SHock-INduced Endotheliopathy (SHINE): A mechanistic justification for viscoelastography-guided resuscitation of traumatic and non-traumatic shock.

Irrespective of the reason for hypoperfusion, hypocoagulable and/or hyperfibrinolytic hemostatic aberrancies afflict up to one-quarter of critically ill patients in shock. Intensivists and traumatologists have embraced the concept of SHock-INduced Endotheliopathy (SHINE) as a foundational derangement in progressive shock wherein sympatho-adrenal activation may cause systemic endothelial injury. The pro-thrombotic endothelium lends to micro-thrombosis, enacting a cycle of worsening perfusion and increasing catecholamines, endothelial injury, de-endothelialization, and multiple organ failure. The hypocoagulable/hyperfibrinolytic hemostatic phenotype is thought to be driven by endothelial release of anti-thrombogenic mediators to the bloodstream and perivascular sympathetic nerve release of tissue plasminogen activator directly into the microvasculature. In the shock state, this hemostatic phenotype may be a counterbalancing, yet maladaptive, attempt to restore blood flow against a systemically pro-thrombotic endothelium and increased blood viscosity. We therefore review endothelial physiology with emphasis on glycocalyx function, unique biomarkers, and coagulofibrinolytic mediators, setting the stage for understanding the pathophysiology and hemostatic phenotypes of SHINE in various etiologies of shock. We propose that the hyperfibrinolytic phenotype is exemplified in progressive shock whether related to trauma-induced coagulopathy, sepsis-induced coagulopathy, or post-cardiac arrest syndrome-associated coagulopathy. Regardless of the initial insult, SHINE appears to be a catecholamine-driven entity which early in the disease course may manifest as hyper- or hypocoagulopathic and hyper- or hypofibrinolytic hemostatic imbalance. Moreover, these hemostatic derangements may rapidly evolve along the thrombohemorrhagic spectrum depending on the etiology, timing, and methods of resuscitation. Given the intricate hemochemical makeup and changes during these shock states, macroscopic whole blood tests of coagulative kinetics and clot strength serve as clinically useful and simple means for hemostasis phenotyping. We suggest that viscoelastic hemostatic assays such as thromboelastography (TEG) and rotational thromboelastometry (ROTEM) are currently the most applicable clinical tools for assaying global hemostatic function-including fibrinolysis-to enable dynamic resuscitation with blood products and hemostatic adjuncts for those patients with thrombotic and/or hemorrhagic complications in shock states.

The association between the neutrophil to lymphocyte ratio and in-hospital mortality among sepsis patients: A prospective study.

The Neutrophil to lymphocyte ratio (NLR) was shown to be associated with disease severity, poor prognosis and increased mortality in sepsis. However, the association between NLR and sepsis prognosis remains controversial. Our study aims to prospectively examine the prognostic ability of NLR in predicting in-hospital mortality among sepsis patients and determine the optimal cutoff of NLR that can most accurately predict in-hospital mortality in sepsis patients. This study was a prospective cohort study that included adult sepsis patients that presented to the emergency department of a tertiary care center between September 2018 and February 2021. Receiver operating characteristic curve was used to determine the optimal cutoff of the neutrophil to lymphocyte ratio that predicts in-hospital mortality. Patients were divided into 2 groups: above and below the optimal cutoff. Stepwise logistic regression was performed to assess the magnitude of the association between NLR and in-hospital mortality. A total of 865 patients were included in the study. The optimal cutoff for the neutrophil to lymphocyte ratio that predicts in-hospital mortality was found to be 14.20 with a sensitivity of 44.8% and a specificity of 65.3% (with PPV = 0.27 and NPV = 0.80). The area under the curve for the ratio was 0.552 with a 95% confidence intervals = [0.504-0.599] with a P value = .03. Patients that have a NLR above the cutoff were less likely to survive with time compared to patients below the cutoff based on the Kaplan-Meier curves. In the stepwise logistic regression, the optimal neutrophil to lymphocyte ratio cutoff was not associated with in-hospital mortality (odds ratios = 1.451, 95% confidence intervals = [0.927-2.270], P = .103). In conclusion the optimal cutoff of the NLR that predicts in-hospital mortality among sepsis patients was 14.20. There was no association between the NLR and in-hospital mortality in sepsis patients after adjusting for confounders. Further studies with a larger sample size should be done to determine the optimal NLR cutoff and its prognostic role in septic patients (in-hospital mortality and other clinically significant outcomes).

The prognostic value of biomarker levels and chest imaging in patients with COVID-19 presenting to the emergency department.

INTRODUCTION: We aimed to compare the prognostic value of a quantitative CT severity score with several laboratory parameters, particularly C-reactive protein, Procalcitonin, Neutrophil to lymphocyte ratio, D-dimer, ferritin, lactate dehydrogenase, lactate, troponin and B-type Natriuretic Peptide in predicting in-hospital mortality. METHODS: This was a retrospective chart review study of COVID-19 patients who presented to the Emergency Department of a tertiary care center between February and December 2020. All patients ≥18 years old who tested positive for the COVID-19 real-time reverse transcriptase polymerase chain reaction and underwent CT imaging at presentation were included. The primary outcome was the prognostic ability of CT severity score versus biomarkers in predicting in-hospital mortality. RESULTS: The AUCs were: D-dimer (AUC: 0.67 95% CI = 0.57-0.77), CT severity score (0.66, 95% CI = 0.55-0.77), LDH (0.66, 95% CI = 0.55-0.77), Pro-BNP (0.65, 95% CI = 0.55-0.76), NLR (0.64, 95% CI = 0.53-0.75) and troponin (0.64, 95% CI = 0.52-0.75). In the stepwise logistic regression, age (OR = 1.07 95% CI = 1.05-1.09), obesity (OR = 2.02 95% CI = 1.25-3.26), neutrophil/lymphocyte ratio (OR = 1.02 95% CI = 1.01-1.04), CRP (OR = 1.01 95% CI = 1.004-1.01), lactate dehydrogenase (OR = 1.003 95% CI = 1.001-1.004) and CT severity score (OR = 1.17 95% CI = 1.12-1.23) were significantly associated with in-hospital mortality. CONCLUSION: In summary, CT severity score outperformed several biomarkers as a prognostic tool for covid related mortality. In COVID-19 patients requiring lung imaging, such as patients requiring ICU admission, patients with abnormal vital signs and those requiring mechanical ventilation, the results suggest obtaining and calculating the CT severity score to use it as a prognostic tool. If a CT was not performed, the results suggest using LDH, CRP or NLR if already done as prognostic tools in COVID-19 as these biomarkers were also found to be prognostic in COVID-19 patients.

The Risk Factors for Mortality among Septic Trauma Patients: A Retrospective Cohort Study Using the National Trauma Data Bank.

Introduction: In trauma patients, the development of sepsis as a hospital complication is significantly associated with morbidity and mortality. We aimed to assess the risk factors associated with in-hospital mortality among trauma patients who developed sepsis during their hospital stay. Material and methods. Using the 2017 National Trauma Data Bank, a retrospective cohort study was conducted to identify adult trauma patients who developed sepsis during their hospital stay. The primary outcome of interest was in-hospital mortality. Multivariate analysis was used to determine the risk factors associated with in-hospital mortality. Results: 1782 trauma patients developed sepsis. 567 patients (31.8%) died during their hospital stay. The following patient factors were associated with higher odds of in-hospital mortality: age (OR = 1.045 95% CI = 1.036-1.054), chronic renal failure (OR = 2.564 95% CI = 1.528-4.301), and liver cirrhosis (OR = 3.699 95% CI = 2.267-6.033). Patients who developed cardiac arrest (OR = 4.994 95% CI = 3.381-7.378), acute kidney injury (OR = 3.808 95% CI = 2.837-5.110), acute respiratory distress syndrome (OR = 1.688 95% CI = 1.197-2.379), and stroke (OR = 1.998 95% CI = 1.075-3.714) during their hospital stay had higher odds of mortality. Higher Glasgow Coma Scale (13-15) at presentation was associated with lower odds of mortality (OR = 0.467 95% CI = 0.328-0.667). Conclusion: Among trauma patients who developed sepsis, age, chronic renal failure, cirrhosis, the development of cardiac arrest, acute kidney injury, acute respiratory distress syndrome, and stroke in the hospital were associated with in-hospital mortality. These factors can be used to identify patients who are at higher risk of adverse outcomes and implement standardized or protocol-driven methods to improve patient care.

Comparing the demographic data and outcomes of septic shock patients presenting to teaching or non-teaching metropolitan hospitals in the United States.

BACKGROUND: Studies looking at the effect of hospital teaching status on septic shock related in-hospital mortality are lacking. The aim of this study was to examine the effect of hospital teaching status on mortality in septic shock patients in the United States. METHODS: This was a retrospective observational study, using the Nationwide Emergency Department Sample Database (released in 2018). All patients with septic shock were included. Complex sample logistic regression was performed to assess the impact of hospital teaching status on patient mortality. RESULTS: A total of 388,552 septic shock patients were included in the study. The average age was 66.93 years and 51.7% were males. Most of the patients presented to metropolitan teaching hospitals (68.2%) and 31.8% presented to metropolitan non-teaching hospitals. Septic shock patients presenting to teaching hospitals were found to have a higher percentage of medical comorbidities, were more likely to be intubated and placed on mechanical ventilation (50.5% vs. 46.9%) and had a longer average length of hospital stay (12.47 d vs. 10.20 d). Septic shock patients presenting to teaching hospitals had greater odds of in-hospital mortality compared to those presenting to metropolitan non-teaching hospitals (adjusted odd ratio [OR]=1.295, 95% confidence interval [CI]: 1.256-1.335). CONCLUSION: Septic shock patients presenting to metropolitan teaching hospitals had significantly higher risks of mortality than those presenting to metropolitan non-teaching hospitals. They also had higher rates of intubation and mechanical ventilation as well as longer lengths of hospital stay than those in non-teaching hospitals.

The prognostic value of the lactate/albumin ratio for predicting mortality in septic patients presenting to the emergency department: a prospective study.

OBJECTIVES: Lactate/albumin (L/A) ratio is a biomarker in sepsis that has been shown to outperform lactate. This prospective study aims to validate the superior prognostic value of the L/A ratio to lactate in sepsis and septic shock. METHODS: Prospective cohort conducted from September 2018 till February 2021 on adult patients presenting to the Emergency Department (ED) at a tertiary care centre with sepsis or septic shock. The primary outcome was the prognostic value of the L/A ratio compared to lactate with regards to mortality. RESULTS: A total of 939 septic patients were included throughout the study period. A total of 236 patients developed septic shock. The AUC value of the L/A ratio in septic patients was 0.65 (95% CI 0.61-0.70) and was higher than that of lactate alone 0.60 (95% CI 0.55-0.64) with a p < .0001. The optimal L/A ratio cut-off threshold that separated survivors from non-survivors was found to be 0.115 for all septic patients. The AUC of the L/A ratio was significantly higher for patients with a lactate ≥2 mmol/L: 0.69 (95% CI 0.64-0.74) versus 0.60 (95% CI 0.54-0.66) with a p < .0001 as well as for patients with an albumin level less than 30 g/L (AUC = 0.69 95% CI= 0.62-0.75 vs AUC= 0.66 95% CI= 0.59-0.73, p = .04). Among septic shock patients there was no statically significant difference in the AUC value of the L/A ratio compared to lactate (0.53 95% CI 0.45-0.61 vs 0.50 95% CI 0.43-0.58 respectively with a p-value = .11). CONCLUSIONS: The L/A ratio is a better predictor of in-patient mortality than lactate in sepsis patients. This superiority was not found in the septic shock subgroup. Our results encourage the use of the ratio early in the ED as a superior prognostic tool in sepsis patients.Key messagesWe aimed to assess the prognostic usefulness of the Lactate/Albumin ratio compared to lactate alone in septic and septic shock patients.The L/A ratio proved to be a better predictor of in-patient mortality than lactate alone in sepsis patients. This pattern also applies across various subgroups in our study (malignancy, diabetics, age above 65, lactate level less than 2 mmol/L, albumin less than 30 g/L). Our results favour the use of the L/A ratio over lactate alone in patients with sepsis and the previously mentioned subgroups.Our results do not favour the use of the ratio instead of lactate in septic shock patients as there was no statistically significant difference between the AUCs of the ratio and lactate alone.

The prevalence and predictors of extended spectrum B-lactamase urinary tract infections among emergency department patients: A retrospective chart review.

BACKGROUND AND IMPORTANCE: Inadequate initial antibiotic treatment of ESBL urinary tract infections (UTI) can lead to increase in the number of antibiotics used, return visits, longer hospitalizations, increased morbidity and mortality and increased costs. Given the important health implications on patients, this study aimed to examine the prevalence and predictors of ESBL UTIs among Emergency Department (ED) patients of a tertiary care center in Beirut, Lebanon. DESIGN, SETTING AND PARTICIPANTS: Single-center retrospective observational study involving all adult UTI patients who presented to the ED of the American University of Beirut Medical Center, a tertiary care center between August 2019 and August 2020. RESULTS: Out of the 886 patients that were included, 24.9% had an ESBL organism identified by urine culture. They had higher bladder catheter use within the previous 90 days, antibiotic use within last 90 days, and were more likely to have a history of an ESBL producing isolate from any body site in the last year. Antibiotic use in the last 90 days and a history of ESBL producing isolate at any site in the previous year were significantly associated with developing an ESBL UTI (OR = 1.66, p = 0.001 and OR = 2.53, p < 0.001 respectively). Patients diagnosed with cystitis were less likely to have an ESBL organism (OR = 0.4 95%CI [0.20-0.81], p = 0.01) CONCLUSION: The prevalence of ESBL organisms was found to be 24.9% in urinary tract infections. The predictors of an ESBL UTI infection were antibiotic use in the last 90 days, a history of ESBL producing isolate at any site in the previous year. Based on the findings of our study, we can consider modifying initial empiric antibiotic treatment for patients presenting with a UTI with the above stated risk factors.