Objectives: To determine the clinical characteristics and outcomes of culture-negative septic shock in comparison with culture-positive septic shock. Design: Retrospective nested cohort study. Setting: ICUs of 28 academic and community hospitals in three countries between 1997 and 2010. Subjects: Patients with culture-negative septic shock and culture-positive septic shock derived from a trinational (n = 8,670) database of patients with septic shock. Interventions: None. Measurements and Main Results: Patients with culture-negative septic shock (n = 2,651; 30.6%) and culture-positive septic shock (n = 6,019; 69.4%) were identified. Culture-negative septic shock compared with culture-positive septic shock patients experienced similar ICU survival (58.3% vs 59.5%; p = 0.276) and overall hospital survival (47.3% vs 47.1%; p = 0.976). Severity of illness was similar between culture-negative septic shock and culture-positive septic shock groups ([mean and sd Acute Physiology and Chronic Health Evaluation II, 25.7 ± 8.3 vs 25.7 ± 8.1]; p = 0.723) as were serum lactate levels (3.0 [interquartile range, 1.7–6.1] vs 3.2 mmol/L [interquartile range, 1.8–5.9 mmol/L]; p = 0.366). As delays in the administration of appropriate antimicrobial therapy after the onset of hypotension increased, patients in both groups experienced congruent increases in overall hospital mortality: culture-negative septic shock (odds ratio, 1.56; 95% CI [1.47–1.66]; p < 0.0001) and culture-positive septic shock (odds ratio, 1.65; 95% CI [1.59–1.71]; p < 0.0001). Conclusions: Patients with culture-negative septic shock behave similarly to those with culture-positive septic shock in nearly all respects; early appropriate antimicrobial therapy appears to improve mortality. Early recognition and eradication of infection is the most obvious effective strategy to improve hospital survival.

Acute kindney injury (AKI) is a clinical syndrome which is generally defined as an abrupt decline in glomerular filtration rate, causing accumulation of nitrogenous products and rapid development of fluid, electrolyte and acid base disorders. In intensive care unit sepsis and septic shock are leading causes of AKI. Sepsis-induced AKI literally acts as a biologic indicator of clinical deterioration. AKI triggers variety of immune, inflammatory, metabolic and humoral patways; ultimately leading distant organ dysfunction and increases morbidity and mortality. Serial mesurements of creatinine and urine volume do not make it possible to diagnose AKI at early stages. Serum creatinine influenced by age, weight, hydration status and become apparent only when the kidneys have lost 50% of their function. For that reason we need new markers, and many biomarkers in the diagnosis of early AKI activity is assessed. Historically "Risk-Injury-Failure-Loss-Endstage" (RIFLE), "Acute Kidney Injury Netwok" (AKIN) and "The Kidney Disease/ Improving Global Outcomes" (KDIGO) classification systems are used for diagnosing easily in clinical practice and research and grading disease. Classifications including diagnostic criteria are formed for the identification of AKI. Neutrophil gelatinase associated lipocalin (NGAL), cystatin-C (Cys-C), kidney injury molecule-1 (KIM-1) and also "cell cycle arrest" molecules has been concerned for clinical use. In this review the pathophysiology of AKI, with the relationship of sepsis and the importance of early diagnosis of AKI is evaluated.

Rapid, accurate, and reproducible assessment of intravascular volume status is crucial in order to predict the efficacy of volume expansion in septic patients. The aim of this study was to verify the feasibility and usefulness of the internal jugular vein collapsibility index (IJV-CI) as an adjunct to the inferior vena cava collapsibility index (IVC-CI) to predict fluid responsiveness in spontaneously-breathing patients with sepsis. Three stages of sonographic scanning were performed. Hemodynamic data were collected using the Ultrasonic Cardiac Output Monitor 1A system (Uscom, Ltd., Sydney, NSW, Australia) coupled with paired assessments of IVC-CI and IJV-CI at baseline, after passive leg raise (PLR), and again in semi-recumbent position. Fluid responsiveness was assessed according to changes in the cardiac index (CI) induced by PLR. Patients were retrospectively divided into 2 groups: fluid responder if an increase in CI (ΔCI) ≥15% was obtained after PLR maneuver, and non-responder if ΔCI was <15%. Total of 132 paired scans of IJV and IVC were completed in 44 patients who presented with sepsis and who were not receiving mechanical ventilation (mean age: 54.6±16.1 years). Of these, 23 (52.2%) were considered to be responders. Responders had higher IJV-CI and IVC-CI before PLR maneuver than non-responders (p<0.001). IJV-CI of more than 36% before PLR maneuver had 78% sensitivity and 85% specificity to predict responder. Furthermore, less time was needed to measure venous diameters for IJV-CI (30 seconds) compared with IVC-CI (77.5 seconds; p<0.001). IJV-CI is a precise, easily acquired, non-invasive parameter of fluid responsiveness in patients with sepsis who are not mechanically ventilated, and it appears to be a reasonable adjunct to IVC-CI.

Ancillary tests can be used for the diagnosis of brain death in cases wherein uncertainty exists regarding the neurological examination and apnoea test cannot be performed. Transcranial Doppler ultrasonography (TCD) is a useful, valid, non-invasive, portable, and repeatable ancillary test for the confirmation of brain death. Despite its varying sensitivity and specificity rates with regard to the diagnosis of the brain death, its clinical use has steadily increased in the intensive care unit because of its numerous superior properties. The use of TCD as an ancillary test for the diagnosis of brain death and cerebral circulatory arrest is discussed in the current review.

Objective: The aim was to compare the effects of low tidal volume (V_T) and moderate positive end-expiratory pressure (PEEP) with high V_T and zero end-expiratory pressure (ZEEP) on postoperative pulmonary functions and oxygenation in patients undergoing robot-assisted laparoscopic radical prostatectomy. Subjects and Methods: Forty-four patients were randomized into low V_T-PEEP and high V_T-ZEEP groups. The patients were ventilated with a V_T of 6 mL/kg and 8 cm H₂O PEEP in the low V_T-PEEP group and a V_T of 10 mL/kg and 0 cm H₂O PEEP in the high V_T-ZEEP group. Preoperative and postoperative spirometric measurements were done and chest X-rays were evaluated using the radiological atelectasis score (RAS). p < 0.05 was considered statistically significant. Results: The intraoperative and postoperative arterial partial pressure of oxygen and arterial oxygen saturation values were significantly higher in the low V_T-PEEP group than in the high V_T-ZEEP group. At all times, the arterial-to-alveolar oxygenation gradients were significantly lower in the low V_T-PEEP group than in the high V_T-ZEEP group. Preoperative RAS were similar in both groups, but the postoperative RAS was significantly lower in the low V_T-PEEP group (p < 0.001). Forced vital capacity, forced expiratory volume in 1 s, and peak expiratory flow rate recorded postoperatively were significantly lower in the high V_T-ZEEP group (p < 0.001). Conclusions: Postoperative pulmonary functions were less impaired in patients ventilated with a V_T of 6 mL/kg and 8 cm H₂O PEEP than in patients ventilated with a V_T of 10 mL/kg and ZEEP.

Article: Utilizing Bi-Spectral Index (BIS) for the monitoring of sedated adult ICU patients: a systematic review - Minerva Anestesiologica 2017 March;83(3):288-301 - Minerva Medica - Journals