Asociación entre índice de masa corporal y mortalidad en pacientes críticos con choque séptico / Association between body mass index and mortality in critical ill patients with septic shock

INTRODUCCIÓN. La paradoja de la obesidad propone que, en determinadas enfermedades, los enfermos con obesidad tienen menor mortalidad. OBJETIVO. Asociar el índice de masa corporal con la mortalidad a 30 días en adultos con choque séptico. MATERIALES Y MÉTODOS. Estudio observacional, analítico, retrospectivo, multicéntrico. Se analizaron 673 pacientes con choque séptico, ingresados en terapia intensiva de dos hospitales de la ciudad de la ciudad de Quito ­ Ecuador, durante enero 2017 - diciembre 2019. Criterios de inclusión: Mayores a 18 años, choque séptico, registro de peso, talla y condición vital al día 30. Criterios de exclusión: Orden de no reanimación, embarazadas, protocolo de donación de órganos, cuidados paliativos. Las variables se recolectaron a partir de las historias clínicas digitales y físicas de los centros participantes. Las estimaciones de riesgo calculadas se presentaron como OR (Odds Ratio) en el análisis bivariado y OR Adj (OR ajustado) para el análisis multivariado. Un valor de p <0.05 se consideró estadísticamente significativo. Todos los análisis estadísticos se realizaron usando el software estadístico R® (Versión 4.1.2). RESULTADOS. La edad promedio fue de 65 años, índice de masa corporal promedio 25,9 Kg/m2 (+4,9 Kg/m2). El 54,3% tuvo índice de masa corporal > 25 Kg/m2. La mortalidad general fue 49.2%. Sujetos con sobrepeso y obesidad tuvieron menor mortalidad, OR: 0,48 (IC 95%: 0.34, 0.68; p <0.0001) y OR 0.45 (IC 95 %: 0.28, 0.70; p =0.001) respectivamente, con similar tendencia en el análisis multivariado. Los sujetos con peso bajo tuvieron la mayor mortalidad (OR: 2.12. IC 95%: 0.91 - 5.54. p: 0.097). DISCUSIÓN. Los resultados obtenidos apoyan la teoría de paradoja de obesidad, sin embargo, no se realizó evaluación según los niveles de obesidad. CONCLUSIÓN. La mortalidad en choque séptico es menor en sujetos con sobrepeso y obesidad comparada con sujetos con peso normal o bajo peso.

The obesity paradox proposes that, in certain diseases, patients with obesity have lower mortality. OBJECTIVE. To associate body mass index with 30-day mortality in adults with septic shock. MATERIALS AND METHODS. Observational, analytical, retrospective, multicenter, retrospective study. We analyzed 673 patients with septic shock, admitted to intensive care in two hospitals in the city of Quito - Ecuador, during January 2017 - December 2019. Inclusion criteria: older than 18 years, septic shock, weight, height and vital condition at day 30. Exclusion criteria: Do not resuscitate order, pregnant women, organ donation protocol, palliative care. Variables were collected from the digital and physical medical records of the participating centers. Calculated risk estimates were presented as OR (Odds Ratio) in bivariate analysis and OR Adj (adjusted OR) for multivariate analysis. A p value <0.05 was considered statistically significant. All statistical analyses were performed using R® statistical software (Version 4.1.2). RESULTS. The mean age was 65 years, mean body mass index 25.9 kg/m2 (+4.9 kg/m2). Body mass index > 25 kg/m2 was 54.3%. Overall mortality was 49.2%. Overweight and obese subjects had lower mortality, OR: 0.48 (95% CI: 0.34, 0.68; p<0.0001) and OR 0.45 (95 % CI: 0.28, 0.70; p=0.001) respectively, with similar trend in multivariate analysis. Underweight subjects had the highest mortality (OR: 2.12. 95% CI: 0.91 - 5.54. p: 0.097). DISCUSSION. The results obtained support the obesity paradox theory, however, assessment according to obesity levels was not performed. CONCLUSIONS. Mortality in septic shock is lower in overweight and obese subjects compared to normal weight or underweight subjects.

Sepsis et choc septique en réanimation à Brazzaville (Congo) / Sepsis and septic shock in polyvalent intensive care at Brazzaville (Congo)

Objectifs. Décrire les aspects cliniques, bactériologiques et évolutifs du sepsis et du choc septique dans le service de réanimation polyvalente du CHUB. Patients et méthodes. Il s'agit d'une étude transversale, monocentrique et descriptive, durant 12 mois, incluant les patients âgés d'au moins 18 ans admis en réanimation polyvalente pour un sepsis ou choc septique. Les variables épidémiologiques, cliniques, bactériologiques et évolutives ont été analysées avec Excel 2019. Résultats. 56 patients ont été retenus (20,7%). Leur âge moyen était de 43,1 ± 17,9 ans (extrêmes de 18 et 84 ans), avec 66,1% des hommes. Le foyer infectieux initial était péritonéal (64,3 %). À l'admission, le nombre médian de défaillances d'organes par patient était de trois (maximum 5). Les défaillances rénale (71,4%), hépatique (69,6%) et hémodynamique (62,5%) étaient les plus représentées. Le taux de réalisation du bilan bactériologique était de 35,7% : hémoculture (10,7%), uroculture (14,3%), porte d'entrée infectieuse (7,1%). La durée d'hospitalisation des patients sortis vivants était de 8,1 ± 6,3 jours (extrêmes de 2 et 31 jours). Le taux de mortalité était de 57,1%. Les décès survenaient au-delà de 24 h d'hospitalisation (75%), chez des patients avec comorbidités (65,6%), porte d'entrée péritonéale (59,4%), et défaillances hémodynamique (81,2%) et rénale (75%). Conclusion. Les prévalences du sepsis et du choc septique dans notre série sont superposables à celles de la littérature. Le taux de réalisation des bilans bactériologiques reste faible. La mortalité du sepsis demeure très élevée.

Introduction. No accurate data on sepsis and septic shock in intensive care unit (ICU) in the Republic of Congo are available. The aim of the study was to describe the course of patients with sepsis and/or septic shock in the polyvalent ICU of the University Teaching Hospital of Brazzaville. Patients and methods. This was a cross-sectional, monocentric and descriptive study, lasting 12 months, including patients aged at least 18 years admitted to ICU for sepsis or septic shock. The clinical presentation, the bacteriological findings and the outcome were analyzed with Excel 2019. Results. 56 patients were selected (20.7%). The average age was 43.1 ± 17.9 years (extremes 18 and 84 years), with 66.1% of men. The initial infection was peritoneal (64.3%). At admission, the median number of organ failures per patient was three (maximum 5). Renal (71.4%), hepatic (69.6%) and hemodynamic (62.5%) failures were the most common. Bacteriological assessment rate was 35.7%: blood culture (10.7%), urine culture (14.3%). The duration of hospitalization of alive patients was 8.1 ± 6.3 days (extremes 2 and 31 days). The mortality rate was 57.1%. Deaths occurred beyond 24 hours of hospitalization (75%), in patients with comorbidities (65.6%), peritonitis (59.4%), hemodynamic (81.2%) and renal (75%) failures. Conclusion. The prevalence of sepsis and septic shock in our study is comparable to other published series. The bacteriological assessments rate is still low. The mortality is very high.

Infections sévères vue au service des urgences du Centre Hospitalier Universitaire Mahavoky Atsimo: Facteurs pronostics et Issue / Severe infections at the emergency department of the Mahavoky Atsimo teaching hospital: prognosis factors and outcome

: Une infection sévère constitue une situation préoccupante, car elle s'accompagne d'un taux élevé mortalité dans le monde. L'objectif de cette étude était de déterminer les facteurs pronostiques des infections sévères vues dans le service Accueil­triage­Urgence (ATU) du Centre Hospitalier Universitaire (CHU) Mahavoky Atsimo. Méthodes : Il s'agit d'une étude rétrospective et analytique réalisée dans le service ATU du CHU Mahavoky Atsimo durant 24 mois (Janvier 2020-Décembre 2021). Nous avons inclus tous les patients avec une infection sévère, âgés de 15 et plus ayant un score qSOFA≥2. Résultats : la prévalence d'infection sévère était de 9,8% dont 68,3% de sepsis et 31,7% de choc septique. Les principales étiologies étaient la pneumopathie (26,8%), le paludisme (22%), les méningites (14,6%). Le taux de létalité était de 43,9%. L'âge moyen des patients était de 48,34ans ±2,46 avec une majorité masculine (61%). Les facteurs prédictifs d'un mauvais pronostic étaient : l'HTA (p=0,009), la présence de cardiopathie (p=0,001), l'antécédent d'infection urinaire (p=0,000), le score de Glasgow (p=0,006), le score qSOFA (p=0,010), l'extrémité froide (p=0,000), la présence des signes de lutte (p = 0,005), les râle s crépitants (p = 0,005), la VS élevée (p=0,002), l'élévation de la procalcitonine (p<0,0005), le traitement par quinolone (p=0,048), l'utilisation d'amine Vasopressive (p=0,040), la durée longue de perfusion de catécholamines (p=0,039), l'oxygénothérapie (p= 0,014) et l'utilisation de canule oropharyngée (p=0,003). Conclusions: L'infection sévère est une situation difficile à maîtriser. Le pronostic reste dépendant à la fois de la rapidité du diagnostic et de l'instauration rapide d'un traitement adapté au germe en cause

Clinical value of new coagulation biomarkers in pediatric sepsis / 中华儿科杂志

Objective: To evaluate the clinical value of new coagulation biomarkers including soluble thrombomodulin (sTM) and tissue plasminogen activator inhibitor complex (t-PAI·C) for the diagnosis and prognosis of sepsis in children. Methods: The prospective observational study enrolled 59 children who were diagnosed with sepsis including severe sepsis and septic shock in the Department of Pediatric Critical Care Medicine of Shanghai Children's Medical Center affiliated to the Medical College of Shanghai Jiao Tong University from June 2019 to June 2021. The sTM, t-PAI·C and conventional coagulation tests were detected on illness day one of sepsis. Twenty healthy children were selected as the control group, and the above parameters were detected on the day of inclusion. Children with sepsis were divided into survival group and non-survival group according to prognosis at discharge. Baseline comparisons between groups were performed using Mann-Whitney U test. Multivariate Logistic regression analysis was used to evaluate the risk factors for the diagnosis and prognosis of sepsis in children. Receiver operating characteristic (ROC) curve was conducted to evaluate the predictive values of above variables for the diagnosis and prognosis of sepsis in children. Results: The sepsis group included 59 patients (39 boys and 20 girls), aged 61(22, 136)months. There were 44 patients in the survival group and 15 patients in the non-survival group, respectively. The control group consisted of 20 boys, aged 107 (94,122) months. Patients in the sepsis group had higher sTM and t-PAI·C ((12 (9, 17)×103 vs. 9(8, 10)×103 TU/L, 10(6, 22) vs. 2 (1, 3) μg/L, Z=-2.15, -6.05, both P<0.05) compared with children in the control group. The t-PAI·C was superior to sTM for the diagnosis of sepsis. The areas under the curve (AUC) of t-PAI·C and sTM for the diagnosis of sepsis were 0.95 and 0.66, respectively, and the optimal cut-off value were 3 μg/L and 12×103 TU/L, respectively. Patients in the survival group had lower sTM (10 (8, 14)×103 vs. 17 (11, 36)×103 TU/L, Z=-2.73, P=0.006) than those in the non-survival group. Logistic regression analysis showed that sTM was a risk factor for death at discharge (OR=1.14, 95%CI 1.04-1.27, P=0.006). The AUC of sTM and t-PAI·C for predicting death at discharge were 0.74 and 0.62, respectively, and the optimal cut-off values were 13×103 TU/L and 6 μg/L, respectively. The AUC of sTM combined with platelet counts for predicting death at discharge was 0.89, which was superior to sTM and t-PAI·C. Conclusion: The sTM and t-PAI·C had clinical application values in diagnosing and predicting prognosis in pediatric sepsis.

Diagnosis and treatment of pediatric septic shock in pediatric intensive care units from hospitals of different levels / 中华儿科杂志

Objective: To investigate the differences in clinical characteristics, diagnosis, and treatment of pediatric septic shock in pediatric intensive care unit (PICU) among hospitals of different levels. Methods: This retrospective study enrolled 368 children with septic shock treated in the PICU of Beijing Children's Hospital, Henan Children's Hospital, and Baoding Children's Hospital from January 2018 to December 2021. Their clinical data were collected, including the general information, location of onset (community or hospital-acquired), severity, pathogen positivity, consistence of guideline (the rate of standard attainment at 6 h after resuscitation and the rate of anti-infective drug administration within 1 h after diagnosis), treatment, and in-hospital mortality. The 3 hospitals were national, provincial, and municipal, respectively. Furthermore, the patients were divided into the tumor group and the non-tumor group, and into the in-hospital referral group and the outpatient or emergency admission group. Chi-square test and Mann-Whitney U test were used to analyze the data. Results: The 368 patients aged 32 (11, 98) months, of whom 223 were males and 145 females. There were 215, 107, and 46 patients with septic shock, with males of 141, 51, and 31 cases, from the national, provincial, and municipal hospitals, respectively. The difference in pediatric risk of mortality Ⅲ (PRISM Ⅲ) scores among the national,provincial and municipal group was statistically significant (26(19, 32) vs.19(12, 26) vs. 12(6, 19), Z=60.25,P<0.001). The difference in community acquired septic shock among the national,provincial and municipal group was statistically significant (31.6%(68/215) vs. 84.1%(90/107) vs. 91.3%(42/46), χ2=108.26,P<0.001). There were no significant differences in compliance with guidelines among the 3 groups (P>0.05). The main bacteria detected in the national group were Klebsiella pneumoniae (15.4% (12/78)) and Staphylococcus aureus (15.4% (12/78)); in the provincial group were Staphylococcus aureus (19.0% (12/63)) and Pseudomonas aeruginosa (12.7% (8/63)), and in the municipal group were Streptococcus pneumoniae (40.0% (10/25)) and Enteric bacilli (16.0% (4/25)). The difference in the proportion of virus and the proportion of 3 or more initial antimicrobials used among the national,provincial and municipal group was statistically significant (27.7% (43/155) vs. 14.9% (13/87) vs. 9.1% (3/33), 22.8%(49/215) vs. 11.2%(12/107) vs. 6.5%(3/46), χ2=8.82, 10.99, both P<0.05). There was no difference in the in-hospital mortality among the 3 groups (P>0.05). Regarding the subgroups of tumor and non-tumor, the national group had higher PRISM Ⅲ (31(24, 38) vs. 22 (21, 28) vs.16 (9, 22), 24 (18, 30) vs. 17(8, 24) vs. 10 (5, 16), Z=30.34, 10.45, both P<0.001), and it was the same for the subgroups of in-hospital referral and out-patient or emergency admission (29 (21, 39) vs. 23 (17, 30) vs. 15 (10, 29), 23 (17, 29) vs. 18 (10, 24) vs. 11 (5, 16), Z=20.33, 14.25, both P<0.001) as compared to the provincial and municipal group. There was no significant difference in the in-hospital mortality among the 2 pairs of subgroups (all P>0.05). Conclusion: There are differences in the severity, location of onset, pathogen composition, and initial antibiotics of pediatric septic shock in children's hospitals of different levels, but no differences in compliance with guidelines and in-hospital survival rate.

The value of maximal rate of left ventricular pressure in evaluating cardiac function in patients with sepsis-induced cardiomyopathy / 中华危重病急救医学

OBJECTIVE@#To investigate the value of maximal rate of left ventricular pressure (dp/dtmax) in evaluating the changes of cardiac function before and after heart rate reduction in patients with sepsis-induced cardiomyopathy (SIC).@*METHODS@#A single-center, prospective randomized controlled study was conducted. Adult patients with sepsis/septic shock admitted to the department of intensive care unit (ICU) of Tianjin Third Central Hospital from April 1, 2020 to February 28, 2022 were enrolled. Speckle tracking echocardiography (STE) and pulse indication continuous cardiac output (PiCCO) monitoring were performed immediately after the completion of the 1 h-Bundle therapy. The patients with heart rate over 100 beats/minutes were selected and randomly divided into esmolol group and regular treatment group, 55 cases in each group. All patients underwent STE and PiCCO monitoring at 6, 24 and 48 hours after admission in ICU and calculated acute physiology and chronic health evaluation II (APACHE II) and sequential organ failure assessment (SOFA). Primary outcome measure: change in dp/dtmax after reducing heart rate by esmolol. Secondary outcome measures: correlation between dp/dtmax and global longitudinal strain (GLS); changes of vasoactive drug dosage, oxygen delivery (DO2), oxygen consumption (VO2) and stroke volume (SV) after the administration of esmolol; proportion of heart rate reaching the target after the administration of esmolol; 28-day and 90-day mortality in two groups.@*RESULTS@#Baseline data on age, gender, body mass index, SOFA score, APACHE II score, heart rate, mean arterial pressure, lactic acid, 24-hour fluid balance, sepsis etiology and prior comorbidities were similar between esmolol group and regular treatment group, there were no significant differences between the two groups. All SIC patients achieved the target heart rate after 24 hours of esmolol treatment. Compared with regular treatment group, parameters reflecting myocardial contraction such as GLS, global ejection fraction (GEF) and dp/dtmax were significantly increased in esmolol group [GLS: (-12.55±4.61)% vs. (-10.73±4.82)%, GEF: (27.33±4.62)% vs. (24.18±5.35)%, dp/dtmax (mmHg/s): 1 312.1±312.4 vs. 1 140.9±301.0, all P < 0.05], and N-terminal pro-brain natriuretic peptide (NT-proBNP) significantly decreased [μg/L: 1 364.52 (754.18, 2 389.17) vs. 3 508.85 (1 433.21, 6 988.12), P < 0.05], DO2 and SV were significantly increased [DO2 (mL×min-1×m-2): 647.69±100.89 vs. 610.31±78.56, SV (mL): 49.97±14.71 vs. 42.79±15.77, both P < 0.05]. The system vascular resistance index (SVRI) in esmolol group was significantly higher than that in regular treatment group (kPa×s×L-1: 287.71±66.32 vs. 251.17±78.21, P < 0.05), even when the dosage of norepinephrine was similar between the two groups. Pearson correlation analysis showed that dp/dtmax was negatively correlated with GLS in SIC patients at 24 hours and 48 hours after ICU admission (r values were -0.916 and -0.935, respectively, both P < 0.05). Although there was no significant difference in 28-day mortality between esmolol group and regular treatment group [30.9% (17/55) vs. 49.1% (27/55), χ2 = 3.788, P = 0.052], the rate of esmolol use in patients who died within 28 days was lower than that in patients who survived [38.6% (17/44) vs. 57.6% (38/66), χ2 = 3.788, P = 0.040]. In addition, esmolol has no effect on the 90-day mortality of patients. Logistic regression analysis showed that after adjusting for SOFA score and DO2 factors, patients who used esmolol had a significantly lower risk of 28-day mortality compared with patients who did not use esmolol [odds ratio (OR) = 2.700, 95% confidence interval (95%CI) was 1.038-7.023, P = 0.042].@*CONCLUSIONS@#dp/dtmax in PiCCO parameter can be used as a bedside indicator to evaluate cardiac function in SIC patients due to its simplicity and ease of operation. Esmolol control of heart rate in SIC patients can improve cardiac function and reduce short-term mortality.

Diagnostic and prognostic value of neutrophil CD64, IL-6, and PCT in ICU patients with sepsis / 中华危重病急救医学

OBJECTIVE@#To explore the significance of neutrophil CD64 (nCD64), interleukin-6 (IL-6), and procalcitonin (PCT) alone and in combination in the diagnosis and prognosis evaluation of patients with sepsis.@*METHODS@#A prospective study was conducted. Adult patients admitted to the Western Intensive Care Unit (ICU) of Yantai Yuhuangding Hospital Affiliated to Medical College of Qingdao University from September 2020 to October 2021 were selected as subjects. The venous blood of the selected patients was collected within 6 hours of entering the ICU to measure the levels of nCD64, IL-6 and PCT. The levels of nCD64, IL-6 and PCT of septic patients were measured again on the 3rd and 7th days after admission to ICU. According to the diagnostic criteria of Sepsis-3, the patients were divided into sepsis group and non-sepsis group to evaluate the diagnostic value of nCD64, IL-6 and PCT in sepsis. The patients with sepsis were divided into sepsis group and septic shock group according to their condition on admission to ICU, and the evaluation value of three biomarkers for sepsis was evaluated. Sepsis patients were divided into the survival group and the death group according to survival after 28 days, and the relationship between the three biomarkers and the prognosis of sepsis was evaluated.@*RESULTS@#Finally, 47 patients with sepsis, 43 patients with septic shock, and 41 patients without sepsis were enrolled. Seventy-six patients with sepsis survived and 14 died after 28 days. (1) The levels of nCD64, IL-6 and PCT on the first day of ICU admission in the sepsis group were significantly higher than those in the non-sepsis group [nCD64: 26.95 (14.05, 86.18) vs. 3.10 (2.55, 5.10), IL-6 (ng/L): 93.45 (52.73, 246.30) vs. 34.00 (9.76, 62.75), PCT (μg/L): 6.63 (0.57, 68.50) vs. 0.16 (0.08, 0.35), all P < 0.01]. The receiver operator characteristic curve (ROC curve) showed that the area under curve (AUC) of nCD64, IL-6 and PCT in the diagnosis of sepsis were 0.945, 0.792 and 0.888, respectively. The diagnostic value of nCD64 was the highest. When the cut-off value of nCD64 was 7.45, the sensitivity and specificity were 92.2% and 95.1% respectively. When nCD64, IL-6 and PCT were diagnosed in pairs or in combination, the combination of the three had the highest diagnostic performance, with AUC of 0.973, sensitivity of 92.2% and specificity of 97.6%. (2) The levels of nCD64, IL-6 and PCT in septic shock group were higher than those in sepsis group on the 1st, 3rd and 7th day after admission to ICU. ROC curve analysis showed that nCD64, IL-6 and PCT had some accuracy in evaluating the severity of sepsis on the 1st, 3rd and 7th day after entering ICU, with AUC ranging from 0.682 to 0.777. (3) The levels of nCD64, IL-6 and PCT in the death group were significantly higher than those in the survival group. Except for the nCD64 and PCT values on the first day after admission to the ICU, there were significant differences between the two groups in all indicators at other time points. ROC curve analysis showed that the AUC of nCD64, IL-6 and PCT predicting the prognosis of sepsis at each time point ranged from 0.600 to 0.981. The clearance rates of nCD64, IL-6 and PCT at 3 and 7 days after ICU admission were calculated by dividing the difference between the 1st and 3rd or 7th days after entering the ICU by the value at the 1st day. Logistic regression was used to analyze their predictive value for the prognosis of sepsis. The results showed that the clearance rates of nCD64, IL-6 and PCT on the 3rd and 7th day of ICU were protective factors for 28-day mortality in patients with sepsis, except the clearance rate of IL-6 on the 7th day.@*CONCLUSIONS@#nCD64, IL-6 and PCT have good value as biomarkers for the diagnosis of sepsis. The diagnostic value of nCD64 is higher than that of PCT and IL-6. When they are used together, the diagnostic value is the highest. nCD64, IL-6 and PCT have certain value in evaluating the severity and predicting the prognosis of patients with sepsis. The higher the clearance rate of nCD64, IL-6 and PCT, the lower the 28-day mortality risk of patients with sepsis.

Comparison between the 2020 international guidelines for the management of sepsis and septic shock and the Japanese guidelines for the management of sepsis / 中华危重病急救医学

In 2021, the Society of Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM) jointly released the Surviving Sepsis Campaign: international guidelines for management of sepsis and septic shock 2020 with 93 recommendations. In the same year, the Japanese Society of Intensive Care Medicine (JSICM) and the Japanese Association for Acute Medicine (JAAM) also cooperated to publish the Japanese clinical practice guidelines for management of sepsis and septic shock 2020, covering 118 clinical issues in 22 areas. In this paper, 50 items in the contents of the two guidelines are compared in accordance with the order of international guidelines, including screening, initial resuscitation, mean arterial pressure, transfer to intensive care unit (ICU), diagnosis of infection, timing of antimicrobial administration, biomarkers for initiation of antimicrobial therapy, selection of antibiotic, antifungal therapy, antiviral therapy, infusion of antibiotic, pharmacokinetics and pharmacodynamics, source of infection control, antimicrobial de-escalation strategy, course of antimicrobial administration, biomarkers for discontinuation of antibiotic, fluid management, vasoactive agents, positive inotropic agents, monitoring and intravenous access, fluid balance, oxygenation targets, high-flow nasal cannula oxygen therapy, noninvasive ventilation, protective ventilation in acute respiratory distress syndrome (ARDS), low tidal volume in respiratory failure patients with non-ARDS, lung recruitment maneuvers, prone position ventilation, muscle relaxants, extracorporeal membrane oxygenation (ECMO), glucocorticoids, blood purification, red blood cell (RBC) transfusion, immunoglobulin, stress ulcer prevention, prevention of venous thromboembolism (VTE), renal replacement therapy, glycemic management, vitamin C, sodium bicarbonate therapy, nutrition, treatment goals, palliative care, peer support groups, transition of care, screening economic and social support, education for the knowledge about sepsis to the patients and their families, common decision-making, discharge planning, cognitive therapy and follow-up after discharge. It is convenient for everyone to understand some views in the field of sepsis and septic shock, and deepen their understanding.

Clinical management and prognosis for descending necrotizing mediastinitis / 中华耳鼻咽喉头颈外科杂志

Objective: To investigate the clinical characteristics, treatment experiences and prognostic factors for descending necrotizing mediastinitis (DNM). Methods: A retrospective analysis was performed on the data of 22 patients with DNM diagnosed and treated in Henan Provincial People's Hospital from January 2016 to August 2022, including 16 males and 6 females, aged 29-79 years. After admission, all patients underwent CT scanning of the maxillofacial, cervical, and thoracic regions to confirm their diagnoses. Emergency incision and drainage were performed. The neck incision was treated with continuous vacuum sealing drainage. According to the prognoses, the patients were divided into cure group and death group, and the prognostic factors were analyzed. SPSS 25.0 software was used to analyze the clinical data. Rusults: The main complaints were dysphagia (45.5%, 10/22) and dyspnea (50.0%, 11/22). Odontogenic infection accounted for 45.5% (10/22) and oropharyngeal infection accounted for 54.5% (12/22). There were 16 cases in the cured group and 6 cases in the death group, with a total mortality rate of 27.3%. The mortality rates of DNM typeⅠand typeⅡwere respectively 16.7% and 40%. Compared with the cured group, the death group had higher incidences for diabetes, coronary heart disease and septic shock (all P<0.05). There were statistically significant differences between the cure group and the death group in procalcitonin level (50.43 (137.64) ng/ml vs 2.92 (6.33) ng/ml, M(IQR), Z=3.023, P<0.05) and acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score (16.10±2.40 vs 6.75±3.19, t=6.524, P<0.05). Conclution: DNM is rare, with high mortality, high incidence of septic shock, and the increased procalcitonin level and APACHE Ⅱ score combined diabetes and coronary heart disease are the poor prognostic factors for DNM. Early incision and drainage combined with continuous vacuum sealing drainage technique is a better way to treat DNM.

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.

Síndrome inflamatorio multisistémico asociado a COVID-19: a propósito de un caso clínico con fenotipo shock e íleo paralítico / Multisystem inflammatory syndrome associated with COVID-19: clinical case with shock phenotype and paralytic ileus / Síndrome inflamatória multissistêmica associada à COVID-19: relato de caso com fenótipo de choque e íleo paralítico

La enfermedad por coronavirus 2019 (COVID-19) causada por la infección por SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) se ha extendido por todo el mundo desde diciembre de 2019. Luego de la primera ola de COVID-19, se reporta por primera vez en mayo de 2020 en el Reino Unido un estado hiperinflamatorio asociado temporalmente a la infección por SARS-CoV-2 en un grupo de niños ingresados a unidades de cuidado intensivo pediátrico. Este nuevo fenotipo, con características similares a la enfermedad de Kawasaki y al síndrome del shock tóxico, se ha denominado síndrome inflamatorio multisistémico en niños (MIS-C). Es fundamental la sospecha y el reconocimiento tempranos de esta entidad, con el fin de ofrecer un tratamiento médico oportuno, para prevenir la muerte y el desarrollo de secuelas. Presentamos el caso de una preescolar de 5 años, en la que se realizó diagnóstico de MIS-C con un fenotipo shock e íleo paralítico.

The coronavirus disease 2019 (COVID-19) caused by the infection by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) has spread worldwide since December 2019. After the first wave of COVID-19, a hyperinflammatory condition temporarily associated with SARS-CoV-2 infection appeared in a group of children admitted to pediatric intensive care units and reported for the first time in May 2020 in the United Kingdom. This new phenotype shared characteristics with the Kawasaki disease and toxic shock syndrome and has been called multisystem inflammatory syndrome in children (MIS-C). Early suspicion and recognition of this condition is key in order to offer timely medical treatment to prevent death and the development of sequelae. We present the case of a 5-year-old child, in which diagnosis of MIS-C with a shock phenotype and paralytic ileus.

A doença de coronavírus 2019 (COVID-19) causada pela infecção por SARS-CoV-2 (síndrome respiratória aguda grave coronavírus 2) se espalhou pelo mundo desde dezembro de 2019. Após a primeira onda de COVID-19, houve relatos pela primeira vez em maio de 2020 no Reino Unido duma doença hiperinflamatória temporariamente associada à infecção por SARS-CoV-2 num grupo de crianças internadas em unidades de terapia intensiva pediátrica. Esse novo fenótipo com características semelhantes à doença de Kawasaki e a síndrome do choque tóxico foi chamado de síndrome inflamatória multissistêmica em crianças (MIS-C). A suspeita precoce e o reconhecimento dessa entidade são essenciais, a fim de oferecer tratamento médico oportuno, para prevenir a morte e o desenvolvimento de sequelas. Apresentamos o caso de uma menina pré-escolar de 5 anos que foi diagnosticada com MIS-C com fenótipo de choque e íleo paralítico.

Perfil de pacientes com sepse e choque séptico em um hospital de trauma: estudo transversal / Profile of patients with sepsis and septic shock in a trauma hospital: cross-sectional study / Perfil de pacientes con sepsis y shock séptico en un hospital de trauma: estudio transversal

Objetivo: Avaliar o perfil e o desfecho clínico de pacientes com sepse e choque séptico em um hospital de trauma de Belo Horizonte. Métodos: Trata-se de estudo transversal, retrospectivo e descritivo dos casos de sepse e choque séptico. Resultados: Constatou-se que 97 (73%) pacientes eram do sexo masculino, com idade entre 19 e 59 anos, 87 (65%) previamente hígidos. Principal motivo de internação foi queda da própria altura com 23 (17%) casos e 37 (28%) diagnósticos de trauma crânio encefálico. Oitenta e seis (65%) pacientes tiveram diagnóstico de sepse e 47 (35%) choque séptico, o principal foco de infecção foi pulmonar 83 (62%). Obtivemos 88 (66%) resultados de hemoculturas negativas e 45 (34%) positivas, 64 (48%) pacientes receberam antibiótico em até 60 minutos após o diagnóstico e o tempo de internação mais prevalente após o evento séptico foi de 7 dias, representado por 31 (46%) pacientes que já estavam internados em uma Unidade de Terapia Intensiva (UTI). Mortalidade de 37 (28%) e 96 (72%) sobreviventes da população estudada. Conclusão: O evento séptico é um problema de saúde pública e tem alta letalidade em pacientes traumatizados. (AU)

Objective: To evaluate the profile and clinical outcome of patients with sepsis and septic shock in a trauma hospital in Belo Horizonte. Methods: This is a cross-sectional, retrospective and descriptive study of cases of sepsis and septic shock. Results: It was found that 97 (73%) patients were male, aged 19 to 59 years, 87 (65%) were previously healthy. Main reason for hospitalization was a fall from one's own height with 23 (17%) cases and 37 (28%) diagnosis of traumatic brain injury. Eighty-six (65%) patients were diagnosed with sepsis and 47 (35%) septic shock, the main focus of infection was pulmonary 83 (62%). We got 88 (66%) negative blood culture results and 45 (34%) positive, 64 (48%) patients received antibiotics within 60 minutes after diagnosis and the most prevalent hospital stay after septic event was 7 days, represented by 31 (46%) patients who were already hospitalized in an Intensive Care Unit (ICU). Mortality of 37 (28%) and 96 (72%) survivors of the population studied. Conclusion: Septic event is a public health problem and has high lethality in traumatized patients. (AU)

Objetivo: Evaluar el perfil y el resultado clínico de los pacientes con sepsis y shock séptico en un hospital de trauma en Belo Horizonte. Métodos: Este es un estudio transversal, retrospectivo y descriptivo de casos de sepsis y shock séptico. Resultados: Se encontró que 97 (73%) pacientes eran hombres, de 19 a 59 años, 87 (65%) antes estaban sanos. La razón principal de la hospitalización fue una caída desde la propia altura con 23 (17%) casos y 37 (28%) diagnóstico de lesión cerebral traumática. Ochenta y seis (65%) pacientes fueron diagnosticados con sepsis y 47 (35%) shock séptico, el foco principal de infección fue pulmonar 83 (62%). Tenemos 88 (66%) resultados negativos del cultivo sanguíneo y 45 (34%) positivo, 64 (48%) los pacientes recibieron antibióticos dentro de los 60 minutos posteriores al diagnóstico y la estancia hospitalaria más frecuente después del evento séptico fue de 7 días, representados por 31 (46%) pacientes que ya estaban hospitalizados en una Unidad de Cuidados Intensivos (UCI). Mortalidad de 37 (28%) y 96 (72%) sobrevivientes de la población estudiada. Conclusión: El evento séptico es un problema de salud pública y tiene alta letalidad en pacientes traumatizados. (AU)

Caracterización demográfica y clínica de pacientes críticos con neumonía por influenza A H1N1 / Demographic and clinical characterization of critically ill patients with influenza A H1N1 pneumonia

INTRODUCCIÓN. La epidemia de influenza y sus complicaciones profundizaron el estudio de las neumonías virales en cuidados intensivos. En nuestro país hay pocos datos sobre este tema. OBJETIVOS. Realizar una caracterización demográfica y clínica de pacientes críticos con neumonía por Influenza A H1N1 en un hospital de tercer nivel de complejidad. MATERIALES Y MÉTODOS. Estudio observacional, analítico, retrospectivo, con análisis univariante y multivariante. Población de 293 y muestra de 44 datos de historias clínicas electrónicas de pacientes diagnosticados con A H1N1 ingresados a la Unidad de cuidados intensivos del Hospital de Especialidades Carlos Andrade Marín en el período enero 2016 a diciembre de 2018. Como criterios de inclusión se consideró a todos los pacientes adultos mayores de 18 años que ingresaron a la UCI, con el diagnóstico de neumonía comunitaria grave con confirmación por reacción de cadena de polimerasa en tiempo real para influenza A H1N1 en hisopado nasal o aspirado traqueal. Se excluyó a pacientes embarazadas con diagnóstico de influenza A H1N1, pacientes con más de 48 horas de ingreso hospitalario previo a su ingreso a UCI, pacientes con datos insuficientes en los registros. Los datos se obtuvieron del sistema AS-400. El análisis estadístico se realizó en el programa Statistical Package for Social Sciences, versión 22. El nivel de significación fue una p<0.05. RESULTADOS. La prevalencia en pacientes críticos de neumonía por influenza A H1N1 durante 2016-2018 fue de 16,72%, la mediana de edad fue de 55 años, 25% masculinos, 34% obesos, 34% con hipertensión arterial. Escala "Acute Physiology and Chronic Health Evaluation II" 23,50, "Simplified Acute Physiologic Score III" 54, "Sepsis related Organ Failure Assessment" 11,50, Lactato deshidrogenasa 99,50, Procalcitonina 0,99; 9 días de ventilación mecánica invasiva, 10,50 días de estancia en la unidad. El 91% presentó shock séptico, 59% lesión renal aguda. El 89% tuvo Síndrome de Distrés Respiratorio del Adultos, 69% fue grave, 87% usó ventilación mecánica, 38,50% corticoides, 36% posición prona, Presión parcial de oxígeno/Fracción inspirada de oxígeno 74, volumen tidal/kilogramo de 7 mililitros, presión plateau de 27,50 centímetros de agua. La mortalidad general en la Unidad de Cuidados Intensivos fue de 38,63% y a los 28 días de 63,60%, en shock séptico fue 42,50% y en Síndrome de Distrés Respiratorio del Adultos del 41,02%. El análisis de regresión logística multivariable identificó como factores independientes asociados a mortalidad el incremento de Lactato deshidrogenasa (OR 2,69, 9% IC 1,090-6,642) y Procalcitonina (OR 2,51, IC 1,005-6,272). CONCLUSIONES. Las características, frecuencia y mortalidad de este grupo de pacientes críticos con neumonía por influenza A H1N1 son similares a lo reportado en la literatura mundial.

INTRODUCTION. The influenza epidemic and its complications deepened the study of viral pneumonias in intensive care. In our country there is little data on this subject. OBJECTIVES. To perform a demographic and clinical characterization of critical patients with pneumonia due to pneumonia due to Influenza A H1N1 in a third level hospital. MATERIALS AND METHODS. Observational, analytical, retrospective study, with univariate and multivariate analysis. We compared the groups of dead patients and survivors. The significance level was p<0,05. RESULTS. The prevalence in critically ill patients of influenza A H1N1 pneumonia during 2016-2018 was 16,72%, 44 cases were collected, median age 55 years, 25% male, 34% obese, 34% with arterial hypertension. APACHE II 23,50, SAPS III 54, SOFA 11,50, LDH 99,50, PCT 0,99, 9 days of invasive mechanical ventilation, 10,50 days of unit stay. 91% presented septic shock, 59% with acute kidney injury 89% had ARDS, 69% were severe, 87% used mechanical ventilation, 38,50% corticosteroids, 36% prone position, PaO2/FiO2 74, tidal volume/kg of 7 ml, plateau pressure of 27,50 cmH2O. Overall mortality in the ICU was 38,63% and at 28 days was 63,60%, in septic shock it was 42,50% and in Adult Respiratory Distress Syndrome it was 42,50%. was 42,50% and 41,02% in Adult Respiratory Distress Syndrome. The ultivariate logistic regression analysis identified as independent factors associated with mortality, the increase in LDH (OR 2,69, 9% CI 1,090-6,642) and PCT (OR 2,51, CI 1,005-6,272). CONCLUSIONS. The characteristics, frequency and mortality of this group of critical patients with pneumonia due to influenza A H1N1 are similar to those reported in the world literature.

Clinical management of COVID-19: living guideline - 15 September 2022

The WHO COVID-19 Clinical management: living guidance contains the Organization's most up-to-date recommendations for the clinical management of people with COVID-19. Providing guidance that is comprehensive and holistic for the optimal care of COVID-19 patients throughout their entire illness is important. The latest version of this living guideline is available in pdf format (via the 'Download' button) and via an online platform, and is updated regularly as new evidence emerges. No further updates to the previous existing recommendations were made in this latest version. This updated (fifth) version contains 16 new recommendations for the rehabilitation of adults with post COVID-19 condition (see Chapter 24), which includes: strong recommendation that exertional desaturation and cardiac impairment following COVID-19 should be ruled out and managed before consideration of physical exercise training

Síndrome Inflamatória Multissistêmica Pediátrica (SIM-P) em crianças e adolescente com até 19 anos de idade, temporalmente associada à Covid-19 / Pediatric Multisystem Inflammatory Syndrome (P-SIM) in children and adolescents up to 19 years of age, temporally associated with Covid-19

A Síndrome Inflamatória Multissistêmica Pediátrica (SIM-P) é uma condição que afeta e prejudica diversas partes do corpo, incluindo coração, pulmões, rins, cérebro, pele, olhos ou órgãos gastrointestinais. É uma síndrome rara que ainda necessita de estudo. No entanto, é sabido que muitas crianças que apresentaram SIM-P tiveram o vírus que causa a COVID-19 ou entraram em contato com alguém com COVID-19. A SIM-P pode ser grave e fatal, e grande parte dos casos pode necessitar de internação em unidade de terapia intensiva

Shock séptico secundario a fascitis necrotizante abdominal tras drenaje de absceso interesfintérico perianal / Septic shock secondary to abdominal necrotizing fascitis after drainage of perianal intersphyteric abscess

Resumen Objetivo: El objetivo de este manuscrito es presentar el caso de un varón de 41 años que debuta con shock séptico y fascitis necrotizante abdominal en el posoperatorio del desbridamiento de un absceso perianal para focalizar la atención del lector en la posible evolución clínica hacia gangrena de Fournier. Materiales y Método: Tras la intervención, el paciente refiere aumento de temperatura y sensación de crepitación subcutánea a nivel abdominal, junto con empeoramiento clínico y hemodinámico, evidenciándose evolución tórpida hacia gangrena de Fournier extendida a región abdominal. Resultados: Tras la reintervención, el paciente presentó una evolución favorable aunque requirió sucesivas curas y desbridamientos quirúrgicos. Conclusiones y Discusión: Cabe destacar la importancia de una exploración clínica completa y detallada previa a cualquier intervención quirúrgica, así como el diagnóstico temprano en situaciones de shock séptico que permitan inicio de antibioterapia precoz y control del foco eficaz.

Aim: The objective of this manuscript is to present the case of a 41-year-old man with septic shock and abdominal necrotizing fasciitis after drainage of an interesphinteric perianal abscess to focus the reader's attention on the possible clinical evolution towards Fournier's gangrene. Materials and Method: After the intervention, the patient reported an increase in temperature and a sensation of subcutaneous crepitus at the abdominal level, with clinical and hemodynamic worsening, showing a torpid evolution towards Fournier's gangrene extended to the abdominal area. Results: After the reoperation, the patient presented a favorable evolution, although he required successive cures and surgical debridements. Conclusions and Discussion: It is worth highlighting the importance of a complete and detailed clinical examination prior to any surgical intervention, as well as the early diagnosis in situations of septic shock that allow early initiation of antibiotic therapy and effective control of the focus.

Caracterización de los pacientes con enfermedades vasculares periféricas fallecidos en un período de cuatro años / Characterization of patients with peripheral vascular diseases who died in a period of four years

Introducción: Las enfermedades vasculares periféricas constituyen un problema de salud en el ámbito mundial por resultar causa importante de discapacidad y de invalidez. Objetivo: Caracterizar a los pacientes con enfermedades vasculares periféricas fallecidos en un período de cuatro años. Método: Se realizó un estudio descriptivo y analítico en los pacientes fallecidos entre enero de 2015 y diciembre de 2018. Se estudiaron variables sociodemográficas y clínicas. Se estimaron las frecuencias absolutas y relativas, así como la tasa de mortalidad. Se identificó la asociación entre las variables con la causa directa de muerte. Resultados: El 42,7 por ciento de los diabéticos fallecieron; de estos, el 57,5 por ciento estaban descompensados. La hipertensión arterial, el tabaquismo y la diabetes mellitus fueron los factores de riesgo más frecuentes. La tasa de mortalidad total resultó 0,171/1000 ingresos. Como enfermedades arteriales más frecuente aparecieron los AAA (28,1 por ciento ) y la angiopatía diabética (25 por ciento ); y, como parte de esta última, el pie (25,7 por ciento ). La aneurismectomía con injerto por sustitución representó la cirugía revascularizadora más realizada (58,8 por ciento ). El shock hipovolémico y el tromboembolismo pulmonar predominaron como complicaciones posquirúrgicas (15,7 por ciento ). El shock séptico (31,6 por ciento ) y la bronconeumonía bacteriana (25,7 por ciento) fueron las causas directas de muerte. Conclusiones: Se logró caracterizar a los pacientes con enfermedades vasculares periféricas fallecidos en los últimos cuatro años, por lo que estimaron la tasa de prevalencia y la tendencia anual de la mortalidad en el Instituto Nacional de Angiología y Cirugía Vascular en ese período; asimismo, las variables asociadas a las causas directas de muerte(AU)

Introduction: Peripheral vascular diseases are a global health problem because they are a major cause of disability. Objective: Characterize patients with peripheral vascular diseases who died over a period of four years. Method: A descriptive and analytical study was conducted in patients who died between January 2015 and December 2018. Socio-demographic and clinical variables were studied. Absolute and relative frequencies were estimated, as well as the mortality rate. The association between the variables with the direct cause of death was identified. Results: 42.7 percent of diabetic patients died; of these, 57.5 percent were decompensated. High blood pressure, smoking and diabetes mellitus were the most frequent risk factors. The total mortality rate was 0.171/1000 admissions. The most frequent arterial diseases were AAA (28.1 percent) and diabetic angiopathy (25 percent); and, as part of the latter, foot angiopathy (25.7 percent). Aneurysmectomy with graft substitution represented the most performed revascularizing surgery (58.8 percent). Hypovolemic shock and pulmonary thromboembolism predominated as post-surgical complications (15.7 percent). Septic shock (31.6 percent) and bacterial bronchopneumonia (25.7 percent) were the direct causes of death. Conclusions: It was possible to characterize patients with peripheral vascular diseases who died in the last four years, so they estimated the prevalence rate and the annual trend of mortality at the National Institute of Angiology and Vascular Surgery in that period; also, the variables associated with direct causes of death(AU)

Inmunodeficiencia combinada grave: Presentación de un caso / Severe Combined Immunodeficiency: Case presentation

Introducción: Las inmunodeficiencias primarias son un grupo heterogéneo de trastornos hereditarios ocasionados por defectos del desarrollo o función del sistema inmunológico. Las inmunodeficiencias combinadas graves constituyen el 15 por ciento de las inmunodeficiencias primarias, son graves y los pacientes rara vez sobreviven sin tratamiento después del primer año de vida, lo que obliga a un diagnóstico y tratamiento oportuno. Objetivo: Presentar un caso con inmunodeficiencia combinada grave, condición reportada con poca frecuencia y evolución desfavorable. Presentación de caso: Lactante masculino de seis meses con antecedentes de cuatro ingresos en Unidad de Terapia Intensiva por infecciones, el último por bronconeumonía bilateral. Fue valorado por Inmunología y se diagnosticó una inmunodeficiencia combinada grave por la clínica (infecciones por gérmenes oportunistas: Candida albicans y Pneumocistys jirovecii) y estudios inmunológicos (con disminución de los anticuerpos IgG: 0,02 g/L, IgM: 0.1 g/L e IgA: 0 g/L), subpoblaciones linfocitarias disminuidas (CD3/CD4: 9,3 por ciento, CD3/CD8: 5,6 por ciento, CD19: 0 por ciento, CD 16: 0,73 por ciento), además hipoplasia tímica severa (120 mm2). Se inició tratamiento con antimicrobianos de amplio espectro e inmunoestimulantes (Hebertrans y Biomodulina T). Evolucionó desfavorablemente y falleció por shock séptico. Conclusiones: La inmunodeficiencia combinada grave es una emergencia pediátrica que debe tenerse en cuenta en pacientes con antecedentes de infecciones recurrentes, es vital conocer las manifestaciones clínicas tempranas que permitan la sospecha diagnóstica, haciendo uso de todas las herramientas disponibles para su confirmación. El diagnóstico precoz es el elemento clave para la reducción de la morbilidad y mortalidad relacionada con estas enfermedades(AU)

Introduction: Primary Immunodeficiencies are a heterogeneous group of inherited disorders caused by defects in development or function of the immune system. Severe Combined Immunodeficiencies constitute 15% of the primary immunodeficiencies, they are acute and patients rarely survive without treatment after the first year of life, requiring a quick diagnosis and treatment. Objective: To present a case on Severe Combined Immunodeficiency, a condition infrequently reported and with unfavorable evolution. Case presentation: Six-month-old male infant with a history of four admissions to the Intensive Care Unit due to infections, in the latter one due to bilateral bronchopneumonia. He was evaluated by Immunology and a Severe Combined Immunodeficiency was diagnosed by the clinic (infections by opportunistic germs: Candida albicans and Pneumocistys jirovecii) and immunological studies (with a decrease in IgG antibodies: 0.02 g/L, IgM: 0.1 g/L and IgA: 0 g/L), decreased lymphocyte subpopulations (CD3/CD4: 9.3 percent, CD3/CD8: 5.6 percent, CD19: 0 percent, CD 16: 0.73 percent), in addition to severe thymic hypoplasia (120 mm2). Treatment with broad spectrum antimicrobials and immunostimulants (Hebertrans and Biomodulin T) was started. He evolved unfavorably and died of septic shock. Conclusions: Severe Combined Immunodeficiency is a pediatric emergency that must be taken into account in patients with a history of recurrent infections, it is vital to know the early clinical manifestations that allow a suspected diagnosis, making use of all the available tools for its confirmation. Early diagnosis is the key element in reducing morbidity and mortality related to these diseases(AU)

COVID-19, shock séptico refractario y terapia extracorpórea de purificación sanguínea con OXIRIS® / Management of refractory septic shock with blood purification therapy using a special filter: report of one case

Sepsis is one of the leading causes of death in critically ill patients with COVID-19 and blood purification therapies have a role to immunomodulate the excessive inflammatory response and improve clinical results. One of the devices designed for these therapies is the oXiris® filter, allowing to perform renal replacement therapy combined with selective adsorption of endotoxins and cytokines. We report a 55-year-old male with COVID who developed a septic shock secondary to a sepsis caused by Pseudomona aeruginosa, refractory to the usual management. A veno-venous continuous hemofiltration was started using the oXiris® filter for 48 hours. Subsequently, there was an improvement in clinical perfusion parameters and a reduction in inflammatory markers. The patient was discharged from the intensive care one month later.