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Purpose: The prevalence of hyperdynamic left ventricular (LV) systolic function in septic patients and its impact on mortality remain controversial. In this systematic review and meta-analysis, we investigated the prevalence and association of hyperdynamic LV systolic function with mortality in patients with sepsis. Methods: We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. Primary outcomes were the prevalence of hyperdynamic LV systolic function in adult septic patients and the associated short-term mortality as compared to normal LV systolic function. Hyperdynamic LV systolic function was defined using LV ejection fraction (LVEF) of 70% as cutoff. Secondary outcomes were heart rate, LV end-diastolic diameter (LVEDD), and E/e' ratio. Results: Four studies were included, and the pooled prevalence of hyperdynamic LV systolic function was 18.2% ([95% confidence interval (CI) 12.5, 25.8]; I2 = 7.0%, P < 0.0001). Hyperdynamic LV systolic function was associated with higher mortality: odds ratio of 2.37 [95%CI 1.47, 3.80]; I2 = 79%, P < 0.01. No difference was found in E/e' (P = 0.43) between normal and hyperdynamic LV systolic function, while higher values of heart rate (mean difference: 6.14 beats/min [95%CI 3.59, 8.69]; I2 = 51%, P < 0.0001) and LVEDD (mean difference: − 0.21 cm [95%CI − 0.33, − 0.09]; I2 = 73%, P < 0.001) were detected in patients with hyperdynamic LV systolic function. Conclusion: The prevalence of hyperdynamic LV systolic function is not negligible in septic patients. Such a finding is associated with significantly higher short-term mortality as compared to normal LV systolic function. [ABSTRACT FROM AUTHOR]

Background: Tissue Doppler-derived left ventricular systolic velocity (mitral S') has shown excellent correlation to left ventricular ejection fraction (LVEF) in non-critically patients. However, their correlation in septic patients remains poorly understood and its impact on mortality is undetermined. We investigated the relationship between mitral S' and LVEF in a large cohort of critically-ill septic patients. Methods: We conducted a retrospective cohort study between 01/2011 and 12/2020. All adult patients (≥ 18 years) who were admitted to the medical intensive care unit (MICU) with sepsis and septic shock that underwent a transthoracic echocardiogram (TTE) within 72 h were included. Pearson correlation test was used to assess correlation between average mitral S' and LVEF. Pearson correlation was used to assess correlation between average mitral S' and LVEF. We also assessed the association between mitral S', LVEF and 28-day mortality. Results: 2519 patients met the inclusion criteria. The study population included 1216 (48.3%) males with a median age of 64 (IQR: 53–73), and a median APACHE III score of 85 (IQR: 67, 108). The median septal, lateral, and average mitral S' were 8 cm/s (IQR): 6.0, 10.0], 9 cm/s (IQR: 6.0, 10.0), and 8.5 cm/s (IQR: 6.5, 10.5), respectively. Mitral S' was noted to have moderate correlation with LVEF (r = 0.46). In multivariable logistic regression analysis, average mitral S' was associated with an increase in both 28-day ICU and in-hospital mortality with odds ratio (OR) 1.04 (95% CI 1.01–1.08, p = 0.02) and OR 1.04 (95% CI 1.01–1.07, p = 0.02), respectively. Conclusions: Even though mitral S' and LVEF may be related, they are not exchangeable and were only found to have moderate correlation in this study. LVEF is U-shaped, while mitral S' has a linear relation with 28-day ICU mortality. An increase in average mitral S' was associated with higher 28-day mortality. [ABSTRACT FROM AUTHOR]

The impact of left ventricular (LV) systolic function on outcomes in patients with sepsis and septic shock remains uncertain. The association, if any, may be nonlinear. Is LV systolic dysfunction associated with increased mortality among patients with sepsis and septic shock? Retrospective cohort study comprising all adult patients admitted to the medical ICU from January 1, 2011, through December 31, 2020, with sepsis and septic shock as defined by the Third International Consensus Definitions for Sepsis and Septic Shock guidelines. All adult patients with sepsis or septic shock who underwent transthoracic echocardiography within 3 days from admission to the medical ICU were included. We divided patients into five groups based on LV ejection fraction (LVEF). In addition to univariate analysis, we also performed multivariate logistic regression analysis adjusting for patients' baseline characteristics and severity of illness. The primary outcome was the association between each classification of LVEF and in-hospital mortality. A total of 3,151 patients were included in this study (LVEF < 25%, 133 patients; 25% ≤ LVEF < 40%, 305 patients; 40% ≤ LVEF < 55%, 568 patients; 55% ≤ LVEF < 70%, 1,792 patients; and LVEF ≥ 70%, 353 patients). In-hospital mortalities in each LVEF category were 51.1%, 34.8%, 26.6%, 26.2%, and 41.9%, respectively. In the multivariate logistic regression analysis, LVEF of < 25% (OR, 2.75; 95% CI, 1.82-4.17; P <.001) and LVEF of ≥ 70% (OR, 1.70; 95% CI, 1.09-1.88; P =.010) were associated independently with significantly higher in-hospital mortality compared with the reference LVEF category of 55% to 70%. The association of LVEF to in-hospital mortality in sepsis and septic shock was U-shaped. Both severe LV systolic dysfunction (LVEF < 25%) and hyperdynamic LVEF (LVEF ≥ 70%) were associated independently with significantly higher in-hospital mortality. [ABSTRACT FROM AUTHOR]

Background: Ventricular-arterial coupling (V-A coupling) recently gathers attention from clinicians to evaluate the interaction between afterload and left ventricular systolic function. We aimed to describe the chronological demographics of V-A decoupling in patients with sepsis and septic shock through the clinical course. Method: We conducted a single-center prospective observational study comprising adult patients with sepsis and septic shock admitted to the tertiary care hospital between 04/2017 and 03/2019. Patients' characteristics, lab data on admission, and echocardiographic parameters including Ea and Ees on the day- 1, 2, 3, 7, and 14–28 were collected. V-A decoupling was defined as Ea/Ees ≥ 1.36. Results: Seventy-one patients with sepsis or septic shock were enrolled. The prevalence of V-A decoupling was as follows; day-1: 25.4%, day-2: 23.8%, day-3: 13.3%, day-7: 18.5%, day-14–28: 30.3%, respectively. Ea was higher in patients with V-A decoupling than those without throughout the clinical course (day1; 2.8 vs. 1.8, p < 0.01, day2; 2.7 vs. 1.9, p < 0.01, day3; 2.8 vs. 2.1, p = 0.06, day7; 2.7 vs. 1.9, p = 0.02, day14-28; 2.4 vs. 1.8, p = 0.08). This increase in Ea was mainly induced by reduced stroke volume (SV) as well as high systolic blood pressure (SBP) in the earlier course of sepsis but only by increased SBP in the later course of sepsis. Ees was lower in patients with V-A decoupling than those without throughout the clinical course (day1; 1.3 vs. 2.1, p < 0.01, day2; 1.5 vs. 2.3, p < 0.01, day3; 1.6 vs. 2.3, p = 0.02, day7; 1.8 vs. 2.3, p = 0.01, day14-28; 1.2 vs. 1.9, p = 0.07). Conclusion: We reported that V-A decoupling was commonly seen in patients with sepsis and septic shock. In patients with V-A decoupling, both Ea and Ees were significantly altered, but the causes of these alterations appeared to be changing over the clinical course of sepsis. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to conduct a systematic review and meta-analysis of randomized controlled trials to investigate whether IV high-dose vitamin C improves the short-term mortality of patients with sepsis.Design: This study is a systematic review and meta-analysis of randomized controlled trials. We searched EMBASE, the Cochrane Central Register of Controlled Trials, and MEDLINE for randomized controlled trials that met inclusion criteria. The protocol was registered at the University hospital Medical Information Network Clinical Trials Registry (UMIN000040528). All analyses were presented with the use of random-effects models. The primary outcome was short-term mortality defined as 28-day, 30-day, or in-hospital mortality.Patients: Two authors independently evaluated the following eligibility criteria: 1) randomized controlled trial, 2) patients with sepsis aged ≥18 years, and 3) received intravenous high-dose vitamin C in addition to standard of care, or standard of care alone. Then, two authors independently extracted the selected patient and study characteristics and outcomes from studies that met above eligibility criteria.Measurements and Main Results: Eleven randomized controlled trials (n = 1,737 patients) were included in this meta-analysis. High-dose IV vitamin C was not associated with a significantly lower short-term mortality (risk ratio, 0.88; 95% CI, 0.73-1.06; p = 0.18; I2 = 29%) but was associated with a significantly shorter duration of vasopressor use (standardized mean difference, -0.35; 95% CI, -0.63 to -0.07; p < 0.01; I2 = 80%) and a significantly greater decline in the Sequential Organ Failure Assessment score at 72-96 hours (standardized mean difference, -0.20; 95% CI, -0.32 to -0.08; p < 0.01; I2 = 16%). One study reported significant association with hypernatremia, but adverse effects were rare, and high-dose vitamin C is deemed relatively safe.Conclusions: In this meta-analysis, the use of IV high-dose vitamin C in patients with sepsis was not associated with lower short-term mortality although it was associated with significantly shorter duration of vasopressor use and greater decline in the Sequential Organ Failure Assessment score at 72-96 hours. [ABSTRACT FROM AUTHOR]

Background: Historically, β-blockers have been considered to be relatively contraindicated for septic shock because they may cause cardiac suppression. On the other hand, there is an increasing interest in the use of β-blockers for treating patients with sepsis with persistent tachycardia despite initial resuscitation.Research Question: Do ultrashort-acting β-blockers such as esmolol and landiolol improve mortality in patients with sepsis with persistent tachycardia despite initial resuscitation?Study Design and Methods: This was a systematic review and meta-analysis. We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase for randomized controlled trials (RCTs) that compared the mortality of patients with sepsis and septic shock treated with esmolol or landiolol. We updated our search on April 20, 2020. Two independent reviewers assessed whether titles and abstracts met the following eligibility criteria: (1) RCT, (2) patients with sepsis and septic shock ≥ 18 years of age, and (3) treatment with either esmolol/landiolol or placebo/no interventions. Two authors independently extracted selected patient and study characteristics and outcomes. The results of all analyses are presented using random effect models.Results: Seven RCTs with a pooled sample size of 613 patients were included. Of these, six RCTs with 572 patients reported 28-day mortality. Esmolol or landiolol use in patients with sepsis and septic shock was significantly associated with lower 28-day mortality (risk ratio, 0.68; 95% CI, 0.54-0.85; P < .001). Unimportant heterogeneity was observed (I2 = 31%). The absolute risk reduction and number of patients to be treated to prevent one death were 18.2% and 5.5, respectively.Interpretation: The use of ultrashort-acting β-blockers such as esmolol and landiolol in patients with sepsis with persistent tachycardia despite initial resuscitation was associated with significantly lower 28-day mortality.Trial Registry: UMIN Clinical Trials Registry; No.: UMIN000040174; URL: https://www.umin.ac.jp/ctr/index.htm. [ABSTRACT FROM AUTHOR]

Background: The use of ultrashort-acting β1-blockers recently has attracted attention in septic patients with non-compensatory tachycardia. We summarized the metabolic and hemodynamic effects and the clinical evidence of ultrashort-acting β1-blockers. Main body: A recent meta-analysis showed that ultrashort-acting β1-blockers reduced the mortality in septic patients with persistent tachycardia. However, its mechanism to improve mortality is not fully understood yet. We often use lactate as a marker of oxygen delivery, but an impaired oxygen use rather than reduced oxygen delivery has been recently proposed as a more reasonable explanation of hyperlactatemia in patients with sepsis, leading to a question of whether β1-blockers affect metabolic systems. While the stimulation of the β2-receptor accelerates glycolysis and lactate production, the role of β1-blocker in lactate production remains unclear and studies investigating the role of β1-blockers in lactate kinetics are warranted. A meta-analysis also reported that ultrashort-acting β1-blockers increased stroke volume index, while it reduced heart rate, resulting in unchanged cardiac index, mean arterial pressure, and norepinephrine requirement at 24 h, leading to an improvement of cardiovascular efficiency. On the other hand, a recent study reported that heart rate reduction using fast esmolol titration in the very early phase of septic shock caused hemodynamic instability, suggesting that ultrashort-acting β1-blockers should be started only after completing initial resuscitation. While many clinicians still do not feel comfortable controlling sinus tachycardia, one randomized controlled trial in which the majority had sinus tachycardia suggested the mortality benefit of ultrashort-acting β1-blockers. Therefore, it still deems to be reasonable to control sinus tachycardia with ultrashort-acting β1-blockers after completing initial resuscitation. Conclusion: Accumulating evidence is supporting the use of ultrashort-acting β1-blockers while larger randomized controlled trials to clarify the effect of ultrashort-acting β1-blockers are still warranted. [ABSTRACT FROM AUTHOR]

Objectives: Clinicians often encounter adult patients with septic shock who fail to respond to fluid therapy and vasopressors. There is an increasing interest in venoarterial extracorporeal membranous oxygenation in the treatment of patients with septic shock, but its outcomes and safety remain unclear. The aim of this study is to describe in-hospital mortality and complication rate in adult patients with septic shock who underwent venoarterial extracorporeal membranous oxygenation, and to identify patients who may potentially benefit from venoarterial extracorporeal membranous oxygenation.Data Sources: The protocol for this systematic review was registered at International Prospective Register of Systematic Reviews (CRD42018098848). We searched MEDLINE, Embase, and Igaku Chuo Zasshi for studies of any design in which patients with septic shock were treated with venoarterial extracorporeal membranous oxygenation. Our search was updated on October 6, 2019.Study Selection: Two independent reviewers assessed whether titles and abstracts met the eligibility criteria. Studies were included when patients met the following criteria: 1) age 18 years old or older; 2) septic shock; and 3) treated with venoarterial extracorporeal membranous oxygenation as hemodynamic support. When there were disagreements between reviewers, the full text was reviewed, and discussion was continued until a consensus was reached.Data Extraction: Two authors independently extracted the selected patient and study characteristics and outcomes.Data Synthesis: A total of 6,457 studies were screened. Six retrospective studies were included. The in-hospital mortality rate of patients with septic shock who underwent venoarterial extracorporeal membranous oxygenation was 76.7% (188/245). Four studies provided cardiac function with left ventricular ejection fraction and/or cardiac index. In two of these four studies where median left ventricular ejection fraction and cardiac index were 16.0% and 1.3 L/min/m and median left ventricular ejection fraction and mean cardiac index were 30.0% and 2.4 L/min/m, respectively, the in-hospital mortalities were markedly lower (14.8% and 28.6%, respectively) than the other two studies (78.1% and 91.5%, respectively) that included populations with median left ventricular ejection fraction of 25.0% and mean cardiac index of 2.1 L/min/m. Complications were reported in five studies (39 events/174 cases), hemorrhage (22 events/174 cases) being the most common.Conclusions: Venoarterial extracorporeal membranous oxygenation remains a controversial treatment strategy in septic shock. The reported in-hospital mortality rates in patients with sepsis-induced cardiogenic shock who underwent venoarterial extracorporeal membranous oxygenation were quite inconsistent. There is a need for well-designed studies to assess the benefit and safety of venoarterial extracorporeal membranous oxygenation in patients with sepsis-induced cardiogenic shock. [ABSTRACT FROM AUTHOR]

Sepsis, septic shock, and transthoracic echocardiogram (TTE) were identified using the International Classification of Diseases, Tenth Revision codes. B Introduction: b While the current Surviving Sepsis Campaign Guidelines suggests echocardiogram for the hemodynamic assessment in sepsis and septic shock, the evidence to support the utility of echocardiogram has been limited. B Conclusions: b This study using the large national database described that the use of TTE was associated with significantly lower in-hospital mortality in patients with septic shock while it was not in patients with sepsis without septic shock. [Extracted from the article]

Background: Various complications are reported with Clostridium difficile infection (CDI), including fulminant CDI. Fulminant CDI is an underappreciated life-threatening condition associated with complications such as toxic megacolon and bowel perforation.Case Report: A 79-year-old woman presented to the Emergency Department with altered mental status. She was admitted and conservatively treated for a left thalamic hemorrhage. While hospitalized, she developed watery diarrhea due to Clostridium difficile. Although metronidazole was initiated, she developed altered mental status and septic shock. Abdominal x-ray study and computed tomography revealed a significantly dilatated colon and a massive pneumoperitoneum. She underwent subtotal colectomy with a 14-day course of intravenous meropenem. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case suggests that we must be aware of the complications that CDI may present and adequately consider surgical management because early diagnosis and surgical treatment is critical to reduce the mortality of fulminant CDI. [ABSTRACT FROM AUTHOR]

After controlling for baseline characteristics, past medical history, and vasopressor requirements within the first 24 hours of septic shock, late-onset septic shock, compared to early-onset septic shock, was associated with significantly higher in-hospital mortality [odds ratio (OR): 2.22, 95% confidence interval (CI): 1.72 - 2.85, p < 0.01]. B Conclusion: b In this study, late-onset septic shock (> 7days) after hospital admission was associated with a significantly higher in-hospital mortality compared to early-onset septic shock. B Result: b A total of 3,508 patients with septic shock (2,821 early-onset and 687 late-onset septic shock) were included. [Extracted from the article]

This study aimed to compare the maximum VIS and norepinephrine equivalent (NEE) dose in the first 24 hours of septic shock for the prediction of in-hospital mortality and explore the optimal definition of refractory septic shock. NEE dose showed significantly better prediction accuracy than VIS for in-hospital mortality [NEE dose; area under the curve (AUC): 0.78, 95% confidence interval (CI): 0.76-0.79 versus. [Extracted from the article]

Purpose: The prevalence and its impact on mortality of sepsis-induced cardiomyopathy (SICM) remain controversial. In this systematic review and meta-analysis, we investigated the prevalence and prognosis of SICM. Materials and Methods: We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. Titles and abstracts were evaluated based on the following criteria: (1) published in English, (2) randomized controlled trials, cohort studies, or cross-sectional studies, (3) ≥ 18 years with sepsis, (4) reporting the prevalence and/or comparison of short-term mortality between those with and without SICM, defined as the new-onset reduction in left ventricular ejection fraction (LVEF) within 72 h on admission or from the diagnosis of sepsis. The random-effect model was used for all analyses. This meta-analysis was registered at PROSPERO (CDR42022332896). Results: Sixteen studies reported the prevalence of SICM and the pooled prevalence of SICM was 20% (95% confidence interval [CI], 16-25%; I 2 = 89.9%, P < 0.01). Eleven studies reported short-term mortality and SICM was associated with significantly higher short-term mortality (The pooled odds ratio: 2.30, 95% CI, 1.43-3.69; I 2 = 0%, P = 0.001). Conclusion: The prevalence of SICM was 20% in patients with sepsis, and the occurrence of SICM was associated with significantly higher short-term mortality. [ABSTRACT FROM AUTHOR]

Similarly, there was no significant improvement in mortality amongst patients with solid-tumor malignancy (2011: 47.80% to 2020: 41.37%, p=0.913) and non-solid tumor (2011: 56% to 2020: 42.35%, p=0.393). We report the trend in survival over the last decade for patients with septic shock without malignancy and those with septic shock and malignancy. [Extracted from the article]

B Introduction: b Septic shock patients have heterogeneous and dynamic cardiovascular dysfunction. B Methods: b This retrospective study included patients with septic shock receiving vasopressin as a catecholamine adjunct who had an echo performed after shock onset and prior to vasopressin initiation. Patients with LV systolic dysfunction were less frequently vasopressin responsive (with LV dysfunction: 10/27 [37%] vs. without LV dysfunction: 62/102 [61%], absolute difference -24%; 95% CI -44% to -3%). [Extracted from the article]