AN69 Filter Membranes with High Ultrafiltration Rates during Continuous Venovenous Hemofiltration Reduce Mortality in Patients with Sepsis-Induced Multiorgan Dysfunction Syndrome

Polyacrylonitrile (AN69) filter membranes adsorb cytokines during continuous venovenous hemofiltration (CVVH). Although high-volume hemofiltration has shown limited benefits, the dose-effect relationship in CVVH with AN69 membranes on severe sepsis remains undetermined. This multi-centered study enrolled 266 patients with sepsis-induced multiorgan dysfunction syndrome (MODS) who underwent CVVH with AN69 membranes between 2014 and 2015. We investigated the effects of ultrafiltration rates (UFR) on mortality. We categorized patients that were treated with UFR of 20–25 mL/kg/h as the standard UFR group (n = 124) and those that were treated with a UFR >25 mL/kg/h as the high UFR group (n = 142). Among the patient characteristics, the baseline estimated glomerular filtration rates (eGFR) <60 mL/min/1.73 m2, hemoglobin levels <10 g/dL, and a sequential organ failure assessment (SOFA) score ≥15 at CVVH initiation were independently associated with in-hospital mortality. In the subgroup analysis, for patients with SOFA scores that were ≥15, the 90-day survival rate was higher in the high UFR group than in the standard UFR group (HR 0.54, CI: 0.36–0.79, p = 0.005). We concluded that in patients with sepsis-induced MODS, SOFA scores ≥15 predicted a poor rate of survival. High UFR setting >25 mL/kg/h in CVVH with AN69 membranes may reduce the mortality risk in these high-risk patients.

Hypereosinophilia: a rare cause of stroke and multiorgan dysfunction

Eosinophilia can occur due to a plethora of allergic, infective, neoplastic and idiopathic conditions. Hypereosinophilic syndrome (HES) is characterised by sustained eosinophilia and multiorgan dysfunction in the absence of an identifiable cause. It may range from a self-limiting condition to a rapidly progressive life-threatening disorder, of which ischaemic stroke is a rare presentation. Such episodes can rarely be the presenting manifestation, and may develop before any other laboratory abnormality or organ involvement. We report a case of HES presented with multiorgan (neurological and renal) involvement, managed successfully with steroids and cytoreductive therapy. High initial absolute eosinophil count can be a clue to the diagnosis and early treatment should be initiated in such patients, to prevent fatal outcomes.

Beware of the ambiguous enemy of Multisystem Inflammatory Syndrome in Adult (MIS-A) following Covid-19 infection or vaccination.

Multisystem Inflammatory Syndrome is a rare and novel clinical presentation described during the evolving Covid- 19 pandemic. The condition is usually presenting as a sepsis-like syndrome leading to secondary multiorgan dysfunction post-COVID-19 infection. Although the syndrome has been mainly described in children, rare adults’ form has been similarly described.

An Arab Adolescent with Multisystem Inflammatory Syndrome Associated with COVID-19: A Report from Syria

Multisystem inflammatory syndrome in children (MIS-C) is a rare and critical condition that affects children following exposure to severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) infection, leading to multiorgan dysfunction and shock. MIS-C has been reported from different parts of the world but rarely from Arab countries. In this report, we describe a 15-year-old Arab boy who was admitted to the ICU during the surge of Coronavirus transmission in Syria with a clinical picture consistent with MIS-C, including high-grade fever, gastrointestinal symptoms, rash, multiorgan dysfunction, and shock. Laboratory profile showed significant elevation of inflammatory markers, negative SARS-CoV-2 RT-PCR testing but positive serologic testing for SARS-CoV-2. The patient received intravenous immunoglobulins (IVIG) and glucocorticoids with remarkable cardiac improvement and significant alleviation in inflammatory markers. To our knowledge, this is the first reported case of MIS-C from Syria, which adds to the epidemiological data about this new syndrome.

Spectrum of Multiorgan Dysfunction in Scrub Typhus Infection

Objectives We planned this study to determine the clinical spectrum and compare incidence of multiorgan dysfunction in children hospitalized with scrub typhus with other etiologies of tropical fever. Design Prospective cohort study. Setting Pediatric emergency and PICU services of a university teaching hospital situated in the sub-Himalayan region. Patient Children aged 2 months to 14 years with acute undifferentiated fever of more than 5 days. Interventions Detailed fever workup was performed in all children. We compared scrub typhus IgM positive children (cases) with remaining febrile children who were negative for scrub IgM assay (controls) for mortality and morbidity. Main results We enrolled 224 febrile children; 76 children (34%) were positive for scrub typhus IgM ELISA. Scrub typhus group had a significantly higher incidence of multiorgan dysfunction [OR 3.5 (95% CI 2.0–6.3); p &lt; 0.001] as compared to non-scrub typhus group requiring supportive care. The incidence of altered sensorium [OR 8.8 (95% CI 3.1–24.9)], seizures [OR 3.0 (95% CI 1.1–8.3)], acute respiratory distress syndrome [OR 17.1 (95% CI 2.1–140.1)], acute renal failure (5% vs. 0%), meningitis [OR 6.2 (95% CI 1.2–31.6)], thrombocytopenia [OR 2.8 (95% CI 1.5–5.1)], transaminitis [OR 2.7 (95% CI 1.6–4.8)], requirement of oxygen [OR 17.8 (95% CI 4.0–80.3)], positive pressure support [OR 3.7 (95% CI 1.2–10.5)] and shock requiring inotropes [OR 3.0 (95% CI 1.3–6.7)] was significantly higher in scrub typhus group as compared to the non-scrub typhus group (Table 1). Conclusions Pediatric scrub typhus who were hospitalized had severe systemic manifestations when compared to other causes of fever.

Triage and resuscitation tools for low and middle income countries: how to catch the killer?

Under-5 mortality rates in low and middle-income countries (LMIC) remain high. One major contributing factor is the failure to recognise critically unwell children when they first present to hospital. This leads to delayed or inadequate resuscitation and an increased risk of death.Triage is a key skill in this setting to sort the queue and prioritise patients, even when staff and equipment are scarce. In LMIC, children generally present late in their illness and often have progressed to some degree of multiorgan dysfunction.Following triage, a structured systematic primary survey is critical to ensure the detection of subtle signs of multiorgan dysfunction. Repeated physiological assessments of the child guide subsequent resuscitation management decisions, which depend somewhat on the resources available.It is possible to achieve significant improvements in survival of critically unwell children presenting for emergency care in the resource-limited setting. The three key steps in the patient’s journey that we can influence in emergency care are triage, primary survey and initial stabilisation. Resources that address these steps have been developed for all settings. However, these resources were developed in a specific clinical context, and must therefore be adapted to local structures and processes. A systematic approach to triage and resuscitation saves lives.