Critical Care Echocardiography-A Driven Approach to Undifferentiated Shock

The clinical approach to undifferentiated shock in critically ill patients should be revised to use modern, point-of-care tools that are readily available. With the increasing availability of 2-dimensional ultrasonography and advanced Doppler capabilities, a quick, simplified, and integrated stepwise approach to shock using critical care echocardiography is proposed. Evidence supports the feasibility and usefulness of critical care echo-cardiography in enhancing diagnostic accuracy for shock, but there is a lack of systematic application of the technology in patients with undifferentiated shock. The proposed approach begins with the use of noninvasive ultrasonography with pulsed-wave Doppler capability to determine the flow state by measuring the velocity time integral of the left ventricular outflow tract. This narrative review explores the use left ventricular outflow tract velocity time integral, velocity time integral variation, limited visceral organ Doppler, and lung ultrasonography as a systematic approach for patients with undifferentiated shock.

Severe Adult Rotavirus Gastroenteritis: A Rare Case with Multi-Organ Failure and Critical Management

BACKGROUND Infectious diarrheal illnesses such as rotavirus gastroenteritis are significant contributors to childhood morbidity and mortality, especially in low socio-demographic index regions. Major advances in addressing this issue include sanitation and clean water initiatives, as well as rotavirus immunization. In Australia, a robust vaccination program has significantly reduced childhood rotavirus infections, leading to decreased hospitalizations and mortality. However, cases of adult rotavirus still occur, and although these adult patients usually do not require interventional management, it is possible for them to present critically unwell and require resuscitation. CASE REPORT A previously well 65-year-old man presented to the Emergency Department febrile and hypotensive with severe diarrhea attributed to rotavirus. Clinically, he presented with mixed hypovolemic and septic shock. Despite initial resuscitation, he had multiple severe acute end-organ complications, secondary to poor perfusion. He acquired an acute kidney injury, type-2 myocardial infarction, and ischemic hepatic injury. The mainstay of management was rapid fluid resuscitation, continuous renal replacement therapy, and monitoring in the Intensive Care Unit; however, it was crucial to empirically treat for other causes of shock. CONCLUSIONS To the best of our knowledge, there is a scarcity of reports documenting the management of severe rotavirus gastroenteritis in adults. We recommend advising elderly patients to avoid contact with individuals with diarrheal illnesses, especially rotavirus gastroenteritis. Clinicians should also promote awareness regarding the potential severity of a disease that is typically managed conservatively, and be aware that intervention can be required in severe gastroenteritis.

Changes in Heparin-Binding Protein, Procalcitonin, and C-Reactive Protein Within the First 72 Hours Predict 28-Day Mortality in Patients Admitted to the Intensive Care Unit with Septic Shock

BACKGROUND This study aimed to evaluate the possible associations of heparin-binding protein (HBP), procalcitonin (PCT), and C-reactive protein (CRP) levels with 28-day mortality in septic shock patients admitted to Intensive Care Units (ICUs). MATERIAL AND METHODS Blood samples were taken at ICU admission and measured again 72 h later to calculate changes in HBP (ΔHBP), changes in PCT (ΔPCT), changes in CRP (ΔCRP), and changes in Sequential Organ Failure Assessment (DSOFA) relative to baseline. RESULTS Variables included in the univariable logistic regression model for survival were age, Acute Physiology and Chronic Health Evaluation (APACHE) II scores, decreasing ΔSOFA, decreasing DHBP, decreasing ΔPCT, and decreasing ΔCRP. Survival was directly related to decreasing ΔHBP with odds ratio (OR)=9.95 (95% confidence interval [CI] 4.63 to 21.35; P<0.001), decreasing ΔPCT with OR=7.85 (3.74 to 16.49; P<0.001), decreasing ΔCRP with OR=5.83 (2.84 to 11.97; P<0.001), decreasing ΔSOFA with OR=1.93 (1.00 to 3.75; P=0.051) and APACHE II score with OR=1.93 (1.14 to 1.68; P=0.001). In a multivariable logistic regression model for survival, only decreasing DHBP with OR=7.18 (2.91 to 17.69; P<0.001), decreasing ΔPCT with OR=5.17 (2.12 to 12.56; P<0.001), and decreasing ΔCRP with OR=4.33 (1.77 to 10.61; P=0.001) remained significant. CONCLUSIONS Measuring changes in HBP, PCT, and CRP within 72 h of admission may aid in predicting 28-day mortality for patients with septic shock in ICUs.

Prediction of septic and hypovolemic shock in intensive care unit patients using machine learning

OBJECTIVE

To create and validate a model for predicting septic or hypovolemic shock from easily obtainable variables collected from patients at admission to an intensive care unit.

METHODS

A predictive modeling study with concurrent cohort data was conducted in a hospital in the interior of northeastern Brazil. Patients aged 18 years or older who were not using vasoactive drugs on the day of admission and were hospitalized from November 2020 to July 2021 were included. The Decision Tree, Random Forest, AdaBoost, Gradient Boosting and XGBoost classification algorithms were tested for use in building the model. The validation method used was k-fold cross validation. The evaluation metrics used were recall, precision and area under the Receiver Operating Characteristic curve.

RESULTS

A total of 720 patients were used to create and validate the model. The models showed high predictive capacity with areas under the Receiver Operating Characteristic curve of 0.979; 0.999; 0.980; 0.998 and 1.00 for the Decision Tree, Random Forest, AdaBoost, Gradient Boosting and XGBoost algorithms, respectively.

CONCLUSION

The predictive model created and validated showed a high ability to predict septic and hypovolemic shock from the time of admission of patients to the intensive care unit.

An Atypical Source of Persistent Fungemia in the Intensive Care Unit

BACKGROUND Candidemia is a common complication of critically ill and immunocompromised patients, with more than 50% associated mortality. Typical etiologies include valvular vegetations, intra-abdominal fluid collections, and central venous catheters. Treatment often entails surgical excision, but anticoagulation may be sufficient. CASE REPORT Our case was a 63-year-old woman with diabetes mellitus, left hip osteoarthritis status after hemiarthroplasty, and alcohol use disorder, admitted to the Intensive Care Unit with diabetic ketoacidosis (DKA) and hemorrhagic shock from an upper gastrointestinal bleed. Complicating her course was the development of Candida species fungemia. An extensive workup including transthoracic echocardiography, computed tomography of the chest, abdomen, and pelvis, ocular examination, and hip aspiration was unrevealing in determining the etiology. Despite early line removal and appropriate antifungal therapy, the fungemia persisted. A broader evaluation revealed a venous thromboembolism, which ultimately was thought to be the source. Subsequent initiation of anticoagulation and continued antifungal therapy led to clearance of blood cultures with overall clinical improvement. CONCLUSIONS In critically ill patients at higher risk for development of venous thromboembolism, septic thrombi should be considered in the differential diagnosis when evaluating for source control in a patient with fungemia.

Predictive Value of Procalcitonin and Neutrophil-to-Lymphocyte Ratio Variations for Bloodstream Infection with Septic Shock

BACKGROUND Little is known of neutrophil-to-lymphocyte ratio (NLR) variations in septic shock. Hence, the predictive value of procalcitonin (PCT) and NLR variations for septic shock in bloodstream infection were explored. MATERIAL AND METHODS We analyzed 146 patients with bloodstream infection admitted to the Intensive Care Unit (ICU) of the First Affiliated Hospital of Anhui Medical University from October 2016 to May 2020. PCT and NLR were evaluated at 0 and 48 h after admission, and their variations (ΔPCT and DNLR) were calculated. The patients were divided into a shock group (n=80) and a non-shock group (n=66) and a gram-positive cocci group (n=69) and a gram-negative bacilli group (n=77). The predictive value of ΔPCT and DNLR was compared among groups. RESULTS AUROC of NLR0h (0.756) higher than PCT0h (0.743).DPCT (0.561 vs 0.301) and ΔNLR (0.609 vs 0.361) were significantly higher in the shock group than in the non-shock group (P<0.05). No significant difference was seen in DPCT and DNLR in the gram-positive cocci infection group. However, the gram-negative bacilli infection group showed a significant difference in ΔPCT (0.606 vs 0.312) and ΔNLR (0.872 vs 0.508) between the shock and non-shock groups (P<0.05). ΔPCT+ΔNLR showed the best area under the curve (0.937), with a high sensitivity (78.80%) and specificity (90.80%), for predicting septic shock. CONCLUSIONS The prediction efficiency of initial NLR is higher than that of PCT. ΔPCT+ΔNLR best predicted septic shock in patients with bloodstream infections, with better accuracy for gram-negative infections.

Comparison of the effects of albumin and crystalloid on mortality among patients with septic shock: systematic review with meta-analysis and trial sequential analysis

BACKGROUND

This study aimed to compare the effects on mortality of albumin and crystalloid, used for fluid resuscitation among adult patients with septic shock, through conducting a meta-analysis and trial sequential analysis (TSA).

DESIGN AND SETTING

Meta-analysis and TSA conducted at Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China.

METHODS

Data were collected from several major databases including MEDLINE, EMBASE, Clinical Trials.gov and Cochrane Central Register of Controlled Trials. Studies that compared the effects of albumin therapy versus crystalloid therapy on mortality among adult septic shock patients were eligible for inclusion in the analyses. The study name, year of publication, country of the trial, albumin concentration, type of crystalloid and all reported mortalities at different follow-up endpoints were extracted.

RESULTS

Compared with crystalloid, albumin did not decrease all-cause mortality at the final follow-up. However, in TSA, the required information size was not achieved in all groups, which means that the effect size was not definitive and further RCTs are needed to confirm or deny these findings.

CONCLUSIONS

Compared with crystalloid solutions, albumin was unable to decrease all-cause mortality. However, TSA indicated that these results could be false-negative. Additional randomized controlled trials are needed to clarify this discrepancy.

Implications of Plasma Renin Activity and Plasma Aldosterone Concentration in Critically Ill Patients with Septic Shock

Background

The renin-angiotensin-aldosterone system is closely associated with volume status and vascular tone in septic shock. The present study aimed to assess whether plasma renin activity (PRA) and plasma aldosterone concentration (PAC) measurements compared with conventional severity indicators are associated with mortality in patients with septic shock.

Methods

We evaluated 105 patients who were admitted for septic shock. Plasma levels of the biomarkers PRA and PAC, the PAC/PRA ratio, C-reactive protein (CRP) level, and cortisol level on days 1, 3, and 7 were serially measured. During the intensive care unit stay, relevant clinical information and laboratory results were recorded.

Results

Patients were divided into two groups according to 28-day mortality: survivors (n = 59) and non-survivors (n = 46). The survivor group showed lower PRA, PAC, Acute Physiologic and Chronic Health Evaluation (APACHE) II score, and Sequential Organ Failure Assessment (SOFA) score than did the non-survivor group (all P < 0.05). The SOFA score was positively correlated with PRA (r = 0.373, P < 0.001) and PAC (r = 0.316, P = 0.001). According to receiver operating characteristic analysis, the areas under the curve of PRA and PAC to predict 28-day mortality were 0.69 (95% confidence interval [CI], 0.58 to 0.79; P = 0.001) and 0.67 (95% CI, 0.56 to 0.77; P = 0.003), respectively, similar to the APACHE II scores and SOFA scores. In particular, the group with PRA value ≥3.5 ng ml^-1 h^-1 on day 1 showed significantly greater mortality than did the group with PRA value <3.5 ng ml^-1 h^-1 (log-rank test, P < 0.001). According to multivariate analysis, SOFA score (hazard ratio, 1.11; 95% CI, 1.01 to 1.22), PRA value ≥3.5 ng ml^-1 h^-1 (hazard ratio, 3.25; 95% CI, 1.60 to 6.60), previous history of cancer (hazard ratio, 3.44; 95% CI, 1.72 to 6.90), and coronary arterial occlusive disease (hazard ratio, 2.99; 95% CI, 1.26 to 7.08) were predictors of 28-day mortality.

Conclusions

Elevated PRA is a useful biomarker to stratify the risk of critically ill patients with septic shock and is a prognostic predictor of 28-day mortality.

Corticosteroids for treating sepsis

BACKGROUND

Sepsis occurs when an infection is complicated by organ failures as defined by a sequential organ failure assessment (SOFA) score of two or higher. Sepsis may be complicated by impaired corticosteroid metabolism. Giving corticosteroids may benefit patients. The original review was published in 2004 and was updated in 2010 and again in 2015.

OBJECTIVES

To examine the effects of corticosteroids on death at one month in patients with sepsis, and to examine whether dose and duration of corticosteroids influence patient response to this treatment.

SEARCH METHODS

We searched the Central Register of Controlled Trials (CENTRAL; 2014, Issue 10), MEDLINE (October 2014), EMBASE (October 2014), Latin American Caribbean Health Sciences Literature (LILACS; October 2014) and reference lists of articles, and we contacted trial authors. The original searches were performed in August 2003 and in October 2009.

SELECTION CRITERIA

We included randomized controlled trials of corticosteroids versus placebo or supportive treatment in patients with sepsis.

DATA COLLECTION AND ANALYSIS

All review authors agreed on the eligibility of trials. One review author extracted data, which were checked by the other review authors, and by the primary author of the paper when possible. We obtained some missing data from trial authors. We assessed the methodological quality of trials.

MAIN RESULTS

We identified nine additional studies since the last update, for a total of 33 eligible trials (n = 4268 participants). Twenty-three of these 33 trials were at low risk of selection bias, 22 were at low risk of performance and detection bias, 27 were at low risk of attrition bias and 14 were at low risk of selective reporting.Corticosteroids reduced 28-day mortality (27 trials; n = 3176; risk ratio (RR) 0.87, 95% confidence interval (CI) 0.76 to 1.00; P value = 0.05, random-effects model). The quality of evidence for this outcome was downgraded from high to low for imprecision (upper limit of 95% CI = 1) and for inconsistency (significant heterogeneity across trial results). Heterogeneity was related in part to the dosing strategy. Treatment with a long course of low-dose corticosteroids significantly reduced 28-day mortality (22 trials; RR 0.87, 95% CI 0.78 to 0.97; P value = 0.01, fixed-effect model). The quality of evidence was downgraded from high to moderate for inconsistency (owing to non-significant effects shown by one large trial). Corticosteroids also reduced mortality rate in the intensive care unit (13 trials; RR 0.82, 95% CI 0.68 to 1.00; P value = 0.04, random-effects model) and at the hospital (17 trials; RR 0.85, 95% CI 0.73 to 0.98; P value = 0.03, random-effects model). Quality of the evidence for in-hospital mortality was downgraded from high to moderate for inconsistency and imprecision (upper limit of 95% CI for RR approaching 1). Corticosteroids increased the proportion of shock reversal by day seven (12 trials; RR 1.31, 95% CI 1.14 to 1.51; P value = 0.0001) and by day 28 (seven trials; n = 1013; RR 1.11, 95% CI 1.02 to 1.21; P value = 0.01) and reduced the SOFA score by day seven (eight trials; mean difference (MD) -1.53, 95% CI -2.04 to -1.03; P value < 0.00001, random-effects model) and survivors' length of stay in the intensive care unit (10 trials; MD -2.19, 95% CI -3.93 to -0.46; P value = 0.01, fixed-effect model) without inducing gastroduodenal bleeding (19 trials; RR 1.24, 95% CI 0. 92 to 1.67; P value = 0.15, fixed-effect model), superinfection (19 trials; RR 1.02, 95% CI 0.87 to 1.20; P value = 0.81, fixed-effect model) or neuromuscular weakness (three trials; RR 0.62, 95% CI 0.21 to 1.88; P value = 0.40, fixed-effect model). Corticosteroid increased the risk of hyperglycaemia (13 trials; RR 1.26, 95% CI 1.16 to 1.37; P value < 0.00001, fixed-effect model) and hypernatraemia (three trials; RR 1.64, 95% CI 1.28 to 2.09; P value < 0.0001, fixed-effect model).

AUTHORS' CONCLUSIONS

Overall, low-quality evidence indicates that corticosteroids reduce mortality among patients with sepsis. Moderate-quality evidence suggests that a long course of low-dose corticosteroids reduced 28-day mortality without inducing major complications and led to an increase in metabolic disorders.

Extracorporeal Membrane Oxygenation as a Bridge to Surgery for Infective Endocarditis Complicated by Aorto-Atrial Fistula and Cardiopulmonary Collapse

The timing of surgery for active infective endocarditis is challenging when patients exhibit mechanical dysfunction and hemodynamic compromise. Extracorporeal membrane oxygenation has been described in treating sepsis but not, insofar as we know, in treating the acute mechanical sequelae that arise from infective endocarditis. We report perhaps the first case that shows the usefulness of extracorporeal membrane oxygenation as a bridge to definitive treatment in a 35-year-old man who had infective endocarditis followed by aorto-atrial fistula and cardiopulmonary collapse.

Relative adrenal insufficiency as a predictor of disease severity and mortality in severe septic shock

OBJECTIVE

To evaluate if cortisol responses to 250 µg of intravenously administered adrenocorticotropic hormone are related to disease severity and, hence, mortality.

METHODS

This is a retrospective study in a medical-surgical intensive care unit of a university hospital. We studied 69 consecutive patients with septic shock over a 1-yr period; these patients underwent a short 250-µg adrenocorticotropic hormone test because they exhibited >6 hours of progressive hemodynamic instability requiring repeated fluid challenges and vasopressor treatment to maintain blood pressure. The test was performed by intravenously injecting 250 µg of synthetic adrenocorticotropic hormone and measuring cortisol immediately before injection, 30 minutes post-injection and 60 minutes post-injection.

RESULTS

The mean APACHE II score was 22±7. The intensive care unit mortality rate at day 28 was 55%. Median baseline cortisol levels (19 [11-27] µg/dL versus 24 [18-34] µg/dL, p=0.047) and median baseline cortisol/albumin ratios (7.6 [4.6-12.3] versus 13.9 [8.8-18.5]; p=0.01) were lower in survivors than in non-survivors. Responders and non-responders had similar baseline clinical data and outcomes. The variables that were significantly correlated with outcome based on the area under the ROC curves (AUC) were APACHE II (AUC=0.67 [0.535 to 0.781]), baseline cortisol (µg/dl) (AUC=0.662 [0.536 to 0.773], peak cortisol (µg/dl) (AUC=0.642 [0.515 to 0.755]) and baseline cortisol/albumin (AUC=0.75 [0.621 to 0.849]).

CONCLUSIONS

Increased basal cortisol is associated with mortality and disease severity. Cortisol responses upon adrenocorticotropic hormone stimulation were not related to outcome. The cortisol/albumin ratio does not predict unfavorable outcomes better than total cortisol levels or help to improve the accuracy of the adrenocorticotropic hormone test.

Comparison of lactate values obtained from different sites and their clinical significance in patients with severe sepsis

CONTEXT AND OBJECTIVE

The ideal site for lactate collection has not been clearly established. This study aimed to evaluate associations between lactate levels in arterial blood (Lart), peripheral venous blood (Lper) and central venous blood (Lcen) in patients with severe sepsis or septic shock.

DESIGN AND SETTING

Cross-sectional analytical study in an tertiary university hospital.

METHOD

Samples from patients with a central venous catheter and from healthy volunteers (control group) were collected. Blood was drawn simultaneously for measurements of Lart, Lper and Lcen, and the first sample was collected less than 24 hours after the onset of organ dysfunction. The results were analyzed using Pearson correlation, Bland-Altman and McNemar tests.

RESULTS

A total of 238 samples were collected from 32 patients. The correlation results were r = 0.79 (P < 0.0001) for Lart/Lper and r = 0.84 (P < 0.0001) for Lart/Lcen. Bland-Altman showed large limits of agreement: -3.2 ± 4.9 (-12.8 to 6.4) and -0.8 ± 5.9 (-12.5 to 10.8), for Lper and Lcen respectively. In the control group, there was greater correlation (r = 0.9009, P = 0.0004) and agreement: -0.7 ± 1.2 (-3.1 to 1.7). Regarding clinical intervention, there was good agreement between Lart/Lcen (96.3%; three disagreements), with worst results for Lart/Lper (87.0%) with 10 cases of disagreement (P = 0.04). In eight patients (80.0%) Lper was higher than Lart.

CONCLUSION

Lcen, and not Lper, can replace Lart with good correlation and clinical agreement. Lper tends to overestimate Lart, thus leading to unnecessary therapeutic interventions.