Management of sepsis and septic shock in infants and children

Integrated Electrochemical Aptamer Biosensing and Colorimetric pH Monitoring via Hydrogel Microneedle Assays for Assessing Antibiotic Treatment

Current methods for therapeutic drug monitoring (TDM) have a long turnaround time as they involve collecting patients' blood samples followed by transferring the samples to medical laboratories where sample processing and analysis are performed. To enable real-time and minimally invasive TDM, a microneedle (MN) biosensor to monitor the levels of two important antibiotics, vancomycin (VAN) and gentamicin (GEN) is developed. The MN biosensor is composed of a hydrogel MN (HMN), and an aptamer-functionalized flexible (Flex) electrode, named HMN-Flex. The HMN extracts dermal interstitial fluid (ISF) and transfers it to the Flex electrode where sensing of the target antibiotics happens. The HMN-Flex performance is validated ex vivo using skin models as well as in vivo in live rat animal models. Data is leveraged from the HMN-Flex system to construct pharmacokinetic profiles for VAN and GEN and compare these profiles with conventional blood-based measurements. Additionally, to track pH and monitor patient's response during antibiotic treatment, an HMN is developed that employs a colorimetric method to detect changes in the pH, named HMN-pH assay, whose performance has been validated both in vitro and in vivo. Further, multiplexed antibiotic and pH detection is achieved by simultaneously employing the HMN-pH and HMN-Flex on live animals.

Zerumin A attenuates the inflammatory responses in LPS-stimulated H9c2 cardiomyoblasts

Zerumin A (ZA) is one of the potential components of Curcuma amada rhizomes, and it has been shown to possess a variety of pharmacological activities. This study deals with the beneficial activity of ZA in lipopolysaccharide (LPS)-stimulated inflammation in H9c2 cardiomyoblasts. Herein, H9c2 cells were preincubated with ZA for 1 h and stimulated with LPS for 24 h. The cells were analyzed for the expression of various pro-inflammatory mediators and signaling molecules. Results showed that the cell viability was significantly improved and reactive oxygen species production was alleviated remarkably with ZA pretreatment. We also found that ZA pretreatment significantly suppressed the upregulation of inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX-2) protein levels, and nitric oxide (NO) release in LPS-stimulated cells. In addition, ZA significantly ameliorated LPS-elicited overexpression of pro-inflammatory chemokines and cytokines such as monocyte chemoattractant protein-1 (MCP-1), tumor necrosis factor α (TNF- α), interferon-γ (IFN-γ), and interleukin-1 (IL-1) in H9c2 cells, and it upregulated the synthesis of the anti-inflammatory cytokine interleukin-10 (IL-10). Moreover, pretreatment with ZA and the mitogen-activated protein kinases (MAPK) pathway inhibitors also reduced the phosphorylation of extracellular signal-regulated kinase (ERK), c-Jun N-terminal kinases (JNK), and p38. ZA significantly inhibited IkB-a phosphorylation and nuclear factor (NF)-kB p65 subunit translocation into nuclei. Overall data demonstrated that ZA protects cardiomyocytes against LPS injury by inhibiting NF-kB p65 activation via the MAPK signaling pathway in vitro. These findings suggest that ZA may be a promising agent for a detailed study for the prevention or treatment of myocardial dysfunction in sepsis.

Acute dialysis in children: results of a European survey

The number of children with acute kidney injury (AKI) requiring dialysis is increasing. To date, systematic analysis has been largely limited to critically ill children treated with continuous renal replacement therapy (CRRT). We conducted a survey among 35 European Pediatric Nephrology Centers to investigate dialysis practices in European children with AKI. Altogether, the centers perform dialysis in more than 900 pediatric patients with AKI per year. PD and CRRT are the most frequently used dialysis modalities, accounting for 39.4% and 38.2% of treatments, followed by intermittent HD (22.4%). In units treating more than 25 cases per year and in those with cardiothoracic surgery programs, PD is the most commonly chosen dialysis modality. Also, nearly one quarter of centers, in countries with a gross domestic product below $35,000/year, do not utilize CRRT at all. Dialysis nurses are exclusively in charge of CRRT management in 45% of the cases and pediatric intensive care nurses in 25%, while shared management is practiced in 30%. In conclusion, this survey indicates that the choice of treatment modalities for dialysis in children with AKI in Europe is affected by the underlying ethiology of the disease, organization/set-up of centers and socioeconomic conditions. PD is utilized as often as CRRT, and also intermittent HD is a commonly applied treatment option. A prospective European AKI registry is planned to provide further insights on the epidemiology, management and outcomes of dialysis in pediatric AKI.

Sitagliptin attenuates inflammatory responses in lipopolysaccharide-stimulated cardiomyocytes via nuclear factor-κB pathway inhibition

Glucagon-like peptide-1 (GLP-1) and GLP-1 receptors (GLP-1Rs) are responsible for glucose homeostasis, and have been shown to reduce inflammation in preclinical studies. The aim of the present study was to determine whether sitagliptin, an inhibitor of the enzyme dipeptidyl peptidase-4 (DPP-4), as a GLP-1 receptor agonist, exerts an anti-inflammatory effect on cardiomyoblasts during lipopolysaccharide (LPS) stimulation. Exposure to LPS increased the expression levels of tumor necrosis factor (TNF)-α, interleukin-6 (IL)-6 and IL-1β in H9c2 cells, and also resulted in elevations in cyclooxygenase-2 (COX-2) and inducible nitric oxide synthase (iNOS) expression and nuclear factor-κB (NF-κB) nuclear translocation. Treatment with the DPP-4 inhibitor sitagliptin dose-dependently downregulated the mRNA levels of IL-6, COX-2 and iNOS in LPS-stimulated H9c2 cells. In addition, sitagliptin inhibited the increased protein expression of IL-6, TNF-α and IL-1β. NF-κB mRNA expression was reduced and its translocation to the nucleus was suppressed by treatment with sitagliptin. The present results demonstrated that sitagliptin exerts a beneficial effect on cardiomyoblasts exposed to LPS by inhibiting expression of inflammatory mediators and suppressing NF-κB activation. These findings indicate that the DPP-4 inhibitor sitagliptin may serve a function in cardiac remodeling attributed to sepsis-induced inflammation.

Prognostic value of shock index in children with septic shock

OBJECTIVES

Septic shock is frequent in children and is associated with high mortality and morbidity rates. Early recognition of severe sepsis improve outcome. Shock index (SI), ratio of heart rate (HR) and systolic blood pressure (SBP), may be a good noninvasive measure of hemodynamic instability that has been poorly studied in children. The aim of the study was to explore the usefulness of SI as an early index of prognosis for septic shock in children.

METHODS

The study was retrospective and performed in 1 pediatric intensive care unit at a university hospital. The following specific data were collected at 0, 1, 2, 4, and 6 hours after admission: HR and SBP for SI calculation and lactate concentration. Patients were divided into 2 groups according to their outcome (death/survival).

RESULTS

A total of 146 children admitted with septic shock between January 2000 and April 2010 were included. Shock index was significantly different between survivors and nonsurvivors at 0, 4, and 6 hours after admission (P = 0.02, P = 0.03, and P = 0.008, respectively). Age-adjusted SIs were different between survivors and nonsurvivors at 0 and 6 hours, with a relative risk of death at these time points of 1.85 (1.04-3.26) (P = 0.03) and 2.17 (1.18-3.96) (P = 0.01), respectively. Moreover, an abnormal SI both at admission and at 6 hours was predictive of death with relative risk of 1.36 (1.05-1.76).

CONCLUSIONS

In our population of children with septic shock, SI was a clinically relevant and easily calculated predictor of mortality. It could be a better measure of hemodynamic status than HR and SBP alone, allowing for the early recognition of severe sepsis.

Serum level of cardiac troponin I in pediatric patients with sepsis or septic shock

OBJECTIVES

To evaluate serum level of contractile protein troponin I (cTnI) within the 24 hrs of sepsis and septic shock diagnosis in children and to correlate with the outcome (discharge from hospital or death).

DESIGN

Prospective, observational study.

SETTING

Pediatric Intensive Care Unit, at Hospital Infantil Nossa Senhora da Glória, Vitória, ES, Brazil.

PATIENTS

Two hundred eighteen consecutive admissions of septic patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Measurement of serum cTnI (IMMULITE cTnI assay, Diagnostic Product Corporation, Los Angeles, CA) and creatine kinase MB isoenzyme and electrocardiographic tracings were performed within 24 hrs of sepsis or septic shock diagnosis. The pediatric index of mortality, pediatric index of mortality-2 was calculated for each patient. Primary diseases most frequently associated were pneumonia (42%) and meningitis (18%). The overall mortality was 12% (27 cases), 2.7% in the sepsis group, and 33% in the septic shock group. Both Pediatric Index of Mortality and Pediatric Index of Mortality-2 reached good discrimination. Electrocardiographic abnormalities were infrequent (9.2%). Abnormal serum levels of cTnI occurred in ten (4.5%) patients, significantly more frequent in the septic shock group than in sepsis group (13% vs. 0.7%, respectively; p = 0.000). Although frequency of elevated serum cTnI was significantly higher in nonsurvivors than in survivors (5 of 27 vs. 5 of 191, respectively; p = 0.003), this frequency not showed significant relationship with electrocardiogram alteration, creatine kinase MB isoenzyme levels, etiology of sepsis, or length of hospital days. In addition, a logistic regression analysis, taking in account age, gender, length of hospital days, sepsis definition, presence of meningitis, creatine kinase MB isoenzyme, and cTnI serum levels, demonstrated that severity of septic disease was the only variable significantly associated with the death.

CONCLUSIONS

Evaluation of serum levels of cTnI within the first 24 hrs of diagnosis of sepsis or septic shock in children was not better than creatine kinase MB isoenzyme or clinical evaluation, to predict the outcome (death or discharge from hospital) of septic process.

Bench-to-bedside review: Developmental influences on the mechanisms, treatment and outcomes of cardiovascular dysfunction in neonatal versus adult sepsis

Sepsis is a significant cause of morbidity and mortality in neonates and adults, and the mortality rate doubles in patients who develop cardiovascular dysfunction and septic shock. Sepsis is especially devastating in the neonatal population, as it is one of the leading causes of death for hospitalized infants. In the neonate, there are multiple developmental alterations in both the response to pathogens and the response to treatment that distinguish this age group from adults. Differences in innate immunity and cytokine response may predispose neonates to the harmful effects of pro-inflammatory cytokines and oxidative stress, leading to severe organ dysfunction and sequelae during infection and inflammation. Underlying differences in cardiovascular anatomy, function and response to treatment may further alter the neonate's response to pathogen exposure. Unlike adults, little is known about the cardiovascular response to sepsis in the neonate. In addition, recent research has demonstrated that the mechanisms, inflammatory response, response to treatment and outcome of neonatal sepsis vary not only from that of adults, but vary among neonates based on gestational age. The goal of the present article is to review key pathophysiologic aspects of sepsis-related cardiovascular dysfunction, with an emphasis on defining known differences between adult and neonatal populations. Investigations of these relationships may ultimately lead to 'neonate-specific' therapeutic strategies for this devastating and costly medical problem.

Pediatric Sepsis: The Infection unto Death

A significant percentage of pediatric patients admitted to an ICU have an infectious disease process. Many infants and children go on to develop sepsis, a major cause of death in the intensive care unit. Caring for these children presents a collaborative challenge because of the multifactorial etiology and the complicated pathophysiology. This article focuses on the specific implications of sepsis for infants and children.

Management of septic shock in childhood

OBJECTIVE

The object of this review is to discuss the recognition and treatment of septic shock in children based on principles of resuscitation, antibiotic use and recent therapeutic advances.

METHODS

A comprehensive literature search combining these

METHODS

on-line searches of Ovid, PubMed, and Medline; hand searches of 25 international journals; a trawl of 26 textbooks; searches of reference lists of pertinent articles; and scans of abstracts of recent international meetings. Various national and international units were contacted with regard to current research therapeutic strategies, both published and unpublished.

CONCLUSIONS

Septic shock remains a leading cause of morbidity and mortality in children. Early administration of empirical antibiotic therapy reduces mortality. The keystone of resuscitation is aggressive volume replacement. Adjunctive therapies to modulate the inflammatory response may further enhance outcome, but do not replace principles of resuscitation.