Daily Sepsis Research Analysis

STUDY OBJECTIVES: Concentrated albumin early in sepsis resuscitation remains largely unexplored. Objectives were to determine 1) feasibility of early intervention with concentrated albumin in emergency department (ED) patients with suspected infection and hypoperfusion and 2) whether early albumin therapy improves outcomes. METHODS: ED patients with suspected infection and hypoperfusion (systolic blood pressure [SBP]<90 mmHg or lactate ≥4.0 mmol/L) were randomized to receive either 400 mL 20% albumin over 4 hours or no albumin. All patients were treated with crystalloids, antibiotics, and other therapies at the treating team's discretion. Primary outcome was SBP at 24 hours; secondary outcomes included SBP at 6 hours, fluid and organ support requirements, organ dysfunction, and mortality. Quantile and logistic regressions were used to calculate differences (and 95% CI) between study groups. RESULTS: Compliance with study protocol was more than 95%, and infection was confirmed in 95% of the 464 study patients enrolled. SBP at 24 hours did not differ between intervention (110.5 mmHg) and standard care arms (110 mmHg). In patients treated with albumin, SBP was higher at 6 hours, less total fluid was infused at 72 hours, fewer patients required vasopressor therapy at 24 and 72 hours, and organ function was improved. Mortality was not significantly different. CONCLUSIONS: Early identification, trial enrollment, and intervention in ED patients with sepsis is feasible. In this pilot study, concentrated albumin given early in resuscitation did not improve SBP at 24 hours. Albumin was associated with less total fluid and vasopressor requirements and improved organ dysfunction. A multicenter study is indicated.

Understanding clinical trajectories of sepsis patients is crucial for prognostication, resource planning, and to inform digital twin models of critical illness. This study aims to identify common clinical trajectories based on dynamic assessment of cardiorespiratory support using a validated electronic health record data that covers retrospective cohort of 19,177 patients with sepsis admitted to intensive care units (ICUs) of Mayo Clinic Hospitals over 8-year period. Patient trajectories were modeled from ICU admission up to 14 days using an unsupervised machine learning two-stage clustering method based on cardiorespiratory support in ICU and hospital discharge status. Of 19,177 patients, 42% were female with a median age of 65 (interquartile range [IQR], 55-76) years, The Acute Physiology, Age, and Chronic Health Evaluation III score of 70 (IQR, 56-87), hospital length of stay (LOS) of 7 (IQR, 4-12) days, and ICU LOS of 2 (IQR, 1-4) days. Four distinct trajectories were identified: fast recovery (27% with a mortality rate of 3.5% and median hospital LOS of 3 (IQR, 2-15) days), slow recovery (62% with a mortality rate of 3.6% and hospital LOS of 8 (IQR, 6-13) days), fast decline (4% with a mortality rate of 99.7% and hospital LOS of 1 (IQR, 0-1) day), and delayed decline (7% with a mortality rate of 97.9% and hospital LOS of 5 (IQR, 3-8) days). Distinct trajectories remained robust and were distinguished by Charlson Comorbidity Index, The Acute Physiology, Age, and Chronic Health Evaluation III scores, as well as day 1 and day 3 SOFA ( P < 0.001 ANOVA). These findings provide a foundation for developing prediction models and digital twin decision support tools, improving both shared decision making and resource planning.

OBJECTIVES: Small studies of extracorporeal membrane oxygenation (ECMO) support for children with refractory septic shock (RSS) suggest that high-flow (≥ 150 mL/kg/min) venoarterial ECMO and a central cannulation strategy may be associated with lower odds of mortality. We therefore aimed to examine a large, international dataset of venoarterial ECMO patients for pediatric sepsis to identify outcomes associated with flow and cannulation site. DESIGN: Retrospective analysis of the Extracorporeal Life Support Organization (ELSO) database from January 1, 2000, to December 31, 2021. SETTING: International pediatric ECMO centers. PATIENTS: Patients 18 years old young or younger without congenital heart disease (CHD) cannulated to venoarterial ECMO primarily for a diagnosis of sepsis, septicemia, or septic shock. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 1242 pediatric patients undergoing venoarterial ECMO runs in the ELSO dataset, overall mortality was 55.6%. We used multivariable logistic regression analyses to evaluate explanatory factors associated with adjusted odds ratios (aORs) and 95% CI of mortality. In the regression analysis of data 4 hours after ECMO initiation, logarithm of the aOR, plotted against ECMO flow as a continuous variable, showed that higher flow was associated with lower aOR of mortality ( p = 0.03). However, at 24 hours, we failed to find such a relationship. Finally, peripheral cannulation, as opposed to central cannulation, was independently associated with greater odds of mortality (odds ratio, 1.7 [95% CI, 1.1-2.6]). CONCLUSIONS: In this 2000-2021 international cohort of venoarterial ECMO for non-CHD children with sepsis, we have found that higher ECMO flow at 4 hours after support initiation, and central- rather than peripheral-cannulation, were both independently associated with lower odds of mortality. Therefore, flow early in the ECMO run and cannula location are two important factors to consider in future research in pediatric patients requiring cannulation to venoarterial ECMO for RSS.