Emoke Almasy1, Janos Szederjesi1, Bianca Liana Grigorescu2, Iudita Badea1, Marius Petrisor3, Cristina Manasturean4, Valentina Negrea4, Leonard Azamfirei1, Ario Santini5, Sanda Maria Copotoiu1
1 Department of Anesthesiology and Intensive Care, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Romania
2 Discipline of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Romania
3 Department of Simulation Applied to Medicine, George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Romania
4 Infectious Diseases Clinic, University Hospital Targu Mures, Romania
5 George Emil Palade University of Medicine, Pharmacy, Science and Technology of Targu Mures, Romania
Introduction: Variations in the expression of vascular endothelial growth factor (VEGF) could be used as a biomarker in critically ill patients with sepsis and septic shock. Inflammation potently upregulates VEGF-C expression via macrophages with an unpredictable response. This study aimed to assess one of the newer biomarkers (VEGF-C) in patients with sepsis or septic shock and its clinical value as a diagnostic and prognostic tool.
Material and methods: The study involved 142 persons divided into three groups. Group A consisted of fifty-eight patients with sepsis; Group B consisted of forty-nine patients diagnosed as having septic shock according to the Sepsis -3 criteria. A control group of thirty-five healthy volunteers comprised Group C. Severity scores, prognostic score and organ dysfunction score, were recorded at the time of enrolment in the study. The analysis included specificity and sensitivity of plasma VEGF-C for diagnosis of septic shock. Circulating plasma VEGF-C levels were correlated with the APACHE II, MODS and severity scores and mortality.
Results: The mean (SD) plasma VEGF-C levels in septic shock patients (1374(789) pg./m), on vasopressors at the time of admission to the ICU, were significantly higher 1374(789)pg./mL, compared the mean (SD) plasma VEGF-C levels in sepsis patients (934(468) pg./mL); (p = 0.0005, Student’s t-test.). Plasma VEGF-C levels in groups A and B were shown to be significantly correlated with the APACHE II (r = 0.21, p = 0.02; r = 0.45, p = 0.0009) and MODS score (r = 0.29, p = 0.03; r = 0.4, p = 0.003). There was no association between plasma VEGF-C levels and mortality [p = 0.1]. The cut-off value for septic shock was 1010 pg./ml.
Conclusions: VEGF-C may be used as a prognostic marker in sepsis and septic shock due to its correlation with APACHE II values and as an early marker to determine the likelihood of developing MODS. It could be used as an early biomarker for diagnosing patients with septic shock.
1 Department of Microbiology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, Romania
2 Department of Pathophysiology, George Emil Palade University of Medicine, Pharmacy, Sciences and Technology of Targu Mures, Romania
Nowadays, one of the most challenging medical issues is related to high morbidity and mortality in sepsis and septic shock. Despite the medical progress regarding early diagnosis and management, this complex pathology remains a life-threatening condition. During the last decades, many definitions and including criteria were developed both in sepsis and septic shock, principally as many early biomarkers became available. However, many issues still exist regarding this subject.
The clinical definitions of sepsis and systemic inflammatory response syndrome (SIRS) have been refined, but both conditions manifest with similar clinical features . The Third International Consensus Definitions Task Force (Sepsis-3) defined sepsis as “a life-threatening organ dysfunction resulting from a dysregulated host response to infection”. Septic shock is “a subset of sepsis in which circulatory, cellular and metabolic alterations are associated with a higher mortality rate than sepsis alone”  morphology, cell biology, biochemistry, immunology, and circulation. These definitions are related to the pathophysiology of sepsis, which are the cornerstones of a better understanding of the underlying mechanisms and disorders that occur . [More]
1 Emergency Department, University Hospitals of Morecambe Bay NHS Foundation Trust, United Kingdom
2 Critical Care Department, King Hamad University Hospital, Kingdom of Bahrain
3 Surgical Department, University Hospitals of Morecambe Bay NHS Foundation Trust, United Kingdom
4 Surgical Department, King Hamad University Hospital, Kingdom of Bahrain
5 Internal Medicine department, King Hamad University Hospital, Kingdom of Bahrain
Introduction: Hypernatremia is a commonly associated electrolyte disturbance in sepsis and septic shock patients in the ICU. The objective of this study was to identify the prognostic value of hypernatremia in sepsis and septic shock.
Material and Methods: A prospective study conducted on sepsis and septic shock patients diagnosed prior to admission in the ICU in King Hamad University Hospital, Bahrain from January 1st 2017 to February 28th 2019. Data including age, sex, comorbidities, source of sepsis, sodium levels on days one, three, and seven. Data was correlated with the outcome (survival/death and the length of ICU stay).
Results: Patients included were 168, 110 survived, and 58 died. Hypernatraemia at day seven was associated with significantly higher mortality (P= 0.03). Hypernatraemia at Day1was associated with a significantly prolonged stay in the ICU (p= 0.039).Multivariate analysis to identify the independent predictors of mortality revealed that immunosuppression and hypernatraemia at Day7 proved to be independent predictors of mortality (P= 0.026 and 0.039 respectively).
Conclusion: Hypernatremia can be an independent predictor of poor outcome in septic and septic shock patients in the ICU.
Alina Orfanu1,2, Victoria Aramă1,2, Cristina Popescu1,2, Cătălin Tilişcan1,2, Adrian Streinu-Cercel1,2, Ştefan Sorin Aramă1,2
1 National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, Bucharest
2 University of Medicine and Pharmacy “Carol Davila”, Bucharest
Aims: To evaluate the kinetics of inflammatory biomarkers in septic patients in order to identify the most reliable predictor of unfavorable outcome.
Methods: A prospective analysis of septic patients was performed. Median levels of neutrophil/lymphocyte count ratio, fibrinogen, C-reactive protein and procalcitonin were dynamically assessed and comparatively analyzed.
Results: Seventy-seven patients were included. Descendent kinetic patterns were registered for all biomarkers, except C-reactive protein. At 24 hours, neutrophil/lymphocyte count ratio significantly decreased in 42.85% of cases, procalcitonin in 37.33%, C-reactive protein in 16.12% and fibrinogen in 1.58% of cases. At 72 hours, procalcitonin decreased to one-half in 70% of cases and neutrophil/lymphocyte count ratio in 67.53% of cases.
Conclusions: Neutrophil/lymphocyte count ratio and procalcitonin significantly decreased in the first 72 hours, while C-reactive protein increased in the first 24 hours. The proportions of patients with major decrease of baseline values were higher for neutrophil/lymphocyte count ratio and procalcitonin.
Yingke He1, John Ong2, Thuan Tong Tan3, Brian K. P. Goh4, Sharon G. K. Ong5
1 Division of Anaesthesiology, Singapore General Hospital, Singapore
2 Department of Engineering, Materials Engineering and Material-Tissue Interactions Group, University of Cambridge, United Kingdom
3 Department of Infectious Diseases, Singapore General Hospital, Singapore
4 Department of Hepato-pancreato-biliary and Transplant Surgery, Singapore General Hospital, Singapore
5 Department of Surgical Intensive Care, Singapore General Hospital, Singapore
Background: The systemic inflammatory response syndrome (SIRS) is a complex immune response which can be precipitated by non-infectious aetiologies such as trauma, burns or pancreatitis. Addressing the underlying cause is crucial because it can be associated with increased mortality. Although the current literature associates chronic heart failure with SIRS, acute right ventricular dysfunction has not previously been reported to trigger SIRS. This case report describes the presentation of acute right ventricular dysfunction that triggered SIRS and mimicked septic shock.
Case presentation: A 70-year-old male presented to the Intensive Care Unit (ICU) with elevated inflammatory markers and refractory hypotension after a robotic-assisted laparoscopic radical choledochectomy with pancreaticoduodenectomy. Septic shock was misdiagnosed, and he was later found to have a pulmonary embolus. Thrombectomy and antimicrobials had no significant effect on lowering the elevated inflammatory markers or improving the persistent hypotension. Through Point of Care Ultrasound (POCUS), right ventricular dysfunction was diagnosed. Treatment with intravenous milrinone improved blood pressure, normalised inflammatory markers and led to a prompt discharge from the ICU.
Conclusion: Acute right ventricular dysfunction can trigger SIRS, which may mimic septic shock and delay appropriate treatment.
Md. Jahidul Hasan1, Raihan Rabbani2, Shihan Mahmud Redwanul Huq2
1 Department of Clinical Pharmacy, Square Hospitals Ltd., Dhaka, Bangladesh
2 Internal Medicine and ICU, Square Hospitals Ltd., Dhaka, Bangladesh
Introduction: Sepsis is a life-threatening condition, and sepsis-associated thrombocytopenia (SAT) is a common consequence of the disease where platelet count falls drastically within a very short time. Multiple key factors may cause platelet over-activation, destruction and reduction in platelet production during the sepsis. Eltrombopag is a thrombopoietin receptor agonist and is the second-line drug of choice in the treatment of chronic immune thrombocytopenia (ITP).
Aim of the study: The objective of this study was to observe the therapeutic outcome of high dose eltrombopag in SAT management in critically ill patients.
Material and Methods: This 6-month-long single group, observational study was conducted on seventeen ICU patients with SAT. Eltrombopag 100 mg/day in two divided doses was given to each patient. Platelet counts were monitored. A low platelet blood count returning to 150 K/μL or above, is taken as indicative of a successful reversal of a thrombocytopenia event.
Results: The mean Apache II score of patients (n= 17) was 18.71 (p-value: >0.05). No eltrombopag-induced adverse event was observed among the patients during the study period. Thrombocytopenia events were reversed successfully in 64.71% of patients (11; n= 17) within eight days of eltrombopag therapy.
Conclusions: The therapeutic potentiality of high dose eltrombopag regime in the management of sepsis-associated thrombocytopenia was found clinically significant in over two-thirds of critically ill adult patients enrolled in the study. These data may point to a new strategy in the management of acute type of thrombocytopenia in septic patients.
Alexandra Lazăr1, Anca Meda Georgescu2, Alexander Vitin3, Leonard Azamfirei1
1 Department of Anesthesiology and Intensive Care, University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Romania
2 Department of Infectious Diseases, University of Medicine, Pharmacy, Science and Technology of Târgu Mureș, Romania
3 Department of Anesthesiology & Pain, Medicine University of Washington Medical Center, Seattle WA, USA
In recent years, a new form of medicine has become increasingly significant, namely, personalised medicine (PM). PM is a form of care in which treatment is tailored for an individual patient.
PM is about using multiple data sets to create a digital human mapping. A person’s biological traits are determined by the interactions of hundreds of genes and gene networks, as well as external factors such as diet and exercise. Combining and then investigating these multiple databases with powerful statistical tools, allows a new understanding of how genetic intricacy drives health and disease and so leads to a closer personalised medical approach that targets each individual’s unique genetic make-up.
Sepsis is a systemic inflammatory response to infection, ranging from systemic inflammatory response syndrome (SIRS) to septic shock and multiple organ dysfunction syndromes (MODS). Sepsis is the most common cause of death in intensive care patients. Treatments in an ICU may need to be adapted to the continuous and rapid changes of the disease, making it challenging to identify a single target. PM is thus seen as the future of sepsis treatment in the ICU.
The fact that individual patients respond differently to treatment should be regarded as a starting point in the approach to providing treatment. The disease itself comes secondary to this concept.
Iulia Armean1, Carmen Duicu2, Cornel Aldea3, Lorena Melit1
1 Pediatric Clinic No 1, County Emergency Clinical Hospital, Tirgu Mures, Romania
2 1st Department of Pediatrics, University of Medicine and Pharmacy of Tirgu Mureș, Romania
3 2nd Pediatric Clinic, Clinical Emergency Hospital for Children, Cluj-Napoca, Romania
Introduction: Venous thromboembolism is a rare condition in paediatrics that included both deep venous thrombosis and pulmonary embolism. Serratia marcescens is a gram-negative bacterium that belongs to the Enterobacteriaceae family and tends to affect immunocompromised hosts.
Case report: We report the case of an 11-year-old boy, admitted in the Pediatric Clinic I from Emergency County Hospital Tîrgu Mureș, Romania with intense pain, swelling, cyanosis and claudication of the left foot. His personal history revealed a recent appendectomy. A close family was reported to have had a deep venous thrombosis. The laboratory tests, performed on the day of admission, revealed increased inflammatory biomarkers and D-dimer. Coagulation tests gave a low activated partial thromboplastin time (APTT). Doppler venous ultrasound and CT-exam established a diagnosis of deep venous thrombosis. Anticoagulant therapy was initiated, but on the tenth day of admission, the patient developed signs and symptoms of sepsis, and the blood culture revealed Serratia marcescens. After antibiotic and anticoagulant therapy, the patient progressed favourably. The patient was a carrier of the heterozygous form of Factor V Leiden.
Conclusions: The association between deep venous thrombosis and Serratia marcescens sepsis can compromise a condition in pediatric patients.
1 Department of Anaesthesiology and Critical Care III, Fundeni Clinical Institute, Bucharest, Romania
2 University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
The current definition of sepsis is based on comparatively contemporary knowledge. However, the disease process is not fully understood and treatment still profoundly challenging. Definitions and guidelines have changed over the recent years, and clinicians are always interested to know what the new and current thoughts on the subject are.
Many papers have been published in the medical press, reporting on definitions, scores, models, cytokines, therapies, new trends, statistics, campaigns, including a sepsis anniversary day-which is not celebrating but fighting against sepsis. Together they signify the enormous interest in the subject.
The American College of Chest Physicians and the Society of Critical Care Medicine met in 1992 and gave the first definition of sepsis and associated organ failure . Eleven years later, American intensivists met European intensivists to evaluate if there was a need for a new definition of sepsis . [More]
Rafael Garcia-Carretero1, Marta Lopez-Lomba2, Blanca Carrasco-Fernandez2, Maria Teresa Duran-Valle2
1 Department of Internal Medicine, Mostoles University Hospital, Madrid, Spain
2 Department of Microbiology, Mostoles University Hospital, Madrid, Spain
Objective. Although uncommon, Fusobacterium infections have a wide clinical spectrum, ranging from local pharyngeal infections to septic shock. Our aim was to characterize and analyze the clinical features and outcomes in patients with Fusobacterium infections, and determine which variables were able to predict a poor outcome.
Methods. We conducted a retrospective, hospital-based study using the computerized records of a second-level Spanish general hospital, serving a population of 155,000 inhabitants. The cohort was enrolled among patients cared for at the hospital between 2007 and 2016. Demographic, clinical data, microbiological characterization and outcomes at discharge, were analyzed.
Results. We collected data for all 26 patients over a 10-year period (annual incidence of 1.78 per 100,000), with an incidence of bacteremia of 0.53 cases per 100,000 population per year. F. nucleatum and F. necrophorum were the most frequent isolations (53.8% and 38.5%, respectively). F. necrophorum was found to be associated with a younger population. Although we found no deaths attributable to Fusobacterium, 15 patients (57%) were found to have severe infections due to this pathogen, and 7 patients (26.9%) were admitted to the Intensive Care Unit (ICU). The only identifiable risk factor for a severe infection (sepsis, septic shock or ICU admission) was the presence of bacteremia.
Conclusions. Fusobacterium infections are uncommon. F. necrophorum tends to cause infection in younger individuals, while F. nucleatum has a preference for older patients. The clinical spectrum is wide, ranging from local, non-severe infections, such as sinusitis or pharyngitis, to abscess formation and life-threatening infections.
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