Purpose
To determine whether early goal-directed therapy (EGDT) reduces mortality compared with other resuscitation strategies for patients presenting to the emergency department (ED) with septic ...shock.
Methods
Using a search strategy of PubMed, EmBase and CENTRAL, we selected all relevant randomised clinical trials published from January 2000 to January 2015. We translated non-English papers and contacted authors as necessary. Our primary analysis generated a pooled odds ratio (OR) from a fixed-effect model. Sensitivity analyses explored the effect of including non-ED studies, adjusting for study quality, and conducting a random-effects model. Secondary outcomes included organ support and hospital and ICU length of stay.
Results
From 2395 initially eligible abstracts, five randomised clinical trials (
n
= 4735 patients) met all criteria and generally scored high for quality except for lack of blinding. There was no effect on the primary mortality outcome (EGDT: 23.2 % 495/2134 versus control: 22.4 % 582/2601; pooled OR 1.01 95 % CI 0.88–1.16,
P
= 0.9, with heterogeneity
I
2
= 57 %;
P
= 0.055). The pooled estimate of 90-day mortality from the three recent multicentre studies (
n
= 4063) also showed no difference pooled OR 0.99 (95 % CI 0.86–1.15),
P
= 0.93 with no heterogeneity (
I
2
= 0.0 %;
P
= 0.97). EGDT increased vasopressor use (OR 1.25 95 % CI 1.10–1.41;
P
< 0.001) and ICU admission OR 2.19 (95 % CI 1.82–2.65);
P
< 0.001. Including six non-ED randomised trials increased heterogeneity (
I
2
= 71 %;
P
< 0.001) but did not change overall results pooled OR 0.94 (95 % CI 0.82 to 1.07);
P
= 0.33.
Conclusion
EGDT is not superior to usual care for ED patients with septic shock but is associated with increased utilisation of ICU resources.
In a cluster-randomized trial conducted in five ICUs, a nurse-led family-support intervention did not affect surrogates’ scores for anxiety and depression 6 months after the patients’ ...hospitalization, but it improved surrogates’ ratings of the patient-centeredness of care.
Recent retrospective epidemiological studies demonstrated that new-onset cardiovascular disease is one of the most emerging issues among sepsis survivors. Sepsis incident may also accelerate ...cardiovascular dysfunction/disease existing prior to sepsis. This review summarizes recent key literature on long-term cardiovascular outcomes after sepsis and pneumonia, and highlights potential biologic and pathophysiologic mechanisms that contribute to long-term cardiovascular disease after a sepsis incident. Prospective pre-clinical and clinical studies are warranted to characterize cardiovascular dysfunction after sepsis, the role of chronic biologic sequelae in pathophysiology of post-sepsis cardiovascular disease, and design interventions to prevent and reduce long-term cardiovascular burden of sepsis.
The aim of this Intensive Care Medicine Rapid Practice Guideline (ICM-RPG) is to formulate an evidence-based guidance for the use of neuromuscular blocking agents (NMBA) in adults with acute ...respiratory distress syndrome (ARDS). The panel comprised 20 international clinical experts from 12 countries, and 2 patient representatives. We adhered to the methodology for trustworthy clinical practice guidelines and followed a strict conflict of interest policy. We convened panelists through teleconferences and web-based discussions. Guideline experts from the guidelines in intensive care, development, and evaluation Group provided methodological support. Two content experts provided input and shared their expertise with the panel but did not participate in drafting the final recommendations. We followed the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty of evidence and grade recommendations and suggestions. We used the evidence to decision framework to generate recommendations. The panel provided input on guideline implementation and monitoring, and suggested future research priorities. The overall certainty in the evidence was low. The ICM-RPG panel issued one recommendation and two suggestions regarding the use of NMBAs in adults with ARDS. Current evidence does not support the early routine use of an NMBA infusion in adults with ARDS of any severity. It favours avoiding a continuous infusion of NMBA for patients who are ventilated using a lighter sedation strategy. However, for patients who require deep sedation to facilitate lung protective ventilation or prone positioning, and require neuromuscular blockade, an infusion of an NMBA for 48 h is a reasonable option.
Abstract
We present panchromatic observations and modeling of calcium-strong supernovae (SNe) 2021gno in the star-forming host-galaxy NGC 4165 and 2021inl in the outskirts of elliptical galaxy NGC ...4923, both monitored through the Young Supernova Experiment transient survey. The light curves of both, SNe show two peaks, the former peak being derived from shock cooling emission (SCE) and/or shock interaction with circumstellar material (CSM). The primary peak in SN 2021gno is coincident with luminous, rapidly decaying X-ray emission (
L
x
= 5 × 10
41
erg s
−1
) detected by Swift-XRT at
δ
t
= 1 day after explosion, this observation being the second-ever detection of X-rays from a calcium-strong transient. We interpret the X-ray emission in the context of shock interaction with CSM that extends to
r
< 3 × 10
14
cm. Based on X-ray modeling, we calculate a CSM mass
M
CSM
= (0.3−1.6) × 10
−3
M
⊙
and density
n
= (1−4) × 10
10
cm
−3
. Radio nondetections indicate a low-density environment at larger radii (
r
> 10
16
cm) and mass-loss rate of
M
̇
<
10
−
4
M
⊙
yr
−1
. SCE modeling of both primary light-curve peaks indicates an extended-progenitor envelope mass
M
e
= 0.02−0.05
M
⊙
and radius
R
e
= 30−230
R
⊙
. The explosion properties suggest progenitor systems containing either a low-mass massive star or a white dwarf (WD), the former being unlikely given the lack of local star formation. Furthermore, the environments of both SNe are consistent with low-mass hybrid He/C/O WD + C/O WD mergers.
Abstract
We present UV and/or optical observations and models of SN 2023ixf, a type II supernova (SN) located in Messier 101 at 6.9 Mpc. Early time (
flash
) spectroscopy of SN 2023ixf, obtained ...primarily at Lick Observatory, reveals emission lines of H
i
, He
i/ii
, C
iv
, and N
iii/iv/v
with a narrow core and broad, symmetric wings arising from the photoionization of dense, close-in circumstellar material (CSM) located around the progenitor star prior to shock breakout. These electron-scattering broadened line profiles persist for ∼8 days with respect to first light, at which time Doppler broadened the features from the fastest SN ejecta form, suggesting a reduction in CSM density at
r
≳ 10
15
cm. The early time light curve of SN 2023ixf shows peak absolute magnitudes (e.g.,
M
u
= −18.6 mag,
M
g
= −18.4 mag) that are ≳2 mag brighter than typical type II SNe, this photometric boost also being consistent with the shock power supplied from CSM interaction. Comparison of SN 2023ixf to a grid of light-curve and multiepoch spectral models from the non-LTE radiative transfer code
CMFGEN
and the radiation-hydrodynamics code
HERACLES
suggests dense, solar-metallicity CSM confined to
r
= (0.5–1) × 10
15
cm, and a progenitor mass-loss rate of
M
̇
=
10
−
2
M
⊙
yr
−1
. For the assumed progenitor wind velocity of
v
w
= 50 km s
−1
, this corresponds to enhanced mass loss (i.e.,
superwind
phase) during the last ∼3–6 yr before explosion.
Abstract
We present multiwavelength observations of the Type II SN 2020pni. Classified at ∼1.3 days after explosion, the object showed narrow (FWHM intensity <250 km s
−1
) recombination lines of ...ionized helium, nitrogen, and carbon, as typically seen in flash-spectroscopy events. Using the non-LTE radiative transfer code CMFGEN to model our first high-resolution spectrum, we infer a progenitor mass-loss rate of
M
̇
=
(
3.5
–
5.3
)
×
10
−
3
M
⊙
yr
−1
(assuming a wind velocity of
v
w
= 200 km s
−1
), estimated at a radius of
R
in
= 2.5 × 10
14
cm. In addition, we find that the progenitor of SN 2020pni was enriched in helium and nitrogen (relative abundances in mass fractions of 0.30–0.40 and 8.2 × 10
−3
, respectively). Radio upper limits are also consistent with dense circumstellar material (CSM) and a mass-loss rate of
M
̇
>
5
×
10
−
4
M
☉
yr
−
1
. During the initial 4 days after first light, we also observe an increase in velocity of the hydrogen lines (from ∼250 to ∼1000 km s
−1
), suggesting complex CSM. The presence of dense and confined CSM, as well as its inhomogeneous structure, indicates a phase of enhanced mass loss of the progenitor of SN 2020pni during the last year before explosion. Finally, we compare SN 2020pni to a sample of other shock-photoionization events. We find no evidence of correlations among the physical parameters of the explosions and the characteristics of the CSM surrounding the progenitors of these events. This favors the idea that the mass loss experienced by massive stars during their final years could be governed by stochastic phenomena and that, at the same time, the physical mechanisms responsible for this mass loss must be common to a variety of different progenitors.
Epidemiology of sepsis: An update Angus, Derek C; Wax, Randy S
Critical care medicine,
2001-July, Letnik:
29, Številka:
7 Suppl 1
Journal Article, Conference Proceeding
Recenzirano
OBJECTIVEWe review the case definition, occurrence, and outcome of sepsis. We discuss whether the epidemiology of sepsis has changed over time and discuss issues important to our understanding of ...sepsis.
DATA SOURCESLiterature review.
DATA SUMMARYOur understanding of the epidemiology of sepsis is hampered by the lack of a reliable case definition. Inconsistent application of sepsis definition criteria contributes to confusion and variability in the literature. Variability in the time course of sepsis also introduces difficulty. The Centers for Disease Control estimated an incidence of 73.6 per 100,000 population in 1979, rising to 175.9 per 100,000 in 1989. However, this study was of septicemia, not severe sepsis. There are several hospital-based studies of the occurrence of severe sepsis, defined using the American College of Chest Physicians/Society of Critical Care Medicine consensus criteria. These studies reported variable hospital and intensive care unit (ICU) occurrence rates, ranging from 2% to 11% of all hospital or ICU admissions. Most of these data are from academic, tertiary care centers, which limits generalizability. More population-based studies are required to better delineate the incidence and risk factors of sepsis in the general population.Hospital mortality from sepsis has ranged from 25% to 80% over the last few decades. Although mortality may be lower in recent years, sepsis is clearly still a very serious condition. Achieving a better understanding of whether the mortality rate for sepsis is falling, however, is confounded by the lack of a uniform definition. Risk factors for adverse outcome include the degree of physiologic derangement, organ dysfunction, underlying illness, site of infection, and microbiological etiology. We do not know, however, the factors that predict response to new therapies. This dilemma has led researchers to explore whether markers of the inflammatory cascade might be more specific for sepsis, more accurate for risk prediction, or more useful for predicting response to therapy. However, there as yet is no equivalent of the CPK-MB for acute myocardial infarction. Whether we will find such a marker as we develop a greater understanding of the genetic control of the inflammatory cascade is uncertain but promising.One might assume intuitively that the epidemiology of sepsis is changing. For example, the number of patients being treated in ICUs has increased over time, the technologies used in the ICU have changed, and the choice and the use of antibiotics have changed. Predisposing factors, such as chemotherapeutic regimens, have also changed, and there have been marked changes in antibiotic resistance. Furthermore, there have been wide changes in the microbiological etiologies of diseases such as pneumonia and acute exacerbations of chronic bronchitis. However, lacking good case definitions and true incidence studies, we can only make inferences about whether the epidemiology of sepsis is truly changing.
CONCLUSIONMany studies have documented many aspects of the epidemiology of sepsis. However, the composite picture they provide, although rich in many aspects, remains incomplete and emphasizes the heterogeneity of the condition. Unfortunately, few population-based prospective cohort studies exist that allow us to accurately delineate the risk factors for sepsis, its course, and its outcome. To place new information, such as the role of genetic predisposition, in the correct context, it is essential that such studies be conducted.
ABSTRACT
We present optical and near-infrared (NIR) observations of the Type Icn supernova (SN Icn) 2022ann, the fifth member of its newly identified class of SNe. Its early optical spectra are ...dominated by narrow carbon and oxygen P-Cygni features with absorption velocities of ∼800 km s−1; slower than other SNe Icn and indicative of interaction with a dense, H/He-poor circumstellar medium (CSM) that is outflowing slower than typical Wolf–Rayet wind velocities of >1000 km s−1. We identify helium in NIR spectra 2 weeks after maximum and in optical spectra at 3 weeks, demonstrating that the CSM is not fully devoid of helium. Unlike other SNe Icn, the spectra of SN 2022ann never develop broad features from SN ejecta, including in the nebular phase. Compared to other SNe Icn, SN 2022ann has a low luminosity (o-band absolute magnitude of ∼−17.7), and evolves slowly. The bolometric light curve is well-modelled by 4.8 M⊙ of SN ejecta interacting with 1.3 M⊙ of CSM. We place an upper limit of 0.04 M⊙ of 56Ni synthesized in the explosion. The host galaxy is a dwarf galaxy with a stellar mass of 107.34 M⊙ (implied metallicity of log(Z/Z⊙) ≈ 0.10) and integrated star-formation rate of log (SFR) = −2.20 M⊙ yr−1; both lower than 97 per cent of galaxies observed to produce core-collapse supernovae, although consistent with star-forming galaxies on the galaxy Main Sequence. The low CSM velocity, nickel and ejecta masses, and likely low-metallicity environment disfavour a single Wolf–Rayet progenitor star. Instead, a binary companion is likely required to adequately strip the progenitor and produce a low-velocity outflow.
Abstract
We present the Young Supernova Experiment Data Release 1 (YSE DR1), comprised of processed multicolor PanSTARRS1
griz
and Zwicky Transient Facility (ZTF)
gr
photometry of 1975 transients ...with host–galaxy associations, redshifts, spectroscopic and/or photometric classifications, and additional data products from 2019 November 24 to 2021 December 20. YSE DR1 spans discoveries and observations from young and fast-rising supernovae (SNe) to transients that persist for over a year, with a redshift distribution reaching
z
≈ 0.5. We present relative SN rates from YSE’s magnitude- and volume-limited surveys, which are consistent with previously published values within estimated uncertainties for untargeted surveys. We combine YSE and ZTF data, and create multisurvey SN simulations to train the ParSNIP and SuperRAENN photometric classification algorithms; when validating our ParSNIP classifier on 472 spectroscopically classified YSE DR1 SNe, we achieve 82% accuracy across three SN classes (SNe Ia, II, Ib/Ic) and 90% accuracy across two SN classes (SNe Ia, core-collapse SNe). Our classifier performs particularly well on SNe Ia, with high (>90%) individual completeness and purity, which will help build an anchor photometric SNe Ia sample for cosmology. We then use our photometric classifier to characterize our photometric sample of 1483 SNe, labeling 1048 (∼71%) SNe Ia, 339 (∼23%) SNe II, and 96 (∼6%) SNe Ib/Ic. YSE DR1 provides a training ground for building discovery, anomaly detection, and classification algorithms, performing cosmological analyses, understanding the nature of red and rare transients, exploring tidal disruption events and nuclear variability, and preparing for the forthcoming Vera C. Rubin Observatory Legacy Survey of Space and Time.
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