Objective
To evaluate the predicting effect of quick Sequential Organ Failure Assessment (qSOFA) on septic shock, and investigate the probability of improving the predicting effect.
Methods
Patients with sepsis diagnosed in Emergency Department from July 2015 to June 2016 were enrolled. They were divided into shock group and non-shock group based on whether or not they had septic shock during 72 hours after admission. The multivariate logistic regression analysis was used to find out the independent risk factors affecting the incidence of septic shock. Receiver operating characteristic (ROC) curve was used to analyze those risk factors. Modified Early Warning Score (MEWS), Mortality in Emergency Department Sepsis Score (MEDS), Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic HealthEvaluation (APACHE)Ⅱ and qSOFA were also compared with ROC curve analysis. The possibility of improvement of qSOFA predicting effect was discussed.
Results
A total of 821 patients were enrolled, with 108 in septic shock group and 713 in non-septic shock. The result of multivariate logistic regression analysis indicated that respiratory rate, systolic blood pressure, pH value, oxygenation index, lactate, albumin, Glasgow Coma Score and procalcitonin were the independent risk factors (P<0.05). The result of ROC analysis showed that the area under curve (AUC) of pH value, lactate and procalcitonin was 0.695, 0.678 and 0.694, respectively. Lactate had the highest value of specificity (0.868), positive predictive value (0.356) and positive likelihood ratio (3.644), while the sensitivity (0.889) and negative predictive value (0.961) of procalcitonin were the highest. MEWS, MEDS, SOFA, APACHEⅡ and qSOFA were compared with ROC. SOFA had the best predicting effect with the statistical results of AUC (0.833), sensitivity (0.835), specificity (0.435), positive predictive value (0.971), negative predictive value (0.971), and positive likelihood ratio (5.048); and MEWS had the highest negative likelihood ratio (0.581). qSOFA did not show a best predicting value.
Conclusion
qSOFA is not the best choice to predict the possibility of septic shock, but its predicting value might be improved when combined with pH value, lactate and procalcitonin.
Objective To evaluate the effects and the clinical significances of liquid resuscitation on blood gas analysis， acid-base balance， electrolytes， acute physiology and chronic health evaluationsⅡ（APACHEⅡ） score of patients with septic shock， and then to analyze the relations between serum chlorine （Cl－） level and APACHEⅡscore and the volume of liquid resuscitation. Methods According to the target of resuscitation （centre venous pressure 8-12mm Hg and mean arterial pressure≥65mm Hg）， 21 patients with septic shock received enough fluid for resuscitation during 24h . The results of blood gas analysis， acid-base balance， electrolytes， and APACHE Ⅱ score were compared between pre-resuscitation and 24h post-resuscitation by self-controlled prospective study. The relationships of the level of serum Cl－ and APACHEⅡ score with the volume of liquid used in resuscitation were analyzed . Results The mean resus-citation duration was （18.09±4.57） h， and the volume of liquid during 24 h resuscitation was 5 320-11 028mL with mean volume of （7 775±1 735） mL in 21 patients with septic shock. Serum sodium （Na＋， mmol/L） and Cl－（mmol/L）levels of post-resuscitation were significant higher than those of pre-resuscitation （Na＋：138.71±5.67 versus 135.62±7.23， P=0.024；Cl－：109.10±4.90 versus 101.67±8.59， P=0.000）. Compared with the levels of pre-resuscitation， the blood pH value， hematocrit （Hct，%）， anion gap （AG， mmol/L）， lactic acid （mmol/L）， and APACHE Ⅱscore significantly decreased （pH：7.31±0.05 versus 7.37±0.06， P=0.000；Hct：28.48±2.56 versus 32.76±9.19， P=0.049；AG：8.33±3.45 versus 14.17±8.83， P=0.004；lactic acid：1.66±0.89 versus 2.96±1.23， P=0.001；APACHEⅡ：10.90±3.73 versus 17.24±4.06， P=0.000） after 24h resuscitation. The correlation analysis showed that the level of serum Cl- was positively correlated with the volume of liquid used in resuscitation （r=0.717，P＜0.01）. However， there was no correlation between APACHEⅡscore and the volume of liquid used in resuscitation （P＞0.05）. Conclusions The target of liquid resuscitation in patients with septic shock should be cautiously determined， including control of the volume of crystal liquid for resuscitation， in order to avoid acid-base imbalance or hyperchloraemia. At the same time， the change in internal environment should be monitored. An optimistic fluid resuscitation to decrease APACHE Ⅱ score in patients with septic shock is unrelated to the volume of liquid resuscitation.
ObjectiveTo explore the influence of norepinephrine on the prediction of fluid responsiveness by passive leg raising (PLR) during septic shock.
MethodsForty-six septic shock patients in intensive care unit of Nanjing Drum Tower Hospital were prospectively observed from September to November 2012. Among which 36 septic shock patients were enrolled with a positive PLR test (defined by an increase in stroke volume index ≥10%). A PLR test was performed at baseline (PLR1). A second PLR test (PLR2) was performed at returning to supine position for 10 min and the dose of norepinephrine was increased to maintain MAP ≥65 mmHg for 20 min. The changes of heart rate(HR),mean arterial pressure(MAP),central venous pressure(CVP),cardiac index(CI),stroke volume index(SVI),index of systemic vascular resistance(SVRI),global end-diastolic volume index(GEDVI),and cardiac function index(CFI) were monitored by transpulmonary thermodilution technique (PiCCO).
ResultsPLR1 significantly increased SVI by (20.54±9.63)%,CI by (20.57±9.89)%,MAP by (7.64±5.77)%,and CVP by (25.83±23.39)%. As the dose of norepinephrine increased,SVI was increased by (16.97±9.06)%,CI by (16.78±8.39)%,GEDVI by (9.08±4.47)%,MAP by (28.07±12.48)%,and CVP by (7.86±8.52)%. PLR2 increased SVI by (13.74±8.79)%,CI by (13.79±9.08)%,MAP by (2.93±5.06)%,and CVP by (13.36±14.74)%. The PLR2 and the dose increase of norepinephrine augmented SVI to a significantly lesser extent than the PLR1 performed at baseline (both P<0.05). However,SVI increased by <10% in 6 patients while the baseline PLR was positive in these patients.
ConclusionIn septic patients with a positive PLR at baseline,norepinephrine increases cardiac preload and cardiac output and influences the fluid responsiveness.
ObjectiveTo investigate the influence of norepinephrine on pulmonary vessel pressure in animal model of septic shock.
MethodsTwelve health mongrel dogs were randomly divided into a control group (n=5, intravenously injected with normal saline 1 mL/kg) and an endotoxin group(n=7, intravenously injected with lipopolysaccharide 1 mg/kg). When the systemic blood pressure decreased by more than 40% of baseline before administration, the dogs in two groups were intravenously injected with NE 0.5, 1.0, 2.0, 5.0μg·kg-1·min-1. The interval of each dose was more than 10 minutes. The changes of the pulmonary arterial pressure (PAP), pulmonary venous pressure (PVP), and systemic arterial rressure (SAP) were recorded and compared between two groups.
ResultsIn the control group, PAP didn't change significantly after administration (P < 0.05), however, PVP increased obviously after NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 (P < 0.05), and SAP increased obviously after NE administration in dose of 1.0, 2.0 and 5.0μg·kg-1·min-1 (P < 0.01). In the endotoxin group, PAP increased obviously after NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 (P < 0.05), while PVP didn't change significantly (P > 0.05), and SAP increased obviously after NE administration in dose of 1.0, 2.0 and 5.0μg·kg-1·min-1 (P < 0.05). There were significant differences in SAP (P < 0.05), not in PAP and PVP (P > 0.05), between two groups after NE administration at dose of 1.0, 2.0 and 5.0μg·kg-1·min-1. The PVP/SAP and PAP/SAP values didn't change significantly after administration in the control group (P > 0.05). In the endotoxin group, the PVP/SAP and PAP/SAP values increased significantly after LPS administration, and decreased slightly after NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 (P < 0.05).
ConclusionsNE administration in septic shock can not increase the angiotasis of the pulmonary vein. NE administration in dose of 2.0 and 5.0μg·kg-1·min-1 can cause the increase of PAP and SAP, but the increase of PAP is lower than the increase of SAP.
Objective To systemically review the efficacy and safety of dopamine versus norepinephrine in patients with septic shock. Methods Database searches of MEDLINE, EMbase, Cochrane Controlled Trials Register, VIP, CNKI, and CBM (from the date of database establishment to June 2011) were conducted. Additional studies for collecting relevant data were retrieved via both references of articles and direct contact with authors. Prospectively, randomized controlled trials (RCTs) of dopamine compared with norepinephrine therapy in septic shock patients were selected. The quality of included trials was assessed and relevant data were extracted. Then statistical analysis was performed using RevMan 5.1. Results Nine trials with 3 179 participants were included. The results of meta-analysis showed: compared with norepinephrine, dopamine was associated with a significant 12% elevation in the risk ratio of in-hospital death events of septic shock patients (RR=1.12, 95%CI 1.04 to 1.21, P=0.002). The risk of arrhythmias in dopamine group was 2.63-fold than that in norepinephrine group (RR=2.63, 95%CI 1.51 to 4.55, P=0.000 6). The cardiac index of septic patients in dopamine group was higher than that in norepinephrine group (MD=0.42, 95%CI 0.21 to 0.63, Plt;0.000 1). No significant difference could be found in the heart rate (MD=17.05, 95%CI –0.71 to 34.81, P=0.06) and mean arterial pressure (MD= –0.87, 95%CI –24.97 to 7.62, P=0.30). Conclusion Findings from this meta-analysis suggest that compared with dopamine, norepinephrine significantly reduces both 28-day mortality of septic shock patients and incidence rate of arrhythmias. Norepinephrine is better than dopamine in aspects of efficacy and safety.
Objective To identify potential hub genes and key pathways in the early period of septic shock via bioinformatics analysis. MethodsThe gene expression profile GSE110487 dataset was downloaded from the Gene Expression Omnibus database. Differentially expressed genes were identified by using DESeq2 package of R project. Then Kyoto Encyclopedia of Genes and Genomes (KEGG) and Gene Ontology (GO) analyses were constructed to investigated pathways and biological processes using clusterProfiler package. Subsequently, protein-protein interaction (PPI) network was mapped using ggnetwork package and the molecular complex detection (MCODE) analysis was implemented to further investigate the interactions of differentially expressed genes using Cytoscape software. Results A total of 468 differentially expressed genes were identified in septic shock patients with different responses who accepted early supportive hemodynamic therapy, including 255 upregulated genes and 213 downregulated genes. The results of GO and the KEGG pathway enrichment analysis indicated that these up-regulated genes were highly associated with the immune-related biological processes, and the down-regulated genes are involved in biological processes related to organonitrogen compound, multicellular organismal process, ion transport. Finally, a total of 23 hub genes were identified based on PPI and the subcluster analysis through MCODE software plugin in Cytoscape, which included 19 upregulated hub genes, such as CD28, CD3D, CD8B, CD8A, CD160, CXCR6, CCR3, CCR8, CCR9, TLR3, EOMES, GZMB, PTGDR2, CXCL8, GZMA, FASLG, GPR18, PRF1, IDO1, and additional 4 downregulated hub genes, such as CNR1, GPER1, TMIGD3, GRM2. KEGG pathway enrichment analysis and GO functional annotation showed that differentially expressed genes were primarily associated with the items related to cytokine-cytokine receptor interaction, natural killer cell mediated cytotoxicity, hematopoietic cell lineage, T cell receptor signaling pathway, phospholipase D signaling pathway, cell adhesion molecules, viral protein interaction with cytokine and cytokine receptor, primary immunodeficiency, graft-versus-host disease, type 1 diabetes mellitus. Conclusions Some lymphocytes such as T cells and natural killer cells, cytokines and chemokines participate in the immune process, which plays an important role in the early treatment of septic shock, and CD160, CNR1, GPER1, and GRM2 may be considered as new biomarkers.
This article reports the management of thirty elderly patients of septic shock during anesthesia. Twenty-four of them received continious epidural anesthesia, five of them were under intravenous general anesthesia with endotracheal intubation, and onr patients recerived intravenous ketamine anesthesia. The effects of these patients on enesthesia wer satisfactory. Twenty-four patients recouverd after roperation. Six patients died. The authors atresses the high risk of anesthetic management in these patients. Experiences are introduced in per-anesthetic preparation and medication selection and maintenance of anesthesia, monitoring and treatment during anesthesia and postoperative care of septic shock of the elderly.
Objective
To investigate the value of central venous-to-arterial carbon dioxide difference/arterial-to-venous oxygen difference ratio [P(cv-a)CO2/C(a-cv)O2] in predicting oxygen metabolism after fluid resuscitation in patients with septic shock.
Methods
A prospective observational study was carried out on septic shock patients admitted in the intensive care unit of Nanjng Drum Tower Hospital from November 2013 to April 2014. All patients underwent fluid challenge (300 ml saline for 20 min, rapid intravenous infusion). The patients were divided into a fluid responded group (ΔCI≥10%) and a fluid unresponded group (ΔCI＜10%), according to the change of cardiac output index (ΔCI) after fluid challenge. Then the patients were divided into two subgroups in the fluid responded group, namely a ΔVO2≥10% group and a ΔVO2＜10% group, according to the change of VO2 (ΔVO2). Cardiac output index (CI) were determined by pulse indicator continuous cardiac output (PICCO). Hemoglobin, arterial carbon dioxide (PaCO2), arterial oxygen (PaO2), arterial oxygen saturation (SaO2), arterial blood lactate, central venous carbon dioxide (PcvCO2), central venous oxygen (PcvO2) and central venous oxygen saturation (ScvO2) were measured by blood gas analysis. P(cv-a)CO2/C(a-cv)O2 and oxygen consumption (VO2) were calculated. P(cv-a)CO2/C(a-cv)O2 before and after fluid challenge was compared between two subgroups.
Results
Fluid challenges were performed in 23 instances in 18 patients, among which 17 instances were defined as the fluid responded group. Compared with the fluid unresponded group, P(cv-a)CO2/C(a-cv)O2, arterial lactate and ScvO2 had no significant difference [P(cv-a)CO2/C(a-cv)O2](mm Hg/ml): 2.05±0.75vs. 1.58±0.67; arterial lactate (mmol/l): 3.78±2.50vs. 3.26±2.42; ScvO2(%): 73.71±9.64vs. 70.30±12.01,P＞0.05] in the fluid responded group before resuscitation. In the fluid responded group, there were 10 instances in the ΔVO2≥10% group and 7 instances in the ΔVO2＜10% group. P(cv-a)CO2/C(a-cv)O2 (mm Hg/ml) was significantly higher in the ΔVO2≥10% group before resuscitation compared with the ΔVO2＜10% group (2.43±0.73vs. 1.51±0.37,P＜0.01). Lactate (mmol/l) was also higher in the ΔVO2≥10% group before resuscitation (4.53±2.52vs. 1.46±0.82,P＜0.01). ScvO2 (%) had no significant difference between two groups (70.79±9.15vs. 72.13±13.42,P＞0.05). The areas under ROC curve (AUCs) of P(cv-a)CO2/C(a-cv)O2, lactate and ScvO2 for predicting ΔVO2≥10% were 0.843, 0.921, and 0.529, respectively. The sensitivity and specificity of P(cv-a)CO2/C(a-cv)O2≥1.885 mm Hg/ml for predicting ΔVO2≥10% after fluid resuscitation were 70% and 86%, respectively.
Conclusion
For septic shock patients with fluid responsiveness, P(cv-a)CO2/C(a-cv)O2 can predict oxygen metabolism after fluid resuscitation and can be used as a reliable parameter to guide fluid resuscitation.
ObjectiveTo investigate the clinical value of quick sequential organ failure assessment (qSOFA) score in predicting the outcome of patients with septic shock.
MethodsWe collected the clinical data of 170 patients with septic shock treated in the Emergency Intensive Care Unit between January 2013 and January 2014. According to the 28-day outcomes of the patients, they were recorded as survival group and non-survival group. We calculated the qSOFA score, acute physiology and chronic health evaluation (APACHE)Ⅱ score on patients' admission. Using receiver operating characteristic (ROC) curve, we analyzed the qSOFA score, the effect of APACHE Ⅱ score in predicting the 28-day prognosis for patients with septic shock. The correlation between qSOFA score and APACHEⅡ score was also assessed.
ResultsThe qSOFA and APACHEⅡ scores in non-survivors were higher than those in the survivors. According to ROC curve analysis, the area under the curve for qSOFA score and APACHE Ⅱ score was 0.666 and 0.791, respectively. For qSOFA score with 2 cut-off points to evaluate the prognosis of septic shock, the sensitivity was 62.7%, specificity was 61.1%, positive predictive value was 56.0%, negative predictive value was 67.4%, positive likelihood ratio was 1.61, and negative likelihood ratio was 0.61. For the APACHEⅡ score with 24 cut-off points to evaluate the prognosis of septic shock, the sensitivity was 70.7%, specificity was 80%, positive predictive value was 73.6%, negative predictive value was 67.3%, positive likelihood ratio was 3.54, and negative likelihood ratio was 0.37. The correlation coefficient of qSOFA score and APACHE Ⅱ score was 0.499.
ConclusionThe qSOFA score is useful to evaluate the prognosis of the patients with septic shock early in Emergency Department.
ObjectiveTo evaluate the value of stroke volume variation (SVV) and intrathoracic blood volume index (ITBVI) to predict fluid responsiveness in mechanically ventilated septic shock patients with spontaneous breathing.
MethodsA prospective observational study was conducted in the Department of Critical Care Medicine of the First Affiliated Hospital of Guangzhou Medical University. Fluid resuscitation data was collected in septic shock patients who received PiCCO monitoring from June 2013 to June 2014. Transpulmonary thermodilution data were collected before and after fluid resuscitation, including cardiac index (CI), SVV, ITBVI, and central venous pressure (CVP). Seventeen patients were defined as responders by an observed increase of≥15% in the cardiac index (CI) after fluid resuscitation, 12 patients were defined as non-responders. Pearson correlation between changes of CI (ΔCI) and SVV, ITBVI, CVP was established. Area under the receiver operating characteristic (ROC) curve of SVV, ITBVI and CVP was calculated for predicting fluid responsiveness.
ResultsBaseline CI and ITBVI were significantly lower in the responders (P < 0.05).There was no significant difference in baseline SVV between the responders and the non-responders (P > 0.05). A significant correlation was found between baseline ITBVI andΔCI (r=-0.593, P < 0.001), but no significant correlation between SVV andΔCI (r=0.037, P=0.847) or CVP andΔCI (r=0.198, P=0.302). The area under ROC curve of SVV, ITBVI and SVV for predicting fluid responsiveness was 0.640 (P=0.207), 0.865 (P=0.001), and 0.463 (P=0.565), respectively. The cut-off value of ITBVI for predicting fluid responsiveness was 784 mL/m2 with a sensitivity of 100.0% and a specificity of 70.6%.
ConclusionIn mechanically ventilated septic shock patients with spontaneous breathing, ITBVI may be a valuable indicator in predicting fluid responsiveness compared with SVV.
