Evaluation of the Neonatal Sequential Organ Failure Assessment and Mortality Risk in Preterm Infants With Late-Onset Infection.

Importance: Infection in neonates remains a substantial problem. Advances for this population are hindered by the absence of a consensus definition for sepsis. In adults, the Sequential Organ Failure Assessment (SOFA) operationalizes mortality risk with infection and defines sepsis. The generalizability of the neonatal SOFA (nSOFA) for neonatal late-onset infection-related mortality remains unknown. Objective: To determine the generalizability of the nSOFA for neonatal late-onset infection-related mortality across multiple sites. Design, Setting, and Participants: A multicenter retrospective cohort study was conducted at 7 academic neonatal intensive care units between January 1, 2010, and December 31, 2019. Participants included 653 preterm (<33 weeks) very low-birth-weight infants. Exposures: Late-onset (>72 hours of life) infection including bacteremia, fungemia, or surgical peritonitis. Main Outcomes and Measures: The primary outcome was late-onset infection episode mortality. The nSOFA scores from survivors and nonsurvivors with confirmed late-onset infection were compared at 9 time points (T) preceding and following event onset. Results: In the 653 infants who met inclusion criteria, median gestational age was 25.5 weeks (interquartile range, 24-27 weeks) and median birth weight was 780 g (interquartile range, 638-960 g). A total of 366 infants (56%) were male. Late-onset infection episode mortality occurred in 97 infants (15%). Area under the receiver operating characteristic curves for mortality in the total cohort ranged across study centers from 0.71 to 0.95 (T0 hours), 0.77 to 0.96 (T6 hours), and 0.78 to 0.96 (T12 hours), with utility noted at all centers and in aggregate. Using the maximum nSOFA score at T0 or T6, the area under the receiver operating characteristic curve for mortality was 0.88 (95% CI, 0.84-0.91). Analyses stratified by sex or Gram-stain identification of pathogen class or restricted to infants born at less than 25 weeks' completed gestation did not reduce the association of the nSOFA score with infection-related mortality. Conclusions and Relevance: The nSOFA score was associated with late-onset infection mortality in preterm infants at the time of evaluation both in aggregate and in each center. These findings suggest that the nSOFA may serve as the foundation for a consensus definition of sepsis in this population.

Socio-Economic Status and Peritonitis in Australian Non-Indigenous Peritoneal Dialysis Patients.

UNLABELLED: ♦ BACKGROUND: The aim of the present study was to investigate the relationship between socio-economic status (SES) and peritoneal dialysis (PD)-related peritonitis. ♦ METHODS: Associations between area SES and peritonitis risk and outcomes were examined in all non-indigenous patients who received PD in Australia between 1 October 2003 and 31 December 2010 (peritonitis outcomes). SES was assessed by deciles of postcode-based Australian Socio-Economic Indexes for Areas (SEIFA), including Index of Relative Socio-economic Disadvantage (IRSD), Index of Relative Socio-economic Advantage and Disadvantage (IRSAD), Index of Economic Resources (IER) and Index of Education and Occupation (IEO). ♦ RESULTS: 7,417 patients were included in the present study. Mixed-effects Poisson regression demonstrated that incident rate ratios for peritonitis were generally lower in the higher SEIFA-based deciles compared with the reference (decile 1), although the reductions were only statistically significant in some deciles (IRSAD deciles 2 and 4 - 9; IRSD deciles 4 - 6; IER deciles 4 and 6; IEO deciles 3 and 6). Mixed-effects logistic regression showed that lower probabilities of hospitalization were predicted by relatively higher SES, and lower probabilities of peritonitis-associated death were predicted by less SES disadvantage status and greater access to economic resources. No association was observed between SES and the risks of peritonitis cure, catheter removal and permanent hemodialysis (HD) transfer. ♦ CONCLUSIONS: In Australia, where there is universal free healthcare, higher SES was associated with lower risks of peritonitis-associated hospitalization and death, and a lower risk of peritonitis in some categories.

Laser speckle contrast imaging for assessment of abdominal visceral microcirculation in acute peritonitis: does sequential impairments exist?

OBJECTIVE: It is believed that the microcirculation of multiple organs is impaired during acute peritonitis, however whether distinct susceptibilities of visceral microvasculature exist is still unknown. The present study aims to verify whether the microcirculatory alterations occur sequentially among multiple abdominal viscera during acute peritonitis. MATERIALS AND METHODS: Acute peritonitis was achieved on 29 Sprague-Dawley rats through colon ascendens stent peritonitis (CASP) model. With laser speckle contrast imaging (LSCI), the microcirculation of the liver, ileum and renal cortex was monitored in each rat at baseline before CASP sepsis and continued monitoring at 4h, 8h, or 12h after the surgery. Another 9 rats served for sham operation. One-way analysis of variance with a post hoc Dunnett's test was used for analysis. RESULTS: The ileum microcirculation was impaired earliest from 342.1±61.0 laser speckle perfusion unit (LSPU) at baseline to 271.7±74.0 LSPU at 4h (P<0.05), while the decline of renal microcirculation was not obvious until 8h after peritonitis (289.1±111.2 vs 376.2±53.4, P<0.05). However hepatic microcirculation was not significantly changed during 12h of observation period. CONCLUSION: The microcirculation of various viscera has shown distinct susceptibilities to acute peritonitis: the ileum is more susceptible than the kidney, while the hepatic microcirculation seems to be the most resistant to peritonitis.

Costs of relaparotomy on-demand versus planned relaparotomy in patients with severe peritonitis: an economic evaluation within a randomized controlled trial.

INTRODUCTION: Results of the first randomized trial comparing on-demand versus planned-relaparotomy strategy in patients with severe peritonitis (RELAP trial) indicated no clear differences in primary outcomes. We now report the full economic evaluation for this trial, including detailed methods, nonmedical costs, further differentiated cost calculations, and robustness of different assumptions in sensitivity analyses. METHODS: An economic evaluation was conducted from a societal perspective alongside a randomized controlled trial in 229 patients with severe secondary peritonitis and an acute physiology and chronic health evaluation (APACHE)-II score >or=11 from two academic and five regional teaching hospitals in the Netherlands. After the index laparotomy, patients were randomly allocated to an on-demand or a planned-relaparotomy strategy. Primary resource-utilization data were used to estimate mean total costs per patient during the index admission and after discharge until 1 year after the index operation. Overall differences in costs between the on-demand relaparotomy strategy and the planned strategy, as well as relative differences across several clinical subgroups, were evaluated. RESULTS: Costs were substantially lower in the on-demand group (mean, 65,768 euro versus 83,450 euro per patient in the planned group; mean absolute difference, 17,682 euro; 95% CI, 5,062 euro to e29,004 euro). Relative differences in mean total costs per patient (approximately 21%) were robust to various alternative assumptions. Planned relaparotomy consistently generated more costs across the whole range of different courses of disease (quick recovery and few resources used on one end of the spectrum; slow recovery and many resources used on the other end). This difference in costs between the two surgical strategies also did not vary significantly across several clinical subgroups. CONCLUSIONS: The reduction in societal costs renders the on-demand strategy a more-efficient relaparotomy strategy in patients with severe peritonitis. These differences were found across the full range of healthcare resources as well as across patients with different courses of disease. TRIAL REGISTRATION: ISRCTN51729393.

An assessment of the effects of two types of bioresorbable barriers to prevent postoperative intra-abdominal adhesions in rats.

PURPOSE: This study assessed and compared the efficacy of two types of bioresorbable membranes in the prevention of postoperative adhesion under clean contaminated and bacterial peritonitis conditions using a cecal ligation and puncture model in rats. METHODS: Wistar albino rats (n = 72) were divided into six groups. Bacterial peritonitis was induced using a cecal ligation and puncture model in groups 2, 4, and 6. Groups 1, 3, and 5 served as controls for clean contaminated procedures in the absence of bacterial peritonitis. Groups 1 and 2 were the untreated clean contaminated and bacterial peritonitis groups and served as controls for the effect of the bioresorbable membranes in each condition. In groups 3 and 4, a 1.5 x 3 cm USP glycerol/sodium hyaluronate/carboxymethylcellulose membrane was wrapped around the cecal resection area and a 2 x 4 cm membrane was left under the incision. The oxidized regenerated cellulose membrane was similarly applied in groups 5 and 6. Four weeks later, the adhesions were evaluated. In addition, fibrosis and inflammation were observed histopathologically. RESULTS: Adhesion development (P = .008), fibrosis (P = .008), and inflammation (P = .0001) differed among the groups. Both materials increased adhesion formation in the bacterial peritonitis condition. Increased fibrotic activity was detected in all material-applied groups under both conditions. In addition, more inflammation was detected in the groups that received the application of a material, especially in the presence of bacterial peritonitis. CONCLUSION: Neither material prevented adhesions in clean contaminated conditions. Moreover, they increased adhesion formation in bacterial peritonitis.

[The diagnosis and clinical assessment of the disseminated intravascular coagulation syndrome in complicated cancer of the gastrointestinal tract]. / Diagnostika i klinicheskaia otsenka sindroma disseminirovannogo vnutrisosudistogo svertyvaniia krovi pri oslozhnennom rake zheludochno-kishechnogo trakta.

Under study were the state of the hemostasis system, the level of endogenous intoxication and anti-infectional defense in 63 patients with complicated carcinoma of the gastro-intestinal tract (GIT). It was established that the patients had the syndrome of disseminated intravascular coagulation (DIC) of blood which at first was of local character. Acute complications of carcinoma of GIT, first of all purulent peritonitis and profuse gastro-intestinal bleedings, aggravate endotoxicosis and facilitate the development of the acute DIC syndrome. A conception of the development of the intoxicative DIC syndrome is presented and proposed are informative methods of the assessment of hemostasis in emergency surgery of carcinoma of the GIT.

[Omegametry for the rapid assessment of the patient's condition in peritonitis]. / Omegametriia v ékspress-otsenke sostoianiia bol'nykh peritonitom.

Omegametry was performed to 114 patients with peritonitis at various phases of the disease. Six types of omegagrams have been obtained. Reactive phase of peritonitis was characterized by monophase changes in omega-potential after a functional load with positive or negative monophase waves and an omegagram in the form of a straight line with baseline values of omega-potential 24 to 40 mV. In toxic phase of peritonitis monophase changes in omega-potential were observed after the functional load with a positive or negative incomplete phase. Omegagrams in the form of a straight line with baseline values of omega-potential 2 to 15 mV or chaotic changing curve were revealed in terminal stage of peritonitis. The data obtained make it possible to diagnose peritonitis phase, optimize intensive care and predict the outcome of the disease.

Assessment of the intrinsic contractile status of the heart during sepsis by myocardial pressure-dimension analysis.

The effect of sepsis on the intrinsic contractile status of the myocardium is best examined in the awake, closed-chest animal with intact circulation because anesthesia, open thoracotomy, and circulatory support are all known to affect hemodynamics. To fulfill these criteria, 18 adult dogs were chronically studied in the awake state after instrumentation with left ventricular high-fidelity pressure catheters and ultrasonic dimension transducers to measure left ventricular transmural pressure and minor axis dimension. This allowed computer assessment of the left ventricular end-systolic pressure-dimension relationship in the control state and at intervals following cecal ligation in one group of dogs. A second group of control animals was studied over variable time intervals without cecal ligation to evaluate the temporal stability and reproducibility of the animal model and the end-systolic pressure-dimension relationship. Evaluation of contractility by use of the end-systolic pressure-dimension relationship was essential because this relationship is a sensitive indicator of the intrinsic myocardial contractile state while remaining insensitive to the wide swings in preload and after load that are commonly seen in sepsis. In the control group of dogs, the temporal consistency and stability of the end-systolic pressure-dimension relationship in this model was confirmed; no significant changes in the slope and dimension-axis intercept were demonstrated over the study interval. In the septic group of dogs, however, the intrinsic myocardial contractility significantly deteriorated as the mean slope of the end-systolic pressure-dimension relationship (mmHg/mm) decreased from 16.87 +/- 0.85 to 12.79 +/- 1.67 over 120 hours following cecal ligation. Intrinsic contractility of the heart during sepsis was therefore isolated for the first time from the widely variant loading conditions seen during sepsis by pressure-dimension analyses in the chronically instrumented, awake, closed-chest canine with intact circulation.