Advances in Shock Management and Fluid Resuscitation in Children

Shock in children is associated with signifcant mortality and morbidity, particularly in resource-limited settings. The principles of management include early recognition, fuid resuscitation, appropriate inotropes, antibiotic therapy in sepsis, supportive therapy for organ dysfunction, and regular hemodynamic monitoring. During the past decade, each step has undergone several changes and evolved as evidence that has been translated into recommendations and practice. There is a paradigm shift from protocolized-based care to personalized management, from liberal strategies to restrictive strategies in terms of fuids, blood transfusion, ventilation, and antibiotics, and from clinical monitoring to multimodal monitoring using bedside technologies. However, uncertainties are still prevailing in terms of the volume of fuids, use of steroids, and use of extracorporeal and newer therapies while managing shock. These changes have been summarized along with evidence in this article with the aim of adopting an evidence-based approach while managing children with shock.

How to view multiple disagreements of IDSA about the Surviving Sepsis Campaign's recommendations / 医学研究生学报

Infectious Diseases Society of America (IDSA) published a POSITION STATEMENT to declare not endorse the Surviving Sepsis Campaign guidelines (2016) which is issused shortly after. The article summarizes some of IDSA's specific concerns about distinguishing sepsis from non-infectious syndromes, time to initiation of empiric antibiotic therapy, blood cultures and iv access catheters, combination and multidrug therapy, procalcitonin, pharmacokinetics/pharmacodynamics, prolonged prophylaxis, and duration of therapy. IDSA pays more attention to reduce the unnecessary overexposure of antibiotics and its perspectives are valuable to optimize antibiotic therapy.

Assessment of compliance to 2016 surviving Sepsis campaign bundles among adult patients admitted at ManilaMed–Medical Center Manila diagnosed with Sepsis

Introduction@#Sepsis is an emerging problem that needs to be recognized early and addressed promptly with hydration and appropriate antibiotics. This study aims to assess the adherence to surviving sepsis campaign (SSC) bundle within three hours and six hours, length of hospital stay and mortality among adult patients admitted at ManilaMed–Medical Center Manila diagnosed with sepsis.@*Methods@#A retrospective cohort study was performed in all adult patients admitted at ManilaMed–Medical Center Manila diagnosed with sepsis and septic shock from January to September 2017. Parameters for SSC bundle for three and six hours were used to assess compliance. Outcomes such as length of hospital stay and mortality were determined.@*Results@#This study included a total of 85 subjects and majority are females (56%). Mean age of study subject was 67.5±17.67 years. Adherence to SSC bundle in three and six hours were observed particularly in blood cultures (45%), administering broad-spectrum antibiotics (69%), fluid resuscitation at 30 mL/kg for hypotensive patients (22%) and administering vasopressors (78%) to maintain systemic perfusion. However, adherence to other parameters of the bundle was not observed, namely: measurement and re-measurement of lactate levels and measurement of CVP and SCVO2. In terms of outcome, the average length of hospital stay is 11 days and mortality was 42%.@*Discussion@#Sepsis is a fatal disease if not promptly recognized and addressed. The SSC bundle was formulated to guide clinicians and other healthcare providers in managing sepsis or septic shock patients. Some of the parameters are absent or are not routinely done in some institution, maximizing the resources that are present is ideal. @*Conclusion@#The compliance rate is deemed submaximal since eyeing for a 90-100% compliance rate is recommendable in a tertiary hospital. Emphasis on early identification, obtaining blood cultures and timely initiation of antimicrobials should be done.

Critical analysis of maternal deaths from sepsis in a tertiary care center and lessons learned

Background: Maternal mortality in India is reported to be 300 to 500 per 100,000 births in the Bulletin of World Health Organisation. It is far away from Millennium development goal 5 where it is required to reduce MMR to 109 per 100, 000 live births. Sepsis in pregnancy continues to be the third leading cause of preventable maternal deaths in India, still accounts for up to 10 to 50% of maternal deaths in our country. Aim: It was to critically analyze all the mothers who died due to sepsis in order to identify factors associated with deaths. Materials and methods: This prospective study was carried out in the labor room, Department of Obstetrics and Gynecology, King George hospital, Andhra Medical College for a period of twelve months from November 2016 to October 2017. All the mothers who died due to sepsis were included in the study and they were all analyzed modelled on the United Kingdom Confidential Enquiries into maternal deaths. Results: During the study period there were 44 total maternal deaths out of 5863 births giving maternal mortality ratio of 641 per 100,000 maternities. Out of 44 maternal deaths, 14 were due to sepsis making it the leading cause of maternal mortality in our institute. Out of fourteen deaths due to Chuppana Ragasudha, Atluri Phani Madhavi, Pulidindi Sanjana Sharon, Hyma, Sirisha, Syamala, Sravanthi, Sagarika. Critical analysis of maternal deaths from sepsis in a tertiary care center and lessons learned. IAIM, 2017; 4(12): 5-9. Page 6 sepsis nine were due to direct causes and the remaining five were due to indirect causes such as pneumonia, sickle cell disease with malaria, and pancytopenia. The ages of the women who died ranged from 19 to 38 years with a median age of 26 years. All had normal body mass index. Five women who died were tribals, six from rural areas and the remaining three from slums of urban areas. Eight women were primigravid. Eight women died from sepsis in the antenatal period, two deaths were in the first trimester after criminal abortion, three due to pneumonia, one had intrauterine dead fetus infected and the other was due to pancytopenia. Four deaths were due to genital tract sepsis after cesarean section and two were due to genital tract sepsis after normal delivery. These six had risk factors such as anemia, prolonged rupture of membranes etc. Conclusion: In few cases, the outcome was inevitable, but for majority it might have been different had the infection been diagnosed and treated more promptly. There are lessons learned from the deaths of these women to improve the survival of mothers and to achieve millennium development goal 5.

Surviving Sepsis Guidelines 2016:continuous changes in sepsis managements / 中国小儿急救医学

The Surviving Sepsis Guidelines were first published in 2004,with revisions in 2008 and 2012.In January 2017,the fourth revision of the Surviving Sepsis Guidelines was presented at the 46th annual SCCM meeting and published online in Critical Care Medicine.The updated guideline was generated by 55 international experts and providing 93 recommendations on early management of sepsis and septic shock.There are numerous major advances in the revision of the guidelines.Among the various topics covered,initial resuscitation and antibiotic therapy are the domains in which the most important changes and advances were made.

Undergone and expecttation from Sepsis 1 to Sepsis 3 of Sepsis / 医学研究生学报

The knowledge about sepsis has undergone a transition from that of Sepsis 1.0 to that of Sepsis 3.0, which reflects a deeper insight into this syndrome -multiple organ dysfunctions resulting from SIRS-CARS, immunity, metabolism, microcirculation, and other comprehensive factors .Although sepsis 3.0 does not represent a perfect understanding of the disease , it is an improvement on the cognition of the body's response to the stimulation of infection .

Undergone and expecttation from Sepsis 1 to Sepsis 3 of Sepsis / 医学研究生学报

The knowledge about sepsis has undergone a transition from that of Sepsis 1.0 to that of Sepsis 3.0, which reflects a deeper insight into this syndrome -multiple organ dysfunctions resulting from SIRS-CARS, immunity, metabolism, microcirculation, and other comprehensive factors .Although sepsis 3.0 does not represent a perfect understanding of the disease , it is an improvement on the cognition of the body's response to the stimulation of infection .

Relative Impact of the 2012 SSC Guideline Recommendations under the Scope of Numbers Needed to Treat (NNTs).

The surviving sepsis campaign (SSC) guidelines aimed to reduce mortality in severe sepsis and septic shock. The present study was performed to find out which and how many recommendations of the 2012 SSC update were based on significant effects from clinical studies in adult patients with severe sepsis and septic shock, leading to numbers needed to treat (NNTs). Every reference of the SSC 2012 guideline regarding clinical trials in adult patients was screened for absolute risk reduction regarding mortality to calculate NNTs. 17 relevant clinical trials out of 338 were identified. The NNTs ranged between 3.55 to 23.24. Significant reductions of mortality were detected, and items recommended in the SSC guidelines regarding early goal directed therapy (EGDT)/standard operating procedures (SOP)/sepsis bundles, early therapy with antibiotics, combined antibiotic therapy, and use of norepinephrine. Therapy with norepinephrine and the 6h bundles revealed the lowest NNTs. Significant reductions in mortality with restricted or no recommendations regarded therapy with hydrocortisone, therapy with highdose antithrombin III, and enteral feeding with eicosapentaenoic acid, gamma-linolenic acid and antioxidants. In conclusion, only a few recommendations of the 2012 SSC guidelines are based on significant beneficial effects coming from clinical trials in patients with severe sepsis and septic shock. When transferring study results and NNTs, physicians should take into account the own setting and own subgroup of patients. If feasible, costs of additional treatment success may be quantified underlying NNTs.

Clinical studies of surviving sepsis bundles according to PiCCO on septic shock patients / 中华危重病急救医学

Objective To explore the effect of early goal-directed therapy (EGDT) according to pulse indicated continuous cardiac output (PiCCO) on septic shock patients.Methods Eighty-two septic shock patients in Subei People's Hospital of Jiangsu Province from January 2009 to December 2012 were enrolled and randomly divided into two groups using a random number table,standard surviving sepsis bundle group (n=40) and modified surviving sepsis bundles group (n =42).The patients received the standard EGDT bundles in standard surviving sepsis bundle group.PiCCO catheter was placed in modified surviving sepsis bundles group.Fluid resuscitation was guided by intrathoracic blood volume index (ITBVI) with the aim of 850-1 000 mL/m2.Dobutamine was used to improve the heart function according to left ventricular contractile index (dPmax) and stroke volume index (SVI).The mean arterial blood pressure (MAP) was maintained 65 mmHg (1 mmHg=0.133 kPa) or above with norepinephrine.Extra-vascular lung water was monitored for the titration of liquid and diuretics.The acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,sequential organ failure assessment (SOFA) score,the number of patients needed vasopressor,serum procalcitonin (PCT),lactic acid and lactate extraction ratio,the amount of fluid resuscitation,duration of mechanical ventilation,duration of intensive care unit (ICU) stay,hospital mortality were recorded in both groups.Results After treatment,the APACHE Ⅱ score,SOFA score and the number of patients needed vasopressor were gradually reduced in both groups,and those in modified surviving sepsis bundle group were significantly lower than those of standard sepsis bundle group at 72 hours (APACHE Ⅱ score:13.1 ± 6.5 vs.20.9 ± 7.5,SOFA score:8.8 ± 4.3 vs.14.6 ± 4.9,the number of patients needed vasopressor:8 vs.17,all P＜0.05).Arterial blood lactate clearance rate was gradually increased after treatment in both groups.Lactate clearance rate in modified surviving sepsis bundle group was significantly higher than that of standard surviving sepsis bundle group [6 hours:(18.2 ± 8.3)％ vs.(10.8 ± 7.5)％,t=-6.036,P=0.001 ; 12 hours:(22.6 ± 7.3)％ vs.(12.4 ± 8.1)％,t=-4.536,P=0.001 ; 24 hours:(27.8 ± 5.6)％ vs.(16.4 ± 9.5)％,t=-5.882,P=0.000].The amount of fluid resuscitation within 6 hours in modified surviving sepsis bundle group increased significantly compared with standard surviving sepsis bundle group (mL:3 608 ± 715 vs.2 809 ± 795,t=-3.865,P=0.033).The amount of fluid resuscitation within 24,48 and 72 hours in modified surviving sepsis bundle group was significantly less than that of standard modified surviving sepsis bundle group with the nadir at 72 hours (mL:918 ± 351 vs.1 805 ± 420,t=5.907,P=0.037).Duration of mechanical ventilation (hours:98.4 ± 20.3 vs.143.3 ± 29.6,t=9.766,P=0.001) and ICU stay (days:7.1 ± 3.1 vs.9.5 ± 2.5,t=2.993,P=0.004) were significantly reduced in modified surviving sepsis bundle group compared with standard surviving sepsis bundle group.The hospital mortality in modified surviving sepsis bundle group was slightly lower than that in standard surviving sepsis bundle group [16.7％(7/42)比 17.5％(7/40),x2=0.010,P=0.920].Conclusions Modified surviving sepsis bundle treatment according PiCCO can reduce the severity of disease in patients with septic shock,can make more accurately guide fluid resuscitation,and can reduce lung water and duration of mechanical ventilation and ICU stay.It has great clinical significance.

Medidas de resucitación precoz durante la pandemia de gripe A (H1N1). ¿Se beneficiaron los pacientes? / Resuscitation measures early in the pandemic of influenza A (H1N1). HE benefited the patients?

Objetivo. Evaluar el impacto del uso de un protocolo de medidas de detección y resucitación precoz durante la pandemia de gripe A (H1N1) sobre el ingreso de pacientes en el Servicio de Terapia Intensiva (STI). Diseño. Estudio de observación y retrospectivo de pacientes críticos. Ámbito. Un STI médico-quirúrgico. Pacientes. Adultos que ingresaron en el STI desde el Servicio de Urgencia entre el 28 de abril de 2009 y el 4 de septiembre de 2009. Variables de interés principal. Sexo, edad, comorbilidades, APACHE II, SOFA al ingreso en el STI, sintomatología clínica, imágenes radiográficas, necesidad de asistencia respiratoria mecánica (ARM), ácido láctico (AL), creatinfosfoquinasa (CPK), lactato deshidrogenasa (LDH), leucocitosis, saturación de O2 (SatO2) y PaO2/FiO2 al ingresar en el STI, presión al final de la espiración (PEEP), días de ARM, tratamiento con oseltamivir (dosis/tiempo), aislamiento bacteriológico y virológico en secreción bronquial, tratamiento con corticoides, estadía en el STI y mortalidad. Resultados. Se incluyeron 13 pacientes que ingresaron en el STI durante el período estudiado; media de la edad 45 ± 3; mujeres: 8 (61,5%), comorbilidades (n = 7, 53,8%): enfermedad pulmonar obstructiva crónica (n = 3), diabetes (n = 2), insuficiencia cardíaca (n = 1), cirrosis (n = 1), APACHE II: 18, SOFA: 9 ± 2. La sintomatología clínica predominante fue la siguiente: fiebre (n = 13, 100%), tos (n = 11, 84,6%), disnea (n = 9, 69,2%), infiltrados intersticiales (5/13, 38,4%), opacidades alveolares (6/13, 46,1%), opacidades mixtas (2/13, 15,3%), cuatro cuadrantes (9/13, 69,2%) y dos cuadrantes (4/13, 30,7%); se hallaron los siguientes valores medios: AL 25 mg/dl, CPK 480 U/l (p <0,05), LDH 2100 U/l (p <0,001), leucocitosis 12.500 mm3 , PEEP 18 cm H2O, SatO2 <91% (n = 11, 84,6%), PaO2/FiO2 <150 (n = 11, 84,6%), necesidad de ARM (n = 11, 84,6%), días de ARM 9,5 ± 3 días. Oseltamivir: dosis 150 mg/12 h; aislamiento bacteriológico: neumococo (n = 7, 53,8%); aislamiento virológico: H1N1 (n = 5, 38,4%); duración: 9,5 ± 3 días, corticoides (n = 8, 61,5%). Tiempo en el STI: 11 ± 4. No hubo muertes.    Conclusión. La aplicación de un protocolo inicial en el que además se evalúo la gravedad benefició la correcta evaluación y resucitación inicial en el grupo estudiado. Los valores de CPK y de LDH se acompañaron de hipoxemia severa y mayor compromiso pulmonar en la radiología de tórax(AU)

Objective. To evaluate the impact of a protocol for screening and resuscitation measures during the pandemic H1N1 on patients´ admission to the Intensive Care Unit (ICU). Design. Retrospective observational study of critically ill patients. Place. A medical-surgical Intensive Care Unit (ICU). Patients. Adults admitted to the ICU from the Emergency Department from April 28th 2009 to September 4th 2009. Variables of primary interest. Sex, age, comorbidities, APACHE II, SOFA at admission to the ICU, clinical symptoms, radiographic images, need for mechanical ventilation (MV), lactic acid (AL), creatine kinase (CPK), lactate dehydrogenase (LDH), leukocytosis, O2 saturation (O2Sat) and PaO2/FiO2 at admission to the ICU, end-expiratory pressure (PEEP), days of MV (DMV), oseltamivir (dose/time), bacteriological and virological isolations in bronchial secretions, corticosteroid treatment, stay in the ICU and mortality. Results. We included 13 patients admitted to ICU during the study period; mean age: 45 ± 3; females: 8 (61.5%); comorbidities (n = 7, 53.8%): COPD (n = 3), diabetes (n = 2), heart failure (n = 1), cirrhosis (n = 1), APACHE II: 18, SOFA: 9 ±-2. Clinical symptoms were: fever (n = 13, 100%), cough (n = 11, 84.6%), dyspnea (n = 9, 69.2%), interstitial infiltrates (5/13, 38.4%), alveolar opacities (6/13, 46.1%), mixed opacities (2/13, 15.3%), four quadrants (9/13, 69.2%) and two quadrants (4/13, 30.7%), average measures: AL 25 mg/dL, CPK 480 U/L (p <0.05), LDH 2,100 U/L (p <0.001), leukocytosis 12,500 mm3 , PEEP 18 cm H2O, O2Sat <91% (n = 11, 84.6%), PaO2/FiO2 <150 (n = 11, 84.6%), MV (n = 11, 84.6%), DMV: 9.5 ± 3; oseltamivir: 150 mg/12 hours; bacteriological isolation (Pneumococcus: n = 7, 53.8%), virological isolation (H1N1: n = 5, 38.4%); length: 9.5 ± 3 days, corticosteroids (n = 8, 61.5%); ICU stay 11 ± 4; no deaths were reported. Conclusion. The application of a protocol in which severity was also evaluated benefited in the correct assessment and initial resuscitation. The values of CPK and LDH were associated with severe hypoxemia and lung involvement in the thorax xrays. (AU)

The impact of duration of organ dysfunction on the outcome of patients with severe sepsis and septic shock

OBJECTIVES: This study aimed to assess the impact of the duration of organ dysfunction on the outcome of patients with severe sepsis or septic shock. METHODS: Clinical data were collected from hospital charts of patients with severe sepsis and septic shock admitted to a mixed intensive care unit from November 2003 to February 2004. The duration of organ dysfunction prior to diagnosis was correlated with mortality. Results were considered significant if p<0.05. RESULTS: Fifty-six patients were enrolled. Mean age was 55.6 ± 20.7 years, mean APACHE II score was 20.6 ± 6.9, and mean SOFA score was 7.9 ± 3.7. Thirty-six patients (64.3 percent) had septic shock. The mean duration of organ dysfunction was 1.9 ± 1.9 days. Within the univariate analysis, the variables correlated with hospital mortality were: age (p=0.015), APACHE II (p=0.008), onset outside the intensive care unit (p=0.05), blood glucose control (p=0.05) and duration of organ dysfunction (p=0.0004). In the multivariate analysis, only a duration of organ dysfunction persisting longer than 48 hours correlated with mortality (p=0.004, OR: 8.73 (2.37-32.14)), whereas the APACHE II score remained only a slightly significant factor (p=0.049, OR: 1.11 (1.00-1.23)). Patients who received therapeutic interventions within the first 48 hours after the onset of organ dysfunction exhibited lower mortality (32.1 percent vs. 82.1 percent, p=0.0001). CONCLUSIONS: These findings suggest that the diagnosis of organ dysfunction is not being made in a timely manner. The time elapsed between the onset of organ dysfunction and initiation of therapeutic intervention can be quite long, and this represents an important determinant of survival in cases of severe sepsis and septic shock.