Azithromycin and Septic Shock Outcomes

Introduction: Although there is evidence describing the immunomodulatory effects of macrolide antibiotics, there is little literature exploring the clinical effects these properties may have and their impact on measurable outcomes. Objective: The purpose of this study was to determine if empiric antimicrobial regimens containing azithromycin shorten time to shock resolution. Methods: A retrospective study was performed in adults with septic shock admitted to intensive care units (ICUs) of 3 university-affiliated, urban teaching hospitals between June 2012 and June 2016. Eligible patients with septic shock required treatment with norepinephrine as the first-line vasopressor for a minimum of 4 hours and received at least 48 hours of antimicrobial treatment from the time of shock onset. Propensity scores were utilized to match patients who received azithromycin to those who did not. Results: A total of 3116 patients met initial inclusion criteria. After propensity score matching, 258 patients were included, with 124 and 134 patients in the azithromycin and control groups, respectively. Median shock duration was similar in patients treated with or without azithromycin (45.6 hr vs 59.7 hr, P = .44). In-hospital mortality was also similar (37.9% vs 38.1%, P = .979). There were no significant differences in mechanical ventilation duration, ICU length of stay (LOS), or hospital LOS. Conclusions: In patients admitted to the ICU with septic shock, empiric azithromycin did not have a significant effect on shock duration, mechanical ventilation duration, ICU LOS, hospital LOS, or in-hospital mortality.

The In-hospital Outcome of Ventricular Septal Defect Closure and Predictor of Morbidity and Mortality at Tertiary Level Cardiac Center

Background and Aims: Factors responsible for complications and outcomes of surgical closure of ventricular septal defect differ between different cardiac centers globally. In this study, we tried to evaluate outcomes and predictors of morbidity and mortality of surgical closure of VSD in a single center. Methods: The retrospective cohort study was conducted in Shahid Gangalal National Heart Centre from 14th April 2018 to 13th April 2020. It included consecutive series of patients undergoing ventricular septal defect closure as a primary surgery Results: Out of a total 166 patients, males were 100 (60%). Adverse complications occurred on 36 (21%) with mortality of 6 (3.6%). The age ranged from 4 months to 35 years. The weight <10 kgs at the time of operation had significant post-operative prolong ventilation duration (more than 6 hours) with a p value of 0.012; significant prolong ICU stays (>2 days) with a p value of <0.001; significant prolong hospital stay (> 7 days) with a p value of <0.001. The longer CPB time was associated with significantly prolonged ventilation duration (p value 0.001); significant longer ICU stay (p value 0.02). The age <1 year at the time of operation had significant prolonged ICU stay; significantly prolonged hospital stays (p value of 0.033). Severe pulmonary artery hypertension (PAH) and weight up to 10 kgs at the time of operation demonstrated a trend towards association with mortality. Conclusion: Surgical VSD closure can be done with acceptable level of mortality and morbidity in our context.

Pepsin A in Tracheal Secretions From Patients Receiving Mechanical Ventilation

Background In patients in the intensive care unit (ICU) receiving mechanical ventilation, aspiration of gastric contents may lead to ventilator-associated events and other adverse outcomes. Pepsin in pulmonary secretions is a biomarker of microaspiration of gastric contents. Objectives To evaluate the association between tracheal pepsin A and clinical outcomes related to ventilator use. Methods A subset of 297 patients from a larger clinical trial on aspiration of oral secretions in adults receiving mechanical ventilation consented to have pepsin A measured in their tracheal aspirate samples. A concentration ≥6.25 ng/mL indicated a positive result. Abundant microaspiration was defined as pepsin A in ≥30% of samples. Statistical analyses included analysis of variance, analysis of covariance, and χ2 tests. Results Most patients were White men, mean age 59.7 (SD, 18.8) years. Microaspiration was found in 43.8% of patients (n = 130), with abundant microaspiration detected in 17.5% (n = 52). After acuity was controlled for, patients with tracheal pepsin A had a longer mechanical ventilation duration (155 vs 104 hours, P &lt; .001) and ICU stay (9.9 vs 8.2 days, P = .04), but not a longer hospital stay. Conclusions Microaspiration of gastric contents occurred in nearly half of patients and was associated with a longer duration of mechanical ventilation and a longer stay in the ICU. Additional preventative interventions beyond backrest elevation, oropharyngeal suctioning, and management of endotracheal tube cuff pressure may be needed. Also, the timing of pepsin measurements to capture all microaspiration events requires additional exploration.

Impact of Permissive Hypoxia and Hyperoxia Avoidance on Clinical Outcomes in Septic Patients Receiving Mechanical Ventilation: A Retrospective Single-Center Study

Background. Septic patients often require mechanical ventilation due to respiratory dysfunction, and effective ventilatory strategies can improve survival. The effects of the combination of permissive hypoxia and hyperoxia avoidance for managing mechanically ventilated patients are unknown. This study examines these effects on outcomes in mechanically ventilated septic patients. Methods. In a retrospective before-and-after study, we examined adult septic patients (aged ≥18 years) requiring mechanical ventilation at a university hospital. On April 1, 2017, our mechanical ventilation policy changed from a conventional oxygenation target (SpO2: ≥96%) to more conservative targets with permissive hypoxia (SpO2: 88-92% or PaO2: 60 mmHg) and hyperoxia avoidance (reduced oxygenation for Pa O 2 > 110 mmHg ). Patients were divided into a prechange group (April 2015 to March 2017; n = 83 ) and a postchange group (April 2017 to March 2019; n = 130 ). Data were extracted from clinical records and insurance claims. Using a multiple logistic regression model, we examined the association of the postchange group (permissive hypoxia and hyperoxia avoidance) with intensive care unit (ICU) mortality after adjusting for variables such as Sequential Organ Failure Assessment (SOFA) score and PaO2/FiO2 ratios. Results. The postchange group did not have significantly lower adjusted ICU mortality (0.67, 0.33-1.43; P = 0.31 ) relative to the prechange group. However, there were significant intergroup differences in mechanical ventilation duration (prechange: 11.0 days, postchange: 7.0 days; P = 0.01 ) and ICU stay (prechange: 11.0 days, postchange: 9.0 days; P = 0.02 ). Conclusions. Permissive hypoxia and hyperoxia avoidance had no significant association with reduced ICU mortality in mechanically ventilated septic patients. However, this approach was significantly associated with shorter mechanical ventilation duration and ICU stay, which can improve patient turnover and ventilator access.

The Prognostic Value of Hypophosphatemia in Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Background Phosphorus (P) is an important electrolyte that plays a significant role in different physiological processes especially muscle contraction and adenosine triphosphate high energy bonds. Low phosphorus level in blood may increase the exacerbation of chronic obstructive pulmonary disease, need, and duration of mechanical ventilation. Objective To examine the prognostic effects of hypophosphatemia in COPD patients and evaluate the correlation between phosphorus levels and severity of attacks, need for mechanical ventilation, duration of The ICU stays and mortality. Methods This study was performed on 72 patients with acute exacerbation of COPD admitted in chest department and respiratory ICU in Ain Shams University Hospital in the period between June 2019 & March 2020. Results The study showed Low blood phosphorus levels contribute to an increase in: COPD flare-up with high statistically significant value (p &lt; 0.001), also the need for ventilation, duration of ventilation, duration of hospitalization, days in intensive care units and finally increased rate of mortality were statistically significant value p-value (0.002, 0.024, 0.021 & 0.001) respectively. Conclusion Close monitoring and careful adjustment of disorders correlated to electrolyte such as phosphorus, are crucial and may improve prognosis and also increase the survival rate of patients with COPD.

Transient and persistent acute kidney injury phenotypes following the Norwood operation: a retrospective study

Background: Acute kidney injury is a common complication following the Norwood operation. Most neonatal studies report acute kidney injury peaking within the first 48 hours after cardiac surgery. The aim of this study was to evaluate if persistent acute kidney injury (>48 postoperative hours) after the Norwood operation was associated with clinically relevant outcomes. Methods: Two-centre retrospective study among neonates undergoing the Norwood operation. Acute kidney injury was initially identified as developing within the first 48 hours after cardiac surgery and stratified into transient (≤48 hours) and persistent (>48 hours) using the neonatal modification of the Kidney Disease: Improving Global Outcomes serum creatinine criteria. Severe was defined as stage ≥2. Primary and secondary outcomes were mortality and duration of ventilation and hospital length of stay. Results: One hundred sixty-eight patients were included. Transient and persistent acute kidney injuries occurred in 24 and 17%, respectively. Cardiopulmonary bypass and aortic cross clamp duration, and incidence of cardiac arrest were greater among those with persistent kidney injury. Mortality was four times higher (41 versus 12%, p < 0.001) and mechanical ventilation duration 50 hours longer in persistent acute kidney injury patients (158 versus 107 hours; p < 0.001). In multivariable analysis, persistent acute kidney injury was not associated with mortality, duration of ventilation or length of stay. Severe persistent acute kidney injury was associated with a 59% increase in expected ventilation duration (aIRR:1.59, 95% CI:1.16, 2.18; p = 0.004). Conclusions: Future large studies are needed to determine if risk factors and outcomes change by delineating acute kidney injury into discrete timing phenotypes.

Impact of plasma 5-hydroxyindoleacetic acid, a serotonin metabolite, on clinical outcome in septic shock, and its effect on vascular permeability

Septic shock is characterized by dysregulated vascular permeability. We hypothesized that the vascular permeability of endothelial cells (ECs) would be regulated by serotonin via serotonin-Rho-associated kinase (ROCK) signaling. We aimed to determine the impact of 5-hydroxyindoleacetic acid (5-HIAA) on septic shock as a novel biomarker. Plasma 5-HIAA levels and disease severity indices were obtained from 47 patients with sepsis. The association between 5-HIAA levels and severity indices was analyzed. Permeability upon serotonin stimulation was determined using human pulmonary microvascular ECs. 5-HIAA were significantly higher in septic shock patients than in patients without shock or healthy controls (p = 0.004). These elevated levels were correlated with severity indexes (SOFA score [p < 0.001], APACHE II [p < 0.001], and PaO2:FiO2 [p = 0.02]), and longitudinally associated with worse clinical outcomes (mechanical ventilation duration [p = 0.009] and ICU duration [p = 0.01]). In the experiment, serotonin increased the permeability of ECs, which was inhibited by the ROCK inhibitor (p < 0.001). Serotonin increases vascular permeability of ECs via ROCK signaling. This suggests a novel mechanism by which serotonin disrupts endothelial barriers via ROCK signaling and causes the pathogenesis of septic shock with a vascular leak. Serotonin serves as a novel biomarker of vascular permeability.

Characterization of urinary cotinine concentrations among non-smoking adults in smoking and smoke-free homes in the Korean national environmental health survey (KoNEHS) cycle 3 (2015–2017)

Background Although many indoor public places have implemented smoke-free regulations, private homes have remained sources of tobacco smoke pollutants. This study examined differences in urinary cotinine concentrations in the Korean non-smoking adult population between living in smoking and smoke-free homes, and the relationship of urinary cotinine concentrations with socio-demographic factors in smoke-free homes. Methods Samples from 2575 non-smoking adults (≥19 years old) in the Korean National Environmental Health Survey cycle 3 (2015–2017), a representative Korean study, were used. Smoking and smoke-free homes were defined based on whether there were smokers at homes. Weighted linear regression models were used to determine urinary cotinine concentrations and identify factors associated with urinary cotinine. Results The geometric mean of urinary cotinine concentrations for non-smoking adults living in smoking homes was 2.1 μg/L (95% confidence interval [CI] = 1.8–2.4), which was significantly higher than the mean of 1.3 μg/L (95% CI = 1.2–1.4) for those living in smoke-free homes. Urinary cotinine concentrations were different significantly by home smoking status in most socio-demographic subgroups. Data from smoke-free home showed urinary cotinine concentration in adults was significantly higher in those who lived in homes with ventilation duration < 30 min/day, those who spent more time indoors at home, those who spent less time outdoors, and those who worked in non-manual or manual occupations. Conclusions The urinary cotinine concentration in Korean non-smoking adults living in smoking homes was higher than that in adults living in smoke-free homes. Even in smoke-free homes, home-related factors, such as ventilation duration and time spent indoors, were associated with urinary cotinine concentration. Further study is warranted to examine potential sources of tobacco smoke pollution in smoke-free homes.

Optimal Nutritional Factors Influencing the Duration of Mechanical Ventilation Among Adult Patients with Critical Illnesses in an Intensive Care Unit

Objective: This study aims to identify the impact of nutritional factors on mechanical ventilation duration for critical patients. Patients and Methods: The current study was a single-center, prospective observational design which enrolled one-hundred critically ill patients who were admitted to an intensive care unit (ICU). It demonstrates purposive sampling and also performs the descriptive nutritional factors influencing the mechanical ventilation duration. Daily calories target requirement scale (DCRS), subjective global assessment form (SGA), dyspnea assessment form, and APACHE II have been used as methods in the study along with time to initial enteral nutrition (EN) after 24-hour admission and daily calories target requirement over 7 days to assess patients. Data is analyzed using the multiple regressions. Results: As a result, nutritional status monitoring, time to initial EN, calories and target requirements are statistically positive significance associated with the mechanical ventilation duration respectively (R = 0.54, R = 0.30, R= 0.40, p &lt; 0.05). However, age, illness severity, and dyspnea scales are not associated with the mechanical ventilation duration (p&gt; 0.05). Therefore, the nutritional status, malnutrition scores and calorie target requirements can be used to significantly predict the mechanical ventilation duration. The predictive power is 58 and 28.0% of variance. The most proper influencer to predict the mechanical ventilation duration is nutritional status or malnutrition scores. Conclusion: The research findings show that the nutritional status, time to initial EN, and calorie target requirement within 7 days of admission are associated with the mechanical ventilation duration in the critical patients. Therefore, it can be used to develop guidelines reducing the mechanical ventilation duration and to promote the ventilator halting for critical patients.