Anti-endotoxin antibodies consumption in cardiovascular collapse: Pathophysiological concerns / Consumo de anticuerpos antiendotoxina en el shock: relación etiológica

Objective Abnormal endotoxin activity in critically ill patients has been described in the absence of Gram-negative bacterial (GNB) infection. As disease severity seems to be crucial in the detection of this phenomenon, we decided to assess and compare endotoxin exposure in those patients representing the critical situation: septic shock and cardiogenic shock. Design Prospective, observational non intervention study. Setting Critical Care Department of a University tertiary hospital. Patients Cardiogenic shock (CS) and septic shock (SS) patients. Interventions None. Measurements and main results Follow-up was performed for the first three days. Inflammatory biomarkers (C-reactive protein, procalcitonin and interleuquin-6) and IgM antiendotoxin-core antibodies titter (IgM EndoCAb) were daily analyzed. Sixty-two patients were included; twenty-five patients with SS and thirty-seven with CS. Microbial etiology was established in 23 SS patients (92%) and GNB were present in 13 cases (52%). Although infection was suspected and even treated in 30 CS patients (81%), any episode could be finally confirmed. EndoCAb consumption was more intense in SS patients, although twenty-two CS patients (59.5%) had IgM anti-endotoxin value below 10th percentile range for healthy people. No statistically significant difference in endotoxin exposure was detected between Gram-positive and Gram-negative infections in the SS group. Endotoxin exposure ability to distinguish between SS and CS was moderate (AUC 0.7892, 95% IC: 0.6564–0.9218).Conclusions In the severely ill patient some mechanisms take place allowing endotoxin incursion and therefore blurring the limits of diseases pathophysiology. Our work representatively shows how exposure to endotoxin was not fully capable of distinguishing between CS and SS. (AU)

Objetivo En el paciente crítico se ha descrito una actividad incrementada de la endotoxina no asociada a infección por bacterias gramnegativas (BGN). La gravedad de la enfermedad influye en este fenómeno, por ello realizamos este estudio en el paciente crítico por antonomasia: shock séptico y cardiogénico. Diseño Estudio prospectivo, observacional, sin intervención.Lugar de estudioUnidad de Cuidados Intensivos. Pacientes Pacientes en shock cardiogénico (SC) o séptico (SS).Intervención Ninguna. Determinaciones y principales resultados Seguimiento durante los 3 primeros días. Proteína C reactiva, procalcitonina e interleucina-6, y el título de anticuerpos IgM anti-edotoxina (IgM EndoCAb) se analizaron diariamente. Se incluyó a 62 pacientes; 25 con SS y 37 con SC. La etiología fue identificada en 23 pacientes con SS (92%), los BGN estuvieron presentes en 13 casos (52%). Se sospechó e incluso trató la infección en 30 pacientes con SC, pero en ningún caso se pudo confirmar. El consumo de EndoCAb fue más intenso en los pacientes con SS, pero 22 pacientes con SC (59,5%) tuvieron unos valores por debajo del percentil 10. Los niveles de EndoCAb no fueron significativamente diferentes entre las infecciones por BGN y cocos grampositivos. La capacidad de EndoCab para diferenciar entre SC y SS resultó ser moderada (AUC 0,7892; IC del 95%, 0,6564-0,9218).Conclusiones En el paciente crítico es frecuente que la endotoxina provoque una respuesta inflamatoria y la sumación de distintos mecanismos fisiopatológicos. En este sentido, nuestro trabajo pone de manifiesto que la determinación de exposición a endotoxina no es totalmente capaz de distinguir entre los pacientes con SC y SS. (AU)

Anti-endotoxin antibodies consumption in cardiovascular collapse: Pathophysiological concerns.

OBJECTIVE: Abnormal endotoxin activity in critically ill patients has been described in the absence of Gram-negative bacterial (GNB) infection. As disease severity seems to be crucial in the detection of this phenomenon, we decided to assess and compare endotoxin exposure in those patients representing the critical situation: septic shock and cardiogenic shock. DESIGN: Prospective, observational non intervention study. SETTING: Critical Care Department of a University tertiary hospital. PATIENTS: Cardiogenic shock (CS) and septic shock (SS) patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Follow-up was performed for the first three days. Inflammatory biomarkers (C-reactive protein, procalcitonin and interleuquin-6) and IgM antiendotoxin-core antibodies titter (IgM EndoCAb) were daily analyzed. Sixty-two patients were included; twenty-five patients with SS and thirty-seven with CS. Microbial etiology was established in 23 SS patients (92%) and GNB were present in 13 cases (52%). Although infection was suspected and even treated in 30 CS patients (81%), any episode could be finally confirmed. EndoCAb consumption was more intense in SS patients, although twenty-two CS patients (59.5%) had IgM anti-endotoxin value below 10th percentile range for healthy people. No statistically significant difference in endotoxin exposure was detected between Gram-positive and Gram-negative infections in the SS group. Endotoxin exposure ability to distinguish between SS and CS was moderate (AUC 0.7892, 95% IC: 0.6564-0.9218). CONCLUSIONS: In the severely ill patient some mechanisms take place allowing endotoxin incursion and therefore blurring the limits of diseases pathophysiology. Our work representatively shows how exposure to endotoxin was not fully capable of distinguishing between CS and SS.

Utilidad de la procalcitonina para el diagnóstico de infección en el paciente crítico con cirrosis hepática / Usefulness of procalcitonin for diagnosing infection in critically ill patients with liver cirrhosis

OBJETIVO: Analizar la utilidad de la procalcitonina (PCT) para el diagnóstico de infección en pacientes con cirrosis hepática ingresados en una unidad de cuidados intensivos. DISEÑO: Estudio observacional retrospectivo. ÁMBITO: unidad de cuidados intensivos. polivalente, 24 camas. PARTICIPANTES: Pacientes con cirrosis hepática ingresados en nuestra unidad de cuidados intensivos en los últimos 4 años con diagnóstico de sospecha de infección y determinación de PCT. RESULTADOS: Entre los 255 pacientes con cirrosis ingresados en nuestra unidad; se determinó la PCT para el diagnóstico diferencial de infección en 69 casos (27%). Tres pacientes fueron excluidos del análisis por falta de datos clínicos. La estancia media fue de 10,6 ± 9,2 días y la mortalidad del 65%. El origen de la cirrosis fue vírico (57%) o enólico (37%), con una puntuación de 9,5 ± 2 en la escala de Child-Pugh y 23±8 en la escala de MELD. En 54 pacientes (82%) se estableció el diagnóstico de infección. La infección más frecuente fue la neumonía (72%), seguida de la infección intraabdominal (18%), y la bacteriemia (5%). En los pacientes sin infección la mediana de PCT fue de 0,57 ng/ml (0,28-1,14) frente a 2,99 (1,31-9,4) p < 0,001 en aquellos con infección. La capacidad diagnóstica se mantuvo en los pacientes con infección intraabdominal. El punto de corte diagnóstico se estableció en 0,8ng/ml (sensibilidad 83%, especificidad 75%, AUC 0,82 [0,702-0,93]). CONCLUSIONES: En los pacientes con cirrosis hepática la PCT es útil para identificar la presencia de infecciones bacterianas incluyendo las intraabdominales

OBJECTIVE: To evaluate the usefulness of procalcitonin (PCT) for diagnosing infection in patients with liver cirrhosis admitted to an Intensive Care Unit. DESIGN: A retrospective study was carried out. SCOPE: Intensive Care Unit. Versatile, twenty-four beds. PARTICIPANTS: Patients with liver cirrhosis admitted to our Intensive Care Unit in the last four years with suspected infection and measurement of PCT. RESULTS: Among the 255 patients with cirrhosis admitted to our unit, PCT was determined for the differential diagnosis of infection in 69 cases (27%). Three patients were excluded from analysis due to a lack of clinical data. The average stay was 10.6 ± 9.2 days, with a mortality rate of 65%. The origin of cirrhosis was mainly viral (57%) or alcoholic (37%). The Child-Pugh and MELD scores were 9.5±2 and 23±8, respectively. Infection was diagnosed in 54 patients (82%). The most common infection was pneumonia (72%), followed by intraabdominal infections (18%) and bacteremia (5%). In patients without infection, the median PCT concentration was 0.57ng/ml (range 0.28 to 1.14) versus 2.99 (1.31 to 9.4) in those with infection (p <.001). Diagnostic capacity was maintained in patients with intraabdominal infections. The diagnostic cutoff point was set at 0.8ng/ml (sensitivity 83%, specificity 75%, AUC 0.82 [0.702-0.93]). CONCLUSIONS: In patients with liver cirrhosis, PCT is useful for identifying bacterial infections, including intraabdominal processes

[Usefulness of procalcitonin for diagnosing infection in critically ill patients with liver cirrhosis]. / Utilidad de la procalcitonina para el diagnóstico de infección en el paciente crítico con cirrosis hepatica.

OBJECTIVE: To evaluate the usefulness of procalcitonin (PCT) for diagnosing infection in patients with liver cirrhosis admitted to an Intensive Care Unit. DESIGN: A retrospective study was carried out. SCOPE: Intensive Care Unit. Versatile, twenty-four beds. Participants Patients with liver cirrhosis admitted to our Intensive Care Unit in the last four years with suspected infection and measurement of PCT. RESULTS: Among the 255 patients with cirrhosis admitted to our unit, PCT was determined for the differential diagnosis of infection in 69 cases (27%). Three patients were excluded from analysis due to a lack of clinical data. The average stay was 10.6 ± 9.2 days, with a mortality rate of 65%. The origin of cirrhosis was mainly viral (57%) or alcoholic (37%). The Child-Pugh and MELD scores were 9.5 ± 2 and 23 ± 8, respectively. Infection was diagnosed in 54 patients (82%). The most common infection was pneumonia (72%), followed by intraabdominal infections (18%) and bacteremia (5%). In patients without infection, the median PCT concentration was 0.57 ng/ml (range 0.28 to 1.14) versus 2.99 (1.31 to 9.4) in those with infection (p<.001). Diagnostic capacity was maintained in patients with intraabdominal infections. The diagnostic cutoff point was set at 0.8 ng/ml (sensitivity 83%, specificity 75%, AUC 0.82 [0.702-0.93]). CONCLUSIONS: In patients with liver cirrhosis, PCT is useful for identifying bacterial infections, including intraabdominal processes.