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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Tag: sepsis (Page 1 of 4)

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

Abstract

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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Metabolic resuscitation in sepsis: could antioxidants be the answer?

Introduction

Antioxidants are molecules that inhibit oxidation which under certain conditions leads to the production of free radicals, highly reactive species characterized by an unpaired electron which enter into further chain reactions that lead to cell damage. (1) In biological systems these include reactive oxygen species (ROS) which include the hydroxyl radical (OH.), hydrogen peroxide (H2O2) and the superoxide anion (O2.-) among others. The generation of such species may trigger a variety of pathological responses and any disequilibrium between production of ROS and the ability to attenuate the damage that such species may incur is referred to as oxidative stress. Oxidative stress may result in damage to any component of the cell and may result in DNA damage through base damage as well as strand breaks and also some ROS may act as cellular messengers causing disruption in cellular signaling. Cellular protection against oxidative stress may be through chelation of trace metals involved in free radical generation or through the actions of antioxidants. Antioxidants are broadly classified into two groups, depending on whether they are soluble in water (hydrophilic), such as vitamin C or fat soluble such as Vitamin E (lipophilic). Hydrophilic antioxidants are thought to predominantly react with oxidants in the cell cytosol and plasma whereas lipophilic antioxidants protect cell membranes from oxidation: a process termed lipid peroxidation. (2) The synergism between different antioxidant systems is complex. Indeed, both vitamin C and vitamin E were shown to have a direct interaction with vitamin C “repairing” the α-tocopherol radical with rates approaching diffusion limited outlining the reactivity of these species. (3)

One of the areas that has attracted considerable interest with regard to the role of oxidative stress is the host response to sepsis. (4) Sepsis remains a major cause of death worldwide affecting over 18 million people annually with a mortality rate approaching 80% in those individuals with multi-organ failure and in the US hospital costs total over $24 billion dollars. (5, 6) Therapy for severe sepsis is predominantly supportive with the relatively recent introduction of care bundles including antibiotic therapy being introduced. However, the precise pathogenesis of sepsis-induced organ failure remains elusive and although likely multifactorial in nature certainly microvascular dysfunction appears to be central to the process. (7) Microvascular dysfunction involves impairment of arteriolar reactivity, derangement of endothelial barrier integrity and microthombi induced plugging of the capillaries thus any therapy that addresses these issues may translate into improved outcomes.

Key words: sepsis, antioxidants, resuscitation

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Septic cardiomyopathy : pathophysiology and prognosis

Abstract

Septic cardiomyopathy is a separate clinical entity clearly distinct from myocarditis on histological grounds. Physiologically it characteristically presents, unlike other types of heart failure, with normal or increased cardiac output with normal or low preload pressures & a reduced systemic vascular resistance. Speckle tracking echocardiography is now the diagnostic tool of choice for detecting subtle changes in myocardial dysfunction

Ventricular contractility is invariably reduced to some degree in septic shock but, if severe ventricular dysfunction with low blood pressure and a falling cardiac output develops, mortality is twice that of septic shock without cardiac organ failure. However if the patient survives the episode of sepsis, septic cardiomyopathy is largely reversible since the changes are predominantly functional rather than structural although it is as yet uncertain if this applies when contraction band necrosis has developed as a result of the use of high doses of vasopressors.

Key words: sepsis, septic shock, septic cardiomyopathy, sepsis induced cardiomyopathy, ventricular contractility, speckle tracking echocardiography, ventricular re-synchronisation

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Causes of respiratory distress among neonates of gestational age 32 weeks and more

Abstract

Respiratory distress (RD) is the commonest reason for admission in Neonatology intensive care units (NICU) and it is caused by respiratory and non-respiratory illnesses. The goal of the study is to find out most important causes of RD in preterm babies with 32 or more weeks of gestation, and to compare the etiology factors for RD in those preterm and in full term babies. Retrospective study in the NICU, Clinical Hospital Osijek, during the year 2016 was done. Almost 20% of admitted in NICU have RD, 34% of preterm babies of or older than 32 weeks, and 12% of terms babies. Among newborns with RD 61% were boys, and 39% girls. Among all live born 4% of boys and 2, 6% of girls had RD. Mother’s illnesses as a cause of RD were found in 23, 2% and illnesses of the child in the other 60, 1%. Complications during delivery caused RD in the last 4% of newborns (some neonates have had more than one reason for RD). In 18, 9% of newborns the etiological factor was not found, and RD is probably genetically caused. The proportion of unknown causes is higher in preterm babies (22%). RD in term babies is mainly caused by illnesses of the child himself, and in preterm by mother’s illnesses.

Key words: neonatal respiratory distress, sepsis, complications in pregnancy, gestational diabetes

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Cardiac surgery and sepsis in postoperative period – our experience

Abstract

The occurrence of sepsis after cardiac surgery is a rare event; however, its occurrence showed catastrophic clinical outcomes. The high morbidity and mortality revealed the need to improve treatment, aiming at patients’ better clinical outcome.

Patients that develop sepsis, regardless of the infectious focus and the subjacent disease, present high morbidity and mortality, which vary from 17% to 65%. The main predictors of infections in the postoperative period are: body mass index ≥40kg/m², haemodialysis in the preoperative period, pre-op cardiogenic shock, age ≥80 years, pre-op treatment with immunosuppressive agents, diabetes mellitus, ECC time ≥200 minutes, mechanical circulatory support, three or more revascularized vessels.

From January 2015 to December 2015, we studied 675 adult patients who underwent cardiac surgery. Prophylactic antibiotic therapy was prescribed and given according to our protocol, from the induction of anaesthesia to the first postoperative day.

Sepsis in the postoperative period was defined as evidence on infection associated with two or more criteria of systemic inflammatory response syndrome: body temperature >38°C or <36°C, leukocytes >12,000 cells/mm³, positive blood cultures, respiratory rate >20/min, heart rate >100/min.

Key words: sepsis, postoperative period, cardiac surgery

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