Completion rates of bundle treatment of among patients with sepsis shock in intensive care departments of hospitals in Jiangsu Province from 2016 to 2020 years / 中华内科杂志

Current clinical approaches for septic shock increasingly incorporate bundle treatment, a multi-component approach that uses a collection of tests and agents to assist in the identification and treatment of infection. The present study analyzed completion rates of 3 h and 6 h bundle treatment among patients with septic shock in intensive care units (ICUs) of hospitals in Jiangsu Province from 2016 to 2020, using data from the Jiangsu Provincial Intensive Care Medical Quality Control Center. Current approaches and factors affecting treatment completion were assessed.The completion rates of 3 h and 6 h bundle treatment in ICUs of all medical units in Jiangsu Province and in ICUs of hospitals of different levels were recorded. Analyses show that the completion rate of 3 h and 6 h bundle treatment for patients with septic shock in ICUs in Jiangsu Province increased year by year from 2016 to 2020.The completion rate of 3 h bundle treatment increased from 69.82% (3 604/5 162) to 82.47% (8 915/10 775) (all P<0.001). The completion rate of 6 h bundle treatment increased from 62.69% (3 236/5 162) to 72.54% (7 816/10 775) (all P<0.001). In addition, year by year, the completion rate of 3 h bundle treatment in ICUs in tertiary hospitals increased, from 69.80% (3 596/5 152) to 82.23% (7 375/8 969), while the completion rate of 6 h bundle treatment increased from 62.69% (3 230/5 152) to 72.18% (6 474/8 969) (all P<0.001). Completion rates in secondary hospitals also increased year by year, from 80.00% (8/10) to 85.27% (1 540/1 806) for 3 h treatment and from 60.00% (6/10) to 74.31% (1 342/1 806) (all P<0.001) for 6 h treatment. Completion rates for 3 h treatment in first-tier cities (83.99% (2 099/2 499)) and second-tier cities (84.68% (3 952/4 667)) was higher than in third-tier cities (79.36% (2 864/3 609)). The completion rate of 6 h bundle treatment gradually decreased in first-line (77.19% (1 929/2 499)), second-line (74.37% (3 471/4 667)), and third-line (66.94% (2 416/3 609)) cities (all P<0.001). The data collectively show that from 2016 to 2020, the completion rate of bundle treatment in septic shock patients in ICUs in Jiangsu Province improved significantly.

Is Regular Probiotic Practice Safe for Management of Sepsis? / 中国结合医学杂志

For decades, the gut has been thought to play an important role in sepsis pathogenesis. Sepsis is a serious life-threatening, chronic condition of an infection caused by dysregulated host immune response in most of the intensive care unit patients. Probiotics have dual roles in polymicrobial sepsis i.e. probiotics may induce sepsis in many cases and may prevent its prognosis in many cases. Experimental evidence from both pre-clinical and clinical studies have demonstrated that probiotic therapy ameliorates various inflammatory mediators such as tumor necrosis factor, interleukin-10 (IL-10), IL-6, etc., in septicemia. In addition, probiotic use was also found to reduce the severity of pathological conditions associated with irritable bowel disorder and prevent development of endocarditis in septicemia. On contrary, probiotic therapy in neonatal and athymic adult mice fail to provide any beneficial effects on mortality and sepsis-induced inflammation. Importantly, in few clinical trials probiotic use was found to aggravate sepsis by promoting inflammatory cascade rather than suppressing it. This review discusses various studies regarding the beneficial or harmful effects associated with probiotic therapy in sepsis.

Adequação calórico proteica da terapia nutricional enteral em pacientes críticos / Caloric-protein adequacy of enteral nutritional therapy in critical patients

A doença crítica promove um estado hipercatabólico associado a uma resposta inflamatória intensa. Admite-se que essas alterações contribuem para o aumento do gasto de energia e para a elevação do catabolismo proteico. Objetivo: analisar a adequação calórico-proteica da terapia de nutrição enteral e o seu impacto no desfecho clínico de pacientes críticos. Método: Trata-se de um estudo longitudinal prospectivo realizado com 36 pacientes internados em unidades de terapia intensiva. A adequação da oferta calórico-proteica foi obtida pela relação percentual a partir do quarto dia de implementação da terapia nutricional. Realizou-se o teste de Shapiro Wilk para averiguar a normalidade dos dados e a partir disso, foi aplicado o teste de Mann-Whitney ou de t-Student não pareado. Foi realizada a análise de regressão logística com estimativa de seu coeficiente. Para a regressão estimou-se o intervalo de confiança de 95% e nível de significância de 5%. Foi utilizado o software STATA® versão 14.0 nesta análise. Resultados: Ao avaliar 36 pacientes verificou-se que a sobrevida foi menor entre os indivíduos que apresentaram o menor percentual de adequação calórica (p=0,010) e proteica (p=<0,001). Observou-se que oferta proteica impactou mais expressivamente os desfechos clínicos, ao aumento de 1% na média de adequação proteica as chances de óbito diminuíram 21%. Conclusão: O menor percentual de adequação calórico-proteica foi associado a menor sobrevida de pacientes críticos. Ainda, observou-se que o percentual de adequação proteica se associou mais expressivamente aos desfechos clínicos nessa amostra

The critical illness promotes a hypercatabolic state associated with an intense inflammatory response. It is recognized that those changes contribute to the rise of consumption of energy expenditure and to protein metabolism rise. Objective: to analyze the adequacy caloric-protein of enteral nutrition therapy and its impact on the clinical outcome of critical patients. Method: This is a prospective longitudinal study conducted with 36 hospitalized patients in intensive care units. The caloric-protein adequacy was acquired by percent ratio from the fourth day of nutritional therapy implementation. The Shapiro Wilk test was performed to check the data normality and based on that the Mann-Whitney test or unpaired Student t test was applied. The logistic regression analysis was performed with an estimate of its coefficient. For regression, it was estimated the confidence interval of 95% and significance level of 5%. In this analysis was utilized the STATA® software version 14.0. Results: In the evaluation of 36 patients, it was found that survival was lower among the individuals who had the lower percentage of caloric adequacy (p=0,010) and protein (p=<0,001). It was observed that the protein supply impacted expressively the clinical outcome with an increase of 1% in the average protein adequacy, the chances of death decreased by 21%. Conclusion: The lower percentage of caloric-protein adequacy was associated with lower mortality of critical patients. In addition, in this sampling, it was observed that the protein adequacy percentual joined expressively in the clinical outcome

Effect of fluid load on the prognosis of children with sepsis-associated acute kidney injury undergoing continuous renal replacement therapy / 中国当代儿科杂志

OBJECTIVES@#To evaluate the effect of fluid load on the prognosis of children with sepsis-associated acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT).@*METHODS@#A total of 121 children who underwent CRRT for sepsis-associated AKI from August 2018 to March 2021 were enrolled in the retrospective study. According to the fluid load from admission or disease progression to CRRT, they were divided into three groups: low fluid load (fluid load: <5%; n=35), high fluid load (fluid load: 5% - <10%; n=35), and fluid overload (fluid load: ≥10%; n=51). Baseline data and clinical biochemical data before CRRT were collected for comparison and analysis. The Kaplan-Meier survival curve analysis was used for comparison of 28-day survival between groups. The multivariate logistic regression model was used to identify the influencing factors for the prognosis of the children.@*RESULTS@#The survival analysis showed that the fluid overload group had a significantly higher 28-day mortality rate than the low fluid load and high fluid load groups (P<0.05). The multivariate logistic regression analysis showed that an increase in fluid overload volume was a risk factor for increased 28-day mortality in the fluid overload group, while earlier initiation of CRRT was a protective factor (P<0.05).@*CONCLUSIONS@#Fluid overload before CRRT may increase the mortality in children with sepsis-associated AKI, and CRRT should be performed for these children as early as possible.

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.

Atualização das recomendações da Sociedade Portuguesa de Cuidados Intensivos e do Grupo de Infeção e Sépsis para a abordagem da COVID-19 em Medicina Intensiva / Update of the recommendations of the Sociedade Portuguesa de Cuidados Intensivos and the Infection and Sepsis Group for the approach to COVID-19 in Intensive Care Medicine

RESUMO Introdução: A Sociedade Portuguesa de Cuidados Intensivos e o Grupo de Infeção e Sépsis emitiram previamente recomendações visando à organização dos serviços de saúde e ao manejo dos doentes críticos com COVID-19. Em virtude da evolução do conhecimento, o painel de peritos voltou a se organizar para rever a atual evidência e emitir recomendações atualizadas. Métodos: Foi reunido um painel nacional de peritos que declararam não ter conflitos de interesse para o desenvolvimento das recomendações. Foram desenvolvidas perguntas operacionais conforme a metodologia PICO, e foi conduzida uma revisão sistemática rápida por meio da consulta de diferentes fontes bibliográficas. O painel determinou a direção e a força das recomendações com a utilização de duas rodadas de um método Delphi, conduzido seguindo princípios do sistema GRADE. Uma recomendação forte recebeu a redação "recomenda-se", e uma recomendação fraca foi redigida como "sugere-se". Resultados: Foram emitidas 48 recomendações e 30 sugestões abrangendo os seguintes tópicos: diagnóstico de infecção por SARS-CoV-2, coinfecção e superinfecção; critérios de admissão, cura e suspensão de isolamento; organização dos serviços; Equipamentos de Proteção Individual; terapêuticas de suporte respiratório e outras e terapêuticas específicas (antivirais, imunomodeladores e anticoagulação). Conclusão: Essas recomendações, especificamente orientadas para a realidade portuguesa, mas que podem se aplicar também aos Países Africanos de Língua Oficial Portuguesa e ao Timor-Leste, visam apoiar os profissionais de saúde no manejo de doentes críticos com COVID-19. Pretende-se que sejam constantemente revistas, de modo a refletir o avanço de nossa compreensão e o da terapêutica dessa patologia.

ABSTRACT Introduction: The Sociedade Portuguesa de Cuidados Intensivos and the Infection and Sepsis Group have previously issued health service and management recommendations for critically ill patients with COVID-19. Due to the evolution of knowledge, the panel of experts was again convened to review the current evidence and issue updated recommendations. Methods: A national panel of experts who declared that they had no conflicts of interest regarding the development of the recommendations was assembled. Operational questions were developed based on the PICO methodology, and a rapid systematic review was conducted by consulting different bibliographic sources. The panel determined the direction and strength of the recommendations using two Delphi rounds, conducted in accordance with the principles of the GRADE system. A strong recommendation received the wording "is recommended", and a weak recommendation was written as "is suggested." Results: A total of 48 recommendations and 30 suggestions were issued, covering the following topics: diagnosis of SARS-CoV-2 infection, coinfection and superinfection; criteria for admission, cure and suspension of isolation; organization of services; personal protective equipment; and respiratory support and other specific therapies (antivirals, immunomodulators and anticoagulation). Conclusion: These recommendations, specifically oriented to the Portuguese reality but that may also apply to Portuguese-speaking African countries and East Timor, aim to support health professionals in the management of critically ill patients with COVID-19. They will be continuously reviewed to reflect the progress of our understanding and the treatment of this pathology.

Improvement of 1st-hour bundle compliance and sepsis mortality in pediatrics after the implementation of the surviving sepsis campaign guidelines

Abstract Objectives To study the impact of the implementation of the Pediatric Surviving Sepsis Campaign protocol on early recognition of sepsis, 1 -h treatment bundle and mortality. Methods Retrospective, single-center study, before and after the implementation of the sepsis protocol. Outcomes: sepsis recognition, compliance with the 1 -h bundle (fluid resuscitation, blood culture, antibiotics), time interval to fluid resuscitation and antibiotics administration, and mortality. Patients with febrile neutropenia were excluded. The comparisons between the periods were performed using non-parametric tests and odds ratios or relative risk were calculated. Results We studied 84 patients before and 103 after the protocol implementation. There was an increase in sepsis recognition (OR 21.5 [95% CI: 10.1-45.7]), in the compliance with the 1 -h bundle as a whole (62% x 0%), and with its three components: fluid resuscitation (OR 31.1 [95% CI: 3.9−247.2]), blood culture (OR 15.9 [95% CI: 3.9−65.2]), and antibiotics (OR 35.6 [95% CI: 8.9−143.2]). Significant reduction between sepsis recognition to fluid resuscitation (152min × 12min, p < 0.001) and to antibiotics administration (137min × 30min) also occurred. The risk of death before protocol implementation was four times greater (RR 4.1 [95% CI: 1.2-14.4]), and the absolute death risk reduction was 9%. Conclusion Even if we considered the low precision of some estimates, the lower limits of the Confidence Intervals show that the implementation of the Pediatric Surviving Sepsis Campaign guidelines alongside a qualitive assurance initiative has led to improvements in sepsis recognition, compliance with the 1 -h treatment bundle, reduction in the time interval to fluid resuscitation and antibiotics, and reduction in sepsis mortality.

Impacto da transfusão de eritrócitos no transporte e no metabolismo de oxigênio em pacientes com sepse e choque séptico: uma revisão sistemática e metanálise / Impact of red blood cell transfusion on oxygen transport and metabolism in patients with sepsis and septic shock: a systematic review and meta-analysis

RESUMO Considera-se que a transfusão de eritrócitos melhora a respiração celular durante o choque séptico. Contudo, seu impacto agudo no transporte e no metabolismo de oxigênio nessa condição ainda é amplamente debatido. O objetivo deste estudo foi avaliar o impacto da transfusão de eritrócitos na microcirculação e no metabolismo do oxigênio em pacientes com sepse e choque séptico. Conduzimos um levantamento nas bases de dados MEDLINE®, Elsevier e Scopus. Incluímos estudos realizados com seres humanos adultos com sepse e choque séptico. Realizamos uma revisão sistemática e metanálise com utilização do modelo de efeitos aleatórios de DerSimonian e Laird. Consideramos significante valor de p < 0,05. Incluíram-se na análise 19 manuscritos, correspondentes a 428 pacientes. As transfusões de eritrócitos se associaram com aumento de 3,7% na média combinada de saturação venosa mista de oxigênio (p < 0,001), diminuição de razão de extração de oxigênio de -6,98 (p < 0,001) e nenhum efeito significante no índice cardíaco (0,02 L/minuto; p = 0,96). Obtiveram-se resultados similares em estudos que incluíram mensurações simultâneas de saturação venosa mista de oxigênio, razão de extração de oxigênio e índice cardíaco. As transfusões de eritrócitos levaram a aumento significante na proporção de pequenos vasos perfundidos (2,85%; p = 0,553), enquanto os parâmetros de oxigenação tissular revelaram aumento significante no índice de hemoglobina tissular (1,66; p = 0,018). Estudos individuais relataram melhoras significantes na oxigenação tissular e nos parâmetros microcirculatórios sublinguais em pacientes com microcirculação alterada na avaliação inicial. A transfusão de eritrócitos pareceu melhorar o metabolismo sistêmico de oxigênio com aparente independência de variações no débito cardíaco. Observaram-se alguns efeitos benéficos para a oxigenação tissular e parâmetros microcirculatórios, em particular em pacientes com alterações iniciais mais graves. São necessários mais estudos para avaliar seu impacto clínico e individualizar as decisões relativas à transfusão.

ABSTRACT Red blood cell transfusion is thought to improve cell respiration during septic shock. Nevertheless, its acute impact on oxygen transport and metabolism in this condition remains highly debatable. The objective of this study was to evaluate the impact of red blood cell transfusion on microcirculation and oxygen metabolism in patients with sepsis and septic shock. We conducted a search in the MEDLINE®, Elsevier and Scopus databases. We included studies conducted in adult humans with sepsis and septic shock. A systematic review and meta-analysis were performed using the DerSimonian and Laird random-effects model. A p value < 0.05 was considered significant. Nineteen manuscripts with 428 patients were included in the analysis. Red blood cell transfusions were associated with an increase in the pooled mean venous oxygen saturation of 3.7% (p < 0.001), a decrease in oxygen extraction ratio of -6.98 (p < 0.001) and had no significant effect on the cardiac index (0.02L/minute; p = 0,96). Similar results were obtained in studies including simultaneous measurements of venous oxygen saturation, oxygen extraction ratio, and cardiac index. Red blood cell transfusions led to a significant increase in the proportion of perfused small vessels (2.85%; p = 0.553), while tissue oxygenation parameters revealed a significant increase in the tissue hemoglobin index (1.66; p = 0.018). Individual studies reported significant improvements in tissue oxygenation and sublingual microcirculatory parameters in patients with deranged microcirculation at baseline. Red blood cell transfusions seemed to improve systemic oxygen metabolism with apparent independence from cardiac index variations. Some beneficial effects have been observed for tissue oxygenation and microcirculation parameters, particularly in patients with more severe alterations at baseline. More studies are necessary to evaluate their clinical impact and to individualize transfusion decisions.

The role of fistuloclysis in the treatment of patients with enteroatmospheric fistulas / O papel da fistuloclise no tratamento de pacientes com fístulas enteroatmosféricas

ABSTRACT Background: Enterocutaneous fistulas represent a connection between the gastrointestinal tract and adjacent tissues. Among them, there is a subdivision - the enteroatmospheric fistulas, in which the origin is the gastrointestinal tract in connection with the external environment through an open wound in the abdomen. Due to the high output in enterocutaneous fistulas, the loss of fluids, electrolytes, minerals and proteins leads to complications such as sepsis, malnutrition and electrolyte derangements. The parenteral nutrition has its secondary risks, and the fistuloclysis, that consist in the infusion of enteral feeding and also the chyme through the distal fistula, represents an alternative to the management of these patients until the definitive surgical approach. Aim: To evaluate the current evidence on the fistuloclysis technique, its applicability, advantages and disadvantages for patients with high output fistulas. Method: A systematic literature search was conducted in May 2020 with the headings "fistuloclysis", "chyme reinfusion" and "succus entericus reinfusion", in the PubMed, Medline and SciELO databases. Results: There were 29 articles selected for the development of this narrative synthesis, from 2003 to 2020, including reviews and case reports. Conclusion: Fistuloclysis is a safe method which optimizes the clinical, nutritional, and immunological conditions of patients with enteroatmospheric fistulas, increasing the chances of success of the reconstructive procedure. In cases where the definitive repair is not possible, chances of reducing or even stopping the use of nutrition through the parental route are increased, thus representing a promising modality for the management of most challenging cases.

RESUMO Racional: As fístulas enterocutâneas representam uma conexão entre o trato gastrointestinal e os tecidos adjacentes. Dentre elas, há uma subdivisão - as fístulas enteroatmosféricas, em que a origem é o trato gastrointestinal em conexão com o meio externo por meio de uma ferida aberta no abdômen. Devido ao alto débito nas fístulas enterocutâneas, a perda de fluidos, eletrólitos, minerais e proteínas levam a complicações como sepse, desnutrição e desequilíbrios eletrolíticos. A nutrição parenteral tem seus riscos secundários, e a fistuloclise, que consiste na infusão de nutrição enteral e também do quimo pela fístula distal, representa uma alternativa no manejo desses pacientes até a abordagem cirúrgica definitiva. Objetivo: Avaliar as evidências atuais sobre a técnica de fistuloclise, sua aplicabilidade, vantagens e desvantagens para pacientes com fístulas de alto débito. Método: Foi realizada uma busca sistemática da literatura em maio de 2020 com os títulos "fistuloclysis", "chyme reinfusion" e "succus entericus reinfusion", nas bases de dados PubMed, Medline e SciELO. Resultados: Foram selecionados 29 artigos para o desenvolvimento desta síntese narrativa, no período de 2003 a 2020, incluindo revisões e relatos de caso. Conclusão: A fistuloclise é um método seguro que otimiza as condições clínicas, nutricionais e imunológicas dos pacientes com fístulas enteroatmosféricas, aumentando as chances de sucesso do procedimento de reconstrução. Nos casos em que o reparo definitivo não é possível, aumentam as chances de reduzir ou mesmo interromper o uso da nutrição pela via parental, representando uma modalidade promissora para o manejo dos casos mais desafiadores.

Bundle for pediatric COVID-19 sepsis

SUMMARY COVID-19 infection can progress to severe respiratory infection and have high mortality rates. Several pathophysiological factors are observed in fatal cases, with mortality related to multiple organ failure, in addition to the evolution with high levels of serum ferritin, D-dimer, and C-reactive protein. These severe cases often meet the criteria for macrophage activation syndrome with changes in the host's inflammatory response and an inadequate resolution phase. In the present study, the bundle for COVID-19 sepsis is proposed, including early recognition; protection, handwashing and isolation measures; oxygen therapy; early invasive mechanical ventilation; treatment aimed at modifying the clinical course. This strategy may be useful in the control of children with severe COVID-19 cases, as already demonstrated with the implementation of bundles in sepsis and other etiologies.

Desenlaces asociados con solución salina normal versus lactato de ringer en sepsis y choque séptico o hipovolémico / Outcomes associated with normal saline solution vs lactated ringer´s solution in sepsis and septic or hypovelemic shock

Introducción: los cristaloides son medicamentos usados en pacientes críticamente enfermos, con resultados ambiguos cuando se utilizan soluciones balanceadas versus solución salina normal. Objetivo: conocer si existen diferencias al usar solución salina 0.9% vs. lactato de Ringer en pacientes críticamente enfermos con sepsis y choque séptico o hipovolémico, en cuanto a mortalidad, lesión renal aguda y tiempo de estancia hospitalaria. Métodos: estudio observacional de tipo cohorte retrospectiva en mayores de 18 años con diagnóstico de sepsis, choque séptico o hipovolémico. Se excluyeron aquellos con enfermedad renal crónica en diálisis, las hospitalizadas por ginecología/obstetricia y aquellos con diagnóstico de muerte encefálica o donantes de órganos. Se evaluaron los desenlaces primarios de mortalidad, lesión renal aguda y estancia hospitalaria. Resultados y discusión: se incluyeron 314 pacientes, 158 en el grupo expuesto a solución salina al 0.9% y 156 con lactato de Ringer. Se presentó lesión renal aguda en 22.7% con solución salina y 25.8% con lactato de Ringer (OR 1.18 IC 95%:0.7-2). La mortalidad con solución salina fue de 49%, y en lactato 49% (OR 1.01 IC 95%:0.63-1.63). Los factores de riesgo identificados para mortalidad fueron uso de soporte vasopresor (OR 35 IC 95% 12-83) y lesión renal aguda (1.3 IC 95% 1.01-1.69). Conclusiones: en el paciente críticamente enfermo con sepsis, choque séptico o hipovolémico el uso desolución salina 0.9% no representa diferencias al compararlo con lactato de Ringer en cuanto a mortalidad, lesión renal aguda o estancia hospitalaria. La elección de un cristaloide debe ser individualizada, teniendo en cuenta las comorbilidades, la presencia de hipercloremia o hiperpotasemia.

Objective: crystalloids are drugs used in critically ill patients, with ambiguous results when balanced solutions versus normal saline solution (NS) are used. The objective of this study is to determine if there are differences when NS (0.9%) vs. lactated Ringer ́s (LR) solution are given to critically ill patients in sepsis or septic or hypovolemic shock, in terms of mortality, acute renal injury and length of hospital stay. Methods: a retrospective observational cohort study in patients over 18 years old with sepsis or septic or hypovolemic shock. Patients with chronic renal disease on dialysis, those hospitalized by gynecology/obstetrics and those diagnosed with brain death or organ donors were excluded. The primary mortality outcomes, acute renal injury and hospital stay were evaluated. Results: 314 patients were included, 158 in the NS group and 156 in the LR group. Acute renal injury occurred in 22.7% in the NS group and 25.8% in the LR group (OR 1.18 IC 95%:0.7-2). Mortality rate was 49% in the NS group and 49% in the LR group (OR 1.01 95%: CI 0.63-1.63). Mortality risk factors included the use of vasopressor support (OR 35 95% CI 12-83) and acute renal injury (1.3 95% CI 1.01-1.69). Conclusions: no difference was found with the use of NS in critically ill patients with sepsis or septic or hypovolemic shock when compared with LR in terms of mortality, acute renal injury or hospital stay. The choice of which crystalloid to administer should be individualized, based on the comorbidities and the presence of hyperchloremia or hyperkalemia.

What's new in trauma 2020 / 中华创伤杂志(英文版)

Throughout the past 2020, the pandemic COVID-19 has caused a big global shock, meanwhile it brought a great impact on the public health network. Trauma emergency system faced a giant challenge and how to manage trauma under the pandemic of COVID-19 was widely discussed. However, the trauma treatment of special population (geriatric patients and patients taking anticoagulant drugs) has received inadequate attention. Due to the high mortality following severe traumatic hemorrhage, hemostasis and trauma-induced coagulopathy are the important concerns in trauma treatment. Sepsis is another topic should not be ignored when we talking about trauma. COVID-19 itself is a special kind of sepsis, and it may even be called as serious systemic infection syndrome. Sepsis has been become a serious problem waiting to be solved urgently no matter in the fields of trauma, or in intensive care and infection, etc. This article reviewed the research progress in areas including trauma emergency care, trauma bleeding and coagulation, geriatric trauma and basic research of trauma within 2020.

Performance of scores in the prediction of clinical outcomes in patients admitted from the emergency service / Desempenho de escores na predição de desfechos clínicos em pacientes admitidos a partir de emergência / Rendimiento de los puntajes en la predicción de desenlaces clínicos en pacientes ingresados en el servicio de emergencia

Objective: to evaluate the performance of the quickSOFA scores and Systemic Inflammatory Response Syndrome as predictors of clinical outcomes in patients admitted to an emergency service. Method: a retrospective cohort study, involving adult clinical patients admitted to the emergency service. Analysis of the ROC curve was performed to assess the prognostic indexes between scores and outcomes of interest. Multivariate analysis used Poisson regression with robust variance, evaluating the relationship between variables with biological plausibility and outcomes. Results: 122 patients were selected, 58.2% developed sepsis. Of these, 44.3% had quickSOFA ≥2 points, 87% developed sepsis, 55.6% septic shock and 38.9% died. In the evaluation of Systemic Inflammatory Response Syndrome, 78.5% obtained results >2 points; of these, 66.3% developed sepsis, 40% septic shock and 29.5% died. quickSOFA ≥2 showed greater specificity for diagnosis of sepsis in 86% of the cases, for septic shock 70% and for mortality 64%, whereas the second score showed better results for sensitivity with diagnosis of sepsis in 87.5%, septic shock in 92.7% and death in 90.3%. Conclusion: quickSOFA showed by its practicality that it can be used clinically within the emergency services, bringing clinical applicability from the risk classification of patients for the early recognition of unfavorable outcomes.

Objetivo: avaliar o desempenho dos escores quickSOFA e Síndrome da Resposta Inflamatória Sistêmica como fatores preditores de desfechos clínicos em pacientes admitidos em um serviço de emergência. Método: coorte retrospectiva, envolvendo pacientes adultos clínicos admitidos em serviço de emergência. A análise da curva ROC foi realizada para a avaliação dos índices prognósticos entre escores e desfechos de interesse. Análise multivariável utilizou regressão de Poisson com variância robusta avaliando a relação entre as variáveis com plausibilidade biológica e os desfechos. Resultados: foram selecionados 122 pacientes, 58,2% desenvolveram sepse. Destes 44,3% tiveram quickSOFA ≥2 pontos, 87% desenvolveram sepse, 55,6% choque séptico e 38,9% morreram. Na avaliação de Síndrome da Resposta Inflamatória Sistêmica 78,5% obtiveram resultados >2 pontos, destes 66,3% desenvolveram sepse, 40% choque séptico e 29,5% morreram. O quickSOFA ≥2 apresentou maior especificidade para diagnóstico de sepse em 86% dos casos, para choque séptico 70% e para mortalidade 64%, já o segundo escore mostrou melhores resultados para sensibilidade com diagnóstico de sepse de 87,5%, choque séptico 92,7% e óbito 90,3%. Conclusão: o quickSOFA demonstrou pela sua praticidade que pode ser utilizado clinicamente dentro dos serviços de emergência trazendo aplicabilidade clínica a partir da classificação de risco de pacientes para o reconhecimento precoce de desfechos desfavoráveis.

Objetivo: evaluar el rendimiento de los puntajes quick SOFA y del Síndrome de Respuesta Inflamatoria Sistémica como predictores de desenlaces clínicos en pacientes ingresados en un servicio de emergencia. Método: cohorte retrospectiva de pacientes clínicos adultos ingresados en el servicio de emergencia. El análisis de la curva ROC se realizó para evaluar los índices de pronóstico entre puntajes y desenlaces de interés. El análisis multivariado utilizó regresión de Poisson con varianza robusta, evaluando la relación entre las variables con plausibilidad biológica y los desenlaces. Resultados: se seleccionaron 122 pacientes, 58,2% desarrollaron sepsis. De estos, el 44,3% tenía quick SOFA ≥2 puntos, el 87% desarrolló sepsis, el 55,6% shock séptico y el 38,9% falleció. En la evaluación del Síndrome de Respuesta Inflamatoria Sistémica el 78,5% obtuvo resultados ≥2 puntos, de los cuales el 66,3% desarrolló sepsis, el 40% shock séptico y el 29,5% falleció. El quick SOFA ≥2 mostró mayor especificidad para el diagnóstico de sepsis en el 86% de los casos, para shock séptico en el 70% y para mortalidad en el 64%, mientras que el segundo puntaje mostró mejores resultados de sensibilidad para el diagnóstico de sepsis de 87,5%, shock séptico 92,7% y muerte 90,3%. Conclusión: el quick SOFA demostró, por su practicidad, que se puede utilizar clínicamente dentro de los servicios de emergencia aportando aplicabilidad clínica por medio de la clasificación de riesgo de los pacientes para el reconocimiento temprano de desenlaces desfavorables.

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.

Tempo para evacuação de foco séptico abdominal e mortalidade em portadores de sepse / Time to clearance of abdominal septic focus and mortality in patients with sepsis

RESUMO Objetivo: Aferir a relação entre tempo para evacuação de foco e mortalidade hospitalar em portadores de sepse e choque séptico. Métodos: Estudo observacional, unicêntrico, com análise retrospectiva do tempo para evacuação de foco séptico abdominal. Os pacientes foram classificados conforme o tempo para evacuação do foco em grupo precoce (≤ 12 horas) ou tardio (> 12 horas). Resultados: Foram avaliados 135 pacientes. Não houve associação entre tempo para evacuação do foco e mortalidade hospitalar (≤ 12 horas versus > 12 horas): 52,3% versus 52,9%, com p = 0,137. Conclusão: Não houve diferença na mortalidade hospitalar entre pacientes com sepse ou choque séptico que tiveram foco infeccioso evacuado antes ou após 12 horas do diagnóstico de sepse.

ABSTRACT Objective: To assess the relationship between time to focus clearance and hospital mortality in patients with sepsis and septic shock. Methods: This was an observational, single-center study with a retrospective analysis of the time to clearance of abdominal septic focus. Patients were classified according to the time to focus clearance into an early (≤ 12 hours) or delayed (> 12 hours) group. Results: A total of 135 patients were evaluated. There was no association between time to focus clearance and hospital mortality (≤ 12 hours versus > 12 hours): 52.3% versus 52.9%, with p = 0.137. Conclusion: There was no difference in hospital mortality among patients with sepsis or septic shock who had an infectious focus evacuated before or after 12 hours after the diagnosis of sepsis.

Recomendações da Sociedade Portuguesa de Cuidados Intensivos e Grupo de Infeção e Sépsis para a abordagem do COVID-19 em medicina intensiva / Recommendations from the Sociedade Portuguesa de Cuidados Intensivos and Infection & Sepsis Group for intensive care approach to COVID-19

RESUMO A atual epidemia de COVID-19 foi declarada em 31 de dezembro de 2019 no mercado de frutos do mar da cidade de Wuhan, com rápida disseminação na China e, posteriormente, envolvendo múltiplos países (como maior expressão na Coreia do Sul, Japão, Itália e Irã) incluindo, desde 1º de março, Portugal. A maioria dos doentes infetados apresenta doença ligeira sem necessidade de hospitalização. Dentre os internados, de 6% a 10% necessitam de cuidados intensivos. As presentes recomendações visam facilitar a organização dos serviços de medicina intensiva para a resposta ao COVID-19, proporcionado os melhores cuidados aos doentes e protegendo os profissionais de saúde.

ABSTRACT Current COVID-19 epidemics was declared on December 31, 2019 at the Wuhan city seafood market, rapidly spreading throughout China, and later reaching several countries (mainly South Korea, Japan, Italy and Iran) and, since March 1, reaching Portugal. Most of the infected patients present with mild symptoms, not requiring hospitalization. Among those admitted to the hospital, 6% to 10% require admission to the intensive care unit. These recommendations are aimed to support the organization of intensive care services to respond COVID-19, providing optimized care to the patient and protection for healthcare professionals.

Sepsis en Cirugía / Sepsis in Surgery

Resumen La sepsis constituye una causa frecuente de muerte por lo que es muy importante el diagnóstico precoz para conseguir un manejo oportuno y eficiente. Las definiciones y consensos han ido sufriendo modificaciones a lo largo del tiempo por lo que el equipo médico quirúrgico debe estar atento a estos cambios y debe mantenerse en constante actualización. El consenso de Sepsis-3, propone el uso del qSOFA y SOFA con el fin de mejorar la especificidad del reconocimiento de pacientes de mayor gravedad; no obstante, esto se logra a expensas de una menor sensibilidad, es por esto que los criterios clásicos de SIRS deben seguir utilizándose ante la sospecha de sepsis. Es clave la identificación temprana de los pacientes para que el resultado de las medidas a tomar sea el óptimo. La sepsis quirúrgica sigue siendo un cuadro clínico difícil de reconocer y manejar, es una urgencia que requiere medidas iniciales durante la primera hora de sospecha por lo que es transcendental para el cirujano conocer estas medidas, para poder planificar una posible cirugía de urgencia con el respaldo médico adecuado, según corresponda. El objetivo de esta revisión es que el cirujano y el equipo médico actualicen los cambios de los consensos de sepsis en cuanto al diagnóstico y al manejo bajo una mirada crítica y conozcan también el enfrentamiento adecuado de una sepsis quirúrgica para, de esta manera, mejorar la sobrevida de nuestros pacientes.

Sepsis constitutes a frequent cause of death, early diagnosis is essential to achieve proper management. Definitions and consensus have undergone modifications over time, so the surgical and medical team must be aware of these changes and must be constantly updated. The consensus of Sepsis-3 proposes the use of qSOFA and SOFA in order to improve the specificity of the recognition of patients with greater severity; however, this is achieved at the expense of lower sensitivity, so that the standard SIRS criteria should continue to be used when sepsis is suspected.The early identification of patients is very important to optimize the handling of the medical team. Surgical sepsis remains a difficult clinical picture to recognize and manage. It is an emergency that requires initial actions during the first hour of suspicion. By this it is important for the surgeon to know these actions that allow him or her to plan a possible emergency surgery when appropriate with adequate medical support. The objective of this update is for surgeon and medical team to know the changes in sepsis consensus regarding diagnosis and management under a critical view, as well as to know the therapeutic approach of a surgical sepsis to improve the survival of our patients.