OBJECTIVE: We evaluated the clinical characteristics and prognoses of patients with septic shock who transferred to the emergency department (ED) in a tertiary referral center. METHODS: This study was performed using a prospective, multi-center registry of septic shock, with the participation of 11 tertiary referral centers in the Korean Shock Society between October 2015 and February 2017. We classified the patients as a transferred group who transferred from other hospitals after meeting the inclusion criteria upon ED arrival and a non-transferred group who presented directly to the ED. Primary outcome was hospital mortality. We conducted multiple logistic regression analysis to assess variables related to in-hospital mortality. RESULTS: A total of 2,098 patients were included, and we assigned 717 patients to the transferred group and 1,381 patients to the non-transferred group. The initial Sequential Organ Failure Assessment score was higher in the transferred group than the non-transferred group (6; interquartile range [IQR], 4–9 vs. 6; IQR, 4–8; P < 0.001). Mechanical ventilator (29% vs. 21%, P < 0.001) and renal replacement therapy (12% vs. 9%, P=0.034) within 24 hours after ED arrival were more frequently applied in the transferred group than the non-transferred group. Overall hospital mortality was 22% and there was no significant difference between transferred and non-transferred groups (23% vs. 22%, P=0.820). Multivariable analysis showed an odds ratio for in-hospital mortality of 1.00 (95% confidence interval, 0.78–1.28; P=0.999) for the transferred group compared with the non-transferred group. CONCLUSION: The transferred group showed higher severity and needed more organ support procedures than the nontransferred group. However, inter-hospital transfer did not affect in-hospital mortality.
Emergencies* ; Emergency Service, Hospital* ; Hospital Mortality ; Humans ; Logistic Models ; Mortality ; Observational Study* ; Odds Ratio ; Prognosis ; Prospective Studies ; Renal Replacement Therapy ; Retrospective Studies* ; Sepsis ; Shock ; Shock, Septic* ; Tertiary Care Centers* ; Ventilators, Mechanical

BACKGROUND: Proenkephalin (PENK) has been suggested as a novel biomarker for kidney function. We investigated the diagnostic and prognostic utility of plasma PENK in comparison with neutrophil gelatinase-associated lipocalin (NGAL) and estimated glomerular filtration rates (eGFR) in septic patients. METHODS: A total of 167 septic patients were enrolled: 99 with sepsis, 37 with septic shock, and 31 with suspected sepsis. PENK and NGAL concentrations were measured and GFR was estimated by using the isotope dilution mass spectrometry traceable-Modification of Diet in Renal Disease (MDRD) Study and three Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equations: CKD-EPI(Cr), CDK-EPI(CysC), and CKD-EPI(Cr-CysC). The PENK, NGAL, and eGFR results were compared according to sepsis severity, presence or absence of acute kidney injury (AKI), and clinical outcomes. RESULTS: The PENK, NGAL, and eGFR results were significantly associated with sepsis severity and differed significantly between patients with and without AKI only in the sepsis group (all P<0.05). PENK was superior to NGAL in predicting AKI (P=0.022) and renal replacement therapy (RRT) (P=0.0085). Regardless of the variable GFR category by the different eGFR equations, PENK showed constant and significant associations with all eGFR equations. Unlike NGAL, PENK was not influenced by inflammation and predicted the 30-day mortality. CONCLUSIONS: PENK is a highly sensitive and objective biomarker of AKI and RRT and is useful for prognosis prediction in septic patients. With its diagnostic robustness and predictive power for survival, PENK constitutes a promising biomarker in critical care settings including sepsis.
Acute Kidney Injury ; Cooperative Behavior ; Critical Care ; Diet ; Epidemiology ; Glomerular Filtration Rate* ; Humans ; Inflammation ; Kidney ; Lipocalins* ; Mass Spectrometry ; Mortality ; Neutrophils* ; Plasma ; Prognosis ; Renal Insufficiency, Chronic ; Renal Replacement Therapy ; Sepsis* ; Shock, Septic

PURPOSE: Owing to the recommendations of the Surviving Sepsis Campaign guidelines, protocol-based resuscitation or goal-directed therapy (GDT) is broadly advocated for the treatment of septic shock. However, the most recently published trials showed no survival benefit from protocol-based resuscitation in septic shock patients. Hence, we aimed to assess the effect of GDT on clinical outcomes in such patients. MATERIALS AND METHODS: We performed a systematic review that included a meta-analysis. We used electronic search engines including PubMed, Embase, and the Cochrane database to find studies comparing protocol-based GDT to common or standard care in patients with septic shock and severe sepsis. RESULTS: A total of 13269 septic shock patients in 24 studies were included [12 randomized controlled trials (RCTs) and 12 observational studies]. The overall mortality odds ratio (OR) [95% confidence interval (CI)] for GDT versus conventional care was 0.746 (0.631-0.883). In RCTs only, the mortality OR (95% CI) for GDT versus conventional care in the meta-analysis was 0.93 (0.75-1.16). The beneficial effect of GDT decreased as more recent studies were added in an alternative, cumulative meta-analysis. No significant publication bias was found. CONCLUSION: The result of this meta-analysis suggests that GDT reduces mortality in patients with severe sepsis or septic shock. However, our cumulative meta-analysis revealed that the reduction of mortality risk was diminished as more recent studies were added.
Humans ; *Observational Studies as Topic ; *Randomized Controlled Trials as Topic ; Resuscitation/*methods ; Shock, Septic/mortality/*therapy

BACKGROUND/AIMS: The modified early warning score (MEWS) is used to predict patient intensive care unit (ICU) admission and mortality. Lactate (LA) in the blood lactate (BLA) is measured to evaluate disease severity and treatment efficacy in patients with severe sepsis/septic shock. The usefulness of a combination of MEWS and BLA to predict ICU transfer in severe sepsis/septic shock patients is unclear. We evaluated whether use of a combination of MEWS and BLA enhances prediction of ICU transfer and mortality in hospitalized patients with severe sepsis/septic shock. METHODS: Patients with severe sepsis/septic shock who were screened or contacted by a medical emergency team between January 2012 and August 2012 were enrolled at a university-affiliated hospital with ~2,700 beds, including 28 medical ICU beds. RESULTS: One hundred patients were enrolled and the rate of ICU admittance was 38%. MEWS (7.37 vs. 4.85) and BLA concentration (5 mmol/L vs. 2.19 mmol/L) were significantly higher in patients transferred to ICU than those in patients treated in general wards. The combination of MEWS and BLA was more accurate than MEWS alone in terms of ICU transfer (C-statistics: 0.898 vs. 0.816, p = 0.019). The 28-day mortality rate was 19%. MEWS was the only factor significantly associated with 28-day mortality rate (odds ratio, 1.462; 95% confidence interval, 1.122 to 1.905; p = 0.005). CONCLUSIONS: The combination of MEWS and BLA may enhance prediction of ICU transfer in patients with severe sepsis/septic shock.
Adult ; Aged ; Biomarkers/blood ; *Decision Support Techniques ; Female ; Health Status ; *Health Status Indicators ; Hospital Bed Capacity ; Hospital Mortality ; Hospitals, University ; Humans ; *Intensive Care Units ; Lactic Acid/*blood ; Male ; Middle Aged ; *Patient Transfer ; Predictive Value of Tests ; Prognosis ; Retrospective Studies ; Risk Assessment ; Risk Factors ; Sepsis/blood/*diagnosis/mortality/therapy ; Shock, Septic/blood/*diagnosis/mortality/therapy ; Time Factors

OBJECTIVETo assess the value of central venous-to-arterial carbon dioxide difference [ P( cv-a) CO₂] in evaluation of disease severity and prognosis in children with septic shock who already had central venous oxygen saturation (ScvO₂) higher than 70% after early resuscitation.

METHODIn this prospective study, 48 septic shock children seen in Shanghai Children's Hospital, Shanghai Jiao Tong University were enrolled from Jun 2012 to May 2014. 36(75.0%) were male, 12 (25.0%) were female, the average age was (31.9 ± 24.5) months. The critically ill patients with septic shock were treated to achieve ScvO₂greater than 70% depending on early goal-directed therapy (EGDT). All patients were divided into two groups, based on P(cv-a)CO₂, low P(cv-a)CO₂group with P(cv-a)CO₂< 6 mmHg (1 mmHg = 0.133 kPa) and high P(cv-a)CO₂group with P(cv-a)CO₂≥ 6 mmHg. The parameters of hemodynamics including mean blood pressure (MAP), heart rate (HR), central venous pressure (CVP), perfusion-related parameters [ScvO₂, P(cv-a)CO₂, serum lactate (Lac), Lac clearance rate], pediatric critical illness score, PRISMIII score, and 28 days in-hospital mortality were recorded for all patients.

RESULTOf the 48 cases with septic shock whose ScvO₂was higher than 70%, 17 patients (35.4%) had high P(cv-a)CO₂( ≥ 6 mmHg) and 31 (65.6%) had lower P(cv-a)CO₂(<6 mmHg). There were no significant differences between the 2 groups of patients in age, PRISMIII score and PCIS (P > 0.05 ), but Lac and P(cv-a)CO₂values were significantly different ( P < 0.05). Low P(cv-a) CO₂group patients had lower 28 days mortality than high P(cv-a) CO₂group[11/17 vs. 32.3% (10/31), P < 0.05]; 24 h after resuscitation, compared with high P(cv-a) CO₂group, low P(cv-a) CO₂group patients had lower Lac values [(2.0 ± 1.3) vs.( 2.7 ± 1.2) mmol/L, P < 0.05]. Low P(cv-a) CO₂group patients had shorter duration of vasoactive drugs use [(16 ± 14) vs. (44 ± 21)h, P < 0.05], 24 h Lac clearance rate was significantly higher for low P(cv-a) CO₂group than for high P(cv-a) CO₂group[ (31 ± 10) % vs. (26 ± 6)%, P < 0.05].

CONCLUSIONWhen ScvO₂> 70% was achieved after early resuscitation in septic shock children, P(cv-a) CO₂is a sensitive biomarker to assess tissue perfusion, and high P(cv-a) CO₂group patients had poor outcome.

Arterial Pressure ; Blood Gas Analysis ; Carbon Dioxide ; blood ; Central Venous Pressure ; Child, Preschool ; China ; Critical Illness ; Female ; Heart Rate ; Hemodynamics ; Hospital Mortality ; Humans ; Infant ; Lactic Acid ; blood ; Male ; Oximetry ; Prognosis ; Prospective Studies ; Resuscitation ; Severity of Illness Index ; Shock, Septic ; blood ; therapy

PURPOSE: Recently, several studies for immature granulocyte proportion (IG%) in patients with sepsis have revealed its association with diagnosis and prognosis of patients with sepsis. In this study, we enrolled patients with severe sepsis and septic shock and compared IG% with other biologic markers as a predictor of 28-day mortality. METHODS: This was a retrospective study for patients with severe sepsis and septic shock who were admitted to the emergency department of a tertiary care hospital for four-months. The IG% measured using Sysmex XE-2100 and other inflammatory markers, including C-reactive protein, lactate, and procalcitonin were evaluated and compared for 28-day mortality. RESULTS: A total of 85 patients with septic shock and 45 patients with severe sepsis were enrolled. In the non-survivors group (n=32, 24.6%), APACHE II score (p=0.017), use of continuous renal replacement therapy (CRRT) (p=0.002), and septic shock (p=0.009) were statistically higher compared with thesurvivors group. APACHE II score (Odd ratio [OR] 1.099, p=0.008) and IG% (> or =0.5%) (OR 3.568, p=0.036) predicted the 28-day mortality independently after adjusting SOFA score, septic shock,disseminated intravascular coagulopathy, use of CRRT, and gender. However, IG (> or =0.5%) had low specificity of 33.7% and positive predictive value (PPV) of 30.1% for 28-day mortality. CONCLUSION: IG% could be a useful biologic marker for prediction of 28-day mortality in patients with severe sepsis or septic shock. However, the limitation of low specificity and PPV must be considered in clinical use.
APACHE ; Biomarkers ; C-Reactive Protein ; Diagnosis ; Emergency Service, Hospital ; Granulocytes* ; Humans ; Lactic Acid ; Mortality* ; Prognosis ; Renal Replacement Therapy ; Retrospective Studies ; Sensitivity and Specificity ; Sepsis* ; Shock, Septic* ; Tertiary Healthcare

Sepsis is a systemic, deleterious host response to infection. The term "severe sepsis" is used when sepsis is complicated by acute organ dysfunction, and "septic shock" as sepsis complicated by either hypotension that is refractory to fluid resuscitation or by hyperlactatemia. The number of cases with severe sepsis exceeds 750,000 per year in the United States and the mortality is now closer to 20 to 30% in these days. The principles of the initial management bundle are to provide sufficient hemodynamic resuscitation and early initiation of appropriate antibiotics to mitigate uncontrolled infection. Initial resuscitation requires the use of intravenous fluids and vasopressors. It is very important to achieve the target of initial resuscitation. The supportive cares in ICU are also significant such as blood component transfusion, glucose control, renal replacement therapy, deep vein thrombosis prophylaxis and stress ulcer prophylaxis. The goals of care and prognosis including end-of-life care should be discussed with patients and families as early as feasible.
Anti-Bacterial Agents ; Blood Component Transfusion ; Evidence-Based Medicine ; Glucose ; Hemodynamics ; Humans ; Hypotension ; Mortality ; Patient Care Planning ; Prognosis ; Renal Replacement Therapy ; Resuscitation ; Sepsis* ; Shock, Septic ; Ulcer ; United States ; Venous Thrombosis

BACKGROUND: Nasopharyngeal carcinoma (NPC) is very rare in children and adolescents. The aim of this study was to evaluate clinical characteristics and treatment outcomes of pediatric NPC.METHODS: Medical records of 9 patients treated for NPC at the Seoul National University Children's Hospital between 1988 and 2012 were analyzed retrospectively.RESULTS: The median age at diagnosis was 11 years (range, 9-13 years). One patient had stage II disease, 3 had stage III disease, and 5 had stage IV disease. The histologic subtypes were undifferentiated carcinoma and squamous cell carcinoma in 7 and 2 patients, respectively. All patients were initially treated with cisplatin (100 mg/m2 intravenous [IV] every 4 weeks for 4-6 months), bleomycin (15 unit/m2 IV every 1 weekx7), and fluorouracil (1,000 mg/m2 IV every 4 weeks for 1 year). Eight patients received radiotherapy with doses of 45-59.4 Gy at the primary site and neck nodes. Seven patients (77.8%) achieved complete remission, 1 (11.1%) achieved partial remission, and 1 (11.1%) showed disease progression. Six patients developed fluorouracil-related neurotoxicity; the regimen was changed to cisplatin, epirubicin, and bleomycin in five of the 6 patients. One patient died of progressive disease without responding to treatment. Treatment-related mortality occurred in 1 patient owing to septic shock. Secondary osteosarcoma developed in 1 patient 6 years after treatment. The overall survival was 77.8%, with a median follow-up of 40.8 months (range, 4.5-287.6 months).CONCLUSION: Children and adolescents with advanced NPC treated with combined chemotherapy and radiotherapy have a good survival rate.
Adolescent ; Bleomycin ; Carcinoma ; Carcinoma, Squamous Cell ; Chemoradiotherapy ; Child ; Cisplatin ; Diagnosis ; Disease Progression ; Drug Therapy ; Epirubicin ; Fluorouracil ; Follow-Up Studies ; Humans ; Korea ; Medical Records ; Mortality ; Nasopharyngeal Neoplasms ; Neck ; Osteosarcoma ; Pediatrics ; Radiotherapy ; Retrospective Studies ; Seoul ; Shock, Septic ; Survival Rate

OBJECTIVETo investigate the correlation between different Chinese medicine (CM) syndromes and variations in microcirculation in septic shock patients.

METHODSseventy Septic shock patients were divided into four groups: heat damaging qi-yin group (HDQY, 23 cases); yin exhaustion and yang collapse group (YEYC, 26 cases); excessive heat in Fu organ group (EHFO, 10 cases); and heat damaging nutrient-blood group (HDNB, 11 cases). Sublingual microcirculation parameters were observed by sidestream dark-field (SDF) imaging and scored by Acute Physiology and Chronic Health Evaluation II (APACHE II) and the Sequential Organ Failure Assessment (SOFA), and parameters of microcirculation perfusion variations and prognoses were analyzed.

RESULTSCompared with those with qi-yin heat damage, perfused vessel density (PVD) in other groups decreased dramatically (P<0.05), and APACHE II scores increased significantly (P<0.05). In addition, the recovery time was prolonged substantially (P<0.05), and the mixed venous oxygen saturation (SVO2) decreased (P<0.05). Blood lactic acid increased significantly (P<0.05), and the mixed SVO decreased (P<0.05), in the YEYC group. Compared with the thermal injury camp blood group, sublingual microcirculation parameter variations showed no obvious difference in the YEYC and EHFO groups (P>0.05). There were significant positive correlations between CM syndromes and APACHE II scoring in different groups (r=0.512, P<0.05). There were negative correlations between PVD and APACHE II scoring (r=-0.378, P=0.043), the proportion of perfused vessels (PPV) and APACHE II scoring (r=-0.472, P=0.008), as well as between the microvascular flow index (MFI) and APACHE II scoring (r=-0.424, P=0.023) in different patients.

CONCLUSIONSublingual microcirculation may serve as a clinical diagnostic parameter of the patient condition, as well as being a prognostic indicator.

Aged ; Dopamine ; therapeutic use ; Dose-Response Relationship, Drug ; Female ; Hemodynamics ; Humans ; Male ; Medicine, Chinese Traditional ; Microcirculation ; physiology ; Middle Aged ; Mouth Floor ; blood supply ; physiopathology ; Perfusion ; Shock, Septic ; blood ; drug therapy ; mortality ; physiopathology ; Syndrome

This study investigated predictors associated with 14-day mortality, and focused especially on the impact of appropriate antimicrobial treatment among patients with carbapenem-resistant Acinetobacter baumannii (CRAB) bacteremia. This retrospective study was performed at a tertiary care hospital in Korea from June 2007 to June 2010. Antibiotic therapy was considered appropriate if the antibiotics were administered via an appropriate route within 24 hr after the result of blood culture, had in vitro sensitivity to isolated strains, and of an adequate dosage according to the current guidelines. Ninety-five patients with A. baumannii bacteremia were included; of these, 53 (55.8%) were infected with CRAB. The overall infection-related 14-day mortality was higher in patients receiving inappropriate antimicrobial therapy than in patients receiving appropriate therapy (59.5% [22/37] vs 13.8% [8/58], P < 0.05). Multivariate analysis showed that septic shock (OR 10.5, 95% CI, 1.93-57.4; P = 0.006), carbapenem-resistance (OR 7.29, 95% CI 1.57-33.8; P = 0.01), pneumonia as a source of bacteremia (OR 5.29, 95% CI 1.07-26.1; P = 0.04), and inappropriate antimicrobial therapy (OR 8.05, 95% CI 1.65-39.2; P = 0.009) were independent risk factors for 14-day mortality. Early definite antimicrobial therapy had an influence on favorable outcomes in patients with A. baumannii bacteremia.
APACHE ; Acinetobacter Infections/drug therapy/microbiology/*mortality ; Acinetobacter baumannii/drug effects/*isolation & purification ; Adult ; Age Factors ; Aged ; Anti-Bacterial Agents/*therapeutic use ; Carbapenems/pharmacology ; Diabetes Complications ; Drug Resistance, Bacterial ; Female ; Humans ; Male ; Middle Aged ; Odds Ratio ; Pneumonia/etiology ; Prognosis ; Retrospective Studies ; Risk Factors ; Shock, Septic/etiology ; Survival Rate