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New therapy strategies for treatment of severe sepsis and septic shock in Intensive care unit of Clinical centre in Kragujevac  [PDF]
Jev?i? Jasna,?urbatovi? Maja,Drakuli?-Mileti? Svetlana,Vuki?evi? Vladimir
Srpski Arhiv za Celokupno Lekarstvo , 2008, DOI: 10.2298/sarh0806248j
Abstract: INTRODUCTION Despite numerous advances in medicine, the mortality rate of severe sepsis and septic shock remains high, 30-50%. New therapy strategies include: early goaldirected therapy, fluid replacement, early and appropriate antimicrobials, source of infection control, use of corticosteroids, vasopressors and inotropic therapy, use of recombinant activated protein C, tight glucose control, low-tidal-volume mechanical ventilation. They have been shown to improve the outcomes. The adequacy and speed of treatment influence the outcome, too. OBJECTIVE The objective was to evaluate if new therapy strategies had been integrated in our routine practice. METOD Patients with severe sepsis or septic shock, who were treated in the Intensive Care Unit (ICU) over a ten-month period, were analyzed retrospectively. The descriptive epidemiological method was applied. Central venous catheterization, central venous pressure, antibiotics, fluid resuscitation, mechanical ventilation, vasopressors, corticosteroids, blood administration, deep vein thrombosis prophylaxis, stress ulcer prophylaxis, glucose control, were evaluated. RESULTS 27 patients were analyzed. Patient characteristics were: age, 49.9 years (18-77) with 30-day in-hospital mortality rate of 48.1%. All patients received broad-spectrum antibiotics. Blood cultures were obtained in 85.2% patients. Adequate antimicrobial treatment was applied to 59.3% and 74.1% patients had central venous pressure monitoring. Average central venous pressure was 8.47±5.6 mm Hg (-2- 20). Aggressive fluid therapy was given to 33.3% of the cases and 66.7% of the patients with septic shock received vasoactive drugs while 29.6% received corticosteroids. Red blood cell transfusions were applied in 59.3% of patients. All patients received stress ulcer prophylaxis, and 37% of them deep vein thrombosis prophylaxis. The average value of morning glucose was 9.11±5.03 mmol/l (3.7-22.0). 63% of patients were mechanically ventilated. Blood lactate was not determined. CONCLUSION Evidence-based clinical guidelines for management of severe sepsis and septic shock have not been implemented in a widespread, systematic way in the ICU of the Clinical Centre, Kragujevac. Institutional acceptance of this protocol, and education of clinicians may improve survivability for patients with sepsis.
Clinical management guidelines of pediatric septic shock  [cached]
Khilnani Praveen
Indian Journal of Critical Care Medicine , 2005,
Abstract: Septic shock in children is the prototype combination of hypovolemia,cardiogenic and distributive shock. Recently published American college of critical care medinie(ACCM )recommendations for hemodynamic support of neonatal and pediatric patients with sepsis,Surviving sepsis campaign and its pediatric considerations and subsequent revision of definitions for pediatric sepsis has led to compilation of this review article. Practical application of this information in Indian set up in a child with septic shock will be discussed based on available evidence.Though guidelines mainly apply to pediatric age group,however a reference has been made to neonatal age group wherever applicable.
OUR EXPERIENCE IN PEDIATRIC SEPSIS  [cached]
M Militaru,,D Martinovici
Jurnalul Pediatrului , 2005,
Abstract: Despite the existence of an international consensus regarding both pediatric sepsis-related definitions, and the management of this serious condition, there is no detailed analysis of the epidemiology, diagnosis and prognosis of pediatric sepsis n Romania. We sought to determine the influence of age, gender, microbiologic etiology, and underlying condition on the incidence, outcome, and associated hospital resources use of sepsis and its complications in pediatric patients. We analyzed our Clinic’s patients’ files for the years 2003 and 2004. Of 2876 hospitalizations for an infectious process in children, 248met the International Pediatric Sepsis Consensus Conference definitions for sepsis, or 124 cases of pediatric sepsis per year. The incidence was highest in infants (12 per 100 infected children) and fell constantly with age. The incidence of sepsis in children did not vary significantly by sex in any of the age groups. One third of the cases had underlying disease (33%). The majority of infections causing sepsis were respiratory (64%). Microbiologic etiology was determined in 25% of all cases, with Gramnegative bacteria being the most important pathogens. Hospital mortality was 5% overall, with a mortality of 53%for the patients presenting with septic shock. The mean length of stay was 12 days. Several factors were significantly associated (p<0.005) with a poor outcome: shock, metabolic acidosis, increased serum bilirubin and creatinine levels, the presence of 4 or more organ dysfunctions. The therapy with corticosteroids was found to improve the outcome of pediatric patients with severe sepsis or septic shock. Sepsis is a significant healthcare problem in children and is associated with the use of extensive healthcare resources. We therefore need to make efforts to increase awareness and adopt the existing evidence-based recommendations for the management of sepsis and its complications.
Human protein C concentrate in pediatric septic patients
GIOVANNI LANDONI,GIACOMO MONTI,ALBERTO FACCHINI,FRANCESCO CAMA
Signa Vitae , 2010,
Abstract: Severe sepsis and septic shock are leading causes of morbidity and mortality in the pediatric population. Unlike what is suggested for the adult population, recombinant human activated protein C (rhAPC) is contraindicated in children. Long before rhAPC was considered for use in pediatric patients, case reports appeared on the safe administration of protein C zymogen. Therefore, we conducted a systemic review of currently available data on protein C zymogen (PC) use among children affected by severe sepsis or septic shock.A total number of 13 case series or case reports and a dose-finding study were found on the use of PC in the pediatric intensive care unit, reporting on 118 treated children, with an overall survival of 84%. There was no bleeding complication, the only reported complication being a single mild allergic reaction. These studies show that PC is safe, not associated with bleeding and possibly useful for improving coagulation abnormalities of sepsis.
Effects on management and outcome of severe sepsis and septic shock patients admitted to the intensive care unit after implementation of a sepsis program: a pilot study
Massimo Girardis, Laura Rinaldi, Lara Donno, Marco Marietta, Mauro Codeluppi, Patrizia Marchegiano, Claudia Venturelli, the 'Sopravvivere alla Sepsi 'group of the Modena-University Hospital
Critical Care , 2009, DOI: 10.1186/cc8029
Abstract: This prospective observational cohort study included 67 patients with severe sepsis/septic shock admitted to a multidisciplinary ICU at a University Hospital from January 2005 to June 2007. Compliance to 5 resuscitation and 4 management sepsis interventions and in-hospital mortality were measured following an educational program on sepsis for physician and nurses of all hospital departments and hospital implementation of a specific protocol for recognition and management of patients with severe sepsis/septic shock, including an early consultation by a skilled 'sepsis team'.During the study period, the compliance to all 9 interventions increased from 8% to 35% of the patients (P < 0.01). The implementation of resuscitation and management interventions was associated with a lower risk of in-hospital mortality (23% vs 68% and 27% vs 68%, P < 0.01). In the latter 2 semesters, after activation of the 'sepsis team', in-hospital mortality of ICU septic shock patients decreased by about 40% compared with the previous period (32% vs 79%, P < 0.01).In our experience, an in-hospital sepsis program, including education of health-care personnel and process-changes, improved the adherence to guidelines and the survival rate of patients with severe sepsis/septic shock admitted to the ICU.The high incidence, costs and mortality rate of patients with sepsis in the recent years has led the critical care scientific community to develop specific strategies aimed to improve the outcome of these patients [1-4]. In 2004, the Surviving Sepsis Campaign (SSC) guidelines [3] recommended a series of diagnostic and therapeutic interventions whose implementation was expected to lead to a survival benefit in patients with severe sepsis/septic shock. Afterwards, to facilitate the application of these guidelines in clinical practice, the Institute for Healthcare Improvement (IHI) proposed the severe sepsis resuscitation (6-hours) and management (24-hours) bundles, that integrate the interventions d
The pediatric sepsis biomarker risk model
Hector R Wong, Shelia Salisbury, Qiang Xiao, Natalie Z Cvijanovich, Mark Hall, Geoffrey L Allen, Neal J Thomas, Robert J Freishtat, Nick Anas, Keith Meyer, Paul A Checchia, Richard Lin, Thomas P Shanley, Michael T Bigham, Anita Sen, Jeffrey Nowak, Michael Quasney, Jared W Henricksen, Arun Chopra, Sharon Banschbach, Eileen Beckman, Kelli Harmon, Patrick Lahni, Christopher J Lindsell
Critical Care , 2012, DOI: 10.1186/cc11652
Abstract: Twelve candidate serum protein stratification biomarkers were identified from previous genome-wide expression profiling. To derive the risk stratification tool, biomarkers were measured in serum samples from 220 unselected children with septic shock, obtained during the first 24 hours of admission to the intensive care unit. Classification and Regression Tree (CART) analysis was used to generate a decision tree to predict 28-day all-cause mortality based on both biomarkers and clinical variables. The derived tree was subsequently tested in an independent cohort of 135 children with septic shock.The derived decision tree included five biomarkers. In the derivation cohort, sensitivity for mortality was 91% (95% CI 70 - 98), specificity was 86% (80 - 90), positive predictive value was 43% (29 - 58), and negative predictive value was 99% (95 - 100). When applied to the test cohort, sensitivity was 89% (64 - 98) and specificity was 64% (55 - 73). In an updated model including all 355 subjects in the combined derivation and test cohorts, sensitivity for mortality was 93% (79 - 98), specificity was 74% (69 - 79), positive predictive value was 32% (24 - 41), and negative predictive value was 99% (96 - 100). False positive subjects in the updated model had greater illness severity compared to the true negative subjects, as measured by persistence of organ failure, length of stay, and intensive care unit free days.The pediatric sepsis biomarker risk model (PERSEVERE; PEdiatRic SEpsis biomarkEr Risk modEl) reliably identifies children at risk of death and greater illness severity from pediatric septic shock. PERSEVERE has the potential to substantially enhance clinical decision making, to adjust for risk in clinical trials, and to serve as a septic shock-specific quality metric.In developed countries with ready access to powerful antibiotics and modern intensive care units, septic shock continues to be a major cause of morbidity and mortality in both adult and pediatric popula
Pilot Study of the Association of the DDAH2 ?449G Polymorphism with Asymmetric Dimethylarginine and Hemodynamic Shock in Pediatric Sepsis  [PDF]
Scott L. Weiss,Min Yu,Lawrence Jennings,Shannon Haymond,Gang Zhang,Mark S. Wainwright
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0033355
Abstract: Genetic variability in the regulation of the nitric oxide (NO) pathway may influence hemodynamic changes in pediatric sepsis. We sought to determine whether functional polymorphisms in DDAH2, which metabolizes the NO synthase inhibitor asymmetric dimethylarginine (ADMA), are associated with susceptibility to sepsis, plasma ADMA, distinct hemodynamic states, and vasopressor requirements in pediatric septic shock.
Elevated plasma levels of heparin-binding protein in intensive care unit patients with severe sepsis and septic shock
Adam Linder, Per ?kesson, Malin Inghammar, Carl-Johan Treutiger, Anna Linnér, Jonas Sundén-Cullberg
Critical Care , 2012, DOI: 10.1186/cc11353
Abstract: A prospective study was conducted of two patient cohorts treated in the ICU at Karolinska University Hospital Huddinge in Sweden. A total of 179 patients was included, of whom 151 had sepsis (126 with septic shock and 25 patients with severe sepsis) and 28 a non-septic critical condition. Blood samples were collected at five time points during six days after admission.HBP levels were significantly higher in the sepsis group as compared to the control group. At admission to the ICU, a plasma HBP concentration of ≥15 ng/mL and/or a HBP (ng/mL)/white blood cell count (109/L) ratio of >2 was found in 87.2% and 50.0% of critically ill patients with sepsis and non-septic illness, respectively. A lactate level of >2.5 mmol/L was detected in 64.9% and 56.0% of the same patient groups. Both in the sepsis group (n = 151) and in the whole group (n = 179), plasma HBP concentrations at admission and in the last measured sample within the 144 hour study period were significantly higher among 28-day non-survivors as compared to survivors and in the sepsis group, an elevated HBP-level at baseline was associated with an increased case-fatality rate at 28 days.Plasma HBP levels were significantly higher in patients with severe sepsis or septic shock compared to patients with a non-septic illness in the ICU. HBP was associated with severity of disease and an elevated HBP at admission was associated with an increased risk of death. HBP that rises over time may identify patients with a deteriorating prognosis. Thus, repeated HBP measurement in the ICU may help monitor treatment and predict outcome in patients with severe infections.Sepsis is defined as the systemic inflammatory response to infection. In its more severe forms it causes tissue hypoperfusion, hypoxia, lactic acidosis, and organ dysfunction [1,2]. Despite increasing awareness of the diagnosis, faster administration of antibiotics and intravenous fluids, better technological support of organ function and other recent advance
Clasificación PIRO en sepsis grave y shock séptico pediátrico: Nuevo modelo de estratificación y su utilidad en pronóstico PIRO classification in pediatric severe sepsis and septic shock: A new model for staging and its potential usefulness in prognoses
Daniela Arriagada S,Franco Díaz R,Alejandro Donoso F,Pablo Cruces R
Revista chilena de infectología , 2010,
Abstract: Introducción: La compresión de la sepsis como un proceso dinámico, resultado de la interacción entre hospedero y agente infeccioso, ha llevado al sistema de estratificación "PIRO" (P) Predisposición, (I) Injuria/ Infección, (R) Respuesta y (O) disfunción de órganos, clasificación orientada a predecir la muerte en pacientes con sepsis, a ganar adeptos. Sin embargo, faltan estudios clínicos que lo validen. Objetivo: Evaluar la certeza de la clasificación "PIRO" en sepsis grave y shock séptico para predecir mortalidad. Pacientes y Método: Estudio retrospectivo efectuado en una UCI pediátrica de 13 camas durante 24 meses (enero 2006 a diciembre 2007). Uno de los cuatro autores registró las características demográficas, clínicas y microbiológicas de la totalidad de pacientes ingresados con diagnóstico de sepsis grave y shock séptico, agrupándolos según sobrevida. Fueron clasificadas estas variables según sistema PIRO Se evaluó la asociación de estas variables con la mortalidad. Resultados: 42 pacientes, edad 11 meses (3,2-58) y mortalidad 19%. Las variables asociadas a mortalidad fueron: (P) antecedente de patología crónica (OR: 7; IC95% 0,95-51) e inmunodeficiencia (6,2; 1,1-35,2); (R) leucopenia (9; 1,96-41,72); (O) disfunción de 3 o más órganos (6,1; 1,22-31). Ninguna de las variables (I) se asoció a mortalidad. Conclusiones: El sistema "PIRO" es un modelo en desarrollo para una clasificación individual, de fácil aplicación. Permite reconocer factores asociados a un resultado fatal, en la presente casuística dado por inmunodeficiencia, leucopenia y fallo de tres o más sistemas. Es importante realizar estudios transversales para definir una etapificación PIRO consensuada y luego validarla prospectivamente. Background: Sepsis is a dynamic process that involves complex interactions between the pathogenic micro-organisms and the host. The understanding of this heterogeneous disease has led to the development of a new system for stratification of septic patients: the PIRO system: Predisposition (P) -Insult/Infection (I) -Response (R) -Organ disfunction (O), a classification aimed to determine the risk of death in patients with sepsis. Only a few studies have validated this classification system in children. Objective: To empirically test the accuracy of the PIRO system in pediatric patients with septic shock and severe sepsis and associate its individual components to predict mortality. Patients and Method: A retrospective chart review was performed in a 13 bed PICU during 24 months (January 2006 to December 2007) Demographic, clinical and microbiological data
Modeling effect of the septic condition and trauma on C-reactive protein levels in children with sepsis: a retrospective study
Michal Kyr, Michal Fedora, Lubomir Elbl, Nishan Kugan, Jaroslav Michalek
Critical Care , 2007, DOI: 10.1186/cc5955
Abstract: We performed a retrospective analysis of 99 patients with systemic inflammatory response syndrome, sepsis, or septic shock who were admitted to the Pediatric Critical Care Unit at the University Hospital, Brno. CRP blood levels were monitored for 10 days following the onset of the septic condition. The effect of different septic conditions and of the surgical or nonsurgical diagnosis on CRP blood levels was statistically analyzed using mixed linear models with a multilevel modeling approach.A significant effect of septic condition and diagnosis on the course of CRP levels was identified. In patients who did not progress to septic shock, CRP blood levels decreased rapidly after reaching peak values – in contrast to the values in patients with septic shock in whom CRP protein levels decreased slowly. Moreover, CRP levels in patients with a surgical diagnosis were higher than in patients with a nonsurgical condition. The magnitude of this additional elevation in surgical patients did not depend on the septic condition.Understanding the pattern of change in levels of CRP associated with a particular condition may improve its diagnostic and prognostic value in children with sepsis.Sepsis remains the main cause of morbidity and mortality in intensive care units [1,2]. Host immunodeficiency, increasing bacterial resistance to antibiotics, and problematic discrimination of an early onset of infection are the major factors altering the course of infections [3,4]. Early diagnosis of sepsis and consequently its correct treatment are fundamental to achieving a positive outcome for patients. Many studies have evaluated the usefulness of various markers of infection in different septic conditions – C-reactive protein (CRP), procalcitonin (PCT), TNFα, and IL-6, IL-8, and IL-10 [5-9].In clinical practice, CRP is the most accessible and widely used marker of infection, and many authors have addressed its sensitivity and specificity [5,10-14], some of whom compared CRP levels among v
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