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Clinics and Practice May 2024Lactate is a useful prognostic marker, as its level increases in hypoxic tissue and/or during accelerated aerobic glycolysis due to excessive beta-adrenergic stimulation...
INTRODUCTION
Lactate is a useful prognostic marker, as its level increases in hypoxic tissue and/or during accelerated aerobic glycolysis due to excessive beta-adrenergic stimulation and decreased lactate clearance. The Surviving Sepsis Campaign Bundle 2018 Update suggests premeasurement of lactate within 2-4 h so that physicians perform, assist, administer, and introduce lactate-guided resuscitation to reduce mortality due to sepsis.
METHODS
A total of 108 patients with septic shock who underwent continuous renal replacement therapy (CRRT) for acute kidney injury were enrolled in this observational study. Demographic, clinical, and laboratory data were collected, and patients were divided into two groups: survivors and non-survivors.
RESULTS
Multivariate analysis demonstrated that lactate levels at 24 h after initiation of CRRT treatment, but not lactate levels at intensive care unit (ICU) admission, were associated with mortality. Lactate clearance was associated with lower mortality among the survivors (OR = 0.140) at 6 h after ICU admission and late mortality (OR = 0.260) after 24 h. The area under the ROC curves for mortality was 0.682 for initial lactate; 0.797 for lactate at 24 h; and 0.816 for lactate clearance at 24 h.
CONCLUSIONS
Our result reinforces that the determination of lactate dynamics represents a good predictor for mortality, and serial lactate measurements may be more useful prognostic markers than initial lactate in patients with septic shock.
PubMed: 38921256
DOI: 10.3390/clinpract14030078 -
The Pediatric Infectious Disease Journal Jun 2024This study aimed to investigate the efficacy and safety of intravenous colistin in pediatric patients with nosocomial gram-negative bacteria infections and to determine...
Treatment Outcomes and Associated Factors of Intravenous Colistin for Nosocomial Infections in Pediatric Patients: A Retrospective Study in a University Hospital in Thailand.
BACKGROUND
This study aimed to investigate the efficacy and safety of intravenous colistin in pediatric patients with nosocomial gram-negative bacteria infections and to determine factors associated with treatment outcomes.
METHODS
This retrospective study recruited patients aged <18 years receiving intravenous colistin between January 2014 and December 2018. Clinical data and treatment outcomes were reviewed, and factors associated with treatment outcomes were assessed.
RESULTS
This study included 178 patients with a median age of 3.4 years (range, 0.1-17.8). The mean ± SD dose of colistin prescribed to patients without renal impairment was 5.1 ± 0.6 mg/kg/day. The clinical response rate was 70.8% in patients receiving colistin for specific treatment. Infection-related mortality and crude mortality were 17.5% and 19.7%, respectively. The nephrotoxicity rate was 29.8%; approximately 70% of the episodes occurred between the 3rd and 7th day of treatment. The presence of at least 2 organ dysfunctions [adjusted hazard ratio (aHR): 7.17; 95% CI: 1.64-31.40], septic shock (aHR: 2.69; 95% CI: 1.36-5.32) and receiving chemotherapy/immunosuppressants (aHR: 2.68; 95% CI: 1.36-5.25) were observed to be associated with clinical failure. The factors observed to be associated with nephrotoxicity included hypoalbuminemia (aHR: 2.93; 95% CI: 1.26-6.78), receiving amphotericin B (aHR: 2.29; 95% CI: 1.16-4.52), vancomycin (aHR: 3.36; 95% CI: 1.50-7.56) and vasopressors (aHR: 2.57; 95% CI: 1.27-5.21).
CONCLUSION
Colistin is generally effective in the treatment of nosocomial gram-negative bacteria infections in pediatric patients. Close monitoring of renal function should be considered, especially in high-risk patients. Optimal dosage regimens for pediatric populations to promote more favorable clinical outcomes and minimize nephrotoxicity require further investigation.
PubMed: 38916921
DOI: 10.1097/INF.0000000000004450 -
CJEM Jun 2024
PubMed: 38916847
DOI: 10.1007/s43678-024-00732-1 -
Journal of Artificial Organs : the... Jun 2024Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a rescue therapy for severe respiratory failure in which conventional mechanical ventilation therapy is...
Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a rescue therapy for severe respiratory failure in which conventional mechanical ventilation therapy is unsuccessful. Hemolysis during VV-ECMO support arises from multiple factors associated with organ damage and poor outcomes. Therefore, close and prompt monitoring is needed. Hemolytic uremic syndrome (HUS) is characterized by hemolysis, acute renal failure, and thrombocytopenia. Hemolytic features of the disease may complicate VV-ECMO management. A 26-year-old man with a history of cerebral palsy underwent VV-ECMO for acute respiratory distress syndrome (ARDS) due to septic shock caused by bacterial translocation during treatment for HUS. He showed features of hemolysis, with elevated lactate dehydrogenase (LDH), fragmented red blood cells, and low haptoglobin levels. Plasma free hemoglobin was measured daily throughout the whole course of ECMO with levels higher than 10 mg/dL but not exceeding 50 mg/dL. The extracorporeal membrane oxygenation (ECMO) circuit pressures were carefully monitored to ensure the pump generated no excessive negative pressure. The patient was weaned off ECMO on the eleventh day. There have been several cases of VA-ECMO in patients with HUS; however, there is limited literature on VV-ECMO. As the days on VV-ECMO tend to be longer than those on VA-ECMO, features of hemolysis may complicate management. Although HUS did not directly influence the clinical course in the present case, features of hemolysis were continuously observed. This case highlighted the importance of standard ECMO monitoring, especially daily measurement of plasma free hemoglobin.
PubMed: 38916825
DOI: 10.1007/s10047-024-01457-9 -
European Journal of Pediatrics Jun 2024This study aimed to evaluate the current evidence on various aspects of fluid therapy such as type, volume, and timing of fluid bolus administration in children with...
UNLABELLED
This study aimed to evaluate the current evidence on various aspects of fluid therapy such as type, volume, and timing of fluid bolus administration in children with septic shock. Systematic review and meta-analysis of clinical trials including children less than 18 years of age admitted to the pediatric emergency and intensive care unit with severe infection and shock requiring fluid resuscitation. The intervention included balanced crystalloids (BC) vs normal saline (NS), colloids vs NS, restricted vs liberal fluid bolus, and slow vs fast fluid bolus. The primary outcome was mortality rate. Of the 219 citations retrieved, 12 trials (3526 children with severe infection with or without malaria and shock) were included. The pooled results found no significant difference in the mortality rate between groups comparing balanced crystalloids (BC) vs normal saline (NS), colloids vs NS, restricted vs liberal fluid bolus, and slow vs fast fluid bolus. The risk of acute kidney injury (AKI) was significantly less in the BC group compared to the NS group. The certainty of evidence for mortality was of "moderate certainty" in the BC vs NS group, and was of "very low certainty" for the other two groups.
CONCLUSIONS
The current meta-analysis found no significant difference in the mortality rate between the types of resuscitation fluid, and their speed or volume of administration. However, a significantly decreased risk of AKI was found in the BC group. More evidence is needed regarding the speed and volume of administration of fluid boluses in critically ill children.Prospero registration: CRD42020209066.
WHAT IS KNOWN
• Balanced crystalloids (BC) may be better than normal saline (NS) for fluid resuscitation in critically ill children.
WHAT IS NEW
• BC are better than NS for fluid resuscitation in critically ill children as they decrease AKI and hyperchloremia.
PubMed: 38916738
DOI: 10.1007/s00431-024-05653-w -
Critical Care Explorations Jul 2024In critically ill children with severe sepsis, septic cardiomyopathy (SCM) denotes the subset of patients who have myocardial dysfunction with poor response to fluid and... (Review)
Review
OBJECTIVES
In critically ill children with severe sepsis, septic cardiomyopathy (SCM) denotes the subset of patients who have myocardial dysfunction with poor response to fluid and inotropic support, and higher mortality risk. The objective of this review was to evaluate the role of speckle-tracking echocardiography (STE) in the diagnosis and prognosis of pediatric SCM in the PICU setting.
DATA SOURCES
We performed detailed searches using PubMed, Scopus, Web of Science, and Google Scholar. Reference lists of all included studies were also examined for further identification of potentially relevant studies.
STUDY SELECTION
Studies with the following medical subject headings and keywords were selected: speckle-tracking echocardiography, strain imaging, global longitudinal strain, echocardiography, sepsis, severe sepsis, septic shock, septic cardiomyopathy, and myocardial dysfunction.
DATA EXTRACTION
The following data were extracted from all included studies: demographics, diagnoses, echocardiographic parameters, severity of illness, PICU management, and outcomes.
DATA SYNTHESIS
STE is a relatively new echocardiographic technique that directly quantifies myocardial contractility. It has high sensitivity in diagnosing SCM, correlates well with illness severity, and has good prognosticating value as compared with conventional echocardiographic parameters. Further studies are required to establish its role in evaluating biventricular systolic and diastolic dysfunction, and to investigate whether it has a role in individualizing treatment and improving treatment outcomes in this group of patients.
CONCLUSIONS
STE is a useful adjunct to conventional measures of cardiac function on 2D-echocardiography in the assessment of pediatric SCM in the PICU.
Topics: Humans; Cardiomyopathies; Echocardiography; Critical Illness; Child; Sepsis; Intensive Care Units, Pediatric; Prognosis; Child, Preschool; Infant
PubMed: 38916605
DOI: 10.1097/CCE.0000000000001114 -
Scientific Reports Jun 2024Coagulopathy, microvascular alterations and concomitant organ dysfunctions are hallmarks of sepsis. Attempts to attenuate coagulation activation with an inhibitor of...
Coagulopathy, microvascular alterations and concomitant organ dysfunctions are hallmarks of sepsis. Attempts to attenuate coagulation activation with an inhibitor of tissue factor (TF), i.e. tissue factor pathway inhibitor (TFPI), revealed no survival benefit in a heterogenous group of sepsis patients, but a potential survival benefit in patients with an international normalized ratio (INR) < 1.2. Since an increased TF/TFPI ratio determines the procoagulant activity specifically on microvascular endothelial cells in vitro, we investigated whether TF/TFPI ratio in blood is associated with INR alterations, organ dysfunctions, disseminated intravascular coagulation (DIC) and outcome in septic shock. Twenty-nine healthy controls (HC) and 89 patients with septic shock admitted to a tertiary ICU were analyzed. TF and TFPI in blood was analyzed and related to organ dysfunctions, DIC and mortality. Patients with septic shock had 1.6-fold higher levels of TF and 2.9-fold higher levels of TFPI than HC. TF/TFPI ratio was lower in septic shock compared to HC (0.003 (0.002-0.005) vs. 0.006 (0.005-0.008), p < 0.001). Non-survivors had higher TFPI levels compared to survivors (43038 (29354-54023) vs. 28041 (21675-46582) pg/ml, p = 0.011). High TFPI levels were associated with acute kidney injury, liver dysfunction, DIC and disease severity. There was a positive association between TF/TFPI ratio and troponin T (b = 0.531 (0.309-0.754), p < 0.001). A high TF/TFPI ratio is exclusively associated with myocardial injury but not with other organ dysfunctions. Systemic TFPI levels seem to reflect disease severity. These findings point towards a pathophysiologic role of TF/TFPI in sepsis-induced myocardial injury.
Topics: Humans; Shock, Septic; Thromboplastin; Male; Female; Lipoproteins; Middle Aged; Aged; Multiple Organ Failure; Disseminated Intravascular Coagulation; Case-Control Studies; Adult; Biomarkers
PubMed: 38914630
DOI: 10.1038/s41598-024-65262-3 -
Frontiers in Cellular and Infection... 2024Bloodstream infection (BSI) represent a prevalent complication in haematological malignancies (HMs). Typically, Patients with BSI usually undergo empirical treatment...
BACKGROUND
Bloodstream infection (BSI) represent a prevalent complication in haematological malignancies (HMs). Typically, Patients with BSI usually undergo empirical treatment pending pathogen identification. The timely and effective management of BSIs significantly influences patient prognosis. However, pathogen distribution in BSIs exhibits regional variation. In this study, we investigated the clinical characteristics, pathogen spectrum, drug resistance, risk factors of short-term prognosis and long-term prognostic factors of acute myeloid leukemia (AML) patients with BSI at Zhejiang Provincal People's Hospital.
METHODS
From 2019 to 2021, a total of 56 AML patients with BSI were treated in the Department of Haematology at Zhejiang Province People's Hospital. Data regarding pathogen spectrum and drug resistance were collected for analysis. The patients were stratified into non-survivor cohort and survivor cohort within 30 days after BSI, and the predictors of 30-days mortality were identified through both univariate and multivariate Logistic regression analyses. Furthermore, Kaplan-Meier survival analysis and Cox regression analysis were employed to ascertain the risk factors associated with poor prognosis in AML patients complicated by BSI.
RESULTS
A total of 70 strains of pathogenic bacteria were isolated from 56 AML patients with BSI. Gram-negative bacteria constituted the predominant pathogens (71.4%), with being the most prevalent (22.9%). Gram-positive bacteria and fungi accounted for 22.9% and 5.7%, respectively. Univariate and multivariate analyses revealed significant differences in total protein, albumin levels, and the presence of septic shock between the non-survivor cohort and the survior cohort 30 days post-BSI. COX regression analysis showed that agranulocytosis duration exceeding 20 days (HR:3.854; 95% CI: 1.451-10.242) and septic shock (HR:3.788; 95% CI: 1.729-8.299) were independent risk factors for poor prognosis in AML patients complicated by BSI. Notably, the mortality rate within 30 days after infection was up to 71.4%.
CONCLUSIONS
In this study, Gram-negative bacteria, predominantly Klebsiella pneumoniae, constituted the primary pathogens among AML patients with BSIs. Serum albumin levels and the presence of septic shock emerged as independent risk factors for mortality within 30 days among AML patients with BSI. In terms of long-term prognosis, extended agranulocytosis duration exceeding 20 days and septic shock were associated with elevated mortality rates in AML patients with BSI. Additionally, in our centre, infection was found to be associated with a poor prognosis. Early intervention for infection in our centre could potentially improve patient outcomes.
Topics: Humans; Leukemia, Myeloid, Acute; Male; Female; Middle Aged; Retrospective Studies; Adult; Risk Factors; Aged; Bacteremia; Prognosis; Anti-Bacterial Agents; China; Drug Resistance, Bacterial; Young Adult; Bacteria; Gram-Negative Bacteria
PubMed: 38912203
DOI: 10.3389/fcimb.2024.1390053 -
Cureus Jun 2024A 63-year-old man who presented to the hospital with altered mental status and decreased responsiveness was found to have severe symptomatic hyponatremia with a sodium...
A 63-year-old man who presented to the hospital with altered mental status and decreased responsiveness was found to have severe symptomatic hyponatremia with a sodium level of 96 mmol/L and pneumonia. The patient was admitted to the medical intensive care unit for septic shock and acute severe hyponatremia. He was intubated for airway protection, and treated with 3% hypertonic saline bolus and antibiotics. After four days, sodium levels were corrected to 128 mmol/L, and the patient was extubated and downgraded to the medical floor. This case demonstrates one of the lowest recorded sodium lab values ever and the patient was successfully treated and discharged home with appropriate outpatient appointments.
PubMed: 38912083
DOI: 10.7759/cureus.62915 -
Clinical Case Reports Jul 2024Leptospirosis is an important zoonosis worldwide. Due to nonspecific clinical manifestation and poor recognition in non-epidemic area, there is often a delay in...
Metagenomic next-generation sequencing in the early diagnosis of leptospirosis infection presenting as acalculous cholecystitis and septic shock in a non-epidemic area after typhoons: A case report.
KEY CLINICAL MESSAGE
Leptospirosis is an important zoonosis worldwide. Due to nonspecific clinical manifestation and poor recognition in non-epidemic area, there is often a delay in diagnosis and treatment. Early diagnosis from Metagenomic next-generation sequencing test is crucial for timely intervention.
ABSTRACT
We presented a case of a 19-year-old male patient who developed leptospirosis infection characterized by acalculous cholecystitis and septic shock after typhoon events. Metagenomic next-generation sequencing (mNGS) helped to early diagnose leptospirosis infection. Finally, the patient achieved full recovery following the antibiotic treatment in addition to supportive care and was discharged.
PubMed: 38911922
DOI: 10.1002/ccr3.9095