Shock séptico: complicación atípica de duplicación del tracto alimentario / Septic shock: an atypical complication of alimentary tract duplication

Las duplicaciones del tracto alimentario son un conjunto heterogéneo de anomalías congénitas del tubo digestivo. Su forma de presentación es variada, y pueden desarrollar distintas complicaciones libradas a su evolución natural. La infección es una complicación poco frecuente, pero que no puede desconocerse por la gravedad que implica. Se presenta el caso de una paciente de 2 años de edad, previamente sana, con una complicación atípica de una duplicación del tracto alimentario: un shock séptico. Consultó inicialmente por distensión y dolor abdominal asociado a una masa abdominal palpable. Los estudios imagenológicos evidenciaron una formación líquida parcialmente tabicada en el hemiabdomen derecho. Durante la internación, se presentó una infección intratumoral, que evolucionó al shock séptico. Respondió favorablemente al tratamiento médico del shock, y se realizó la exéresis quirúrgica posteriormente. La anatomía patológica confirmó la duplicación del tracto alimentario.

Alimentary tract duplications are heterogenous congenital anomalies of the digestive tract. Their form of presentation is varied, and they may lead to different complications, depending on their natural course. Infection is a rare complication, but it cannot be ignored because of its severity. Here we describe the case of an otherwise healthy 2-year-old girl with an atypical complication of alimentary tract duplication: septic shock. She initially consulted due to abdominal distension and pain associated with a palpable abdominal mass. The imaging studies showed a partial fluid septation in the right side of the abdomen. During hospitalization, an intratumoral infection developed, which progressed to septic shock. The patient responded favorably to medical treatment for shock, and surgical resection was subsequently performed. The pathology report confirmed the presence of alimentary tract duplication.

Bronquitis plástica. Caso clínico interesante / Plastic Bronchitis. Interesting Case Report

La bronquitis plástica es una enfermedad infrecuente y poco estudiada. Se caracteriza por la obstrucción parcial o total de la vía aérea inferior por moldes o yesos gomosos y firmes, compuestos por múltiples sustancias como fibrina, mucina y otros, que se acumulan en la luz bronquial. En la actualidad, no hay un consenso de la fisiopatología real. Puede presentarse con síntomas leves como tos, sibilancias y disnea, hasta eventos fatales de insuficiencia respiratoria. Se clasifican en tipo I (inflamatorios) y tipo II (acelulares). La presencia de la bronquitis plástica es una complicación de varias enfermedades y está relacionada con procedimientos correctivos de cardiopatías congénitas (procedimiento de Fontan). El diagnóstico se hace a través de la identificación de los yesos bronquiales, ya sea cuando el paciente los expectora o por broncoscopía. Se han utilizado múltiples terapias que solo tienen evidencias anecdóticas. En los últimos años se han observado buenos resultados con el uso de heparinas, así como el alteplasa nebulizado e instilado por broncoscopia.

Plastic bronchitis is a rare and little-studied disease. It is characterized by partial or total obstruction of the lower airway by rubbery and firm molds or plasters, made up of multiple substances that accumulate in the bronchial lumen. Currently, there is no consensus on real pathophysiology. It can present itself with mild symptoms such as cough, wheezing and dyspnea, to fatal events of respiratory failure. They are classified into type I (inflammatory) and type II (acellular). The presence of plastic bronchitis is a complication of several diseases and in corrective procedures for congenital heart disease (Fontan procedure). Diagnosis is made by identifying bronchial casts, either by the patient expectorating them or by bronchoscopy. Multiple therapies have been used that only have anecdotal evidence. In recent years, good results have been observed with the use of heparins and tPA nebulized and instilled by bronchoscop.

Skin care for toxic shock syndrome: case report / Cuidados com a pele na síndrome do choque tóxico: relato de caso / Cuidado de la piel en el síndrome de shock tóxico: reporte de caso

Objetivo: A síndrome do choque tóxico (SCT) é uma condição multissistêmica grave, causada por Staphylococcus aureus ou Streptococcus pyogenes,e o manejo inicial e contínuo das lesões de pele é essencial para o controle da infecção. Este relato teve o objetivo de descrever os cuidados com a pele nessa síndrome. Relato do caso: Paciente do sexo masculino com abscesso no quadril que evoluiu com febre e hipotensão e consequente transferência para a Unidade de Terapia Intensiva (UTI). Foi diagnosticado com choque séptico de provável foco no quadril, imediatamente abordado cirurgicamente para tratamento local da infecção. Apresentou insuficiência renal, além de disfunção multissistêmica (hepática e cardíaca), instabilidade hemodinâmnica e lesões disseminadas de pele. Com o isolamento do Staphylococcus aureus, iniciou-se clindamicina e o diagnóstico foi de SCT, uma vez que apresentou lesões epidermolíticas desde o início do quadro. Foram iniciadas medidas de recuperação cutânea com a sulfadiazina de prata e, posteriormente, com hidrofibra com prata com restauração do epitélio em 8 dias. Após 10 dias da pele restaurada, o paciente recebeu alta da UTI para enfermaria com manutenção do tratamento proposto. Conclusão: Neste caso, o uso da hidrofibra obteve uma performancesatisfatória, contudo ainda há necessidade de estudos robustos que comprovem tal eficácia. (AU)

Objective: Toxic shock syndrome (TSS) is a severe multisystemic condition caused by Staphylococcus aureus or Streptococcus pyogenes, and initial management of skin lesions is essential for infection control. This article aimed to describe skin care for TSS. Case report: We report a man with a hip abscess who developed fever and hypotension and was subsequently transferred to an intensive care unit (ICU). He was diagnosed with septic shock, probably of hip origin, and was immediately treated surgically for local infection control. He presented with renal failure besides multiple organ dysfunction (hepatic and cardiac), hemodynamic instability, and disseminated skin lesions. With the isolation of Staphylococcus aureus, clindamycin was initiated, and the diagnosis was TSS due to epidermolytic lesions since the onset of the condition. Cutaneous recovery measures were initiated with silver sulfadiazine, followed by silver hydrofiber with skin recovery in 8 days. After 10 days of skin recovery, the patient was discharged from the ICU to the ward with maintenance of the proposed treatment. Conclusion: In this case, the use of hydrofiber showed satisfactory performance; however, robust studies are needed to confirm such efficacy. (AU)

Objetivo: El síndrome de shock tóxico (SST) es una afección multisistémica grave causada por Staphylococcus aureuso Streptococcus pyogenes, y el tratamiento inicial y continuo de las lesiones cutáneas es esencial para controlar la infección. Este informe tuvo como objetivo describir los cuidado de la piel en este síndrome. Reporte del caso:Paciente masculino con absceso en la cadera que desarrolló fiebre e hipotensión y fue tranferido a la Unidad de Cuidados Intensivos (UCI). Se diagnosticó shock séptico, probablemente focalizado en la cadera, por lo que fue inmediatamente abordado quirúrgicamente para tratamiento local de la infección. Presentó insuficiencia renal además de disfunción multisistémica (hepática y cardiaca), inestabilidad hemodinámica y lesiones cutáneas diseminadas. Con el aislamiento de Staphylococcus aureus, se inició clindamicina y el diagnóstico fue SST, ya que presentaba lesiones epidermolíticas desde el inicio del cuadro. Se iniciaron medidas de recuperación cutánea con sulfadiazina de plata y, posteriormente, se optó por hidrofibra con plata, con restauración del epitelio en 8 días. Después de 10 días de piel restaurada, el paciente fue dado de alta de la UCI a planta con mantenimiento del tratamiento propuesto. Conclusión: Alcen este caso, el uso de hidrofibra obtuvo un desempeño satisfactorio, sin embargo, aún se necesitan estudios robustos para probar tal eficacia. (AU)

Significado biológico y utilidad clínica del lactato en la sepsis / Biological significance and clinical utility of lactate in sepsis

La sepsis es un problema global de salud y la progresión hacia el shock séptico se asocia con un incremento marcado de la morbimortalidad. En este escenario, el aumento del lactato plasmático demostró ser un indicador de gravedad y un predictor de mortalidad, y suele interpretarse casi exclusivamente como marcador de baja perfusión tisular. Sin embargo, últimamente se produjo un cambio de paradigma en la exégesis del metabolismo y propiedades biológicas del lactato. En efecto, la adaptación metabólica al estrés, aun con adecuado aporte de oxígeno, puede justificar la elevación del lactato circulante. Asimismo, otras consecuencias fisiopatológicas de la sepsis, como la disfunción mitocondrial, se asocian con el desarrollo de hiperlactatemia sin que necesariamente se acompañen de baja perfusión tisular. Interpretar el origen y la función del lactato puede resultar de suma utilidad clínica en la sepsis, especialmente cuando sus niveles circulantes fundamentan las medidas de reanimación.

Sepsis is a global health problem; progression to septic shock is associated with a marked increase in morbidity and mortality. In this setting, increased plasma lactate levels demonstrated to be an indicator of severity and a predictor of mortality, and are usually interpreted almost exclusively as a marker of low tissue perfusion. However, a recent paradigm shift has occurred in the exegesis of lactate metabolism and its biological properties. Indeed, metabolic adaptation to stress, even with an adequate oxygen supply, may account for high circulating lactate levels. Likewise, other pathophysiological consequences of sepsis, such as mitochondrial dysfunction, are associated with the development of hyperlactatemia, which is not necessarily accompanied by low tissue perfusion. Interpreting the origin and function of lactate may be of great clinical utility in sepsis, especially when circulating lactate levels are the basis for resuscitative measures.

Obstetric HDU: a supply-based alternative for ICU care in a low-income setting: a descriptive study

Background The demand of ICU care for obstetric patients is rising in low-income settings, where there is low ICU-bed capacity. Introduction of obstetric High-dependency unit (HDU) has been described as an effective strategy to bridge this gap in resource-restricted settings. Objective: To describe the clinical characteristic and maternal outcomes of obstetric patients admitted to the first obstetric HDU in Ethiopia. Study design: This was a descriptive study on clinical characteristics and maternal outcomes of obstetric patients admitted to obstetric HDU over one year (October 2021 to September 2022) at St. Paul's Hospital Millennium Medical College (Ethiopia). Data were collected retrospectively through reviewing patients' medical records using a data extraction format with KOBO collect tool. Data were analyzed using SPSS version 23 and simple descriptive statistics were employed. Proportions and percentages were used to present the results. RESULTS: After excluding 18 patients who did not meet the inclusion criteria, a total of 355 obstetric patients who were admitted to an obstetric HDU were included in the final analysis. Among these all-obstetric patients admitted to obstetric HDU, pre-eclampsia/ eclampsia (82/355, 23.1%) and postpartum hemorrhage (66/355, 18.6%) were the most frequent reasons for admission to the HDU whereas cardiac disease constituted 14.1% (50/355) of the indication for admissions to the unit. Majority (318/355, 89.6%) from the study participants were transferred to other wards with im-provement, while 37(7.9%) deteriorated with 9(2.53%) of them died. Septic shock (6/9, 66.6%) and DIC (2/9, 22.2%) were the leading causes of death in the HDU. Conclusion: Findings of our study demonstrate that opening HDU in a low-income setting is feasible and results in favorable maternal outcomes. Introduction of obstetric HDU in low-income settings is an effective intervention to reduce severe maternal morbidity and mortality associated with low ICU-bed capacity in those settings.

Relação entre os sinais vitais e as concentrações plasmáticas de óxido nítrico / Relationship between vital signs and plasma nitric oxide concentrations

A sepse e o choque séptico são as principais preocupações globais de saúde no mundo e um grave problema de saúde no Brasil, sendo uma das principais causas de mortalidade nas unidades de terapia intensiva. O óxido nítrico na fisiopatologia da sepse tem sido usado como um biomarcador de gravidade em pacientes sépticos devido as alterações hemodinâmicas microvascular e sistêmicas, refletindo em alterações dos sinais vitais, causadas pelo excesso de óxido nítrico. O objetivo deste trabalho, foi demonstrar a relevância da verificação dos sinais vitais e análise de exames laboratoriais mais comuns na sepse, correlacionado os mesmos com as concentrações plasmáticas de óxido nítrico, no sentido de monitorar o paciente com sepse e choque séptico. O estudo foi realizado em dois hospitais brasileiros, sendo o hospital A localizado no sul de minas gerais e o hospital B na região noroeste paulista, constituídos de 166 pacientes maiores de 18 anos, sendo 104 pacientes do hospital A e 62 do hospital B, que apresentaram diagnóstico de sepse e choque séptico confirmados e internados nas unidades de clínica médica/cirúrgica, urgência/emergência, maternidade e terapia intensiva. As orientações e aceite em participar do estudo foram realizadas no próprio leito do paciente após sua estabilização clínica e a abordagem aos familiares e/ou responsável legal para aqueles pacientes com instabilidade hemodinâmica. Os dados demográficos, clínicos e laboratoriais foram coletados por meio do prontuário eletrônico, a aferição dos sinais vitais e coleta de sangue após a confirmação do diagnóstico de sepse ou choque séptico, entre março de 2021 a janeiro de 2022. As amostras contendo 3 ml de sangue, identificadas e rotuladas, foram centrifugadas em rotação de 3.500 rpm, por 10 minutos a temperatura de 23ºC a 25ºC. Ao final, o sobrenadante contendo plasma sanguíneo foi desproteinizado por incubação com etanol absoluto 4ºC, mantido por 30 minutos em freezer (-20ºC). Posteriormente submetidas à centrifugação 10.000 rpm por 10 minutos à 23ºC e realizado a técnica de quimiluminescência NO/ozônio. Os resultados evidenciaram maiores concentrações plasmáticas de nitrato em pacientes com piores prognósticos e desfechos, e correlação com sinais vitais e exames laboratoriais da sepse que evidenciam a presença de disfunção orgânica. Quanto maior o nitrato maior foram os níveis de lactato plasmático, ureia, creatinina, potássio e tempo de protrombina, e menores a contagem das plaquetas no sangue. Dentre os sinais vitais, os valores da temperatura corporal, a pressão diastólica e a pressão arterial média foram menores quando evidenciado maiores concentrações de nitrato. Em conjunto, os resultados encontrados mostram que o aumento da concentração do nitrato se associa com a gravidade da sepse e entre as alterações dos sinais vitais, a hipotermia mostrou-se um dado vital de alerta à gravidade clínica dos pacientes. As alterações da frequência respiratória e a pressão sistólica são componentes de escores de gravidade utilizados na prática clínica atual, porém esses sinais vitais não foram evidenciados como sinalizadores de alerta à gravidade de pacientes sépticos.

Sepsis and septic shock are the main global health concerns in the world and a serious health problem in Brazil, being one of the main causes of mortality in intensive care units. Nitric oxide in the pathophysiology of sepsis plays as a biomarker of severity in septic patients due to microvascular and systemic hemodynamic changes, reflecting changes in vital signs caused by excess nitric oxide. The objective of this work was to demonstrate the relevance of checking vital signs and analyzing the most common laboratory tests in sepsis, correlating them with plasma nitric oxide concentrations, in order to monitor patients with sepsis and septic shock. The study was carried out in two Brazilian hospitals - hospital A located in the south of Minas Gerais and hospital B in the northwestern region of São Paulo - consisting of 166 patients over 18 years old, 104 patients from hospital A and 62 from hospital B, which had had a confirmed diagnosis of sepsis and septic shock and were admitted to medical/surgical, urgency/emergency, maternity and intensive care units. The instructions and acceptance to participate in the study were carried out at the patient's own bed after clinical stabilization and the approach to family members and/or legal guardians for those patients with hemodynamic instability. Demographic, clinical and laboratory data were collected through electronic medical records, measurement of vital signs and blood collection after confirmation of the diagnosis of sepsis or septic shock, between March 2021 and January 2022. Samples containing 3 ml of blood, identified and labeled, were centrifuged at 3,500 rpm for 10 minutes at a temperature of 23ºC to 25ºC. Finally, the supernatant containing blood plasma was deproteinized by incubation with absolute ethanol at 4ºC, kept for 30 minutes in a freezer (-20ºC). Subsequently, they were subjected to centrifugation at 10,000 rpm for 10 minutes at 23ºC and the NO/ozone chemiluminescence technique was performed. The results showed higher plasma nitrate concentrations in patients with worse prognoses and outcomes, and correlation with vital signs and sepsis laboratory tests that demonstrate the presence of organic dysfunction. The higher the nitrate, the higher the levels of plasma lactate, urea, creatinine, potassium and prothrombin time, and the lower the blood platelet count. Among vital signs, body temperature, diastolic pressure and mean arterial pressure values were lower when there was higher nitrate concentrations. Altogether, the results found show that the increase in nitrate concentration is associated with the severity of sepsis and among the changes in vital signs, hypothermia proved to be a vital indicator of the clinical severity of patients. Respiratory rate and systolic pressure are components of severity scores used in current clinical practice, but these vital signs have not been demonstrated as warning signs of the severity of septic patients.

Índice leucocitos/eosinófilos como marcador pronóstico del choque séptico / Leukocyte/eosinophil Ratio as a Prognostic Marker of Septic Choque

Introducción: Se ha reconocido mundialmente el choque séptico como causa de una alta incidencia en la mortalidad. La incorporación de nuevos biomarcadores posibilita la obtención de un diagnóstico rápido y preciso. Objetivo: Evaluar la utilidad del índice leucocitos/eosinófilos como marcador pronóstico del choque séptico. Métodos: Se realizó una investigación en dos etapas: la primera descriptiva en la cual se detallaron las características clínicas, epidemiológicas y las variaciones de los estudios de laboratorio y la segunda explicativa de cohorte para estimar el valor predictivo del biomarcador leucocitos/eosinopenia en el choque séptico. Se realizó el recuento de eosinófilos y se obtuvo la media aritmética. Se consideró eosinopenia relativa con valores por debajo de la media de eosinófilos. Resultados: En el estudio se demostró que la leucocitosis fue de (27,4 células*mm3), la disminución del hematocrito (32,2 por ciento) y el descenso del número plaquetario (125,6 célula*mm3) prevalecen en el choque séptico. Además se refleja el descenso de los eosinófilos (18,5 células/mcl), aumento del índice leucocitos/eosinófilos (148,1) y empeoramiento del SOFA (2,8). El aumento del índice leucocitos/eosinófilos se correlaciona con el aumento de la proteína C reactiva y la procalcitonina. Conclusiones: La correlación de la leucocitosis y la eosinopenia mostró la utilidad del índice leucocitos/eosinopenia como factor de predicción del choque séptico(AU)

Introduction: Septic shock has been recognized worldwide as a cause of high incidence of mortality. The incorporation of new biomarkers makes it possible to obtain a rapid and accurate diagnosis. Objective: To evaluate the usefulness of the leukocyte/eosinophil ratio as a prognostic marker of septic shock. Methods: An investigation was carried out in two stages: in the first (the descriptive phase) the clinical and epidemiological characteristics and variations of the laboratory studies were detailed and in the second (the explanatory cohort phase), the predictive value of the leukocytes/eosinopenia biomarker in septic shock was estimated. The eosinophil count was performed and the arithmetic mean was obtained. Relative eosinopenia was considered with eosinophil values below the average. Results: The study showed that leukocytosis was 27.4 cells*mm3, hematocrit decreased in 32.2percent and decreased platelet number (125.6 cells*mm3) prevail in septic shock. In addition, a decrease in eosinophils (18.5 cells/mcl), an increase in the leukocyte/eosinophil ratio (148.1) and worsening of SOFA (2.8) are reflected. The increase in the leukocyte/eosinophil ratio is correlated with the increase in C-reactive protein and procalcitonin. Conclusions: The correlation of leukocytosis and eosinopenia showed the usefulness of the leukocyte/eosinopenia index as a predictor of septic shock(AU)

Síndrome de disfunción orgánica múltiple progresiva en embarazo adolescente: reporte de caso clínico / Progressive multiple organ dysfunction syndrome in adolescent pregnancy: case report

INTRODUCCIÓN: El embarazo adolescente es un proceso fisiológico, pero puede evolucionar con parto prematuro, patologías obstétricas o médicas graves, mortalidad o secuelas para madre e hijo/a. Nuestro objetivo es reportar el síndrome de disfunción orgánica múltiple progresiva secundario a pielonefritis y sepsis ocurrido durante el preparto, parto y puerperio de embarazo adolescente y sus secuelas. CASO CLÍNIO: Adolescente de 14 años, con embarazo de 27 semanas de gestación controlado desde las 8 hasta 25 semanas. Ingresó de urgencia en unidad de alto riesgo obstétrico por signos de parto prematuro, pielonefritis e injuria renal aguda. Se inició tratamiento con cefazolina intravenosa y betametasona para maduración pulmonar, nifedipino oral y sulfato de magnesio para prevención del parto prematuro y protección neuronal fetal, evolucionando con hipotensión sostenida y shock séptico. A las 13 horas después del ingreso, fue trasladada a unidad de paciente crítico donde evolucionó con falla orgánica múltiple persistente y progresiva durante 28 días, afectando sucesivamente los sistemas cardiovascular, hematológico, respiratorio y gastrointestinal. Se trató con drogas vasoactivas, antibióticos, ventilación mecánica invasiva, ultrafiltración, hemodiálisis, drenaje pleural y colecistectomía. A las 24 horas de ingreso a cuidado intensivo, ocurrió el parto prematuro vaginal. La embarazada desarrolló enfermedad renal crónica etapa KDIGO 5 ( V) y se encuentra en espera de trasplante renal. Por su parte, la recién nacida prematura viva presentó asfixia neonatal severa, displasia broncopulmonar y encefalopatía hipóxico-isquémica. CONCLUSIONES: El embarazo adolescente complicado es una emergencia sanitaria. El diagnóstico y manejo oportuno de la pielonefritis, shock séptico y disfunción orgánica asociada a la sepsis pueden evitar mortalidad y secuelas permanentes materna y/o neonatal.

INTRODUCTION: Adolescent pregnancy is a physiological process, but it can evolve with premature delivery, severe obstetric or clinical pathologies, mortality, or sequelae for mother and child. We aim to report the progressive multiple organ dysfunction syndrome secondary to pyelonephritis and sepsis during prepartum, delivery, and puerperium of adolescent pregnancy and its sequelae. CASE REPORT: A 14-year-old adolescent with a pregnancy of 27 weeks of gestation controlled from 8 to 25 weeks. She was urgently admitted to the high-risk obstetric unit due to signs of preterm labor, pyelonephritis, and acute renal injury. Treatment was started with intravenous cefazolin and betamethasone for lung maturation, oral nifedipine, and magnesium sulfate to prevent preterm labor and fetal neuronal protection, evolving with sustained hypotension and septic shock. At 13 hours after admission, she was transferred to the intensive care unit, where she evolved with persistent and progressive multiple organ failure for 28 days, progressively affecting the cardiovascular, hematologic, respiratory, and gastrointestinal systems. She was treated with vasoactive drugs, antibiotics, invasive mechanical ventilation, ultrafiltration, hemodialysis, pleural drainage, and cholecystectomy. Twenty-four hours after admission to intensive care, preterm vaginal delivery occurred. She developed chronic kidney disease stage KDIGO 5 (Kidney Disease Improving Global Outcomes V) and is awaiting renal transplantation. On the other hand, the preterm newborn presented severe neonatal asphyxia, bronchopulmonary dysplasia, and hypoxic-ischemic encephalopathy. CONCLUSION: Complicated adolescent pregnancy is a health emergency. Avoiding delays in the diagnosis and treatment of pyelonephritis, septic shock and the progressive multiple organ dysfunction syndrome can prevent mortality and permanent sequelae, both maternal and neonatal.

Análise longitudinal dos parâmetros ventilatórios e escore SOFA de pacientes com COVID-19 hospitalizados em uma UTI no Sul do Brasil / Longitudinal analysis of ventilatory parameters and SOFA score of patients with COVID-19 hospitalised in an ICU in southern Brazil

Introdução: embora o Coronavírus da Síndrome Respiratória Aguda Grave 2 (SARS-CoV-2) seja mais conhecido por causar patologias respiratórias substanciais, o vírus também pode resultar em várias manifestações extrapulmonares, sobretudo nas alas de cuidados intensivos. Frente a essas implicações multissistêmicas, a monitoração do suporte ventilatório e utilização do escore Sequential Organ Failure Assessment (SOFA) foram fundamentais no manejo do paciente crítico com COVID-19 nas Unidades de Terapia Intensiva (UTIs) durante a pandemia. Objetivo: esse estudo pretende analisar os parâmetros ventilatórios e escore SOFA de pacientes com COVID-19 numa UTI no sul do Brasil e as principais complicações ocasionadas. Metodologia: foi realizado um estudo de coorte retrospectivo que analisou prontuários de pacientes com diagnóstico de COVID-19 na UTI do Hospital Nossa Senhora da Conceição, no estado de Santa Catarina, entre março de 2020 a dezembro de 2021. Resultados: foram incluídos 448 pacientes, com média de idade de 58,5 (±15,1) anos, mediana de internação de 15 (9-24) dias e média de ventilação mecânica de 15 (±8,7) dias, evoluindo para óbito 63,3%. Durante a internação, 86,4% das pessoas sofreram complicações, dentre as mais prevalentes Insuficiência Renal Aguda (46,8%) seguida por Pneumonia Associada à Ventilação (41,9%) e Choque séptico (22%). Na evolução clínica, o escore SOFA e a relação da pressão parcial de oxigênio pela fração de oxigênio inspirado (PaO2/FiO2) foram fatores de desfecho desfavorável nas três semanas de internação, com SOFA ≥ 5 e relação PaO2/FiO2 < 200. Além disso, 3 dos 6 componentes do SOFA (renal, respiratório e coagulação) tiveram relação com a ocorrência de complicações. Conclusão: o escore SOFA e a relação PaO2/FiO2 tiveram relação no prognóstico de pacientes com COVID-19 durante as três semanas de internação na UTI. Além disso, o SOFA se mostrou um possível indicador de complicações intra-hospitalares durante a evolução clínica.

Introduction: although Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is best known for causing significant respiratory pathologies, the virus can also result in various extrapulmonary manifestations, particularly in intensive care wards. Faced with these multisystem implications, monitoring ventilatory support and using the Sequential Organ Failure Assessment (SOFA) score were fundamental in managing critically ill patients with COVID-19 in Intensive Care Units (ICUs) during the pandemic. Objective: this study will analyse the ventilatory parameters and SOFA score of patients with COVID-19 in an ICU in southern Brazil and the main complications caused. Methodology: a retrospective cohort study was carried out that analysed medical records of patients diagnosed with COVID-19 in the ICU of Hospital Nossa Senhora da Conceição, in the state of Santa Catarina, between March 2020 and December 2021. Results: 448 patients were included, with a mean age of 58.5 (±15.1) years, a median hospital stay of 15 (9-24) days, and mean mechanical ventilation of 15 (±8.7) days, with 63.3% dying. During hospitalisation, 86.4% of people suffered complications, among the most prevalent Acute Renal Failure (46.8%), followed by Ventilation Associated Pneumonia (41.9%) and Septic Shock (22%). In the clinical evolution, the SOFA score and the ratio of partial pressure of oxygen to the fraction of inspired oxygen (PaO2/FiO2) were factors of unfavourable outcome in the three weeks of hospitalisation, with SOFA ≥ 5 and PaO2/FiO2 ratio < 200. In addition, three of the six components of the SOFA (renal, respiratory and coagulation) were related to the occurrence of complications. Conclusion: the SOFA score and the PaO2/FiO2 ratio were related to the prognosis of patients with COVID-19 during the three weeks of ICU stay. Furthermore, the SOFA proved to be a possible indicator of in-hospital complications during clinical evolution.

Asociación entre índice de masa corporal y mortalidad en pacientes críticos con choque séptico / Association between body mass index and mortality in critical ill patients with septic shock

INTRODUCCIÓN. La paradoja de la obesidad propone que, en determinadas enfermedades, los enfermos con obesidad tienen menor mortalidad. OBJETIVO. Asociar el índice de masa corporal con la mortalidad a 30 días en adultos con choque séptico. MATERIALES Y MÉTODOS. Estudio observacional, analítico, retrospectivo, multicéntrico. Se analizaron 673 pacientes con choque séptico, ingresados en terapia intensiva de dos hospitales de la ciudad de la ciudad de Quito ­ Ecuador, durante enero 2017 - diciembre 2019. Criterios de inclusión: Mayores a 18 años, choque séptico, registro de peso, talla y condición vital al día 30. Criterios de exclusión: Orden de no reanimación, embarazadas, protocolo de donación de órganos, cuidados paliativos. Las variables se recolectaron a partir de las historias clínicas digitales y físicas de los centros participantes. Las estimaciones de riesgo calculadas se presentaron como OR (Odds Ratio) en el análisis bivariado y OR Adj (OR ajustado) para el análisis multivariado. Un valor de p <0.05 se consideró estadísticamente significativo. Todos los análisis estadísticos se realizaron usando el software estadístico R® (Versión 4.1.2). RESULTADOS. La edad promedio fue de 65 años, índice de masa corporal promedio 25,9 Kg/m2 (+4,9 Kg/m2). El 54,3% tuvo índice de masa corporal > 25 Kg/m2. La mortalidad general fue 49.2%. Sujetos con sobrepeso y obesidad tuvieron menor mortalidad, OR: 0,48 (IC 95%: 0.34, 0.68; p <0.0001) y OR 0.45 (IC 95 %: 0.28, 0.70; p =0.001) respectivamente, con similar tendencia en el análisis multivariado. Los sujetos con peso bajo tuvieron la mayor mortalidad (OR: 2.12. IC 95%: 0.91 - 5.54. p: 0.097). DISCUSIÓN. Los resultados obtenidos apoyan la teoría de paradoja de obesidad, sin embargo, no se realizó evaluación según los niveles de obesidad. CONCLUSIÓN. La mortalidad en choque séptico es menor en sujetos con sobrepeso y obesidad comparada con sujetos con peso normal o bajo peso.

The obesity paradox proposes that, in certain diseases, patients with obesity have lower mortality. OBJECTIVE. To associate body mass index with 30-day mortality in adults with septic shock. MATERIALS AND METHODS. Observational, analytical, retrospective, multicenter, retrospective study. We analyzed 673 patients with septic shock, admitted to intensive care in two hospitals in the city of Quito - Ecuador, during January 2017 - December 2019. Inclusion criteria: older than 18 years, septic shock, weight, height and vital condition at day 30. Exclusion criteria: Do not resuscitate order, pregnant women, organ donation protocol, palliative care. Variables were collected from the digital and physical medical records of the participating centers. Calculated risk estimates were presented as OR (Odds Ratio) in bivariate analysis and OR Adj (adjusted OR) for multivariate analysis. A p value <0.05 was considered statistically significant. All statistical analyses were performed using R® statistical software (Version 4.1.2). RESULTS. The mean age was 65 years, mean body mass index 25.9 kg/m2 (+4.9 kg/m2). Body mass index > 25 kg/m2 was 54.3%. Overall mortality was 49.2%. Overweight and obese subjects had lower mortality, OR: 0.48 (95% CI: 0.34, 0.68; p<0.0001) and OR 0.45 (95 % CI: 0.28, 0.70; p=0.001) respectively, with similar trend in multivariate analysis. Underweight subjects had the highest mortality (OR: 2.12. 95% CI: 0.91 - 5.54. p: 0.097). DISCUSSION. The results obtained support the obesity paradox theory, however, assessment according to obesity levels was not performed. CONCLUSIONS. Mortality in septic shock is lower in overweight and obese subjects compared to normal weight or underweight subjects.

Shock séptico en niños con bacteriemia por Staphylococcus aureus de la comunidad en un hospital pediátrico de alta complejidad / Septic shock in children with community acquired Staphylococcus aureus bacteremia in a high complexity pediatric hospital

INTRODUCCIÓN: La información disponible sobre los factores de riesgo para el desarrollo de shock séptico es escasa, especialmente en población pediátrica. OBJETIVO: Describir las características epidemiológicas y clínicas de los niños con bacteriemia adquirida en la comunidad por Staphylococcus aureus y comparar las características de los pacientes con y sin shock séptico. PACIENTES Y MÉTODOS: Estudio de cohorte retrospectivo. Criterios de inclusión: niños entre 30 días y 16 años de edad, internados en el Hospital de Pediatría Juan P. Garrahan entre enero de 2017 y diciembre de 2019 por infecciones adquiridas en la comunidad con desarrollo de S. aureus en hemocultivos. Criterios de exclusión: antecedente de internación dentro de los 3 meses previos al ingreso, vivir en una comunidad cerrada, presencia de catéter de larga permanencia, dispositivos intraventriculares o intraperitoneales. Análisis estadístico: STATA 16. RESULTADOS: Se incluyeron 142 niños. 21 niños (15%) presentaron shock séptico. En el análisis multivariado, se asociaron con shock séptico, la bacteriemia persistente (OR 7,15; IC95% 4,39-23,81; p: 0,001) y el foco secundario de infección (OR 6,72; IC 95% 2,02-22,2; p 0,002). La mortalidad relacionada con la infección fue 3,5% (5 pacientes). CONCLUSIONES: El shock séptico se asoció con la bacteriemia persistente y la presencia de focos secundarios de infección.

BACKGROUND: Available information about risk factors for the development of septic shock is scarce, especially in the pediatric population. AIM: To describe the epidemiological and clinical characteristics of children with community-acquired Staphylococcus aureus bacteremia and to compare the characteristics of children with and without septic shock. METHODS: Retrospective cohort study. Inclusion criteria: Children between 30 days and 16 years old, hospitalized in the Juan P. Garrahan Pediatric Hospital between January 2017 and December 2019 for community-acquired infections with S. aureus isolation in blood cultures. Exclusion criteria: History of hospitalization within 3 months prior to admission, living in a closed community, presence of long-term catheter, intraventricular or intraperitoneal devices. Statistical analysis: STATA 16. RESULTS: 142 children were included. 21 children (15%) experienced septic shock. On multivariate analysis, persistent bacteremia (OR 7.15, 95% CI 4.39-23.81, p: 0.001) and secondary focus of infection (OR 6.72, 95% CI 2.02-22.2, p 0.002) were associated with septic shock. The infection-related mortality rate was 3.5% (5 patients). CONCLUSIONS: Septic shock was associated with persistent bacteremia and the presence of secondary foci of infection.

Papel del Delta de PCO2 en la evaluación pronóstica de morbimortalidad en una cohorte de pacientes de un hospital latinoamericano / Role of PCO2 Delta in the Prognostic Evaluation of Morbidity and Mortality in a Cohort of Patients from a Latin American Hospital

Introducción. El shock séptico es la manifestación más grave de sepsis con tasas de letalidad que pueden llegar hasta el 80%. En los últimos años, ha cobrado relevancia la diferencia arteriovenosa de dióxido de carbono, por su implicación teórica en el metabolismo anaerobio y su significado respecto del normal funcionamiento celular. Por lo antes mencionado, creemos necesario realizar un estudio que nos permita establecer la utilidad de la diferencia arteriovenosa de dióxido de carbono en el paciente con shock séptico de la unidad de cuidados intensivos, como medida indirecta de la perfusión tisular y de la utilización de oxígeno por los tejidos, que nos permita establecer un diagnóstico precoz y el pronóstico de los pacientes críticamente enfermos. Métodos. Estudio observacional, descriptivo y transversal. Muestra de veintiocho pacientes adultos. Resultados. Como se ha registrado en otras series, la mayor parte de los pacientes afectados por shock séptico, en nuestro estudio, fueron hombres mayores de 65 años, con al menos una comorbilidad, siendo el principal sitio de infección el respiratorio (67,9%), asociado a una alta tasa de mortalidad (67%). Conclusiones. Los pacientes con diferencia arteriovenosa de PCO2 mayor a 6 mmHg tienen un riesgo aumentado de muerte de 3,2 veces. (AU)

Introduction. Septic shock is the most serious manifestation of sepsis with mortality rates that can reach up to 80%. In recent years, the arteriovenous carbon dioxide difference has gained relevance, due to its theoretical implication in anaerobic metabolism and its significance with respect to normal cell function. Due to the aforementioned, we believe it is necessary to carry out a study that allows us to establish the usefulness of the arteriovenous carbon dioxide difference in the patient with septic shock in the intensive care unit as an indirect measure of tissue perfusion and utilization. of oxygen through the tissues, which allows us to establish an early diagnosis and prognosis of critically ill patients. Methods. Observational, descriptive and cross-sectional study. Sample of 28 adult patients. Results. As has been reported in other series, most of the patients affected by septic shock in our study were men over 65 years of age, with at least one comorbidity, the main site of infection being respiratory (67.9%), associated with a high mortality rate (67%) Conclusions. Patients with an arteriovenous PCO2 difference greater than 6 mmHg have a 3.2-fold increased risk of death. (AU)

Shock séptico de foco respiratorio por Pasteurella multocida en un paciente inmunocompetente. Caso Clínico / Septic shock originating from a pulmonary focus caused by Pasteurella multocida. Report of one case

Pasteurella multocida is a gram-negative coccobacillus bacterium found as a commensal in the oropharynx of domestic animals such as cats and dogs and some farm animals. Soft tissue infections and occasionally bacteremia in immunocompromised patients with direct contact with animals are described. We report a 61 year old male with a history of scratches and close contact with domestic cats, with a septic shock originating from a pulmonary focus, requiring mechanical ventilation and vasopressors. Blood cultures disclosed the presence of Pasteurella multocida. He responded successfully to antimicrobials.

Influence of the Pre-shock State on the Prognosis of Medical Patients with Sepsis: A Retrospective Cohort Study / 生物医学与环境科学（英文）

OBJECTIVE@#To investigate the effects of the pre-shock state on the mortality of patients with sepsis.@*METHODS@#We enrolled patients with sepsis admitted to the medical intensive care unit of a tertiary care university hospital. These patients were then classified into three groups: sepsis, pre-shock state, and septic shock. The primary outcome was the 28-day mortality rate. The secondary outcomes were the 90-day, 180-day, and 1-year mortality rates.@*RESULTS@#A total of 303 patients (groups: sepsis 135 [44.6%]), pre-shock state (93 [30.7%]), and septic shock (75 [24.8%]) completed the 1-year follow-up. The mortality rates at 28 days, 90 days, and 180 days and 1 year were significantly higher in the pre-shock state group than those of the sepsis group, but significantly lower than those in the septic shock group, especially among older patients. When compared with the pre-shock state group, the sepsis group had significantly lower mortality risks at 28 days, 90 days, and 180 days and 1 year, whereas the sepsis shock group had higher mortality risks at these time points.@*CONCLUSION@#The mortality rates of patients in the pre-shock state were notably different from those of patients with sepsis or septic shock. The introduction of a modified sepsis severity classification, which includes sepsis, pre-shock state, and septic shock, could offer valuable additional prognostic information.

Completion rates of bundle treatment of among patients with sepsis shock in intensive care departments of hospitals in Jiangsu Province from 2016 to 2020 years / 中华内科杂志

Current clinical approaches for septic shock increasingly incorporate bundle treatment, a multi-component approach that uses a collection of tests and agents to assist in the identification and treatment of infection. The present study analyzed completion rates of 3 h and 6 h bundle treatment among patients with septic shock in intensive care units (ICUs) of hospitals in Jiangsu Province from 2016 to 2020, using data from the Jiangsu Provincial Intensive Care Medical Quality Control Center. Current approaches and factors affecting treatment completion were assessed.The completion rates of 3 h and 6 h bundle treatment in ICUs of all medical units in Jiangsu Province and in ICUs of hospitals of different levels were recorded. Analyses show that the completion rate of 3 h and 6 h bundle treatment for patients with septic shock in ICUs in Jiangsu Province increased year by year from 2016 to 2020.The completion rate of 3 h bundle treatment increased from 69.82% (3 604/5 162) to 82.47% (8 915/10 775) (all P<0.001). The completion rate of 6 h bundle treatment increased from 62.69% (3 236/5 162) to 72.54% (7 816/10 775) (all P<0.001). In addition, year by year, the completion rate of 3 h bundle treatment in ICUs in tertiary hospitals increased, from 69.80% (3 596/5 152) to 82.23% (7 375/8 969), while the completion rate of 6 h bundle treatment increased from 62.69% (3 230/5 152) to 72.18% (6 474/8 969) (all P<0.001). Completion rates in secondary hospitals also increased year by year, from 80.00% (8/10) to 85.27% (1 540/1 806) for 3 h treatment and from 60.00% (6/10) to 74.31% (1 342/1 806) (all P<0.001) for 6 h treatment. Completion rates for 3 h treatment in first-tier cities (83.99% (2 099/2 499)) and second-tier cities (84.68% (3 952/4 667)) was higher than in third-tier cities (79.36% (2 864/3 609)). The completion rate of 6 h bundle treatment gradually decreased in first-line (77.19% (1 929/2 499)), second-line (74.37% (3 471/4 667)), and third-line (66.94% (2 416/3 609)) cities (all P<0.001). The data collectively show that from 2016 to 2020, the completion rate of bundle treatment in septic shock patients in ICUs in Jiangsu Province improved significantly.

Clinical management and prognosis for descending necrotizing mediastinitis / 中华耳鼻咽喉头颈外科杂志

Objective: To investigate the clinical characteristics, treatment experiences and prognostic factors for descending necrotizing mediastinitis (DNM). Methods: A retrospective analysis was performed on the data of 22 patients with DNM diagnosed and treated in Henan Provincial People's Hospital from January 2016 to August 2022, including 16 males and 6 females, aged 29-79 years. After admission, all patients underwent CT scanning of the maxillofacial, cervical, and thoracic regions to confirm their diagnoses. Emergency incision and drainage were performed. The neck incision was treated with continuous vacuum sealing drainage. According to the prognoses, the patients were divided into cure group and death group, and the prognostic factors were analyzed. SPSS 25.0 software was used to analyze the clinical data. Rusults: The main complaints were dysphagia (45.5%, 10/22) and dyspnea (50.0%, 11/22). Odontogenic infection accounted for 45.5% (10/22) and oropharyngeal infection accounted for 54.5% (12/22). There were 16 cases in the cured group and 6 cases in the death group, with a total mortality rate of 27.3%. The mortality rates of DNM typeⅠand typeⅡwere respectively 16.7% and 40%. Compared with the cured group, the death group had higher incidences for diabetes, coronary heart disease and septic shock (all P<0.05). There were statistically significant differences between the cure group and the death group in procalcitonin level (50.43 (137.64) ng/ml vs 2.92 (6.33) ng/ml, M(IQR), Z=3.023, P<0.05) and acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score (16.10±2.40 vs 6.75±3.19, t=6.524, P<0.05). Conclution: DNM is rare, with high mortality, high incidence of septic shock, and the increased procalcitonin level and APACHE Ⅱ score combined diabetes and coronary heart disease are the poor prognostic factors for DNM. Early incision and drainage combined with continuous vacuum sealing drainage technique is a better way to treat DNM.

Clinical Characteristics and Risk Factors in Children with Acute Leukemia Complicated with Multiple Drug Resistant Bacterial Septicemia / 中国实验血液学杂志

OBJECTIVE@#To investigate the clinical characteristics and risk factors of acute leukemia complicated with multi-drug resistant bacterial septicemia in children.@*METHODS@#The clinical data of children with acute leukemia complicated with septicemia admitted to the Affiliated Hospital of Guangdong Medical University from January 2013 to May 2021 were retrospectively analyzed. Their flora composition and drug resistance were also analyzed. The children were divided into multi-drug resistant bacteria (MDRB) group and non-multi-drug resistant bacteria (non-MDRB) group according to the drug sensitivity results, and the differences in clinical data between the two group were compared.@*RESULTS@#A total of 108 children had drug sensitivity results, 47 cases in the MDRB group, including 26 strians of Gram-positive bacteria (G+), the most common multi-drug resistant G+ bacteria were coagulase-negative staphylococci (CoNS) and Staphylococcus aureus, and the most common multi-drug resistant Gram-negative bacteria G- bacteria were Escherichia coli and Klebsiella pneumoniae subspecies pneumoniae. Compared with non-MDRB group, children in MDRB group had higher C-reactive protein (CRP) level and mortality rate (P <0.001, P =0.009), lower initial empirical anti-infection efficiency (P <0.001), and were more likely to have septic shock (P =0.003). Logistic analysis showed that the risk factors of acute leukemia complicated with MDRB septicemia in children were previous MDRB infection (OR =6.763, 95% CI: 1.141-40.092, P =0.035), duration of agranulocytosis before infection≥7 days (OR =3.071, 95% CI: 1.139-8.282, P =0.027), and previous use of antimicrobial drugs within 90 days before infection (OR =7.675, 95% CI: 1.581-37.261, P =0.011).@*CONCLUSIONS@#The clinical features of acute leukemia complicated with MDRB septicemia in children include a heavy inflammatory response, significantly elevated CRP, susceptibility to secondary septic shock, low efficiency of initial empirical anti-infective therapy, and high mortality rate. Previous MDRB infection, duration of agranulocytosis before infection≥7 days, and previous use of antimicrobial drugs within 90 days before infection are risk factors of acute leukemia complicated with MDRB septicemia in children.

Research progress of exosomes in the diagnosis and treatment of sepsis / 中华危重病急救医学

Sepsis is a life-threatening organ dysfunction caused by infection that lead to dysregulation of the host response. Sepsis and septic shock with a high mortality threaten human health at present, which are important medical and health problems. Early diagnosis and treatment decision-making for sepsis and septic shock still need to be improved. Exosomes are extracellular vesicles with a diameter of 30-150 nm formed by the fusion of multi-vesicle bodies and cell membranes. Exosomes can effectively transport a variety of bioactive substances such as proteins, lipids, RNA, DNA, and participate in the regulation of inflammatory response, immune response, infection and other pathophysiological processes. In recent years, exosomes have become one of the important methods for the diagnosis and treatment of systemic inflammatory diseases. This article will focus on the basic and clinical research of sepsis, and focus on the research progress of exosomes in the diagnosis and targeted therapy of sepsis.

Time-related association between fluid balance and prognosis in sepsis patients: a cohort study based on MIMIC-IV database / 中华危重病急救医学

OBJECTIVE@#To investigate time-related association between fluid balance and prognosis in sepsis patients.@*METHODS@#A retrospective cohort study was conducted based on the data of sepsis patients in the Medical Information Database for Intensive Care-IV 2.0 (MIMIC-IV 2.0) from 2008 to 2019. Sepsis patients aged ≥ 18 years who were admitted to intensive care unit (ICU) for at least 2 days were included. The daily fluid balance and cumulative fluid balance (CFB) were calculated from days 1 to 7 after ICU admission. According to CFB,the patients were divided into negative fluid balance group (CFB% < 0%), fluid balance group (0% ≤ CFB% ≤ 10%), and fluid overload group (CFB% > 10%). In-hospital mortality was the primary outcome. Multifactorial Logistic regression was used to analyze time-related association between different CFB and the risk of in-hospital mortality in patients with sepsis during 7 days after ICU admission. In addition, subgroup analysis was performed on patients with septic shock and patients with sepsis who stayed in the ICU for 7 days or longer.@*RESULTS@#A total of 11 437 patients with sepsis were included, of which 6 595 were male and 4 842 were female. The mean age was (64.4±16.4) years. A total of 10 253 patients (89.6%) survived and 1 184 patients (10.4%) died during hospitalization. Compared with the survival group, patients in the death group were older, lighter, had higher sequential organ failure assessment (SOFA), simplified acute physiology score II (SAPS II), longer ICU stay, higher incidence of septic shock, and higher proportion of invasive mechanical ventilation, renal replacement therapy (RRT) and vasoactive drugs. In terms of comorbidities, congestive heart failure, renal disease, liver disease, and malignancy were more common in the death group. The death group had a higher daily fluid balance than the survival group during 7 days after ICU admission, the CFB in the two groups gradually increased with length of ICU stay. After adjusting variables such as age, gender, race, SOFA score, SAPS II score, comorbidities, and the use of invasive mechanical ventilation, RRT and vasoactive drugs, multivariate Logistic regression analysis showed that fluid overload on day 1 after ICU admission was a protective factor for the reduced risk of in-hospital mortality in sepsis patients [odds ratio (OR) = 0.74, 95% confidence interval (95%CI) was 0.64-0.86, P = 0.001]. However, fluid overload on day 3 was a risk factor for in-hospital mortality in sepsis patients (OR = 1.70, 95%CI was 1.47-1.97, P < 0.001) and the risk of in-hospital mortality was significantly increased from day 4 to day 7. Furthermore, the same results were obtained in patients with septic shock and sepsis patients who stayed in the ICU for 7 days or longer.@*CONCLUSIONS@#Fluid overload on day 1 was associated with reduced in-hospital mortality. However, from the third day, fluid overload increases the risk of in-hospital mortality. Thus, managing fluid balance at different times may improve prognosis.