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BACKGROUND: Patients presenting with cardiogenic shock (CS) are at risk of developing mixed shock (MS), characterized by distributive-inflammatory phenotype. However, no objective definition exists for this clinical entity. METHODS: We assessed the frequency, predictors, and prognostic relevance of MS complicating CS, based on a newly proposed objective definition. MS complicating CS was defined as an objective shock state secondary to both an ongoing cardiogenic cause and a distributive-inflammatory phenotype arising at least 12 hours after the initial CS diagnosis, as substantiated by predefined longitudinal changes in hemodynamics, clinical, and laboratory parameters. RESULTS: Among 213 consecutive patients admitted at 2 cardiac intensive care units with CS, 13 with inflammatory-distributive features at initial presentation were excluded, leading to a cohort of 200 patients hospitalized with pure CS (67±13 years, 96% Society of Cardiovascular Angiography and Interventions CS stage class C or higher). MS complicating CS occurred in 24.5% after 120 (29-216) hours from CS diagnosis. Lower systolic arterial pressure (P=0.043), hepatic injury (P=0.049), and suspected/definite infection (P=0.013) at CS diagnosis were independent predictors of MS development. In-hospital mortality (53.1% versus 27.8%; P=0.002) and hospital stay (21 [13-48] versus 17 [9-27] days; P=0.018) were higher in the MS cohort. At logistic multivariable analysis, MS diagnosis (odds ratio [OR], 3.00 [95% CI, 1.39-6.63]; Padj=0.006), age (OR, 1.06 [95% CI, 1.03-1.10] years; Padj<0.001), admission systolic arterial pressure <100 mm Hg (OR, 2.41 [95% CI, 1.19-4.98]; Padj=0.016), and admission serum creatinine (OR, 1.61 [95% CI, 1.19-2.26]; Padj=0.003) conferred higher odds of in-hospital death, while early temporary mechanical circulatory support was associated with lower in-hospital death (OR, 0.36 [95% CI, 0.17-0.75]; Padj=0.008). CONCLUSIONS: MS complicating CS, objectively defined leveraging on longitudinal changes in distributive and inflammatory features, occurs in one-fourth of patients with CS, is predicted by markers of CS severity and inflammation at CS diagnosis, and portends higher hospital mortality.

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Streptococcus agalactiae or Group B Streptococcus (GBS) infections are commonly associated with infections in neonates and pregnant women. However, there has been a rising incidence in nonpregnant adults. The risk of GBS infection in nonpregnant adults is increased for patients of advanced age and those with underlying medical conditions such as diabetes mellitus and cancer. We present a 77-year-old female with type-2 diabetes mellitus, hypertension, and bilateral foot ulcers that presented in probable septic shock with necrotic foot ulcers and necrotizing fasciitis and underwent bilateral lower limb amputations. The patient fulfilled the Streptococcal Toxic Shock Syndrome (STSS) criteria as defined by The Working Group on Severe Streptococcal Infections. These criteria were created for group A Streptococcus (Streptococcus pyogenes). Our patient fulfilled the Working Group's criteria, except that the blood culture was positive for group B Streptococcus (Streptococcus agalactiae). Numerous studies demonstrate the importance of early detection and antibiotic treatment for GBS infections in general and early surgical management for necrotizing soft tissue infections (NSTIs) such as necrotizing fasciitis.

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ABSTRACT Streptococcus agalactiae or Group B Streptococcus (GBS) infections are commonly associated with infections in neonates and pregnant women. However, there has been a rising incidence in nonpregnant adults. The risk of GBS infection in nonpregnant adults is increased for patients of advanced age and those with underlying medical conditions such as diabetes mellitus and cancer. We present a 77-year-old female with type-2 diabetes mellitus, hypertension, and bilateral foot ulcers that presented in probable septic shock with necrotic foot ulcers and necrotizing fasciitis and underwent bilateral lower limb amputations. The patient fulfilled the Streptococcal Toxic Shock Syndrome (STSS) criteria as defined by The Working Group on Severe Streptococcal Infections. These criteria were created for group A Streptococcus (Streptococcus pyogenes). Our patient fulfilled the Working Group's criteria, except that the blood culture was positive for group B Streptococcus (Streptococcus agalactiae). Numerous studies demonstrate the importance of early detection and antibiotic treatment for GBS infections in general and early surgical management for necrotizing soft tissue infections (NSTIs) such as necrotizing fasciitis.

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The clinical approach to undifferentiated shock in critically ill patients should be revised to use modern, point-of-care tools that are readily available. With the increasing availability of 2-dimensional ultrasonography and advanced Doppler capabilities, a quick, simplified, and integrated stepwise approach to shock using critical care echocardiography is proposed. Evidence supports the feasibility and usefulness of critical care echo-cardiography in enhancing diagnostic accuracy for shock, but there is a lack of systematic application of the technology in patients with undifferentiated shock. The proposed approach begins with the use of noninvasive ultrasonography with pulsed-wave Doppler capability to determine the flow state by measuring the velocity time integral of the left ventricular outflow tract. This narrative review explores the use left ventricular outflow tract velocity time integral, velocity time integral variation, limited visceral organ Doppler, and lung ultrasonography as a systematic approach for patients with undifferentiated shock.

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The current international sepsis guidelines from 2021 are based on the work of a panel of 60 international experts from various fields. They include a total of 93 recommendations, some of which include new aspects compared to the 2016 version of the guidelines. This article provides a subjective compilation by two internal medicine intensivists who highlight some aspects, especially of changes within the guidelines compared to the previous version. The focus is on the fields of screening, sepsis bundles, fluid and vasopressor treatment and adjuvant treatment. In addition, for the first time these guidelines address the important issue of long-term sequelae for sepsis survivors and their environment.

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INTRODUCCIÓN. La paradoja de la obesidad propone que, en determinadas enfermedades, los enfermos con obesidad tienen menor mortalidad. OBJETIVO. Asociar el índice de masa corporal con la mortalidad a 30 días en adultos con choque séptico. MATERIALES Y MÉTODOS. Estudio observacional, analítico, retrospectivo, multicéntrico. Se analizaron 673 pacientes con choque séptico, ingresados en terapia intensiva de dos hospitales de la ciudad de la ciudad de Quito ­ Ecuador, durante enero 2017 - diciembre 2019. Criterios de inclusión: Mayores a 18 años, choque séptico, registro de peso, talla y condición vital al día 30. Criterios de exclusión: Orden de no reanimación, embarazadas, protocolo de donación de órganos, cuidados paliativos. Las variables se recolectaron a partir de las historias clínicas digitales y físicas de los centros participantes. Las estimaciones de riesgo calculadas se presentaron como OR (Odds Ratio) en el análisis bivariado y OR Adj (OR ajustado) para el análisis multivariado. Un valor de p <0.05 se consideró estadísticamente significativo. Todos los análisis estadísticos se realizaron usando el software estadístico R® (Versión 4.1.2). RESULTADOS. La edad promedio fue de 65 años, índice de masa corporal promedio 25,9 Kg/m2 (+4,9 Kg/m2). El 54,3% tuvo índice de masa corporal > 25 Kg/m2. La mortalidad general fue 49.2%. Sujetos con sobrepeso y obesidad tuvieron menor mortalidad, OR: 0,48 (IC 95%: 0.34, 0.68; p <0.0001) y OR 0.45 (IC 95 %: 0.28, 0.70; p =0.001) respectivamente, con similar tendencia en el análisis multivariado. Los sujetos con peso bajo tuvieron la mayor mortalidad (OR: 2.12. IC 95%: 0.91 - 5.54. p: 0.097). DISCUSIÓN. Los resultados obtenidos apoyan la teoría de paradoja de obesidad, sin embargo, no se realizó evaluación según los niveles de obesidad. CONCLUSIÓN. La mortalidad en choque séptico es menor en sujetos con sobrepeso y obesidad comparada con sujetos con peso normal o bajo peso.

The obesity paradox proposes that, in certain diseases, patients with obesity have lower mortality. OBJECTIVE. To associate body mass index with 30-day mortality in adults with septic shock. MATERIALS AND METHODS. Observational, analytical, retrospective, multicenter, retrospective study. We analyzed 673 patients with septic shock, admitted to intensive care in two hospitals in the city of Quito - Ecuador, during January 2017 - December 2019. Inclusion criteria: older than 18 years, septic shock, weight, height and vital condition at day 30. Exclusion criteria: Do not resuscitate order, pregnant women, organ donation protocol, palliative care. Variables were collected from the digital and physical medical records of the participating centers. Calculated risk estimates were presented as OR (Odds Ratio) in bivariate analysis and OR Adj (adjusted OR) for multivariate analysis. A p value <0.05 was considered statistically significant. All statistical analyses were performed using R® statistical software (Version 4.1.2). RESULTS. The mean age was 65 years, mean body mass index 25.9 kg/m2 (+4.9 kg/m2). Body mass index > 25 kg/m2 was 54.3%. Overall mortality was 49.2%. Overweight and obese subjects had lower mortality, OR: 0.48 (95% CI: 0.34, 0.68; p<0.0001) and OR 0.45 (95 % CI: 0.28, 0.70; p=0.001) respectively, with similar trend in multivariate analysis. Underweight subjects had the highest mortality (OR: 2.12. 95% CI: 0.91 - 5.54. p: 0.097). DISCUSSION. The results obtained support the obesity paradox theory, however, assessment according to obesity levels was not performed. CONCLUSIONS. Mortality in septic shock is lower in overweight and obese subjects compared to normal weight or underweight subjects.

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El choque séptico es un estado de hipoperfusión tisular definido como subcategoría de la sepsis en la que las alteraciones circulatorias y del metabolismo celular pueden aumentar considerablemente la mortalidad. A nivel mundial, el choque séptico ocupa el segundo lugar como causa de muerte no coronaria en la Unidad de Cuidados Intensivos (UCI), con una incidencia anual del 10%, y con una mortalidad hospitalaria de 18 a 35%. Objetivo: Describir el abordaje del Proceso de Atención de Enfermería en el paciente con choque séptico y desde la perspectiva del déficit de autocuidado. Metodología: El caso clínico se fundamentó en las etapas del Proceso de Atención de Enfermería (PAE), en la Teoría Enfermera del Déficit de Autocuidado (TEDA) de Dorothea Orem y en herramientas taxonómicas para el abordaje individualizado del plan de cuidados. Resultados: Paciente de 68 años en el servicio de Cuidados Intensivos Adultos, cursa la primera hora del posoperatorio por nefrectomía izquierda secundaria a absceso perirenal, que condiciona a choque séptico. Se abordó el PAE con apoyo del TEDA siendo prioritaria la etiqueta diagnóstica disminución del gasto cardiaco. Conclusiones: La aplicación de las teorías y modelos de enfermería proporcionan un marco de referencia para otorgar cuidados de calidad en los diferentes ámbitos de desempeño, incluyendo unidades de atención de cuidados intensivos. Resulta indispensable usar la metodología del PAE que permite dar evidencia de la profesionalización del cuidado, al usar un lenguaje técnico, con el apoyo de la Teoría de Orem y con las herramientas taxonómicas[AU]

Septic shock is a state of tissue hypoperfusion defined as a subcategory of sepsis in which circulatory and cellular metabolism alterations can considerably increase mortality. Worldwide, septic shock ranks second as a cause of non-coronary death in the Intensive Care Unit (ICU), with an annual incidence of 10%, and a hospital mortality of 18 to 35%. Objective: To describe the approach to the Nursing Care Process in patients with septic shock and from the perspective of self-care deficit. Methodology: The clinical case was based on the stages of the Nursing Care Process (PAE), on the Nursing Theory of Self-Care Deficit (TEDA) by Dorothea Orem and on taxonomic tools for the individualized approach to the care plan. Results: A 68-year-old patient, in the Adult Intensive Care service, undergoes the first postoperative hour due to left nephrectomy secondary to perirenal abscess, which conditions septic shock. The PAE was approached with the support of the TEDA, with a priority being the dignostic label reduction of cardiac output. Conclusions: The application of nursing theories and models provide a frame of reference to provide quality care in different areas of performance, including intensive care units. It is essential to use the PAE methodology that allows to give evidence of the professionalization of care, by using technical language, with the support of Orem's Theory and with taxonomic tools[AU]

O choque séptico é um estado de hipoperfusão tecidual definida como uma subcategoria da sepse em que alterações circulatórias e do metabolismo celular podem aumentar consideravelmente a mortalidade. Mundialmente, o choque séptico ocupa o segundo lugar como causa de morte não coronariana em Unidade de Terapia Intensiva (UTI), com incidência anual de 10% e mortalidade hospitalar de 18 a 35%. Objetivo: Descrever a abordagem do Processo de Cuidado de Enfermagem ao paciente com choque séptico na perspectiva do déficit de autocuidado. Metodologia: O caso clínico baseou-se nas etapas do Processo de Cuidar em Enfermagem (PAE), na Teoria de Enfermagem do Déficit de Autocuidado (TEDA) de Dorothea Orem e em ferramentas taxonômicas para a abordagem individualizada do plano de cuidados. Resultados: Paciente de 68 anos, internada em Unidade de Terapia Intensiva Adulto, com primeira hora de pós-operatório por nefrectomia esquerda secundária a abscesso perirrenal, que acarreta choque séptico. O PAE foi abordado com o apoio do TEDA, tendo como prioridade o rótulo digno de redução do débito cardíaco. Conclusões: A aplicação de teorias e modelos de enfermagem fornecem um quadro de referência para fornecer cuidados de qualidade em diferentes áreas de atuação, incluindo unidades de terapia intensiva. É imprescindível utilizar a metodologia PAE que permita evidenciar a profissionalização do cuidado, por meio de linguagem técnica, com o apoio da Teoria de Orem e com ferramentas taxonómicas[AU]

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PURPOSE: Vasopressin, used as a catecholamine adjunct, is a vasoconstrictor that may be detrimental in some hemodynamic profiles, particularly left ventricular (LV) systolic dysfunction. This study tested the hypothesis that echocardiographic parameters differ between patients with a hemodynamic response after vasopressin initiation and those without a response. METHODS: This retrospective, single-center, cross-sectional study included adults with septic shock receiving catecholamines and vasopressin with an echocardiogram performed after shock onset but before vasopressin initiation. Patients were grouped by hemodynamic response, defined as decreased catecholamine dosage with mean arterial pressure ≥ 65 mmHg six hours after vasopressin initiation, with echocardiographic parameters compared. LV systolic dysfunction was defined as LV ejection fraction (LVEF) <45%. RESULTS: Of 129 included patients, 72 (56%) were hemodynamic responders. Hemodynamic responders, versus non-responders, had higher LVEF (61% [55%,68%] vs. 55% [40%,65%]; p = 0.02) and less-frequent LV systolic dysfunction (absolute difference  -16%; 95% CI -30%,-2%). Higher LVEF was associated with higher odds of hemodynamic response (for each LVEF 10%, response OR 1.32; 95% CI 1.04-1.68). Patients with LV systolic dysfunction, versus without LV systolic dysfunction, had higher mortality risk (HR(t) = e[0.81-0.1*t]; at t = 0, HR 2.24; 95% CI 1.08-4.64). CONCLUSIONS: Pre-drug echocardiographic profiles differed in hemodynamic responders after vasopressin initiation versus non-responders.

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Objective:To investigate the efficacy of phenolamine in the treatment of sepsis-induced myocardial dysfunction and its effect on cardiac function, myocardial injury index, and hemodynamics in patients.Methods:The clinical data of 79 patients with sepsis-induced myocardial dysfunction who received treatment in Huangshi Central Hospital, Edong Healthcare Group from February 2017 to February 2020 were retrospectively analyzed. These patients were divided into a control group (without phenolamine treatment, n = 41) and an observation group (with phenolamine treatment, n = 38) according to whether they received phenolamine treatment or not. Clinical efficacy, cardiac function, myocardial injury index, and hemodynamic index pre- and post-treatment were compared between the two groups. Results:There was no significant difference in 28-day mortality rate between the two groups ( P > 0.05). Intensive care unit length of stay and mechanical ventilation duration in the observation group were (9.33 ± 3.52) days and 83.00 (28.50, 138.00) hours, which were significantly shorter than (12.17 ± 4.15) days and 111.00 (47.50, 169.00) hours in the control group ( t = 3.26, Z = -2.27, both P < 0.05). The response rate in the observation group was significantly higher than that in the control group [81.58% (31/38) vs. 60.98% (25/41), χ2 = 4.05, P < 0.05]. After 7 days of treatment, the left ventricular ejection fraction in each group was significantly increased, and the left ventricular end-diastolic diameter and left ventricular end-systolic diameter in each group were significantly decreased compared with before treatment (all P < 0.05). After 7 days of treatment, the left ventricular ejection fraction in the observation group was significantly higher than that in the control group ( t = 3.29, P < 0.05), and left ventricular end-diastolic diameter and left ventricular end-systolic diameter were significantly lower than those in the control group ( t = 5.94, 11.21, both P < 0.05). N-terminal pro-brain natriuretic peptide and cardiac troponin I levels in each group were significantly decreased with time (both P < 0.05). At 24 and 72 hours and 7 days after treatment, N-terminal pro-brain natriuretic peptide and cardiac troponin I levels in the observation group were significantly lower than those in the control group (both P < 0.05). After 7 days of treatment, heart rate in each group decreased significantly compared with that before treatment (both P < 0.05), mean arterial pressure, cardiac index, and stroke output index in each group increased significantly compared with those before treatment (all P < 0.05). After 7 days of treatment, heart rate in the observation group was significantly lower than that in the control group ( t = 4.90, P < 0.05), and mean arterial pressure, cardiac index, and stroke output index in the observation group were significantly higher than those in the control group ( t = 4.37, 3.23, 6.01, all P < 0.05). Conclusion:Phentolamine can improve hemodynamics, reduce myocardial injury and improve cardiac function in patients with sepsis-induced myocardial dysfunction.

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Objective:To evaluate the value of bedside ultrasound in evaluating volume responsiveness of patients with septic shock.Methods:A total of 102 patients with septic shock admitted to ICU of the First Affiliated Hospital of Hebei North University from April 2018 to February 2021 were selected. Patients were divided into response group and non-response group according to the value of stroke volume increase (ΔSV) after volume loading test (VE), and the hemodynamic parameters before and after VE were compared between the two groups. Pearson correlation was used to analyze the relationship between ΔSV and hemodynamic indexes. Receiver operating characteristic (ROC) curve was drawn to analyze the sensitivity and specificity of each hemodynamic index in evaluating volumetric reactivity in patients with septic shock.Results:Of the 102 patients, 54 responded and 48 did not. Before VE, the distensibility index of inferior vena cava (ΔIVC 1), espiratory variability index of inferior vena cava (ΔIVC 2), respiratory variability of aortic peak velocity (ΔVpeak AO), brachial artery maximum velocity variability (ΔVpeak BA) and respiratory rate of peak flow velocity of femoral artery (ΔVpeak CFA) in response group were higher than those in non-response group (all P<0.05), but there was no statistical significance in heart rate (HR), mean arterial pressure (MAP) and central venous pressure (CVP) between 2 groups (all P>0.05). After VE, the HR, ΔIVC 1, ΔIVC 2, ΔVpeak AO, ΔVpeak BA and ΔVpeak CFA in response group were significantly decreased, while MAP and CVP were significantly increased (all P<0.05). The CVP was significantly decreased in the non-response group ( P<0.05), while other indexes were not significantly changed. Before VE, the ΔIVC 1, ΔIVC 2, ΔVpeak AO, ΔVpeak BA and ΔVpeak CFA were positively correlated with ΔSV ( r=0.589, 0.647, 0.697, 0.621, 0.766; all P<0.05). There was no correlation between CVP and ΔSV ( r=-0.345, P>0.05). Before VE, the area under the curve of ΔIVC 1, ΔIVC 2, ΔVpeak AO, ΔVpeak BA and ΔVpeak CFA were all >0.7, indicating high sensitivity and specificity. Conclusions:Bedside ultrasound monitoring ΔIVC, ΔVpeak AO, ΔVpeak BA and ΔVpeak CFA can better evaluate the volume response of patients with septic shock, and can provide a reference basis for clinical fluid resuscitation treatment.

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Objective:To analyze the predictive value of miR-155-5p, miR-16 and miR-129-5p on the efficacy of continuous renal replacement therapy (CRRT) in children with septic shock.Methods:A total of 179 children with severe sepsis admitted to Shanxi Provincial Children′s Hospital from January 2021 to January 2022 were selected, 89 children with septic shock were selected as group A, 90 children with non-septic shock were selected as group B, and 80 healthy children were selected as group C. The expressions of miR-155-5p, miR-16 and miR-129-5p were measured and compared. The patients in the group A were divided into the effective group and the ineffective group according to the curative effect of CRRT treatment. The expressions of miR-155-5p, miR-16 and miR-129-5p in the two groups were compared, and its predictive value for the efficacy of CRRT treatment was analyzed.Results:Compared with group C and group B, the expressions of miR-155-5p in group A was higher: 2.56 ± 0.98 vs. 1.41 ± 0.35, 0.53 ± 0.11; and the expressions of miR-16 and miR-129-5p were lower: 1.00 ± 0.27 vs. 2.23 ± 0.98, 3.38 ± 1.01; 0.65 ± 0.17 vs.1.39 ± 0.22, 2.25 ± 0.76, there were statistical differences ( P<0.05). The results of Logistic regression analysis showed that the sequential organ failure assessment(SOFA) scores, white blood cell count, C reactive protein, procalcitonin, interleukin-6, tumor necrosis factor-alpha , N-terminal B-type natriuretic peptide precursor and the expressions of miR-155-5p, miR-16, miR-129-5p were independent risk factors for the efficacy of CRRT treatment in the children with septic shock. The results of Pearson correlation analysis showed that miR-155-5p was negative correlation with miR-16 and miR-129-5p ( r = - 0.411, - 0.369, P<0.05); and miR-16 was positive correlation with miR-129-5p ( r = 0.444, P<0.05). The results of receiver operating characteristic curve showed that the combination of the three items had a higher predictive value for the efficacy of CRRT in children with septic shock ( P<0.05). Children with high expression of miR-155-5p and low expression of miR-16 and miR-129-5p had higher mortality ( P<0.05). Conclusions:The expressions of miR-155-5p, miR-16 and miR-129-5p are abnormally in children with septic shock and are related to the efficacy of CRRT, which can be used for early prediction of the efficacy of CRRT.

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Objective:To explore the prognostic value of the serum concentration of human soluble stromelysin-2(sST2)combined with ultrasonic left ventricular diastolic function parameters for elderly patients with septic shock.Methods:This prospective study involved 150 elderly patients with septic shock admitted to the intensive care unit(ICU)of the First Hospital of Jiaxing between May 2019 and May 2022.Data on the following parameters were recorded on days 1, 3, 5, and 7 in the ICU: sST2 concentration, mitral early-diastolic inflow peak velocity(E), mitral late-diastolic inflow peak velocity(A), E/A ratio, early diastolic mitral annular velocity(e'), and E/e' ratio.According to the 28-day prognostic outcome obtained during follow-up, patients were divided into a survival group and a death group to compare differences in values of the above parameters between the two groups and at different time points.Logistic regression was used to analyze independent risk factors for 28-day mortality.The receiver operating characteristic(ROC)curve was used to analyze the predictive value for 28-day mortality, and further risk stratification was performed according to optimal cut-off values to compare differences in 28-day mortality under different risk stratification methods.The Kaplan-Meier survival curve was used to compare 28-day cumulative survival under different risk stratification methods and analyze the predictive value of the combination of the parameters for 28-day mortality.Results:On day 5 following ICU admission, e' was lower and E/e' and sST2 were higher in the death group than in the survival group.Univariate and multivariate Logistic regression analysis suggested that sST2(odds ratio: 1.010, P<0.001)was an independent risk factor for 28-day mortality in elderly patients with septic shock.sST2 had a sensitivity of 50.2%, a specificity of 79.1%, and an area under the curve of 0.660 for predicting 28-day mortality in patients with septic shock.The sST2 concentration was 89.3 μg/L on day 5 after ICU admission, which was the clinical cutoff point for predicting 28-day mortality.Based on the risk stratification of sST2 levels, the 28-day mortality rate was higher in the sST2>89.3 μg/L group than in the sST2≤89.3 μg/L group.Kaplan-Meier survival analysis showed that the 28-day cumulative survival rate was significantly lower in the sST2>89.3 μg/L group than in the sST2≤89.3 μg/L group(44.0% vs.66.7%, log-rank test: χ2=9.101, P=0.003).The receiver operating characteristic curve showed that the combination of sST2, e', and E/e' significantly improved the prediction efficiency of 28-day mortality in elderly patients with septic shock, with an area under the curve of 0.844, a sensitivity of 89.7%, and a specificity of 66.5%. Conclusions:sST2 is an independent risk factor for 28-day mortality in elderly patients with septic shock.When combined with e' and E/e', sST2 can more accurately evaluate the survival prognosis of these patients.

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RESUMO Objetivo: Criar e validar um modelo de predição de choque séptico ou hipovolêmico a partir de variáveis de fácil obtenção coletadas na admissão de pacientes internados em uma unidade de terapia intensiva. Métodos: Estudo de modelagem preditiva com dados de coorte concorrente realizada em um hospital do interior do nordeste brasileiro. Foram incluídos pacientes com 18 anos ou mais sem uso de droga vasoativa no dia da admissão e que foram internados entre novembro de 2020 e julho de 2021. Foram testados os algoritmos de classificação do tipo Decision Tree, Random Forest, AdaBoost, Gradient Boosting e XGBoost para a construção do modelo. O método de validação utilizado foi o k-fold cross validation. As métricas de avaliação utilizadas foram recall, precisão e área sob a curva Receiver Operating Characteristic. Resultados: Foram utilizados 720 pacientes para criação e validação do modelo. Os modelos apresentaram alta capacidade preditiva com área sob a curva Receiver Operating Characteristic de 0,979; 0,999; 0,980; 0,998 e 1,00 para os algoritmos de Decision Tree, Random Forest, AdaBoost, Gradient Boosting e XGBoost, respectivamente. Conclusão: O modelo preditivo criado e validado apresentou elevada capacidade de predição do choque séptico e hipovolêmico desde o momento da admissão de pacientes na unidade de terapia intensiva.

ABSTRACT Objective: To create and validate a model for predicting septic or hypovolemic shock from easily obtainable variables collected from patients at admission to an intensive care unit. Methods: A predictive modeling study with concurrent cohort data was conducted in a hospital in the interior of northeastern Brazil. Patients aged 18 years or older who were not using vasoactive drugs on the day of admission and were hospitalized from November 2020 to July 2021 were included. The Decision Tree, Random Forest, AdaBoost, Gradient Boosting and XGBoost classification algorithms were tested for use in building the model. The validation method used was k-fold cross validation. The evaluation metrics used were recall, precision and area under the Receiver Operating Characteristic curve. Results: A total of 720 patients were used to create and validate the model. The models showed high predictive capacity with areas under the Receiver Operating Characteristic curve of 0.979; 0.999; 0.980; 0.998 and 1.00 for the Decision Tree, Random Forest, AdaBoost, Gradient Boosting and XGBoost algorithms, respectively. Conclusion: The predictive model created and validated showed a high ability to predict septic and hypovolemic shock from the time of admission of patients to the intensive care unit.

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BACKGROUND: Streptococcal toxic shock syndrome (STSS) is diagnosed based on signs of shock with multiorgan system involvement, a generalized erythematous macular rash, and rapidly progressive and destructive soft tissue infection. CASE REPORT: The patient was a 2-year-old girl with intramuscular venous malformation in the neck in which an infection occurred, developing into STSS. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Group A streptococcal infections are common in children and usually have a mild clinical presentation, but may be life threatening in severe cases. Patients with venous malformations are known to have slow-flow anomalies with venous pooling, which can result in hypoxia and possible immune cell dysfunction. Thus, clinicians should be aware of STSS when a patient with venous malformation has a rapidly progressive infection.

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Introducción: En UCI, 19% tienen hongos, 23% desarrollan shock séptico. Cándida albicans el más frecuente. Antimicótico más utilizado es fluconazol. Objetivos: En residentes de la altitud con shock séptico (SS) describiremos: Características, evolución y sensibilidad de la infección fúngica invasiva (IFI) y los contrastaremos con los publicados a nivel del mar. El estudio: Retrospectivo y transversal. Analizamos hemocultivos de adultos con SS y IFIs en una UCI a 3,250 metros de altitud, durante 7 años. Hallazgos: 123 muestras. Las IFIs aumentaron 3.6 para candida albicans. Mujeres con 74 años fue frecuente. BGN representaron 52.88%, BGP 37.9% y hongos 9.22%. Cándida albicans 79.67% con sensibilidad mayor al 90% para Voriconazol, Anfotericina B y Fluconazol. Conclusiones: IFIs con SS fueron causadas por cándida albicans, IFIs aumentaron, existe adecuada sensibilidad a los antimicóticos En la altitud existe mayor frecuencia del sexo femenino, mayor promedio de edad y una buena sensibilidad al fluconazol.

Introduction: In the ICU, 19% have fungi, 23% develop septic shock. Candida albicans the most frequent. The most commonly used antifungal is fluconazole. Objectives: In high altitude residents with septic shock (SS) we will describe: Characteristics, evolution and sensitivity of invasive fungal infection (IFI) and we will contrast them with those published at sea level. The study: Retrospective and transversal. We analyzed blood cultures of adults with SS and IFIs in an ICU at 3,250 meters of altitude, for 7 years. Findings: 123 samples. The IFIs increased 3.6 for candida albicans. Women with 74 years was frequent. BGN represented 52.88%, BGP 37.9% and fungi 9.22%. Candida albicans 79.67% with sensitivity greater than 90% for Voriconazole, Amphotericin B and Fluconazole. Conclusions: IFIs with SS were caused by candida albicans, IFIs increased, there is adequate sensitivity to antifungals. At high altitudes there is a higher frequency of females, higher average age, and good sensitivity to fluconazole.

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BACKGROUND: The use of vasopressors is vital in septic shock. However, the optimal timing of treatment remains unclear. Therefore, we aimed to explore the impact of early norepinephrine initiation on the survival of patients with septic shock. METHODS: We selected 4253 patients from the Medical Information Mart for Intensive Care IV database between 2008 and 2019. The primary outcome was 28-day mortality. Propensity score matching (PSM) was applied to minimize between-group imbalances, and a restricted mean survival time was used to quantify the beneficial impact of early norepinephrine treatment on survival. Sensitivity analyses were conducted to test the robustness of the study results in multiple cohorts. RESULTS: In the PSM cohort, 2862 patients were equally assigned to early (receiving norepinephrine within the first 3 h) and delayed (> 3 h) norepinephrine initiation groups. Patients in the early norepinephrine initiation group received significantly less fluid therapy (0 vs. 79 mL/kg), had lower 28-day mortality (30.0% vs. 37.8%), longer survival days (21.89 vs. 20.37 days), shorter duration of intensive care unit (4.9 vs. 7.2 days) and hospital stays (12.4 vs. 13.6 days), shorter duration of supportive norepinephrine and invasive mechanical ventilation, lower incidence of organ failure progression (64.4% vs. 79.2%) within 24 h after shock onset, and higher mean arterial pressure within 6 and 24 h after shock onset than patients in the delayed norepinephrine initiation group (p < 0.05). CONCLUSIONS: Norepinephrine initiation within the first 3 h, regardless of preload dependency, was associated with longer survival time and shorter duration of supportive norepinephrine and invasive mechanical ventilation and may delay or partially reverse rapid onset organ failure.

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Sepsis is one of the leading causes of death in critically ill patients with COVID-19 and blood purification therapies have a role to immunomodulate the excessive inflammatory response and improve clinical results. One of the devices designed for these therapies is the oXiris® filter, allowing to perform renal replacement therapy combined with selective adsorption of endotoxins and cytokines. We report a 55-year-old male with COVID who developed a septic shock secondary to a sepsis caused by Pseudomona aeruginosa, refractory to the usual management. A veno-venous continuous hemofiltration was started using the oXiris® filter for 48 hours. Subsequently, there was an improvement in clinical perfusion parameters and a reduction in inflammatory markers. The patient was discharged from the intensive care one month later.

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Many cases of Clostridium perfringens sepsis prove to be fatal. We present a case of C. perfringens sepsis with a liver abscess as the focus of infection, which was successfully treated by an interdisciplinary intensive medical care management. The sepsis with this rare pathogen was favored by the presence of a bilioenteric anastomosis and immunosuppressive treatment of a pre-existing Crohn's disease. Antibiotic treatment with clindamycin and penicillin G was initiated and the abscess was drained. Hemodialysis with high cut-off filters was started because of acute kidney failure in the Acute Kidney Injury Network (AKIN) stage III, hemolysis and rhabdomyolysis. Therapeutic plasma exchange was performed due to sepsis and acute liver failure.

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Objective:To investigate the clinical characteristics of septic shock caused by an invasive pneumococcal disease (IPD) and analyze the factors that affect the prognosis of this disease.Methods:We retrospectively analyzed the clinical data of 42 children with an IPD-caused septic shock, who received treatment in The Second Hospital of Jiaxing from January 2015 to December 2020, and evaluated the clinical characteristics and prognosis of this disease.Results:The age of the included children averaged 1.3 (0.75, 4.15) years. The Pediatric Index of Mortality 2 was (23.38 ± 9.26) points. Infections were primarily in the blood and brain. Eighteen cases were sensitive to penicillin, 20 cases to cefepime, 22 cases to cefotaxime, and 20 cases to meropenem, vancomycin, and linezolid simultaneously. The mortality was 61.90% (26/42). The Pediatric Index of Mortality 2 [(37.17 ± 10.58) points vs. (0.92 ± 0.39) points, t = 17.45, P < 0.001], and the rate of children developing an intracranial hypertension crisis (69.23% vs. 25.03%) ( χ2 = 7.77, P = 0.05) were significantly higher in the death group than in the survival group. Compared with the survival group, the thoracic infection rate was significantly lower in the death group (7.69% vs. 50.00%, P < 0.05). Conclusion:Most children with an IPD-caused septic shock are young, and most infection sites are in the brain and blood. The IPD-caused septic shock is highly resistant to cephalosporins and penicillin and has high mortality because of an intracranial hypertension crisis. The IPD-caused septic shock should be screened and treated as early as possible.

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Objective:To investigate the implementation status of sepsis hour-1 bundle strategy for patients with septic shock in emergency department.Methods:A total of 116 septic shock patients admitted to the emergency department from January 2020 to December 2020 were included in this prospective study, and the implementation of sepsis bundles and the clinical outcomes of patients were recorded.Results:Among 116 patients, 20 cases (17.2%) had lactic acid monitored within 1 h, 20 cases (17.2%) had blood culture before antibiotics, 82 cases (70.1%) received broad-spectrum antibiotics, 16 cases (13.8%) received fluid resuscitation ≥30 ml/kg, and 57 cases (49.1%) received vasoactive drugs during resuscitation. Finally, the sepsis hour-1 bundle strategy was fully implemented only in 13 cases (11.2%). Compared with the group with incomplete implementation of sepsis hour-1 bundle strategy, the volume of fluid recovery in the group with full implementation was significantly increased [33.7 (30.0,37.5) vs. 8.9(7.3,10.8) ml/kg, Z=-4.78, P<0.001], mean artery blood pressure significantly increased [70.0 (70.0,76.7) vs. 67.7 (61.7,76.7)mmHg(1 mmHg=0.133 kPa) , Z=-2.00, P<0.001], and lactic acid significantly decreased [3.0 (2.0,3.2) vs. 4.4 (3.7,7.2) mmol/L, Z=-2.76, P=0.006]. However, there were no significant differences in ICU mortality, in-hospital mortality and 28-day mortality between the two groups ( P>0.05). Conclusions:Septic shock patients in emergency department have poor compliance with the implementation of sepsis hour-1 bundle strategy, and relevant management training should be strengthened.