Research progress of critical care ultrasound in volume management of sepsis / 中华危重病急救医学

Critical care ultrasound has many operational advantages such as visualization, reproducibility, noninvasiveness, and real-time dynamic monitoring, and is now widely used in the treatment process of various clinical diseases. Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection. On the basis of active anti-infection, early administration of fluid resuscitation to maintain organ tissue perfusion and individualized adjustment of volume management is the core of improving patient prognosis and reducing mortality. Currently, there are many shortcomings in the commonly used clinical physical examination and static parameters to assess volume status. Critical care ultrasound has many advantages in volume management of sepsis due to its diversified advantages, which promoted the development of critical care medicine. This article presents a review of critical care ultrasound in volume management in sepsis, aiming to highlight the value and limitations of the application of critical care ultrasound in volume management in sepsis.

Effect of improved nursing strategy on prognosis of older immunosuppressed patients with pneumonia and sepsis / 中华危重病急救医学

OBJECTIVE@#To investigate the effect of improved nursing strategy on prognosis of older immunosuppressed patients with pneumonia and sepsis.@*METHODS@#A prospective study was conducted. The older immunosuppressed patients with pneumonia and sepsis admitted to the department of intensive care medicine and emergency intensive care unit (ICU) of Peking Union Medical College Hospital from January 2017 to July 2022 were enrolled. In the first stage (from January 2017 to December 2019), patients received the original nursing strategy (original nursing strategy group), including: (1) nurses were randomly assigned; (2) routine terminal cleaning; (3) ICU environmental cleaning twice a day; (4) oral care was performed with chlorhexidine twice a day; (5) original lung physiotherapy [head of bed elevated at 30 degree angle-45 degree angle, maintaining a Richmond agitation-sedation scale (RASS) -2 to 1, sputum aspiration as needed]. After 1 month of learning and training of the modified nursing treatment strategy for nurses and related medical staff, the patients in the second stage (from February 2020 to July 2022) received the improved nursing strategy (improved nursing strategy group). The improved nursing strategy improved the hospital infection prevention and control strategy and lung physical therapy strategy on the basis of the original nursing strategy, including: (1) nurses were fixed assigned; (2) patients were placed in a private room; (3) enhanced terminal cleaning; (4) ICU environmental cleaning four times a day; (5) education and training in hand hygiene among health care workers was improved; (6) bathing with 2% chlorhexidinegluconate was performed once daily; (7) oral care with a combination of chlorhexidine and colistin was provided every 6 hours; (8) surveillance of colonization was conducted; (9) improved lung physiotherapy (on the basis of the original lung physiotherapy, delirium score was assessed to guide early mobilization of the patients; airway drainage was enhanced, the degree of airway humidification was adjusted according to the sputum properties, achieving sputum viscosity grade II; lung ultrasound was also used for lung assessment, and patients with atelectasis were placed in high lateral position and received the lung recruitment maneuver). Baseline patient information were collected, including gender, age, underlying diseases, source of admission, disease severity scores, vital signs, ventilatory parameters, blood gas analysis, life-sustaining treatments, clinical laboratory evaluation, indicators of infection and inflammation, pathogens and drug therapy. The primary outcome was 28-day mortality, and the secondary outcomes were duration of mechanical ventilation, length of ICU stay, and ICU mortality. Multivariate Logistic regression analysis was used to determine the risk factors for 28-day death in older immunosuppressed patients with pneumonia and sepsis.@*RESULTS@#Finally, 550 patients were enrolled, including 199 patients in the original nursing strategy group and 351 patients in the improved nursing strategy group. No significant differences were found in gender, age, underlying diseases, source of admission, disease severity scores, vital signs, ventilatory parameters, blood gas analysis, life-sustaining treatments, clinical laboratory evaluation, indicators of infection and inflammation, coexisting pathogens or drug therapy between the two groups. Compared with patients in the original nursing strategy group, those in the improved nursing strategy group had significantly fewer duration of mechanical ventilation and length of ICU stay [duration of mechanical ventilation (days): 5 (4, 7) vs. 5 (4, 9), length of ICU stay (days): 11 (6, 17) vs. 12 (6, 23), both P < 0.01], and lower ICU mortality and 28-day mortality [ICU mortality: 23.9% (84/351) vs. 32.7% (65/199), 28-day mortality: 23.1% (81/351) vs. 33.7% (67/199), both P < 0.05]. Multivariate Logistic regression analysis showed that the improved nursing strategy acted as an independent protective factor in 28-day death of older immunosuppressed patients with pneumonia and sepsis [odds ratio (OR) = 0.543, 95% confidence interval (95%CI) was 0.334-0.885, P = 0.014].@*CONCLUSIONS@#Improved nursing strategy shortened the duration of mechanical ventilation and the length of ICU stay, and decreased ICU mortality and 28-day mortality in older immunosuppressed patients with pneumonia and sepsis, significantly improving the short-term prognosis of such patients.

Study of perioperative safety of laparoscopic pancreaticoduodenectomy in elderly patients / 中华危重病急救医学

OBJECTIVE@#To investigate the safety of laparoscopic pancreaticoduodenectomy (LPD) in elderly patients and the related risk factors admitted to the intensive care unit (ICU) after LPD.@*METHODS@#The perioperative data of patients who underwent LPD in Tianjin Medical University General Hospital from February 2017 to June 2023 were retrospectively collected, including basic data, preoperative laboratory indicators, intraoperative and postoperative indicators, pathological results (tumor size, lymph node dissection and pathological type), postoperative complications, ICU postoperative management and prognosis. The patients were divided into the elderly group (≥ 65 years) and the non-elderly group (< 65 years) according to age. Perioperative data between two groups were compared. Kaplan-Meier survival curve was drawn to analyze the survival rate of the elderly group and the non-elderly group, and the pancreatic head carcinoma group and other type of tumors group after LPD. Logistic regression was used to analyze the risk factors of ICU stay (length of ICU stay > 1 day) after LPD in elderly patients. The receiver operator characteristic curve (ROC curve) was drawn to analyze the predictive value of this risk factor for ICU stay after LPD in elderly patients.@*RESULTS@#A total of 160 patients were enrolled, including 57 cases in the elderly group (17 cases of vascular reconstruction) and 103 cases in the non-elderly group (40 cases of vascular reconstruction). All patients underwent R0 resection and were transferred to the comprehensive ICU for treatment. The follow-up time of patients with malignant tumors was 43 (6, 72) months. The elderly group had significantly longer surgery time, postoperative hospital stay and oral feeding time than the non-elderly group, and the incidence of delayed gastric emptying (DGE) was significantly higher than that in the non-elderly group. There were no significant differences in intraoperative blood transfusion rate, intraoperative blood loss, pathological results, short-term and severe postoperative complications, reoperation rate and 90-day mortality between the two groups. In patients with vascular resection reconstruction, the intraoperative blood loss in the elderly group was significantly higher than that in the non-elderly group, and the operation time and postoperative hospital stay were significantly longer. During ICU, the acute physiology and chronic health evaluation II [APACHE II: 12 (9, 14) vs. 8 (7, 10)], sequential organ failure assessment [SOFA: 6 (4, 8) vs. 3 (2, 5)] within 24 hours after admission to ICU were significantly increased in the elderly group (both P < 0.05), the time of mechanical ventilation [hours: 12 (10, 15) vs. 9 (5, 13)] and the length of ICU stay [days: 2 (1, 2) vs. 1 (1, 1)] were significantly increased in the elderly group (both P < 0.05), and the proportion of multi-disciplinary team (MDT) was also significantly increased in the elderly group (33.3% vs. 17.4%, P < 0.05), there were no significant differences in the levels of hemoglobin (Hb), albumin, and blood lactic acid between the two groups. Logistic regression analysis showed that the APACHE II score was an independent risk factor for ICU stay after LPD in elderly patients (β = 1.737, P = 0.028). ROC curve showed that the prediction performance was the best when the APACHE II score was 13, with the sensitivity of 72.41% and the specificity of 96.43%, and the area under the ROC curve (AUC) of 0.884. The Kaplan-Meier survival curve showed that there were no significant difference in median survival time (months: 24.1 vs. 24.7) and 5-year survival rate (19.01% vs. 19.02%) between the elderly group (52 cases) and the non-elderly group (92 cases) among the 144 patients with malignant tumors (both P > 0.05). The median survival time in the pancreatic head carcinoma group was significantly shorter than that in the other tumors group (63 cases; months: 20.2 vs. 40.1, P < 0.05), 5-year survival rate was significantly lower than that in the other tumors group (21.98% vs. 30.91%, P < 0.05).@*CONCLUSIONS@#LPD is a safe and feasible treatment for elderly patients. APACHE II score has a certain predictive value for ICU stay after LPD in elderly patients.

Research progress of exosomes in the diagnosis and treatment of sepsis / 中华危重病急救医学

Sepsis is a life-threatening organ dysfunction caused by infection that lead to dysregulation of the host response. Sepsis and septic shock with a high mortality threaten human health at present, which are important medical and health problems. Early diagnosis and treatment decision-making for sepsis and septic shock still need to be improved. Exosomes are extracellular vesicles with a diameter of 30-150 nm formed by the fusion of multi-vesicle bodies and cell membranes. Exosomes can effectively transport a variety of bioactive substances such as proteins, lipids, RNA, DNA, and participate in the regulation of inflammatory response, immune response, infection and other pathophysiological processes. In recent years, exosomes have become one of the important methods for the diagnosis and treatment of systemic inflammatory diseases. This article will focus on the basic and clinical research of sepsis, and focus on the research progress of exosomes in the diagnosis and targeted therapy of sepsis.

Clinical study of evaluating the clinical effect of Dachengqi decoction in the treatment of sepsis complication with gastrointestinal dysfunction via gastric antrum cross-sectional area measured by bedside ultrasound / 中华危重病急救医学

OBJECTIVE@#To evaluate the clinical value of Dachengqi decoction in the treatment of sepsis complication with gastrointestinal dysfunction via gastric antrum cross-sectional area (CSA) measured by bedside ultrasound.@*METHODS@#A parallel group randomized controlled trial was conducted. A total of 80 patients with sepsis with gastrointestinal dysfunction admitted to the Second Affiliated Hospital of Nanjing University of Chinese Medicine from January 2021 to October 2022 were enrolled. According to whether patients agree to use Dachengqi decoction after admission, all patients were divided into Dachengqi decoction group (observation group) and conventional treatment group (control group) by 1 : 1 randomization, each group has 40 patients. Both groups were treated with fluid resuscitation, anti-infection, maintaining stable respiratory circulation, early nourishing feeding, promoting gastrointestinal motility, and regulating intestinal flora. The observation group was treated with Dachengqi decoction on the basis of western medicine, 30 mL decoction was taken in the morning and evening. Both groups were treated for 7 days. The CSA of the two groups was measured by bedside ultrasound before and after treatment. The gastric residual volume (GRV1 and GRV2) were calculated by formula and traditional gastric tube withdrawal method. The gastrointestinal dysfunction score, acute physiology and chronic health evaluation II (APACHE II), intraperitoneal pressure (IAP), serum preprotein (PA), albumin (Alb), white blood cell count (WBC), procalcitonin (PCT), hypersensitivity C-reactive protein (hs-CRP), length of intensive care unit (ICU) stay and incidence of aspiration were detected to evaluate the clinical efficacy of Dachengqi decoction, the correlation and advantages and disadvantages between CSA measured by bedside ultrasound and other evaluation indicators of gastrointestinal dysfunction in sepsis were also analyzed.@*RESULTS@#There were no significant differences in the indicators before treatment between the two groups, which were comparable. In comparison with the pre-treatment period, CSA, GRV, gastrointestinal dysfunction score, APACHE II score, IAP, WBC, PCT, and hs-CRP of the two groups after treatment were significantly decreased, PA and Alb were significantly increased, and the observation group decreased or increased more significantly than the control group [CSA (cm2): 4.53±1.56 vs. 6.04±2.52, GRV1 (mL): 39.85±8.21 vs. 53.05±11.73, GRV2 (mL): 29.22±5.20 vs. 40.91±8.97, gastrointestinal dysfunction score: 0.87±0.19 vs. 1.35±0.26, APACHE II score: 11.54±3.43 vs. 14.28±3.07, IAP (cmH2O, 1 cmH2O ≈ 0.098 kPa): 9.79±2.01 vs. 13.30±2.73, WBC (×109/L): 9.35±1.24 vs. 12.35±1.36, PCT (μg/L): 3.68±1.12 vs. 6.43±1.45, hs-CRP (mg/L): 24.76±5.41 vs. 46.76±6.38, PA (mg/L): 370.29±45.89 vs. 258.33±34.58, Alb (g/L): 38.83±5.64 vs. 33.20±4.98, all P < 0.05]. The length of ICU stay (days: 10.56±3.19 vs. 14.24±3.45) and incidence of aspiration (12.5% vs. 25.0%) were lower than those in the control group (both P < 0.05). Correlation analysis showed that CSA measured by bedside ultrasound was positively correlated with GRV2, gastrointestinal dysfunction score, APACHE II score, and IAP (r values were 0.84, 0.78, 0.75, 0.72, all P < 0.01) and negatively correlated with PA and Alb (r values were -0.64 and -0.62, both P < 0.01).@*CONCLUSIONS@#The Dachengqi decoction can significantly improve the clinical symptoms of septic patients with gastrointestinal dysfunction, reduce systemic inflammatory response, improve nutritional status, and shorten ICU hospital stay. Bedside ultrasound monitoring of CSA is a simple, accurate and effective means to evaluate gastrointestinal dysfunction, which is worthy of further clinical promotion.

Evaluation of ICUs and weight of quality control indicators: an exploratory study based on Chinese ICU quality data from 2015 to 2020 / 医学前沿

This study aimed to explore key quality control factors that affected the prognosis of intensive care unit (ICU) patients in Chinese mainland over six years (2015-2020). The data for this study were from 31 provincial and municipal hospitals (3425 hospital ICUs) and included 2 110 685 ICU patients, for a total of 27 607 376 ICU hospitalization days. We found that 15 initially established quality control indicators were good predictors of patient prognosis, including percentage of ICU patients out of all inpatients (%), percentage of ICU bed occupancy of total inpatient bed occupancy (%), percentage of all ICU inpatients with an APACHE II score ⩾15 (%), three-hour (surviving sepsis campaign) SSC bundle compliance (%), six-hour SSC bundle compliance (%), rate of microbe detection before antibiotics (%), percentage of drug deep venous thrombosis (DVT) prophylaxis (%), percentage of unplanned endotracheal extubations (%), percentage of patients reintubated within 48 hours (%), unplanned transfers to the ICU (%), 48-h ICU readmission rate (%), ventilator associated pneumonia (VAP) (per 1000 ventilator days), catheter related blood stream infection (CRBSI) (per 1000 catheter days), catheter-associated urinary tract infections (CAUTI) (per 1000 catheter days), in-hospital mortality (%). When exploratory factor analysis was applied, the 15 indicators were divided into 6 core elements that varied in weight regarding quality evaluation: nosocomial infection management (21.35%), compliance with the Surviving Sepsis Campaign guidelines (17.97%), ICU resources (17.46%), airway management (15.53%), prevention of deep-vein thrombosis (14.07%), and severity of patient condition (13.61%). Based on the different weights of the core elements associated with the 15 indicators, we developed an integrated quality scoring system defined as F score=21.35%xnosocomial infection management + 17.97%xcompliance with SSC guidelines + 17.46%×ICU resources + 15.53%×airway management + 14.07%×DVT prevention + 13.61%×severity of patient condition. This evidence-based quality scoring system will help in assessing the key elements of quality management and establish a foundation for further optimization of the quality control indicator system.

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

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

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

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

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

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

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

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

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

Epidemiology and treatment of sepsis at a public pediatric emergency department

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bundle for pediatric COVID-19 sepsis

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

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

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

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

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