摘要
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.
Subject(s)
Humans , Female , Child, Preschool , Shock, Septic/etiology , Digestive System Abnormalities/surgery , Digestive System Abnormalities/complications , Digestive System Abnormalities/diagnosis , Pain , Gastrointestinal Tract , Ileum摘要
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.
Subject(s)
Humans , Shock, Septic , Sepsis/diagnosis , Hyperlactatemia/complications , Hyperlactatemia/etiology , Lactic Acid/metabolism摘要
Objective:To discuss the clinical characteristics,diagnosis processes,and treatment methods of one patient with congenital intrabdominal hernia,and to summarize the potential misconceptions during the diagnostic and treatment processes,and to improve the clinicians'awareness of this disease.Methods:The clinical data and auxiliary examination results of one patient with congenital intrabdominal hernia were collected and analyzed,and the related literatures were reviewed.Results:The patient,a 65-year-old male,sought care at the local hospital due to upper abdominal pain before 2 d;there were no significant abnormalities in the examination results at the cocal hospital;blood glucose>25 mmol·L-1.After receiving hypoglycemic,rehydration,and blood purification treatment,the condition of the patient was worsened,presenting with confusion,hypotension,and respiratory distress;the patient admitted in our hospital for further diagnosis and treatment.After admission,the patient was given despite fluid resuscitation,mechanical ventilation,and supportive treatment,but there was no improvement in the symptoms;interventional radiology was performed angiography of the abdominal artery and right femoral vein,which showed no significant vascular abnormalities in the abdomen.An abdominal paracentesis yielded a mixed bloody fluid,suggesting the concealed intraperitoneal disease;exploratory laparotomy was performed.During operation,the intrabdominal hernia with small intestine necrosis and septic shock were diagnosed,and partial small intestine resection,anastomosis,adhesiolysis,and abdominal irrigation and drainage were carried out.The patient had a good recovery and was discharged on the 14th day after operation.Conclusion:Congenital intrabdominal hernia is a very rare cause of intestinal obstruction in the adults,and high suspicion for intrabdominal hernia is one of the differential diagnosis for atypical acute abdomen;early multidisciplinary intervention can be lifesaving for the patients.
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Objective To analyze the independent factors impacting the in-hospital prognosis of patients with septic shock,and to construct a simplified scoring system and evaluate its predictive value.Methods A retrospective analysis was carried out on 247 patients with septic shock admitted to the People's Hospital of Xinjiang Uygur Autonomous Region from January 2021 to July 2022,among whom 122 patients survived and 125 died.Univariate analysis and multivariate Cox proportional hazard regression model were used to screen the independent factors affecting in-hospital mortality of septic shock patients.The best cut-off value was ob-tained by using the receiver operating characteristics(ROC)curve,and the continuous variables were conver-ted into binary variables and assigned.Finally,a simplified scoring system was established,and its predictive efficacy for hospital death in septic shock patients was verified.Results The results of multivariate Cox pro-portional hazard regression model showed that the Glasgow coma scale(GCS)score(HR=0.929,95%CI:0.875-0.985,P=0.014),quick sequential organ failure assessment(qSOFA)score(HR=1.475,95%CI:1.094-1.989,P=0.011),lactate level(HR=1.096,95%CI:1.049-1.145,P<0.001),procalcitonin level(HR=1.009,95%CI:1.000-1.018,P=0.048),and albumin level(HR=0.958,95%CI:0.922-0.996,P=0.029)were identified as independent influencing factors for in-hospital mortality in patients with septic shock.The ROC curve showed that the simplified scoring system,based on GCS score,qSOFA score,lactate,procalcitonin,and albumin levels,exhibited an area under the curve and 95%CI of 0.866(0.822-0.910),with an optimal cutoff value of 2.5.The sensitivity and specificity were 80.0%and 78.7%,respectively.Con-clusion The simplified scoring system,based on early assessments of GCS score,qSOFA score,lactate,pro-calcitonin,and albumin levels,demonstrates substantial predictive value for in-hospital mortality in patients with septic shock.
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Objective To investigate the expression changes and clinical significance of interleukin-1 recep-tor-associated kinase 1(IRAK1)and tumor necrosis factor receptor-associated factor 6(TRAF6)in patients with septic shock.Methods A total of 142 patients with septic shock admitted from November 2020 to No-vember 2022(septic shock group)were selected as the study subjects,and those who came to the hospital for physical examination during the same period were selected as the control group.Patients with septic shock were divided into survival group(100 cases)and death group(42 cases)according to their survival status after 28 days of hospitalization observation and treatment.The expression changes of IRAK1 and TRAF6 in pa-tients with septic shock were monitored at admission and after 2,4 and 6 days of treatment.The dynamic changes of acute physiology and chronic health evaluation Ⅱ(APACHEⅡ)score and sequential organ failure assessment(SOFA)score were recorded.Spearman correlation analysis was used to evaluate the correlation between IRAK1,TRAF6 and APACHE Ⅱ score and SOFA score in septic shock patients.The correlation be-tween IRAK1 and TRAF6 was analyzed by Pearson correlation analysis.Logistic regression was used to ana-lyze the factors influencing survival status of patients with septic shock.The diagnostic value of IRAK1 and TRAF6 in survival of patients with septic shock was analyzed by the receiver operating characteristic curve.Results The relative expression levels of IRAK1 and TRAF6 in septic shock group were significantly lower than those in control group,and APACHE Ⅱ score and SOFA score were significantly higher than those in control group,with statistical significance(P＜0.05).Compared with admission,the relative expression levels of IRAK1 and TRAF6 in 2,4 and 6 days after treatment were significantly increased,while APACHE Ⅱ score and SOFA score were significantly decreased,with statistical significance(P＜0.05).Compared with the death group,the relative expression levels of IRAK1 and TRAF6 in the survival group were higher at each corre-sponding time point,and the APACHE Ⅱ score and SOFA score were lower,with statistical significance(P＜0.05).Correlation analysis showed that IRAK1 and TRAF6 were negatively correlated with APACHE Ⅱscores and SOFA scores in septic shock patients,while IRAK1 and TRAF6 were positively correlated(r=0.688,P＜0.05).IRAK1,TRAF6 and APACHE Ⅱ scores were independent risk factors for survival of septic shock patients(P＜0.05).The AUC of the combined diagnosis of IRAK1 and TRAF6 was significantly larger than that of IRAK1 alone(Z=2.044,P=0.041)and that of TRAF6 alone(Z=2.442,P=0.015).Conclusion The expression of IRAK1 and TRAF6 can evaluate the survival and prognosis of patients with septic shock.
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Objective To explore the correlation between serum levels of retinol-binding protein(RBP)and β2-microglobulin(β2-MG)levels with the disease and disease outcome in patients with septic shock.Methods A total of 120 patients with sepsis admitted to Qinzhou Hospital of Traditional Chinese Medicine from November 2020 to November 2022 were selected as research objects,and divided into sepsis group(76 cases)and septic shock group(44 cases)according to the severity of the disease.A total of 96 healthy subjects were selected as control group.According to the 28-day disease outcome of sepsis shock group,10 patients died(worsening group)and 34 patients survived(outcome group).Serum RBP and β2-MG levels were detected by immunoturbidimetry within 24 h after admission.Serum RBP and β2-MG levels were compared among all groups.Receiver operating characteristic curve(ROC)was used to evaluate the predictive value of serum RBP and β2-MG on the disease outcome of patients with septic shock.Multivariate Logistic regression was used to analyze the related factors affecting the disease outcome of patients with septic shock.Results WBC count,procalcitonin,C reactive protein level,acute physiology and chronic health status score system Ⅱ score,se-quential organ failure assessment(SOFA)score in sepsis shock group were higher than those in sepsis group and control group,and platelet count was lower than those in sepsis group and control group,the difference was statistically significant(P＜0.05).Serum RBP and β2-MG levels in sepsis shock group were higher than those in sepsis group and control group,and the difference was statistically significant(P＜0.05).The levels of serum RBP and β2-MG in the worsening group were higher than those in the outcome group,and the differ-ence was statistically significant(P＜0.05).ROC curve analysis showed that the area under the curve of ser-um RBP and β2-MG combined to evaluate the outcome of septic shock disease was 0.910(95％CI:0.865-0.955).Multivariate Logistic regression analysis showed that serum RBP,β2-MG,C reactive protein and SO-FA score were all risk factors affecting the disease outcome of septic shock patients(P＜0.05).Conclusion The serum levels of RBP and β2-MG in patients with septic shock are increased,and the changes of both levels are related to the disease outcome.The combined application has a better predictive value for the disease outcome in patients with septic shock.
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Objective To investigate the clinical features of of patients with Staphylococcus aureus blood-stream infection and risk factors for septic shock.Methods A total of 51 patients diagnosed with Staphylococ-cus aureus bloodstream infection in the hospital from January 2018 to March 2023 were enrolled in the study.According to whether the patients developed septic shock,they were divided into septic shock group and non-septic shock group.The clinical data of the patients were collected,and the clinical laboratory indicators were detected on the day of blood culture samples were collected.Bacteria isolated from blood culture specimens of patients were identified and tested for drug sensitivity.The clinical data and clinical laboratory test indicators of the two groups were compared.Multivariate Logistic regression was used to analyze the independent risk factors of septic shock in patients with Staphylococcus aureus bloodstream infection.The receiver operating characteristic(ROC)curve was used to analyze the predictive value of clinical laboratory test indicators for septic shock in patients with Staphylococcus aureus bloodstream infection.Results Septic shock occurred in 12 of 51 patients,with an incidence of 23.5％.The proportion of patients with diabetes,gouty arthritis,the proportion of patients with long-term glucocorticoid use,the proportion of patients with respiratory tract in-fection,the proportion of patients who died,and the hospitalization cost in the septic shock group were higher than those in the non-septic shock group,and the differences were statistically significant(P＜0.05).Long-term glucocorticoid use was an independent risk factor for septic shock in Staphylococcus aureus bloodstream infection(P＜0.05).The combination of C-reactive protein(CRP),albumin(Alb),neutrophil/lymphocyte ratio(NLR)and procalcitonin(PCT)had high value in predicting septic shock in patients with Staphylococ-cus aureus bloodstream infection,and the area under the ROC curve was 0.983.Conclusion Long-term use of glucocorticoids can lead to an increased risk of septic shock in patients with Staphylococcus aureus blood-stream infection.The combined detection of CRP,Alb,NLR and PCT has a higher predictive value than single detection for septic shock in patients with Staphylococcus aureus bloodstream infection.
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Objective:To observe the clinical effect of Shenfu injection in preventing septic cardiomyopathy (SIC) in septic patients.Methods:From June 2022 to January 2023, patients with sepsis or septic shock who did not develop SIC were randomly divided into treatment group and control group according to the ratio of 1:1. In the treatment group, Shenfu injection (50 mL) was pumped intravenously once every 12 hours for 5 days. In the control group, 50 mL of normal saline was pumped intravenously once every 12 hours, and the course of treatment was 5 days. The primary end point was the incidence of SIC in the first 5 days. The secondary end points were the application time of vasoactive drugs, fluid balance in the previous week, hospitalization time in ICU, total ventilation time and 28-day mortality.Results:112 patients were randomly divided into two groups. Seven patients in the treatment group were excluded twice, and finally 49 patients were included in the analysis, while six patients in the control group were excluded twice and 50 patients included in the analysis. The total incidence of SIC in the treatment group within 5 days was significantly lower than that in the control group (42.9% vs. 64.0%, P = 0.035). Among them, the left ventricular systolic dysfunction in the treatment group was significantly lower than that in the control group (24.5% vs 52.0%, P=0.005), and there was no significant difference in the incidence of left ventricular diastolic dysfunction between the two groups. The incidence of right ventricular dysfunction in the control group was 28.0%, which was significantly higher than 10.2% in the treatment group ( P = 0.025). The duration of using vasoconstrictors in the treatment group was 75(48, 97) hours, which was significantly lower than 97(66, 28) hours in the control group ( P = 0.039). The duration of inotropic drugs use in the treatment group was 32(18, 49) h, which was also significantly shorter than 44(25, 61) h in the control group ( P=0.046). The fluid balance of the control group in the first week was (1 260±850) mL, which was significantly higher than (450±520) mL in the treatment group ( P=0.008). There was no statistical difference in ICU stay, total ventilation time and 28-day mortality between the two groups (all P > 0.05). Conclusion:Early application of Shenfu injection can significantly reduce the incidence of SIC, accompanied by less use of vasoactive drugs and positive fluid balance, which has a good clinical application prospect.
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Objective To explore the correlation between the expression level of serum peptidylarginine deiminase type 2(PAD2)and acute physiology and chronic health evaluationⅡ(APACHE Ⅱ)scores in patients with septic shock.Methods A total of 103 patients with septic shock admitted to the First People's Hospital of Neijiang from June 2020 to June 22 were regarded as the study group.According to the severity of the condition,the APACHE Ⅱ scores were used to classify study group into mild group(n=39),moderate group(n=51)and severe group(n=13).In addition,103 healthy individuals who underwent physical examination in the hospital during the same period,whose general information matched the study group patients,were selected as the control group.Serum PAD2 expression level in patients with septic shock was determined by enzyme-linked immunosorbent assay.Spearman method was applied to analyze the correlation between serum PAD2 expression level and APACHE Ⅱ scores in patients with septic shock.Logistic regression was applied to analyze the factors affecting the severity of patients with septic shock.The diagnostic value of serum PAD2 in moderate and severe septic shock was evaluated using receiver operating characteristic(ROC)curve analysis.Results The differences in blood creatinine levels(137.52±9.01μmol/L vs 112.22±8.67μmol/L)and platelet counts(74.58±5.19 vs 86.02±5.34)×109/L between study group and control group were statistically significant(t=20.535,15.591,all P<0.05).The expression level of PAD2 in the study group(42.47±6.62 ng/ml)was higher than that in the control group(38.59±5.31 ng/ml),with significant difference(t=4.815,P<0.05).The expression level of serum PAD2 and APACHE Ⅱ scores in patients with septic shock gradually increased with the severity of the condition(F=3.777,176.582,all P<0.05).The expression level of serum PAD2 in patients with septic shock was positively correlated with APACHE Ⅱ scores(r=0.859,P<0.05).Serum creatinine(OR=1.927),PAD2(OR=1.803)and APACHE Ⅱscores(OR=1.657)were risk factors for moderate and severe septic shock(P<0.05),while platelet count(OR=0.781)was a protective factor(P<0.05).The area under the curve(AUC)of serum PAD2 in the diagnosis of moderate and severe septic shock was 0.880,and the sensitivity and specificity were 75.73%(95%CI:0.701～0.826)and 90.29%(95%CI:0.851～0.935),respectively,indicating it had high diagnostic value for moderate and severe septic shock.Conclusion The expression level of serum PAD2 was positively correlated with APACHE Ⅱ scores,and may have a good diagnostic value for moderate and severe septic shock.
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OBJECTIVE To compare the clinical effects of different doses of meropenem in the treatment of septic shock. METHODS One hundred and six patients with septic shock were randomly divided into standard-dose group and high-dose group， with 53 cases in each group. Patients in the standard-dose group were given standard dose of meropenem （initial intravenous injection of 1 g meropenem more than 30 minutes， followed by 1 g meropenem intravenously every 8 hours， each time for more than 3 hours）； patients in the high-dose group were given high dose of meropenem （initial intravenous injection of 2 g meropenem more than 30 minutes， followed by 2 g meropenem intravenously every 8 hours， each time for more than 3 hours）； other treatment measures were determined based on the specific conditions of the patients. The main observation indicators were the increments of sequential organ failure assessment （SOFA） scores and simplified acute physiology score Ⅱ （SAPS Ⅱ） after 3， 5 and 7 days of treatment in both groups. Secondary observation indicators included in-hospital mortality， 90-day all-cause mortality， 7-day microbial cure rate， 7-day clinical cure rate， serum procalcitonin （PCT） and C-reactive protein （CRP） levels after 3， 5 and 7 days of treatment， hospitalization days in the intensive care unit， ventilator treatment days， the highest dose of norepinephrine. The occurrence of adverse drug reaction in the two groups was observed. RESULTS The increments of SOFA scores and SAPS Ⅱ after 7 days of treatment， the levels of PCT and CRP after 5 and 7 days of treatment as well as the 90-day all-cause mortality in the high- dose group were significantly lower than the standard-dose group （P＜0.05）. There were no statistically significant differences in other indicators between the two groups （P＞0.05）. CONCLUSIONS High-dose meropenem treatment for septic shock has better clinical effects and is safer than standard-dose meropenem.
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@#Vibrio vulnificus is a halophilic gram-negative bacillus that can cause fulminant septicaemia in immunocompromised patients. A 67-year-old man who was immunosuppressed as a result of cytotoxic chemotherapy presented with a brief history of fever, lethargy, myalgia, and reduced oral intake. He had recently travelled to the beach to consume seafood. His blood pressure was 81/47 mm Hg, necessitating fluid resuscitation followed by inotropic support and admission to the intensive care unit. His blood culture was positive for curved gram-negative bacilli. The isolate was oxidase-positive and produced an acid butt with an alkaline slant in triple sugar iron agar. Matrix-assisted laser desorption ionization-time of flight mass spectrometry conclusively identified the isolate as V. vulnificus. Intravenous ceftazidime plus ciprofloxacin were administered, and by the fifth day of admission, he was successfully transferred out to the general ward. In total, the patient completed a 14-day course of antibiotic therapy.
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As one of the important causes of death in critically ill patients，septic shock has always been the focus of research in the field of critical care medicine.Correct and rational use of vasoactive drug is an important treatment for septic shock.The hemodynamic changes of septic shock in children and adults are different，which lead to the different use of vasoactive drugs.This review summarized the similarities and differences of the application of vasoactive drugs between children and adults with septic shock，thus could provide a reference for clinical practice.
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The mortality rate of septic shock in children is high，and the number of cases has been increasing year by year.In recent years，the number of deaths has decreased with the development of medical technology.With the increasing number of surviving children with septic shock，the prognosis regarding these patients is gaining more attention of PICU physicians than before.The long-term sequelae of patients with septic shock，which often leads to multiple organ dysfunction and complications，severely affects the quality of children life after discharge from the hospital.Notably，the meaningful outcomes mainly include physical，mental，emotional，and social functioning.Currently，few studies focusing on quality of life in children surviving from septic shock have been reported in China.Herein，this review summarized the progress of research on the long-term prognosis of patients with septic shock.
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Objective:To explore the clinical characteristics of children with septic shock and analyze the drug resistance of blood culture positive bacteria.Methods:The clinical data,positive blood culture strains and drug sensitivity results of 127 children with septic shock admitted to the Department of Intensive Care Medicine of Hunan Children's Hospital from September 2015 to August 2021 were retrospectively analyzed.Results:A total of 134 strains of bacteria or fungi were isolated from the blood culture samples of 127 children with septic shock,and gram-negative strains were the main ones,accounting for 67.16% (90/134).Haemophilus influenzae and Escherichia coli were the main gram-negative bacteria,accounting for 38.81% (52/134) and 20.15% (27/134)，respectively,while Streptococcus pneumoniae was the main gram-positive bacteria,accounting for 8.21% (11/134),and Candida albicans was the main fungus,accounting for 10.45% (14/134).The number of white blood cells,the levels of serum C-reactive protein,procalcitonin,venous blood sugar and arterial blood lactic acid in patients were all significantly higher than normal values,and the white blood cells count and neutrophil percentage in gram-positive bacterial infections were significantly higher than those with gram-negative bacterial infections and fungal infections( P<0.05).Procalcitonin increased most obviously when infected by gram-negative bacteria,and the difference was statistically significant ( P<0.05).Gram-positive strains were sensitive to vancomycin,teicoplanin,and linezolid,but only 50% of Streptococcus pneumoniae were sensitive to penicillin.Gram-negative strains had relatively high drug resistance,among which Klebsiella pneumoniae were only highly resistant to imipenem,cilastatin and levofloxacin,reaching 50%.Haemophilus influenzae was resistant to cephalosporins and β-amides enzyme antibiotic,and the drug sensitivity rate of lactamase antibiotics was high,with a resistance rate of 50% only to ampicillin,cefuroxime,amikacin,and compound sulfamethoxazole.There were not many fungal strains,and most antifungal drugs were effective against blood culture-positive fungi. Conclusion:The main pathogens of infection in children with septic shock are gram-negative bacteria,and have high resistance to general antibiotics.We should pay attention to their drug resistance when using antibiotics empirically.
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Objective:To study the early predictors of refractory septic shock (RSS) in neonates.Methods:From July 2020 to December 2021, clinical data of neonates with septic shock admitted to the Neonatal Department of our hospital were retrospectively reviewed. According to the maximum septic shock score (SSS) during clinical course, the neonates were assigned into RSS group and non-RSS group. Perinatal data, laboratory results and hemodynamic parameters at diagnosis were compared between the two groups. Multiple logistic regression analysis was used to identify independent risk factors of RSS and septic shock-related death. Receiver operating characteristic (ROC) curve was constructed to evaluate the early predictors of poor prognosis.Results:A total of 130 neonates were enrolled, including 54 in RSS group and 76 in non-RSS group. Compared with the non-RSS group, the RSS group had significantly lower pH, base excess (BE), stroke volume index (SVI), cardiac output (CO) and cardiac index (CI).Meanwhile, the RSS group had significantly higher mean arterial pressure (MAP) to CI ratio (MAP/CI) and SSS [including bedside SSS (bSSS), computed SSS (cSSS) and modified version of cSSS (mcSSS)] (all P<0.05). Multiple logistic regression analysis showed that increased MAP/CI was an independent predictor of RSS. The cut-off value of MAP/CI was 11.6 [sensitivity 62%, specificity 87%, positive predictive value (PPV) 79% and negative predictive value (NPV) 77%], with an area under the curve (AUC) of 0.734. Increased mcSSS was an independent predictor of septic shock-related death. The cut-off value of mcSSS was 5.8 (sensitivity 83%, specificity 72%, PPV 21% and NPV 97%), with an AUC of 0.845. Conclusions:Increased MAP/CI (≥11.6) and mcSSS (≥5.8) may be early predictors of RSS and septic shock-related death in neonates.
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Objective To evaluate the efficacy of vitamin C intravenous injection in the treatment of patients with sepsis.Methods PubMed,Embase,Scopus,Cochrane Library,and Clinical Trial databases were retrieved,with a retrieval period from database establishment to December 2022.English literatures on randomized controlled trial(RCT)of vitamin C intravenous injection for the treatment of sepsis or septic shock were collected.Meta-analysis was conducted using RevMan 5.3 software and Stata 15.0 software after literature screening,extraction,and evalua-tion of the bias risk included in the studies by two researchers independently.Results A total of 16 RCT studies involving 3 301 patients were included in the analysis.In terms of main outcomes,the 28-day mortality of patients in the vitamin C treatment group was slightly lower than that of the control group,but the difference was not statis-tically significant(RR=0.86,95％CI[0.72-1.03],P=0.10;I2=44％,P=0.10).In terms of secondary out-comes,vitamin C intravenous injection can reduce the duration of vasoactive drug usage time(MD=-23.44,95％CI[-30.53--16.35],P＜0.01;I2=0,P=0.97),but has no significant effect on the 90-day mortality,inten-sive care unit mortality,hospital mortality,duration of mechanical ventilation,difference in estimated sequential organ failure assessment score at 72 hour,length of stay in ICU,and total length of hospital stay of patients(P＞0.05).Conclusion Intravenous vitamin C injection can significantly reduce vasoactive drug usage time,but the available evidence is insufficient to support that intravenous vitamin C can improve the prognosis of patients with sepsis or septic shock.More high-quality,multicenter randomized controlled trial is needed to provide more substantial evidence about the efficacy of vitamin C in treating sepsis or septic shock.
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The main clinical research advances of critical care in 2023 includes: new trials of Chinese herbal medicine, hydroxocobalamin (vitamin B12), methylene blue as well glucocorticoids have shown the potential to improve outcomes of patients with sepsis and septic shock; international committees launched new global definition and managing recommendations for acute respiratory distress syndrome (ARDS). Besides, a cluster of new evidences has emerged in many aspects as following: fluid control strategy in sepsis (restrictive/liberative), antibiotic infusion strategy (continuous/intermittent), oxygen-saturation targets for mechanical ventilation (conservative/liberative), blood pressure targets after resuscitation from out-of-hospital cardiac arrest (hypotension/hypertension), blood pressure targets after successful stroke thrombectomy (intensive/conventional), and nutritional support strategies (low protein-calories/conventional protein-calories, fasting/persistent feeding before extubation). Thus, given above progress, carrying out high -quality domestic multi-center clinical registration researches, constructing shareable standardized databases, as well raising public awareness of sepsis, should be the essential steps to improve our level of intensive care medicine.
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Objective:To explore the relationship between the completion time of fluid resuscitation as well as negative fluid balance volumes and the prognosis of patients with septic shock, and to try to construct a prediction model based on the completion time of fluid resuscitation and negative fluid balance volumes, and to verify the predictive efficacy of the model on the prognosis of patients with septic shock.Methods:Patients with septic shock admitted to Wuxi People's Hospital from April 2020 to April 2023 were selected. The general data (gender, age, body mass index, infection site), pathological indicators on admission, the difference of acute physiology and chronic health evaluation Ⅱ (APACHEⅡ) and sequential organ failure assessment (SOFA) between admission and 24 hours after fluid resuscitation, the completion time of fluid resuscitation and negative fluid balance volume were recorded. Multivariate Logistic analysis was used to screen the influencing factors of the prognosis of patients with septic shock, and a nomogram model was established. Bootstrap method was used for internal validation of the model. The consistency index, calibration curve and receiver operator characteristic curve (ROC curve) were used to evaluate the accuracy and prediction efficiency of the model.Results:A total of 96 patients with septic shock were enrolled, 38 patients died and 58 patients survived at 28 days. Compared with the survival group, the difference of APACHEⅡscore, SOFA score, the proportion of fluid resuscitation completed within 1 to 3 hours, and the proportion of negative fluid balance volume -500 to -250 mL per day in the death group were lower, and the differences were statistically significant (all P < 0.05). Multivariate Logistic analysis showed that the completion time of fluid resuscitation was a risk factor for the prognosis of patients with septic shock [odds ratio ( OR) = 26.285, 95% confidence interval (95% CI) was 9.984-76.902, P < 0.05]. The difference of APACHEⅡscore ( OR = 0.045, 95% CI was 0.015-0.131), SOFA score ( OR = 0.056, 95% CI was 0.019-0.165) between admission and 24 hours after fluid resuscitation, and negative fluid balance volume ( OR = 0.043, 95% CI was 0.015-0.127) were protective factors for the prognosis of patients with septic shock (all P < 0.05). The model validation results showed that the consistency index was 0.681 (95% CI was 0.596-0.924), indicating good discrimination. The calibration curve showed that the calibration curve fitted well with the ideal curve. The ROC curve showed that the sensitivity of the nomogram model for predicting the death of patients with septic shock was 83.7%, the specificity was 97.2%, and the area under the ROC curve (AUC) was 0.931 (95% CI was 0.846-0.985), indicating that the model had good prediction efficiency. Conclusion:The completion time of fluid resuscitation and negative fluid balance volumes are related to the prognosis of septic shock patients, and the alignment diagram model improve the identification of the risk of death in septic shock patients.
摘要
Resumo Objetivo Mapear as evidências disponíveis sobre as ações do óxido nítrico na fisiopatologia da sepse e sua relação com a gravidade de pacientes sépticos. Método Revisão de escopo de acordo com a metodologia do Joanna Briggs Institute. Realizou-se busca por estudos que evidenciaram as ações do óxido nítrico na sepse e se o seu aumento está associado à gravidade de pacientes sépticos. Dois revisores independentes fizeram o mapeamento das informações utilizando um instrumento de extração de dados previamente elaborado. Os dados foram analisados quanto à sua relevância, sendo posteriormente extraídos e sintetizados. Resultados De 1342 estudos, 11 foram incluídos na revisão. O primeiro foi publicado em 2017 e o último, em 2022. A maioria foi desenvolvida nos Estados Unidos, na China e na Alemanha. Os estudos apresentaram informações referentes as ações do óxido nítrico, sintetizando sua biodisponibilidade e os inibidores endógenos relacionados a sua produção, além de abordarem a relação do óxido nítrico com a gravidade da sepse. Conclusão A produção de óxido nítrico fisiológico durante a sepse atua como protetor vascular, principalmente na microcirculação, porém, em altas concentrações, contribui para a disfunção vascular, que subverte a fisiologia da regulação da pressão arterial, causando profunda vasodilatação e hipotensão refratária e aumentando a gravidade de pacientes sépticos.
Resumen Objetivo Mapear las evidencias disponibles sobre las acciones del óxido nítrico en la fisiopatología de la sepsis y su relación con la gravedad de pacientes sépticos. Métodos Revisión de alcance de acuerdo con la metodología del Joanna Briggs Institute. Se realizó una búsqueda de estudios que evidenciaron las acciones del óxido nítrico en la sepsis y si su aumento estaba asociado a la gravedad de pacientes sépticos. Dos revisores independientes hicieron el mapeo de la información utilizando un instrumento de extracción de datos previamente elaborado. Los datos se analizaron respecto a su relevancia, para luego extraerlos y sintetizarlos. Resultados De 1342 estudios, se incluyeron 11 en la revisión. El primero fue publicado en 2017 y el último en 2022. La mayoría se realizó en Estados Unidos, China y Alemania. Los estudios presentaron información referente a las acciones del óxido nítrico, sintetizando su biodisponibilidad y los inhibidores endógenos relacionados con su producción, además de abordar la relación del óxido nítrico con la gravedad de la sepsis. Conclusión La producción de óxido nítrico fisiológico durante la sepsis actúa como protector vascular, principalmente en la microcirculación. Sin embargo, en altas concentraciones, contribuye a la disfunción vascular, que subvierte la fisiología de la regulación de la presión arterial, causa una profunda vasodilatación e hipotensión refractaria y aumenta la gravedad de pacientes sépticos. Registro da revisão de escopo no Open Science Framework: https://doi.org/10.17605/OSF.IO/MXDK2
Abstract Objective Map the available evidence on the actions of nitric oxide in the pathophysiology of sepsis and its relationship with the severity of sepsis in patients. Method Scoping review following the Joanna Briggs Institute methodology. A search was carried out for studies that highlighted the actions of nitric oxide in sepsis, informing whether its increase is associated with the severity of sepsis in patients. Two independent reviewers mapped the information using a previously designed data extraction instrument. The data was analyzed for its relevance and then extracted and synthesized. Results Eleven of 1342 studies were included in the review. The first of them was published in 2017 and the last in 2022. Most of them were developed in the USA, China, and Germany. Studies have reported the actions and bioavailability of nitric oxide and endogenous inhibitors related to its production, and related nitric oxide to the severity of sepsis. Conclusion The physiological production of nitric oxide during sepsis acts as a vascular protector, mainly in the microcirculation but contributes to vascular dysfunction in high concentrations, subverting the regulation of blood pressure, causing deep vasodilation and refractory hypotension, and increasing the severity of sepsis in patients. Registration of the scoping review in the Open Science Framework: https://doi.org/10.17605/OSF.IO/MXDK2
摘要
Abstract Background: The optimal amount for initial fluid resuscitation is still controversial in sepsis and the contribution of non-resuscitation fluids in fluid balance is unclear. We aimed to investigate the main components of fluid intake and fluid balance in both survivors and non-survivor patients with septic shock within the first 72 hours. Methods: In this prospective observational study in two intensive care units, we recorded all fluids administered intravenously, orally, or enterally, and losses during specific time intervals from vasopressor initiation: T1 (up to 24 hours), T2 (24 to 48 hours) and T3 (48 to 72 hours). Logistic regression and a mathematical model assessed the association with mortality and the influence of severity of illness. Results: We included 139 patients. The main components of fluid intake varied across different time intervals, with resuscitation and non-resuscitation fluids such as antimicrobials and maintenance fluids being significant contributors in T1 and nutritional therapy in T2/T3. A positive fluid balance both in T1 and T2 was associated with mortality (p = 0.049; p = 0.003), while nutritional support in T2 was associated with lower mortality (p = 0.040). The association with mortality was not explained by severity of illness scores. Conclusions: Non-resuscitation fluids are major contributors to a positive fluid balance within the first 48 hours of resuscitation. A positive fluid balance in the first 24 and 48 hours seems to independently increase the risk of death, while higher amount of nutrition seems protective. This data might inform fluid stewardship strategies aiming to improve outcomes and minimize complications in sepsis.