Healthcare trajectory of critically ill patients with necrotizing soft tissue infections: a multicenter retrospective cohort study using the clinical data warehouse of Greater Paris University Hospitals

BACKGROUND

Necrotizing skin and soft tissue infections (NSTIs) are rare but serious and rapidly progressive infections characterized by necrosis of subcutaneous tissue, fascia and even muscle. The care pathway of patients with NSTIs is poorly understood. A better characterization of the care trajectory of these patients and a better identification of patients at risk of a complicated evolution, requiring prolonged hospitalization, multiple surgical re-interventions, or readmission to the intensive care unit (ICU), is an essential prerequisite to improve their care. The main objective of this study is to obtain large-scale data on the care pathway of these patients. We performed a retrospective multicenter observational cohort study in 13 Great Paris area hospitals, including patients hospitalized between January 1, 2015 and December 31, 2019 in the ICU for surgically confirmed NSTIs.

RESULTS

170 patients were included. The median duration of stay in ICU and hospital was 8 (3-17) and 37 (14-71) days, respectively. The median time from admission to first surgical debridement was 1 (0-2) day but 69.9% of patients were re-operated with a median of 1 (0-3) additional debridement. Inter-hospital transfer was necessary in 52.4% of patients. 80.2% of patients developed organ failures during the course of ICU stay with 51.8% of patients requiring invasive mechanical ventilation, 77.2% needing vasopressor support and 27.7% renal replacement therapy. In-ICU and in-hospital mortality rates were 21.8% and 28.8%, respectively. There was no significant difference between patients with abdomino-perineal NSTIs (n = 33) and others (n = 137) in terms of in-hospital or ICU mortality. Yet, immunocompromised patients (n = 43) showed significantly higher ICU and in-hospital mortality rates than non-immunocompromised patients (n = 127) (37.2% vs. 16.5%, p = 0.009, and 53.5% vs. 20.5%, p < 0.001). Factors associated with a complicated course were the presence of a polymicrobial infection (adjusted odds ratio [aOR = 3.18 (1.37-7.35); p = 0.007], of a bacteremia [aOR = 3.29 (1.14-9.52); p = 0.028] and a higher SAPS II score [aOR = 1.05 (1.02-1.07); p < 0.0001]. 62.3% of patients were re-hospitalized within 6 months.

CONCLUSION

In this retrospective multicenter study, we showed that patients with NSTI required complex management and are major consumers of care. Two-thirds of them underwent a complicated hospital course, associated with a higher SAPS II score, a polymicrobial NSTI and a bacteremia.

Early echocardiography by treating physicians and outcome in the critically ill: An ancillary study from the prospective multicenter trial FROG-ICU

PURPOSE

This study aimed to investigate the association between the use of early echocardiography performed by the treating physician certified in critical care ultrasound and mortality in ICU patients.

MATERIALS AND METHODS

FROG-ICU was a multi-center cohort designed to investigate the outcome of critically ill patients. Of the 1359 patients admitted to centers where echocardiography was available, 372 patients underwent echocardiography during the initial 3 days.

RESULTS

Of the ICU patients admitted for cardiac disease, 47.4% underwent echocardiography, and those patients had the lowest left ventricular ejection fraction 40 [31-58] % and the lowest cardiac output 4.2 [3.2-5.7] L/min compared to patients admitted for other causes (p < 0.001 for both). One-year mortality was 36.8% and 39.9% in patients with and without echocardiography, respectively [HR 0.92 (95% CI 0.75-1.11)]. This result was confirmed after multivariable Cox regression analysis [HR 0.88 (95% CI 0.71-1.08)]. Subgroup analyses suggest that among patients admitted to ICU for cardiac disease, those managed with echocardiography had a lower risk of one-year mortality [HR 0.65 (95% CI 0.43-0.98)].

CONCLUSIONS

Early echocardiography by treating physicians was not associated with short- or long-term survival in ICU patients. In subgroups, early echocardiography improved survival in ICU patients admitted for cardiac disease.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01367093.

Factors associated with hospital admission and adverse outcome for COVID-19: role of social factors and medical care

Background

Beyond sex, age, and various comorbidities, geographical origin and socioeconomic deprivation are associated with Coronavirus Disease (COVID-19) morbidity and mortality in the general population. We aimed to assess factors associated with severe forms of COVID-19 after a hospital emergency department visit, focusing on socioeconomic factors.

Methods

Patients with laboratory-confirmed COVID-19 attending the emergency department of Béclère Hospital (France) in March–April 2020 were included. Postal addresses were used to obtain two geographical deprivation indices at the neighborhood level. Factors associated with hospitalization and factors associated with adverse outcomes, i.e. mechanical ventilation or death, were studied using logistic and Cox analyses, respectively.

Results

Among 399 included patients, 321 were hospitalized. Neither geographical origin nor socioeconomic deprivation was associated with any of the outcomes. Being male, older, overweight or obese, diabetic, or having a neuropsychiatric disorder were independent risk factors for hospitalization. Among 296 patients hospitalized at Béclère Hospital, 91 experienced an adverse outcome. Older age, being overweight or obese, desaturation and extent of chest CT scan lesions > 25% at admission (aHR: 2.2 [95% CI: 1.3–3.5]) and higher peak CRP levels and acute kidney failure (aHR: 2.0 [1.2–3.3]) during follow-up were independently associated with adverse outcomes, whereas treatment with hydrocortisone reduced the risk of mechanical ventilation or death by half (aHR: 0.5 [0.3–0.8]).

Conclusion

No association between geographical origin or socioeconomic deprivation and the occurrence of a severe form of COVID-19 was observed in our population after arrival to the emergency department. Empirical corticosteroid use with hydrocortisone had a strong protective impact.

Monitoring circulating dipeptidyl peptidase 3 (DPP3) predicts improvement of organ failure and survival in sepsis: a prospective observational multinational study

Background

Dipeptidyl peptidase 3 (DPP3) is a cytosolic enzyme involved in the degradation of various cardiovascular and endorphin mediators. High levels of circulating DPP3 (cDPP3) indicate a high risk of organ dysfunction and mortality in cardiogenic shock patients.

Methods

The aim was to assess relationships between cDPP3 during the initial intensive care unit (ICU) stay and short-term outcome in the AdrenOSS-1, a prospective observational multinational study in twenty-four ICU centers in five countries. AdrenOSS-1 included 585 patients admitted to the ICU with severe sepsis or septic shock. The primary outcome was 28-day mortality. Secondary outcomes included organ failure as defined by the Sequential Organ Failure Assessment (SOFA) score, organ support with focus on vasopressor/inotropic use and need for renal replacement therapy. cDPP3 levels were measured upon admission and 24 h later.

Results

Median [IQR] cDPP3 concentration upon admission was 26.5 [16.2–40.4] ng/mL. Initial SOFA score was 7 [5–10], and 28-day mortality was 22%. We found marked associations between cDPP3 upon ICU admission and 28-day mortality (unadjusted standardized HR 1.8 [CI 1.6–2.1]; adjusted HR 1.5 [CI 1.3–1.8]) and between cDPP3 levels and change in renal and liver SOFA score (p = 0.0077 and 0.0009, respectively). The higher the initial cDPP3 was, the greater the need for organ support and vasopressors upon admission; the longer the need for vasopressor(s), mechanical ventilation or RRT and the higher the need for fluid load (all p < 0.005). In patients with cDPP3 > 40.4 ng/mL upon admission, a decrease in cDPP3 below 40.4 ng/mL after 24 h was associated with an improvement of organ function at 48 h and better 28-day outcome. By contrast, persistently elevated cDPP3 at 24 h was associated with worsening organ function and high 28-day mortality.

Conclusions

Admission levels and rapid changes in cDPP3 predict outcome during sepsis.

Trial Registration ClinicalTrials.gov, NCT02393781. Registered on March 19, 2015.

Incidence and Outcome of Subclinical Acute Kidney Injury Using penKid in Critically Ill Patients

Rationale: Subclinical acute kidney injury (sub-AKI) refers to patients with low serum creatinine but elevated alternative biomarkers of AKI. Its incidence and outcome in critically ill patients remain, however, largely unknown. Plasma proenkephalin A 119-159 (penKid) has been proposed as a sensitive biomarker of glomerular function.Objectives: In this ancillary study of two cohorts, we explored the incidence and outcome of sub-AKI based on penKid.Methods: A prospective observational study in ICUs was conducted. FROG-ICU (French and European Outcome Registry in ICUs) enrolled 2,087 critically ill patients, and AdrenOSS-1 (Adrenomedullin and Outcome in Severe Sepsis and Septic Shock-1) enrolled 583 septic patients. The primary endpoint was 28-day mortality after ICU admission. Sub-AKI was defined by an admission penKid concentration above the normal range (i.e., >80 pmol/L) in patients not meeting the definition of AKI. A sensitivity analysis was performed among patients with estimated glomerular filtration rate above 60 ml/min/1.73 m² at ICU admission.Measurements and Main Results: In total, 6.1% (122/2,004) and 6.7% (39/583) of patients from the FROG-ICU and AdrenOSS-1 cohorts met the definition of sub-AKI (11.6% and 17.5% of patients without AKI). In patients without AKI or with high estimated glomerular filtration rate, penKid was associated with higher mortality (adjusted standardized hazard ratio [HR], 1.4 [95% confidence interval, 1.1-1.8]; P = 0.010; and HR, 1.6 [95% confidence interval, 1.3-1.8]; P < 0.0001, respectively) after adjustment for age, sex, comorbidities, diagnosis, creatinine, diuresis, and study. Patients with sub-AKI had higher mortality compared with no AKI (HR, 2.4 [95% confidence interval, 1.5-3.7] in FROG-ICU and 2.5 [95% confidence interval, 1.1-5.9] in AdrenOSS-1).Conclusions: Sub-AKI defined using penKid occurred in 11.6-17.5% of patients without AKI and was associated with a risk of death close to patients with AKI.

Tracheostomy and long-term mortality in ICU patients undergoing prolonged mechanical ventilation

Introduction

In critically ill patients undergoing prolonged mechanical ventilation (MV), the difference in long-term outcomes between patients with or without tracheostomy remains unexplored.

Methods

Ancillary study of a prospective international multicentre observational cohort in 21 centres in France and Belgium, including 2087 patients, with a one-year follow-up after admission. We included patients with a MV duration ≥10 days, with or without tracheostomy. We explored the one-year mortality with a classical Cox regression model (adjustment on age, SAPS II, baseline diagnosis and withdrawal of life-sustaining therapies) and a Cox regression model using tracheostomy as a time-dependant variable.

Results

29.5% patients underwent prolonged MV, out of which 25.6% received tracheostomy and 74.4% did not. At one-year, 45.2% patients had died in the tracheostomy group and 51.5% patients had died in the group without tracheostomy (p = 0.001). In the Cox-adjusted regression model, tracheostomy was not associated with improved one-year outcome (HR CI95 0.7 [0.5–1.001], p = 0.051), as well as in the model using tracheostomy as a time-dependent variable (OR CI 95 1 [0.7–1.4], p = 0.9).

Conclusions

In our study, there was no statistically significant difference in the one-year mortality of patients undergoing prolonged MV when receiving tracheostomy or not.

Trial registration

NCT01367093

Evolution of B-type natriuretic peptide and N-terminal pro-brain natriuretic peptide during acute decompensated heart failure in a chronic heart failure patient with reduced ejection fraction treated with Sacubitril/Valsartan: a case report

Background

B-type natriuretic peptide (BNP) and the N-terminal proBNP (NT-proBNP) exhibit different evolution in chronic heart failure patients with reduced ejection fraction treated with Sacubitril/Valsartan; BNP increasing or remaining stable, while NT-proBNP decreases. However, how this difference translates upon acute decompensation is unknown.

Case summary

Herein, we described in a 78-year-old woman with chronic heart failure with reduced ejection fraction treated with Sacubitril/Valsartan who had acute decompensated heart failure (ADHF). BNP and NT-proBNP were markedly high during ADHF and showed parallel return to baseline level after clinical improvement.

Discussion

BNP and NT-proBNP retained similar value for the diagnosis of ADHF in patient treated with Sacubitril/Valsartan. These findings strongly suggest that either BNP or NT-proBNP can be used indifferently in this context, while their relative use is debated in chronic heart failure.

Influence of systemic hemodynamics on microcirculation during sepsis

PURPOSE

During sepsis, improvement of hemodynamic may not be related to improvement of microcirculation. The aim of this study was to investigate influence of systemic circulation on microcirculation in septic ICU patients.

METHODS

This is a prospective cohort study of septic ICU patients. Microcirculation was investigated with Near infrared spectrometry (NIRS) measuring tissue oxygen saturation (StO₂). StO₂ desaturation (desStO₂) and resaturation (resStO₂) slopes were determined. Analyses were made at baseline and after fluid challenges.

RESULTS

Seventy-two patients were included. One hundred and sixty measures were performed at baseline. StO₂ was 77.8% [72.4-85.0] and resStO₂ was 87.3%/min [57.8-141.7]. Univariate analysis showed an association between resStO₂ and diastolic arterial pressure (DAP) (p = .001), and norepinephrine dose (p = .033). In multivariate linear regression, there was an association between resStO₂ and DAP (β = 1.85 (0.64 to 3.08), p = .004)_. Fluid challenges (n = 60) increased CO, and resStO₂ (all p < .001). In multivariate analysis, variation of stroke volume was associated with variation of resStO₂ (p = .004) after fluid challenge. There was no association between CVP and resStO₂.

CONCLUSIONS

DAP was the only independent determinant of resStO2 in septic patients. Fluid challenges may improve microcirculation. CVP did not influence resStO₂.

Circulating adrenomedullin estimates survival and reversibility of organ failure in sepsis: the prospective observational multinational Adrenomedullin and Outcome in Sepsis and Septic Shock-1 (AdrenOSS-1) study

BACKGROUND

Adrenomedullin (ADM) regulates vascular tone and endothelial permeability during sepsis. Levels of circulating biologically active ADM (bio-ADM) show an inverse relationship with blood pressure and a direct relationship with vasopressor requirement. In the present prospective observational multinational Adrenomedullin and Outcome in Sepsis and Septic Shock 1 (, AdrenOSS-1) study, we assessed relationships between circulating bio-ADM during the initial intensive care unit (ICU) stay and short-term outcome in order to eventually design a biomarker-guided randomized controlled trial.

METHODS

AdrenOSS-1 was a prospective observational multinational study. The primary outcome was 28-day mortality. Secondary outcomes included organ failure as defined by Sequential Organ Failure Assessment (SOFA) score, organ support with focus on vasopressor/inotropic use, and need for renal replacement therapy. AdrenOSS-1 included 583 patients admitted to the ICU with sepsis or septic shock.

RESULTS

Circulating bio-ADM levels were measured upon admission and at day 2. Median bio-ADM concentration upon admission was 80.5 pg/ml [IQR 41.5-148.1 pg/ml]. Initial SOFA score was 7 [IQR 5-10], and 28-day mortality was 22%. We found marked associations between bio-ADM upon admission and 28-day mortality (unadjusted standardized HR 2.3 [CI 1.9-2.9]; adjusted HR 1.6 [CI 1.1-2.5]) and between bio-ADM levels and SOFA score (p < 0.0001). Need of vasopressor/inotrope, renal replacement therapy, and positive fluid balance were more prevalent in patients with a bio-ADM > 70 pg/ml upon admission than in those with bio-ADM ≤ 70 pg/ml. In patients with bio-ADM > 70 pg/ml upon admission, decrease in bio-ADM below 70 pg/ml at day 2 was associated with recovery of organ function at day 7 and better 28-day outcome (9.5% mortality). By contrast, persistently elevated bio-ADM at day 2 was associated with prolonged organ dysfunction and high 28-day mortality (38.1% mortality, HR 4.9, 95% CI 2.5-9.8).

CONCLUSIONS

AdrenOSS-1 shows that early levels and rapid changes in bio-ADM estimate short-term outcome in sepsis and septic shock. These data are the backbone of the design of the biomarker-guided AdrenOSS-2 trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02393781 . Registered on March 19, 2015.

Proenkephalin A 119-159 (Penkid) Is an Early Biomarker of Septic Acute Kidney Injury: The Kidney in Sepsis and Septic Shock (Kid-SSS) Study

Introduction

Sepsis is the leading cause of acute kidney injury (AKI) in critically ill patients. The Kidney in Sepsis and Septic Shock (Kid-SSS) study evaluated the value of proenkephalin A 119-159 (penkid)-a sensitive biomarker of glomerular function, drawn within 24 hours upon intensive care unit (ICU) admission and analyzed using a chemiluminescence immunoassay-for kidney events in sepsis and septic shock.

Methods

The Kid-SSS study was a substudy of Adrenomedullin and Outcome in Severe Sepsis and Septic Shock (AdrenOSS) (NCT02393781), a prospective, observational, multinational study including 583 patients admitted to the intensive care unit with sepsis or septic shock and a validation cohort of 525 patients from the French and euRopean Outcome reGistry in Intensive Care Units (FROG-ICU) study. The primary endpoint was major adverse kidney events (MAKEs) at day 7, composite of death, renal replacement therapy, and persistent renal dysfunction. The secondary endpoints included AKI, transient AKI, worsening renal function (WRF), and 28-day mortality.

Results

Median age was 66 years (interquartile range 55-75), and 28-day mortality was 22% (95% confidence interval [CI] 19%-25%). Of the patients, 293 (50.3%) were in shock upon ICU admission. Penkid was significantly elevated in patients with MAKEs, persistent AKI, and WRF (median = 65 [IQR = 45-106] vs. 179 [114-242]; 53 [39-70] vs. 133 [79-196] pmol/l; and 70 [47-121] vs. 174 [93-242] pmol/l, all P < 0.0001), also after adjustment for confounding factors (adjusted odds ratio = 3.3 [95% CI = 1.8-6.0], 3.9 [95% CI = 2.1-7.2], and 3.4 [95% CI = 1.9-6.2], all P < 0.0001). Penkid increase preceded elevation of serum creatinine with WRF and was low in renal recovery.

Conclusion

Admission penkid concentration was associated with MAKEs, AKI, and WRF in a timely manner in septic patients.

Multicenter testing of the rapid quantification of radical oxygen species in cerebrospinal fluid to diagnose bacterial meningitis

Purpose

Meningitis is a serious concern after traumatic brain injury (TBI) or neurosurgery. This study tested the level of reactive oxygen species (ROS) in cerebrospinal fluid (CSF) to diagnose meningitis in febrile patients several days after trauma or surgery.

Methods

Febrile patients (temperature > 38°C) after TBI or neurosurgery were included prospectively. ROS were measured in CSF within 4 hours after sampling using luminescence in the basal state and after cell stimulation with phorbol 12-myristate 13-acetate (PMA). The study was conducted in a single-center cohort 1 (n = 54, training cohort) and then in a multicenter cohort 2 (n = 136, testing cohort) in the Intensive Care and Neurosurgery departments of two teaching hospitals. The performance of the ROS test was compared with classical CSF criteria, and a diagnostic decision for meningitis was made by two blinded experts.

Results

The production of ROS was higher in the CSF of meningitis patients than in non-infected CSF, both in the basal state and after PMA stimulation. In cohort 1, ROS production was associated with a diagnosis of meningitis with an AUC of 0.814 (95% confidence interval (CI) [0.684–0.820]) for steady-state and 0.818 (95% CI [0.655–0.821]) for PMA-activated conditions. The best threshold value obtained in cohort 1 was tested in cohort 2 and showed high negative predictive values and low negative likelihood ratios of 0.94 and 0.36 in the basal state, respectively, and 0.96 and 0.24 after PMA stimulation, respectively.

Conclusion

The ROS test in CSF appeared suitable for eliminating a diagnosis of bacterial meningitis.

Comparison of two different generations of "NIRS" devices and transducers in healthy volunteers and ICU patients

The purpose of this study is to compare Near Infrared Spectroscopy (NIRS) thenar eminence parameters obtained with 2 different devices from the same manufacturer (InSpectra Models 325 and 650, Hutchinson Tech, Min USA), and 2 different probes (15 vs. 25 mm spacing), in healthy volunteers (HV) and ICU patients. Prospective, observational study in ICU setting. Simultaneous, cross over NIRS inter-device comparison and comparison between different probes (25 vs. 15 mm spacing) were done at baseline and during vascular occlusion tests (VOTs). Forty patients (19 septic shock, 21 trauma), and 29 HV were included. NIRS inter-device comparison showed similar baseline StO(2) values in HV and patients. The VOT result were significantly different for minimal StO(2) value reached during VOT (StO(2min)) (intraclass concordance coefficient (ICC) = 0.18), the occlusion slope (ICC = 0.16) and the reperfusion slope (StO(2reperf)) (ICC = 0.26). The probe comparison was also significantly different for VOT parameters (StO(2min) (ICC = 0.43), occlusion (ICC = 0.50) and StO(2reperf) (ICC = 0.48). The low concordance, poor agreement and large bias (ICC and Bland & Altman) observed, were related both to the device used and the probe spacing. StO(2) data obtained with NIRS model 650 and 15 mm probe differ from values obtained with the previous device (325 and probe spacing 25 or 15 mm). This difference is not related to the population tested, but to the device and probe spacing. As a consequence, despite similar trends for variations between HV and patients during VOT, threshold and predictive values for outcome should be revisited with the new device before the acceptance for routine clinical use.

Bench-to-bedside review: Glucose and stress conditions in the intensive care unit

The physiological response to blood glucose elevation is the pancreatic release of insulin, which blocks hepatic glucose production and release, and stimulates glucose uptake and storage in insulin-dependent tissues. When this first regulatory level is overwhelmed (that is, by exogenous glucose supplementation), persistent hyperglycaemia occurs with intricate consequences related to the glucose acting as a metabolic substrate and as an intracellular mediator. It is thus very important to unravel the glucose metabolic pathways that come into play during stress as well as the consequences of these on cellular functions. During acute injuries, activation of serial hormonal and humoral responses inducing hyperglycaemia is called the 'stress response'. Central activation of the nervous system and of the neuroendocrine axes is involved, releasing hormones that in most cases act to worsen the hyperglycaemia. These hormones in turn induce profound modifications of the inflammatory response, such as cytokine and mediator profiles. The hallmarks of stress-induced hyperglycaemia include 'insulin resistance' associated with an increase in hepatic glucose output and insufficient release of insulin with regard to glycaemia. Although both acute and chronic hyperglycaemia may induce deleterious effects on cells and organs, the initial acute endogenous hyperglycaemia appears to be adaptive. This acute hyperglycaemia participates in the maintenance of an adequate inflammatory response and consequently should not be treated aggressively. Hyperglycaemia induced by an exogenous glucose supply may, in turn, amplify the inflammatory response such that it becomes a disproportionate response. Since chronic exposure to glucose metabolites, as encountered in diabetes, induces adverse effects, the proper roles of these metabolites during acute conditions need further elucidation.

Is thenar tissue hemoglobin oxygen saturation in septic shock related to macrohemodynamic variables and outcome?

INTRODUCTION

The study objectives were to evaluate septic shock-induced alterations in skeletal muscle hemoglobin oxygenation saturation (StO2) using near-infrared spectroscopy (NIRS) and forearm skin blood flow velocity using laser Doppler (LD) to determine the relationship of macroperfusion and microperfusion parameters, and to test the relationship of the worst NIRS parameters during the first 24 hours of shock with 28-day prognosis.

METHODS

A prospective, observational study was performed in a 21-bed university hospital surgical intensive care unit. Forty-three septic shock patients with at least another organ failure underwent a 3-minute, upper arm (brachial artery) vascular occlusion test (VOT). Microperfusion parameters (thenar eminence StO2 and forearm LD skin blood flow) were collected on days 1, 2 and 3, before (baseline StO2 and LD values) and during the 3-minute VOT with calculation of occlusion and reperfusion slopes for StO2 and LD. Daily Sequential Organ Failure Assessment (SOFA) score, macrohemodynamic parameters (systolic arterial blood pressure, cardiac output (pulmonary artery catheter or transesophageal Doppler), mixed venous oxygen saturation (pulmonary artery or superior vena cava catheter)) and metabolic parameters (pH, base excess, lactate) were determined.

RESULTS

Baseline StO2 (82% (75 to 88) vs. 89% (85 to 92), P = 0.04) and reperfusion slope (2.79%/second (1.75 to 4.32) vs. 9.35%/second (8.32 to 11.57), P < 0.0001) were lower in septic shock patients than in healthy volunteers. StO2 reperfusion slope correlated with occlusion slope (P < 0.0001), cardiac output (P = 0.01) and LD reperfusion slope (P = 0.08), and negatively with lactate level (P = 0.04). The worst StO2 reperfusion slope during the first day of shock was lower in nonsurvivors than in survivors (P = 0.003) and improved significantly the predictive value of Simplified Acute Physiology Score II and SOFA scores.

CONCLUSIONS

The alteration of StO2 reperfusion slope in septic shock patients compared with healthy volunteers was related with macrohemodynamic, microhemodynamic and metabolic parameters. The addition of the worst value of the day 1 StO2 reperfusion slope improved the outcome prediction of Simplified Acute Physiology Score II and SOFA scores.