A multicenter prospective cohort study of late-onset sepsis and its poor prognosis in very low birth weight infants / 中华儿科杂志

Objective: To investigate the prevalence and poor prognosis of late-onset sepsis (LOS) in very low birth weight infant (VLBWI). Methods: This prospective, multicenter observational cohort study was conducted based on the data from Sina-Northern Neonatal Network (SNN). The general data, perinatal information and poor prognosis of 6 639 VLBWI, who were admitted to the 35 neonatal intensive care units from 2018 to 2021, were collected and analyzed. According to the occurrence of LOS during hospitalization, the VLBWI were assigned to the LOS group and non-LOS group. The LOS group was further divided into 3 subgroups according to the occurrence of neonatal necrotizing enterocolitis (NEC) and purulent meningitis. The Chi-square test or Fisher exact probability method, independent sample t test, Mann-Whitney U test and multivariate Logistic regression model were used to analyze the relationship between LOS and poor prognosis in VLBWI. Results: A total of 6 639 eligible VLBWI were enrolled, including 3 402 cases (51.2%) of males and 1 511 cases (22.8%) with LOS. The incidences of LOS in extremely low birth weight infants (ELBWI) and extremely preterm infants were 33.3% (392/1 176) and 34.2% (378/1 105), respectively. There were 157 cases (10.4%) who died in the LOS group and 48 cases (24.9%) in the subgroup of LOS complicated with NEC. Multivariate Logistic regression analysis showed that LOS complicated with NEC was associated with increased mortality and incidence of grade Ⅲ-Ⅳ intraventricular hemorrhage (IVH) or periventricular leukomalacia (PVL), moderate or severe bronchopulmonary dysplasia (BPD), and extrauterin growth retardation (EUGR) (ORadjust=5.27, 2.59, 3.04, 2.04; 95%CI 3.60-7.73, 1.49-4.50, 2.11-4.37, 1.50-2.79; all P<0.01); LOS complicated with purulent meningitis was also associated with increased mortality and incidence of grade Ⅲ-Ⅳ IVH or PVL, and moderate or severe BPD (ORadjust=2.22, 8.13, 3.69, 95%CI 1.30-3.37, 5.22-12.67, 2.49-5.48; all P<0.01); the infants without NEC or purulent meningitis in the LOS group was only associated with increased incidence of moderate or severe BPD (ORadjust=2.20, 95%CI 1.83-2.65, P<0.001). After ruling out contaminated bacteria, a total of 456 cases showed positive blood culture, including 265 cases (58.1%) of Gram-negative bacteria, 126 cases (27.6%) of Gram-positive bacteria, and 65 cases (14.3%) of fungi. The most common pathogenic bacteria was Klebsiella pneumoniae (n=147, 32.2%), followed by coagulase-negative Staphylococcus (n=72, 15.8%) and subsequently Escherichia coli (n=39, 8.6%). Conclusions: The incidence of LOS is high in VLBWI. Klebsiella pneumoniae is the most common pathogenic bacteria, followed by coagulase-negative Staphylococcus and Escherichia coli. LOS is associated with a poor prognosis for moderate to severe BPD. The prognosis of LOS complicated with NEC is poor with the highest mortality, and the risk of brain damage is significantly increased when LOS complicated with purulent meningitis.

Status of fungal sepsis among preterm infants in 25 neonatal intensive care units of tertiary hospitals in China / 中华儿科杂志

Objective: To analyze the prevalence and the risk factors of fungal sepsis in 25 neonatal intensive care units (NICU) among preterm infants in China, and to provide a basis for preventive strategies of fungal sepsis. Methods: This was a second-analysis of the data from the "reduction of infection in neonatal intensive care units using the evidence-based practice for improving quality" study. The current status of fungal sepsis of the 24 731 preterm infants with the gestational age of <34+0 weeks, who were admitted to 25 participating NICU within 7 days of birth between May 2015 and April 2018 were retrospectively analyzed. These preterm infants were divided into the fungal sepsis group and the without fungal sepsis group according to whether they developed fungal sepsis to analyze the incidences and the microbiology of fungal sepsis. Chi-square test was used to compare the incidences of fungal sepsis in preterm infants with different gestational ages and birth weights and in different NICU. Multivariate Logistic regression analysis was used to study the outcomes of preterm infants with fungal sepsis, which were further compared with those of preterm infants without fungal sepsis. The 144 preterm infants in the fungal sepsis group were matched with 288 preterm infants in the non-fungal sepsis group by propensity score-matched method. Univariate and multivariate Logistic regression analysis were used to analyze the risk factors of fungal sepsis. Results: In all, 166 (0.7%) of the 24 731 preterm infants developed fungal sepsis, with the gestational age of (29.7±2.0) weeks and the birth weight of (1 300±293) g. The incidence of fungal sepsis increased with decreasing gestational age and birth weight (both P<0.001). The preterm infants with gestational age of <32 weeks accounted for 87.3% (145/166). The incidence of fungal sepsis was 1.0% (117/11 438) in very preterm infants and 2.0% (28/1 401) in extremely preterm infants, and was 1.3% (103/8 060) in very low birth weight infants and 1.7% (21/1 211) in extremely low birth weight infants, respectively. There was no fungal sepsis in 3 NICU, and the incidences in the other 22 NICU ranged from 0.7% (10/1 397) to 2.9% (21/724), with significant statistical difference (P<0.001). The pathogens were mainly Candida (150/166, 90.4%), including 59 cases of Candida albicans and 91 cases of non-Candida albicans, of which Candida parapsilosis was the most common (41 cases). Fungal sepsis was independently associated with increased risk of moderate to severe bronchopulmonary dysplasia (BPD) (adjusted OR 1.52, 95%CI 1.04-2.22, P=0.030) and severe retinopathy of prematurity (ROP) (adjusted OR 2.55, 95%CI 1.12-5.80, P=0.025). Previous broad spectrum antibiotics exposure (adjusted OR=2.50, 95%CI 1.50-4.17, P<0.001), prolonged use of central line (adjusted OR=1.05, 95%CI 1.03-1.08, P<0.001) and previous total parenteral nutrition (TPN) duration (adjusted OR=1.04, 95%CI 1.02-1.06, P<0.001) were all independently associated with increasing risk of fungal sepsis. Conclusions: Candida albicans and Candida parapsilosis are the main pathogens of fungal sepsis among preterm infants in Chinese NICU. Preterm infants with fungal sepsis are at increased risk of moderate to severe BPD and severe ROP. Previous broad spectrum antibiotics exposure, prolonged use of central line and prolonged duration of TPN will increase the risk of fungal sepsis. Ongoing initiatives are needed to reduce fungal sepsis based on these risk factors.

Desempeño profesional de enfermería en la atención al paciente quirúrgico séptico / Nursing Professional Performance in the Care of the Septic Surgical Patient

Introducción: Las unidades de cuidados intensivos quirúrgicas muestran, en los últimos tiempos, un incremento en la incidencia de casos sépticos. La actuación del profesional de enfermería es fundamental en la atención a estos pacientes. Objetivo: Caracterizar el desempeño profesional de enfermería en la atención al paciente quirúrgico séptico. Métodos: Estudio descriptivo, observacional en la Unidad de Cuidados Intensivos del Centro Nacional de Cirugía de Mínimo Acceso en La Habana, de enero a agosto de 2020. En el universo de 17 enfermeras, se realizó un muestreo no probabilístico intencional de 12 profesionales. Se realizó prueba de desempeño, con análisis de tres dimensiones: actitud, dominio asistencial y superación profesional, se evaluaron con un rango de puntuación entre 0-8, se calculó media, desviación estándar y porcentajes con la siguiente valoración: inadecuado (<30 por ciento), poco adecuado (30 por ciento -49 por ciento), medio adecuado (50 por ciento-69 por ciento), adecuado (70 por ciento-89 por ciento) y muy adecuado (90 por ciento-100 por ciento). Resultados: De los profesionales estudiados, 66,66 por ciento obtuvieron un desempeño adecuado y 33,33 por ciento medio adecuado. En la puntuación general, la dimensión actitud se calificó de adecuada con 85,41 por ciento; sin embargo, las dimensiones dominio asistencial y superación profesional fueron calificadas de medio adecuada, con 67,08 por ciento y 52,08 por ciento, respectivamente. Conclusiones: Los profesionales muestran una actitud adecuada en la atención a los pacientes quirúrgicos sépticos, el dominio asistencial y la superación profesional fue medio adecuado, las deficiencias más significativas fueron en el dominio de las nuevas tecnologías y escasa participación en las alternativas de superación posgraduada(AU)

Introduction: Surgical intensive care units show, in recent times, an increase in the incidence of septic cases. The nursing professional's performance is essential for the care of these patients. Objective: To characterize the nursing professional's performance in the care of the septic surgical patient. Methods: Descriptive and observational study carried out in the intensive care unit of the National Center for Minimal Access Surgery in Havana, from January to August 2020. In the universe of seventeen nurses, a nonprobabilistic intentional sampling of twelve professionals was done. A performance test was performed, in which three dimensions were analyzed: attitude, care provision skills and professional improvement, evaluated. The three dimensions were evaluated with a score range of 0-8. Mean, standard deviation and percentages were calculated under the following scale: inadequate (<30 percent), little adequate (30 percent-49 percent), partially adequate (50 percent-69 percent), adequate (70 percent-89 percent) and very adequate (90 percent-100 percent). Results: Of the studied professionals, 66.66 percent performed adequately and 33.33 percent performed partially adequately. In the overall score, the dimension of attitude was rated as adequate, with 85.41 percent; however, the dimensions of care provision skills and professional improvement were rated as partially adequate, with 67.08 percent and 52.08 percent, respectively. Conclusions: The professionals show an adequate attitude in the care of septic surgical patients. Care provision skills and professional improvement were partially adequate. The most significant deficiencies were found in the competent usage of new technologies, apart from the scarce participation in postgraduate alternatives for professional improvement(AU)

Effect of improvement in antibiotic use strategy on the short-term clinical outcome of preterm infants with a gestational age of <35 weeks / 中国当代儿科杂志

OBJECTIVES@#To study the effect of improvement in antibiotic use strategy on the short-term clinical outcome of preterm infants with a gestational age of <35 weeks.@*METHODS@#The medical data were retrospectively collected from 865 preterm infants with a gestational age of <35 weeks who were admitted to the Neonatal Intensive Care Unit of Xiangya Hospital of Central South University from January 1, 2014 to December 31, 2016. The improved antibiotic use strategy was implemented since January 1, 2015. According to the time of implementation, the infants were divided into three groups: pre-adjustment (January 1, 2014 to December 31, 2014; n=303), post-adjustment Ⅰ (January 1, 2015 to December 31, 2015; n=293), and post-adjustment Ⅱ (January 1, 2016 to December 31, 2016; n=269). The medical data of the three groups were compared.@*RESULTS@#There were no significant differences among the three groups in gestational age, proportion of small-for-gestational-age infants, sex, and method of birth (P>0.05). Compared with the pre-adjustment group, the post-adjustment I and post-adjustment Ⅱ groups had a significant reduction in the rate of use of antibiotics and the duration of antibiotic use in the early postnatal period and during hospitalization (P<0.05), with a significant increase in the proportion of infants with a duration of antibiotic use of ≤3 days or 4-7 days and a significant reduction in the proportion of infants with a duration of antibiotic use of >7 days in the early postnatal period (P<0.05). Compared with the post-adjustment Ⅰ group, the post-adjustment Ⅱ group had a significant reduction in the duration of antibiotic use in the early postnatal period and during hospitalization (P<0.05), with a significant increase in the proportion of infants with a duration of antibiotic use of ≤3 days and a significant reduction in the proportion of infants with a duration of antibiotic use of 4-7 days or >7 days (P<0.05). Compared with the pre-adjustment group, the post-adjustment I and post-adjustment Ⅱ groups had significantly shorter duration of parenteral nutrition and length of hospital stay (P<0.05). There were gradual reductions in the incidence rates of grade ≥Ⅲ intraventricular hemorrhage (IVH) and late-onset sepsis (LOS) after the adjustment of antibiotic use strategy. The multivariate logistic regression analysis showed that the adjustment of antibiotic use strategy had no effect on short-term adverse clinical outcomes, and antibiotic use for >7 days significantly increased the risk of adverse clinical outcomes (P<0.05).@*CONCLUSIONS@#It is feasible to reduce unnecessary antibiotic use by the improvement in antibiotic use strategy in preterm infants with a gestational age of <35 weeks, which can also shorten the duration of parenteral nutrition and the length of hospital stay and reduce the incidence rates of grade ≥Ⅲ IVH and LOS.

Evidence-based standardized nutrition protocol can shorten the time to full enteral feeding in very preterm/very low birth weight infants / 中国当代儿科杂志

OBJECTIVES@#To investigate whether evidence-based standardized nutrition protocol can facilitate the establishment of full enteral nutrition and its effect on short-term clinical outcomes in very preterm/very low birth weight infants.@*METHODS@#A retrospective analysis was performed on the medical data of 312 preterm infants with a gestational age of ≤32 weeks or a birth weight of <1 500 g. The standardized nutrition protocol for preterm infants was implemented in May 2020; 160 infants who were treated from May 1, 2019 to April 30, 2020 were enrolled as the control group, and 152 infants who were treated from June 1, 2020 to May 31, 2021 were enrolled as the test group. The two groups were compared in terms of the time to full enteral feeding, the time to the start of enteral feeding, duration of parenteral nutrition, the time to recovery to birth weight, the duration of central venous catheterization, and the incidence rates of common complications in preterm infants.@*RESULTS@#Compared with the control group, the test group had significantly shorter time to full enteral feeding, time to the start of enteral feeding, duration of parenteral nutrition, and duration of central venous catheterization and a significantly lower incidence rate of catheter-related bloodstream infection (P<0.05). There were no significant differences between the two groups in the mortality rate and the incidence rate of common complications in preterm infants including grade II-III necrotizing enterocolitis (P>0.05).@*CONCLUSIONS@#Implementation of the standardized nutrition protocol can facilitate the establishment of full enteral feeding, shorten the duration of parenteral nutrition, and reduce catheter-related bloodstream infection in very preterm/very low birth weight infants, without increasing the risk of necrotizing enterocolitis.

Sepsis, cardiovascular events and short-term mortality risk in critically ill patients

INTRODUCTION@#There is paucity of data on the occurrence of cardiovascular events (CVEs) in critically ill patients with sepsis. We aimed to describe the incidence, risk factors and impact on mortality of CVEs in these patients.@*METHODS@#This was a retrospective cohort study of critically ill patients admitted to the medical intensive care unit (ICU) between July 2015 and October 2016. The primary outcome was intra-hospital CVEs, while the secondary outcomes were in-hospital mortality, ICU and hospital length of stay.@*RESULTS@#Patients with sepsis (n=662) had significantly more CVEs compared to those without (52.9% versus 23.0%, P<0.001). Among sepsis patients, 350 (52.9%) had 1 or more CVEs: 59 (8.9%) acute coronary syndrome; 198 (29.9%) type 2 myocardial infarction; 124 (18.7%) incident atrial fibrillation; 76 (11.5%) new or worsening heart failure; 32 (4.8%) cerebrovascular accident; and 33 (5.0%) cardiovascular death. Factors associated with an increased risk of CVEs (adjusted relative risk [95% confidence interval]) included age (1.013 [1.007-1.019]); ethnicity-Malay (1.214 [1.005-1.465]) and Indian (1.240 [1.030-1.494]) when compared to Chinese; and comorbidity of ischaemic heart disease (1.317 [1.137-1.527]). There were 278 patients (79.4%) who developed CVEs within the first week of hospitalisation. Sepsis patients with CVEs had a longer median (interquartile range [IQR]) length of stay in the ICU (6 [3-12] vs 4 [2-9] days, P<0.001), and hospital (21 [10-42] vs 15 [7-30] days, P<0.001) compared to sepsis patients without CVEs. There was no difference in in-hospital mortality between the 2 groups (46.9% vs 45.8%, P=0.792).@*CONCLUSION@#CVEs complicate half of the critically ill patients with sepsis, with 79.4% of patients developing CVEs within the first week of hospitalisation, resulting in longer ICU and hospital length of stay.

Epidemiology and treatment of sepsis at a public pediatric emergency department

ABSTRACT Objective To describe the clinical characteristics and treatment of children with sepsis, severe sepsis, and septic shock at a pediatric emergency department of a public hospital. Methods A retrospective, observational study. The medical records of patients included in the hospital Pediatric Sepsis Protocol and patients with discharge ICD-10 A41.9 (sepsis, unspecified), R57 (shock) and A39 (meningococcal meningitis) were evaluated. Results A total of 399 patients were included. The prevalence of sepsis, severe sepsis, and septic shock at the emergency room were 0.41%, 0.14% and 0.014%, respectively. The median age was 21.5 months for sepsis, 12 months for severe sepsis, and 20.5 months for septic shock. Sepsis, severe sepsis, and septic shock were more often associated with respiratory diseases. The Respiratory Syncytial Virus was the most common agent. The median time to antibiotic and fluid administration was 3 hours in patients with sepsis and severe sepsis. In patients with septic shock, the median times to administer antibiotics, fluid and vasoactive drugs were 2 hours, 2.5 hours and 6 hours, respectively. The median length of hospital stay for patients with sepsis, severe sepsis and septic shock were 3 days, 4 days and 1 day, respectively. The overall mortality was 2%. Conclusion Sepsis had a low prevalence. Early diagnosis and recognition are a challenge for the emergency care pediatrician, the first place of admission.

Prevalência e desfechos da sepse em crianças internadas em hospitais públicos e privados na América Latina: um estudo observacional multicêntrico / Prevalence and outcomes of sepsis in children admitted to public and private hospitals in Latin America: a multicenter observational study

RESUMO Objetivo: Relatar a prevalência e os desfechos da sepse em crianças admitidas em hospitais públicos e privados na América Latina. Métodos: Análise post-hoc dos dados do Latin American Pediatric Sepsis Study (LAPSES), um estudo de coorte que avaliou a prevalência e os desfechos da sepse em crianças admitidas em 21 unidades de terapia intensiva pediátricas de cinco países latino-americanos. Resultados: Dentre os 464 pacientes com sepse, 369 (79,5%) foram admitidos em hospitais públicos e 95 (20,5%) em privados. Em comparação com os admitidos em hospitais privados, os pacientes com sepse admitidos em hospitais públicos não diferiram em termos de idade, sexo, condição de imunização, tempo de permanência no hospital ou tipo de admissão, porém tiveram incidência mais alta de choque séptico, escores Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2) e Pediatric Logistic Organ Dysfunction (PELOD) mais altos e taxas mais elevadas de doenças de base e analfabetismo materno. A proporção entre pacientes admitidos a partir de enfermarias pediátricas e mortalidade relacionada à sepse foi mais alta nos hospitais públicos. A análise multivariada não mostrou qualquer correlação entre mortalidade e tipo de hospital, porém, nos hospitais públicos, a mortalidade se associou com níveis mais altos de gravidade no momento da admissão à unidade de terapia intensiva. Conclusão: Nesta amostra de crianças admitidas em condições críticas em cinco países latino-americanos, a prevalência de choque séptico nas primeiras 24 horas da admissão e a mortalidade relacionada à sepse foram mais elevadas em hospitais públicos do que nos privados. A mortalidade relacionada à sepse mais elevada em crianças admitidas em unidades de terapia intensiva pediátrica de hospitais públicos se associou com maior gravidade por ocasião da admissão à unidade de terapia intensiva, porém não com o tipo de hospital. São necessários novos estudos para elucidar as causas da maior prevalência e mortalidade de sepse pediátrica em hospitais públicos.

ABSTRACT Objective: To report the prevalence and outcomes of sepsis in children admitted to public and private hospitals. Methods: Post hoc analysis of the Latin American Pediatric Sepsis Study (LAPSES) data, a cohort study that analyzed the prevalence and outcomes of sepsis in critically ill children with sepsis on admission at 21 pediatric intensive care units in five Latin American countries. Results: Of the 464 sepsis patients, 369 (79.5%) were admitted to public hospitals and 95 (20.5%) to private hospitals. Compared to those admitted to private hospitals, sepsis patients admitted to public hospitals did not differ in age, sex, immunization status, hospital length of stay or type of admission but had higher rates of septic shock, higher Pediatric Risk of Mortality (PRISM), Pediatric Index of Mortality 2 (PIM 2), and Pediatric Logistic Organ Dysfunction (PELOD) scores, and higher rates of underlying diseases and maternal illiteracy. The proportion of patients admitted from pediatric wards and sepsis-related mortality were higher in public hospitals. Multivariate analysis did not show any correlation between mortality and the type of hospital, but mortality was associated with greater severity on pediatric intensive care unit admission in patients from public hospitals. Conclusion: In this sample of critically ill children from five countries in Latin America, the prevalence of septic shock within the first 24 hours at admission and sepsis-related mortality were higher in public hospitals than in private hospitals. Higher sepsis-related mortality in children admitted to public pediatric intensive care units was associated with greater severity on pediatric intensive care unit admission but not with the type of hospital. New studies will be necessary to elucidate the causes of the higher prevalence and mortality of pediatric sepsis in public hospitals.

Perfil epidemiológico e clínico de pacientes com suspeita de sepse e choque séptico em emergência hospitalar / Perfil epidemiológico y clínico de pacientes con sospecha de sepsis y choque septico en urgencia hospitalaria / Epidemiological and clinical profile of patients with suspected sepsis and septic shock in a hospital emergency

RESUMO Objetivo: analisar características clínicas, demográficas e conformidade com a "Campanha Sobrevivendo à Sepse" nos casos suspeitos ou confirmados de sepse e choque séptico registrados em prontuários de uma emergência hospitalar. Método: estudo quantitativo, descritivo. A amostra foi composta de 127 prontuários de pacientes adultos internados em emergência hospitalar no período de junho a outubro de 2019. Para análise dos dados, utilizaram-se frequências, média, desvio-padrão, teste qui-quadrado e teste de Kruskal-Wallis. Resultados: os casos de sepse e choque séptico tiveram como principal foco o pulmonar. O diagnóstico clínico predominante foi infecção com disfunção orgânica. O desfecho clínico predominante foi a alta hospitalar. A realização das medidas recomendadas pela Campanha de Sobrevivência à Sepse na primeira hora após a suspeita diagnóstica - coleta de lactato, administração de antibióticos e coleta de hemoculturas - foi registrada em 10 (7,9%) prontuários. Conclusão: o conhecimento das características epidemiológicas dos casos de sepse e choque séptico suspeitos ou confirmados demonstrou que a prática clínica dos profissionais envolvidos não estava em conformidade com as condutas preconizadas pela Campanha Sobrevivendo à Sepse.

RESUMEN Objetivo: analizar las características clínicas, demográficas y el cumplimiento de la "Campaña Sobreviviendo a la Sepsis" en casos sospechosos o confirmados de sepsis y choque séptico registrados en la historia clínica de una emergencia hospitalaria. Método: estudio descriptivo cuantitativo. La muestra estuvo conformada por 127 historias clínicas de pacientes adultos ingresados en una emergencia hospitalaria de junio a octubre de 2019. Para el análisis de los datos se utilizaron frecuencias, media, desviación estándar, prueba de chi-cuadrado y prueba de Kruskal-Wallis. Resultados: los casos de sepsis y choque séptico tuvieron al pulmonar como foco principal. El diagnóstico clínico predominante fue infección con disfunción orgánica. El resultado clínico predominante fue el alta hospitalaria. La realización de las medidas recomendadas por la Campaña Sobreviviendo a la Sepsis en la primera hora posterior al diagnóstico de sospecha - recolección de lactato, administración de antibióticos y recolección de hemocultivos - se registró en 10 (7,9%) historias clínicas. Conclusión: el conocimiento de las características epidemiológicas de los casos sospechosos o confirmados de sepsis y choque séptico mostró que la práctica clínica de los profesionales involucrados no se ajusta a la conducta recomendada por la Campaña Sobreviviendo a la Sepsis.

ABSTRACT Objective: to analyze clinical and demographic characteristics and compliance with the 'Surviving Sepsis Campaign' in suspected or confirmed cases of sepsis and septic shock recorded in medical records of a hospital emergency. Method: quantitative, descriptive study. The sample consisted of 127 medical records of adult patients admitted to a hospital emergency from June to October 2019. For data analysis, frequencies, mean, standard deviation, chi-square test and Kruskal-Wallis test were used. Results: the cases of sepsis and septic shock had the pulmonary as their main focus. The predominant clinical diagnosis was infection with organ dysfunction. The predominant clinical outcome was hospital discharge. The performance of measures recommended by the Sepsis Survival Campaign in the first hour after the suspected diagnosis - collection of lactate, administration of antibiotics and collection of blood cultures - was recorded in 10 (7.9%) medical records. Conclusion: knowledge of the epidemiological characteristics of suspected or confirmed cases of sepsis and septic shock showed that the clinical practice of the professionals involved was not in accordance with the conduct recommended by the Surviving Sepsis Campaign.

Biomarcadores como predictores de mortalidad en pacientes graves con infecciones / Biomarkers as mortality predictors in severely-ill patients with infections

Introducción: Actualmente se buscan biomarcadores que se modifiquen paralelamente con la historia natural de la sepsis. Objetivo: Describir las variaciones de la proteína C reactiva, la eritrosedimentación y el conteo de eosinófilos en pacientes graves portadores de enfermedad infecciosa en diferentes etapas. Método: Se realizó una investigación aplicada y analítica de cohorte, según el estado de la temática, alcance y aplicabilidad de los resultados. Se realizó en pacientes graves con enfermedades infecciosas ingresados en la unidad cuidados intensivos del Hospital Saturnino Lora, durante marzo de 2018 hasta marzo de 2019. El universo estuvo constituido luego de aplicar los criterios de inclusión y exclusión por 41 pacientes, 21 fallecidos y 20 vivos. Las variables estudiadas fueron edad, sexo, origen, gravedad y seguimiento del proceso infeccioso, biomarcadores de respuesta inflamatoria e infección y estado al egreso. Para el procesamiento de la información estadística se emplearon valores promedios como medidas de resumen para variables cuantitativas y porcentajes para variables cualitativas. Para la asociación estadísticamente significativa entre los criterios de interés se aplicó el Test X2 de Independencia. Resultados: La sepsis resultó más frecuente en pacientes masculinos en edades intermedias de la vida, fundamentalmente de origen respiratorio y fue la eosinopenia el biomarcador que más se alteró en los diferentes momentos de la investigación Conclusión: El biomarcador asociado a la sepsis que más se alteró en los diferentes momentos del estudio fue la eosinopenia con mayor asociación como predictor de mortalidad en los diferentes momentos que se realizó el análisis(AU)

Introduction: Currently, biomarkers are being sought that become modified in parallel with the natural history of sepsis. Objective: To describe the variations in C-reactive protein, erythrocyte sedimentation and eosinophil count in severely-ill patients with infectious disease at different stages. Method: An applied and analytical cohort research was carried out, according to the state of the subject, scope and applicability of the outcomes. It was carried out in severely-ill patients with infectious diseases admitted to the intensive care unit of the Saturnino Lora Hospital, from March 2018 to March 2019. The study population was made up after applying the inclusion and exclusion criteria in 41 patients, 21 deceased and 20 alive. The variables studied were age, sex, origin, severity, and monitoring of the infectious process, biomarkers of inflammatory response and infection, and discharge status. For the processing of statistical information, mean values TX 2;were used as summary measures for quantitative variables and percentages for qualitative variables. For the statistically significant association between the criteria of interest, the chi-square Independence test was applied. Results: Sepsis was more frequent among male patients in intermediate ages of life, mainly of respiratory origin; while eosinopenia was the biomarker that was most altered at different moments of the investigation Conclusion: The biomarker associated with sepsis that was most altered at different times of the study was eosinopenia, with the greatest association as a predictor for mortality at the different times when the analysis was performed(AU)

Coagulación intravascular diseminada y sepsis: tratamiento y criterios diagnósticos / Disseminated intravascular coagulation and sepsis: treatment and diagnostic criteria

Introducción: La sepsis es un proceso patológico que se caracteriza por un estado inflamatorio desmesurado que puede generar coagulopatías graves como la coagulación intravascular diseminada. Esta coagulopatía se caracteriza principalmente por la exposición del factor tisular que activa la cascada de coagulación y genera un estado protrombótico que puede empeorar la falla orgánica. Objetivo: Analizar criterios diagnósticos e implicación terapéutica con el fin de mostrar una actualización en el abordaje de un paciente con coagulación intravascular diseminada y sepsis. Métodos: Se realizó una búsqueda de artículos en la base de datos PubMed, Science direct y Scielo, utilizando los siguientes descriptores: coagulopatía, sepsis, coagulación intravascular diseminada, criterios diagnósticos y tratamiento. Conclusión: Se ha encontrado una mejora en la mortalidad de los pacientes tratados con anticoagulantes como la proteína C, la antitrombina, entre otros, sin embargo, estos hallazgos no han logrado la trascendencia necesaria para ser recomendados en las guías de tratamiento de coagulación intravascular diseminada(AU)

Introduction: Sepsis is a pathological process characterized by inordinate inflammation which may cause severe coagulopathies, such as disseminated intravascular coagulation. This coagulopathy is mainly characterized by exposure of the tissue factor, activating the coagulation cascade and generating a prothrombotic state which may worsen organ failure. Objective: Analyze diagnostic criteria and therapeutic implications to present an update on the management of patients with disseminated intravascular coagulation and sepsis. Methods: A search was conducted for papers published in the databases PubMed, Science Direct and SciELO, using the search terms coagulopathy, sepsis, disseminated intravascular coagulation, diagnostic criteria and treatment. Conclusion: Improvement was observed in the mortality of patients treated with anticoagulants such as protein C and antithrombin, among others. However, these findings have not achieved the relevance required to be recommended for inclusion in the treatment guides for disseminated intravascular coagulation(AU)

Sepsis y choque séptico en los servicios de urgencias de México: estudio multicéntrico de prevalencia puntual / Sepsis and septic shock in emergency departments of Mexico: a multicenter point-prevalence study

Resumen Introducción: La sepsis es una de las principales causas de consulta en los servicios de urgencias médicas. Objetivo: Identificar la prevalencia de la sepsis en servicios de urgencias médicas de México. Método: Estudio transversal con seguimiento a 30 días de los pacientes con diagnóstico de sepsis o choque séptico; se analizaron las variables demográficas, el manejo y los desenlaces. Resultados: En 68 servicios de urgencias médicas analizados se atendió a 2379 pacientes, de los cuales 307 presentaron sepsis. La prevalencia de la sepsis fue de 12.9 %, con mortalidad global de 16.93 %, que en los casos de sepsis fue de 9.39 % y en los de choque séptico, de 65.85 %; no se identificaron diferencias significativas en las variables demográficas o tipo de hospital. Se observó balance hídrico alto en las primeras tres horas y falta de apego a las recomendaciones internacionales de reanimación superior en los pacientes que fallecieron. Conclusiones: Se encontró alta prevalencia de la sepsis en los servicios de urgencias médicas mexicanos. La mortalidad de los pacientes con choque séptico fue similar e, incluso, mayor a la reportada internacionalmente.

Abstract Introduction: Sepsis is one of the main reasons for consultation at emergency departments. Objective: To identify the prevalence of sepsis in emergency departments of Mexico. Method: Cross-sectional study with a 30-day follow-up of patients diagnosed with sepsis or septic shock; demographic variables, management and outcomes were analyzed. Results: In 68 emergency departments analyzed, 2379 patients were attended to, out of whom 307 had sepsis. The prevalence of sepsis was 12.9 %, and overall mortality was 16.93 %, which in the cases of sepsis was 9.39 %, and in those of septic shock, 65.85 %; no significant differences were identified in demographic variables or type of hospital. A significantly higher fluid balance was observed within the first three hours in those patients who died, as well as a lack of adherence to international resuscitation recommendations. Conclusions: A high prevalence of sepsis was found in Mexican emergency departments. Mortality of patients with septic shock was similar and even higher than that internationally reported.

Sepsis de inicio precoz en el recién nacido pretérmino / Sepsis of early beginning in the preterm newborn

La sepsis es una enfermedad potencialmente mortal que puede afectar al neonato. En tal sentido, se expone la información necesaria para brindar una atención adecuada al recién nacido pretérmino con sepsis de inicio precoz: concepto, epidemiologia, patogenia, manifestaciones clínicas, diagnóstico, tratamiento y prevención. Asimismo, se abordan los factores que aumentan la posibilidad de infección en este recién nacido, las condiciones predisponentes en la madre y la corioamnionitis (clínica e histológica). Dicha infección puede prevenirse mediante un adecuado control prenatal y una correcta atención durante el parto, lo cual disminuirá la morbilidad y la mortalidad, así como tendrá gran impacto en la salud pública del país.

The sepsis is a potentially mortal disease that can affect the newborn. In such a sense, the necessary information is exposed to offer an appropriate care to the preterm newborn with sepsis of early beginning: concept, epidemiology, pathogenesis, clinical signs, diagnosis, treatment and prevention. Also, some factors that increase the infection possibility in this newborn, the predisposing conditions in the mother and the chorioamnionitis (clinical and histological) are approached. This infection can be prevented by means of an appropriate prenatal control and a correct care during the childbirth, which will diminish the morbidity and mortality, as well as will have great impact in the public health of the country.

Características e desfechos em curto prazo de pacientes com câncer esofágico em admissões não planejadas a unidades de terapia intensiva: um estudo de coorte retrospectiva / Characteristics and short-term outcomes of patients with esophageal cancer with unplanned intensive care unit admissions: a retrospective cohort study

RESUMO Objetivo: Mostrar o quadro clínico e os desfechos de uma coorte de pacientes críticos com câncer esofágico. Métodos: Conduzimos um estudo multicêntrico retrospectivo que incluiu pacientes com câncer esofágico admitidos a unidades de terapia intensiva em razão de doença aguda entre setembro de 2009 e dezembro de 2017. Colhemos os dados demográficos e as características clínicas de todos os pacientes incluídos, assim como as medidas de suporte a órgãos e os desfechos no hospital. Realizamos uma análise de regressão logística para identificar os fatores associados de forma independente com mortalidade hospitalar. Resultados: Dentre os 226 pacientes incluídos no estudo, 131 (58,0%) faleceram antes de receber alta hospitalar. O carcinoma espinocelular foi mais frequente do que o adenocarcinoma, e 124 (54,9%) pacientes tinham câncer metastático. As principais razões para admissão foram sepse/choque séptico e insuficiência respiratória aguda. Uso de ventilação mecânica (RC = 6,18; IC95% 2,86 - 13,35) e doença metastática (RC = 7,10; IC95% 3,35 - 15,05) tiveram associação independente com mortalidade hospitalar. Conclusão: Nesta coorte de pacientes com câncer esofágico admitidos à unidades de terapia intensiva em razão de doença aguda, a taxa de mortalidade hospitalar foi muito elevada. A necessidade de utilizar ventilação mecânica invasiva e a presença de doença metastática foram fatores independentes de prognóstico e devem ser levados em conta nas discussões a respeito dos desfechos destes pacientes em curto prazo.

ABSTRACT Objective: To depict the clinical presentation and outcomes of a cohort of critically ill patients with esophageal cancer. Methods: We carried out a multicenter retrospective study that included patients with esophageal cancer admitted to intensive care units with acute illness between September 2009 and December 2017. We collected the demographic and clinical characteristics of all included patients, as well as organ-support measures and hospital outcomes. We performed logistic regression analysis to identify independent factors associated with in-hospital mortality. Results: Of 226 patients included in the study, 131 (58.0%) patients died before hospital discharge. Squamous cell carcinoma was more frequent than adenocarcinoma, and 124 (54.9%) patients had metastatic cancer. The main reasons for admission were sepsis/septic shock and acute respiratory failure. Mechanical ventilation (OR = 6.18; 95%CI 2.86 - 13.35) and metastatic disease (OR = 7.10; 95%CI 3.35 - 15.05) were independently associated with in-hospital mortality. Conclusion: In this cohort of patients with esophageal cancer admitted to intensive care units with acute illness, the in-hospital mortality rate was very high. The requirement for invasive mechanical ventilation and metastatic disease were independent prognostic factors and should be considered in discussions about the short-term outcomes of these patients.

Caracterización clínica, epidemiológica y microbiológica de pacientes con sepsis en una unidad de cuidados intensivos / Clinical, epidemiological and microbiological characterization of patients with sepsis in an intensive cares unit

Introducción: La incidencia, morbilidad y mortalidad de la sepsis la convierten en un importante problema sanitario que requiere la adopción de medidas específicas, a fin de tomar conciencia del problema. Objetivo: Caracterizar a los pacientes con sepsis según variables clínicas, epidemiológicas y microbiológicas seleccionadas. Métodos: Se realizó un estudio descriptivo y transversal de 119 pacientes con sepsis, egresados de la Unidad de Cuidados Intensivos del Hospital General Orlando Pantoja Tamayo, del municipio de Contramaestre, desde enero de 2014 hasta julio de 2017. Se aplicó la prueba de Ji al cuadrado de independencia, para identificar asociación estadísticamente significativa entre las variables, con un nivel de significación de α= 0,05. Resultados: Prevalecieron las féminas (54,6 %), el grupo etario de 66-80 años de edad para ambos sexos (33,6 %) y la neumonía asociada a la ventilación como la forma de presentación más frecuente de la sepsis (51,6 %), principalmente la producida por Enterobacter sp. (34,4 %). Conclusiones: La sepsis se presenta fundamentalmente por infecciones respiratorias producidas por gérmenes gramnegativos en pacientes que requirieren procederes invasivos como parte del tratamiento.

Introduction: The incidence, morbidity and mortality of sepsis transforms it into an important health care problem that requires the adoption of specific measures, in order to take conscience of the problem. Objectives: To characterize the patients with sepsis according to selected clinical, epidemiological and microbiological variables. Methods: A descriptive and cross-sectional study of 119 patients with sepsis, discharged from the Intensive Cares Unit of Orlando Pantoja Tamayo General Hospital, in Contramaestre was carried out, from January, 2014 to July, 2017. The chi-square test was applied, to identify association statistically significant between the variables, with a significance level of α = 0.05. Results: There was a prevalence of females (54.6 %), 66-80 years age group for both sexes (33.6 %) and pneumonia associated to ventilation as the most frequent form of presentation of sepsis (51.6 %), mainly the one produced by Enterobacter sp. (34.4 %). Conclusions: Sepsis is presented fundamentally by breathing infections produced by gramnegative germs in patients who required invasive procedures as part of the treatment.

Snappe ii: analysis of accuracy and determination of the cutoff point as a death predictor in a brazilian neonatal intensive care unit / Snappe ii: análise da acurácia e determinação do ponto de corte como preditor de óbito em uma unidade de terapia inensiva neonatal brasileira

ABSTRACT Objective: To analyze the accuracy of the Score for Neonatal Acute Physiology Perinatal Extension (SNAPPE II) as a death predictor, to determine the cutoff point for mortality, and to analyze the association of independent variables with death. Methods: Prospective, longitudinal, hospital-based study on newborns admitted to the Neonatal Intensive Care Unit (NICU) for the first time from November 1, 2016 to April 30, 2017. Newborns with less than 12 hours of length of stay at the NICU, out-of-hospital births, major congenital malformations, and inter-hospital transfer were excluded. Variables were grouped according to hierarchical framework, related to maternal characteristics (distal level), prenatal and childbirth care (intermediate level), and birth conditions (proximal level). Descriptive analyses of SNAPPE II score ranges, Receiver Operating Characteristics Curve (ROC curve) to define the cutoff point for mortality, and bivariate analysis by the Wald test and multiple logistic regression were conducted. Results: After selection, the sample consisted of 247 newborns. In this study, the SNAPPE II cutoff point for mortality was 27, with sensitivity of 84.1% and specificity of 82.4%. 61% of those with a score ≥27 died. Multiple logistic regression showed an association between death and proximal-level variables: sepsis (Odds Ratio [OR] 10.68; 95% confidence interval [95%CI] 2.82-40.48; p<0.001); SNAPPE II ≥27 (OR 5.85; 95%CI 1.90-18.05; p=0.002); birth weight 750-999 g (OR 4.15; 95%CI 1.06-16.14; p=0.040); and nonuse of surfactant (OR 0.159; 95%CI 0.04-0.53; p=0.003). Conclusions: Neonatal mortality was directly proportional to increase in SNAPPE II. Score≥27 increased the odds of dying by six times compared with neonates with lower scores. The proximal variables related to health conditions and neonatal care were associated with death.

RESUMO Objetivo: Analisar a acurácia do Score for Neonatal Acute Physiology Perinatal Extension (SNAPPE II) como preditor de óbito, determinar o ponto de corte para mortalidade e analisar a associação das variáveis independentes com óbito. Métodos: Estudo prospectivo, longitudinal, de base hospitalar com recém-nascidos admitidos pela primeira vez na Unidade de Terapia Intensiva Neonatal (UTIN) entre 1° de novembro de 2016 e 30 de abril de 2017. Foram excluídos recém-nascidos com permanência menor que 12 horas na UTIN, nascimento extra-hospitalar, malformações congênitas maiores e transferência inter-hospitalar. As variáveis foram agrupadas sob determinação hierarquizada, relacionadas a características maternas (nível distal), assistência ao pré-natal e parto (nível intermediário) e condições do nascimento (nível proximal). Foram conduzidas análises descritivas dos graus de pontuação do SNAPPE II, Receiver Operating Characteristics Curve (curva ROC) para definição do ponto de corte para mortalidade e análise bivariada pelo teste de Wald e regressão logística múltipla. Resultados: Após seleção, a amostra constituiu-se de 247 recém-nascidos. Neste estudo, o ponto de corte do SNAPPE II para mortalidade foi 27, com sensibilidade de 84,1% e especificidade de 82,4%. Evoluíram a óbito 61% daqueles com pontuação ≥27. A regressão logística múltipla mostrou associação entre óbito e variáveis de nível proximal: sepse (Odds Ratio [OR] 10,68; intervalo de confiança de 95% [IC95%] 2,82-40,48; p<0,001); pontuação ≥27 (OR 5,85; IC95% 1,90-18,05; p=0,002); peso ao nascer entre 750 e 999 g (OR 4,15; IC95% 1,06-16,14; p=0,040); e não uso de surfactante (OR 0,159; IC95% 0,04-0,53; p=0,003). Conclusões: A mortalidade neonatal foi diretamente proporcional ao aumento do SNAPPE II. Escore≥27 aumentou seis vezes a chance de óbito em relação aos neonatos com escore inferior. As variáveis proximais relacionadas às condições de saúde e da atenção neonatal associaram-se ao óbito.

Disponibilidade de recursos para tratamento da sepse no Brasil: uma amostra aleatória de instituições brasileiras / Availability of resources to treat sepsis in Brazil: a random sample of Brazilian institutions

RESUMO Objetivo: Caracterizar a disponibilidade de recursos a partir de amostra aleatória representativa das unidades de terapia intensiva do Brasil. Métodos: Realizou-se um questionário estruturado on-line para ser respondido pelo diretor médico de cada unidade participante do estudo SPREAD (Sepsis PREvalence Assessment Database), um estudo de prevalência de um único dia para avaliar o ônus da sepse no Brasil. Resultados: Uma amostra representativa de 277 das 317 unidades convidadas participou por meio de resposta ao questionário estruturado. Em sua maior parte, os hospitais participantes tinham menos que 500 leitos (94,6%), com mediana de 14 leitos na unidade de terapia intensiva. A principal fonte de recursos financeiros para dois terços das unidades pesquisadas era o atendimento de pacientes do sistema público de saúde. Não havia disponibilidade de laboratório de microbiologia próprio em 26,8% das unidades de terapia intensiva pesquisadas, e 10,5% geralmente não tinham acesso à realização de hemoculturas. Em 10,5% das unidades pesquisadas geralmente não estavam disponíveis antibióticos de amplo espectro, e 21,3% das unidades geralmente não podiam obter mensurações de lactato dentro de 3 horas. As instituições com alta disponibilidade de recursos (158 unidades; 57%) eram, em geral, maiores e atendiam principalmente pacientes do sistema de saúde privado. As unidades sem alta disponibilidade de recursos geralmente não dispunham de antibióticos de amplo espectro (24,4%), vasopressores (4,2%) e cristaloides (7,6%). Conclusão: Um número importante de unidades não tem condições para realizar intervenções básicas de monitoramento e terapêutica em pacientes sépticos. Nossos resultados salientam importantes oportunidades que o Brasil tem para melhorar, em termos de adesão a intervenções simples, porém eficazes.

ABSTRACT Objective: To characterize resource availability from a nationally representative random sample of intensive care units in Brazil. Methods: A structured online survey of participating units in the Sepsis PREvalence Assessment Database (SPREAD) study, a nationwide 1-day point prevalence survey to assess the burden of sepsis in Brazil, was sent to the medical director of each unit. Results: A representative sample of 277 of the 317 invited units responded to the resources survey. Most of the hospitals had fewer than 500 beds (94.6%) with a median of 14 beds in the intensive care unit. Providing care for public-insured patients was the main source of income in two-thirds of the surveyed units. Own microbiology laboratory was not available for 26.8% of the surveyed intensive care units, and 10.5% did not always have access to blood cultures. Broad spectrum antibiotics were not always available in 10.5% of surveyed units, and 21.3% could not always measure lactate within three hours. Those institutions with a high resource availability (158 units, 57%) were usually larger and preferentially served patients from the private health system compared to institutions without high resource availability. Otherwise, those without high resource availability did not always have broad-spectrum antibiotics (24.4%), vasopressors (4.2%) or crystalloids (7.6%). Conclusion: Our study indicates that a relevant number of units cannot perform basic monitoring and therapeutic interventions in septic patients. Our results highlight major opportunities for improvement to adhere to simple but effective interventions in Brazil.