Prospective Cohort Study

Acute kidney injury

Early goal-directed therapy in the treatment of severe sepsis and septic shock

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the cause of a rapidly spreading illness, Coronavirus Disease 2019 (COVID-19), affecting thousands of people around the world. Urgent guidance for clinicians caring for the sickest of these patients is needed.
 We formed a panel of 36 experts from 12 countries. All panel members completed the World Health Organization conflict of interest disclosure form. The panel proposed 53 questions that are relevant to the management of COVID-19 in the ICU. We searched the literature for direct and indirect evidence on the management of COVID-19 in critically ill patients in the ICU. We identified relevant and recent systematic reviews on most questions relating to supportive care. We assessed the certainty in the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach, then generated recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility. Recommendations were either strong or weak, or in the form of best practice recommendations.
 The Surviving Sepsis Campaign COVID-19 panel issued 54 statements, of which 4 are best practice statements, 9 are strong recommendations, and 35 are weak recommendations. No recommendation was provided for 6 questions. The topics were: (1) infection control, (2) laboratory diagnosis and specimens, (3) hemodynamic support, (4) ventilatory support, and (5) COVID-19 therapy.
 The Surviving Sepsis Campaign COVID-19 panel issued several recommendations to help support healthcare workers caring for critically ill ICU patients with COVID-19. When available, we will provide new recommendations in further releases of these guidelines.

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Surviving Sepsis Campaign: guidelines on the management of critically ill adults with Coronavirus Disease 2019 (COVID-19)

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Role of WHO.

Acute renal failure during sepsis: Potential role of cell cycle regulation

Background Encephalopathy is a common complication of sepsis, and its onset can occur at any stage of sepsis and implies worse prognosis. However, the incidence, epidemiology, and pathogenesis of sepsis-associated encephalopathy remain controversial. The purpose of this study was to investigate the epidemiological features and risk factors for sepsis-associated encephalopathy. Methods Our retrospective study included all patients with sepsis admitted to our intensive care unit from 2008 to 2011. After excluding 91 patients, 232 patients were assigned to either a sepsis-associated encephalopathy group or sepsis without encephalopathy group. Between-group differences in baseline patient data including vital signs, disease severity, pathogens, sites of infection, biochemical indicators, and time on a mechanical ventilator, intensive care unit (ICU) stay, and 28-day mortality rate were analyzed. Results The incidence of sepsis-associated encephalopathy was 17.7%. The sepsis-associated encephalopathy group had significantly higher 28-day mortality (56.1% vs. 35.1%; P=0.013), spent a significantly longer time on a ventilator ((8.2±2.2) days vs. (2.9±0.4) days; P=0.021), and had a significantly longer ICU stay ((12.4±2.4) days vs. (7.1±0.6) days; P=0.042). Acute physiology and chronic health evaluation II score, Glasgow coma scale, heart rate, blood lactate, serum sodium, platelets, serum albumin, and pH values were related to the presence of encephalopathy. Patients with biliary tract infections and intestinal infections caused by Staphylococcus aureus, Enterococcus faecium, Acinetobacter spp, Pseudomonas aeruginosa, and Stenotrophomonas maltophilia, were more prone to develop sepsis-associated encephalopathy. Conclusions Encephalopathy increases mortality rate in septic patients. Clinical intervention to reduce risk factors and thereby morbidity and mortality depends on a correct understanding of the differences between patients with sepsis and patients with both sepsis and encephalopathy.

Epidemiological features and risk factors of sepsis-associated encephalopathy in intensive care unit patients: 2008-2011

The peripheral perfusion index (PI) is a noninvasive numerical value of peripheral perfusion, and the transcutaneous oxygen challenge test (OCT) is defined as the degree of transcutaneous partial pressure of oxygen (PtcO2) response to 1.0 FiO2. The value of noninvasive monitoring peripheral perfusion to predict outcome remains to be established in septic patients after resuscitation. Moreover, the prognostic value of PI has not been investigated in septic patients. Forty-six septic patients, who were receiving PiCCO-Plus cardiac output monitoring, were included in the study group. Twenty stable postoperative patients were studied as a control group. All the patients inspired 1.0 of FiO2 for 10 minutes during the OCT. Global hemodynamic variables, traditional metabolic variables, PI and OCT related-variables were measured simultaneously at 24 hours after PiCCO catheter insertion. We obtained the 10min-OCT ((PtcO2 after 10 minutes on inspired 1.0 oxygen) - (baseline PtcO2)), and the oxygen challenge index ((10min-OCT)/(PaO2 on inspired 1.0 oxygen - baseline PaO2)) during the OCT. The PI was significantly correlated with baseline PtcO2, 10min-OCT and oxygen challenge index (OCI) in all the patients. The control group had a higher baseline PtcO2, 10min-OCT and PI than the septic shock group. In the sepsis group, the macro hemodynamic parameters and ScvO2 showed no differences between survivors and nonsurvivors. The nonsurvivors had a significantly lower PI, 10min-OCT and OCI, and higher arterial lactate level. The PI, 10min-OCT and OCI predicted the ICU mortality with an accuracy that was similar to arterial lactate level. A PI <0.2 and a 10min-OCT <66mmHg were related to poor outcome after resuscitation. The PI and OCT are predictive of mortality for septic patients after resuscitation. Further investigations are required to determine whether the correction of an impaired level of peripheral perfusion may improve the outcome of septic shock patients.

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The peripheral perfusion index and transcutaneous oxygen challenge test are predictive of mortality in septic patients after resuscitation

It is very important to assess the effectiveness of prone positioning (PP) in patients with severe acute respiratory distress syndrome (ARDS). However, it is difficult to identify patients who may benefit from PP. The purpose of this study was to investigate whether prone positioning potential (PPP) can be predicted by lung ultrasound in patients with ARDS. In this prospective study, 45 patients with ARDS were included for the assessment of PPP. A PP lung ultrasound examination (PLUE) protocol was performed in the dorsal regions of the lung in 16 areas at H0, H3, and H6 (0, 3, and 6 h after PP). The ultrasonography videos were blindly evaluated by two expert clinicians to classify the lung regions as normal pattern (N), moderate loss of lung aeration (B1), severe loss of lung aeration (B2), and consolidation (C). The aeration scores were collected at H0, H3, and H6. According to the ratio of partial pressure of arterial oxygen to fraction of inspired oxygen (P/F ratio) at 7 days, patients were classified into PPP-positive (P/F ratio >300) and PPP-negative groups; also, the patients were classified into survival and nonsurvival groups according to 28-day mortality. Aeration scores was compared at H0, H3, and H6. The scores were significantly reduced between H3 and H0, but there was no difference between H3 and H6. The aeration score variation (ASV) of the PPP-positive group between H3 and H0 was significantly higher than that in the PPP-negative group, and the sensitivity and specificity of ASV ≥5.5 for the PPP-positive group were 73.9% and 86.4%, respectively. The area under the receiver operating characteristic curve (AUROC) was 0.852 for the ASV. The ASV between H3 and H0 in the survival group was significantly higher than in the nonsurvival group. The sensitivity and specificity of ASV ≥7 for survival were 51.5% and 75%, respectively. The AUROC was 0.702 for the ASV. The PLUE protocol can be used to predict PPP and assess prognosis in patients with ARDS.

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Lung ultrasound can be used to predict the potential of prone positioning and assess prognosis in patients with acute respiratory distress syndrome.

To explore the mechanism of mitochondrial uncoupling protein 2 (UCP2) mediating the protective of melatonin when septic cardiomyopathy. UCP2 knocked out mice and cardiomyocytes were used to study the effect of melatonin in response to LPS. Indicators of myocardial and mitochondria injury including mitochondrial membrane potential, mitochondrial permeability transition pore, calcium loading, ROS, and ATP detection were assessed. In addition cell viability and apoptosis as well as autophagy-associated proteins were evaluated. Melatonin was able to protect heart function from LPS, which weakened in the UCP2-knockout mice. Consistently, genipin, a pharmacologic inhibitor of UCP2, augmented LPS-induced damage of AC16 cells. In contrast, melatonin upregulated UCP2 expression and protected the cells from the changes in morphology, mitochondrial membrane potential loss, mitochondrial Ca2+ overload, the opening of mitochondrial permeability transition pore, and subsequent increased ROS generation as well as ATP reduction. Mitophagy proteins (Beclin-1 and LC-3β) were increased while apoptosis-associated proteins (cytochrome C and caspase-3) were decreased when UCP2 was up-regulated. In conclusion, UCP2 may play a protecting role against LPS by regulating the balance between autophagy and apoptosis of cardiomyocytes, and by which mechanisms, it may contribute to homeostasis of cardiac function and cardiomyocytes activity. Melatonin may protect cardiomyocytes through modulating UCP2.

https://www.mdpi.com/1420-3049/23/3/675/pdf

Xiaoting Wang

Papers

Acute renal failure during sepsis: Potential role of cell cycle regulation

Epidemiological features and risk factors of sepsis-associated encephalopathy in intensive care unit patients: 2008-2011

The peripheral perfusion index and transcutaneous oxygen challenge test are predictive of mortality in septic patients after resuscitation

Lung ultrasound can be used to predict the potential of prone positioning and assess prognosis in patients with acute respiratory distress syndrome.

Melatonin Balance the Autophagy and Apoptosis by Regulating UCP2 in the LPS-Induced Cardiomyopathy.