Validation of a Modified Early Warning Score to Predict ICU Transfer for Patients with Severe Sepsis or Septic Shock on General Wards

PURPOSE: To assess whether the Modified Early Warning Score (MEWS) predicts the need for intensive care unit (ICU) transfer for patients with severe sepsis or septic shock admitted to general wards. METHODS: A retrospective chart review of 100 general ward patients with severe sepsis or septic shock was implemented. Clinical information and MEWS according to point of time between ICU group and general ward group were reviewed. Data were analyzed using multivariate logistic regression and the area under the receiver operating characteristic curves with SPSS/WIN 18.0 program. RESULTS: Thirty-eight ICU patients and sixty-two general ward patients were included. In multivariate logistic regression, MEWS (odds ratio [OR] 2.02, 95% confidence interval [CI] 1.43-2.85), lactic acid (OR 1.83, 95% CI 1.22-2.73) and diastolic blood pressure (OR 0.89, 95% CI 0.80-1.00) were predictive of ICU transfer. The sensitivity and the specificity of MEWS used with cut-off value of six were 89.5% and 67.7% for ICU transfer. CONCLUSION: MEWS is an effective predictor of ICU transfer. A clinical algorithm could be created to respond to high MEWS and intervene with appropriate changes in clinical management.

Propolis derivatives inhibit the systemic inflammatory response and protect hepatic and neuronal cells in acute septic shock

BACKGROUND: Severe pathogenic infection triggers excessive release of cytokines as part of the massive inflammatory response associated with septic shock. OBJECTIVES: To investigate the protective effect of caffeic acid phenethye ester (CAPE) against lipopolysaccharide (LPS) induced endotoxemia, hepatic and neuronal damage and the associated systemic inflammatory response (SIR). METHODS: Fifty male Wister rats were divided into: control, LPS, and CAPE+LPS groups. Plasma concentrations of various cytokines, including TNF-α, IL-1α, IL-1β, IL-6, IL-4, IL-10, and sICAM-1 were evaluated. In addition, the histopathological changes in the hepatic and neural cells were assessed. RESULTS: The LPS group showed high inflammatory cytokines and sICAM-1 levels reflecting the presence of SIR. Hepatocyte necrosis, apoptosis, extensive hemorrhage and inflammatory cellular infiltration together with brain astrocytes swelling, early neuron injury and presence of inflammatory foci confirmed the toxic tissue damage. Use of CAPE decreased the inflammatory cytokines and increased the anti-inflammatory cytokines levels. This biochemical evidence of decreased SIR was confirmed histologically by decreased cellular infiltration in the liver and brain tissue which coincides with preserved structure and protection of the liver and brain cells from the toxic effects of LPS. CONCLUSION: The ability of CAPE to alleviate the SIR, hepatic and neuronal cell damage induced by LPS and galactosamine could be attributed to its ability to reverse the imbalance of the pro- and anti-inflammatory cytokines which may lead to the inhibition of adhesion molecules' expression. CAPE is a promising agent that could help in the prophylaxis and treatment of septic shock.

Development of Acute Megakaryoblastic Leukemia with Isochromosome (12p) after a Primary Mediastinal Germ Cell Tumor in Korea

The association of hematological malignancies with a mediastinal germ cell tumor (GCT) is very rare. We report one case of a young adult male with primary mediastinal GCT who subsequently developed acute megakaryoblastic leukemia involving isochromosome (12p). A 25-yr-old man had been diagnosed with a mediastinal GCT and underwent surgical resection and adjuvant chemotherapy. At 1 week after the last cycle of chemotherapy, his peripheral blood showed leukocytosis with blasts. A bone marrow study confirmed the acute megakaryoblastic leukemia. A cytogenetic study revealed a complex karyotype with i(12p). Although additional chemotherapy was administered, the patient could not attain remission and died of septic shock. This case was definitely distinct from therapy-related secondary leukemia in terms of clinical, morphologic, and cytogenetic features. To our knowledge, this is the first case report of a patient with mediastinal GCT subsequently developing acute megakaryoblastic leukemia involving i(12p) in Korea.

Characterization of an animal model of severe sepsis associated with respiratory dysfunction

PURPOSE: Pathophysiological studies in humans regarding sepsis are difficult to perform due to ethical and methodological concerns. In this context, animal models of sepsis can be useful to better understand this condition and to test therapeutic strategies. The purpose of this study was to characterize a feasible and clinically relevant model of sepsis in pigs that could be useful for testing different therapeutic interventions. METHODS: 5 White Large pigs were anesthetized, arterial and pulmonary catheters were introduced, and sepsis was induced by fecal peritonitis. Several biochemical indicators of organ dysfunction and infectious parameters were measured. The pigs were monitored until death, when fragments of organs were removed for pathology. Three animals without peritonitis served as controls and were sacrificed 24 hours after surgery without developing significant changes in organ function. RESULTS: Septic pigs survived 17 hours on average (range, 16-18 h), and Escherichia coli was recovered from blood cultures. They developed a significant decrease in left ventricular work and a nonsignificant reduction in mixed venous oxygen saturation. Respiratory dysfunction was characterized by a decrease in the PaO2/FiO2 ratio and respiratory compliance. Pathology of the lungs revealed areas of pulmonary collapse, hemorrhage, pulmonary congestion, and discrete neutrophil infiltrate. CONCLUSIONS: Fecal peritonitis in pigs is a clinically relevant model of sepsis associated with acute lung injury without direct pulmonary insult. This model may prove to be useful for studying pathogenic aspects of secondary lung injury as well as for validating ventilatory or pharmacologic interventions.

PROPOSTA: Estudos sobre sepse envolvendo sua fisiopatologia são difíceis de serem realizados devido a razões éticas e metodológicas. Neste sentido, modelos animais criam oportunidades de estudos para entender a fisiopatologia e testar estratégias terapêuticas. O objetivo deste estudo foi criar um modelo relevante de choque séptico em porcos para testar e entender diferentes intervenções. MÉTODOS: 5 porcos da raça "White Large" foram anestesiados e monitorizados com uma linha arterial e um cateter de artéria pulmonar. Uma peritonite fecal foi induzida através de laparotomia. Marcadores de disfunções orgânicas e infecciosos foram mensurados. Todos porcos evoluíram até a morte e amostras de órgãos foram coletadas para exame anátomo patológico. Três animais controles com o mesmo preparo cirúrgico e sem peritonite foram sacrificados após 24 horas de evolução, sem desenvolver mudanças significativas nas funções orgânicas. RESULTADOS: Os animais séptico sobreviveram na média 17 horas (16 - 18h), e Escherichia coli foi cultivada nas amostras de sangue. Os animais sépticos evoluíram com redução do trabalho de ventrículo esquerdo. A disfunção respiratória foi caracterizada por uma redução na relação PaO2/FiO2 e na complacência respiratória. A anatomia patológica dos pulmões revelou colapso pulmonar, hemorragia, congestão e infiltrado neutrofílico. CONCLUSÕES: A peritonite fecal em porcos é um modelo de choque séptico clinicamente relevante e associada a uma lesão pulmonar sem um insulto direto. Este é um modelo que pode ser utilizado para estudar aspectos fisiopatológicos das lesões pulmonares secundárias, assim como para estudar intervenções ventilatórias ou farmacológicas.

Mecanismos de aumento de la PCO2 tisular en el shock / Mechanisms of increased tissue PCO2 in shock

Un aumento en la PCO2 venosa o tisular podría ser provocado por un exceso de producción anaeróbica de CO2 debido al tamponamiento por bicarbonato de protones derivado de ácidos fijos, o por falta de remoción de CO2, secundaria a hipoperfusión tisular. En este Artículo, revisaremos los mecanismos fisiológicos que determinan la hipercarbia venosa y tisular, así como los estudios en los que se han comparado los gradientes venoarteriales e intramucosos arteriales de PCO2, durantes las tres formas clásicas de hipoxia: isquémica, hipóxica y anémica. De estos estudios se concluye que estos gradientes fallan para reflejar la disoxia tisular cuando el flujo sanguíneo es su principal determinante. Estos datos experimentales han sido avalados por un modelo matemático que reafirma estos conceptos. También se discute el comportamiento de los gradientes de CO2 en la situación más relevante para la terapia intensiva, la sepsis. En la sepsis clínica y experimental, el gasto cardíaco está frecuentemente normal o elevado. No obstante, la acidosis intramucosa es un hallazgo común. Esta aparente paradoja se ha intentado explicar por la presencia de alteraciones en el metabolismo ejergético celular, la llamada hipoxia citopática. Sin embargo, actualmente existen fuertes evidencias que vinculan la acidosis intramucosa a las severas alteraciones microcirculatorias que están presentes en la sepsis. Adicionalmente, se discuten modelos experimentales en los que el aumento de la perfusión previene la acidosis intramucosa, pero es incapaz de evitar alteraciones metabólicas como la acidosis por elevación del anión gap y la hiperlactacidemia. En resumen, el PCO2 no es un marcador de disoxia, sino un sensible indicador de perfusión tisular.

¿Cómo manejar la sepsis en el niño? / How to manage sepsis in children?

El propósito de este artículo es revisar el manejo convencional del paciente pediátrico con sepsis severa y shock séptico, que incluye el efectivo control del foco de infección, el soporte hemodinámico y de la función respiratoria, así como la prevención de las complicaciones. Recientes reportes apuntan que la terapia coadyuvante ha mejorado la sobrevida

Disfunción ventricular: el shock séptico / Ventricular dysfunction in septic shock

A pesar del uso amplio de antibióticos y manejo hemodinámico adecuado, el shock séptico ha ido aumentando de frecuencia y es fatal en aproximadamente la mitad de los pacientes. La disfunción miocárdica es una complicación común de pacientes con tensión

Sepsis y embarazo: parte 1 / Sepsis and pregnancy: part 1

La infección, aunque representa una fracción importante como causa de muerte en la mujer grávida, por fortuna rara vez conduce a la muerte en la paciente obstétrica, no obstante, la sepsis grave en obstetricia, es una de las causas más frecuentes de mortalidad. El shock séptico, expresión clínica de la sepsis grave, mantiene una mortalidad en obstétrica, entre 20 por ciento y 50 por ciento . La siguiente revisión, se divide en dos partes: en la primera, trataremos los aspectos epidemiológicos, definiciones, fisiopatología, etiología, factores de riesgo, microbiología, manifestaciones clínicas, efectos del embarazo y sobre la sepsis, y de ésta sobre el embarazo

Síndrome do choque tóxico: discussåo e relato de dois casos / Toxic shock syndrome: discussion and two cases reports

Såo relatados dois casos de Sindrome de Choque Tóxico (SCT) no puerpério, relacionados a abscesso de parede abdominal pós-cesariana e à mastite, com evoluçåo satisfatória. Em ambos os casos foi isolado o Staphylococus aureus nos locais dos abscessos. O tratamento deve ser imediato, devido à gravidade das manifestaçöes clínicas, sendo baseado na reposiçåo hídrica e antibioticoterapia