Definitions of sepsis and septic shock were last revised in 2001. Considerable advances have since been made into the pathobiology (changes in organ function, morphology, cell biology, biochemistry, immunology, and circulation), management, and epidemiology of sepsis, suggesting the need for reexamination.
To evaluate and, as needed, update definitions for sepsis and septic shock.
A task force (n = 19) with expertise in sepsis pathobiology, clinical trials, and epidemiology was convened by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. Definitions and clinical criteria were generated through meetings, Delphi processes, analysis of electronic health record databases, and voting, followed by circulation to international professional societies, requesting peer review and endorsement (by 31 societies listed in the Acknowledgment).
Limitations of previous definitions included an excessive focus on inflammation, the misleading model that sepsis follows a continuum through severe sepsis to shock, and inadequate specificity and sensitivity of the systemic inflammatory response syndrome (SIRS) criteria. Multiple definitions and terminologies are currently in use for sepsis, septic shock, and organ dysfunction, leading to discrepancies in reported incidence and observed mortality. The task force concluded the termsevere sepsiswas redundant.
Sepsis should be defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Septic shock should be defined as a subset of sepsis in which particularly profound circulatory, cellular, and metabolic abnormalities are associated with a greater risk of mortality than with sepsis alone. Patients with septic shock can be clinically identified by a vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or greater and serum lactate level greater than 2 mmol/L (>18 mg/dL) in the absence of hypovolemia. This combination is associated with hospital mortality rates greater than 40%. In out-of-hospital, emergency department, or general hospital ward settings, adult patients with suspected infection can be rapidly identified as being more likely to have poor outcomes typical of sepsis if they have at least 2 of the following clinical criteria that together constitute a new bedside clinical score termed quickSOFA (qSOFA): respiratory rate of 22/min or greater, altered mentation, or systolic blood pressure of 100 mm Hg or less.
These updated definitions and clinical criteria should replace previous definitions, offer greater consistency for epidemiologic studies and clinical trials, and facilitate earlier recognition and more timely management of patients with sepsis or at risk of developing sepsis.
AU - Singer, Mervyn AU - Deutschman, Clifford S. AU - Seymour, Christopher Warren AU - Shankar-Hari, Manu AU - Annane, Djillali AU - Bauer, Michael AU - Bellomo, Rinaldo AU - Bernard, Gordon R. AU - Chiche, Jean-Daniel AU - Coopersmith, Craig M. AU - Hotchkiss, Richard S. AU - Levy, Mitchell M. AU - Marshall, John C. AU - Martin, Greg S. AU - Opal, Steven M. AU - Rubenfeld, Gordon D. AU - van der Poll, Tom AU - Vincent, Jean-Louis AU - Angus, Derek C. DA - 2016/2// DO - 10.1001/jama.2016.0287 IS - 8 KW - infection KW - organ failure KW - sepsis KW - septic shock KW - sequential organ failure assessment scores KW - systemic inflammatory response syndrome KW - third international consensus definitions for sepsis and septic shock (sepsis-3) PB - American Medical Association PY - 2016 SP - 801 EP - 801 TI - The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) T2 - JAMA UR - http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2016.0287 VL - 315 ER - TY - JOUR AB - Objective: A comparison is made of the accuracy between severity models, based on different sepsis definitions (systemic inflammatory response syndrome (SIRS), predisposition, insult, response, organ dysfunction (PIRO), and sequential organ failure assessment (SOFA) concepts), in predicting outcomes among sepsis patients. Design: A retrospective study was carried out. Setting: The study was conducted in the Intensive Care Unit (ICU) of a university teaching hospital. Patients: Septic patients admitted to the ICU during 2007–2016. Main variables of interest: The primary outcome was in-hospital mortality, with ICU mortality being the secondary outcome. Results: A total of 2152 septic patient were identified, with ICU and in-hospital mortality rates of 33.3% and 45.9%, respectively. The Moreno PIRO (AUC, 95%CI) (0.835; 0.818–0.852) showed the highest discriminating capacity, followed by SOFA (0.828; 0.811–0.846), qSOFA (0.792; 0.775–0.809), Rubulotta PIRO (0.708; 0.687–0.730), Howell PIRO (0.706; 0.685–0.728) and SIRS (0.578; 0.556–0.600). The AUC of the SOFA score was comparable to that of the Moreno PIRO (p = 0.43), though the AUCs of both of these scores were significantly higher than those of the other scores (p < 0.001 for all other comparisons). However, the SOFA score showed the best discriminating capacity in predicting ICU mortality (0.838; 0.820–0.855), followed by Moreno PIRO (0.804; 0.785–0.823) and qSOFA (0.787; 0.770–0.805). The accuracy of the qSOFA in predicting ICU mortality was comparable to that of the Moreno PIRO score (p = 0.15). Conclusion: The SOFA score and Moreno PIRO score showed the best accuracy in predicting in-hospital mortality among septic patients admitted to the ICU. AU - Songsangjinda, T. AU - Khwannimit, B. DO - 10.1016/j.medin.2018.12.004 IS - xx KW - Outcome KW - Predisposition, insult, response, organ dysfunctio KW - Septic shock KW - Sequential organ failure assessment KW - Systemic inflammatory response syndrome PB - Elsevier España, S.L.U. y SEMICYUC PY - 2019 TI - Comparison of severity score models based on different sepsis definitions to predict in-hospital mortality among sepsis patients in the Intensive Care Unit T2 - Medicina Intensiva UR - https://doi.org/10.1016/j.medin.2018.12.004 ER - TY - JOUR AB - Circulatory shock is present when physical signs and changes in laboratory values suggest tissue hypoperfusion. This article in the Critical Care Medicine series reviews the diagnosis and treatment of various forms of shock. AU - Vincent, Jean-Louis AU - De Backer, Daniel DA - 2013/10// DO - 10.1056/NEJMra1208943 ED - Finfer, Simon R. ED - Vincent, Jean-Louis IS - 18 PB - Massachusetts Medical Society PY - 2013 SP - 1726 EP - 1734 TI - Circulatory Shock T2 - New England Journal of Medicine UR - http://www.nejm.org/doi/10.1056/NEJMra1208943 VL - 369 ER - TY - JOUR AU - Wacharasint, Petch AU - Nakada, Taka-aki AU - Boyd, John H. AU - Russell, James A. AU - Walley, Keith R. DA - 2012/7// DO - 10.1097/SHK.0b013e318254d41a IS - 1 PY - 2012 SP - 4 EP - 10 TI - Normal-Range Blood Lactate Concentration in Septic Shock Is Prognostic and Predictive T2 - Shock UR - http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00024382-201207000-00002 VL - 38 ER - TY - JOUR AU - Fischer, J. Howard James; Fred A. Luchette; Freda D. McCarter; Josef E. DA - 1999/8// DO - 10.1016/S0140-6736(98)91132-1 IS - 9177 PB - Elsevier PY - 1999 SP - 505 EP - 508 TI - Lactate is an unreliable indicator of tissue hypoxia in injury or sepsis T2 - The Lancet UR - https://www-sciencedirect-com.ez.urosario.edu.co/science/article/pii/S0140673698911321?via%3Dihub VL - 354 ER - TY - JOUR AU - Mustafa, Iqbal AU - Roth, Hubert AU - Hanafiah, Asikin AU - Hakim, Tarmizi AU - Anwar, Maizul AU - Siregar, Erwin AU - Leverve, Xavier M. DA - 2003/8// DO - 10.1007/s00134-003-1860-6 IS - 8 PB - Springer-Verlag PY - 2003 SP - 1279 EP - 1285 TI - Effect of cardiopulmonary bypass on lactate metabolism T2 - Intensive Care Medicine UR - http://link.springer.com/10.1007/s00134-003-1860-6 VL - 29 ER - TY - JOUR AB - The pyruvate dehydrogenase (PDH) complex undergoes reversible phosphorylation catalyzed by a PDH kinase (inactivating) and a PDH phosphatase (activating). In skeletal muscle, a decreased proportion of PDH complex in the active, nonphosphorylated form (PDHa) limits glucose oxidation and promotes the conversion of pyruvate to lactate. Increased lactate formation with the accompanying hyperlactatemia is a frequent metabolic complication of sepsis. The time course for inactivation of the PDH complex in skeletal muscle during sepsis was contrasted with changes in PDHa during sterile inflammation 3,7, or 14 days following the implantation of the foreign body nidus. Total PDH complex activity was not altered in any of the conditions examined. Sepsis, but not sterile inflammation, caused a reduction in the muscle PDHa measured 3 or 7 days following induction of sepsis. The inhibition of the muscle PDHa during sepsis was associated with a sustained hyperlactatemia. PDH kinase activity measured in extracts of mitochondria was enhanced twofold during this period. Fourteen days after induction of sepsis, there were no differences in the PDHa or plasma lactate concentrations in septic rats compared with either control or sterile inflammation. Furthermore, the PDH kinase activity was decreased to values observed in control values. The results are consistent with the hypothesis that a reduced PDHa in skeletal muscle during sepsis is responsible, in part, for the hyperlactatemia characteristic of septic hypermetabolism. Furthermore, the results provide evidence that the decrease in PDHa results from a stable stimulation of PDH kinase activity. AU - Vary, T C DA - 1996/8// IS - 2 PY - 1996 SP - 89 EP - 94 TI - Sepsis-induced alterations in pyruvate dehydrogenase complex activity in rat skeletal muscle: effects on plasma lactate. T2 - Shock (Augusta, Ga.) UR - http://www.ncbi.nlm.nih.gov/pubmed/8856841 VL - 6 ER - TY - JOUR AB - There is overwhelming evidence that sepsis and septic shock are associated with hyperlactatemia (sepsis-associated hyperlactatemia (SAHL)). SAHL is a strong independent predictor of mortality and its presence and progression are widely appreciated by clinicians to define a very high-risk population. Until recently, the dominant paradigm has been that SAHL is a marker of tissue hypoxia. Accordingly, SAHL has been interpreted to indicate the presence of an 'oxygen debt' or 'hypoperfusion', which leads to increased lactate generation via anaerobic glycolysis. In light of such interpretation of the meaning of SAHL, maneuvers to increase oxygen delivery have been proposed as its treatment. Moreover, lactate levels have been proposed as a method to evaluate the adequacy of resuscitation and the nature of the response to the initial treatment for sepsis. However, a large body of evidence has accumulated that strongly challenges such notions. Much evidence now supports the view that SAHL is not due only to tissue hypoxia or anaerobic glycolysis. Experimental and human studies all consistently support the view that SAHL is more logically explained by increased aerobic glycolysis secondary to activation of the stress response (adrenergic stimulation). More importantly, new evidence suggests that SAHL may actually serve to facilitate bioenergetic efficiency through an increase in lactate oxidation. In this sense, the characteristics of lactate production best fit the notion of an adaptive survival response that grows in intensity as disease severity increases. Clinicians need to be aware of these developments in our understanding of SAHL in order to approach patient management according to biological principles and to interpret lactate concentrations during sepsis resuscitation according to current best knowledge. AU - Garcia-Alvarez, Mercedes AU - Marik, Paul AU - Bellomo, Rinaldo DA - 2014/9// DO - 10.1186/s13054-014-0503-3 IS - 5 PB - BioMed Central PY - 2014 SP - 503 EP - 503 TI - Sepsis-associated hyperlactatemia. T2 - Critical care (London, England) UR - http://www.ncbi.nlm.nih.gov/pubmed/25394679 UR - http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC4421917 VL - 18 ER - TY - JOUR AU - McMahon, M AU - Gerich, J AU - Rizza, R DA - 1988/2// IS - 1 PY - 1988 SP - 17 EP - 30 TI - Effects of glucocorticoids on carbohydrate metabolism. T2 - Diabetes/metabolism reviews UR - http://www.ncbi.nlm.nih.gov/pubmed/3278872 VL - 4 ER - TY - JOUR AB - OBJECTIVE The purpose of this study was to quantitate the derangements in intermediary carbohydrate metabolism and oxygen use in severely septic patients in comparison with healthy volunteers. SUMMARY BACKGROUND DATA It commonly has been assumed that the development of lactic acidosis during sepsis results from a deficit in tissue oxygen availability. Dichloroacetate (DCA), which is known to increase pyruvate oxidation but only when tissue oxygen is available, provides a means to assess the role of hypoxia in lactate production. METHODS Stable isotope tracer methodology and indirect calorimetry was used to determine the rates of intermediary carbohydrate metabolism and oxygen use in five severely septic patients with lactic acidosis and six healthy volunteers before and after administration of DCA. RESULTS Oxygen consumption and the rates of glucose and pyruvate production and oxidation were substantially greater (p < 0.05) in the septic patient compared with healthy volunteers. Administration of DCA resulted in a further increase in oxygen consumption and the percentage of glucose and pyruvate directed toward oxidation. Dichloroacetate also decreased glucose and pyruvate production, with a corresponding decrease in plasma lactate concentration. CONCLUSIONS These findings clearly indicate that the accumulation of lactate during sepsis is not the result of limitations in tissue oxygenation, but is a sequelae to the markedly increased rate of pyruvate production. Furthermore, the substantially higher rate of pyruvate oxidation in the septic patients refutes the notion of a sepsis-induced impairment in pyruvate dehydrogenase activity. AU - Gore, D C AU - Jahoor, F AU - Hibbert, J M AU - DeMaria, E J DA - 1996/7// DO - 10.1097/00000658-199607000-00015 IS - 1 PB - Lippincott, Williams, and Wilkins PY - 1996 SP - 97 EP - 102 TI - Lactic acidosis during sepsis is related to increased pyruvate production, not deficits in tissue oxygen availability. T2 - Annals of surgery UR - http://www.ncbi.nlm.nih.gov/pubmed/8678625 UR - http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC1235253 VL - 224 ER - TY - JOUR AB - Objective: Under conditions of tissue hypoxia total CO 2 production (VCO 2) should be less reduced than O 2 consumption (VO 2) since an anaerobic CO 2 production should occur. Thus the VCO 2 /VO 2 ratio, and hence the venoarterial CO 2 tension difference/arteriovenous O 2 content difference ratio (∆PCO 2 AU - Mekontso-Dessap, Armand AU - Castelain, Vincent AU - Anguel, Nadia AU - Bahloul, Mabrouk AU - Schauvliege, Franck AU - Richard, Christian AU - Teboul, Jean-Louis DA - 2002/3// DO - 10.1007/s00134-002-1215-8 IS - 3 PB - Springer-Verlag PY - 2002 SP - 272 EP - 277 TI - Combination of venoarterial PCO2 difference with arteriovenous O2 content difference to detect anaerobic metabolism in patients T2 - Intensive Care Medicine UR - https://link-springer-com.ez.urosario.edu.co/content/pdf/10.1007%2Fs00134-002-1215-8.pdf UR - http://link.springer.com/10.1007/s00134-002-1215-8 VL - 28 ER - TY - BOOK AU - Tobin, Martin J. PB - New York : McGraw-Hill, Health Professions Division, c1998. PY - 1998 SN - 0070650942 (alk. paper) SP - 1525 EP - 1525 TI - Principles and practice of intensive care monitoring / editor, Martin J. Tobin. ER - TY - JOUR AB - Índices estáticos y dinámicos de la hiperlactatemia resumen La hiperlactatemia es un parámetro de gravedad utilizado ampliamente en el ámbito clínico en unidades hospitalarias de cualquier nivel de atención; sin embargo, es común la omisión de conceptos importantes relacionados con su fisiopatología, principalmente el desconocimiento de todas las causas de su producción, y el equilibrio que guarda con su depuración y con los factores que la alteran. Lo más frecuente en la práctica clínica es su asociación con la hipoxia tisular en la mayoría de los pacientes; sin embargo, este sesgo puede llevar a la no identi-ficación de padecimientos subyacentes y a la elección de estrategias terapéuticas incorrectas. La hiperlactatemia no se correlaciona siempre con la estabilidad hemodinámica; es multifactorial y debe interpretarse de manera sistemática y minuciosa. abstract Hyperlactatemia is a severity parameter used widely in the clinical services at the hospital units of any attention level; however, it is common the omission of important concepts related to its physiopathology, mainly the ignorance of all causes of lactate production and the balance that it keeps with its depuration, and the factors that alter this equilibrium. The most frequent situation in clinical practice is the association of hyperlac-tatemia to tissue hypoxia in most patients; nevertheless, it is well known that this can conduct to the misidentification of subjacent diseases, and to the election of incorrect therapeutic choices. Hyperlactatemia is not always correlated to hemodynamic stability; it is multifactorial and must be analyzed in a systematic and meticulous way. Static and dynamic indexes of hyperlactatemia. AU - Jl, Ángeles-Velázquez AU - Ac, García-González AU - Ej, Díaz-Greene AU - Fl, Rodríguez-Weber AU - Rodríguez-Weber, Federico IS - 2 PY - 2016 SP - 225 EP - 231 TI - Índices estáticos y dinámicos de la hiperlactatemia T2 - Med Int Méx UR - https://www.medigraphic.com/pdfs/medintmex/mim-2016/mim162j.pdf VL - 32 ER - TY - JOUR AB - Recibido el 13 de agosto de 2015; aceptado el 9 de noviembre de 2015 Disponible en Internet el 8 de enero de 2016 PALABRAS CLAVE Shock séptico; Dióxido de carbono; Ácido láctico; Análisis de los gases de la sangre; Consumo de oxígeno; Evaluación del resultado de la atención al paciente Resumen El metabolismo anaerobio es clave en la fisiopatología del shock séptico. Actual-mente disponemos de la saturación venosa central y mixta, y del lactato para monitorizar estos pacientes. Hay trabajos que han demostrado que la normalización de parámetros hemodinámi-cos y de oxigenación no previene la progresión del daño orgánico o de mayor mortalidad. Recientemente se ha propuesto como marcador de hipoperfusión tisular la diferencia venoar-terial de pCO 2 (pvaCO 2), equivalente al gasto cardiaco; un gradiente elevado se ha relacionado con resultados adversos. Así mismo se ha propuesto la ratio pvaCO 2 entre diferencia de con-tenido arteriovenoso de oxígeno (CavO 2): pvaCO 2 /CavO 2 , también la ratio diferencia de contenido venoarterial de CO 2 entre CavO 2 : CvaCO 2 /CavO 2 , como marcadores de meta-bolismo anaerobio. Ambas ratios elevadas están relacionadas con mayores niveles de lactato y peor pronóstico. Por lo tanto, en pacientes con sepsis pudiera ser importante la combinación de objetivos de reanimación para mejorar los resultados. Prognostic value of gasometric parameters of carbon dioxide in resuscitation of septic patients. A bibliography review Abstract The anaerobic metabolism is the cornerstone in physiopathology of septic shock. Nowadays we have both the central or mixed venous oxigen saturation and lactate levels to monitoring the metabolism in septic patients. Some studies have shown that normalization of Este artículo pertenece al Programa de Formación Médica Continuada en Anestesiología y Reanimación. La evaluación de las preguntas de este artículo se podrá realizar a través de internet accediendo al apartado de formación de la siguiente página web: www.elsevier.es/redar * Autor para correspondencia. Correo electrónico: joseangel.lamsfus@scsalud.es (J.Á. Lamsfus-Prieto). AU - Lamsfus-Prieto, J Á AU - De Castro-Fernández, R AU - Hernández-García, A M AU - Marcano-Rodriguez, G DO - 10.1016/j.redar.2015.11.005 IS - 4 PY - 2016 SP - 220 EP - 230 TI - Valor pronóstico de los parámetros gasométricos del dióxido de carbono en pacientes con sepsis. Una revisión bibliográfica T2 - Rev Esp Anestesiol Reanim UR - www.elsevier.es/redar VL - 63 ER - TY - JOUR AU - Rebollo CP, Arfelís NJ. PY - 2016 SP - 2327 EP - 2402. TI - Sepsis, Sepsis Grave y Choque Séptico T2 - Medicina Interna.18va ed. España: Elsevier ER - TY - JOUR AB - Study objective: Little is known about risk-stratification biomarkers in emergency department (ED) patients with suspected infection, and lactate is a biologically plausible candidate. We determine whether a serum venous lactate is associated with an increased risk of death in ED patients with infection. Methods: This was a prospective cohort study in an urban, academic medical center with 50,000 annual ED visits. A total of 1,278 consecutive patient visits met enrollment criteria between July 24, 2003, and March 24, 2004, and all patients were enrolled. Inclusion criteria were age 18 years or older, serum lactate level obtained, and admission to the hospital with an infection-related diagnosis. The main outcome measure was all-cause 28-day inhospital mortality and death within 3 days of presentation. Results: Among 1,278 patient visits, there were 105 (8.2%) deaths during hospitalization, with 55 (4.3%) of 1,278 deaths occurring in the first 3 days. Mortality rates increased as lactate increased: 43 (4.9%) of 877 of patients with a lactate level between 0 and 2.5 mmol/L died, 24 (9.0%) of 267 patients with a lactate level between 2.5 and 4.0 mmol/L died, and 38 (28.4%) of 134 patients with a lactate level greater than or equal to 4.0 mmol/L died. Lactate level greater than or equal to 4.0 mmol/L was 36% (95% confidence interval [CI] 27% to 45%) sensitive and 92% (95% CI 90% to 93%) specific for any death; it was 55% (95% CI 41% to 68%) sensitive and 91% (95% CI 90% to 93%) specific for death within 3 days. Conclusion: In this cohort of ED patients with signs and symptoms suggestive of infection, our results support serum venous lactate level as a promising risk-stratification tool. Multicenter validation, as well as comparison of the lactate level with clinical predictors, needs to be done before widespread implementation. Copyright © 2005 by the American College of Emergency Physicians. AU - Shapiro, Nathan I AU - Howell, Michael D AU - Talmor, Daniel AU - Nathanson, Larry A AU - Lisbon, Alan AU - Wolfe, Richard E AU - Weiss, J Woodrow DA - 2005/5// DO - 10.1016/j.annemergmed.2004.12.006 IS - 5 PY - 2005 SP - 524 EP - 528 TI - Serum Lactate as a Predictor of Mortality in Emergency Department Patients with Infection T2 - Annals of Emergency Medicine VL - 45 ER - TY - JOUR AB - Background: We sought to compare the association of whole-blood lactate kinetics with survival in patients with septic shock undergoing early quantitative resuscitation. Methods: This was a preplanned analysis of a multicenter, ED-based, randomized, controlled trial of early sepsis resuscitation. Inclusion criteria were suspected infection, two or more systemic inflammation criteria, either systolic BP < 90 mm Hg after a fluid bolus or lactate level > 4 mM, two serial lactate measurements, and an initial lactate level > 2.0 mM. We calculated the relative lactate clearance, rate of lactate clearance, and occurrence of early lactate normalization (decline to < 2.0 mM in the first 6 h). Area under the receiver operating characteristic curve (AUC) and multivariate logistic regression were used to determine the lactate kinetic parameters that were the strongest predictors of survival. Results: The analysis included 187 patients, of whom 36% (n = 68) normalized their lactate level. Overall survival was 76.5% (143 of 187 patients), and the AUC of initial lactate to predict survival was 0.64. The AUCs for relative lactate clearance and lactate clearance rate were 0.67 and 0.58, respectively. Lactate normalization was the strongest predictor of survival (adjusted OR, 5.2; 95% CI, 1.7-15.8), followed by lactate clearance ≥ 50% (OR, 4.0; 95% CI, 1.6-10.0). Lactate clearance ≥ 10% (OR, 1.6; 95% CI, 0.6-4.4) was not a significant independent predictor in this cohort. Conclusions: In patients in the ED with a sepsis diagnosis, early lactate normalization during the first 6 h of resuscitation was the strongest independent predictor of survival and was superior to other measures of lactate kinetics. © 2013 American College of Chest Physicians. AU - Puskarich, Michael A. AU - Trzeciak, Stephen AU - Shapiro, Nathan I. AU - Albers, Andrew B. AU - Heffner, Alan C. AU - Kline, Jeffrey A. AU - Jones, Alan E. DA - 2013/6// DO - 10.1378/chest.12-0878 IS - 6 PB - American College of Chest Physicians PY - 2013 SP - 1548 EP - 1553 TI - Whole blood lactate kinetics in patients undergoing quantitative resuscitation for severe sepsis and septic shock T2 - Chest UR - http://www.ncbi.nlm.nih.gov/pubmed/23740148 UR - http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC3673659 VL - 143 ER - TY - JOUR AB - Background Low mixed or central venous saturation (S(c)vO 2) can reveal global tissue hypoxia and therefore can predict poor prognosis in critically ill patients. Early goal directed therapy (EGDT), aiming at an ScvO 2 ≥ 70%, has been shown to be a valuable strategy in patients with sepsis or septic shock and is incorporated in the Surviving Sepsis Campaign guidelines. AU - Van Beest, P A AU - Hofstra, J J AU - Schultz, M J AU - Boerma, E C AU - Kuiper, M A DO - 10.1186/cc6811 PY - 2008 SP - 1 EP - 6 TI - The incidence of low venous oxygen saturation on admission to the intensive care unit: a multi-center observational study in The Netherlands T2 - Journal of Critical Care. Elsevier UR - http://ccforum.com/content/12/2/R33Thisarticleisonlineat:http://ccforum.com/content/12/2/R33 VL - Vol 12 No 2 ER - TY - JOUR AU - Mikkelsen, Mark E. AU - Miltiades, Andrea N. AU - Gaieski, David F. AU - Goyal, Munish AU - Fuchs, Barry D. AU - Shah, Chirag V. AU - Bellamy, Scarlett L. AU - Christie, Jason D. DA - 2009/5// DO - 10.1097/CCM.0b013e31819fcf68 IS - 5 PY - 2009 SP - 1670 EP - 1677 TI - Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock* T2 - Critical Care Medicine UR - https://insights.ovid.com/crossref?an=00003246-200905000-00018 VL - 37 ER - TY - GEN AB - Por la cual se establecen las normas científicas, técnicas y administrativas para la investigación en salud. AU - Colombia.Ministerio de salud y protección social PY - 1993 SP - 1 EP - 12 TI - Resolución N° 008430:Por la cual se establecen las normas científicas, técnicas y administrativas para la investigación en salud. T2 - Constitución Política de Colombia ER - TY - JOUR AB - IMPORTANCE: The Third International Consensus Definitions Task Force defined sepsis as "life-threatening organ dysfunction due to a dysregulated host response to infection." The performance of clinical criteria for this sepsis definition is unknown. OBJECTIVE To evaluate the validity of clinical criteria to identify patients with suspected infection who are at risk of sepsis. DESIGN, SETTINGS, AND POPULATION: Among 1.3 million electronic health record encounters from January 1, 2010, to December 31, 2012, at 12 hospitals in southwestern Pennsylvania, we identified those with suspected infection in whom to compare criteria. Confirmatory analyses were performed in 4 data sets of 706 399 out-of-hospital and hospital encounters at 165 US and non-US hospitals ranging from January 1, 2008, until December 31, 2013. EXPOSURES: Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score, systemic inflammatory response syndrome (SIRS) criteria, Logistic OrganDysfunction System (LODS) score, and a new model derived using multivariable logistic regression in a split sample, the quick Sequential [Sepsis-related] Organ Failure Assessment (qSOFA) score (range, 0-3 points, with 1 point each for systolic hypotension [≤100mmHg], tachypnea [≥22/min], or altered mentation). MAIN OUTCOMES AND MEASURES: For construct validity, pairwise agreementwas assessed. For predictive validity, the discrimination for outcomes (primary: in-hospital mortality; secondary: in-hospital mortality or intensive care unit [ICU] length of stay≥3 days) more common in sepsis than uncomplicated infection was determined. Results were expressed as the fold change in outcome over deciles of baseline risk of death and area under the receiver operating characteristic curve (AUROC). RESULTS: In the primary cohort, 148 907 encounters had suspected infection (n = 74 453 derivation; n = 74 454 validation), of whom 6347 (4%) died. Among ICU encounters in the validation cohort (n = 7932 with suspected infection, of whom 1289 [16%] died), the predictive validity for in-hospital mortalitywas lower for SIRS (AUROC = 0.64; 95%CI, 0.62-0.66) and qSOFA (AUROC = 0.66; 95%CI, 0.64-0.68) vs SOFA (AUROC = 0.74; 95%CI, 0.73-0.76; P <.001 for both) or LODS (AUROC = 0.75; 95%CI, 0.73-0.76; P <.001 for both). Among non-ICU encounters in the validation cohort (n = 66 522 with suspected infection, of whom 1886 [3%] died), qSOFA had predictive validity (AUROC = 0.81; 95%CI, 0.80-0.82) thatwas greater than SOFA (AUROC = 0.79; 95%CI, 0.78-0.80; P <.001) and SIRS (AUROC = 0.76; 95% CI, 0.75-0.77; P <.001). Relative to qSOFA scores lower than 2, encounters with qSOFA scores of 2 or higher had a 3- to 14-fold increase in hospital mortality across baseline risk deciles. Findings were similar in external data sets and for the secondary outcome. CONCLUSIONS AND RELEVANCE: Among ICU encounters with suspected infection, the predictive validity for in-hospital mortality of SOFA was not significantly different than the more complex LODS but was statistically greater than SIRS and qSOFA, supporting its use in clinical criteria for sepsis. Among encounters with suspected infection outside of the ICU, the predictive validity for in-hospital mortality of qSOFA was statistically greater than SOFA and SIRS, supporting its use as a prompt to consider possible sepsis. AU - Seymour, Christopher W. AU - Liu, Vincent X. AU - Iwashyna, Theodore J. AU - Brunkhorst, Frank M. AU - Rea, Thomas D. AU - Scherag, André AU - Rubenfeld, Gordon AU - Kahn, Jeremy M. AU - Shankar-Hari, Manu AU - Singer, Mervyn AU - Deutschman, Clifford S. AU - Escobar, Gabriel J. AU - Angus, Derek C. DA - 2016/2// DO - 10.1001/jama.2016.0288 IS - 8 PB - American Medical Association PY - 2016 SP - 762 EP - 774 TI - Assessment of clinical criteria for sepsis for the third international consensus definitions for sepsis and septic shock (sepsis-3) T2 - JAMA - Journal of the American Medical Association VL - 315 ER - TY - JOUR AU - Levy, Mitchell M. AU - Evans, Laura E. AU - Rhodes, Andrew DA - 2018/6// DO - 10.1007/s00134-018-5085-0 IS - 6 PB - Springer Verlag PY - 2018 SP - 925 EP - 928 TI - The Surviving Sepsis Campaign Bundle: 2018 update T2 - Intensive Care Medicine UR - http://link.springer.com/10.1007/s00134-018-5085-0 VL - 44 ER - TY - JOUR AB - Context: Evaluation of trends in organ dysfunction in critically ill patients may help predict outcome. Objective: To determine the usefulness of repeated measurement the Sequential Organ Failure Assessment (SOFA) score for prediction of mortality in intensive care unit (ICU) patients. Design: Prospective, observational cohort study conducted from April 1 to July 31, 1999. Setting: A 31-bed medicosurgical ICU at a university hospital in Belgium. Patients: Three hundred fifty-two consecutive patients (mean age, 59 years) admitted to the ICU for more than 24 hours for whom the SOFA score was calculated on admission and every 48 hours until discharge. Main Outcome Measures: Initial SOFA score (0-24), Δ-SOFA scores (differences between subsequent scores), and the highest and mean SOFA scores obtained during the ICU stay and their correlations with mortality. Results: The initial, highest, and mean SOFA scores correlated well with mortality. Initial and highest scores of more than 11 or mean scores of more than 5 corresponded to mortality of more than 80%. The predictive value of the mean score was independent of the length of ICU stay. in univariate analysis, mean and highest SOFA scores had the strongest correlation with mortality, followed by Δ-SOFA and initial SOFA scores. The area under the receiver operating characteristic curve was largest for highest scores (0.90; SE, 0.02; P<.001 vs initial score). When analyzing trends in the SOFA score during the first 96 hours, regardless of the initial score, the mortality rate was at least 50% when the score increased, 27% to 35% when it remained unchanged, and less than 27% when it decreased. Differences in mortality were better predicted in the first 48 hours than in the subsequent 48 hours. There was no significant difference in the length of stay among these groups. Except for initial scores of more than 11 (mortality rate >90%), a decreasing score during the first 48 hours was associated with a mortality rate of less than 6%, while an unchanged or increasing score was associated with a mortality rate of 37% when the initial score was 2 to 7 and 60% when the initial score was 8 to 11. Conclusions: Sequential assessment of organ dysfunction during the first few days of ICU admission is a good indicator of prognosis. Both the mean and highest SOFA scores are particularly useful predictors of outcome. Independent of the initial score, an increase in SOFA score during the first 48 hours in the ICU predicts a mortality rate of at least 50%. AU - Lopes Ferreira, F. AU - Peres Bota, D. AU - Bross, A. AU - Mélot, C. AU - Vincent, J. L. DA - 2001/10// DO - 10.1001/jama.286.14.1754 IS - 14 KW - belgium KW - critical illness KW - hospitals, university KW - intensive care unit KW - length of stay KW - organ failure KW - roc curve PB - American Medical Association PY - 2001 SP - 1754 EP - 1758 TI - Serial evaluation of the SOFA score to predict outcome in critically ill patients T2 - Journal of the American Medical Association UR - https://jamanetwork.com/journals/jama/fullarticle/194262 VL - 286 ER - TY - JOUR AU - Evans, Laura AU - Rhodes, Andrew AU - Alhazzani, Waleed AU - Antonelli, Massimo AU - Coopersmith, Craig M. AU - French, Craig AU - Machado, Flávia R. AU - Mcintyre, Lauralyn AU - Ostermann, Marlies AU - Prescott, Hallie C. AU - Schorr, Christa AU - Simpson, Steven AU - Wiersinga, W. Joost AU - Alshamsi, Fayez AU - Angus, Derek C. AU - Arabi, Yaseen AU - Azevedo, Luciano AU - Beale, Richard AU - Beilman, Gregory AU - Belley-Cote, Emilie AU - Burry, Lisa AU - Cecconi, Maurizio AU - Centofanti, John AU - Coz Yataco, Angel AU - De Waele, Jan AU - Dellinger, R. Phillip AU - Doi, Kent AU - Du, Bin AU - Estenssoro, Elisa AU - Ferrer, Ricard AU - Gomersall, Charles AU - Hodgson, Carol AU - Møller, Morten Hylander AU - Iwashyna, Theodore AU - Jacob, Shevin AU - Kleinpell, Ruth AU - Klompas, Michael AU - Koh, Younsuck AU - Kumar, Anand AU - Kwizera, Arthur AU - Lobo, Suzana AU - Masur, Henry AU - McGloughlin, Steven AU - Mehta, Sangeeta AU - Mehta, Yatin AU - Mer, Mervyn AU - Nunnally, Mark AU - Oczkowski, Simon AU - Osborn, Tiffany AU - Papathanassoglou, Elizabeth AU - Perner, Anders AU - Puskarich, Michael AU - Roberts, Jason AU - Schweickert, William AU - Seckel, Maureen AU - Sevransky, Jonathan AU - Sprung, Charles L. AU - Welte, Tobias AU - Zimmerman, Janice AU - Levy, Mitchell DA - 2021/10// DO - 10.1007/S00134-021-06506-Y IS - 11 KW - Anesthesiology KW - Emergency Medicine KW - Intensive / Critical Care Medicine KW - Pain Medicine KW - Pediatrics KW - Pneumology/Respiratory System PB - Springer PY - 2021 SP - 1181 EP - 1247 TI - Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021 T2 - Intensive Care Medicine 2021 47:11 UR - https://link.springer.com/article/10.1007/s00134-021-06506-y VL - 47 ER - TY - JOUR AB - Background Lactate is measured in hospital settings to identify patients with sepsis and severe infections, and to guide initiation of early treatment. Point-of-care technology could facilitate measurement of lactate by clinicians in the community. However, there has been little research into its utility in these environments. Aim To investigate the effect of using point-of-care lactate at presentation to health care on mortality and other clinical outcomes, in patients presenting with acute infections. Design and setting Studies comparing the use of point-of-care lactate to usual care in initial patient assessment at presentation to health care were identified using a maximally sensitive search strategy of six electronic databases. Method Two independent authors screened 3063 records for eligibility, and extracted data from eligible studies. Quality assessment for observational studies was performed using the ROBINS-I tool. Results Eight studies were eligible for inclusion (3063 patients). Seven studies were recruited from emergency departments, and one from a pre-hospital aeromedical setting. Five studies demonstrated a trend towards reduced mortality with point-of-care lactate; three studies achieved statistical significance. One study demonstrated a significant reduction in length of hospital stay, although another did not find any significant difference. Two studies demonstrated a significant reduction in time to treatment for antibiotics and intravenous fluids. Conclusion This review identifies an evidence gap — there is no high-quality evidence to support the use of point-of-care lactate in community settings. There are no randomised controlled trials (RCTs) and no studies in primary care. RCT evidence from community settings is needed to evaluate this potentially beneficial diagnostic technology. AU - Morris, Elizabeth AU - McCartney, David AU - Lasserson, Daniel AU - Van Den Bruel, Ann AU - Fisher, Rebecca AU - Hayward, Gail DA - 2017/12// DO - 10.3399/BJGP17X693665 IS - 665 KW - General practice KW - Lactate KW - Point-of-care testing KW - Pre-hospital care KW - Primary health care KW - Sepsis PB - British Journal of General Practice PY - 2017 SP - e859 EP - e870 TI - Point-of-care lactate testing for sepsis at presentation to health care: a systematic review of patient outcomes T2 - British Journal of General Practice UR - https://bjgp.org/content/67/665/e859 UR - https://bjgp.org/content/67/665/e859.abstract VL - 67 ER - TY - JOUR AB - As coronavirus disease 2019 (COVID-19) spreads across the world, the intensive care unit (ICU) community must prepare for the challenges associated with this pandemic. Streamlining of workflows for rapid diagnosis and isolation, clinical management, and infection prevention will matter not only to patients with COVID-19, but also to health-care workers and other patients who are at risk from nosocomial transmission. Management of acute respiratory failure and haemodynamics is key. ICU practitioners, hospital administrators, governments, and policy makers must prepare for a substantial increase in critical care bed capacity, with a focus not just on infrastructure and supplies, but also on staff management. Critical care triage to allow the rationing of scarce ICU resources might be needed. Researchers must address unanswered questions, including the role of repurposed and experimental therapies. Collaboration at the local, regional, national, and international level offers the best chance of survival for the critically ill. AU - Phua, Jason AU - Weng, Li AU - Ling, Lowell AU - Egi, Moritoki AU - Lim, Chae Man AU - Divatia, Jigeeshu Vasishtha AU - Shrestha, Babu Raja AU - Arabi, Yaseen M. AU - Ng, Jensen AU - Gomersall, Charles D. AU - Nishimura, Masaji AU - Koh, Younsuck AU - Du, Bin DA - 2020/5// DO - 10.1016/S2213-2600(20)30161-2 IS - 5 PB - Elsevier PY - 2020 SP - 506 EP - 506 TI - Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations T2 - The Lancet. Respiratory Medicine UR - /pmc/articles/PMC7198848/ UR - /pmc/articles/PMC7198848/?report=abstract UR - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7198848/ VL - 8 ER - TY - JOUR AU - Liao, Xuelian AU - Wang, Bo AU - Kang, Yan DA - 2020/2// DO - 10.1007/S00134-020-05954-2 IS - 2 PB - Nature Publishing Group PY - 2020 SP - 357 EP - 357 TI - Novel coronavirus infection during the 2019–2020 epidemic: preparing intensive care units—the experience in Sichuan Province, China T2 - Intensive Care Medicine UR - /pmc/articles/PMC7042184/ UR - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042184/ VL - 46 ER - TY - JOUR AB - Background: Acute respiratory distress syndrome (ARDS) is a heterogeneous syndrome, and the identification of homogeneous subgroups and phenotypes is the first step toward precision critical care. We aimed to explore whether ARDS phenotypes can be identified using clinical data, are reproducible and are associated with clinical outcomes and treatment response. Methods: This study is based on a retrospective analysis of data from the telehealth intensive care unit (eICU) collaborative research database and three ARDS randomized controlled trials (RCTs) (ALVEOLI, FACTT and SAILS trials). We derived phenotypes in the eICU by cluster analysis based on clinical data and compared the clinical characteristics and outcomes of each phenotype. The reproducibility of the derived phenotypes was tested using the data from three RCTs, and treatment effects were evaluated. Results: Three clinical phenotypes were identified in the training cohort of 3875 ARDS patients. Of the three phenotypes identified, phenotype I (n = 1565; 40%) was associated with fewer laboratory abnormalities, less organ dysfunction and the lowest in-hospital mortality rate (8%). Phenotype II (n = 1232; 32%) was correlated with more inflammation and shock and had a higher mortality rate (18%). Phenotype III (n = 1078; 28%) was strongly correlated with renal dysfunction and acidosis and had the highest mortality rate (22%). These results were validated using the data from the validation cohort (n = 3670) and three RCTs (n = 2289) and had reproducibility. Patients with these ARDS phenotypes had different treatment responses to randomized interventions. Specifically, in the ALVEOLI cohort, the effects of ventilation strategy (high PEEP vs low PEEP) on ventilator-free days differed by phenotype (p = 0.001); in the FACTT cohort, there was a significant interaction between phenotype and fluid-management strategy for 60-day mortality (p = 0.01). The fluid-conservative strategy was associated with improved mortality in phenotype II but had the opposite effect in phenotype III. Conclusion: Three clinical phenotypes of ARDS were identified and had different clinical characteristics and outcomes. The analysis shows evidence of a phenotype-specific treatment benefit in the ALVEOLI and FACTT trials. These findings may improve the identification of distinct subsets of ARDS patients for exploration in future RCTs. AU - Liu, Xiaowei AU - Jiang, Yusheng AU - Jia, Xiaonan AU - Ma, Xiaohui AU - Han, Ci AU - Guo, Nana AU - Peng, Yahui AU - Liu, Haitao AU - Ju, Yingnan AU - Luo, Xiangfeng AU - Li, Xueting AU - Bu, Yue AU - Zhang, Jin AU - Liu, Yansong AU - Gao, Yan AU - Zhao, Mingyan AU - Wang, Hongliang AU - Luo, Ligang AU - Yu, Kaijiang AU - Wang, Changsong DA - 2021/12// DO - 10.1186/S13054-021-03734-Y/FIGURES/3 IS - 1 KW - Acute respiratory distress syndrome KW - Clinical characteristics and outcomes KW - Cluster analysis KW - Phenotype KW - Treatment strategy PB - BioMed Central Ltd PY - 2021 SP - 1 EP - 11 TI - Identification of distinct clinical phenotypes of acute respiratory distress syndrome with differential responses to treatment T2 - Critical Care UR - https://ccforum.biomedcentral.com/articles/10.1186/s13054-021-03734-y VL - 25 ER - TY - JOUR AB - ContextEvaluation of trends in organ dysfunction in critically ill patients may help predict outcome.ObjectiveTo determine the usefulness of repeated measurement the Sequential Organ Failure Assessment (SOFA) score for prediction of mortality in intensive care unit (ICU) patients.DesignProspective, observational cohort study conducted from April 1 to July 31, 1999.SettingA 31-bed medicosurgical ICU at a university hospital in Belgium.PatientsThree hundred fifty-two consecutive patients (mean age, 59 years) admitted to the ICU for more than 24 hours for whom the SOFA score was calculated on admission and every 48 hours until discharge.Main Outcome MeasuresInitial SOFA score (0-24), Δ-SOFA scores (differences between subsequent scores), and the highest and mean SOFA scores obtained during the ICU stay and their correlations with mortality.ResultsThe initial, highest, and mean SOFA scores correlated well with mortality. Initial and highest scores of more than 11 or mean scores of more than 5 corresponded to mortality of more than 80%. The predictive value of the mean score was independent of the length of ICU stay. In univariate analysis, mean and highest SOFA scores had the strongest correlation with mortality, followed by Δ-SOFA and initial SOFA scores. The area under the receiver operating characteristic curve was largest for highest scores (0.90; SE, 0.02; P<.001 vs initial score). When analyzing trends in the SOFA score during the first 96 hours, regardless of the initial score, the mortality rate was at least 50% when the score increased, 27% to 35% when it remained unchanged, and less than 27% when it decreased. Differences in mortality were better predicted in the first 48 hours than in the subsequent 48 hours. There was no significant difference in the length of stay among these groups. Except for initial scores of more than 11 (mortality rate >90%), a decreasing score during the first 48 hours was associated with a mortality rate of less than 6%, while an unchanged or increasing score was associated with a mortality rate of 37% when the initial score was 2 to 7 and 60% when the initial score was 8 to 11.ConclusionsSequential assessment of organ dysfunction during the first few days of ICU admission is a good indicator of prognosis. Both the mean and highest SOFA scores are particularly useful predictors of outcome. Independent of the initial score, an increase in SOFA score during the first 48 hours in the ICU predicts a mortality rate of at least 50%. AU - Ferreira, Flavio Lopes AU - Peres Bota, Daliana AU - Bross, Annette AU - Mélot, Christian AU - Vincent, Jean-Louis AU - Vin-Cent, Jean-Louis AU - Bihari, David AU - Brun-Buisson, Christian AU - Evans, Timothy AU - Heffner, John AU - Paradis, Norman DA - 2001/10// DO - 10.1001/JAMA.286.14.1754 IS - 14 KW - belgium KW - critical illness KW - hospitals, university KW - intensive care unit KW - length of stay KW - organ failure KW - roc curve PB - American Medical Association PY - 2001 SP - 1754 EP - 1758 TI - Serial Evaluation of the SOFA Score to Predict Outcome in Critically Ill Patients T2 - JAMA UR - https://jamanetwork.com/journals/jama/fullarticle/194262 VL - 286 ER - TY - JOUR AB - Objective: To validate two severity scoring systems, the Simplified Acute Physiology Score (SAPS II) and Acute Physiology and Chronic Health Evaluation (APACHE II), in a single-center ICU population. Design and setting: Prospective data collection in a two four-bed multidisciplinary ICUs of a teaching hospital. Patients and methods: Data were collected in ICU over 4 years on 1721 consecutively admitted patients (aged 18 years or older, no transferrals, ICU stay at least 24 h) regarding SAPS II, APACHE II, predicted hospital mortality, and survival upon hospital discharge. Results: At the predicted risk of 0.5, sensitivity was 39.4% for SAPS II and 31.6 % for APACHE II, specificity 95.6 % and 97.2 %, and correct classification rate 85.6 % and 85.5 %, respectively. The area under the ROC curve was higher than 0.8 for both models. The goodness-of-fit statistic showed no significant difference between observed and predicted hospital mortality (H = 7.62 for SAPS II, H = 3.87 for APA-CHE II; and C = 9.32 and C = 5.05, respectively). Observed hospital mortality of patients with risk of death higher than 60% was overpredicted by SAPS II and underpredieted by APACHE II. The observed hospital mortality was significantly higher than that predicted by the models in medical patients and in those admitted from the ward. Conclusions: This study validates both SAPS II and APACHE II scores in an ICU population comprised mainly of surgical patients. The type of ICU admission and the location in the hospital before ICU admission influence the predictive ability of the models. AU - Capuzzo, M. AU - Valpondi, V. AU - Sgarbi, A. AU - Bortolazzi, S. AU - Pavoni, V. AU - Gilli, G. AU - Candini, G. AU - Gritti, G. AU - Alvisi, R. DO - 10.1007/S001340000715 IS - 12 KW - APACHE* KW - Age Distribution KW - Aged KW - Bias KW - Calibration KW - Comparative Study KW - Critical Care / standards KW - Discriminant Analysis KW - Health Care KW - Hospital Mortality* KW - Hospitals KW - Humans KW - Intensive Care Units / statistics & numerical data* KW - Italy / epidemiology KW - Length of Stay / statistics & numerical data KW - M Capuzzo KW - MEDLINE KW - Middle Aged KW - Models KW - NCBI KW - NIH KW - NLM KW - National Center for Biotechnology Information KW - National Institutes of Health KW - National Library of Medicine KW - Non-U.S. Gov't KW - Outcome Assessment KW - Patient Admission / statistics & numerical data KW - Prospective Studies KW - PubMed Abstract KW - R Alvisi KW - Research Support KW - Risk Factors KW - Sensitivity and Specificity KW - Statistical KW - Survival Analysis KW - Teaching KW - V Valpondi KW - Validation Study KW - doi:10.1007/s001340000715 KW - pmid:11271085 PB - Intensive Care Med PY - 2000 SP - 1779 EP - 1785 TI - Validation of severity scoring systems SAPS II and APACHE II in a single-center population T2 - Intensive care medicine UR - https://pubmed.ncbi.nlm.nih.gov/11271085/ VL - 26 ER - TY - JOUR AB - IMPORTANCE: Estimates from claims-based analyses suggest that the incidence of sepsis is increasing and mortality rates from sepsis are decreasing. However, estimates from claims data may lack clinical fidelity and can be affected by changing diagnosis and coding practices over time. OBJECTIVE: To estimate the US national incidence of sepsis and trends using detailed clinical data from the electronic health record (EHR) systems of diverse hospitals. DESIGN, SETTING, AND POPULATION: Retrospective cohort study of adult patients admitted to 409 academic, community, and federal hospitals from 2009-2014. EXPOSURES: Sepsis was identified using clinical indicators of presumed infection and concurrent acute organ dysfunction, adapting Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) criteria for objective and consistent EHR-based surveillance. MAIN OUTCOMES AND MEASURES: Sepsis incidence, outcomes, and trends from 2009-2014 were calculated using regression models and compared with claims-based estimates using International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe sepsis or septic shock. Case-finding criteria were validated against Sepsis-3 criteria using medical record reviews. RESULTS: A total of 173 690 sepsis cases (mean age, 66.5 [SD, 15.5] y; 77 660 [42.4%] women) were identified using clinical criteria among 2 901 019 adults admitted to study hospitals in 2014 (6.0% incidence). Of these, 26 061 (15.0%) died in the hospital and 10 731 (6.2%) were discharged to hospice. From 2009-2014, sepsis incidence using clinical criteria was stable (+0.6% relative change/y [95% CI, −2.3% to 3.5%], P = .67) whereas incidence per claims increased (+10.3%/y [95% CI, 7.2% to 13.3%], P < .001). In-hospital mortality using clinical criteria declined (−3.3%/y [95% CI, −5.6% to −1.0%], P = .004), but there was no significant change in the combined outcome of death or discharge to hospice (−1.3%/y [95% CI, −3.2% to 0.6%], P = .19). In contrast, mortality using claims declined significantly (−7.0%/y [95% CI, −8.8% to −5.2%], P < .001), as did death or discharge to hospice (−4.5%/y [95% CI, −6.1% to −2.8%], P < .001). Clinical criteria were more sensitive in identifying sepsis than claims (69.7% [95% CI, 52.9% to 92.0%] vs 32.3% [95% CI, 24.4% to 43.0%], P < .001), with comparable positive predictive value (70.4% [95% CI, 64.0% to 76.8%] vs 75.2% [95% CI, 69.8% to 80.6%], P = .23). CONCLUSIONS AND RELEVANCE: In clinical data from 409 hospitals, sepsis was present in 6% of adult hospitalizations, and in contrast to claims-based analyses, neither the incidence of sepsis nor the combined outcome of death or discharge to hospice changed significantly between 2009-2014. The findings also suggest that EHR-based clinical data provide more objective estimates than claims-based data for sepsis surveillance. AU - Rhee, Chanu AU - Dantes, Raymund AU - Epstein, Lauren AU - Murphy, David J. AU - Seymour, Christopher W. AU - Iwashyna, Theodore J. AU - Kadri, Sameer S. AU - Angus, Derek C. AU - Danner, Robert L. AU - Fiore, Anthony E. AU - Jernigan, John A. AU - Martin, Greg S. AU - Septimus, Edward AU - Warren, David K. AU - Karcz, Anita AU - Chan, Christina AU - Menchaca, John T. AU - Wang, Rui AU - Gruber, Susan AU - Klompas, Michael DA - 2017/10// DO - 10.1001/JAMA.2017.13836 IS - 13 PB - American Medical Association PY - 2017 SP - 1241 EP - 1241 TI - Incidence and Trends of Sepsis in US Hospitals Using Clinical vs Claims Data, 2009-2014 T2 - JAMA UR - /pmc/articles/PMC5710396/ UR - /pmc/articles/PMC5710396/?report=abstract UR - https://www-ncbi-nlm-nih-gov.ez.urosario.edu.co/pmc/articles/PMC5710396/ VL - 318 ER - TY - JOUR AB - Objective: To better define the incidence of sepsis and the characteristics of critically ill patients in European intensive care units. Design: Cohort, multiple-center, observational study. Setting: One hundred and ninety-eight intensive care units in 24 European countries. Patients: All new adult admissions to a participating intensive care unit between May 1 and 15, 2002. Interventions: None. Measurements and Main Results: Demographic data, comorbid diseases, and clinical and laboratory data were collected prospectively. Patients were followed up until death, until hospital discharge, or for 60 days. Of 3,147 adult patients, with a median age of 64 yrs, 1,177 (37.4%) had sepsis; 777 (24.7%) of these patients had sepsis on admission. In patients with sepsis, the lung was the most common site of infection (68%), followed by the abdomen (22%). Cultures were positive in 60% of the patients with sepsis. The most common organisms were Staphylococcus aureus (30%, including 14% methicillin-resistant), Pseudomonas species (14%), and Escherichia coli (13%). Pseudomonas species was the only microorganism independently associated with increased mortality rates. Patients with sepsis had more severe organ dysfunction, longer intensive care unit and hospital lengths of stay, and higher mortality rate than patients without sepsis. In patients with sepsis, age, positive fluid balance, septic shock, cancer, and medical admission were the important prognostic variables for intensive care unit mortality. There was considerable variation between countries, with a strong correlation between the frequency of sepsis and the intensive care unit mortality rates in each of these countries. Conclusions: This large pan-European study documents the high frequency of sepsis in critically ill patients and shows a close relationship between the proportion of patients with sepsis and the intensive care unit mortality in the various countries. In addition to age, a positive fluid balance was among the strongest prognostic factors for death. Patients with intensive care unit acquired sepsis have a worse outcome despite similar severity scores on intensive care unit admission. Copyright © 2006 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. AU - Vincent, Jean Louis AU - Sakr, Yasser AU - Sprung, Charles L. AU - Ranieri, V. Marco AU - Reinhart, Konrad AU - Gerlach, Herwig AU - Moreno, Rui AU - Carlet, Jean AU - Le Gall, Jean Roger AU - Payen, Didier DO - 10.1097/01.CCM.0000194725.48928.3A IS - 2 PB - Lippincott Williams and Wilkins PY - 2006 SP - 344 EP - 353 TI - Sepsis in European intensive care units: Results of the SOAP study T2 - Critical Care Medicine VL - 34 ER - TY - JOUR AB - The user has requested enhancement of the downloaded file. AU - Acta colombiana de cuidado intensivo PY - 2011 TI - Primer consenso colombiano en lesión renal aguda ER - TY - JOUR AB - Objective. Multicenter study oriented at establishing the incidence and prognosis of acute kidney failure (AKF) in the ICU of our country. Material and methods. Prospective study of adult patients admitted over 8 months in 43 Spanish ICUs to detect AKF defined as creatinine ≥ 2 mg/dl or diuresis < 400 ml/24 hours (in chronic patients 100% increase of creatinine, excluding those with baseline creatinine ≥ 4 mg/dl). Results. 901 episodes of AKF (AKF episodes (incidence 5.7%), 55% of which occurred on admission. A total of 38.4% of the episodes were due to acute tubular necrosis (ATN), 36.6% to prerenal, and 21.2% to mixed. Renal depuration (RC) was required in 38%. Mortality was 42.3% during the AKF episode (34.1% in those who were admitted with AKF versus 50.9% in those who developed it after admission), 80% in patients with Hepatorenal Syndrome, 51.6% in ATN and 29.9% in prerenal. We detect an independent relationship with mortality for age (OR 1.03), background of diabetes (OR 2.06), development of AKF in the ICU (OR 2.51), oliguria (OR 5.76) and RC (OR 2.32). Recovery of the kidney function occurred in 85.6% of the survivors and RC was maintained in only 1.1% on discharge from the ICU. We calculated the area under the curve of APACHE II on admission (0.62), SOFA on onset of AKF (0.68), Lian∼o index (0.7) and maximum SOFA (0.79). Conclusions. AKF in ICU patients does not show an elevated incidence but does have high mortality, presenting greater seriousness when it appears after admission. However, recovery is elevated in patients who survive. The usual prognostic indexes are not exact in this patient group, the ISA and maximum SOFA being those which shows a closer relationship with mortality. AU - Herrera-Gutiérrez, M. E. AU - Seller-Pérez, G. AU - Maynar-Moliner, J. AU - Sánchez-Izquierdo-Riera, J. A. DO - 10.1016/S0210-5691(06)74522-3 IS - 6 KW - Acute kidney failure KW - Epidemiology KW - ICU KW - Mortality PB - Ediciones Doyma, S.L. PY - 2006 SP - 260 EP - 267 TI - Epidemiología del fracaso renal agudo en las UCI Españolas. Estudio prospectivo multicéntrico FRAMI T2 - Medicina Intensiva VL - 30 ER - TY - JOUR AB - ContextAlthough acute renal failure (ARF) is believed to be common in the setting of critical illness and is associated with a high risk of death, little is known about its epidemiology and outcome or how these vary in different regions of the world.ObjectivesTo determine the period prevalence of ARF in intensive care unit (ICU) patients in multiple countries; to characterize differences in etiology, illness severity, and clinical practice; and to determine the impact of these differences on patient outcomes.Design, Setting, and PatientsProspective observational study of ICU patients who either were treated with renal replacement therapy (RRT) or fulfilled at least 1 of the predefined criteria for ARF from September 2000 to December 2001 at 54 hospitals in 23 countries.Main Outcome MeasuresOccurrence of ARF, factors contributing to etiology, illness severity, treatment, need for renal support after hospital discharge, and hospital mortality.ResultsOf 29 269 critically ill patients admitted during the study period, 1738 (5.7%; 95% confidence interval [CI], 5.5%-6.0%) had ARF during their ICU stay, including 1260 who were treated with RRT. The most common contributing factor to ARF was septic shock (47.5%; 95% CI, 45.2%-49.5%). Approximately 30% of patients had preadmission renal dysfunction. Overall hospital mortality was 60.3% (95% CI, 58.0%-62.6%). Dialysis dependence at hospital discharge was 13.8% (95% CI, 11.2%-16.3%) for survivors. Independent risk factors for hospital mortality included use of vasopressors (odds ratio [OR], 1.95; 95% CI, 1.50-2.55; P<.001), mechanical ventilation (OR, 2.11; 95% CI, 1.58-2.82; P<.001), septic shock (OR, 1.36; 95% CI, 1.03-1.79; P = .03), cardiogenic shock (OR, 1.41; 95% CI, 1.05-1.90; P = .02), and hepatorenal syndrome (OR, 1.87; 95% CI, 1.07-3.28; P = .03).ConclusionIn this multinational study, the period prevalence of ARF requiring RRT in the ICU was between 5% and 6% and was associated with a high hospital mortality rate. AU - Uchino, Shigehiko AU - Kellum, John A. AU - Bellomo, Rinaldo AU - Doig, Gordon S. AU - Morimatsu, Hiroshi AU - Morgera, Stanislao AU - Schetz, Miet AU - Tan, Ian AU - Bouman, Catherine AU - Macedo, Ettiene AU - Gibney, Noel AU - Tolwani, Ashita AU - Ronco, Claudio DA - 2005/8// DO - 10.1001/JAMA.294.7.813 IS - 7 KW - cardiogenic shock KW - critical illness KW - dialysis procedure KW - epidemiology KW - hemodialysis KW - hepatorenal syndrome KW - intensive care unit KW - kidney KW - kidney failure KW - mechanical ventilation KW - patient discharge KW - renal failure, acute KW - renal replacement therapy KW - septic shock KW - survivors KW - vasoconstrictor agents PB - American Medical Association PY - 2005 SP - 813 EP - 818 TI - Acute Renal Failure in Critically Ill Patients: A Multinational, Multicenter Study T2 - JAMA UR - https://jamanetwork.com/journals/jama/fullarticle/201386 VL - 294 ER - TY - JOUR AB - ABSTRACT. Acute renal failure (ARF) is a common complication in intensive care unit (ICU) patients. Although there are several reports on outcome of septic patients with ARF, there are no data regarding predisposing factors for ARF. Therefore, the incidence of ARF was investigated in 185 sepsis patients admitted in a surgical ICU during a 16-mo period. Variables predisposing to ARF on day 1 of sepsis were evaluated with univariate and multivariable analyses. APACHE II and SOFA scores were compared during a 14-d period. Additionally, the impact of organ failure on mortality was evaluated. ARF developed in 16.2% of the patients, and 70.0% of these needed renal replacement therapy (RRT). Patients with ARF were more severely ill and had a higher mortality. Remarkably, serum creatinine was already increased on day 1. Creatinine > 1 mg/dl and pH < 7.30, both on day 1 of sepsis, were independently associated with ARF. Age, need for vasoactive therapy, mechanical ventilation, and RRT, but not ARF itself, were associated with mortality. In conclusion, ARF was a frequent complication in sepsis. Sepsis patients with ARF were more severely ill and had a higher mortality. Need for RRT was independently associated with mortality. A simple risk model for ARF, on basis of two readily available parameters on day 1 of sepsis, was developed. This model allows initiating specific therapeutic measures earlier in the course of sepsis, hopefully resulting in a lower incidence of ARF and needi for RRT, thereby lowering mortality. E-mail: erik.hoste@rug.ac.be AU - Hoste, Eric A.J. AU - Lameire, Norbert H. AU - Vanholder, Raymond C. AU - Benoit, Dominique D. AU - Decruyenaere, Johan M.A. AU - Colardyn, Francis A. DA - 2003/4// DO - 10.1097/01.ASN.0000059863.48590.E9 IS - 4 PB - American Society of Nephrology PY - 2003 SP - 1022 EP - 1030 TI - Acute Renal Failure in Patients with Sepsis in a Surgical ICU: Predictive Factors, Incidence, Comorbidity, and Outcome T2 - Journal of the American Society of Nephrology UR - https://jasn.asnjournals.org/content/14/4/1022 UR - https://jasn.asnjournals.org/content/14/4/1022.abstract VL - 14 ER - TY - JOUR AU - Sharkey, RA AU - Mulloy, EM AU - O'Neill, SJ IS - 3 PY - 1998 TI - Acute effects of hypoxaemia, hyperoxaemia and hypercapnia on renal blood flow in normal and renal transplant subjects T2 - European Respiratory Journal VL - 12 ER - TY - JOUR AB - Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. AU - Zhou, Fei AU - Yu, Ting AU - Du, Ronghui AU - Fan, Guohui AU - Liu, Ying AU - Liu, Zhibo AU - Xiang, Jie AU - Wang, Yeming AU - Song, Bin AU - Gu, Xiaoying AU - Guan, Lulu AU - Wei, Yuan AU - Li, Hui AU - Wu, Xudong AU - Xu, Jiuyang AU - Tu, Shengjin AU - Zhang, Yi AU - Chen, Hua AU - Cao, Bin DO - 10.1016/S0140-6736(20)30566-3 PY - 2020 TI - Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study T2 - www.thelancet.com UR - https://doi.org/10.1016/ VL - 395 ER - TY - JOUR AB -Acute renal impairment in coronavirus-associated severe acute respiratory syndrome.
Severe acute respiratory syndrome (SARS) is a newly emerged infection from a novel coronavirus (SARS-CoV). Apart from fever and respiratory complications, acute renal impairment has been observed in some patients with SARS. Herein, we describe the clinical, pathologic, and laboratory features of the acute renal impairment complicating this new viral infection.
We conducted a retrospective analysis of the plasma creatinine concentration and other clinical parameters of the 536 SARS patients with normal plasma creatinine at first clinical presentation, admitted to two regional hospitals following a major outbreak in Hong Kong in March 2003. Kidney tissues from seven other patients with postmortem examinations were studied by light microscopy and electron microscopy.
Among these 536 patients with SARS, 36 (6.7%) developed acute renal impairment occurring at a median duration of 20 days (range 5–48 days) after the onset of viral infection despite a normal plasma creatinine level at first clinical presentation. The acute renal impairment reflected the different prerenal and renal factors that exerted renal insult occurring in the context of multiorgan failure. Eventually, 33 SARS patients (91.7%) with acute renal impairment died. The mortality rate was significantly higher among patients with SARS and acute renal impairment compared with those with SARS and no renal impairment (91.7% vs. 8.8%) (P < 0.0001). Renal tissues revealed predominantly acute tubular necrosis with no evidence of glomerular pathology. The adjusted relative risk of mortality associated with the development of acute renal impairment was 4.057 (P < 0.001). By multivariate analysis, acute respiratory distress syndrome and age were the most significant independent risk factors predicting the development of acute renal impairment in SARS.
Acute renal impairment is uncommon in SARS but carries a high mortality. The acute renal impairment is likely to be related to multi-organ failure rather than the kidney tropism of the virus. The development of acute renal impairment is an important negative prognostic indicator for survival with SARS.
AU - Chu, Kwok Hong AU - Tsang, Wai Kay AU - Tang, Colin S. AU - Lam, Man Fai AU - Lai, Fernand M. AU - To, Ka Fai AU - Fung, Ka Shun AU - Tang, Hon Lok AU - Yan, Wing Wa AU - Chan, Hilda W.H. AU - Lai, Thomas S.T. AU - Tong, Kwoic Lung AU - Lai, Kar Neng DA - 2005/2// DO - 10.1111/J.1523-1755.2005.67130.X IS - 2 KW - acute renal failure KW - acute respiratory distress syndrome KW - acute tubular necrosis KW - coronavirus KW - mortality KW - severe acute respiratory syndrome PB - Elsevier PY - 2005 SP - 698 EP - 705 TI - Acute renal impairment in coronavirus-associated severe acute respiratory syndrome T2 - Kidney International UR - http://www.kidney-international.org/article/S0085253815505061/fulltext UR - http://www.kidney-international.org/article/S0085253815505061/abstract UR - https://www.kidney-international.org/article/S0085-2538(15)50506-1/abstract VL - 67 ER - TY - JOUR AB - Importance: In December 2019, novel coronavirus (2019-nCoV)-infected pneumonia (NCIP) occurred in Wuhan, China. The number of cases has increased rapidly but information on the clinical characteristics of affected patients is limited. Objective: To describe the epidemiological and clinical characteristics of NCIP. Design, Setting, and Participants: Retrospective, single-center case series of the 138 consecutive hospitalized patients with confirmed NCIP at Zhongnan Hospital of Wuhan University in Wuhan, China, from January 1 to January 28, 2020; final date of follow-up was February 3, 2020. Exposures: Documented NCIP. Main Outcomes and Measures: Epidemiological, demographic, clinical, laboratory, radiological, and treatment data were collected and analyzed. Outcomes of critically ill patients and noncritically ill patients were compared. Presumed hospital-related transmission was suspected if a cluster of health professionals or hospitalized patients in the same wards became infected and a possible source of infection could be tracked. Results: Of 138 hospitalized patients with NCIP, the median age was 56 years (interquartile range, 42-68; range, 22-92 years) and 75 (54.3%) were men. Hospital-associated transmission was suspected as the presumed mechanism of infection for affected health professionals (40 [29%]) and hospitalized patients (17 [12.3%]). Common symptoms included fever (136 [98.6%]), fatigue (96 [69.6%]), and dry cough (82 [59.4%]). Lymphopenia (lymphocyte count, 0.8 × 109/L [interquartile range {IQR}, 0.6-1.1]) occurred in 97 patients (70.3%), prolonged prothrombin time (13.0 seconds [IQR, 12.3-13.7]) in 80 patients (58%), and elevated lactate dehydrogenase (261 U/L [IQR, 182-403]) in 55 patients (39.9%). Chest computed tomographic scans showed bilateral patchy shadows or ground glass opacity in the lungs of all patients. Most patients received antiviral therapy (oseltamivir, 124 [89.9%]), and many received antibacterial therapy (moxifloxacin, 89 [64.4%]; ceftriaxone, 34 [24.6%]; azithromycin, 25 [18.1%]) and glucocorticoid therapy (62 [44.9%]). Thirty-six patients (26.1%) were transferred to the intensive care unit (ICU) because of complications, including acute respiratory distress syndrome (22 [61.1%]), arrhythmia (16 [44.4%]), and shock (11 [30.6%]). The median time from first symptom to dyspnea was 5.0 days, to hospital admission was 7.0 days, and to ARDS was 8.0 days. Patients treated in the ICU (n = 36), compared with patients not treated in the ICU (n = 102), were older (median age, 66 years vs 51 years), were more likely to have underlying comorbidities (26 [72.2%] vs 38 [37.3%]), and were more likely to have dyspnea (23 [63.9%] vs 20 [19.6%]), and anorexia (24 [66.7%] vs 31 [30.4%]). Of the 36 cases in the ICU, 4 (11.1%) received high-flow oxygen therapy, 15 (41.7%) received noninvasive ventilation, and 17 (47.2%) received invasive ventilation (4 were switched to extracorporeal membrane oxygenation). As of February 3, 47 patients (34.1%) were discharged and 6 died (overall mortality, 4.3%), but the remaining patients are still hospitalized. Among those discharged alive (n = 47), the median hospital stay was 10 days (IQR, 7.0-14.0). Conclusions and Relevance: In this single-center case series of 138 hospitalized patients with confirmed NCIP in Wuhan, China, presumed hospital-related transmission of 2019-nCoV was suspected in 41% of patients, 26% of patients received ICU care, and mortality was 4.3%. AU - Wang, Dawei AU - Hu, Bo AU - Hu, Chang AU - Zhu, Fangfang AU - Liu, Xing AU - Zhang, Jing AU - Wang, Binbin AU - Xiang, Hui AU - Cheng, Zhenshun AU - Xiong, Yong AU - Zhao, Yan AU - Li, Yirong AU - Wang, Xinghuan AU - Peng, Zhiyong DA - 2020/3// DO - 10.1001/JAMA.2020.1585 IS - 11 PB - American Medical Association PY - 2020 SP - 1061 EP - 1061 TI - Clinical Characteristics of 138 Hospitalized Patients With 2019 Novel Coronavirus–Infected Pneumonia in Wuhan, China T2 - JAMA UR - /pmc/articles/PMC7042881/ UR - /pmc/articles/PMC7042881/?report=abstract UR - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042881/ VL - 323 ER - TY - JOUR AB -The US is currently an epicenter of the coronavirus disease 2019 (COVID-19) pandemic, yet few national data are available on patient characteristics, treatment, and outcomes of critical illness from COVID-19.
To assess factors associated with death and to examine interhospital variation in treatment and outcomes for patients with COVID-19.
This multicenter cohort study assessed 2215 adults with laboratory-confirmed COVID-19 who were admitted to intensive care units (ICUs) at 65 hospitals across the US from March 4 to April 4, 2020.
Patient-level data, including demographics, comorbidities, and organ dysfunction, and hospital characteristics, including number of ICU beds.
The primary outcome was 28-day in-hospital mortality. Multilevel logistic regression was used to evaluate factors associated with death and to examine interhospital variation in treatment and outcomes.
A total of 2215 patients (mean [SD] age, 60.5 [14.5] years; 1436 [64.8%] male; 1738 [78.5%] with at least 1 chronic comorbidity) were included in the study. At 28 days after ICU admission, 784 patients (35.4%) had died, 824 (37.2%) were discharged, and 607 (27.4%) remained hospitalized. At the end of study follow-up (median, 16 days; interquartile range, 8-28 days), 875 patients (39.5%) had died, 1203 (54.3%) were discharged, and 137 (6.2%) remained hospitalized. Factors independently associated with death included older age (≥80 vs <40 years of age: odds ratio [OR], 11.15; 95% CI, 6.19-20.06), male sex (OR, 1.50; 95% CI, 1.19-1.90), higher body mass index (≥40 vs <25: OR, 1.51; 95% CI, 1.01-2.25), coronary artery disease (OR, 1.47; 95% CI, 1.07-2.02), active cancer (OR, 2.15; 95% CI, 1.35-3.43), and the presence of hypoxemia (Pao2:Fio2<100 vs ≥300 mm Hg: OR, 2.94; 95% CI, 2.11-4.08), liver dysfunction (liver Sequential Organ Failure Assessment score of 2-4 vs 0: OR, 2.61; 95% CI, 1.30–5.25), and kidney dysfunction (renal Sequential Organ Failure Assessment score of 4 vs 0: OR, 2.43; 95% CI, 1.46–4.05) at ICU admission. Patients admitted to hospitals with fewer ICU beds had a higher risk of death (<50 vs ≥100 ICU beds: OR, 3.28; 95% CI, 2.16-4.99). Hospitals varied considerably in the risk-adjusted proportion of patients who died (range, 6.6%-80.8%) and in the percentage of patients who received hydroxychloroquine, tocilizumab, and other treatments and supportive therapies.
This study identified demographic, clinical, and hospital-level risk factors that may be associated with death in critically ill patients with COVID-19 and can facilitate the identification of medications and supportive therapies to improve outcomes.
AU - Gupta, Shruti AU - Hayek, Salim S. AU - Wang, Wei AU - Chan, Lili AU - Mathews, Kusum S. AU - Melamed, Michal L. AU - Brenner, Samantha K. AU - Leonberg-Yoo, Amanda AU - Schenck, Edward J. AU - Radbel, Jared AU - Reiser, Jochen AU - Bansal, Anip AU - Srivastava, Anand AU - Zhou, Yan AU - Sutherland, Anne AU - Green, Adam AU - Shehata, Alexandre M. AU - Goyal, Nitender AU - Vijayan, Anitha AU - Velez, Juan Carlos Q. AU - Shaefi, Shahzad AU - Parikh, Chirag R. AU - Arunthamakun, Justin AU - Athavale, Ambarish M. AU - Friedman, Allon N. AU - Short, Samuel A. P. AU - Kibbelaar, Zoe A. AU - Omar, Samah Abu AU - Admon, Andrew J. AU - Donnelly, John P. AU - Gershengorn, Hayley B. AU - Hernán, Miguel A. AU - Semler, Matthew W. AU - Leaf, David E. AU - Investigators, STOP-COVID AU - Walther, Carl P AU - Anumudu, Samaya J AU - Kopecky, Kathleen F AU - Milligan, Gregory P AU - McCullough, Peter A AU - Nguyen, Thuy-Duyen AU - Krajewski, Megan L AU - Shankar, Sidharth AU - Pannu, Ameeka AU - Valencia, Juan D AU - Waikar, Sushrut S AU - Hart, Peter AU - Ajiboye, Oyintayo AU - Itteera, Matthew AU - Rachoin, Jean-Sebastien AU - Schorr, Christa A AU - Shea, Lisa AU - Edmonston, Daniel L AU - Mosher, Christopher L AU - Karp, Aaron AU - Cohen, Zaza AU - Allusson, Valerie AU - Bambrick-Santoyo, Gabriela AU - Bhatti, Noor ul aain AU - Mehta, Bijal AU - Williams, Aquino AU - Walters, Patricia AU - Go, Rolando C AU - Rose, Keith M AU - Zhou, Amy M AU - Kim, Ethan C AU - Lisk, Rebecca AU - Coca, Steven G AU - Altman, Deena R AU - Saha, Aparna AU - Soh, Howard AU - Wen, Huei Hsun AU - Bose, Sonali AU - Leven, Emily A AU - Wang, Jing G AU - Mosoyan, Gohar AU - Nadkarni, Girish N AU - Guirguis, John AU - Kapoor, Rajat AU - Meshberger, Christopher AU - Garibaldi, Brian T AU - Corona-Villalobos, Celia P AU - Wen, Yumeng AU - Menez, Steven AU - Malik, Rubab F AU - Cervantes, Carmen Elena AU - Gautam, Samir C AU - Nguyen, H Byrant AU - Ahoubim, Afshin AU - Thomas, Leslie F AU - Sirganagari, Dheeraj Reddy AU - Guru, Pramod K AU - Bergl, Paul A AU - Rodriguez, Jesus AU - Shah, Jatan A AU - Gupta, Mrigank S AU - Kumar, Princy N AU - Lazarous, Deepa G AU - Kassaye, Seble G AU - Johns, Tanya S AU - Mocerino, Ryan AU - Prudhvi, Kalyan AU - Zhu, Denzel AU - Levy, Rebecca V AU - Azzi, Yorg AU - Fisher, Molly AU - Yunes, Milagros AU - Sedaliu, Kaltrina AU - Golestaneh, Ladan AU - Brogan, Maureen AU - Raichoudhury, Ritesh AU - Cho, Soo Jung AU - Plataki, Maria AU - Alvarez-Mulett, Sergio L AU - Gomez-Escobar, Luis G AU - Pan, Di AU - Lee, Stefi AU - Kirshnan, Jamuna AU - Whalen, William AU - Charytan, David AU - Macina, Ashley AU - Ross, Daniel W AU - Leidner, Alexander S AU - Martinez, Carlos AU - Kruser, Jacqueline M AU - Wunderink, Richard G AU - Hodakowski, Alexander J AU - Price-Haywood, Eboni G AU - Matute-Trochez, Luis A AU - Hasty, Anne E AU - Mohamed, Muner MB AU - Avasare, Rupali S AU - Zonies, David AU - Baron, Rebecca M AU - Sise, Meghan E AU - Newman, Erik T AU - Pokharel, Kapil K AU - Sharma, Shreyak AU - Singh, Harkarandeep AU - Correa, Simon AU - Shaukat, Tanveer AU - Kamal, Omer AU - Yang, Heather AU - Boateng, Jeffery O AU - Lee, Meghan AU - Strohbehn, Ian A AU - Li, Jiahua AU - Muhsin, Saif A AU - Mandel, Ernest I AU - Mueller, Ariel L AU - Cairl, Nicholas S AU - Rowan, Chris AU - Madhai-Lovely, Farah AU - Peev, Vasil AU - Byun, John J AU - Vissing, Andrew AU - Kapania, Esha M AU - Post, Zoe AU - Patel, Nilam P AU - Hermes, Joy-Marie AU - Patrawalla, Amee AU - Finkel, Diana G AU - Danek, Barbara A AU - Arikapudi, Sowminya AU - Paer, Jeffery M AU - Puri, Sonika AU - Sunderram, Jag AU - Scharf, Matthew T AU - Ahmed, Ayesha AU - Berim, Ilya AU - Hussain, Sabiha AU - Anand, Shuchi AU - Levitt, Joseph E AU - Garcia, Pablo AU - Boyle, Suzanne M AU - Song, Rui AU - Zhang, Jingjing AU - Sharshir, Moh'd A AU - Rusnak, Vadym V AU - Podoll, Amber S AU - Chonchol, Michel AU - Sharma, Sunita AU - Burnham, Ellen L AU - Rashidi, Arash AU - Hejal, Rana AU - Judd, Erik T AU - Latta, Laura AU - Tolwani, Ashita AU - Albertson, Timothy E AU - Adams, Jason Y AU - Chang, Steven Y AU - Beutler, Rebecca M AU - Schulze, Carl E AU - Macedo, Etienne AU - Rhee, Harin AU - Liu, Kathleen D AU - Jotwani, Vasantha K AU - Koyner, Jay L AU - Shah, Chintan V AU - Jaikaransingh, Vishal AU - Toth-Manikowski, Stephanie M AU - Joo, Min J AU - Lash, James P AU - Neyra, Javier A AU - Chaaban, Nourhan AU - Iardino, Alfredo AU - Au, Elizabeth H AU - Sharma, Jill H AU - Sosa, Marie Anne AU - Taldone, Sabrina AU - Contreras, Gabriel AU - Zerda, David De La AU - Blakely, Pennelope AU - Berlin, Hanna AU - Azam, Tariq U AU - Shadid, Husam AU - Pan, Michael AU - O'Hayer, Patrick AU - Meloche, Chelsea AU - Feroze, Rafey AU - Padalia, Kishan J AU - Bitar, Abbas AU - Flythe, Jennifer E AU - Tugman, Matthew J AU - Brown, Brent R AU - Spiardi, Ryan C AU - Miano, Todd A AU - Roche, Meaghan S AU - Vasquez, Charles R AU - Bansal, Amar D AU - Ernecoff, Natalie C AU - Kovesdy, Csaba P AU - Molnar, Miklos Z AU - Azhar, Ambreen AU - Hedayati, Susan S AU - Nadamuni, Mridula V AU - Khan, Sadaf S AU - Willett, Duwayne L AU - Renaghan, Amanda D AU - Bhatraju, Pavan K AU - Malik, Bilal A AU - Joy, Christina Mariyam AU - Li, Tingting AU - Goldberg, Seth AU - Kao, Patricia F AU - Schumaker, Greg L AU - Faugno, Anthony J AU - Hsu, Caroline M AU - Tariq, Asma AU - Meyer, Leah AU - Weiner, Daniel E AU - Christov, Marta AU - Wilson, Francis P AU - Arora, Tanima AU - Ugwuowo, Ugochukwu DA - 2020/11// DO - 10.1001/JAMAINTERNMED.2020.3596 IS - 11 KW - beds KW - cancer KW - coronary arteriosclerosis KW - covid-19 KW - critical illness KW - intensive care unit KW - organ failure PB - American Medical Association PY - 2020 SP - 1436 EP - 1447 TI - Factors Associated With Death in Critically Ill Patients With Coronavirus Disease 2019 in the US T2 - JAMA Internal Medicine UR - https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2768602 VL - 180 ER - TY - JOUR AB -study objective: To determine the pathogenesis and clinical course of lactic acidosis in adults receiving standard medical care.
design: Placebo arm of a 5-year prospective, randomized, blinded study comparing placebo and dichloroacetate as specific lactate-lowering therapy. Each patient received intravenous saline placebo in addition to conventional therapy.
setting: Intensive care units of 10 tertiary care hospitals in North America.
patients: One hundred twenty-six patients with lactic acidosis, defined as arterial blood lactate greater than or equal to 5 mmol/L and either arterial pH of less than or equal to 7.35 or base deficit greater than 6mmol/L. Patients were followed for up to 6 months.
measurements and main results: Mean ± SD demographic entry data for 126 patients included: age 56 ± 17 years, lactate 10.4 ± 5.5 mmol/L, pH 7.24 ± 0.14, calculated base deficit 14.1 ± 5.4, arterial systolic blood pressure 103 ± 29 mm Hg, Glasgow Coma score 7.9 ± 4.9, and APACHE II score 19.2 ± 8.1. Despite fluids and pressors, 32% of patients had systolic blood pressures of less than or equal to 90 mm Hg in association with sepsis (59%), cardiac failure (18%), or hemorrhage (18%). The most common causes of lactic acidosis in the absence of shock were sepsis (49%), liver disease (15%), and respiratory failure (12%). The median survival was 38.5 hours. Survival at 24 hours was 59%. Arterial pH predicted 24-hour survival better than base deficit or bicarbonate level. Percent survival was 41% at 3 days and 17% at 30 days. Only 21% of patients survived to leave the intensive care unit, and 17% were discharged from the hospital. In patients receiving sodium bicarbonate, neither acid-base nor hemodynamic status improved.
conclusions: In this first prospective study of the clinical course of acute lactic acidosis in adults, nearly all subjects had both hemodynamic and nonhemodynamic (metabolic) underlying causes, many of which independently predicted survival and most of which were refractory to standard care.
AU - Stacpoole, Peter W. AU - Wright, Elizabeth C. AU - Baumgartner, Thomas G. AU - Bersin, Robert M. AU - Buchalter, Scott AU - Curry, Stephen H. AU - Duncan, Charles AU - Harman, Eloise M. AU - Henderson, George N. AU - Jenkinson, Steven AU - Lachin, John M. AU - Lorenz, Anthea AU - Schneider, Stephen H. AU - Siegel, John H. AU - Summer, Warren R. AU - Thompson, Douglas AU - Wolfe, Christopher L. AU - Zorovich, Barbara DA - 1994/7// DO - 10.1016/0002-9343(94)90047-7 IS - 1 PB - Elsevier PY - 1994 SP - 47 EP - 54 TI - Natural history and course of acquired lactic acidosis in adults T2 - The American Journal of Medicine UR - http://www.amjmed.com/article/0002934394900477/fulltext UR - http://www.amjmed.com/article/0002934394900477/abstract UR - https://www.amjmed.com/article/0002-9343(94)90047-7/abstract VL - 97 ER - TY - JOUR AB - Introduction: Higher lactate concentrations within the normal reference range (relative hyperlactatemia) are not considered clinically significant. We tested the hypothesis that relative hyperlactatemia is independently associated with an increased risk of hospital death.Methods: This observational study examined a prospectively obtained intensive care database of 7,155 consecutive critically ill patients admitted to the Intensive Care Units (ICUs) of four Australian university hospitals. We assessed the relationship between ICU admission lactate, maximal lactate and time-weighted lactate levels and hospital outcome in all patients and also in those patients whose lactate concentrations (admission n = 3,964, maximal n = 2,511, and time-weighted n = 4,584) were under 2 mmol.L-1(i.e. relative hyperlactatemia).Results: We obtained 172,723 lactate measurements. Higher admission and time-weightedlactate concentration within the reference range was independently associated with increased hospital mortality (admission odds ratio (OR) 2.1, 95% confidence interval (CI) 1.3 to 3.5, P = 0.01; time-weighted OR 3.7, 95% CI 1.9 to 7.00, P < 0.0001). This significant association was first detectable at lactate concentrations > 0.75 mmol.L-1. Furthermore, in patients whose lactate ever exceeded 2 mmol.L-1, higher time-weighted lactate remained strongly associated with higher hospital mortality (OR 4.8, 95% CI 1.8 to 12.4, P < 0.001).Conclusions: In critically ill patients, relative hyperlactataemia is independently associated with increased hospital mortality. Blood lactate concentrations > 0.75 mmol.L-1can be used by clinicians to identify patients at higher risk of death. The current reference range for lactate in the critically ill may need to be re-assessed. © 2010 Nichol et al.; licensee BioMed Central Ltd. AU - Nichol, Alistair D. AU - Egi, Moritoki AU - Pettila, Ville AU - Bellomo, Rinaldo AU - French, Craig AU - Hart, Graeme AU - Davies, Andrew AU - Stachowski, Edward AU - Reade, Michael C. AU - Bailey, Michael AU - Cooper, David James DA - 2010/2// DO - 10.1186/CC8888 IS - 1 PB - BioMed Central PY - 2010 SP - R25 EP - R25 TI - Relative hyperlactatemia and hospital mortality in critically ill patients: a retrospective multi-centre study T2 - Critical Care UR - /pmc/articles/PMC2875540/ UR - /pmc/articles/PMC2875540/?report=abstract UR - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2875540/ VL - 14 ER - TY - JOUR AB - Background: To evaluate the ability of the central venous-to-arterial CO2 content and tension differences to arteriovenous oxygen content difference ratios (∆ContCO2/∆ContO2 and ∆PCO2/∆ContO2, respectively), blood lactate concentration, and central venous oxygen saturation (ScvO2) to detect the presence of global anaerobic metabolism through the increase in oxygen consumption (VO2) after an acute increase in oxygen supply (DO2) induced by volume expansion (VO2/DO2 dependence). Methods: We prospectively studied 98 critically ill mechanically ventilated patients in whom a fluid challenge was decided due to acute circulatory failure related to septic shock. Before and after volume expansion (500 mL of colloid solution), we measured cardiac index, VO2, DO2, ∆ContCO2/∆ContO2 and ∆PCO2/∆ContO2 ratios, lactate, and ScvO2. Fluid-responders were defined as a ≥15 % increase in cardiac index. Areas under the receiver operating characteristic curves (AUC) were determined for these variables. Results: Fifty-one patients were fluid-responders (52 %). DO2 increased significantly (31 ± 12 %) in these patients. An increase in VO2 ≥ 15 % (“VO2-responders”) concurrently occurred in 57 % of the 51 fluid-responders (45 ± 16 %). Compared with VO2-non-responders, VO2-responders were characterized by higher lactate levels and higher ∆ContCO2/∆ContO2 and ∆PCO2/∆ContO2 ratios. At baseline, lactate predicted a fluid-induced increase in VO2 ≥ 15 % with AUC of 0.745. Baseline ∆ContCO2/∆ContO2 and ∆PCO2/∆ContO2 ratios predicted an increase of VO2 ≥ 15 % with AUCs of 0.965 and 0.962, respectively. Baseline ScvO2 was not able to predict an increase of VO2 ≥ 15 % (AUC = 0.624). Conclusions: ∆ContCO2/∆ContO2 and ∆PCO2/∆ContO2 ratios are more reliable markers of global anaerobic metabolism than lactate. ScvO2 failed to predict the presence of global tissue hypoxia. AU - Mallat, Jihad AU - Lemyze, Malcolm AU - Meddour, Mehdi AU - Pepy, Florent AU - Gasan, Gaelle AU - Barrailler, Stephanie AU - Durville, Emmanuelle AU - Temime, Johanna AU - Vangrunderbeeck, Nicolas AU - Tronchon, Laurent AU - Vallet, Benoît AU - Thevenin, Didier DA - 2016/12// DO - 10.1186/S13613-016-0110-3 IS - 1 KW - Acute circulatory failure KW - Anaerobic metabolism KW - Lactate KW - Oxygen consumption KW - Septic shock KW - Tissue hypoxia KW - Venous oxygen saturation KW - Venous-to-arterial carbon dioxide difference PB - Springer PY - 2016 SP - 1 EP - 9 TI - Ratios of central venous-to-arterial carbon dioxide content or tension to arteriovenous oxygen content are better markers of global anaerobic metabolism than lactate in septic shock patients T2 - Annals of Intensive Care UR - /pmc/articles/PMC4740480/ UR - /pmc/articles/PMC4740480/?report=abstract UR - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4740480/ VL - 6 ER - TY - JOUR AB -Sepsis is a heterogeneous syndrome. Identification of distinct clinical phenotypes may allow more precise therapy and improve care.
To derive sepsis phenotypes from clinical data, determine their reproducibility and correlation with host-response biomarkers and clinical outcomes, and assess the potential causal relationship with results from randomized clinical trials (RCTs).
Retrospective analysis of data sets using statistical, machine learning, and simulation tools. Phenotypes were derived among 20 189 total patients (16 552 unique patients) who met Sepsis-3 criteria within 6 hours of hospital presentation at 12 Pennsylvania hospitals (2010-2012) using consensuskmeans clustering applied to 29 variables. Reproducibility and correlation with biological parameters and clinical outcomes were assessed in a second database (2013-2014; n = 43 086 total patients and n = 31 160 unique patients), in a prospective cohort study of sepsis due to pneumonia (n = 583), and in 3 sepsis RCTs (n = 4737).
All clinical and laboratory variables in the electronic health record.
Derived phenotype (α, β, γ,and δ) frequency, host-response biomarkers, 28-day and 365-day mortality, and RCT simulation outputs.
The derivation cohort included 20 189 patients with sepsis (mean age, 64 [SD, 17] years; 10 022 [50%] male; mean maximum 24-hour Sequential Organ Failure Assessment [SOFA] score, 3.9 [SD, 2.4]). The validation cohort included 43 086 patients (mean age, 67 [SD, 17] years; 21 993 [51%] male; mean maximum 24-hour SOFA score, 3.6 [SD, 2.0]). Of the 4 derived phenotypes, the α phenotype was the most common (n = 6625; 33%) and included patients with the lowest administration of a vasopressor; in the β phenotype (n = 5512; 27%), patients were older and had more chronic illness and renal dysfunction; in the γ phenotype (n = 5385; 27%), patients had more inflammation and pulmonary dysfunction; and in the δ phenotype (n = 2667; 13%), patients had more liver dysfunction and septic shock. Phenotype distributions were similar in the validation cohort. There were consistent differences in biomarker patterns by phenotype. In the derivation cohort, cumulative 28-day mortality was 287 deaths of 5691 unique patients (5%) for the α phenotype; 561 of 4420 (13%) for the β phenotype; 1031 of 4318 (24%) for the γ phenotype; and 897 of 2223 (40%) for the δ phenotype. Across all cohorts and trials, 28-day and 365-day mortality were highest among the δ phenotype vs the other 3 phenotypes (P < .001). In simulation models, the proportion of RCTs reporting benefit, harm, or no effect changed considerably (eg, varying the phenotype frequencies within an RCT of early goal-directed therapy changed the results from >33% chance of benefit to >60% chance of harm).
In this retrospective analysis of data sets from patients with sepsis, 4 clinical phenotypes were identified that correlated with host-response patterns and clinical outcomes, and simulations suggested these phenotypes may help in understanding heterogeneity of treatment effects. Further research is needed to determine the utility of these phenotypes in clinical care and for informing trial design and interpretation.
AU - Seymour, Christopher W. AU - Kennedy, Jason N. AU - Wang, Shu AU - Chang, Chung Chou H. AU - Elliott, Corrine F. AU - Xu, Zhongying AU - Berry, Scott AU - Clermont, Gilles AU - Cooper, Gregory AU - Gomez, Hernando AU - Huang, David T. AU - Kellum, John A. AU - Mi, Qi AU - Opal, Steven M. AU - Talisa, Victor AU - Van Der Poll, Tom AU - Visweswaran, Shyam AU - Vodovotz, Yoram AU - Weiss, Jeremy C. AU - Yealy, Donald M. AU - Yende, Sachin AU - Angus, Derek C. DA - 2019/5// DO - 10.1001/JAMA.2019.5791 IS - 20 KW - biological markers KW - immune response KW - organ failure KW - phenotype KW - sepsis KW - treatment outcome PB - American Medical Association PY - 2019 SP - 2003 EP - 2017 TI - Derivation, Validation, and Potential Treatment Implications of Novel Clinical Phenotypes for Sepsis T2 - JAMA UR - https://jamanetwork-com.ez.urosario.edu.co/journals/jama/fullarticle/2733996 VL - 321 ER - TY - JOUR AB - Purpose of review: Acute renal failure is a serious condition that affects as many as 20% of ICU patients. The most common causes of acute renal failure in the ICU patient are severe sepsis and septic shock. The mortality of acute renal failure in septic critically ill patients remains high despite our increasing ability to support vital organs. This is partly the result of our poor understanding of the pathogenesis of sepsis-induced renal dysfunction. Accordingly, a review of our current understanding of the pathogenesis of septic acute renal failure is timely and relevant. Recent findings: Throughout the past half century, acute renal failure of acute illness has essentially been considered a hemodynamic disease caused by kidney ischemia, a view derived by findings in animal models. Unfortunately most such models are greatly deficient in that they do not reproduce the high cardiac output, low systemic vascular resistance state typically seen during human sepsis. Furthermore, most models inducing so-called acute tubular necrosis are based on ischemia-reperfusion (renal artery clamping), an event with little relevance to human sepsis. Recent research highlights a new possible and emerging concept for the pathogenesis of septic acute renal failure: acute apoptosis. This concepts fits well with the typical paucity of histologic changes seen in so-called acute tubular necrosis and with growing evidence of a role for apoptosis in organ injury during sepsis and inflammation in general. Furthermore, the authors present evidence that some potential treatments recently shown to affect the mortality of critically ill patients, (activated protein C, intensive insulin treatment, and low-volume mechanical ventilation) might have antiapoptotic activity. Summary: This review suggests that, on the evidence available, septic acute renal failure is more likely to be an immune or toxic state rather than simply a hemodynamic condition. The authors speculate that future insights into its pathogenesis might lead to a paradigm shift away from the concept of acute tubular necrosis, which has never been convincingly shown in sepsis, to that of acute tubular apoptosis. AU - Wan, Li AU - Bellomo, Rinaldo AU - Di Giantomasso, David AU - Ronco, Claudio DA - 2003/12// DO - 10.1097/00075198-200312000-00006 IS - 6 KW - Activated protein C KW - Acute apoptosis KW - Acute renal failure KW - Sepsis PY - 2003 SP - 496 EP - 502 TI - The pathogenesis of septic acute renal failure T2 - Current Opinion in Critical Care VL - 9 ER - TY - JOUR AB - Acute kidney injury (AKI) is common (especially during critical illness), increasing in incidence, and is associated with considerable morbidity and mortality. The Risk, Injury, Failure, Loss, and End-stage renal disease (RIFLE) classification currently provides a standardized estimate of incidence and outcomes from AKI. Despite advances in the understanding of the pathogenesis of human AKI, our ability to assess kidney function is limited and functional impairment poorly correlates with structural injury to the kidneys. Emerging novel biomarkers are, however, likely to further enhance risk stratification, facilitate early diagnosis, enable early enrollment in therapeutic trials, and assess prognosis. Sepsis remains the leading cause of AKI among the critically ill and over the past few years insights into the pathogenesis of AKI in sepsis are beginning to shift attention from renal blood flow to inflammation-mediated organ injury. Emerging evidence suggests that survivors of AKI incur long-term risks for developing chronic kidney disease and end-stage renal disease compared with those without AKI. Despite decades of research, no specific therapy for AKI other than supportive care currently exists and further work is required to better understand the pathogenesis of AKI during critical illness and to develop novel treatments. © 2011 Macmillan Publishers Limited. All rights reserved. AU - Murugan, Raghavan AU - Kellum, John A. DA - 2011/4// DO - 10.1038/NRNEPH.2011.13 IS - 4 PB - NIH Public Access PY - 2011 SP - 209 EP - 209 TI - Acute kidney injury: what’s the prognosis? T2 - Nature reviews. Nephrology UR - /pmc/articles/PMC3547642/ UR - /pmc/articles/PMC3547642/?report=abstract UR - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3547642/ VL - 7 ER - TY - JOUR AB - Purpose of review Sepsis is a common and frequently fatal condition in which mortality has been consistently linked to increasing organ dysfunction. For example, acute kidney injury (AKI) occurs in 40-50% of septic patients and increases mortality six to eight-fold. However, the mechanisms by which sepsis causes organ dysfunction are not well understood and hence current therapy remains reactive and nonspecific. Recent findings Recent studies have challenged the previous notion that organ dysfunction is solely secondary to hypoperfusion, by showing, for example, that AKI occurs in the setting of normal or increased renal blood flow; and that it is characterized not by acute tubular necrosis or apoptosis, but rather by heterogeneous areas of colocalized sluggish peritubular blood flow and tubular epithelial cell oxidative stress. Evidence has also shown that microvascular dysfunction, inflammation, and the metabolic response to inflammatory injury are fundamental pathophysiologic mechanisms that may explain the development of sepsis-induced AKI. Summary The implications of these findings are significant because in the context of decades of negative clinical trials in the field, the recognition that other mechanisms are at play opens the possibility to better understand the processes of injury and repair, and provides an invaluable opportunity to design mechanism-targeted therapeutic interventions. AU - Gomez, Hernando AU - Kellum, John A. DA - 2016/11// DO - 10.1097/MCC.0000000000000356 IS - 6 KW - Acute kidney injury KW - Inflammation KW - Microvascular dysfunction KW - Sepsis KW - Tubular epithelial cells PB - NIH Public Access PY - 2016 SP - 546 EP - 546 TI - Sepsis-induced acute kidney injury T2 - Current opinion in critical care UR - /pmc/articles/PMC5654474/ UR - /pmc/articles/PMC5654474/?report=abstract UR - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5654474/ VL - 22 ER -