Daniele Orso

Sepsis outside intensive care unit: the other side of the coin

IntroductionA growing body of evidence points out that a large amount of patients with sepsis are admitted and treated in medical ward (MW). With most of the sepsis studies conducted in intensive care unit (ICU), these patients, older and with more comorbidities have received poor attention. Provided the differences between the two groups of patients, results of diagnostic and therapeutic trials from ICU should not be routinely transferred to MW, where sepsis seems to be at least as common as in ICU.MethodsWe analyzed clinical trials on novel tools for an early diagnosis of sepsis published in the last two year adopting strict research criteria. Moreover we conducted a target review of the literature on non-invasive monitoring of severe sepsis and septic shock.Results and ConclusionsThe combination of innovative and non-invasive tools for sepsis rule in/out, as quick alternatives to blood cultures (gold standard) with bedside integrated ultrasonography could impact triage, diagnosis and prognosis of septic patients managed in MW, preventing ICU admissions, poor outcomes and costly complications, especially in elderly that are usually highly vulnerable to invasive procedures.

Procalcitonin in early rule-in/rule-out of sepsis in SIRS patients admitted to a medical ward.

Abstract Background: A relevant amount of patients with clinical suspect of sepsis is admitted and treated in medical wards (MW). These patients have a better prognosis but are older and with more comorbidities compared to those admitted to intensive care units (ICU). Procalcitonin (PCT) is extensively used in emergency departments for the diagnosis of sepsis, but its accuracy in the setting of a MW has not been thoroughly investigated. Predicted low PCT levels also call for the comparison of immunomagnetic-chemiluminescent (L-PCT) and time-resolved amplified cryptate emission (TRACE, K-PCT) technologies, in PCT determination. Methods: In 80 patients with systemic inflammatory response syndrome (SIRS) diagnostic criteria and suspect of sepsis newly admitted to a MW, PCT was determined with L- and K-PCT method. Results: Sixty patients were diagnosed as sepsis (20 microbiologically and 40 clinically proven) and 20 with non-infective SIRS. The sepsis group had significantly higher levels of both PCTs, with no differences between the clinically and microbiologically proven subgroups. The areas under ROC curves for L- and K-PCT were 0.72 and 0.78 (p<0.001 for each), respectively. Based on MW customized cut-off values of 0.150 (L-PCT) and 0.143 ng/mL (K-PCT), overall accuracies were 66.8 (95% CI 58.7–78.9) and 78.2% (69.8–87.2), respectively, compared to the 55% (44.2–66) of 0.5 ng/mL canonical cut-off. Neither PCT-L nor -K held prognostic value on survival. Conclusions: In MW patients, customized PCT cut-off levels provide better accuracy than customary levels adopted from ICU, and TRACE technology seems to offer a wider analysis range.

Accuracy of Ultrasonographic Measurements of Inferior Vena Cava to Determine Fluid Responsiveness: A Systematic Review and Meta-Analysis:

Objective: Fluid responsiveness is the ability to increase the cardiac output in response to a fluid challenge. Only about 50% of patients receiving fluid resuscitation for acute circulatory failure increase their stroke volume, but the other 50% may worsen their outcome. Therefore, predicting fluid responsiveness is needed. In this purpose, in recent years, the assessment of the inferior vena cava (IVC) through ultrasound (US) has become very popular. The aim of our work was to systematically review all the previously published studies assessing the accuracy of the diameter of IVC or its respiratory variations measured through US in predicting fluid responsiveness. Data Sources: We searched in the MEDLINE (PubMed), Embase, Web of Science databases for all relevant articles from inception to September 2017. Study Selection: Included articles specifically addressed the accuracy of IVC diameter or its respiratory variations assessed by US in predicting the fluid responsiveness in critically ill ventilated or not, adult or pediatric patients. Data Extraction: We included 26 studies that investigated the role of the caval index (IVC collapsibility or distensibility) and 5 studies on IVC diameter. Data Synthesis: We conducted a meta-analysis for caval index with 20 studies: The pooled area under the curve, logarithmic diagnostic odds ratio, sensitivity, and specificity were 0.71 (95% confidence interval [CI]: 0.46-0.83), 2.02 (95% CI: 1.29-2.89), 0.71 (95% CI: 0.62-0.80), and 0.75 (95% CI: 0.64-0.85), respectively. Conclusion: An extreme heterogeneity of included studies was highlighted. Ultrasound evaluation of the diameter of the IVC and its respiratory variations does not seem to be a reliable method to predict fluid responsiveness.

Role of Angiopoietin-2 in Medical-Ward Patients with SIRS/Sepsis

Background: SIRS/sepsis accounts for vast majority of deaths in ICU a medical ward department. More than 650,000 cases of sepsis are diagnosed in the United States annually, with 30-50% mortality and individually cost more than 22,000 dollars. Biomarkers could be useful tools for early risk stratification in these patients. Angiopioietin-2 (Ang-2) is a proinflamma- tory mediator of endothelial injury, which has received considerable attention over the past decade but little is known about its correlation with organ failure and mortality in SIRS/sepsis admitted to a medical ward. Methods: Ang-2 plasma levels, Charlson index, SOFA and routine laboratory test were carried out in 80 SIRS patients admitted to medical ward within 4 hours from diagnosis. Survival and organ dysfunction in the following week were recorded. Investigators were blinded from Ang-2 results. Results: Ang-2 plasma levels were higher in patients suffering from renal, pulmonary and hemostatic dysfunction (16, 6, 4% respectively) and patients who died within 1 week (11%). Ang-2 plasma levels higher than 15 ∝/mL account for 13 fold increased risk of death with 94% negative predictive value. Conclusions: Ang-2 plasma level at admission is predictive of early mortality and kidney, lung and hemostasis dysfunc- tion in SIRS/sepsis patients newly admitted in a medical ward.