[The current sepsis guidelines-What do you need to know?]

The current international sepsis guidelines from 2021 are based on the work of a panel of 60 international experts from various fields. They include a total of 93 recommendations, some of which include new aspects compared to the 2016 version of the guidelines. This article provides a subjective compilation by two internal medicine intensivists who highlight some aspects, especially of changes within the guidelines compared to the previous version. The focus is on the fields of screening, sepsis bundles, fluid and vasopressor treatment and adjuvant treatment. In addition, for the first time these guidelines address the important issue of long-term sequelae for sepsis survivors and their environment.

Echocardiographic profiles and hemodynamic response after vasopressin initiation in septic shock: A cross-sectional study

PURPOSE

Vasopressin, used as a catecholamine adjunct, is a vasoconstrictor that may be detrimental in some hemodynamic profiles, particularly left ventricular (LV) systolic dysfunction. This study tested the hypothesis that echocardiographic parameters differ between patients with a hemodynamic response after vasopressin initiation and those without a response.

METHODS

This retrospective, single-center, cross-sectional study included adults with septic shock receiving catecholamines and vasopressin with an echocardiogram performed after shock onset but before vasopressin initiation. Patients were grouped by hemodynamic response, defined as decreased catecholamine dosage with mean arterial pressure ≥ 65 mmHg six hours after vasopressin initiation, with echocardiographic parameters compared. LV systolic dysfunction was defined as LV ejection fraction (LVEF) <45%.

RESULTS

Of 129 included patients, 72 (56%) were hemodynamic responders. Hemodynamic responders, versus non-responders, had higher LVEF (61% [55%,68%] vs. 55% [40%,65%]; p = 0.02) and less-frequent LV systolic dysfunction (absolute difference  -16%; 95% CI -30%,-2%). Higher LVEF was associated with higher odds of hemodynamic response (for each LVEF 10%, response OR 1.32; 95% CI 1.04-1.68). Patients with LV systolic dysfunction, versus without LV systolic dysfunction, had higher mortality risk (HR(t) = e^[0.81-0.1*t]; at t = 0, HR 2.24; 95% CI 1.08-4.64).

CONCLUSIONS

Pre-drug echocardiographic profiles differed in hemodynamic responders after vasopressin initiation versus non-responders.

[Sepsis with hemolysis due to a liver abscess in a 60-year-old male patient]

Many cases of Clostridium perfringens sepsis prove to be fatal. We present a case of C. perfringens sepsis with a liver abscess as the focus of infection, which was successfully treated by an interdisciplinary intensive medical care management. The sepsis with this rare pathogen was favored by the presence of a bilioenteric anastomosis and immunosuppressive treatment of a pre-existing Crohn's disease. Antibiotic treatment with clindamycin and penicillin G was initiated and the abscess was drained. Hemodialysis with high cut-off filters was started because of acute kidney failure in the Acute Kidney Injury Network (AKIN) stage III, hemolysis and rhabdomyolysis. Therapeutic plasma exchange was performed due to sepsis and acute liver failure.

Characterization of circulating thrombin in patients with septic shock: a prospective observational study

Septic shock is characterized by a dysregulated response to infection, hypotension and activation of the coagulation system. Markers of coagulation activation are commonly used to diagnose and monitor ensuing coagulopathies. In this study, we sought to determine levels of circulating thrombin in patients with septic shock. To characterize levels of circulating, active thrombin in patients with septic shock. 48 patients with septic shock were included in this prospective, observational study. Blood samples were obtained on admission, day 1, day 3 and day 6. Levels of active thrombin were measured using a standardized, clinically applicable oligonucleotide (aptamer)-based enzyme-capture assay (OECA). Thrombin levels were correlated with established indirect thrombin parameters, conventional coagulation tests, laboratory parameters, patient characteristics and outcome. Elevated levels of thrombin were detected in 27 patients (56.3%) during the course of the study. Thrombin levels were positively correlated with thrombin-antithrombin complexes (r = 0.30, p < 0.05) and negatively associated with FVII levels (r = - 0.28, p < 0.05). Thrombin levels on admission did not predict 30-day mortality (OR 0.82, 95% CI 0.23-2.92, p = 0.77). Circulating levels of active thrombin can be measured in a subset of patients with septic shock. Although thrombin levels are correlated with established markers of coagulation, they do not provide additional prognostic information.

[One case of atypical septic shock with acute pulmonary edema in a patient with extensive burn]

A 25-year-old man with extensive burn due to industrial dust explosion was admitted to the First Affiliated Hospital of Naval Medical University on 16th October, 2018. Four days after the first skin grafting and vacuum sealing drainage surgery, the patient developed signs of uncontrolled severe inflammation and shock. However, several atypical manifestations interfered the diagnosis of septic shock. After giving emergency treatment including fluid resuscitation, broad-spectrum antibiotics, and administration of vasopressor agents, the patient's condition was alleviated, but quickly relapsed and deteriorated, with acute pulmonary edema appeared in the evening of the same day. Finally, the condition was reversed by completely removing the negative pressure devices on upper limbs and thorough dressing change. This case suggests that the diagnosis and treatment of infection in patients with extensive burn need comprehensive analysis. Timely intervention of the wound is the key to control the exacerbation of sepsis. In addition, the possibility of pulmonary edema in patients with sepsis should be on high alert.

[Influencing factors of severe liver disease complicated with toxic shock]

Patients with severe liver disease are prone to bacterial and fungal infections, and then develop toxic shock. The onset of the disease may be insidious, but the disease progresses rapidly with a high fatality rate. Current research results show that special conditions such as translocation of intestinal flora and immune paralysis in patients with severe liver disease are susceptible factors for infection and toxic shock. Furthermore, it is currently recognized that the treatment of severe liver disease complicated with toxic shock must be treated with antibiotics and maintenance of hemodynamic stability. Other treatments, such as hydrocortisone and strict glycemic control, are quite controversial and may not necessarily reduce mortality. Herein, we summarize the epidemiology, susceptibility factors; diagnosis and management strategies of severe liver disease complicated with toxic shock, highlighting the characteristics of toxic shock under the background of severe liver disease, so as to detect, prevent and treat septic shock in patients with severe liver disease as early as possible to reduce the fatality rate.

Clinical characteristics of coronavirus disease 2019 patients with diarrhea in Daegu

BACKGROUND/AIMS

Coronavirus disease 2019 (COVID-19) can reportedly cause gastrointestinal symptoms. Therefore, we investigated the clinical characteristics of COVID-19 patients with diarrhea.

METHODS

We included 118 COVID-19 patients admitted to a single hospital from February 20 to March 31, 2020. Medical records with clinical characteristics, laboratory data, treatment course, and clinical outcomes were compared based on the presence or absence of diarrhea. Prognostic factors for disease severity and mortality in COVID-19 were also assessed.

RESULTS

Among patients, 54 (45.8%) had diarrhea, whereas seven (5.9%) had only diarrhea. The median age of patients with diarrhea was 59 years (44 to 64), and 22 (40.7%) were male. Systemic steroid use, intensive care unit admission, septic shock, and acute respiratory distress syndrome were less frequent in the diarrhea group than in the non-diarrhea group. No significant differences were observed in total hospital stay and mortality between groups. On multivariate analysis, age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.01 to 1.12; p = 0.044), diabetes (OR, 3.00; 95% CI, 1.25 to 20.47; p = 0.042), and dyspnea (OR, 41.19; 95% CI, 6.60 to 823.16; p < 0.001) were independent risk factors for septic shock. On Cox regression analysis, diabetes (hazard ratio [HR], 4.82; 95% CI, 0.89 to 26.03; p = 0.043) and chronic obstructive pulmonary disease (HR, 16.58; 95% CI, 3.10 to 88.70; p = 0.044) were risk factors for mortality.

CONCLUSION

Diarrhea was present in 45.8% of patients and was a common symptom of COVID-19. Although patients with diarrhea showed less severe clinical features, diarrhea was not associated with disease severity or mortality.

Mortality difference between early-identified sepsis and late-identified sepsis

Objective

The aim of the study was to compare the mortality rates of patients with early-identified (EI) sepsis and late-identified (LI) sepsis.

Methods

We performed a retrospective chart review of patients admitted to the emergency department and diagnosed with sepsis. EI sepsis was defined as patients with a Sequential Organ Failure Assessment (SOFA) score ≥2, based on 3 parameters of the SOFA score (Glasgow coma scale, mean arterial pressure, and partial pressure of oxygen/fraction of inspired oxygen ratio), measured within an hour of emergency department admission. The remaining patients were defined as LI sepsis. The primary outcome was in-hospital mortality.

Results

Of the total 204 patients with sepsis, 113 (55.4%) had EI sepsis. Overall mortality rate was 15.7%, and EI sepsis group had significantly higher mortality than LI sepsis (23.0% vs. 6.6%, P=0.003). The patients with EI sepsis, compared to those with LI sepsis, had higher SOFA score (median: 4 vs. 2, P<0.001); Acute Physiology and Chronic Health Evaluation (APACHE) II score (median: 14 vs. 10, P<0.001); were more likely to progress to septic shock within 6 hours after admission (17.7% vs. 1.1%, P<0.001); were more likely to be admitted to the intensive care unit (2.2% vs. 1.1%, P=0.001).

Conclusion

Mortality was significantly higher in the EI sepsis group than in the LI sepsis group.

Usefulness of ischemia-modified albumin in the diagnosis of sepsis/septic shock in the emergency department

Objective

No studies have evaluated the diagnostic value of ischemia-modified albumin (IMA) for the early detection of sepsis/septic shock in patients presenting to the emergency department (ED). We aimed to assess the usefulness of IMA in diagnosing sepsis/septic shock in the ED.

Methods

This retrospective, observational study analyzed IMA, lactate, high sensitivity C-reactive protein, and procalcitonin levels measured within 1 hour of ED arrival. Patients with suspected infection meeting at least two systemic inflammatory response syndrome criteria were included and classified into the infection, sepsis, and septic shock groups using Sepsis-3 definitions. Areas under the receiver operating characteristic curves (AUCs) with 95% confidence intervals (CIs) and multivariate logistic regression were used to determine diagnostic performance.

Results

This study included 300 adult patients. The AUC (95% CI) of IMA levels (cut-off ≥85.5 U/mL vs. ≥87.5 U/mL) was higher for the diagnosis of sepsis than for that of septic shock (0.729 [0.667–0.791] vs. 0.681 [0.613–0.824]) and was higher than the AUC of procalcitonin levels (cut-off ≥1.58 ng/mL, 0.678 [0.613–0.742]) for the diagnosis of sepsis. When IMA and lactate levels were combined, the AUCs were 0.815 (0.762–0.867) and 0.806 (0.754–0.858) for the diagnosis of sepsis and septic shock, respectively. IMA levels independently predicted sepsis (odds ratio, 1.05; 95% CI, 1.00–1.09; P=0.029) and septic shock (odds ratio, 1.07; 95% CI, 1.02–1.11; P=0.002).

Conclusion

Our findings indicate that IMA levels are a useful biomarker for diagnosing sepsis/ septic shock early, and their combination with lactate levels can enhance the predictive power for early diagnosis of sepsis/septic shock in the ED.

[One case of extremely severe burn combined with stillbirth and multiple organ dysfunction syndrome in the third trimester of pregnancy]

One 24 years old female patient who suffered extremely severe burn in the third trimester of pregnancy was admitted to the Department of Burns and Skin Repair Surgery of the Third Affiliated Hospital of Wenzhou Medical University on 9th May, 2015. Intrauterine distress occurred after injury and stillbirth was confirmed within 12 hours. In cooperation with the obstetrician, the labor was induced on post injury day (PID) 5. Septic shock and multiple organ dysfunction syndrome occurred on PID 8. Through treatments including anti-infection, ventilator-assisted ventilation, cardiotonic diuresis, and escharectomy and skin grafting, the patient was finally cured. This case indicates that it is crucial to grasp the right time and choose a reasonable induction of labor to deal with stillbirth. The scheme of transvaginal induction of labor after shock is a worthy question to explore. The main characteristics of this patient include the extreme paroxysmal changes in breath, circulation, and urine volume within 24 hours after induced labor, which should be monitored dynamically for effective and timely adjustment of respiratory circulation support. This may be another key point for the rescue of this type of patient. To seize the opportunities to perform escharectomy, cover the wound with xenogenic skin graft, and perform skin grafting in time for wound repair remain the top priority.

[Extracorporeal techniques for blood purification in sepsis: an update]

BACKGROUND

Despite ongoing development, mortality in sepsis remains considerable. Various techniques for extracorporeal cytokine removal have been described, but evidence remains conflicting.

OBJECTIVES

The aim of this article is to summarize currently used extracorporeal blood purification techniques and their evidence.

METHODS

Non-systematic literature review RESULTS: There are currently various blood purification techniques used with different levels of evidence regarding cytokine removal, vasopressor sparing effects and reduction of mortality, including high-volume dialysis with and without high cut-off filters, special adsorption filters (including CytoSorb®, CytoSorbents Europe, Berlin, Germany, and polymyxin‑B filters). There is development regarding therapeutic plasma exchange. For some blood purification techniques such as combined plasma filtration and adsorption, multicentric randomized studies found a negative effect on survival.

CONCLUSIONS

Despite a theoretical rationale, the use of blood purification methods cannot be recommended for sepsis patients due to the lack of evidence of their efficacy. Heterogeneous inflammatory responses in sepsis render conduction of larger trials difficult. Thus, future studies should cautiously identify appropriate sepsis subtypes to be included. Available techniques should be chosen as individualized complementary treatments and not as competing systems.

[Surviving Sepsis Campaign update 2018: the 1 h bundle : Background to the new recommendations]

A new update of the sepsis bundle was published by the Surviving Sepsis Campaign (SSC) in April 2018. The original 3 h and 6 h bundles have been restructured and combined into a 1‑h bundle. The recommendations comprehensively focus on diagnostic and therapeutic measures which should be carried out within 1 h after recognition of sepsis. This article presents the background and discusses criticisms of the new recommendations.

Klebsiella pneumoniae necrotizing fasciitis on the upper lip in a patient with uncontrolled diabetes

A 60-year-old woman with a history of diabetes mellitus and chronic renal failure was admitted to the hospital with severe pain in the upper lip, which began 4 days prior to admission, accompanied by a bullous lesion and suspected cellulitis in the upper lip. Immediately after admission, as the patient´s general condition worsened, tests revealed a non-ST elevated myocardial infarction, septic embolism of the lung, as well as septic shock. Her upper lip suddenly presented a gangrenous and necrotic change, which the tissue and blood culture confirmed to be a Klebsiella pneumoniae infection. After a quick response, the patient’s general condition improved. Subsequently, serial debridement was performed to effectively clear away the purulent discharge. While under general anesthesia, the process confirmed full-layer necrosis of the upper lip including the orbicularis oris muscle. Almost half of the entire upper lip sustained a full-layer skin and soft tissue defect, with scar contracture. Six months later, to correct the drooling and lip sealing following the defects, a scar release and an Abbe flap coverage were performed considering both functional and aesthetic aspects. The follow-up revealed a favorable corrective result of the upper lip drooling, and the patient was satisfied from a functional perspective.

The complete blood count to diagnose septic shock

The complete blood count has a longstanding role in the diagnosis of septic shock. Despite its limitations, this is a pragmatic tool because patients will generally have a blood count measured upon presentation to the hospital. Therefore, it is sensible to extract as much information from these values as possible. Although the white blood cell count continues to attract the most attention, it is the least useful. Emerging evidence suggests that emphasis should be shifted to the neutrophil to lymphocyte ratio (NLR) and perhaps the fraction of immune granulocytes.

Association of negative fluid balance during the de-escalation phase of sepsis management with mortality: A cohort study

PURPOSE

We aimed to evaluate the impact of negative fluid balance during the fluid de-escalation phase of sepsis management.

MATERIAL AND METHODS

This is a historical cohort study of adult intensive care units (ICU) patients with septic shock and severe sepsis in a quaternary medical center, from January 2007 through December 2009. We used regression modeling to assess the impact of negative volume balance on mortality after adjustments for age, comorbidities, and illness severity.

RESULTS

Among 633 enrolled patients, 387 patients reached negative fluid balance who in comparison with others had a lower 90-day mortality rate (36% vs. 44%; P = .048), despite higher severity of illness. Each 1-L negative daily fluid balance was associated with reduced ICU, hospital, 90-day and 1-year mortality (hazard ratio [HR] 0.39 [95%CI, 0.28-0.57], 0.76 [95%CI, 0.63-0.94], 0.69 [95%CI, 0.59-0.81], 0.67 [0.58-0.78], respectively; P < .05). This protective effect of negative volume balance was maintained when cumulative ICU fluid balance was utilized.

CONCLUSIONS

There is not only a significant association between outcomes of patients who were resuscitated for sepsis and achieving negative fluid balance, but also the amount of daily or cumulative negative fluid balance is associated with lower mortality of these patients. Prospective clinical trials are needed to validate this finding.

[Clinical study on the effects of global end-diastolic volume index-directed fluid resuscitation on the prognosis of chronic heart failure patients with septic shock]

Objective: To investigate the effect of global end-diastolic volume index (GEDI)-guided fluid resuscitation on the prognosis of patients with chronic heart failure and septic shock. Methods: This study was a prospective randomized controlled study. Consecutive eligible patients were divided into 2 groups according to the random number table method: control group (n=21) and experimental group (n=20). On the basis of routine treatment, patients in the control group received early goal-directed therapy until the central venous pressure (CVP) reaching 8-12 mmHg (1 mmHg=0.133 kPa), mean arterial pressure reaching over 65 mmHg, urine volume reaching over 0.5 ml·kg(-1)·h(-1), and central venous oxygen saturation reaching more than 70%. On the basis of routine treatment, patients in the experimental group were monitored continuously on cardiac output with pulse indication and fluid resuscitation guided by volume index GEDI. The GEDI should be maintained on the range of 680-800 ml/m(2). The remaining resuscitation goals were the same as control group. General clinical data of the two groups were collected at admission. Negative fluid balance onset time, duration of mechanical ventilation, ICU mortality and 28-day mortality were compared between the two groups. The outcomes were recorded as listed: start time of negative fluid balance, duration of mechanical ventilation, mortality in ICU and 28-day mortality. Results: There was no significant difference in age, sex, weight, APACHE Ⅱ score, SOFA score and NYHA functional class score between the two groups (all P>0.05). The negative liquid balance onset time in the control group was 3.5 (2.5, 4.0) days, which was significantly longer than that in the experimental group (2.6 (2.0, 3.0) days,U=115.0, P=0.012). The duration of mechanical ventilation was 355 (118, 552) hours in the control group, which was significantly longer than that in the experimental group (132 (36.75, 233.3) hours, U=130, P=0.038). The ICU mortality was 38.1% (8/21) in the control group, tended to be higher than that in the experimental group (20.0%(4/20), χ(2)=1.620, P=0.203). The 28-day mortality was 42.9% (9/21) in the control group, similar as in the experimental group (25.0%(5/20), χ(2)=1.482,P=0.477). Conclusion: Fluid resuscitation guided by volume index (GEDI) may improve the prognosis of patients with chronic heart failure complicated with septic shock.

[The 2016 Surviving Sepsis Campaign sepsis guideline]

Sepsis is still associated with very high morbidity and mortality. Continuous improvements in the early recognition and management of this syndrome are thus necessary. The 2016 Surviving Sepsis Campaign sepsis guideline presents current evidence and consequences in the management of sepsis. This new guideline came at the beginning of the paradigm shift in sepsis definition, whereby the influence of the current sepsis definition on the management of sepsis is yet to be seen. Despite tremendous research efforts, several recommendations in the new sepsis guideline have a weak to moderate evidence grade. Several issues, such as the effect of the Sepsis-3 definition on the early recognition of sepsis, the selection of appropriate fluid and antibiotic therapy, as well as individualizing sepsis management are yet to be addressed. Therefore, the current guideline is also a call for the intensive care community for more and better research on sepsis treatment.

The hollow adrenal gland sign: a newly described enhancing pattern of the adrenal gland on dual-phase contrast-enhanced CT for predicting the prognosis of patients with septic shock

OBJECTIVE

To investigate the incidence, CT appearance, and implication for prognosis of the hollow adrenal gland sign (HAGS).

METHODS

A total of 194 patients with septic shock and 24 patients with hemorrhagic shock (as control group) were retrospectively included in this study and the patients with septic shock were further divided into four subgroups (digestive tract diseases, DTD, n = 49; biliary and pancreatic diseases, BPD, n = 41; postsurgical infection, PI, n = 64; and other diseases, OD, n = 40). All patients underwent a dual-phase contrast-enhanced CT within 1 week after diagnosis. CT findings and clinical records were reviewed. If in the arterial phase the central zone of adrenal gland showed temporally much lower attenuation than the peripheral zone, it was defined as HAGS positive. The incidence of the HAGS in patients with septic shock and hemorrhagic shock, the demographic features, and mortality between HAGS-positive and HAGS-negative patients in each group were respectively compared.

RESULTS

The incidence of the HAGS in the septic shock group was nearly 30%, while it was 0 in the hemorrhagic shock group. There was no significant difference in age or gender between HAGS-positive and HAGS-negative patients in all groups, while the mortality of HAGS-positive patients was significantly higher than that of HAGS-negative patients in each group (p < 0.05). The concordance correlation coefficient value showed excellent reproducibility of the two observers (κ = 0.977).

CONCLUSION

The HAGS is specific and common on dual-phase contrast-enhanced CT in patients with septic shock and predicts a poor prognosis.

KEY POINTS

• The hollow adrenal gland sign (HAGS) newly described in this study is a special enhancing pattern of adrenal gland on dual-phase contrast-enhanced CT in patients with septic shock. • The HAGS is characterized by the much lower-attenuated central zone of the adrenal gland in arterial phase and it showed excellent reproducibility between different observers. • The HAGS is specific and common on dual-phase contrast-enhanced CT in patients with septic shock and predicts a poor prognosis.

A paradigm shift in the provision of improved critical care in the emergency department

With Hong Kong's ageing population, advancement of medical technologies and hospital congestion, it is not uncommon for emergency physicians to encounter complicated critically ill patients in daily practice. It becomes a fundamental role of emergency physicians to initiate timely diagnostic and therapeutic interventions to save a patient's life and improve their prognosis. It is the reason a critical care service has been developed in emergency departments worldwide over the last decade. This article shares how emergency department intensivists can contribute to this novel model of care with some illustrative cases. Advanced airway and peri-intubation management, difficult mechanical ventilation, treatment of shock, circulatory arrest, and metabolic disturbances can be safely and efficiently handled in the current emergency department setting. Obstacles, barriers, and the road ahead will be discussed.

[The effects of levosimendan on the cardiac function and prognosis in elderly patients with septic shock and myocardial contractility impairment]

Objective: To investigate the effect of levosimendan on cardiac function and prognosis in elderly patients with septic myocardial contractility impairment. Methods: A prospective, randomized, controlled study was conducted. The elderly patients with septic myocardial contractility impairment who were admitted to Intensive Care Unit in Zhejiang Hospital were consecutively enrolled from January 2017 to September 2017. The key inclusive criterion was left ventricular ejection fraction (LVEF) ≤50% after fluid resuscitation. A total of 30 patients were randomly assigned to levosimendan group (n=15) and dobutamine group (n=15). Based onconventional treatment, intravenous dobutamine (5 μg per kilogram of body weight per minute) or levosimendan (0.2 μg per kilogram of body weight per minute)were continuously administrated for 24 hours in two groups. At 0 h,24 h,48 h, 72 h after injection, the following parameters or values were recorded including serum lactic acid (Lac), and echocardiographic parameters such as LVEF, stroke volume (SV). The time of mechanical ventilation, length of stay in ICU and 28-day mortality were compared in two groups. Results: Compared with dobutamine group, blood Lac at 24 h [(1.97±1.10)mmol/L vs. (2.73±2.06) mmol/L, P=0.002] decreased significantlyin levosimendan group. LVEF and SV were significantly higher in levosimendan group at 24 h [LVEF:(47.93±5.01)% vs.(45.60±5.47)%, P=0.004;SV:(47.73±14.01) ml vs. (44.80±16.89) ml, P=0.035;respectively], 48 h [LVEF:(51.07±5.05)% vs.(46.73±6.34)%, P=0.004;SV: (49.87±14.15) ml vs. (45.07±16.94) ml, P=0.005;respectively] and 72 h [LVEF:(53.20±5.92)% vs. (47.70±6.71)%, P=0.002;SV:(51.27±14.98) ml vs. (45.73±17.34) ml, P=0.010]. The time of mechanical ventilation, length of stay in ICU and 28-day mortality were comparable between two groups (P>0.05). Conclusions: Levosimendan improves cardiac systolic function and tissue perfusion in elderly patients with septic myocardial contractility impairment. However, cardiac diastolic function, liver and kidney function are not further improved by levosimendan compare with dubutamine. Time of mechanical ventilation, length of stay in ICU and 28-day mortality in two groups are similar.

[International guidelines from the Surviving Sepsis Campaign : 2016 update]

An update to the international guidelines for sepsis therapy was published by the Surviving Sepsis Campaign (SSC) in March 2017. The guidelines have been completely restructured and comprehensively deal with new evidence. The guidelines discuss sepsis-specific therapeutic measures and provide detailed recommendations on general intensive care measures for sepsis. This article summarizes the most important amendments and suggests delving deeper into the guidelines.

Short-term effects of passive mobilization on the sublingual microcirculation and on the systemic circulation in patients with septic shock

Background

Active mobilization is not possible in patients under deep sedation and unable to follow commands. In this scenario, passive therapy is an interesting alternative. However, in patients with septic shock, passive mobilization may have risks related to increased oxygen consumption. Our objective was to evaluate the impact of passive mobilization on sublingual microcirculation and systemic hemodynamics in patients with septic shock.

Methods

We included patients who were older than 18 years, who presented with septic shock, and who were under sedation and mechanical ventilation. Passive exercise was applied for 20 min with 30 repetitions per minute. Systemic hemodynamic and microcirculatory variables were compared before (T0) and up to 10 min after (T1) passive exercise. p values <0.05 were considered significant.

Results

We included 35 patients (median age [IQR 25–75%]: 68 [49.0–78.0] years; mean (±SD) Simplified Acute Physiologic Score (SAPS) 3 score: 66.7 ± 12.1; median [IQR 25–75%] Sequential Organ Failure Assessment (SOFA) score: 9 [7.0–12.0]). After passive mobilization, there was a slight but significant increase in proportion of perfused vessels (PPV) (T0 [IQR 25–75%]: 78.2 [70.9–81.9%]; T1 [IQR 25–75%]: 80.0 [75.2–85.1] %; p = 0.029), without any change in other microcirculatory variables. There was a reduction in heart rate (HR) (T0 (mean ± SD): 95.6 ± 22.0 bpm; T1 (mean ± SD): 93.8 ± 22.0 bpm; p < 0.040) and body temperature (T0 (mean ± SD): 36.9 ± 1.1 °C; T1 (mean ± SD): 36.7 ± 1.2 °C; p < 0.002) with no change in other systemic hemodynamic variables. There was no significant correlation between PPV variation and HR (r = −0.010, p = 0.955), cardiac index (r = 0.218, p = 0.215) or mean arterial pressure (r = 0.276, p = 0.109) variation.

Conclusions

In patients with septic shock after the initial phase of hemodynamic resuscitation, passive exercise is not associated with relevant changes in sublingual microcirculation or systemic hemodynamics.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-017-0318-x) contains supplementary material, which is available to authorized users.

A combination of early warning score and lactate to predict intensive care unit transfer of inpatients with severe sepsis/septic shock

BACKGROUND/AIMS

The modified early warning score (MEWS) is used to predict patient intensive care unit (ICU) admission and mortality. Lactate (LA) in the blood lactate (BLA) is measured to evaluate disease severity and treatment efficacy in patients with severe sepsis/septic shock. The usefulness of a combination of MEWS and BLA to predict ICU transfer in severe sepsis/septic shock patients is unclear. We evaluated whether use of a combination of MEWS and BLA enhances prediction of ICU transfer and mortality in hospitalized patients with severe sepsis/septic shock.

METHODS

Patients with severe sepsis/septic shock who were screened or contacted by a medical emergency team between January 2012 and August 2012 were enrolled at a university-affiliated hospital with ~2,700 beds, including 28 medical ICU beds.

RESULTS

One hundred patients were enrolled and the rate of ICU admittance was 38%. MEWS (7.37 vs. 4.85) and BLA concentration (5 mmol/L vs. 2.19 mmol/L) were significantly higher in patients transferred to ICU than those in patients treated in general wards. The combination of MEWS and BLA was more accurate than MEWS alone in terms of ICU transfer (C-statistics: 0.898 vs. 0.816, p = 0.019). The 28-day mortality rate was 19%. MEWS was the only factor significantly associated with 28-day mortality rate (odds ratio, 1.462; 95% confidence interval, 1.122 to 1.905; p = 0.005).

CONCLUSIONS

The combination of MEWS and BLA may enhance prediction of ICU transfer in patients with severe sepsis/septic shock.

Uncommon cause of severe pneumonia: co-infection of influenza B and Streptococcus

Influenza and pneumococcus co-infection can cause severe morbidity and mortality. Usually, this entails influenza A, while infection by influenza B is rarely serious. The literature describes influenza A epidemics leading to prolific loss of lives, notably the 1918 epidemic was blamed for the deaths of 40 to 50 million people. In this report, four patients were infected by influenza B during the influenza epidemic of 2011/12 in Hong Kong. All of them were previously healthy and had no chronic diseases; they were admitted to the hospital due to influenza-like symptoms. They rapidly deteriorated with multi-organ failure, and were subsequently diagnosed to be infected with influenza B and streptococci that gave rise to severe pneumonia. Three of them were infected with Streptococcus pneumoniae and one with Streptococcus pyogenes. All of them had leukopenia, septic shock, and acute kidney injury; two of whom died despite aggressive antibiotic treatment and organ support in the intensive care unit. According to the literature, this is the second case report of severe invasive pneumococcal pneumonia secondary to influenza B infection.

Strongyloides stercoralis hyperinfection: a dreaded but still missed diagnosis

Strongyloides stercoralis (S. stercoralis), an intestinal nematode, is endemic in tropical and subtropical regions, being less prevalent in temperate climates. The number of infected persons worldwide ranges between 10 million and 100 million people. In Brazil the reported prevalence is 13%. Chronic infection may be asymptomatic or accompanied by gastrointestinal and respiratory symptoms. Under immunosuppressive conditions, the infection assumes serious proportions frequently accompanied by septic shock, disseminated intravascular coagulopathy and respiratory distress syndrome. The authors report a case of a 50-year-old female patient who was a chronic user of glucocorticoids and had been seeking medical attention for two months because of continuous gastrointestinal symptoms. She was admitted to the emergency room with clinical signs of septic shock and died after four days despite an adequate antibiotic regimen, vasopressor drugs, and ventilatory support. The autopsy revealed the unsuspected finding of S. stercoralis hyperinfection and septicemia.