Importance Definitions of sepsis and septic shock were last revised in 2001. Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management, and epidemiology of sepsis, suggesting the need for reexamination. Objective To evaluate and, as needed, update definitions for sepsis and septic shock. Process A task force (n = 19) with expertise in sepsis pathobiology, clinical trials, and epidemiology was convened by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Definitions and clinical criteria were generated through meetings, Delphi processes, analysis of electronic health record databases, and voting, followed by circulation to international professional societies, requesting peer review and endorsement (by 31 societies listed in the Acknowledgment). Key Findings From Evidence Synthesis Limitations of previous definitions included an excessive focus on inflammation, the misleading model that sepsis follows a continuum through severe sepsis to shock, and inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria. Multiple definitions and terminologies are currently in use for sepsis, septic shock, and organ dysfunction, leading to discrepancies in reported incidence and observed mortality. The task force concluded the term severe sepsis was redundant. Recommendations Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less. Conclusions and Relevance These updated definitions and clinical criteria should replace previous definitions, offer greater consistency for epidemiologic studies and clinical trials, and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis.

https://jamanetwork.com/journals/jama/articlepdf/2492881/jsc160002.pdf

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3)

Acute kidney injury (AKI) is a complex disorder for which currently there is no accepted definition. Having a uniform standard for diagnosing and classifying AKI would enhance our ability to manage these patients. Future clinical and translational research in AKI will require collaborative networks of investigators drawn from various disciplines, dissemination of information via multidisciplinary joint conferences and publications, and improved translation of knowledge from pre-clinical research. We describe an initiative to develop uniform standards for defining and classifying AKI and to establish a forum for multidisciplinary interaction to improve care for patients with or at risk for AKI. Members representing key societies in critical care and nephrology along with additional experts in adult and pediatric AKI participated in a two day conference in Amsterdam, The Netherlands, in September 2005 and were assigned to one of three workgroups. Each group's discussions formed the basis for draft recommendations that were later refined and improved during discussion with the larger group. Dissenting opinions were also noted. The final draft recommendations were circulated to all participants and subsequently agreed upon as the consensus recommendations for this report. Participating societies endorsed the recommendations and agreed to help disseminate the results. The term AKI is proposed to represent the entire spectrum of acute renal failure. Diagnostic criteria for AKI are proposed based on acute alterations in serum creatinine or urine output. A staging system for AKI which reflects quantitative changes in serum creatinine and urine output has been developed. We describe the formation of a multidisciplinary collaborative network focused on AKI. We have proposed uniform standards for diagnosing and classifying AKI which will need to be validated in future studies. The Acute Kidney Injury Network offers a mechanism for proceeding with efforts to improve patient outcomes.

Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury

Context Infection is a major cause of morbidity and mortality in intensive care units (ICUs) worldwide. However, relatively little information is available about the global epidemiology of such infections. Objective To provide an up-to-date, international picture of the extent and patterns of infection in ICUs. Design, Setting, and Patients The Extended Prevalence of Infection in Intensive Care (EPIC II) study, a 1-day, prospective, point prevalence study with follow-up conducted on May 8, 2007. Demographic, physiological, bacteriological, therapeutic, and outcome data were collected for 14 414 patients in 1265 participating ICUs from 75 countries on the study day. Analyses focused on the data from the 13 796 adult (>18 years) patients. Results On the day of the study, 7087 of 13 796 patients (51%) were considered infected; 9084 (71%) were receiving antibiotics. The infection was of respiratory origin in 4503 (64%), and microbiological culture results were positive in 4947 (70%) of the infected patients; 62% of the positive isolates were gram-negative organisms, 47% were gram-positive, and 19% were fungi. Patients who had longer ICU stays prior to the study day had higher rates of infection, especially infections due to resistant staphylococci, Acinetobacter, Pseudomonas species, and Candida species. The ICU mortality rate of infected patients was more than twice that of noninfected patients (25% [1688/6659] vs 11% [ 682/6352], respectively; P  Conclusions Infections are common in patients in contemporary ICUs, and risk of infection increases with duration of ICU stay. In this large cohort, infection was independently associated with an increased risk of hospital death.

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International Study of the Prevalence and Outcomes of Infection in Intensive Care Units

Objective:To better define the incidence of sepsis and the characteristics of critically ill patients in European intensive care units.Design:Cohort, multiple-center, observational study.Setting:One hundred and ninety-eight intensive care units in 24 European countries.Patients:All new adult admissi

Sepsis in European intensive care units: results of the SOAP study.

Objective: The aim was to formulate clinical practice guidelines for pheochromocytoma and paraganglioma (PPGL). Participants: The Task Force included a chair selected by the Endocrine Society Clinical Guidelines Subcommittee (CGS), seven experts in the field, and a methodologist. The authors received no corporate funding or remuneration. Evidence: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. The Task Force reviewed primary evidence and commissioned two additional systematic reviews. Consensus Process: One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of the Endocrine Society, European Society of Endocrinology, and Americal Association for Clinical Chemistry reviewed drafts of the guidelines. Conclusions: The Task Force recommends that initial biochemical testing for PPGLs shou...

/pdf/pheochromocytoma-and-paraganglioma-an-endocrine-society-4ij7m1t7fo.pdf

Pheochromocytoma and paraganglioma: An endocrine society clinical practice guideline

In critically ill patients, tissue hypoperfusion is an important cause leading to multi-organ dysfunction and death, and it cannot always be detected by measuring standard global hemodynamic and oxygen-derived parameters. Gastric intramucosal partial pressure of carbon dioxide (PCO2) as measured by gastric tonometry has been recognized to be of clinical value as a prognostic factor, in assessing the effects of particular therapeutic interventions, and as an end-point of resuscitation. However, this technique has several limitations that have hampered its implementation in clinical practice. The sublingual tissue bed has been shown to be damaged in models of shock, and microcirculatory changes in this area may indicate imminent changes in other important organs. The measurement of sublingual mucosal PCO2 (PslCO2) by sublingual capnography is technically simple, noninvasive and gives near instantaneous results. Clinical studies have established that high PslCO2 values and, more especially, high PslCO2 gap (PslCO2 - arterial PCO2) values are correlated with impaired microcirculatory blood flow and a poor outcome in critically ill patients. Sublingual capnography seems to be the ideal noninvasive monitoring tool to evaluate the severity of shock states and the adequacy of tissue perfusion. However, clinical studies are needed to determine the clinical utility of PslCO2 gap monitoring as end-point target to guide resuscitation in critically ill patients.

Mucosal and cutaneous capnometry for the assessment of tissue hypoperfusion.

Determining the venous-to-arterial PCO2 difference (PCO2gap) during resuscitation of septic shock patients might be useful when deciding when to continue resuscitation despite a ScvO2>70% associated with hyperlacticemia. Because hyperlacticemia is not a discriminatory factor in defining the cause of that stress, a PCO2gap>6 mmHg could be used to identify global tissue hypoperfusion. Monitoring the "Gap" could be a useful complementary tool after optimization of O2-derived parameters was achieved to evaluate the adequacy of blood flow to global metabolic demand. In this regard it can help to titrate inotropes in order to adapt O2 delivery to CO2 production, or to choose between haemoglobin correction or fluid/inotrope infusion in patients with a too low ScvO2 related to metabolic demand.

Difference in venous-arterial carbon dioxide in septic shock.

Since July 2016 in France, blood donations from men who have had sex with men (MSM) in the previous year have been banned. To evaluate a shorter waiting period, data are being collected on retesting MSM who have had sex with only one partner in the previous 4 months.

Changes in France's Deferral of Blood Donation by Men Who Have Sex with Men.

Background. The aim of this paper was to clarify if previously established prognostic factors explain the different mortality rates observed in ICU septic patients around the world. Methods. This is a sub-study from the PROGRESS study, which was an international, prospective, observational registry of ICU patients with severe sepsis. For this study we included 10930 patients from 24 countries that enrolled more than 100 patients in the PROGRESS. The effect of potential prognostic factors on in-hospital mortality was examined using univariate and multivariate logistic regression. The complete set of data was available for 7022 patients, who were considered in the multivariate analysis. Countries were classified according to country income, development status, and in-hospital mortality terciles. The relationship between countries' characteristics and inhospital mortality was evaluated using linear regression. Results. Mean in-hospital mortality was 49.2%. Severe sepsis in-hospital mortality varied widely in different countries, ranging from 30.6% in New Zealand to 80.4% in Algeria. Classification as developed or developing country was not associated with in-hospital mortality (P=0.16), nor were levels of gross national product per capita (P=0.15). Patients in the group of countries with higher in-hospital mortality had a crude OR for in-hospital death of 2.8 (95% CI 2.5-3.1) in comparison to those in the lower risk group. After adjustments were made for all other independent variables, the OR changed to 2.9 (95% CI 2.5-3.3). Conclusion. Severe sepsis mortality varies widely in different countries. All known markers of disease severity and prognosis do not fully explain the international differences in mortality. Country income does not explain this disparity either. Further studies should be developed to verify if other organizational or structural factors account for disparities in patient care and outcomes. © 2012 EDIZIONI MINERVA MEDICA.

Do established prognostic factors explain the different mortality rates in ICU septic patients around the world

Background and objective Ischaemic colitis can be a serious complication after aortic surgery. The paucity of clinical symptoms makes its diagnosis particularly difficult and often delayed. Automated on-line tonometry is now proposed to monitor intestinal perfusion. This study was designed to assess the use of semi-continuous sigmoid-to-arterial [P(r-a)CO2] PCO2 gap monitoring in aortic surgery to detect colonic ischaemia.Methods This prospective clinical study was realized at the University Hospital of Lille, France, including eight males scheduled for abdominal aortic aneurysm surgery. Intraoperative and postoperative P(r-a)CO2 values were compared with conventional monitoring and colonic mucosa aspect performed by sigmoidoscopy 48 h after surgery. Haemodynamic variables, O2 delivery (DO2), O2 consumption (VO2), O2 extraction (ERO2), lactate, P(v-a)CO2, P(r-a)CO2 were measured peroperatively and every 4 h during a 48-h postoperative period.Results Intraoperative P(r-a)CO2 values increased significantly with the highest value (4.36 ± 3.42 kPa) observed during aortic clamping when DO2 was the most altered. P(r-a)CO2 continued to deteriorate after surgery with the maximal values between 8 (4.79 ± 3.85 kPa) and 12 (4.68 ± 3.26 kPa) h after surgery. This peak was associated with a significant ERO2 increase counterbalancing an increase of VO2 whereas DO2 tended to decrease. P(r-a)CO2 values began to decrease only at the end of the study. The highest values of P(r-a)CO2 were registered in patients with the most altered haemodynamic variables, severe ischaemic colitis along with higher hospital lengths of stay.Conclusion Taken together, these data suggest that regional and automated capnometry may be easily used non-invasively to detect peroperative intestinal ischaemia in aortic surgery.

Benoit Vallet

Papers

Mucosal and cutaneous capnometry for the assessment of tissue hypoperfusion.

Difference in venous-arterial carbon dioxide in septic shock.

Changes in France's Deferral of Blood Donation by Men Who Have Sex with Men.

Do established prognostic factors explain the different mortality rates in ICU septic patients around the world

Pilot study with air-automated sigmoid capnometry in abdominal aortic aneurysm surgery.