The Indian Society of Critical Care Medicine Position Statement on the Management of Sepsis in Resource-limited Settings

Prokineticin-2 and Procalcitonin's Diagnostic Accuracy for Sepsis in Critically Ill Patients: A Prospective Observational Study

Objective

Sepsis stands as a significant contributor to mortality in ICU settings worldwide. Early diagnosis and appropriate treatment are therefore essential to reduce mortality. We planned this study to investigate the diagnostic significance of prokineticin-2 (PK-2) in patients with sepsis.

Materials and methods

Adult patients with sepsis who were admitted to our intensive care unit (ICU) were included in this prospective observational study. On the day of admission and the 7th day of the ICU stay, the levels of procalcitonin (PCT) and PK-2 were assessed. Patients' mortality was observed for 28 days.

Results

This research involved 83 patients meeting the inclusion criteria. Prokineticin-2 showed a diagnostic sensitivity of 70.6% for sepsis, outperforming PCT with a sensitivity of 64.7%. In predicting mortality, PCT displayed a sensitivity of 95.5%, whereas Prokineticin-2 demonstrated an even higher sensitivity at 98.4%.

Conclusion

Prokinectin-2 can be used for screening adult patients with sepsis admitted to ICU.

How to cite this article

Bhat K, Kothari N, Sharma A, Goyal S, Meshram T, Paliwal B, et al. Prokineticin-2 and Procalcitonin's Diagnostic Accuracy for Sepsis In Critically Ill Patients: A Prospective Observational Study. Indian J Crit Care Med 2025;29(3):268-272.

Management of adult sepsis in resource-limited settings: global expert consensus statements using a Delphi method

PURPOSE

To generate consensus and provide expert clinical practice statements for the management of adult sepsis in resource-limited settings.

METHODS

An international multidisciplinary Steering Committee with expertise in sepsis management and including a Delphi methodologist was convened by the Asia Pacific Sepsis Alliance (APSA). The committee selected an international panel of clinicians and researchers with expertise in sepsis management. A Delphi process based on an iterative approach was used to obtain the final consensus statements.

RESULTS

A stable consensus was achieved for 30 (94%) of the statements by 41 experts after four survey rounds. These include consensus on managing patients with sepsis outside a designated critical care area, triggers for escalating clinical management and criteria for safe transfer to another facility. The experts agreed on the following: in the absence of serum lactate, clinical parameters such as altered mental status, capillary refill time and urine output may be used to guide resuscitation; special considerations regarding the volume of fluid used for resuscitation, especially in tropical infections, including the use of simple tests to assess fluid responsiveness when facilities for advanced hemodynamic monitoring are limited; use of Ringer's lactate or Hartmann's solution as balanced salt solutions; epinephrine when norepinephrine or vasopressin are unavailable; and the administration of vasopressors via a peripheral vein if central venous access is unavailable or not feasible. Similarly, where facilities for investigation are unavailable, there was consensus for empirical antimicrobial administration without delay when sepsis was strongly suspected, as was the empirical use of antiparasitic agents in patients with suspicion of parasitic infections.

CONCLUSION

Using a Delphi method, international experts reached consensus to generate expert clinical practice statements providing guidance to clinicians worldwide on the management of sepsis in resource-limited settings. These statements complement existing guidelines where evidence is lacking and add relevant aspects of sepsis management that are not addressed by current international guidelines. Future studies are needed to assess the effects of these practice statements and address remaining uncertainties.

The Clinical Utility of Targeted Heart Rate Control in Septic Shock: A Systematic Review and Meta-analysis of Randomized Controlled Trials with Trial Sequential Analysis

Objectives

Heart rate control using beta-blockers in sepsis has traditionally been avoided because of concerns with worsening cardiac index and organ perfusion. Recent studies has explored the possible beneficial effects of targeted heart rate control in patients with septic shock who have tachycardia despite initial resuscitation. We performed a systematic review and meta-analysis to explore the effects of heart rate control in septic shock patients.

Methods

A systematic review and meta-analysis was conducted searching for studies from PubMed, Cochrane Central, and Embase registers for randomized controlled trials (RCTs) that compared the mortality of patients with sepsis and septic shock treated with targeted rate control. The literature search was done to include studies from January 2013 to December 2023. Two independent researchers independently assessed the studies and included RCTS in which adult patients (>18 years of age) with septic shock were treated with targeted heart rate control vs placebo after initial resuscitation due to persistent tachycardia. The study data was extracted by two independent researchers. A random effects model was used to present the results. A trial sequential analysis (TSA) was performed for the primary outcome of 28-day mortality.

Results

A total of 9 studies with a pooled sample size of 807 participants were included in the analysis.Eight of the included studies with a pooled sample size of 766 reported 28-day mortality. Targeted heart rate control was associated with a trend toward lower 28-day mortality [risk ratio (RR): 0.78; 95% CI: 0.62-0.99; p = 0.04; I 2 = 48%]. Trial sequential analysis showed the cumulative effect lying within the zone of uncertainty, with diversity-adjusted required information size of 1,756 and pooled effect size of the pooled RR 0.78 (alpha-spending adjusted 95% CI: 0.53-1.15). There was a statistically significant lower heart rate associated with rate control (MD: -16.66; 95% CI: -23.89 to -9.42; p-value < 0.001) but no difference in mean arterial pressure. cardiac index, lactate levels, norepinephrine (NE) requirements, and ICU length of stay (LOS) in between the groups.

Conclusion

Targeted heart rate control in patients with septic shock may be tolerated from a hemodynamic standpoint. However, the beneficial effect on mortality is less certain than was reported in the initial studies.

How to cite this article

Datta PK, Sathe P, Roy A, Baronia T, Bhattacharjee A, Kundu R. The Clinical Utility of Targeted Heart Rate Control in Septic Shock: A Systematic Review and Meta-analysis of Randomized Controlled Trials with Trial Sequential Analysis. Indian J Crit Care Med 2024;28(12):1170-1179.

Efficacy and Safety of Continuous vs Intermittent Linezolid Infusion in Critically Ill Patients with Septic Shock

The synthetic antimicrobial agent Linezolid effectively penetrates many tissues and exhibits effectiveness against drug-resistant Gram-positive bacteria. This agent's pharmacokinetic qualities cast doubt on the need for intravenous treatment in cases of serious illness. For its time-dependent action to have an impact, serum levels must stay above the minimum inhibitory concentration throughout the dosage interval. According to our research, Linezolid infusions have been proposed to be given as continuous infusions to maintain adequate tissue and serum levels without trough concentration fluctuations. This will optimize the drug's effects and protect against toxicity and drug resistance. In critically ill individuals experiencing septic shock in the ICU, this study sought to validate the safety and efficacy of continuous Linezolid infusion in comparison to the conventional regimen. A prospective, randomized, controlled research involving 140 individuals suffering from septic shock who were older than 18 was carried out. Two groups of patients were randomly assigned. With an average treatment duration of 9.83 ± 2.537 in the intermittent infusion group and 7.39 ± 1.653 in the continuous infusion group, the first group obtained IV linezolid 600 mg twice daily as an intermittent infusion (II) over 60 minutes, whereas the second group obtained 300 mg IV as a loading dosage, and then continuous infusion of 900 mg/day in the first day and 1,200 mg/day in the subsequent days. There was a significantly high clinical cure and less ICU and hospital stay in the continuous infusion group (p < 0.001). Moreover, there was a lower incidence of developing thrombocytopenia in patients with renal impairment who got continuous infusion. Continuous infusion modality showed an advantage in terms of enhancing clinical efficacy in seriously ill cases with septic shock secondary to Gram-positive bacterial infection, especially in cases with renal impairment.

How to cite this article

Albadry AM, Zakaria HY, Elhefny MM, Elsherif IM. Efficacy and Safety of Continuous vs Intermittent Linezolid Infusion in Critically Ill Patients with Septic Shock. Indian J Crit Care Med 2024;28(12):1118-1121.

Deciphering the iron enigma: Navigating the complexities of iron metabolism in critical illness

Iron is a double-edged sword! Despite being essential for numerous physiological processes of the body, a dysregulated iron metabolism can result in tissue damage, exaggerated inflammatory response, and increased susceptibility to infection with certain pathogens that thrive in iron-rich environment. During sepsis, there is an alteration of iron metabolism, leading to increased transport and uptake into cells. This increase in labile iron may cause oxidative damage and cellular injury (ferroptosis) which progresses as the disease worsens. Critically ill patients are often complicated with systemic inflammation which may contribute to multiple organ dysfunction syndrome or sepsis, a common cause of mortality in intensive care unit. Originally, ferritin was known to play an important role in the hematopoietic system for its iron storage capacity. Recently, its role has emerged as a predictor of poor prognosis in chronic inflammation and critical illnesses. Apart from predicting the disease outcome, serum ferritin can potentially reflect disease activity as well.