

CONCLUSIONS

A novel prediction rule with four levels of risk in sepsis based on APACHE II score and serum suPAR is proposed. Prognostication by this rule is confirmed by an independent cohort.

Comparative study of survivor and nonsurvivor sepsis patients in a university hospital

To determine parameters associated with the evolution of sepsis, a five-year retrospective study was conducted in a university hospital. One hundred and four consecutive sepsis patients were evaluated, of whom 55.8% were men. The mortality was 68.3% and was associated with older age (p<0.05). Chronic comorbidities and infection site were not associated with prognosis. Gram-positive bacteria were more frequently identified in survivors (p<0.05), while non-detection of the germ was associated with mortality (p<0.01). Appropriate use of antibiotics (germ sensitive to at least one drug administered) was associated with survival (p<0.0001) while inappropriate use (p<0.05) or empirical use (p<0.01) were more frequent in nonsurvivors. Leukocytosis was the main abnormality (54.8%) detected on diagnosis, from the leukocyte count. During the evolution, normal leukocyte count was associated with survival (p<0.01) and leukocytosis with mortality (p<0.05). In conclusion, mortality was associated with nondetection of the pathogen, leukocytosis during the evolution of the sepsis and inappropriate or empirical use of antimicrobials. Evidence-based treatment that is directed towards modifiable risk factors might improve the prognosis for sepsis patients.

Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003

OBJECTIVE

To determine recent trends in rates of hospitalization, mortality, and hospital case fatality for severe sepsis in the United States.

DESIGN

Trend analysis for the period from 1993 to 2003.

SETTING

U.S. community hospitals from the Nationwide Inpatient Sample that is a 20% stratified sample of all U.S. community hospitals.

PATIENTS

Subjects of any age with sepsis including severe sepsis who were hospitalized in the United States during the study period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Utilizing International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for septicemia and major organ dysfunction, we identified 8,403,766 patients with sepsis, including 2,857,476 patients with severe sepsis, who were hospitalized in the United States from 1993 to 2003. The percentage of severe sepsis cases among all sepsis cases increased continuously from 25.6% in 1993 to 43.8% in 2003 (p < .001). Age-adjusted rate of hospitalization for severe sepsis grew from 66.8 +/- 0.16 to 132.0 +/- 0.21 per 100,000 population (p < .001). Age-adjusted, population-based mortality rate within these years increased from 30.3 +/- 0.11 to 49.7 +/- 0.13 per 100,000 population (p < .001), whereas hospital case fatality rate fell from 45.8% +/- 0.17% to 37.8% +/- 0.10% (p < .001). During each study year, the rates of hospitalization, mortality, and case fatality increased with age. Hospitalization and mortality rates in males exceeded those in females, but case fatality rate was greater in females. From 1993 to 2003, age-adjusted rates for severe sepsis hospitalization and mortality increased annually by 8.2% (p < .001) and 5.6% (p < .001), respectively, whereas case fatality rate decreased by 1.4% (p < .001).

CONCLUSIONS

The rate of severe sepsis hospitalization almost doubled during the 11-yr period studied and is considerably greater than has been previously predicted. Mortality from severe sepsis also increased significantly. However, case fatality rates decreased during the same study period.

Haemodynamic and metabolic effects of resuscitation with Ringer's ethyl pyruvate in the acute phase of porcine endotoxaemic shock

BACKGROUND

Ethyl pyruvate has been shown to possess anti-inflammatory and free radical scavenging properties. However, the haemodynamic effects of ethyl pyruvate have not been studied in detail. We investigated the systemic, regional and microcirculatory haemodynamic and metabolic effects of resuscitation with Ringer's ethyl pyruvate solution (REPS) vs. Ringer's acetate (RA) in an acute model of porcine endotoxaemic shock.

METHODS

Fourteen anaesthetized pigs received an infusion of endotoxin that was increased stepwise over 30 min to a rate of 2.5 microg/kg/h. After 60 min of endotoxaemia, the animals were resuscitated with either ethyl pyruvate 40 mg/kg, given as REPS, or the equivalent volume of RA, administered over 10 min. Thereafter, an infusion of either ethyl pyruvate 40 mg/kg/h, given as REPS, or the equivalent volume of RA, was started, and the maintenance fluid was reduced so that the total amount of fluid given was kept constant. The experiment was terminated after 300 min of endotoxaemia.

RESULTS

Endotoxin infusion led to a hypodynamic state that was reversed by fluid resuscitation after 60 min. Progressive deterioration ensued and, after 300 min, all animals were again hypodynamic. No differences in response to treatment were found between the groups with regard to systemic haemodynamics, renal artery or portal vein flow or microcirculatory flow in the liver, kidney, ileal serosa or mucosa. Metabolic acidosis and increased arterial blood lactate developed in both groups, but, in the REPS group, the base excess was significantly lower from 150 min and the anion gap was significantly higher at 150 and 210 min.

CONCLUSION

We could not demonstrate any difference between REPS and RA for resuscitation in this model of acute porcine endotoxaemic shock.