Shock séptico: complicación atípica de duplicación del tracto alimentario / Septic shock: an atypical complication of alimentary tract duplication

Las duplicaciones del tracto alimentario son un conjunto heterogéneo de anomalías congénitas del tubo digestivo. Su forma de presentación es variada, y pueden desarrollar distintas complicaciones libradas a su evolución natural. La infección es una complicación poco frecuente, pero que no puede desconocerse por la gravedad que implica. Se presenta el caso de una paciente de 2 años de edad, previamente sana, con una complicación atípica de una duplicación del tracto alimentario: un shock séptico. Consultó inicialmente por distensión y dolor abdominal asociado a una masa abdominal palpable. Los estudios imagenológicos evidenciaron una formación líquida parcialmente tabicada en el hemiabdomen derecho. Durante la internación, se presentó una infección intratumoral, que evolucionó al shock séptico. Respondió favorablemente al tratamiento médico del shock, y se realizó la exéresis quirúrgica posteriormente. La anatomía patológica confirmó la duplicación del tracto alimentario.

Alimentary tract duplications are heterogenous congenital anomalies of the digestive tract. Their form of presentation is varied, and they may lead to different complications, depending on their natural course. Infection is a rare complication, but it cannot be ignored because of its severity. Here we describe the case of an otherwise healthy 2-year-old girl with an atypical complication of alimentary tract duplication: septic shock. She initially consulted due to abdominal distension and pain associated with a palpable abdominal mass. The imaging studies showed a partial fluid septation in the right side of the abdomen. During hospitalization, an intratumoral infection developed, which progressed to septic shock. The patient responded favorably to medical treatment for shock, and surgical resection was subsequently performed. The pathology report confirmed the presence of alimentary tract duplication.

Significado biológico y utilidad clínica del lactato en la sepsis / Biological significance and clinical utility of lactate in sepsis

La sepsis es un problema global de salud y la progresión hacia el shock séptico se asocia con un incremento marcado de la morbimortalidad. En este escenario, el aumento del lactato plasmático demostró ser un indicador de gravedad y un predictor de mortalidad, y suele interpretarse casi exclusivamente como marcador de baja perfusión tisular. Sin embargo, últimamente se produjo un cambio de paradigma en la exégesis del metabolismo y propiedades biológicas del lactato. En efecto, la adaptación metabólica al estrés, aun con adecuado aporte de oxígeno, puede justificar la elevación del lactato circulante. Asimismo, otras consecuencias fisiopatológicas de la sepsis, como la disfunción mitocondrial, se asocian con el desarrollo de hiperlactatemia sin que necesariamente se acompañen de baja perfusión tisular. Interpretar el origen y la función del lactato puede resultar de suma utilidad clínica en la sepsis, especialmente cuando sus niveles circulantes fundamentan las medidas de reanimación.

Sepsis is a global health problem; progression to septic shock is associated with a marked increase in morbidity and mortality. In this setting, increased plasma lactate levels demonstrated to be an indicator of severity and a predictor of mortality, and are usually interpreted almost exclusively as a marker of low tissue perfusion. However, a recent paradigm shift has occurred in the exegesis of lactate metabolism and its biological properties. Indeed, metabolic adaptation to stress, even with an adequate oxygen supply, may account for high circulating lactate levels. Likewise, other pathophysiological consequences of sepsis, such as mitochondrial dysfunction, are associated with the development of hyperlactatemia, which is not necessarily accompanied by low tissue perfusion. Interpreting the origin and function of lactate may be of great clinical utility in sepsis, especially when circulating lactate levels are the basis for resuscitative measures.

Bone and joint infection complicated with sepsis in neonates and infants under three months of age

Abstract Objective: Studies focusing on bone and joint infections (BJIs) in young infants are rare. Some cases of BJI are accompanied by sepsis. This study aimed to identify the clinical and bacteriological features of sepsis in neonates and young infants with BJIs. Methods: Neonates and infants younger than 3 months diagnosed with BJI in the present institution from 2014 to 2021 were retrospectively reviewed. Patient characteristics, clinical data, and outcomes were documented and compared between those with and without sepsis. Results: Twenty-five patients with a mean age of 34.8 days were included. Nine BJI cases had concomitant sepsis (group A), and 16 had BJI without sepsis (group B). Within group A, staphylococcus aureus was the major pathogenic germ (5 cases, of which 4 were of the methicillin-resistant staphylococcus aureus (MRSA) type). There was no statistical difference in male-to-female ratio, age, history of hospitalization, anemia, birth asphyxia, peripheral leukocyte counts, C-reactive protein on admission, and sequelae between groups. Univariate analyses indicated a significant difference in the incidence of septic arthritis (SA) combined with osteomyelitis (OM) (88.9% vs 37.5%), congenital deformities (44.4% vs 0%), and mean duration of symptoms (2.83 days vs 9.21 days) in comparisons between groups A and B. Conclusion: Staphylococcus aureus is the main pathogenic bacteria in BJI cases complicated with sepsis in neonates and young infants. Among infants younger than 3 months diagnosed with BJI, those with concurrent SA and OM, MRSA infection, or congenital deformities are more likely to develop sepsis.

Assessment of the components of fluid balance in patients with septic shock: a prospective observational study

Abstract Background: The optimal amount for initial fluid resuscitation is still controversial in sepsis and the contribution of non-resuscitation fluids in fluid balance is unclear. We aimed to investigate the main components of fluid intake and fluid balance in both survivors and non-survivor patients with septic shock within the first 72 hours. Methods: In this prospective observational study in two intensive care units, we recorded all fluids administered intravenously, orally, or enterally, and losses during specific time intervals from vasopressor initiation: T1 (up to 24 hours), T2 (24 to 48 hours) and T3 (48 to 72 hours). Logistic regression and a mathematical model assessed the association with mortality and the influence of severity of illness. Results: We included 139 patients. The main components of fluid intake varied across different time intervals, with resuscitation and non-resuscitation fluids such as antimicrobials and maintenance fluids being significant contributors in T1 and nutritional therapy in T2/T3. A positive fluid balance both in T1 and T2 was associated with mortality (p = 0.049; p = 0.003), while nutritional support in T2 was associated with lower mortality (p = 0.040). The association with mortality was not explained by severity of illness scores. Conclusions: Non-resuscitation fluids are major contributors to a positive fluid balance within the first 48 hours of resuscitation. A positive fluid balance in the first 24 and 48 hours seems to independently increase the risk of death, while higher amount of nutrition seems protective. This data might inform fluid stewardship strategies aiming to improve outcomes and minimize complications in sepsis.

POTENTIAL CONTRIBUTION OF ChatGPT® TO LEARNING ABOUT SEPTIC SHOCK IN INTENSIVE CARE / POTENCIAL APORTE DE APLICAR ChatGPT® EN LA ENSEÑANZA DE SHOCK SÉPTICO EN CUIDADOS INTENSIVOS / CONTRIBUIÇÃO POTENCIAL DE APLICAÇÃO DO ChatGPT® NA APRENDIZAGEM DO CHOQUE SÉPTICO EM TERAPIA INTENSIVA

ABSTRACT Objective: to demonstrate the application of some prompts and to problematize the use of ChatGPT® to guide the best answers for nursing students and teachers on septic shock in intensive care learning. Method: a methodological study where prompt technology was applied in ChatGPT® to support nursing learning in intensive care with an emphasis on septic shock. The study was organized in 3 stages, covering an understanding of ChatGPT® and models, as well as testing and exercising prompts. Results: applications of prompts were presented, based on a structure of pre-defined stages that made it possible to exemplify the answers given and to organize an output generation diagram as a way of summarizing the process of decision support in intensive care. Conclusion: ChatGPT® is a natural language processing model that uses deep learning approaches to generate human-like answers. However, the generation of prompts for the teaching-learning process in intensive care nursing requires in-depth association with the pillars of evidence-based practice.

RESUMEN Objetivo: demostrar la aplicación de algunos prompts y debatir cómo se utiliza ChatGPT® para orientar las mejores respuestas a estudiantes y profesores de Enfermería sobre shock séptico en la enseñanza de cuidados intensivos. Método: estudio metodológico en el que se aplicó la tecnología de prompts en ChatGPT® para respaldar la enseñanza de Enfermería en cuidados intensivos con énfasis en shock séptico. El estudio se organizó en 3 etapas, contemplando lo que se sabe sobre ChatGPT® y diversos modelos, al igual que pruebas y prácticas con prompts. Resultados: Se presentaron aplicaciones de prompts a partir de una estructura de etapas predefinidas que permitieron ejemplificar respuestas dadas por el sistema y organizar un diagrama de generación de salidas como una manera de resumir el proceso de apoyo a las decisiones que se toman en cuidados intensivos. Conclusión: ChatGPT® es un modelo de procesamiento del lenguaje natural que utiliza enfoques de aprendizaje profundo para generar respuestas semejantes a las humanas. Sin embargo, la generación de los prompts para el proceso de enseñanza-aprendizaje en Enfermería de cuidados intensivos requiere una profunda asociación con los pilares de la práctica basada en evidencias.

RESUMO Objetivo: Demostrar a aplicação de alguns prompts e problematizar o uso do ChatGPT® para guiar as melhores respostas aos estudantes e professores de enfermagem sobre choque séptico na aprendizagem em terapia intensiva. Método: Estudo metodológico, com aplicação de tecnologia de prompts no ChatGPT® para apoiar a aprendizagem de enfermagem em terapia intensiva com ênfase no choque séptico. O estudo foi organizado em 3 etapas, contemplando o entendimento sobre o ChatGPT®, modelos, bem como teste e exercício de prompts. Resultados: Foram apresentadas aplicações de prompts a partir de uma estrutura de etapas pré-definidas que permitiram exemplificar respostas dadas e organizar um diagrama de geração de saídas como uma forma de resumir o processo de apoio à tomada de decisão em terapia intensiva. Conclusão: O ChatGPT® é um modelo de processamento de linguagem natural que usa abordagens de aprendizagem profunda para gerar respostas semelhantes às humanas. Contudo, a geração dos prompts para o processo de ensino-aprendizagem em enfermagem de terapia intensiva requer associação profunda com os pilares da prática baseada em evidência.

Desempenho do óxido nítrico na sepse: uma revisão de escopo / Desempeño del óxido nítrico en la sepsis: una revisión de alcance / Performance of nitric oxide in sepsis: a scoping review

Resumo Objetivo Mapear as evidências disponíveis sobre as ações do óxido nítrico na fisiopatologia da sepse e sua relação com a gravidade de pacientes sépticos. Método Revisão de escopo de acordo com a metodologia do Joanna Briggs Institute. Realizou-se busca por estudos que evidenciaram as ações do óxido nítrico na sepse e se o seu aumento está associado à gravidade de pacientes sépticos. Dois revisores independentes fizeram o mapeamento das informações utilizando um instrumento de extração de dados previamente elaborado. Os dados foram analisados quanto à sua relevância, sendo posteriormente extraídos e sintetizados. Resultados De 1342 estudos, 11 foram incluídos na revisão. O primeiro foi publicado em 2017 e o último, em 2022. A maioria foi desenvolvida nos Estados Unidos, na China e na Alemanha. Os estudos apresentaram informações referentes as ações do óxido nítrico, sintetizando sua biodisponibilidade e os inibidores endógenos relacionados a sua produção, além de abordarem a relação do óxido nítrico com a gravidade da sepse. Conclusão A produção de óxido nítrico fisiológico durante a sepse atua como protetor vascular, principalmente na microcirculação, porém, em altas concentrações, contribui para a disfunção vascular, que subverte a fisiologia da regulação da pressão arterial, causando profunda vasodilatação e hipotensão refratária e aumentando a gravidade de pacientes sépticos.

Resumen Objetivo Mapear las evidencias disponibles sobre las acciones del óxido nítrico en la fisiopatología de la sepsis y su relación con la gravedad de pacientes sépticos. Métodos Revisión de alcance de acuerdo con la metodología del Joanna Briggs Institute. Se realizó una búsqueda de estudios que evidenciaron las acciones del óxido nítrico en la sepsis y si su aumento estaba asociado a la gravedad de pacientes sépticos. Dos revisores independientes hicieron el mapeo de la información utilizando un instrumento de extracción de datos previamente elaborado. Los datos se analizaron respecto a su relevancia, para luego extraerlos y sintetizarlos. Resultados De 1342 estudios, se incluyeron 11 en la revisión. El primero fue publicado en 2017 y el último en 2022. La mayoría se realizó en Estados Unidos, China y Alemania. Los estudios presentaron información referente a las acciones del óxido nítrico, sintetizando su biodisponibilidad y los inhibidores endógenos relacionados con su producción, además de abordar la relación del óxido nítrico con la gravedad de la sepsis. Conclusión La producción de óxido nítrico fisiológico durante la sepsis actúa como protector vascular, principalmente en la microcirculación. Sin embargo, en altas concentraciones, contribuye a la disfunción vascular, que subvierte la fisiología de la regulación de la presión arterial, causa una profunda vasodilatación e hipotensión refractaria y aumenta la gravedad de pacientes sépticos. Registro da revisão de escopo no Open Science Framework: https://doi.org/10.17605/OSF.IO/MXDK2

Abstract Objective Map the available evidence on the actions of nitric oxide in the pathophysiology of sepsis and its relationship with the severity of sepsis in patients. Method Scoping review following the Joanna Briggs Institute methodology. A search was carried out for studies that highlighted the actions of nitric oxide in sepsis, informing whether its increase is associated with the severity of sepsis in patients. Two independent reviewers mapped the information using a previously designed data extraction instrument. The data was analyzed for its relevance and then extracted and synthesized. Results Eleven of 1342 studies were included in the review. The first of them was published in 2017 and the last in 2022. Most of them were developed in the USA, China, and Germany. Studies have reported the actions and bioavailability of nitric oxide and endogenous inhibitors related to its production, and related nitric oxide to the severity of sepsis. Conclusion The physiological production of nitric oxide during sepsis acts as a vascular protector, mainly in the microcirculation but contributes to vascular dysfunction in high concentrations, subverting the regulation of blood pressure, causing deep vasodilation and refractory hypotension, and increasing the severity of sepsis in patients. Registration of the scoping review in the Open Science Framework: https://doi.org/10.17605/OSF.IO/MXDK2

Índice leucocitos/eosinófilos como marcador pronóstico del choque séptico / Leukocyte/eosinophil Ratio as a Prognostic Marker of Septic Choque

Introducción: Se ha reconocido mundialmente el choque séptico como causa de una alta incidencia en la mortalidad. La incorporación de nuevos biomarcadores posibilita la obtención de un diagnóstico rápido y preciso. Objetivo: Evaluar la utilidad del índice leucocitos/eosinófilos como marcador pronóstico del choque séptico. Métodos: Se realizó una investigación en dos etapas: la primera descriptiva en la cual se detallaron las características clínicas, epidemiológicas y las variaciones de los estudios de laboratorio y la segunda explicativa de cohorte para estimar el valor predictivo del biomarcador leucocitos/eosinopenia en el choque séptico. Se realizó el recuento de eosinófilos y se obtuvo la media aritmética. Se consideró eosinopenia relativa con valores por debajo de la media de eosinófilos. Resultados: En el estudio se demostró que la leucocitosis fue de (27,4 células*mm3), la disminución del hematocrito (32,2 por ciento) y el descenso del número plaquetario (125,6 célula*mm3) prevalecen en el choque séptico. Además se refleja el descenso de los eosinófilos (18,5 células/mcl), aumento del índice leucocitos/eosinófilos (148,1) y empeoramiento del SOFA (2,8). El aumento del índice leucocitos/eosinófilos se correlaciona con el aumento de la proteína C reactiva y la procalcitonina. Conclusiones: La correlación de la leucocitosis y la eosinopenia mostró la utilidad del índice leucocitos/eosinopenia como factor de predicción del choque séptico(AU)

Introduction: Septic shock has been recognized worldwide as a cause of high incidence of mortality. The incorporation of new biomarkers makes it possible to obtain a rapid and accurate diagnosis. Objective: To evaluate the usefulness of the leukocyte/eosinophil ratio as a prognostic marker of septic shock. Methods: An investigation was carried out in two stages: in the first (the descriptive phase) the clinical and epidemiological characteristics and variations of the laboratory studies were detailed and in the second (the explanatory cohort phase), the predictive value of the leukocytes/eosinopenia biomarker in septic shock was estimated. The eosinophil count was performed and the arithmetic mean was obtained. Relative eosinopenia was considered with eosinophil values below the average. Results: The study showed that leukocytosis was 27.4 cells*mm3, hematocrit decreased in 32.2percent and decreased platelet number (125.6 cells*mm3) prevail in septic shock. In addition, a decrease in eosinophils (18.5 cells/mcl), an increase in the leukocyte/eosinophil ratio (148.1) and worsening of SOFA (2.8) are reflected. The increase in the leukocyte/eosinophil ratio is correlated with the increase in C-reactive protein and procalcitonin. Conclusions: The correlation of leukocytosis and eosinopenia showed the usefulness of the leukocyte/eosinopenia index as a predictor of septic shock(AU)

Síndrome de disfunción orgánica múltiple progresiva en embarazo adolescente: reporte de caso clínico / Progressive multiple organ dysfunction syndrome in adolescent pregnancy: Case report

Introducción El embarazo adolescente es un proceso fisiológico, pero puede evolucionar con parto prematuro, patologías obstétricas o médicas graves, mortalidad o secuelas para madre e hijo/a. Nuestro objetivo es reportar el síndrome de disfunción orgánica múltiple progresiva secundario a pielonefritis y sepsis ocurrido durante el preparto, parto y puerperio de embarazo adolescente y sus secuelas. Caso clínico Adolescente de 14 años, con embarazo de 27 semanas de gestación controlado desde las 8 hasta 25 semanas. Ingresó de urgencia en unidad de alto riesgo obstétrico por signos de parto prematuro, pielonefritis e injuria renal aguda. Se inició tratamiento con cefazolina intravenosa y betametasona para maduración pulmonar, nifedipino oral y sulfato de magnesio para prevención del parto prematuro y protección neuronal fetal, evolucionando con hipotensión sostenida y shock séptico. A las 13 horas después del ingreso, fue trasladada a unidad de paciente crítico donde evolucionó con falla orgánica múltiple persistente y progresiva durante 28 días, afectando sucesivamente los sistemas cardiovascular, hematológico, respiratorio y gastrointestinal. Se trató con drogas vasoactivas, antibióticos, ventilación mecánica invasiva, ultrafiltración, hemodiálisis, drenaje pleural y colecistectomía. A las 24 horas de ingreso a cuidado intensivo, ocurrió el parto prematuro vaginal. La embarazada desarrolló enfermedad renal crónica etapa KDIGO 5 ( V) y se encuentra en espera de trasplante renal. Por su parte, la recién nacida prematura viva presentó asfixia neonatal severa, displasia broncopulmonar y encefalopatía hipóxico-isquémica. Conclusiones El embarazo adolescente complicado es una emergencia sanitaria. El diagnóstico y manejo oportuno de la pielonefritis, shock séptico y disfunción orgánica asociada a la sepsis pueden evitar mortalidad y secuelas permanentes materna y/o neonatal.

Introduction Adolescent pregnancy is a physiological process, but it can evolve with premature delivery, severe obstetric or clinical pathologies, mortality, or sequelae for mother and child. We aim to report the progressive multiple organ dysfunction syndrome secondary to pyelonephritis and sepsis during prepartum, delivery, and puerperium of adolescent pregnancy and its sequelae. Case report A 14-year-old adolescent with a pregnancy of 27 weeks of gestation controlled from 8 to 25 weeks. She was urgently admitted to the high-risk obstetric unit due to signs of preterm labor, pyelonephritis, and acute renal injury. Treatment was started with intravenous cefazolin and betamethasone for lung maturation, oral nifedipine, and magnesium sulfate to prevent preterm labor and fetal neuronal protection, evolving with sustained hypotension and septic shock. At 13 hours after admission, she was transferred to the intensive care unit, where she evolved with persistent and progressive multiple organ failure for 28 days, progressively affecting the cardiovascular, hematologic, respiratory, and gastrointestinal systems. She was treated with vasoactive drugs, antibiotics, invasive mechanical ventilation, ultrafiltration, hemodialysis, pleural drainage, and cholecystectomy. Twenty-four hours after admission to intensive care, preterm vaginal delivery occurred. She developed chronic kidney disease stage KDIGO 5 (Kidney Disease Improving Global Outcomes V) and is awaiting renal transplantation. On the other hand, the preterm newborn presented severe neonatal asphyxia, bronchopulmonary dysplasia, and hypoxic-ischemic encephalopathy. Conclusion Complicated adolescent pregnancy is a health emergency. Avoiding delays in the diagnosis and treatment of pyelonephritis, septic shock and the progressive multiple organ dysfunction syndrome can prevent mortality and permanent sequelae, both maternal and neonatal.

Artromielitis Sacroiliaca: Reporte de caso / Sacroiliac Arthromyelitis: Case report

RESUMEN La sacroileítis infecciosa (SII) es una afección poco común que, en ocasiones, se diagnostica tarde por la escasa especificidad de los síntomas. Además, se requiere de técnicas de imagen como la gammagrafía, tomografía y la resonancia magnética nuclear para valorar la extensión y gravedad de las lesiones. Si se hace un diagnóstico y tratamiento precoz, la evolución clínica es satisfactoria y no deja secuelas. Se presenta el caso de una paciente mujer de 83 años, con antecedentes de enfermedad cerebrovascular isquémico, hipertensión arterial, diabetes mellitus 2 e infección del tracto urinario que presentó dolor abdominal tipo cólico de moderada intensidad, afebril; manifestó que al momento de levantarse de su silla sintió debilidad en el hemicuerpo izquierdo. Al ingreso, hipertensa, febril con T° 38°C SatO2: 98 % con FiO2: 0.4. Al examen físico con edema en MMII con fóvea (+), abdomen distendido, doloroso en flanco derecho y hemiparesia izquierda. Al laboratorio: hemoglobina 14,8 g/dl, plaquetas 38.000 μl. leucocitos 18.000 μl. Posteriormente, confirmando el diagnóstico clínico sustentado en radio imágenes, se procedió al abordaje quirúrgico. La SII es una enfermedad rara con complicaciones graves, cuyo diagnóstico precoz e inicio de tratamiento rápido son fundamentales, basándose principalmente en el cuadro clínico, estudios de imágenes y la duración adecuada de la terapia antibiótica.

ABSTRACT Infectious sacroiliitis is a rare condition that is sometimes diagnosed late due to the poor specificity of the symptoms. In addition, imaging techniques such as scintigraphy, tomography, and nuclear magnetic resonance are required to assess the extent and severity of the lesions. If early diagnosis and treatment are made, the clinical evolution is satisfactory and leaves no sequelae. Clinical case: the case of an 83-year-old female patient is presented, with a history of ischemic cerebrovascular disease, high blood pressure, type 2 diabetes mellitus and urinary tract infection, who presented with moderately intense colic-like abdominal pain, afebrile, and reported that at the time After getting up from his chair he felt weakness in his left side. On admission, hypertensive, febrile with T°: 38°C SatO2: 98% with FiO2: 0.4. On physical examination, there was edema in MMII with pitting (+), distended abdomen, pain in the right flank and left hemiparesis. To the laboratory: hemoglobin 14.8 g/dl, platelets 38,000 μl, leukocytes 18,000 μl.

Lack of change in the respiratory quotient during oxygen supply dependence in endotoxemic shock: a subanalysis of an experimental controlled study / Ausência de alteração no quociente respiratório durante a dependência do suprimento de oxigênio no choque endotoxêmico: subanálise de um estudo experimental controlado

ABSTRACT Objective: To evaluate if the reductions in systemic and renal oxygen consumption are associated with the development of evidence of anaerobic metabolism. Methods: This is a subanalysis of a previously published study. In anesthetized and mechanically ventilated sheep, we measured the respiratory quotient by indirect calorimetry and its systemic, renal, and intestinal surrogates (the ratios of the venous-arterial carbon dioxide pressure and content difference to the arterial-venous oxygen content difference. The Endotoxemic Shock Group (n = 12) was measured at baseline, after 60 minutes of endotoxemic shock, and after 60 and 120 minutes of fluid and norepinephrine resuscitation, and the values were compared with those of a Control Group (n = 12) without interventions. Results: Endotoxemic shock decreased systemic and renal oxygen consumption (6.3 [5.6 - 6.6] versus 7.4 [6.3 - 8.5] mL/minute/kg and 3.7 [3.3 - 4.5] versus 5.4 [4.6 - 9.4] mL/minute/100g; p < 0.05 for both). After 120 minutes of resuscitation, systemic oxygen consumption was normalized, but renal oxygen consumption remained decreased (6.3 [5.9 - 8.2] versus 7.1 [6.1 - 8.6] mL/minute/100g; p = not significance and 3.8 [1.9 - 4.8] versus 5.7 [4.5 - 7.1]; p < 0.05). The respiratory quotient and the systemic, renal and intestinal ratios of the venous-arterial carbon dioxide pressure and content difference to the arterial-venous oxygen content difference did not change throughout the experiments. Conclusion: In this experimental model of septic shock, oxygen supply dependence was not associated with increases in the respiratory quotient or its surrogates. Putative explanations for these findings are the absence of anaerobic metabolism or the poor sensitivity of these variables in detecting this condition.

RESUMO Objetivo: Avaliar se as reduções do consumo de oxigênio sistêmico e renal estão associadas ao desenvolvimento de evidências de metabolismo anaeróbico. Métodos: Esta é uma subanálise de estudo já publicado. Em ovinos anestesiados e ventilados mecanicamente, medimos o quociente respiratório por calorimetria indireta e seus substitutos sistêmicos, renais e intestinais (as razões entre a diferença de pressão venoarterial do teor de dióxido de carbono e a diferença arteriovenosa do teor de oxigênio). O Grupo Choque Endotoxêmico (n = 12) foi medido inicialmente, após 60 minutos do choque endotoxêmico e após 60 e 120 minutos da ressuscitação com fluidos e norepinefrina, e os valores foram comparados com os do Grupo Controle (n = 12) sem intervenções. Resultados: O choque endotoxêmico diminuiu o consumo de oxigênio sistêmico e renal (6,3 [5,6 - 6,6] versus 7,4 [6,3 - 8,5] mL/minuto/kg e 3,7 [3,3 - 4,5] versus 5,4 [4,6 - 9,4] mL/minuto/100g; p < 0,05 para ambos). Após 120 minutos de ressuscitação, o consumo sistêmico de oxigênio foi normalizado, mas o consumo renal de oxigênio permaneceu reduzido (6,3 [5,9 - 8,2] versus 7,1 [6,1 - 8,6] mL/minuto/100g; p = NS e 3,8 [1,9 - 4,8] versus 5,7 [4,5 - 7,1]; p < 0,05). O quociente respiratório e as razões sistêmica, renal e intestinal entre a diferença na pressão venoarterial do teor de dióxido de carbono e a diferença arteriovenosa do teor de oxigênio não se alteraram ao longo dos experimentos. Conclusão: Nesse modelo experimental de choque séptico, a dependência do suprimento de oxigênio não foi associada a aumentos no quociente respiratório ou em seus substitutos. As explicações possíveis para esses achados são a ausência de metabolismo anaeróbico ou a baixa sensibilidade dessas variáveis na detecção dessa condição.

Anticoagulación en paciente con síndrome de Lemierre y embolias sépticas pulmonares / Anticoagulation in a patient with Lemierre syndrome and pulmonary septic embolisms

Resumen El síndrome de Lemierre, también denominado trom boflebitis séptica de la vena yugular interna, necrobaci losis o sepsis postanginal es una infección que inicia en el espacio orofaríngeo, se complica con tromboflebitis séptica de la vena yugular interna y metástasis infeccio sas. La rápida progresión a cuadros clínicos graves que comprometen la vida del paciente y su baja frecuencia justifican la divulgación de casos clínicos. Se presenta el caso de una mujer de 27 años de edad, que a las 48 horas de completar el tratamiento con fenoximetilpenicilina por una infección odontógena evolucionó con edema facial y trismus. En la angio-TC de macizo craneofacial se evidenció extenso trombo en la vena yugular interna y en la tomografía computarizada de tórax, embolias sépticas pulmonares. El tratamiento consistió en antibió ticos endovenosos de amplio espectro y anticoagulación de manera precoz.

Abstract Lemierre's syndrome, also called septic thrombo phlebitis of the internal jugular vein, necrobacillosis or postanginal sepsis, is an infection that begins in the oropharyngeal space, is complicated by septic throm bophlebitis of the internal jugular vein and infectious metastases. The rapid progression to serious clinical conditions that compromise the patient's life and its low frequency justify the disclosure of clinical cases. We present the case of a 27-year-old woman who de veloped facial edema and trismus 48 hours after com pleting treatment with phenoxymethylpenicillin for an odontogenic infection. An angio-CT of the craniofacial massif revealed an extensive thrombus in the internal jugular vein and a computed tomography of the chest showed septic pulmonary emboli. Treatment consisted of broad-spectrum intravenous antibiotics and early anticoagulation.

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.

Nuevas perspectivas en el estudio y tratamiento de la sepsis

La sepsis es una disfunción orgánica potencialmente mortal debida a una respuesta desregulada del hospedero a la infección. No sólo contribuye con el 20 % de todas las causas de muerte de forma global, sino que los sobrevivientes de esta también pueden experimentar una significativa morbilidad a largo plazo. La sepsis y el shock séptico son emergencias médicas que requieren reconocimiento rápido, administración de antimicrobianos apropiados, soporte hemodinámico cuidadoso y control de la fuente infecciosa. El objetivo de esta revisión fue describir la definición y los criterios diagnósticos, la epidemiología, los factores de riesgo, la patogenia y la conducta inicial ante la sepsis.

Sepsis is a life-threatening organ dysfunction due to a dysregulated host response to infection. It severely impacts global disease burden as it constates 20 % of all causes of death; its survivors may experience long-term morbidity. Sepsis and septic shock are medical emergencies that require rapid identification, administration of appropriate antimicrobials, careful hemodynamic support, and control of the infection source. This review aims to update the definition of sepsis and its diagnostic criteria, epidemiology, risk factors, pathogenesis, and baseline behavior.

Shock séptico en niños con bacteriemia por Staphylococcus aureus de la comunidad en un hospital pediátrico de alta complejidad / Septic shock in children with community acquired Staphylococcus aureus bacteremia in a high complexity pediatric hospital

INTRODUCCIÓN: La información disponible sobre los factores de riesgo para el desarrollo de shock séptico es escasa, especialmente en población pediátrica. OBJETIVO: Describir las características epidemiológicas y clínicas de los niños con bacteriemia adquirida en la comunidad por Staphylococcus aureus y comparar las características de los pacientes con y sin shock séptico. PACIENTES Y MÉTODOS: Estudio de cohorte retrospectivo. Criterios de inclusión: niños entre 30 días y 16 años de edad, internados en el Hospital de Pediatría Juan P. Garrahan entre enero de 2017 y diciembre de 2019 por infecciones adquiridas en la comunidad con desarrollo de S. aureus en hemocultivos. Criterios de exclusión: antecedente de internación dentro de los 3 meses previos al ingreso, vivir en una comunidad cerrada, presencia de catéter de larga permanencia, dispositivos intraventriculares o intraperitoneales. Análisis estadístico: STATA 16. RESULTADOS: Se incluyeron 142 niños. 21 niños (15%) presentaron shock séptico. En el análisis multivariado, se asociaron con shock séptico, la bacteriemia persistente (OR 7,15; IC95% 4,39-23,81; p: 0,001) y el foco secundario de infección (OR 6,72; IC 95% 2,02-22,2; p 0,002). La mortalidad relacionada con la infección fue 3,5% (5 pacientes). CONCLUSIONES: El shock séptico se asoció con la bacteriemia persistente y la presencia de focos secundarios de infección.

BACKGROUND: Available information about risk factors for the development of septic shock is scarce, especially in the pediatric population. AIM: To describe the epidemiological and clinical characteristics of children with community-acquired Staphylococcus aureus bacteremia and to compare the characteristics of children with and without septic shock. METHODS: Retrospective cohort study. Inclusion criteria: Children between 30 days and 16 years old, hospitalized in the Juan P. Garrahan Pediatric Hospital between January 2017 and December 2019 for community-acquired infections with S. aureus isolation in blood cultures. Exclusion criteria: History of hospitalization within 3 months prior to admission, living in a closed community, presence of long-term catheter, intraventricular or intraperitoneal devices. Statistical analysis: STATA 16. RESULTS: 142 children were included. 21 children (15%) experienced septic shock. On multivariate analysis, persistent bacteremia (OR 7.15, 95% CI 4.39-23.81, p: 0.001) and secondary focus of infection (OR 6.72, 95% CI 2.02-22.2, p 0.002) were associated with septic shock. The infection-related mortality rate was 3.5% (5 patients). CONCLUSIONS: Septic shock was associated with persistent bacteremia and the presence of secondary foci of infection.

Proceso de enfermería en paciente con choque séptico desde la perspectiva del déficit de autocuidado (caso clínico) / Nursing process in a patient with septic shock from the perspective of self-care deficit

El choque séptico es un estado de hipoperfusión tisular definido como subcategoría de la sepsis en la que las alteraciones circulatorias y del metabolismo celular pueden aumentar considerablemente la mortalidad. A nivel mundial, el choque séptico ocupa el segundo lugar como causa de muerte no coronaria en la Unidad de Cuidados Intensivos (UCI), con una incidencia anual del 10%, y con una mortalidad hospitalaria de 18 a 35%. Objetivo: Describir el abordaje del Proceso de Atención de Enfermería en el paciente con choque séptico y desde la perspectiva del déficit de autocuidado. Metodología: El caso clínico se fundamentó en las etapas del Proceso de Atención de Enfermería (PAE), en la Teoría Enfermera del Déficit de Autocuidado (TEDA) de Dorothea Orem y en herramientas taxonómicas para el abordaje individualizado del plan de cuidados. Resultados: Paciente de 68 años en el servicio de Cuidados Intensivos Adultos, cursa la primera hora del posoperatorio por nefrectomía izquierda secundaria a absceso perirenal, que condiciona a choque séptico. Se abordó el PAE con apoyo del TEDA siendo prioritaria la etiqueta diagnóstica disminución del gasto cardiaco. Conclusiones: La aplicación de las teorías y modelos de enfermería proporcionan un marco de referencia para otorgar cuidados de calidad en los diferentes ámbitos de desempeño, incluyendo unidades de atención de cuidados intensivos. Resulta indispensable usar la metodología del PAE que permite dar evidencia de la profesionalización del cuidado, al usar un lenguaje técnico, con el apoyo de la Teoría de Orem y con las herramientas taxonómicas[AU]

Septic shock is a state of tissue hypoperfusion defined as a subcategory of sepsis in which circulatory and cellular metabolism alterations can considerably increase mortality. Worldwide, septic shock ranks second as a cause of non-coronary death in the Intensive Care Unit (ICU), with an annual incidence of 10%, and a hospital mortality of 18 to 35%. Objective: To describe the approach to the Nursing Care Process in patients with septic shock and from the perspective of self-care deficit. Methodology: The clinical case was based on the stages of the Nursing Care Process (PAE), on the Nursing Theory of Self-Care Deficit (TEDA) by Dorothea Orem and on taxonomic tools for the individualized approach to the care plan. Results: A 68-year-old patient, in the Adult Intensive Care service, undergoes the first postoperative hour due to left nephrectomy secondary to perirenal abscess, which conditions septic shock. The PAE was approached with the support of the TEDA, with a priority being the dignostic label reduction of cardiac output. Conclusions: The application of nursing theories and models provide a frame of reference to provide quality care in different areas of performance, including intensive care units. It is essential to use the PAE methodology that allows to give evidence of the professionalization of care, by using technical language, with the support of Orem's Theory and with taxonomic tools[AU]

O choque séptico é um estado de hipoperfusão tecidual definida como uma subcategoria da sepse em que alterações circulatórias e do metabolismo celular podem aumentar consideravelmente a mortalidade. Mundialmente, o choque séptico ocupa o segundo lugar como causa de morte não coronariana em Unidade de Terapia Intensiva (UTI), com incidência anual de 10% e mortalidade hospitalar de 18 a 35%. Objetivo: Descrever a abordagem do Processo de Cuidado de Enfermagem ao paciente com choque séptico na perspectiva do déficit de autocuidado. Metodologia: O caso clínico baseou-se nas etapas do Processo de Cuidar em Enfermagem (PAE), na Teoria de Enfermagem do Déficit de Autocuidado (TEDA) de Dorothea Orem e em ferramentas taxonômicas para a abordagem individualizada do plano de cuidados. Resultados: Paciente de 68 anos, internada em Unidade de Terapia Intensiva Adulto, com primeira hora de pós-operatório por nefrectomia esquerda secundária a abscesso perirrenal, que acarreta choque séptico. O PAE foi abordado com o apoio do TEDA, tendo como prioridade o rótulo digno de redução do débito cardíaco. Conclusões: A aplicação de teorias e modelos de enfermagem fornecem um quadro de referência para fornecer cuidados de qualidade em diferentes áreas de atuação, incluindo unidades de terapia intensiva. É imprescindível utilizar a metodologia PAE que permita evidenciar a profissionalização do cuidado, por meio de linguagem técnica, com o apoio da Teoria de Orem e com ferramentas taxonómicas[AU]

Septic complications in patients of traumatic brain injury: An impact on clinical and functional outcome

Background: Septic complications in traumatic brain injury causes short- and long-term cerebral dysregulation by disruption of blood brain barrier, reduced brain perfusion, neuroinflammation and deposition of amyloid. Materials and methods: The present study attempted to observe patients of traumatic brain injury for the development of septic complications during the hospital stay. 89 patients were included in the study with different grades of brain injury (Injury Severity Score (ISS) range, 9-72). The patients were managed according to the trauma protocol and classified into 3 groups based on the severity of trauma (ISS 9-17 (moderate), 18-30 (severe), and >32 (most severe)). The patients were observed for the development of major septic complications during the course of their hospital stay, which impacted on the morbidity and mortality while determining the clinical and functional outcome at the end. Results: Mean age of the study population was 33.5 years. TBI was more common in younger age groups with severe grades of injury, those with multiplicity of head injuries, sepsis with a pulmonary focus, prolonged ICU and in-hospital stay together with high mortality. Septic complications were also more common in cases with higher grades of TBI and more prolonged hospital stay. Patients requiring intubation had a higher risk of developing infectious complications. 69 patients (77.5%) required intubation and mechanical ventilation. Pneumonia was the most common source of sepsis leading to the respiratory failure while the most common cause being aspiration at the time of injury Genitourinary complications were also common leading to urosepsis. Most common organisms isolated were Staphylococcus aureus, Acinetobacter, klebsiella and Pseudomonas. Conclusion: Traumatic brain injury (TBI) when complicated by sepsis and multi organ failure increases the mortality and morbidity with less favorable clinical and functional outcome together with increased duration of ICU and hospital stay.

Children with malignancies and septic shock - an attempt to understand the risk factors

Abstract Objectives: To explain the high mortality of septic shock in children with cancer. Methods: A retrospective cohort from 2016 to 2020, of children aged 0 to 18 years, and septic shock. Results: The authors included 139 patients. Acute lymphocytic leukemia was the most frequent diagnosis (16.5%), and Gram-negative bacteria were the most frequent blood culture isolates (22.3%). There were 57 deaths in ICU (41%), 10 in the first 24 hours of shock (early death). A LASSO model with variables: neutropenia (coefficient 0.215), respiratory (0.81), hematological (1.41), and neurological (0.72) dysfunctions, age (-0.002) and solid tumor recurrence (0.34) generated AUC = 0.79 for the early death outcome. Survivors had significant differences in the PRISM-IV score (mean ± SD 10.9 ± 6.2 in the survivors, 14.1 ± 6.5 in the deceased, p = 0.004), and in the mean number of organ dysfunctions (3.2 ± 1.1 in the survivors, 3.8 ± 6.5 in the deceased, p < 0.001). A positive fluid balance in the first 24 hours of sepsis between 2% and 6% of body weight showed a reduction effect on the probability of death in ICU (hazard ratio 0.47, 95% CI 0.24-0.92, p = 0.027). The recurrence of any cancer was a predictor of in-hospital death, regardless of severity. Conclusions: Recurrence of any cancer is an important risk of sepsis-related death. A positive fluid balance between 20 and 60 mL/kg or 2% and 6% of body weight in the first 24 hours after the onset of sepsis is related to lower mortality.

A rare diagnosis has no certainty, but still they occur: A case report

Pain and swelling are among the most frequently encountered complaints in an orthopedics outpatient department (OPD) relatively less common in a pediatric OPD. A high level of suspicion is required to diagnose bone diseases. Common conditions such as rickets, septic arthritis, and tuberculosis must be ruled out. Treatment such as antibiotics, anti-inflammatory drugs, or steroids may mask an underlying serious condition in which if left untreated can cause significant morbidity and mortality to the person. Here, we discuss a case of a young infant 11 months of age who had symptoms suggestive of septic arthritis and was later found to have Brodie’s abscess which is a type of subacute osteomyelitis on further evaluation which is usually mistaken as a tumor. This age at presentation is rare.

Advances in Shock Management and Fluid Resuscitation in Children

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

Sildenafil in endotoxin-induced pulmonary hypertension: an experimental study

Abstract Background Sepsis and septic shock still represent great challenges in critical care medicine. Sildenafil has been largely used in the treatment of pulmonary arterial hypertension, but its effects in sepsis are unknown. The aim of this study was to investigate the hypothesis that sildenafil can attenuate endotoxin-induced pulmonary hypertension in a porcine model of endotoxemia. Methods Twenty pigs were randomly assigned to Control group (n = 10), which received saline solution; or to Sildenafil group (n = 10), which received sildenafil orally (100 mg). After 30 minutes, both groups were submitted to endotoxemia with intravenous bacterial lipopolysaccharide endotoxin (LPS) infusion (4 µg.kg-1.h-1) for 180 minutes. We evaluated hemodynamic and oxygenation functions, and also lung histology and plasma cytokine (TNFα, IL-1β, IL6, and IL10) and troponin I response. Results Significant hemodynamic alterations were observed after 30 minutes of LPS continuous infusion, mainly in pulmonary arterial pressure (from Baseline 19 ± 2 mmHg to LPS30 52 ± 4 mmHg, p< 0.05). There was also a significant decrease in PaO2/FiO2 (from Baseline 411 ± 29 to LPS180 334 ± 49, p< 0.05). Pulmonary arterial pressure was significantly lower in the Sildenafil group (35 ± 4 mmHg at LPS30, p< 0.05). The Sildenafil group also presented lower values of systemic arterial pressure. Sildenafil maintained oxygenation with higher PaO2/FiO2 and lower oxygen extraction rate than Control group but had no effect on intrapulmonary shunt. All cytokines and troponin increased after LPS infusion in both groups similarly. Conclusion Sildenafil attenuated endotoxin-induced pulmonary hypertension preserving the correct heart function without improving lung lesions or inflammation.