Pre-hospital 'dirty adrenaline': A descriptive case series of patients receiving peripheral dilute adrenaline infusions in Central Australian remote nurse-led clinics prior to aeromedical retrieval.

OBJECTIVES: 'Dirty adrenaline' is the informal term used for a rapidly made peripheral dilute adrenaline infusion in the emergency treatment of shock, most commonly 1 mg adrenaline in 1 L 0.9% NaCl. It has long been part of the remote clinician's arsenal despite no supporting scientific literature. Remote clinics in Central Australia can be hours away from critical care support. The region's high prevalence of renal and cardiac disease means that access to early vasopressors and inotropes is a necessity for treating shock. To tackle this, remote clinicians often use 'dirty adrenaline'. We present a review of 'dirty adrenaline' use in this region. METHODS: Central Australian Retrieval Service's database was screened to identify cases in which a peripheral dilute adrenaline infusion was administered in a remote clinic prior to patient aeromedical retrieval. A retrospective chart review collected: patient demographics; clinical characteristics; infusion details; adverse events; hospital lengths of stay; and mortality outcomes. RESULTS: Fifty-seven cases were identified. Median patient age was 50 (range: 2-96). Septic shock was the most common clinical indication (40/57). Median infusion duration was 155 min. Median systolic BP from commencement until retrieval increased from 75.5 to 91 mmHg. Survival to hospital discharge was 86% (49/57). No significant adverse events associated with 'dirty adrenaline' were recorded. CONCLUSION: 'Dirty adrenaline' is safe to administer and appears to considerably improve survival when used to treat fluid-resistant shock in remote nurse-led clinics guided by an off-site critical care physician.

The efficacy, safety and effectiveness of hyperoncotic albumin solutions in patients with sepsis: A systematic review and meta-analysis.

Background: Intravenous fluid therapy is a ubiquitous intervention for the management of patients with sepsis, however excessive cumulative fluid balance has been shown to result in worse outcomes. Hyperoncotic albumin is presented in low volumes, is an effective resuscitation fluid and may have effects beyond plasma volume expansion alone. This systematic review aimed to assess the efficacy, safety and effectiveness of hyperoncotic albumin solutions in the management of sepsis. Methods: We searched four databases and two trial registries for controlled clinical trials of hyperoncotic albumin for management of sepsis. Review outcomes were mortality, need for renal replacement therapy, cumulative-fluid balance, and need for organ support. We used methods guided by the Cochrane Handbook for reviews of clinical interventions. Studies were assessed using Cochrane's Risk of Bias 2 tool. We performed pairwise meta-analysis where possible. Certainty of evidence was assessed using GRADE. Results: We included six trials; four (2772 patients) were meta-analysed. Most studies had moderate or high risk of bias. There was no significant difference in 28-day mortality for septic patients receiving hyperoncotic albumin compared to other intravenous fluids (OR 0.95, [95% CI: 0.8-1.12]); in patients with septic shock (2013 patients) there was a significant reduction (OR 0.82 [95% CI: 0.68-0.98]). There was no significant difference in safety outcomes. Hyperoncotic albumin was associated with variable reduction in early cumulative fluid balance and faster resolution of shock. Conclusions: There is no good-quality evidence to support the use of hyperoncotic albumin in patients with sepsis, but it may reduce short-term mortality in the sub-groups with septic shock. It appears safe in terms of need for renal replacement therapy and is associated with reduced early cumulative fluid balance and faster resolution of shock. Larger, better quality randomised controlled trials in patients with septic shock may enhance the certainty of these findings. Review registration: PROSPERO ref: CRD42021150674.

Evaluation of Sepsis-Related Medical Emergency Team (MET) Calls with Pharmacist Involvement and Time to Antimicrobial Administration.

Objective: To evaluate the difference in proportion of patients receiving antimicrobials within one hour of sepsis recognition at sepsis-related Medical Emergency Team (MET) calls, without or with a sepsis-credentialed pharmacist. Design: Retrospective pre and post-intervention study. Setting: Single centre tertiary referral hospital. Participants: Patients admitted to the General Medicine Unit who had a sepsis-related MET call 24 hrs per day, and all other units from 17:00-08:00 hrs from August 2019 to Jan 2020 in the pre-intervention cohort and Aug 2020 to Jan 2021 for the post-intervention cohort. Interventions: Pharmacists attended MET calls to assist selection of antimicrobials, collaboratively prescribe with the medical officers, ensure supply, provide advice on dosing calculations, reconstitution, and administration. The pre-intervention cohort (Aug 2019-Jan 2020) did not have credentialed pharmacists' involvement at MET calls. Outcome Measures: Proportion of patients who received antimicrobials within one hours of MET call. Results: There were 97 sepsis-related MET calls in the pre-intervention cohort and 110 sepsis-related MET calls in the post-intervention cohort. A significantly higher proportion of patients received antimicrobials within one hour with pharmacist involvement, compared to control (81.3% vs 59.7%, P = .0006). A reduction in median time to antimicrobial administration (43 min vs 54 min, P = .017) was observed. Conclusion: Sepsis-related MET calls with pharmacist involvement experienced a greater proportion of patients receiving antimicrobials within one hour of sepsis recognition, and a reduction in median time to antimicrobial administration. These results provide support for routine pharmacist involvement at MET calls to assist patients receiving medications in a timely and efficient manner.

The Indian Society of Critical Care Medicine Position Statement on the Management of Sepsis in Resource-limited Settings.

Sepsis poses a significant global health challenge in low- and middle-income countries (LMICs). Several aspects of sepsis management recommended in international guidelines are often difficult or impossible to implement in resource-limited settings (RLS) due to issues related to cost, infrastructure, or lack of trained healthcare workers. The Indian Society of Critical Care Medicine (ISCCM) drafted a position statement for the management of sepsis in RLS focusing on India, facilitated by a task force of 18 intensivists using a Delphi process, to achieve consensus on various aspects of sepsis management which are challenging to implement in RLS. The process involved a comprehensive literature review, controlled feedback, and four iterative surveys conducted between 21 August 2023 and 21 September 2023. The domains addressed in the Delphi process included the need for a position statement, challenges in sepsis management, considerations for diagnosis, patient management while awaiting an intensive care unit (ICU) bed, and treatment of sepsis and septic shock in RLS. Consensus was achieved when 70% or more of the task force members voted either for or against statements using a Likert scale or a multiple-choice question (MCQ). The Delphi process with 100% participation of Task Force members in all rounds, generated consensus in 32 statements (91%) from which 20 clinical practice statements were drafted for the management of sepsis in RLS. The clinical practice statements will complement the existing international guidelines for the management of sepsis and provide valuable insights into tailoring sepsis interventions in the context of RLS, contributing to the global discourse on sepsis management. Future international guidelines should address the management of sepsis in RLS. How to cite this article: Juneja D, Nasa P, Chanchalani G, Cherian A, Jagiasi BG, Javeri Y, et al. The Indian Society of Critical Care Medicine Position Statement on the Management of Sepsis in Resource-limited Settings. Indian J Crit Care Med 2024;28(S2):S4-S19.

Serial Trend of Neutrophil CD64, C-reactive Protein, and Procalcitonin as a Prognostic Marker in Critically Ill Patients with Sepsis/Septic Shock: A Prospective Observational Study from a Tertiary Care ICU.

Aim and background: Neutrophil CD64 (nCD64) is evolving as a prognostic biomarker in sepsis. The primary objective of this study was to evaluate whether serial trend of nCD64, procalcitonin (PCT), and C-reactive protein (CRP) predict 28-day mortality in patients with sepsis/septic shock, as per Sepsis-3 criteria. Materials and methods: This prospective, observational single-center cohort study included 60 adult patients (age ≥18 years) with sepsis. Serial biomarker levels with SOFA score were measured at admission (day 0), on day 4, and on day 8. Results: Of the 60 patients, 42 (70%) had septic shock. Biomarker levels at admission did not differ between patients with sepsis and septic shock. Thirty-seven patients survived and 23 were non-survivors by day 28. There was a significant fall in serial trend of all three biomarkers from admission till day 8 (Friedman p < 0.001) in survivors compared to a non-significant change in non-survivors. On multivariate analysis, SOFA score at admission (OR 1.731), more days with vasopressor support (OR 1.077), rise in CD64 from day 0 to day 8 (OR 1.074), and rise in CRP from day 0 to 8 (OR 1.245) were the significant predictors of 28-day mortality (p < 0.05). The highest area under the ROC curve was obtained for more days of vasopressor therapy (0.857), followed by a rise in CD64 from day 0 to day 8 (0.798). Conclusion: Serial trend of biomarkers has prognostic utility. The rise in CD64 from day 0 to day 8 was a good predictor of mortality compared to the trend of other biomarkers. How to cite this article: Patnaik R, Azim A, Singh K, Agarwal V, Mishra P, Poddar B, et al. Serial Trend of Neutrophil CD64, C-reactive Protein, and Procalcitonin as a Prognostic Marker in Critically Ill Patients with Sepsis/Septic Shock: A Prospective Observational Study from a Tertiary Care ICU. Indian J Crit Care Med 2024;28(8):777-784.

Fludrocortisone dose-response relationship in septic shock: a randomised phase II trial.

BACKGROUND: The combination of intravenous hydrocortisone and enteral fludrocortisone may reduce mortality in patients with septic shock. The optimal dose and reliability of absorption of fludrocortisone in critically ill patients are unclear. METHODS: In a multi-centre, open label, phase II randomized clinical trial, intravenous hydrocortisone alone or in combination with one of three doses of enteral fludrocortisone (50 µg, 100 µg or 200 µg daily) for 7 days was compared in patients with septic shock. The primary outcome was time to shock resolution. We conducted pharmacokinetic studies to assess absorption. RESULTS: Out of 153 enrolled patients, 38 (25%) received hydrocortisone alone, 42 (27%) received additional 50 µg, 36 (24%) received 100 µg and 37 (24%) received 200 µg fludrocortisone. Plasma concentrations of fludrocortisone were detected in 97% of patients at 3 h-median (interquartile range [IQR]) 261 (156-334) ng/L. There was no significant difference in the time to shock resolution between groups with median (IQR) of 3 (2.5-4.5), 3 (2-4), 3 (2-6) and 3 (2-5.5) days in the hydrocortisone alone, 50 µg, 100 µg and 200 µg fludrocortisone groups, respectively. The corresponding 28-day mortality rates were 9/38 (24%), 7/42 (17%), 4/36 (11%) and 4/37 (11%), respectively. There were no significant differences between groups with respect to, recurrence of shock, indices of organ failure or other secondary outcomes. CONCLUSIONS: Enteral fludrocortisone resulted in detectable plasma fludrocortisone concentrations in the majority of critically ill patients with septic shock, although they varied widely indicating differing absorption and bioavailability. Its addition to hydrocortisone was not associated with shorter time to shock resolution.

Role of arterial blood glucose and interstitial fluid glucose difference in evaluating microcirculation and clinical prognosis of patients with septic shock: a prospective observational study.

BACKGROUND: Microcirculation abnormality in septic shock is closely associated with organ dysfunction and mortality rate. It was hypothesized that the arterial blood glucose and interstitial fluid (ISF) glucose difference (GA-I) as a marker for assessing the microcirculation status can effectively evaluate the severity of microcirculation disturbance in patients with septic shock. METHODS: The present observational study enrolled patients with septic shock admitted to and treated in the intensive care unit (ICU) of a tertiary teaching hospital. The parameters reflecting organ and tissue perfusion, including lactic acid (Lac), skin mottling score, capillary refill time (CRT), venous-to-arterial carbon dioxide difference (Pv-aCO2), urine volume, central venous oxygen saturation (ScvO2) and GA-I of each enrolled patient were recorded at the time of enrollment (H0), H2, H4, H6, and H8. With ICU mortality as the primary outcome measure, the ICU mortality rate at any GA-I interval was analyzed. RESULTS: A total of 43 septic shock patients were included, with median sequential organ failure assessment (SOFA) scores of 10.5 (6-16), and median Acute Physiology and Chronic Health Evaluation (APACHAE) II scores of 25.7 (9-40), of whom 18 died during ICU stay. The GA-I levels were negative correlation with CRT (r = 0.369, P < 0.001), Lac (r = -0.269, P < 0.001), skin mottling score (r=-0.223, P < 0.001), and were positively associated with urine volume (r = 0.135, P < 0.05). The ICU mortality rate of patients with septic shock presenting GA-I ≤ 0.30 mmol/L and ≥ 2.14 mmol/L was significantly higher than that of patients with GA-I at 0.30-2.14 mmol/L [65.2% vs. 15.0%, odds ratio (OR) = 10.625, 95% confidence interval (CI): 2.355-47.503]. CONCLUSION: GA-I was correlated with microcirculation parameters, and with differences in survival. Future studies are needed to further explore the potential impact of GA-I on microcirculation and clinical prognosis of septic shock, and the bedside monitoring of GA-I may be beneficial for clinicians to identify high-risk patients.

Prognostic risk factors for pyogenic liver abscess caused by Klebsiella pneumoniae.

BACKGROUND: Pyogenic liver abscess (PLA) caused by Klebsiella pneumoniae can vary in severity, and several risk factors for the development of organ dysfunction in PLA have been implicated. However, few studies to date have explored the most common risk factors for clinical severity. METHODS: We conducted a study on patients with PLA caused by Klebsiella pneumoniae between February 2013 and December 2022.Using logistic regression analysis, we sought to identify factors associated with positive blood culture, septic shock, and intensive care unit (ICU) admission. RESULTS: After included 200 patients, we found that an elevated procalcitonin (PCT) level (p = 0.03), higher glucose level (p = 0.03), and lower total cholesterol (TC) level (p = 0.01) were associated with a higher likelihood of positive blood bacteriological culture. Additionally, an increased PCT level (p = 0.02) and lower TC level (p < 0.01) were associated with an elevated risk of septic shock. Furthermore, a higher PCT level (p < 0.01) was associated with a higher probability of ICU admission. CONCLUSION: In patients with PLA caused by Klebsiella pneumoniae, the PCT, glucose, and TC levels were found to be associated with positive blood culture, septic shock, and ICU admission.

Preoperative renal arterial embolization in high-risk nephrectomy: A case report of a 48-year-old patient with severe emphysematous pyelonephritis.

A 48-year-old female with a background history of alcoholic liver cirrhosis and noninsulin-dependent diabetes presented to our institution with emphysematous pyelonephritis of the right kidney diagnosed on CT. Both urine and blood culture grew multidrug-resistant Escherichia coli. The patient developed severe thrombocytopenia, hyponatremia, confusion as well as septic shock. Preoperative right renal arterial embolization was performed, followed by immediate primary nephrectomy. This article reports the first documented case of preoperative angioembolization to prevent severe intraoperative hemorrhage and vascular complications in severe emphysematous pyelonephritis.

Comparison of Modified Early Warning Score (MEWS), Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II) for early prediction of septic shock in diabetic patients in Emergency Departments.

INTRODUCTION: Sepsis is a severe medical condition that can be life-threatening. If sepsis progresses to septic shock, the mortality rate increases to around 40%, much higher than the 10% mortality observed in sepsis. Diabetes increases infection and sepsis risk, making management complex. Various scores of screening tools, such as Modified Early Warning Score (MEWS), Simplified Acute Physiology Score (SAPS II), Sequential Organ Failure Assessment Score (SOFA), and Acute Physiology and Chronic Health Evaluation (APACHE II), are used to predict the severity or mortality rate of disease. Our study aimed to compare the effectiveness and optimal cutoff points of these scores. We focused on the early prediction of septic shock in patients with diabetes in the Emergency Department (ED). METHODS: We conducted a retrospective cohort study to collect data on patients with diabetes. We collected prediction factors and MEWS, SOFA, SAPS II and APACHE II scores to predict septic shock in these patients. We determined the optimal cutoff points for each score. Subsequently, we compared the identified scores with the gold standard for diagnosing septic shock by applying the Sepsis-3 criteria. RESULTS: Systolic blood pressure (SBP), peripheral oxygen saturation (SpO2), Glasgow Coma Scale (GCS), pH, and lactate concentrations were significant predictors of septic shock (p < 0.001). The SOFA score performed well in predicting septic shock in patients with diabetes. The area under the receiver operating characteristics (ROC) curve for the SOFA score was 0.866 for detection within 48 h and 0.840 for detection after 2 h of admission to the ED, with the optimal cutoff score of ≥ 6. CONCLUSION: SBP, SpO2, GCS, pH, and lactate concentrations are crucial for the early prediction of septic shock in patients with diabetes. The SOFA score is a superior predictor for the onset of septic shock in patients with diabetes compared with MEWS, SAPS II, and APACHE II scores. Specifically, a cutoff of ≥ 6 in the SOFA score demonstrates high accuracy in predicting shock within 48 h post-ED visit and as early as 2 h after ED admission.

Emphysematous Osteomyelitis of the Lumbar Spine and Sacrum After Liver Transplantation: A Case Report.

Emphysematous osteomyelitis (EO) is a rare and potentially fatal disease that often occurs in patients with underlying conditions, most commonly diabetes mellitus. Herein, we report a case of a 62-year-old man who presented with fever, tachycardia, and hypotension 112 days after liver transplantation. Blood tests revealed an increased inflammatory response. Computed tomography demonstrated clusters of small gas collections in the first and second lumbar vertebral bodies and the right sacral ala, a finding characteristic of the pumice stone sign of EO. Septic shock due to EO was diagnosed. The patient responded well to treatment and recovered from the infection. This case suggests that the immunosuppressive state after liver transplantation is a risk factor for EO.

COVID-19 Related Acute Respiratory Distress Syndrome versus Classical Acute Respiratory Distress Syndrome Patients: Inflammatory Biomarkers as Predictors of Mortality in Pulmonary Septic Shock.

Introduction and Objectives: Coronavirus disease-2019 (COVID-19)-related severe acute respiratory distress syndrome (ARDS) differs pathophysiological from other pulmonary septic shock-related ARDS. Thus, we assessed whether all-cause in-hospital mortality differs for severe COVID-19-related and classical severe ARDS and which inflammatory biomarkers can predict mortality among these patients. Material and Methods: This single-center, retrospective, observational cohort study included pulmonary septic shock patients (n = 114) with COVID-19-related and classical severe ARDS admitted in the Intensive Care Unit. Results: Patients with a mean age of 73 (IQR 62-82), predominantly male (63%), were divided into two groups based on outcomes: survivors (n = 50) and non-survivors (n = 64). COVID-19-related severe ARDS (n = 48) accounts for 75% of deaths. Present comorbidities like heart disease (p = 0.043), neurologic disorders (p = 0.018), and liver disease (p = 0.038) were associated with in-hospital mortality, as well. Regarding inflammatory biomarkers, the AUC/c-statistic was 0.656 (95% CI: 0.53-0.759) for leukocytes, 0.613 (95% CI: 0.509-0.717) C-reactive protein (CRP) and 0.651 (95% CI: 0.548-0.753) for procalcitonin in predicting all-cause in-hospital mortality among patients with pulmonary septic shock and severe ARDS. Conclusion: Patients with pulmonary septic shock and with COVID-19-related severe ARDS had a higher incidence of in-hospital mortality than those with classical severe ARDS. The high value of leukocytes, C-reactive protein, and procalcitonin were predictive for all-cause in-hospital mortality in patients with pulmonary septic shock and ARDS. Infection with COVID-19 was an independent predictor of in-hospital mortality in the presence of ARDS.

Apelin-13 administration allows for norepinephrine sparing in a rat model of cecal ligation and puncture-induced septic shock.

BACKGROUND: Infusion of exogenous catecholamines (i.e., norepinephrine [NE] and dobutamine) is a recommended treatment for septic shock with myocardial dysfunction. However, sustained catecholamine infusion is linked to cardiac toxicity and impaired responsiveness. Several pre-clinical and clinical studies have investigated the use of alternative vasopressors in the treatment of septic shock, with limited benefits and generally no effect on mortality. Apelin-13 (APL-13) is an endogenous positive inotrope and vasoactive peptide and has been demonstrated cardioprotective with vasomodulator and sparing life effects in animal models of septic shock. A primary objective of this study was to evaluate the NE-sparing effect of APL-13 infusion in an experimental sepsis-induced hypotension. METHODS: For this goal, sepsis was induced by cecal ligation and puncture (CLP) in male rats and the arterial blood pressure (BP) monitored continuously via a carotid catheter. Monitoring, fluid resuscitation and experimental treatments were performed on conscious animals. Based on pilot assays, normal saline fluid resuscitation (2.5 mL/Kg/h) was initiated 3 h post-CLP and maintained up to the endpoint. Thus, titrated doses of NE, with or without fixed-doses of APL-13 or the apelin receptor antagonist F13A co-infusion were started when 20% decrease of systolic BP (SBP) from baseline was achieved, to restore SBP values ≥ 115 ± 1.5 mmHg (baseline average ± SEM). RESULTS: A reduction in mean NE dose was observed with APL-13 but not F13A co-infusion at pre-determined treatment time of 4.5 ± 0.5 h (17.37 ± 1.74 µg/Kg/h [APL-13] vs. 25.64 ± 2.61 µg/Kg/h [Control NE] vs. 28.60 ± 4.79 µg/Kg/min [F13A], P = 0.0491). A 60% decrease in NE infusion rate over time was observed with APL-13 co-infusion, (p = 0.008 vs NE alone), while F13A co-infusion increased the NE infusion rate over time by 218% (p = 0.003 vs NE + APL-13). Associated improvements in cardiac function are likely mediated by (i) enhanced left ventricular end-diastolic volume (0.18 ± 0.02 mL [Control NE] vs. 0.30 ± 0.03 mL [APL-13], P = 0.0051), stroke volume (0.11 ± 0.01 mL [Control NE] vs. 0.21 ± 0.01 mL [APL-13], P < 0.001) and cardiac output (67.57 ± 8.63 mL/min [Control NE] vs. 112.20 ± 8.53 mL/min [APL-13], P = 0.0036), and (ii) a reduced effective arterial elastance (920.6 ± 81.4 mmHg/mL/min [Control NE] vs. 497.633.44 mmHg/mL/min. [APL-13], P = 0.0002). APL-13 administration was also associated with a decrease in lactate levels compared to animals only receiving NE (7.08 ± 0.40 [Control NE] vs. 4.78 ± 0.60 [APL-13], P < 0.01). CONCLUSION: APL-13 exhibits NE-sparing benefits in the treatment of sepsis-induced shock, potentially reducing deleterious effects of prolonged exogenous catecholamine administration.

Extracorporeal Membrane Oxygenation as Circulatory Support in Adult Patients with Septic Shock: A Systematic Review.

Introduction: The utilization of extracorporeal membrane oxygenation (ECMO) in adult patients experiencing septic shock is a subject of ongoing debate within the medical community. This study aims to comprehensively address this issue through a systematic review conducted in accordance with the PRISMA guidelines. Aim of Study: The primary objective of this study is to assess the outcomes of ECMO utilization in adult patients diagnosed with septic shock, thereby providing insights into the potential benefits and uncertainties associated with this treatment modality. Materials and Methods: Our research encompassed a thorough search across electronic databases for relevant English-language articles published up until April 2023. The inclusion criteria were based on studies reporting on ECMO usage in adult patients with septic shock. Among the eligible studies meeting these criteria, a total of eleven were included in our analysis, involving a cohort of 512 patients. The mean age of the participants was 53.4 years, with 67.38% being male. Results: In the pooled analysis, the mean survival rate following ECMO treatment was found to vary significantly across different ECMO modalities. Patients receiving venovenous-ECMO (VV-ECMO) and veno-venous-arterial ECMO (VVA-ECMO) demonstrated higher survival rates (44.5% and 44.4%, respectively) compared to those receiving venoarterial-ECMO (VA-ECMO) at 25% (p<0.05). A chi-square test of independence indicated that the type of ECMO was a significant predictor of survival (χ2(2) = 6.63, p=0.036). Additionally, patients with septic shock stemming from respiratory failure demonstrated survival rates ranging from 39% to 70%. Predictors of mortality were identified as older age and the necessity for cardiopulmonary resuscitation (CPR). Conclusions: In septic shock patients, ECMO outcomes align with established indications like respiratory and cardiogenic shock. VV-ECMO and VVA-ECMO suggest better prognoses, though the optimal mode remains uncertain. Patient selection should weigh age and CPR need. Further research is vital to determine ECMO's best approach for this population.

Sex differences in pediatric sepsis-a systematic review protocol.

BACKGROUND: Pediatric sepsis remains a leading cause of childhood morbidity and mortality worldwide. Despite advancements in modern medicine, it accounts for more than 3 million childhood deaths per year. Multiple studies have emphasized that sex and gender have an impact on the treatment and outcome of various diseases. Adult studies have revealed sex differences in pathophysiological responses to septic shock, as well as a possible protective effect of estrogens on critical illness. Sex-specific maturational and developmental differences in host immunology have been previously demonstrated for neonatal and pediatric age groups. At present, there are no studies assessing the impact of sex on outcomes of children with sepsis. METHODS: The goal of this study is to assess sex-specific differences in childhood sepsis survival outcomes. We will systematically assess associations of sex and gender with outcomes in pediatric sepsis in the literature by performing a systematic search of MEDLINE and Embase databases. We will include all English language randomized trials and cohort studies. The study population will include children > 37 weeks gestational age and < 18 years of age. Exposure will be sepsis, severe sepsis, and septic shock and the main comparison will be between male and female sex. The primary outcome will be hospital mortality. Secondary outcomes will be the pediatric intensive care unit and hospital length of stay. DISCUSSION: Results from this review are expected to provide important information on the association of sex with the outcomes of pediatric sepsis. If an association is noted, this study may serve as a foundation for further research evaluating the pathophysiological aspects as well as potential socioeconomic factors responsible for the clinically detected sex differences. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022315753.

Recent trends in septic shock management: a narrative review of current evidence and recommendations.

Septic shock stands for a group of manifestations that will cause a severe hemodynamic and metabolic dysfunction, which leads to a significant increase in the risk of death by a massive response of the immune system to any sort of infection that ends up with refractory hypotension making it responsible for escalating the numbers of hospitalized patients mortality rate, Organisms that are isolated most of the time are Escherichia coli, Klebsiella, Pseudomonas aeruginosa, and Staph aureus. The WHO considers sepsis to be a worldwide health concern; the incidence of sepsis and septic shock have been increasing over the years while being considered to be under-reported at the same time. This review is a quick informative recap of the recent studies regarding diagnostic approaches using lactic acid (Lac), procalcitonin (PCT), Sequential Organ Failure Assessment (SOFA) score, acute physiology and chronic health evaluation II (APACHE II) score, as well as management recommendations for using vasopressors, fluid resuscitation, corticosteroids and antibiotics that should be considered when dealing with such type of shock.

Clinical diagnosis of fat embolism syndrome with septic shock following polytrauma: a case report.

Introduction and importance: Fat embolism syndrome (FES) arises from the systemic effects of fat emboli in microcirculation. While sepsis is characterized by pathological, physiological, and metabolic abnormalities caused by infection. Septic shock is identified by elevated blood lactate (>2 mmol/l) and the need for vasopressors to maintain a mean arterial pressure of 65 mmHg or higher in the absence of hypovolemia. Case presentation: This case report discusses the clinical course and treatment of a 50-year-old male involved in a road traffic accident resulting in polytrauma. The patient presented with multiple fractures, hemopneumothorax, lung contusions, and rib fractures. He was then stabilized following which fractures were reduced and managed operatively. Postoperatively, the patient developed FES with septic shock, manifested by altered consciousness, petechial rashes, and respiratory distress. He was managed with intubation, chest drainage, and a combination of antibiotics, anticoagulants, and vasoactive agents. A tracheostomy was performed due to respiratory insufficiency. Following 29 days in the SICU, the patient's condition was stabilized and shifted to the general ward for further management. He was discharged after 48 days, with a complete recovery and a 2-week follow-up. This case report depicts the challenges in the management of FES with septic shock following polytrauma. Conclusion: This case report is a comprehensive overview of FES complicated with septic shock. It highlights the importance of supportive care as the primary treatment modality, incorporating various medical interventions. The successful outcome and complete recovery of the patient underline the significance of prolonged monitoring, wound care, and physiotherapy.

Pilot study on optimizing pressure for standardized capillary refill time measurement.

Purpose: Capillary Refill Time (CRT) measurement has gained increasing attention in the field of sepsis and septic shock. Recognizing pressure as a fundamental determinant in CRT measurement is crucial for establishing a standardized CRT measurement procedure. In this preliminary study, we elucidated the optimal pressing strength for CRT measurement by analyzing the CRTs measured under varying pressures. Method: Seventeen healthy individuals were enlisted to undergo CRT tests on their fingertips at various pressure levels. The applied force was initiated at 0.5N and incrementally increased by 0.5N until it reached 10.5N. An integrated Photoplethysmography (PPG) device was employed to capture fluctuations in light intensity. The CRT was automatically derived from the PPG signals via a specialized algorithm. The study included correlation assessment and reliability evaluation. Box plot and Bland-Altman plot were used to visualize the impact of pressure levels on CRTs. Results: A dataset of 1414 CRTs across 21 pressures showed significant differences (Kruskal-Wallis test, p < 0.0001), highlighting the impact of pressure on CRT. CRT values between 4.5N and 10.5N pressures varied less, with an Intraclass Correlation Coefficient (ICC) of 0.499 indicating moderate consistency. Notably, CRTs at 10N and 10.5N pressures revealed a high ICC of 0.790, suggesting strong agreement. Conclusion: A pressure range of 4.5N-10.5N is recommended for stable CRT measurements, with 10.0N-10.5N providing optimal consistency and reliability.

Unraveling the impact of therapeutic drug monitoring via machine learning for patients with sepsis.

Clinical studies investigating the benefits of beta-lactam therapeutic drug monitoring (TDM) among critically ill patients are hindered by small patient groups, variability between studies, patient heterogeneity, and inadequate use of TDM. Accordingly, definitive conclusions regarding the efficacy of TDM remain elusive. To address these challenges, we propose an innovative approach that leverages data-driven methods to unveil the concealed connections between therapy effectiveness and patient data, collected through a randomized controlled trial (DRKS00011159; 10th October 2016). Our findings reveal that machine learning algorithms can successfully identify informative features that distinguish between healthy and sick states. These hold promise as potential markers for disease classification and severity stratification, as well as offering a continuous and data-driven "multidimensional" Sequential Organ Failure Assessment (SOFA) score. The positive impact of TDM on patient recovery rates is demonstrated by unraveling the intricate connections between therapy effectiveness and clinically relevant data via machine learning.

State of the art of sepsis care for the emergency medicine clinician.

Sepsis impacts 1.7 million Americans annually. It is a life-threatening disruption of organ function because of the body's host response to infection. Sepsis remains a condition frequently encountered in emergency departments (ED) with an estimated 850,000 annual visits affected by sepsis each year in the United States. The pillars of managing sepsis remain timely identification, initiation of antimicrobials while aiming for source control and resuscitation with a goal of restoring tissue perfusion. The focus herein is current evidence and best practice recommendations for state-of-the-art sepsis care that begins in the ED.