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Signa Vitae

Journal of Intensive Care and Emergency Medicine

Contribution of Presepsin, Procalcitonin and C-reactive protein to the SOFA Score in Early Sepsis Diagnosis in Emergency Abdominal Surgical Patients


Purpose: This study examined whether the addition of biomarkers presepsin (PSEP), procalcitonin (PCT) and C-reactive protein (CRP) to the initial SOFA (iSOFA) score can improve diagnostic accuracy of early sepsis diagnosis in emergency abdominal surgery patients.

Materials and Methods: Seventy-two study subjects had diagnosis of acute abdomen due to gastrointestinal disturbances. The study evaluated diagnostic accuracy and predictive value of two models (iSOFA only and iSOFA combined with three biomarkers) for sepsis diagnosis.

Results: The AUC value for the iSOFA was highest, followed by the AUC value obtained for PSEP, PCT and CRP (0.989, 0.738, 0.694 and 0.606, respectively).The logistic regression analysis of the two models showed for the first model that patients with a higher iSOFA score are almost two times more likely to suffer from sepsis. In the second model, patients with a higher iSOFA score and a higher level of biomarkers are three times more likely to have sepsis.

Conclusions: Although the SOFA score is known to be the best diagnostic tool for sepsis diagnosis, it seems that among the three investigated markers PSEP and PCT– although not contributing to the iSOFA score– are good independent markers with significantly higher levels in septic than in non-septic patients. PSEP has the highest diagnostic accuracy for sepsis. Only the conventional marker CRP provides certain added value to the iSOFA score for sepsis prediction.

Further investigations should be performed to study the possible diagnostic value of dynamic changes of the three examined markers in prediction and early diagnosis of sepsis.

Keywords: Sepsis, SOFA, presepsin, procalcitonin, abdominal surgery

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Using age, arterial lactate level and sequential organ failure assessment score in risk stratification of sepsis syndromes


Introduction: In low income countries, ICU places are limited and not all sepsis patients will benefit from ICU admission. Stratification is an important step to identify patients who require ICU treatment from patients who can be treated on general ward setting. Improper stratification results in increased length of stay, costs, morbidity and mortality.
Objective: The aim of this study was to stratify the risk of mortality in patients with sepsis syndrome using age, arterial lactate level and SOFA score.
Methods: In this prospective observational study, 250 patients with sepsis were enrolled and followed up until discharge. They were categorized into 2 groups according to 7-days mortality.
Results: SOFA score (≥5) was the only good tool (AUC=0.722) while age (≥65 years) (AUC=0.650) and arterial lactate (≥3.25 mmol/L) (0.690) were fair tools to predict 7-days mortality. A new score “ALSOFA score” (≥10) was an excellent tool for prediction (AUC =0.912, 95%CI: 0.851 to 0.940, p<0.0001). It showed an excellent sensitivity (90.9%) and specificity (85.1%).
Conclusion: In critically ill patients with sepsis syndromes, age, arterial lactate and SOFA score are fair tools of stratification. No single marker/score can be used alone to stratify such patients.

Keywords; Emergency, Critical, Sepsis, SOFA, Arterial Lactate, Stratification

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Ketamine use for endotracheal intubation in severe sepsis and septic shock


Objective. We conducted this study to evaluate the clinical outcomes of patients with severe sepsis and septic shock who were treated with ketamine for endotracheal intubation.

Methods. A single-center, retrospective study was carried out to compare the outcomes of patients with severe sepsis and septic shock who received a ketamine or non-ketamine agent for rapid sequence intubation (RSI). We analyzed the sepsis registry for adult patients who presented to the emergency department (ED), met the criteria for severe sepsis or septic shock, and underwent endotracheal intubation between August 2008 and March 2014. The primary outcome was 28-day mortality. We performed a multivariable logistic regression analysis to assess the association between ketamine use for intubation and 28-day mortality.

Results. In all, 170 patients were intubated during the study period. Of the eligible patients, 95 received ketamine and 75 received a non-ketamine agent. The 28-day mortality of the ketamine group was not significantly different from that of the non-ketamine group (38% vs. 40%, respectively, P=0.78). The unadjusted odds ratio (OR) of ketamine use for 28-day mortality was 0.92 (95% CI: 0.49–1.70, P=0.78). The association remained insignificant after adjusting for age, gender, malignancy, initial lactate level on ED admission, time to first antibiotic administration, Acute Physiology and Chronic Health Evaluation II score on admission day, and propensity score regarding ketamine use (adjusted OR: 1.09; 95% confidence interval [CI]: 0.49–2.40; P=0.84). Initial serum lactate on ED admission was the only significant predictive factor of 28-day mortality (adjusted OR: 1.23; 95% CI: 1.10–1.38; P<0.01).

Conclusions. For patients with severe sepsis and septic shock who were intubated using RSI, we found no significant difference in 28-day mortality between those who received ketamine as a sedative agent and those who received alternative sedatives.

Key words: sepsis, ketamine, intubation, mortality

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The significance of sTREM-1 as a diagnostic biomarker of sepsis in the context of Sepsis-3 definition


Aim. Sepsis remains the leading cause of mortality in spite of advanced diagnostics. The aim of the study was to test the diagnostic value of soluble triggering receptor expressed on myeloid cells-1 (sTREM-1) in the context of a new definition of sepsis.

Methods. The study was conducted on 41 patients who were suspected of having sepsis according to SIRS (Systemic Inflammatory Response Syndrome) criteria or sterile SIRS. 20 healthy volunteer blood donors were the control group (adult patients of both sexes). According to the latest sepsis criteria (Sepsis-3), patients were retrospectively divided into three subgroups: septic patients, patients with SIRS plus infection and patients with sterile SIRS (non-infectious SIRS).

All subjects had concentrations of sTREM-1 determined by the ELISA method (Abcam commercial test, Cambridge, MA, USA). Samples were collected upon admission to hospital and kept at -20°C until laboratory analysis was performed.

Results. Concentrations of sTREM-1 were significantly increased in patients, compared to the healthy population (p=0.021), but there were no significant differences among subgroups of patients (SIRS plus infection vs. sepsis p=0.871, SIRS plus infection vs. sterile SIRS p=0.72, sepsis vs. sterile SIRS p=0.65).

The value of 300pg/mL was determined to be the optimal cut-off. Concentrations of sTREM-1 were significantly higher in septic patients who did not develop Multiple Organ Dysfunction Syndrome (MODS) within the first 48 hours after admission than in those who did.

Conclusion. According to our results, sTREM-1 failed to express significance as a diagnostic biomarker of sepsis, according to the new definition. Also, it seems not to be a valuable marker in differentiation of sepsis and non-infective SIRS.

Key words: sepsis, sTREM-1, SIRS

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Comparıng pulse pressure varıatıon and pleth varıabılıty ındex in the semı-recumbent and trendelenburg posıtıon ın crıtıcally ıll septıc patıents


Introduction. Dynamic tests for predicting fluid responsiveness have generated increased interest in recent years. One of these tests, pulse pressure variation (PPV), is a parameter calculated from respiratory variations of pulse pressure. Another test, pleth variability index (PVI), is based on respiratory variations of the perfusion index and can be measured non-invasively by pulse oximeter. Previous studies have shown that both tests are valuable in determining fluid responsiveness.

Methods. In this observational prospective study, our aim was to compare the PVI and PPV in order to identify a convenient tool for determining fluid responsiveness. Our study was performed in a surgical and reanimation intensive care unit. We enrolled one hundred mechanically ventilated adult patients diagnosed with sepsis. Exclusion criteria included brain death, spontaneous breathing, cardiac arrhythmia, and impaired peripheral circulation. We measured the PPV by arterial monitorization and the PVI by using Masimo Radical 7 in the 45° semi-recumbent position (SP) and then 15° Trendelenbug position (TP). We performed correlation and ROC analysis using a >13% fluid responsiveness cut-off value for the PPV and >14% for the PVI.

Results. Between the SP and the TP, we did not observe significant decreases in PPV (from 14.17 ± 10.57 to 12.66 ± 9.64; p > 0.05), while we did observe significant decreases in PVI (from 21.91 ± 13.99 to 20.46 ± 14.12; p < 0.05). The PPV fluid responsiveness cut-off value in the SP and TP was 20% (78.95% sensitivity, 77.05% specificity) and 18% (76.67% sensitivity, 72.46% specificity), respectively. The PVI fluid responsiveness cut-off value in the SP and TP was 20% (80.49% sensitivity, 81.03% specificity) and 16% (81.25% sensitivity, 62.69% specificity), respectively. The area under the ROC of the PPV and PVI was 0.843 and 0.858 in the SP, respectively, and 0.760 and 0.747 in the TP, respectively. The PPV and PVI were correlated in the SP (r = 0.578; p = 0.001) and the TP (r = 0.517; p = 0.001).

Conclusions. Our results showed that the PPV and PVI were correlated independent of position change in sepsis patients. Both tests appear to be equivalently reliable. However, the ability of the PPV and PVI to predict fluid responsiveness decreased in the TP in our study.

Key words: pulse pressure variation, pleth variability index, fluid responsiveness, sepsis

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