scholarly journals Clinical conundrums in management of sepsis in the elderly

2015 ◽  
Vol 3 (3) ◽  
pp. 106-112 ◽  
Author(s):  
Vishal Sehgal ◽  
Sukhminder Jit Singh Bajwa ◽  
John A. Consalvo ◽  
Anurag Bajaj
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Septic Shock ◽  
Kidney Injury ◽  
The Elderly ◽  
Nutritional Deficiencies ◽  
Surviving Sepsis Campaign ◽  
Clostridium Difficile Colitis ◽  
Sepsis And Septic Shock

Abstract In 2012, surviving sepsis campaign came out with updated international guidelines for management of severe sepsis and septic shock. Paradoxically, there are no specific guidelines for management of sepsis in the elderly, although the elderly are more predisposed to sepsis, and morbidity and mortality related to sepsis. Sepsis in the elderly is, more often than not, complicated by clinical conundrums such as congestive heart failure (CHF), atrial fibrillation (AF), chronic kidney disease (CKD), acute kidney injury (AKI), delirium, dementia, ambulatory dysfunction, polypharmacy, malglycemia, nutritional deficiencies, and antibiotic resistance. Also, with recurrent admissions to the hospital and widespread use of antibiotics, the elderly are more susceptible to Clostridium difficile colitis.

scholarly journals Atrial fibrillation: a risk factor for unfavourable outcome in COVID-19? A case report

2020 ◽  
Vol 4 (FI1) ◽  
pp. 1-6 ◽  
Author(s):  
Sebastian Schnaubelt ◽  
Marie-Kathrin Breyer ◽  
Jolanta Siller-Matula ◽  
Hans Domanovits
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Elderly Population ◽  
Kidney Injury ◽  
The Elderly ◽  
Pericardial Tamponade ◽  
Rhythm Control ◽  
Unfavourable Outcome ◽  
Progressive Heart Failure ◽  
Case Summary

Abstract Background Fulminant cardiac involvement in COVID-19 patients has been reported; the underlying suspected mechanisms include myocarditis, arrhythmia, and cardiac tamponade. In parallel, atrial fibrillation is common in the elderly population which is at particularly high risk for COVID-19 morbidity and mortality. Case summary A 72-year-old male SARS-CoV2-positive patient was admitted to the intensive care unit due to delirium and acute respiratory failure. Atrial fibrillation known from history was exacerbated, and made complex rate and rhythm control necessary. Progressive heart failure with haemodynamic deterioration and acute kidney injury with the need for continuous renal replacement therapy were further aggravated by pericardial tamponade. Discussion Treatment of acute heart failure in COVID-19 patients with a cytokine storm complicated by tachycardic atrial fibrillation should include adequate rate or rhythm control, and potentially immunomodulation.

Trends in complications and mortality following catheter ablation of atrial fibrillation: results from 22,582 ablations in Australia and New Zealand from 2010 to 2015

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
L Ngo ◽  
A Ali ◽  
A Ganesan ◽  
R Woodman ◽  
A McGavigan ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Acute Kidney Injury ◽  
Venous Thromboembolism ◽  
Catheter Ablation ◽  
Kidney Injury ◽  
Funding Source ◽  
Complications And Mortality ◽  
Over Time

Abstract Background Recent studies from the United States report rising rates of in-hospital complications and mortality following catheter ablation of atrial fibrillation (AF) but whether such a trend is observed in other populations is uncertain. Purpose To examine the trends in complications and mortality following AF ablations up to 30 days after discharge in Australia and New Zealand (ANZ) using nationwide data. Methods All patients ≥18y undergoing catheter ablation of AF from 2010–2015 were identified using hospitalisation data from all public and most private hospitals in ANZ. The primary endpoint was one or more procedural complications during the hospital stay or within 30 days of discharge. The secondary endpoints were mortality and other specific complications. Unadjusted trend was evaluated using Cochran-Armitage test while that of complications, adjusting for differences in other characteristics, was evaluated using multivariate logistic regression with the year of ablation modelled as a continuous variable. Results are reported as odd ratios (OR) and 95% confidence intervals (CI). Results A total of 22,582 AF ablations were included (mean age 62.2±11.6y, 29.1% female, 94.4% elective procedures). The number of ablations increased by 26.4% during the study period (3,097 in 2010 to 3,915 in 2015). Rates of heart failure (8.98% to 10.09%, p for trend=0.010), diabetes (4.52% to 12.46%, p<0.001), chronic kidney disease (2.36% to 4.29%, p<0.001) significantly increased over time but that of hypertension decreased (15.27% to 12.29%, p<0.001). The incidence of overall complications (6.55% in 2010 to 6.67% in 2015, OR 0.99, 95% CI 0.96–1.03) was unchanged during the study period (Figure 1A). When individual complications were considered, mortality rate was low with no statistically significant change with time (0.19% to 0.15%, OR 1.03, 95% CI 0.84–1.28) (Figure 1A) while the rate of acute kidney injury (0.23% to 0.51%, OR 1.17, 95% CI 1.02–1.34) increased and that of venous thromboembolism (0.16% to 0.0%, OR 0.71, 95% CI 0.54–0.94) decreased (Figure 1B). Though the incidence of any bleeding (4.49% to 3.98%, OR 0.97, 95% CI 0.93–1.01) was unchanged, that of major bleeding requiring blood transfusion (0.97% to 0.64%, OR 0.87, 95% CI 0.79–0.96) declined significantly (Figure 1B). No significant trend was observed in other complications or when in-hospital (5.13% to 5.21%, OR 1.00, 95% CI 0.97–1.04) and post-discharge (1.55% to 1.63%, OR 0.97, 95% CI 0.91–1.03) complications were separately evaluated. Conclusions Though more patients with heart failure, diabetes and chronic kidney disease underwent catheter ablation of AF over time in ANZ, the overall complication rate was unchanged with a significant decrease in the incidences of major bleeding and venous thromboembolism. However, rate of acute kidney injury nearly doubled, and this could be a potential target for efforts to further improve procedural safety. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): The National Heart Foundation of Australia

scholarly journals Clinical Outcomes of Malignancy-Related Neutropenic Fever Admissions in the United States: A 10-Year National Study

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 43-44
Author(s):  
Moataz Ellithi ◽  
Hafez M Abdullah ◽  
Waqas Ullah ◽  
Radowan Elnair ◽  
Fouad Khalil ◽  
...  
Keyword(s):  
Heart Failure ◽  
Chronic Kidney Disease ◽  
Septic Shock ◽  
Acute Kidney Injury ◽  
Respiratory Failure ◽  
Febrile Neutropenia ◽  
Hospital Mortality ◽  
Kidney Injury ◽  
Neutropenic Fever ◽  
Source Of Infection

Background: Neutropenia and neutropenic fever are a major cause of in-hospital morbidity and mortality in cancer patients. In this study, we aim to analyze trends in hospital outcomes of cancer-related neutropenic fever admissions and investigate clinical predictors associated with outcomes. Methods: We queried the National Inpatient Sample (NIS) database (2008-2017), using ICD-9 and ICD-10 codes accordingly, to identify cancer-related neutropenic fever admissions in the US hospitals. Cases younger than 18 years of age and cases that did not have malignancy as a primary or secondary diagnosis were excluded. Baseline characteristics of survivors were compared with non-survivors. Statistical analysis was performed using SPSS v26 (IBM Corp, Armonk, NY, USA). The adjusted odds ratio (aOR) and 95% confidence interval (CI) were calculated using the Cochran-Mantel-Haenszel test. A multivariate regression model was deployed to assess predictors of inpatient mortality. Complex weights were used throughout all calculations, enabling appropriate national projections. Results: A total of 159,065 records were identified using our inclusion and exclusion criteria, corresponding to 778,427 admissions nationally. The in-hospital mortality rate for all patients was 5.9%. Most common documented sources of infections were respiratory (24.3%), followed by urinary tract infections (13.2%), intraabdominal infections (7.6%), and skin and soft tissue infections (7.1%). Overall, sepsis was present in about quarter of the admissions, while acute kidney injury and respiratory failure were also prevalent (13.2% and 6.9%, respectively). On regression analysis, older age (OR 1.026; 95% CI, 1.025 - 1.027; P <0.001), heart failure (OR 1.90; 95% CI, 1.84 - 1.96; P <0.001), liver disease (OR 1.64; 95% CI, 1.56 - 1.72; P <0.001), chronic kidney disease (OR 1.325 95% CI, 1.30 - 1.39; P <0.001), coagulopathy (OR 1.67; 95% CI, 1.64-1.71; P <0.001), and metastatic disease (OR 1.70; 95% CI, 1.65- 1.74; P <0.001), were independent predictors of increased in-hospital mortality among patients admitted with febrile neutropenia, whereas female sex was associated with relatively favorable outcome (OR 0.93; 0.92-0.95; P <0.001). Based on the source of infection that was documented during admission, we found respiratory infections (OR 1.27; 95% CI, 1.24-1.30; P <0.001), meningoencephalitis (OR 1.23; 95% CI, 1.12-1.36; P <0.001), and systemic mycosis (OR 1.28; 95% CI, 1.24-1.32; P <0.001) were associated with worse outcome, while patients who had urinary (OR 0.75; 95% CI, 0.72-0.78; P <0.001) or soft tissue source of infection (OR 0.75; 95% CI, 0.71-0.79; P <0.001), or neutropenic enterocolitis (OR 0.91; 95% CI, 0.84-0.98; P <0.001) had a relatively better outcome. In terms of complications during admission, we found the occurrence of acute kidney injury (OR 2.13; 95% CI, 2.07-2.18; P <0.001), sepsis (OR 2.39; 95% CI, 2.32-2.45; P <0.001), septic shock (OR 3.25; 95% CI, 3.14-3.35; P <0.001), acute encephalopathy (OR 1.71 95% CI, 1.63-1.79; P <0.001), and acute respiratory failure (OR 9.98; 95% CI, 9.71-10.24; P <0.001) were associated with higher mortality. Conclusion: Despite the advances in risk stratification and frequent use of unified protocols that incorporate prophylactic growth factors in the therapeutic regimens, incidence of in-hospital mortality of febrile neutropenia appears to be unchanged over the decade between 2008 and 2017. We identified older age, metastatic disease, presence of chronic heart failure, liver disease, chronic kidney disease, coagulopathy, presence of acute kidney injury, sepsis, acute respiratory failure, encephalopathy, and septic shock as independent predictors of increased in-hospital mortality among patients admitted with febrile neutropenia. Further studies are needed to further explore predictors of poor outcomes in those patients. Figure Disclosures Anwer: Incyte, Seattle Genetics, Acetylon Pharmaceuticals, AbbVie Pharma, Astellas Pharma, Celegene, Millennium Pharmaceuticals.: Honoraria, Research Funding, Speakers Bureau.

scholarly journals Management of sepsis and septic shock in the emergency department

2021 ◽  
Author(s):  
Francesco Gavelli ◽  
Luigi Mario Castello ◽  
Gian Carlo Avanzi
Keyword(s):  
Emergency Department ◽  
Septic Shock ◽  
Patient Management ◽  
Emergency Physicians ◽  
Surviving Sepsis Campaign ◽  
Sepsis Management ◽  
Early Management ◽  
New Information ◽  
Sepsis And Septic Shock ◽  
Early Phases

AbstractEarly management of sepsis and septic shock is crucial for patients’ prognosis. As the Emergency Department (ED) is the place where the first medical contact for septic patients is likely to occur, emergency physicians play an essential role in the early phases of patient management, which consists of accurate initial diagnosis, resuscitation, and early antibiotic treatment. Since the issuing of the Surviving Sepsis Campaign guidelines in 2016, several studies have been published on different aspects of sepsis management, adding a substantial amount of new information on the pathophysiology and treatment of sepsis and septic shock. In light of this emerging evidence, the present narrative review provides a comprehensive account of the recent advances in septic patient management in the ED.

scholarly journals Plasma natriuretic peptide level is an independent determinant of major clinical outcomes in atrial fibrillation patients without heart failure: the Fushimi AF Registry

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
Y Hamatani ◽  
M Iguchi ◽  
Y Aono ◽  
K Ishigami ◽  
S Ikeda ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Clinical Outcomes ◽  
Prognostic Marker ◽  
Oral Anticoagulants ◽  
Systemic Embolism ◽  
The Mean

Abstract Background Atrial fibrillation (AF) increases the risk of death, stroke/systemic embolism and heart failure (HF). Plasma natriuretic peptide (NP) level is an important prognostic marker in HF patients. However, little is known regarding the prognostic significance of plasma NP level in AF patients without HF. Purpose The aim of this study is to investigate the relationship between plasma NP level and clinical outcomes such as all-cause death, stroke/systemic embolism and HF hospitalization during follow-up period in AF patients without HF. Methods The Fushimi AF Registry is a community-based prospective survey of AF patients in our city. The inclusion criterion of the registry is the documentation of AF at 12-lead electrocardiogram or Holter monitoring at any time, and there are no exclusion criteria. We started to enroll patients from March 2011, and follow-up data were available for 4,466 patients by the end of November 2019. From the registry, we excluded 1,220 patients without a pre-existing HF (defined as having one of the following; prior hospitalization for HF, New York Heart Association class ≥2, or left ventricular ejection fraction <40%). Among 3,246 AF patients without HF, we investigated 1,189 patients with the data of plasma BNP (n=401) or N-terminal pro-BNP (n=788) level at the enrollment. We divided the patients according to the quartile of each plasma BNP or NT-pro BNP level and compared the backgrounds and outcomes between these 4 groups stratified by plasma NP level. Results Of 1,189 patients, the mean age was 72.1±10.2 years, 454 (38%) were female and 684 (58%) were paroxysmal AF. The mean CHADS2 and CHA2DS2-VASc score were 1.6±1.1 and 2.9±1.5, respectively. Oral anticoagulants were prescribed in 671 (56%) at baseline. The median (interquartile range) BNP and N-terminal pro-BNP level were 84 (38, 176) and 500 (155, 984) pg/ml, respectively. Patients with high plasma NP level were older, and demonstrated lower prevalence of paroxysmal AF, higher CHADS2 and CHA2DS2-VASc scores and higher prevalence of chronic kidney disease and oral anticoagulants prescription (all P<0.01). A total of 165 all-cause death, 114 stroke/systemic embolism and 103 HF hospitalization occurred during the median follow-up period of 5.0 years. Kaplan-Meier curves demonstrated that higher plasma NP level was significantly associated with the incidences of all-cause death, stroke/systemic embolism and HF hospitalization in AF patients without HF (Figure 1A). Multivariable Cox regression analysis revealed that plasma NP level could stratify the risk of clinical outcomes even after adjustment by type of AF, CHA2DS2-VASc score, chronic kidney disease and oral anticoagulant prescription (Figure 1B). Conclusion Plasma NP level is a significant prognostic marker for all-cause death, stroke/systemic embolism and HF hospitalization in AF patients without HF, suggesting the importance of measuring plasma NP level in AF patients even without HF. Figure 1 Funding Acknowledgement Type of funding source: None

scholarly journals P0296LAST HIT ‘' INFECTIONS'’ BROUGHT THE END: CHRONIC KIDNEY DISEASE TO RENAL REPLACEMENT TREATMENT

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Feyza Bora ◽  
Emine Asar ◽  
Fatih Yılmaz ◽  
Ümit Çakmak ◽  
Fevzi F Ersoy ◽  
...  
Keyword(s):  
Chronic Kidney Disease ◽  
Kidney Disease ◽  
Outpatient Clinic ◽  
Artery Bypass ◽  
Kidney Injury ◽  
The Elderly ◽  
Severe Form ◽  
Vaccination Programs ◽  
Cardiac Decompensation ◽  
Replacement Treatment

Abstract Background and Aims It is evident that Chronic Kidney Disease (CKD) influences the risk of developing AKI (Acute Kidney Injury) and recent studies suggest that CKD patients who experienced an episode of AKI are more likely to progress to end stage renal disease (ESRD) than patients without CKD. AKI-CKD association might originate from common comorbidities associated with both AKI and CKD, such as diabetes and/or hypertension, and concurrent increase in interventions leading to frequent exposure to various nephrotoxins. AKI in the elderly has been shown to increase the risk of progression to CKD to ESRD. AKI is common in critically ill patients, and those patients with the most severe form of AKI, requiring RRT, have a mortality rate of 50–80 %. Patients with an eGFR <45 ml/min per 1.73m2 who experienced an episode of dialysis-requiring AKI were at very high risk for impaired recovery of renal function. Our aim was to determine the reasons that initiate hemodialysis (renal decompensation) in patients with regular follow-up in the low clearance polyclinic without renal replacement treatment (RRT). Method The retrospective study included predialysis CKD patients who had followed up regularly and had undergone RRT in recent 4 years. Data on baseline characteristics and medical history were obtained from patient hospital records. Results Of the 228 patients, 155 (68%) were male and 73 (32%) were female. The mean age was 58 years (45-66). Diabetes Mellitus was the first in the etiology of CKD (26,3 %), the second was unknown (12,7 %), the third was hypertension (11,8 %). 145 patients (63,6%) underwent regular hemodialysis (HD) (62 years, 55-69), 25 patients (11%) began peritoneal dialysis (PD), 58 patients (25%) had renal transplantation. 52 patients underwent HD with renal decompensation, 22 (%42,3) had working arteriovenous fistula (AVF). There was no decompensation in patients with PD or transplantation plan. 34 patients started HD because of infections (65%), 8 patients (15%) after operations (4 was Coronary Artery Bypass Grafting-CABG), 6 patients (%11,5) after coronary angiography, 4 patients (7,5%) with cardiac decompensation. 2 patients died during the hospitalisation for infections. Of 145 HD patients, 89 (%61,4) had AVF. The patients who had renal decompensation were more older 63 (58-70), have lower Hgb 9,7 g/L (9,1-10,7) and albumin 3,5 g/L (3,2-3,9) level (p<0,05). There was no difference in eGFR at the beginning of HD between renal decompensation and other HD patients. 42 patients did not undergo HD at the time we suggested during visits. Of them 9 patients (%21) had renal decompensation (6 infections,3 CABG), 17 patients (%40) had AVF. 3 of them died. The others underwent HD for uremic complications. Conclusion We have shown that infections are as the leading cause of renal decompensation. Most of our patients who started to RRT from our low clearance outpatient clinic have chosen HD for RRT. Prevention of infections via vaccination programs or early diagnosis at regular policlinic or telephone visits, and informing patients adequately about nephrotoxic drugs or the conditions that may cause renal decompensation are among the first tasks of the predialysis outpatient clinic. Transition of CKD patients to RRTs, with proper preparation, neither late nor early- at the most appropriate time- should be among in our goals. This may reduce the cost of ESRD patients.

Impact of Underlying Congestive Heart Failure on In-Hospital Outcomes in Patients with Septic Shock

2021 ◽  
pp. 088506662110614
Author(s):  
Mohinder R. Vindhyal ◽  
Liuqiang (Kelsey) Lu ◽  
Sagar Ranka ◽  
Prakash Acharya ◽  
Zubair Shah ◽  
...  
Keyword(s):  
Heart Failure ◽  
Septic Shock ◽  
Congestive Heart Failure ◽  
Hospital Mortality ◽  
Secondary Analysis ◽  
Kidney Injury ◽  
Cross Sectional ◽  
Increased Risk ◽  
Icd 10 ◽  
Nationwide Readmission Database

Purpose: Septic shock (SS) manifests with profound circulatory and cellular metabolism abnormalities and has a high in-hospital mortality (25%-50%). Congestive heart failure (CHF) patients have underlying circulatory dysfunction and compromised cardiac reserve that may place them at increased risk if they develop sepsis. Outcomes in patients with CHF who are admitted with SS have not been well studied. Materials and Method: Retrospective cross sectional secondary analysis of the Nationwide Readmission Database (NRD) for 2016 and 2017. ICD-10 codes were used to identify patients with SS during hospitalization, and then the cohort was dichotomized into those with and without an underlying diagnosis of CHF. Results: Propensity match analyses were performed to evaluate in-hospital mortality and clinical cardiovascular outcomes in the 2 groups. Cardiogenic shock patients were excluded from the study. A total of 578,629 patients with hospitalization for SS were identified, of whom 19.1% had a coexisting diagnosis of CHF. After propensity matching, 81,699 individuals were included in the comparative groups of SS with CHF and SS with no CHF. In-hospital mortality (35.28% vs 32.50%, P < .001), incidence of ischemic stroke (2.71% vs 2.53%, P = .0032), and acute kidney injury (69.9% vs 63.9%, P = .001) were significantly higher in patients with SS and CHF when compared to those with SS and no CHF. Conclusions: This study identified CHF as a strong adverse prognosticator for inpatient mortality and several major adverse clinical outcomes. Study findings suggest the need for further investigation into these findings’ mechanisms to improve outcomes in patients with SS and underlying CHF.

Sign in / Sign up

Export Citation Format

Share Document