Expert consensus on the perioperative management of patients with sepsis

Association of Preoperative Functional Status With Short-Term Major Adverse Outcomes After Cardiac Surgery

Introduction Cardiac surgery plays a crucial role in treating a wide range of cardiovascular conditions, offering life-saving interventions for patients with diseases such as coronary artery disease, heart valve disorders, and heart failure. However, these procedures are not without significant risks, including complications such as stroke, acute kidney injury, respiratory failure, and infections. It is important to not only recognize the potential complications associated with these procedures but also identify high-risk patients early in the treatment process. With the aging population and the increasing burden of comorbidities, a growing number of patients are likely to present with suboptimal functional status prior to cardiac surgery. By incorporating functional status into preoperative evaluations, healthcare providers can improve patient selection, enhance perioperative care, and improve outcomes in this high-risk patient population. Therefore, this study aims to investigate whether preoperative dependent functional status is associated with an increased risk of postoperative major adverse outcomes in patients undergoing cardiac surgery. Methods We performed a retrospective cohort analysis on adult cardiac surgery patients based on the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) 2011-2021 database. We compared a primary composite outcome consisting of post-surgery outcomes between independent and partially/totally dependent patients. The primary outcome was defined as experiencing any of the following adverse events: superficial incisional/deep incisional/organ space surgical site infection, death within 30 days post-operation, stroke/cerebral vascular accident (CVA), cardiac arrest requiring cardiopulmonary resuscitation (CPR), myocardial infarction, pulmonary embolism (PE), deep vein thrombosis (DVT)/thrombophlebitis, progressive renal insufficiency, ventilator use for more than 48 hours post-operation, unplanned intubation or reoperation, sepsis, septic shock, and pneumonia. Confounding variables were age, gender, race, emergency case, comorbidities, and baseline laboratory markers. We used multivariable logistic regression analysis to obtain adjusted odds ratio (OR) and 95% confidence intervals (CIs). Results Of the 42,917 patients included in the study, 30.6% were female and 69.4% were male, with 46.5% of the group being 65-79 years old. The prevalence of dependent status was 2.6%. Compared to independent patients, those who were dependent had a higher incidence of the primary outcome (35.68% vs. 20.93%), yielding a crude OR of 2.09 (95% CI 1.85-2.37). The association remained significant: OR of 1.21 (95% CI 1.04-1.41) after adjustment for age, gender, race, body mass index (BMI), emergency case, and other comorbidities such as diabetes, hypertension, heart failure, preoperative blood transfusion or sepsis, and laboratory markers. Conclusion Patients with preoperative dependent functional status were found to have a significantly greater risk of complications after cardiac surgery, even after adjusting for demographics, comorbidities, laboratory markers, and perioperative characteristics. Further investigation is needed to explore the development and clinical application of a predictive tool that includes functional status, which could help identify high-risk patients and facilitate timely interventions such as prehabilitation programs to enhance functional capacity.

How cold is too cold during maternal sepsis? Navigating between maternal hypothermia and fetal bradycardia

Hypothermia is a relatively rare condition in pregnancy and has been associated with fetal bradycardia. The management of maternal hypothermia resulting in fetal bradycardia presents a challenging dilemma for healthcare professionals. Currently, no evidence exists to advise on the duration of this condition before obstetric interventions are necessary for a safe outcome for both mother and infant. We discuss a case of a 26-year old primigravida with a gestational age of 32 weeks, who presented with clinical urosepsis, resulting in severe hypothermia up to 32 degrees Celsius. Active warming measures were taken and intravenous antibiotic treatment was started. Fetal evaluation on the cardiotocogram showed prolonged bradycardia (90 BPM) prompting consideration of a cesarean section. However, after multidisciplinary consultation, conservative treatment was proposed since there were no other signs of fetal hypoxia; no decelerations, good variability and accelerations. The patient started to show clinical improvement and had a body core temperature of 36 degrees Celsius after approximately 60 h of active rewarming measures. Fetal heartrate baseline normalized as the maternal temperature raised. Subsequently the patient was discharged in good clinical condition and had an uncomplicated vaginal delivery of a healthy newborn at term. In conclusion, when fetal bradycardia occurs due to maternal hypothermia, in the absence of signs for fetal hypoxia on the cardiotocogram, treatment of the underlying maternal condition instead of immediate obstetrics intervention is the best clinical option. This strategy aims to address the underlying cause of maternal hypothermia and consequently fetal bradycardia while ensuring the well-being of both mother and fetus and preventing unnecessary premature delivery.

Advancing cell-based therapy in sepsis: An anesthesia outlook

ABSTRACT

Sepsis poses a health challenge globally owing to markedly high rates of morbidity and mortality. Despite employing bundle therapy over two decades, approaches including transient organ supportive therapy and clinical trials focusing on signaling pathways have failed in effectively reversing multiple organ failure in patients with sepsis. Prompt and appropriate perioperative management for surgical patients with concurrent sepsis is urgent. Consequently, innovative therapies focusing on remedying organ injuries are necessitated. Cell therapy has emerged as a promising therapeutic avenue for repairing local damage to vital organs and restoring homeostasis during perioperative treatment for sepsis. Given the pivotal role of immune cell responses in the pathogenesis of sepsis, stem cell-based interventions that primarily modulate immune responses by interacting with multiple immune cells have progressed into clinical trials. The strides made in single-cell sequencing and gene-editing technologies have advanced the understanding of disease-specific immune responses in sepsis. Chimeric antigen receptor (CAR)-immune cell therapy offers an intriguing option for the treatment of sepsis. This review provides a concise overview of immune cell therapy, its current status, and the strides made in the context of sepsis research, discussing potential strategies for the management of patients with sepsis during perioperative stages.

Correlation of Redox Status with Procalcitonin and C-reactive Protein in Septic Patients

Based on the role of oxidative stress in the pathophysiological mechanisms of sepsis and the importance of PCT as a clinically applicable biomarker for early detection of inflammatory response initiation, we aimed this study at examining the correlation between PCT levels and oxidative stress parameters (prooxidants and antioxidants) in patients with sepsis. This study was designed as a case-series prospective clinical study which involved 103 critically ill patients and 17 healthy participants with diagnosis of sepsis/septic shock (over 18 years of age, both gender) admitted to the Intensive Care Unit (ICU) of Valjevo General Hospital in Serbia. All subjects were divided into patients who were operated on/underwent surgery before sampling and have sepsis (n = 24), patients who were operated on/underwent surgery before sampling and have septic shock (n = 25), patients who were not operated on/did not undergo surgery before sampling and have sepsis (n = 26), patients who were not operated on/did not undergo surgery before sampling and have septic shock (n = 28), and participants who are healthy (n = 17). PCT has confirmed a positive correlation with prooxidants and type of critical illness, and performing surgical intervention diminished oxidative stress in patients with septic shock. Prognosis in critically ill patients was strongly associated with PCT levels but not with nonspecifically C-reactive protein.

MiR-155 Alleviates Septic Lung Injury by Inducing Autophagy Via Inhibition of Transforming Growth Factor-β-Activated Binding Protein 2

BACKGROUND

The anti-inflammatory effect of miR-155 was closely linked to transforming growth factor-β-activated kinase-1-binding protein 2 (TAB2) and autophagy. This study investigated the role of miR-155 in attenuation of septic lung injury through TAB2 and autophagy in mouse model and in vitro.

METHODS

Patients who underwent fiberoptic bronchoscope examination with or without septic lung injury were recruited for the collection of bronchoalveolar lavage fluid (BALF) samples. Mouse model of septic lung injury was established by cecal ligation puncture, while alveolar macrophage cell line was treated with lipopolysaccharide (LPS). Agomir miR-155 transfection into the mouse airways was performed to induce miR-155 expression, while miR-155 mimic, miR-155 inhibitor, or TAB2-siRNA was transfected into NR8383 macrophages. Mouse BALF and cell cytokine levels, lung tissue pathology and wet/dry ratio, numbers of autophagy bodies, miR-155, gene and protein expressions were also examined accordingly.

RESULTS

Expression of miR-155 was increased in the BALF of septic lung injury patients, in mouse model and NR8383 macrophages after LPS treatment. Increased numbers of autophagy bodies were also observed in mouse and macrophage models. MiR-155-transfected mice showed alleviation of inflammation, lower water content in lung tissues, increased number of autophagy bodies, increased expression of microtubule-associated protein 1 light chain 3 (LC3 II/I), reduced expressions of cysteinyl aspartate-specific protease-1 (Caspase-1), and TAB2, and decreased cytokines levels. Similar results were obtained in macrophages after LPS treatment. Cells transfected with miR-155 inhibitor showed increased expression of TAB2 and Caspase-1, fewer autophagy bodies, lower LC3 II/I expression, and higher cytokine levels.

CONCLUSION

The current study observed a higher level of miR-155 in the BALF from sepsis patients with acute respiratory distress syndrome and demonstrated that miR-155 alleviated inflammation in septic lung injury in mouse and cell models by inducing autophagy via inhibition of TAB2.