Ariella Tomasini

Relationship between the timing of administration of IgM and IgA enriched immunoglobulins in patients with severe sepsis and septic shock and the outcome: a retrospective analysis.

PURPOSE Because the use of IgM and IgA enriched polyclonal intravenous immunoglobulins (eIg) is a standard of care in critically ill patients admitted to our intensive care unit (ICU) with the diagnosis of severe sepsis or septic shock, we investigated if the delay from the onset of severe sepsis and septic shock and their administration could influence the outcome. MATERIALS AND METHODS The medical records of all patients with severe sepsis or septic shock admitted to our ICU from July 2004 through October 2009 and treated with eIg (Pentaglobin®; Biotest, Dreieich, Germany) were retrospectively examined. RESULTS A total of 129 adult patients with severe sepsis or septic shock were considered eligible. Thirty-two percent of patients died during the ICU stay. Survivors were given eIg significantly earlier than nonsurvivors (23 vs 63 hours, P < .05). The delay in the administration of eIg and the Simplified Acute Physiology Score II were the only variables that entered stepwise a propensity score-adjusted logistic model. The delay in the administration of eIg was a significant predictor of the odds of dying during the ICU stay (odds ratio for 1 hour of delay, 1.007; P < .01; 99% confidence interval from 1.001 to 1.010) and proved to be independent from the Simplified Acute Physiology Score II and other variables. CONCLUSIONS The efficacy of eIg, being maximal in early phases of severe sepsis and/or septic shock, is probably time dependent.

Effects of the Volume of Processed Plasma on the Outcome, Arterial Pressure and Blood Procalcitonin Levels in Patients with Severe Sepsis and Septic Shock Treated with Coupled Plasma Filtration and Adsorption

Aims: To understand how coupled plasma filtration and adsorption (CPFA) could influence the time course of the advanced stages of sepsis, mean arterial pressure (MAP) and norepinephrine dosage. Methods: Patients with severe sepsis and septic shock with ≥2 organ failures not responding to volume resuscitation and vasopressor infusion were treated with CPFA within 8 h of admission to the intensive care unit. Results: Thirty-nine patients were treated (median age: 63 years, median SAPS II score: 45) and 28 survived advanced sepsis. In the latter, the median MAP increased and the norepinephrine dosage decreased significantly after CPFA, whereas in the nonsurvivors these values did not change significantly. The volume of treated plasma was significantly higher in survivors than nonsurvivors. Conclusion: These results suggest a possible existence of a dose-response effect for CPFA. Future studies are therefore recommended to evaluate the efficacy of this treatment and to determine its best timing and intensity.

Fatal Septic Shock in a Patient with Hemophagocytic Lymphohistiocytosis Associated with an Infectious Mononucleosis

The authors describe the case of a young woman who developed a clinical pictures resembling a septic shock-related multiple organ dysfunction syndrome a couple of months after having been diagnosed suffering from a hemophagocytic lymphohistiocytosis associated with an infectious mononucleosis. Despite the aggressive treatment, which included antibiotics, vasopressors, IV immunoglobulins, and the use of an extracorporeal device aimed to remove mediators released both during sepsis and the cytokine storm determined by the hemophagocytic lymphohistiocytosis, the patient died. At the autopsy, an extremely uncommon aggressive lymphoma of Epstein-Barr virus-positive T-lymphocytes with systemic involvement was discovered.

Reply to Dr. Vassallo et al. (ms No. 201807012): Regional Citrate Anticoagulation During Coupled Plasma Filtration and Adsorption May Increase Survival in Septic Shock

Dear Sir, We thank Dr. Vassallo et al. for their interesting observations to our study in which we demonstrated that the outcome of a group of septic shock patients treated with the Coupled Plasma-Filtration and Adsorption (CPFA) was influenced by the volume of plasma processed (Vp), and not by the timing of initiation [1]. Dr. Vassallo et al. argue that the use of regional citrate anticoagulation (RCA) instead of intravenous heparin would increase the running time of the CPFA, and consequently the Vp, which is considered a proxy of the intensity of the treatment. Indeed, Dr. Vassallo’s remark makes sense, considering that previous studies demonstrated (a) a dose-effect relationship between the Vp and the outcome, which is better when this variable exceeds 0.20 L/kg/session [2, 3], and (b) the superiority of RCA over intravenous heparin in patients undergoing renal replacement therapy in terms of duration of the extracorporeal circuit, systemic bleeding and transfusion requirements [4]. Moreover, in septic patients undergoing extracorporeal treatments, finding the right dose of heparin can be challenging due to a number of conditions such as the presence of possible sources of hemorrhage, the low levels of Antithrombin III and the hypercoagulable state determined by the interaction between inflammatory mediators and coagulation factors [5]. For these reasons and a few citrate contraindications, RCA has been recommended even in the absence of an increased risk of bleeding [6]. Our group is well aware of these considerations, but RCA was not yet available in our Department at the time of the study. However, despite the well-known heparin-related shortcomings, we think that its mere replacement with RCA could hardly influence the outcome in septic patients who did not present with increased risk of bleeding. Actually, factors other than clotting can reduce the overall Vp, including the hemodynamic instability, and perhaps more importantly, the interruption of the CPFA due to the need for surgical or diagnostic procedures that cannot be performed at the bedside. In addition, the recent COMPACT II study, which has been prematurely suspended due to an excess mortality rate in the treatment group, required the use of RCA instead of heparin during the CPFA [7, 8].

Influence of Timing of Initiation and Volume of Processed Plasma on the Outcome of Septic Shock Patients Treated with Coupled Plasma Filtration and Adsorption

Background: The extracorporeal removal of mediators is a rescue strategy for septic shock patients, which is still under investigation. Several techniques are available: coupled plasma filtration and adsorption (CPFA) combines plasma processing with renal replacement therapy. Methods: The study aimed to elucidate the role of both timing of initiation and intensity of treatment on the outcome, for which we retrospectively studied 52 patients. We collected the overall pre-CPFA time interval, starting from the first episode of hypotension in the wards and the volume of processed plasma (Vp), which we used as a proxy for intensity of treatment. Results: Timing of initiation did not significantly differ between survivors and non-survivors (25 vs. 27 h), while the Vp did (0.25 vs. 0.17 L/kg/session, p < 0.05). The significance of Vp was confirmed by a multiple logistic regression model. Conclusion: Our study confirms that intensity of CPFA, but not its timing of initiation, correlates with survival of septic shock patients.

Heat stroke: Clinical experience from an Italian ICU during summer 2015

An abnormal peak of mortality attributed to an unusually persisting heat wave (HW) has been recorded throughout Italy by the National Institute of Statistics (ISTAT) during the summer of 2015 [1]. During this time frame a group of patients with an initial diagnosis of severe sepsis or septic shock-related multiple organ dysfunction syndrome (MODS) were admitted to our ICU and treated accordingly; however, the subsequent clinical course indicated the MODS could have been ascribed more appropriately to a classic heat stroke (cHS). Regardless of the cause(s), any sustained increase of the body temperature (BT) not matched by a concomitant heat loss can set the stage for the occurrence of cHS; the responsible mechanisms of both sepsis and cHS are similar and include the production and release of a number of pro-inflammatory cytokines in association with the activation of leukocytes and of the coagulative cascade [2]. Despite these similitudes, the distinction between sepsis and cHS is of paramount importance as the therapeutic approaches of these conditionsdiffer substantially:whereas the prompt administration of broad-spectrum and not the abatement of fever is the cornerstone of the treatment of sepsis, in patients with cHS the rapid cooling of patients represents the main therapeutic goal [2]. Overall, eight patients (4 M and 4 F, age 76 years, IQR 49–81 years) were diagnosed suffering from cHS in the considered period (Table 1). According to the information obtained from the next of kins, no patient

Massive cerebral venous thrombosis associated with the bilateral catheterization of the internal jugular veins: a case report

The authors describe the occurrence of the thrombosis of the cerebral venous sinuses in a patient in coma due to a large hemispheric infarction attributed to the thrombosis of the left internal carotid artery. After his admission to the Intensive Care Unit, a fiberoptic catheter was advanced into the left internal jugular vein to monitor the jugular bulb blood oxygen saturation, and the controlater was catheterized In order to supply fluids and medications. Despite the aggressive treatment, the patient died and, at the autopsy a massive thrombosis of the internal jugular veins was found, which extended to all the sinuses, in the absence of evident carotideal abnormalities. The authors describe the possible mechanisms of the massive thrombosis.