- sepsis
- septic syndrome / septicemia
- multiple organ dysfunction syndrome (MODS) / multiple organ failure (MOF)
Table of contents :
,
reproductive
immunology,
and pregnant's diseases)
(10-15%)
(2-10%),
other agents, rubella,
cytomegalovirus,
herpes
simplex
(TORCH) infection or syndrome : any of a group of infections seen in
neonates due to one of the causative agents having crossed the placental
barrier; they all have similar symptoms in babies and may be clinically
silent in the mothers
(1%)
with no neurological disorders (25.7 every 100,000 born alive)
(16.9 every 100,000 born alive)
(10.9 every 100,000 born alive)
with or without cleft
palate
(9.1 every 100,000 born alive)
without anencephaly
(5.5 every 100,000 born alive)
without anencephaly
(4.8 every 100,000 born alive)
(3.9 every 100,000 born alive)
and intestinal atresia (3.4 every 100,000 born alive)
or those with cerebral gigantism
addicted) during pregnancy; it includes maxillary hypoplasia, prominence
of the forehead and mandible, short palpebral fissures, microphthalmia,
epicanthal folds, severe growth retardation, mental retardation, and microcephaly.,
tracheo-esophageal
fistula
(VACTERL) with hydrocephalus (VACTERL-H)|
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| total body mass (lean, fat, total body water (TBW)) | % ideal body weight (IBW) = (actual wt./ideal wt.) x 100 | 80-90% | 70-80% | < 70% |
| weight loss in 6 months | 5% | 5-10% | > 10% | |
| total body fat | triceps skin fold (TSF) thickness measured with a skin caliper
on the posterior aspect of the nondominant arm by pinching a fold of skin
from the underlying triceps muscle. Total body fat can be estimated from
TSF with the Siri equationref.
subscapular skinfold was measured below the lower vertex of the scapula with the skinfold caliper at 45° to vertical abdominal skinfold was measured halfway along an imaginary line joining the umbilicus and the anterosuperior iliac crest. fat-muscle index |
< 35% | ||
| skeletal muscle mass | midarm muscle circumference (MAMC) = midarm circumference
(MAC : in cm; sometimes arm circumference (AC) is conventionally measured
15 cm above the olecranon) - 0.1 . p(TSF
in mm)
midarm muscle area (MAMA) = (MAC - (p. TSF)2) / (4 . p). single point vs serial measurments. Assumptions : arm, muscle, bone are circular, TSF is 2x the thickness of fat, and bone area is constant
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< 35%
(<110 mm) |
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| creatinine height index (CHI) = (24 hr urinary creatinine / expected 24hr urine creatinine for height) x 100 | 80-90
or 60-80 |
60-80
or 40-60 |
< 60
or < 40 |
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| visceral protein mass | serum albumin | 2.8-3.5 | 2.1-2.8 | < 2.1 |
| serum prealbumin | ||||
| serum transferrin = 0.8 (TIBC) - 43 | 150-200 | 100-150 | < 100 | |
| total lymphocyte count (TLC) | 1200-200 | 800-1200 | < 800 | |
| delayed hypersensitivity skin
tests |
reactive | reactive | anergic | |
| specific nutrients | serum vitamin A | < 20-40 mg/dL | ||
| serum vitamin D | < 15 ng/mL | |||
| prothrombin time (vitamin K) | > 2 sec prolonged | |||
| serum folate | < 3 ng/mL | |||
| RBC folate | < 140 ng/mL | |||
| serum calcium ionized | < 4 mg/dL | |||
| serum phosphorus | < 2 mg/dL | |||
| serum magnesium | < 1.5 mg/dL | |||
| iron-serum | < 50 mg/dL | |||
| serum hemoglobin | < 14 g/dL | |||
| serum ferritin | < 15 ng/mL | |||
: hydration, poor reproducibility
: immunosuppressive drugs, cancer, stress, surgery-associated
cachexia is caused by leptin
signaling through the hypothalamic melanocortin
receptor 4 (MC4-R)ref
or the AIDS,
resulting from a poorly understood relationship between anorexia and cachexia,
manifested by malnutrition, weight loss, muscular weakness, acidosis, and
toxemia. The anorexia may be caused by a severe metabolic disturbance that
contributes to development of cachectic wasting, which in turn reinforces
anorexia by release from the tumor of a humoral product that stimulates
the satiety center in the hypothalamus,
are best visualized on chest computed tomography (CT). Severe trauma to
the chest wall can be associated with large chest wall hematomas or collections
of air within the chest wall that can communicate with the intrathoracic
space. CT scanning can easily distinguish chest wall from parenchymal or
mediastinal injury, whereas this differentiation my not be possible with
chest radiography.
Symptoms & signs :
(22.7%)
(17.4%)
(11%)
(16.2%)
(12.8%)
tongue may slip downback into pharynx,
apnea, stridor, agitation
or nasopharyngeal airway
(better tolerated in awaken patients)
(Ch 14) connecting O2 erogator. First choice in babies as eventual
surgical cricoid injuries would cause developmental laryngeal anomalies
with 14 Ch needle-cannula (not allowing CO2 expulsion => do
not keep for > 15-20' to prevent respiratory acidosis) or open-surgery
requires 1-2 minutes (more superficial but smaller access), while tracheotomy
requires 15 minutes !
or hemothorax,
assess integrity of urethra with DRE => urinary catheterism to monitor
renal function, a good surrogate for heart and brain functions (whose function
cannot be assessed during organ-targeted therapies)
(95%) due to
due to tension
pneumothorax,
cardiac
tamponade
or myocardial
contusion
leading to severe arrhythmias
(jugular vein distension)
(vasodilatation, no tachycardia, flaccid tetra or paraplegia, complete
loss of anal sphincter tone at DRE before insertion of urinary catheter)|
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| vital signs | return to normal | improvement, recurrent | remain abnormal |
| estimated blood loss | minimal (10-20% | moderate & ongoing (20-40%) | severe (> 40%) |
| need for more crystalloid (lactate Ringer's (LR) solution) | low | high | high |
| need for blood | low | moderate/high | immediate |
| need for surgery | possibly | likely | highly likely |
<= 8
<= 8 or decreases >= 2 points (=decreased level of consciousness)
can be postponed in mild traumas,
baby, consciouless, ...)
performed by an emergency physician sonographer (EPS)ref1,
ref2,
ref3,
ref4,
ref5,
ref6
when indicated
scanning allows a detailed view of intra-abdominal pathology. However,
most scanners are located a distance from the emergency department and
the patient must be stable before transfer. Use of a double contrast technique
also necessitates a delay before scanning can commence of typically 40
minutes to 1 hour]
:,
acute respiratory failure, and brain
injury),
20% in 2-3 weeks (e.g. sepsis from external wounds,
intestinal perforations, immunodeficiency (e.g. due to peripheral hypoperfusion
and ventilator-associated
pneumonia (VAP)),
atelectasis due to restrictive respiratory failure
)
,
confined to individuals of African descent, results in the production of
a full-length caspase-12 precursor protein (Csp12-L), instead of a truncated
caspase-12 protein (Csp12-S), leading to reduction in LPS-induced cytokine
production and subsequently an enhanced susceptibility to bacterial invasion
of the bloodstream (septicaemia) and increased mortality. Csp12-L might
function as a dominant negative regulator of the activity of other caspases,
potentially by antagonizing the inflammasome (the protein scaffold within
which active cytokines are produced) and the associated pro-inflammatory
pathways. Csp12-S was also found to inhibit NF-kB
activation, although to a lesser extent than Csp12-L. Caspase-12 antagonists
might have therapeutic potential for treating septic shockref
(hypoperfusion) + respiratory
alkalosis
(fever and tachypnea)
Varieties :
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| Mycoplasma hominis |
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ascending, during labor |
| Ureaplasma urealyticum |
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ascending, during labor |
| Gardnerella vaginalis
and anaerobes |
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ascending, during labor |
| group B Streptococcus
spp. |
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ascending, during labor |
| Chlamydia trachomatis |
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ascending, during labor |
| Listeria monocytogenes |
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ascending, during labor, transplacental |
,
CVS,
cordocentesis,
or in utero fetal surgery)
(77.1%)
(8.9%)
(8.9%)
(4.4%)
(77.3%)
(9%)
(9%)
(4.5%)
: the recommendation for universal prenatal screening of pregnant women
late in pregnancy was maderef.
It would seem that the absence of universal screening might increase the
number of cases but not the case fatality rate. This is a summary of the
pertinent recommendations:,
maternal fever, chorioamnionitis,
asphyxia, cerebral hemorrhage,
IRDS,
and MAS,
but also in 8% of healthy newborns. Limited value in the first 12-24 hours;
variable response to non-bacterial infections; useful in follow-up of antibiotic
therapy,
preeclampsia,
PROM,
chorioamnionitis,
GBS colonization, and perinatal asphyxia; sensitivity = 61-85% (72-100%
after 24 hours) for EONNS, 100% for LONNS; specificity = 50-97% (63-97%
after 24 hours) for EONNS, 100% for LONNS
and expecially by asphyxia and severityref
: high sensitivity (excepted in abscess sequestration) but poor specificity
: high sensitivity (excepted in abscess sequestration) but poor specificity
> 0.9 ng/mL already in the first postoperatory day (sensitivity = 100%,
specificity = 87.5%)
expression profiles can be used to diagnose sepsis, distinguishing in vivo
between sterile and infectious causes of systemic inflammation.Exploratory
studies were conducted using spleens from septic patients and from mice
with abdominal sepsis. Seven patients with sepsis after injury were identified
retrospectively and compared with 6 injured patients. C57BL/6 male mice
were subjected to cecal ligation and puncture, or to IP lipopolysaccharide.
Control mice had sham laparotomy or injection of IP saline, respectively.
A sepsis classification model was created and tested on blood samples from
septic mice. Accuracy of sepsis prediction was obtained using cross-validation
of gene expression data from 12 human spleen samples and from 16 mouse
spleen samples. For blood studies, classifiers were constructed using data
from a training data set of 26 microarrays. The error rate of the classifiers
was estimated on seven de-identified microarrays, and then on a subsequent
cross-validation for all 33 blood microarrays. Estimates of classification
accuracy of sepsis in human spleen were 67.1%; in mouse spleen, 96%; and
in mouse blood, 94.4% (all estimates were based on nested cross-validation).
Lists of genes with substantial changes in expression between study and
control groups were used to identify 9 mouse common inflammatory response
genes, six of which were mapped into a single pathway using contemporary
pathway analysis toolsref
administered within 24 hours of onset helps to thin blood, break up clots
and reduce inflammation, which lowers the number of sepsis-related deaths
by around 7%ref1,
ref2.
Anyway the ADDRESS (Administration of Drotrecogin Alfa [Activated] in Early
Stage Severe Sepsis) trial showed no benefit of drotrecogin alfa (activated)
(DrotAA) in patients with severe sepsis and a low risk of death (defined
by single-organ failure or an APACHE II score
<25)ref
ref1,
ref2,
ref3,
ref4ref1,
ref2,
ref3,
ref4refref1,
ref2
antagonistsref1,
ref2
(TLC C-53)ref
inhibitorsrefref
inhibitors : L-NAMErefrefref1,
ref2
=> reduced C5aR
expressionref-specific
antibodyref
or antagonist (C5aRa)refref-specific
antibodyref1,
ref2-specific
antibodyref1,
ref2-specific
antibody for Gram-positive septic shockref-specific
antibody,
a ligand for the CXCR1
and CXCR2
receptors, is the most potent endogenous proinflammatory chemokine in sepsis.
IL-8 levels rise in blood and lung fluids to activate neutrophils and other
cells, and correlate with shock, lung injury and high mortality. Pepducins
derived from either the i1 or i3 intracellular loops of CXCR1 and CXCR2
prevent the IL-8 response of both receptors and reverse the lethal sequelae
of sepsis, including disseminated intravascular coagulation and multi-organ
failure in mice. Conversely, pepducins selective for CXCR4 cause a massive
leukocytosis that does not affect survival. CXCR1 and CXCR2 pepducins conferred
nearly 100% survival even when treatment was postponed, suggesting that
this approach might be beneficial in the setting of advanced diseaseref.
at doses of 2.5, 5, 10, and 20 mg/kg of body weight (doses above those
used clinically to treat vitamin B2 deficiency), 14-days survival
levels were 35%, 65%, 90%, and 95%, respectively. Moreover, treatment with
vitamin B2 at 20 mg/kg 6 h after LPS injection not only lowered
levels of excessive plasma proinflammatory cytokines, including TNF-a,
IL-1b, IL-6, IFN-g,
MCP-1, and MIP-2, but also decreased NO levels. Vitamin B2 is
best known for its ability to help the body process proteins, fats and
carbohydrates but it can also enhance host resistance to infectionref,
stimulated neutrophil functionsref,
and boosted macrophage function (Kimura, M., M. Suzuki, and S. Araki. 1996.
In vitro and in vivo effects of riboflavin sodium phosphate on the phagocytic
activity of peritoneal macrophages in mice. Anim. Sci. Technol. 67:368-373).
It bursts 1-week survival in rodents inoculated with sepsis-causing Escherichia
coli
from 10% to 95% by speeding the clearance of bacteria from the body and
lowering levels of molecules that cause inflammationref
with pyemia
in man.
during the onset of sepsis and poor clinical outcome associated with compromised
innate immunity as CD88 / C5aR
triggering reduces degradation of IkB. An increased
level of IkB results in decreased NF-kB
activity and, therefore, decreased TNF-a
transcription by neutrophils, one of the innate defences in response to
bacteria
due to acute
tubular necrosis (ATN)
(< 0.5 mL/kg for > 1 hour)
or C5a receptor
blockade
(endotoxic or endotoxin
shock) or other products of the infectious agent on the vascular system
causing large volumes of blood to be sequestered in the capillaries and
veins; activation of the complement
system
and kinin system and the release of histamine, cytokines (toxic
shock : associated with release of TNF-a
by host mononuclear cells), prostaglandins, and other mediators may be
involved
=> hypoxia
=> cyanosis,
respiratory
acidosis
and hypercapnia.
with Döhle
inclusions]
> 6 mg/kg/hour.
monitoring
therapy to achieve a strict normalization of blood glucose levels significantly
reduced morbidity but not mortality among all patients in the medical ICU.
Although the risk of subsequent death and disease was reduced in patients
treated for three or more days, these patients could not be identified
before therapyref
into mice or rats : this causes an early (< 4 hours) high level
of TNF in the plasma followed by shock and death. Prior administration
of LPS-specific or TNF-a-specific
antibody is protective and greatly improves survivalref1,
ref2.
In humans with sepsis, LPS-specific or TNF-specific antibody has not been
protective in clinical trials. This might be due to the fact that LPS models
in rodents do not reflect conditions found in humans with sepsis. LPS has
been infrequently found in the plasma of humans with sepsis. Plasma levels
of TNF are low and transient in humans compared with levels found in miceref.
For all of these reasons, the LPS model in rodents might not be relevant
to human sepsis.
or Pseudomonas spp.)
results in cardiovascular collapse, shock, diffuse activation and consumption
of the clotting and fibrinolytic systems, and death. In humans with sepsis,
the presence of bacteria in the blood sometimes occurs. When detectable
in human blood, the number of bacteria is markedly lower than the amounts
of infused intravenously into animals. The animal models of overwhelming
bacteraemia have questionable relevanc to humans with sepsis, even though
the animals show evidence of MOF in which lung, liver and renal functions
deteriorate, similar to humans with fatal sepsis.
is as follows : encephalon (cortex > encephalic nuclei > brainstem) > liver
> kidneys > heart > lungs > cornea > skin > skin adnexa > spermatozoa (days)
> blood (6 hours : sampling was practiced in ex-USSR, but not in Italy)
maneuvers for 30'.
or narcotic poisoning
in sweet waters)):
after 5-6 minutes of anoxia| cause |
|
|---|---|
| (1) ischemic heart disease | 12.4% |
| (2) cerebrovascular disease | 9.2% |
| (3) lower respiratory infections | 6.9% |
| (4) HIV/AIDS | 5.3% |
| (5) chronic obstructive pulmonary disease | 4.5% |
| (6) perinatal conditions | 4.4% |
| (7) diarrhoeal diseases | 3.8% |
| (8) tuberculosis | 3.0% |
| (9) road traffic injuries | 2.3% |
| (10) trachea, bronchus, lung cancers | 2.2% |
| formal name | informal name |
% of all deaths |
|---|---|---|
| (1) diseases of the heart | heart attack (mainly) | 28.5% |
| (2) malignant neoplasms | cancer :
|
22.8% |
| (3) cerebrovascular disease | stroke | 6.7% |
| (4) chronic lower respiratory disease | emphysema, chronic bronchitis | 5.1% |
| (5) unintentional injuries | accidents :
44% of non-motor vehicle accidents occurred in the home: in 1992 |
4.4% |
| (6) diabetes mellitus | diabetes | 3.0% |
| (7) influenza and pneumonia | flu & pneumonia | 2.7% |
| (8) Alzheimer's disease | Alzheimer's senility | 2.4% |
| (9) nephritis and nephrosis | kidney disease | 1.7% |
| (10) septicemia | systemic infection | 1.4% |
| (11) intentional self-harm | suicide | 1.3% |
| (12) chronic liver/cirrhosis | liver disease | 1.1% |
| (13) essential hypertension | high blood pressure | 0.8% |
| (14) assault | homicide | 0.7% |
| (15) all other causes | other | 17.4% |
5 leading % of top LEADING PERCENT OF TOP 5CAUSES OF DEATH, USA, AGES 15-24, 1998 |
|
|
|---|---|---|
| (1) accidents | 51.8% | 12,752 |
| (2) homicide | 21.3% | 5,233 |
| (3) suicide | 16.3% | 4,003 |
| (4) cancer | 6.8% | 1,670 |
| (5) heart disease | 3.9% | 961 |
|
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| all causes | 2,416,425 | 848.5 | |
| 1 | diseases of heart | 700,142 | 245.8 |
| 2 | malignant neoplasms (cancer) | 553,768 | 194.4 |
| 3 | cerebrovascular diseases | 163,538 | 57.4 |
| 4 | chronic lower respiratory diseases | 123,013 | 43.2 |
| 5 | accidents (unintentional injuries) | 101,537 | 35.7 |
| 6 | diabetes mellitus | 71,372 | 25.1 |
| 7 | influenza and pneumonia | 62,034 | 21.8 |
| 8 | Alzheimer's disease | 53,852 | 18.9 |
| 9 | nephritis, nephrotic syndrome, and nephrosis | 39,480 | 13.9 |
| 10 | septicemia | 32,238 | 11.3 |
| 11 | suicide | 30,622 | 10.8 |
| 12 | chronic liver disease and cirrhosis | 27,035 | 9.5 |
| 13 | homicide | 20,308 | 7.1 |
| 14 | hypertension and hypertensive renal disease | 19,250 | 6.8 |
| 15 | pneumonitis due to solids and liquids | 17,301 | 6.1 |
| all other causes | 400,935 | 140.8 |
| cause |
|
change from 1979 |
|---|---|---|
| Alzheimer's disease | < 1 % | +1,200% |
| septicemia | < 1 % | +91 % |
| chronic obstructive lung diseases | 5 % | +46 % |
| diabetes mellitus | 3 % | +39 % |
| hypertension | < 1 % | +26 % |
| pneumonia/influenza | 4 % | +18 % |
| nephritis | < 1 % | +2 % |
| cancer | 23 % | -6 % |
| suicide | < 1 % | -11 % |
| all causes | 100 % | -18 % |
| homicide | < 1 % | -28 % |
| accidents | 4 % | -30 % |
| heart disease | 31 % | -37 % |
| stroke | 7 % | -40 % |
| liver disease | < 1 % | -40 % |
| atherosclerosis | < 1 % | -67 % |
gene promoter region and in intron 2 are more common among SIDS cases compared
with control subjects. Genes pertinent to early embryologic development
of the autonomic nervous system (ANS), including MASH1, BMP2,
PHOX2a, PHOX2b, RET, ECE1, EDN1, TLX3, and EN1 : 11 protein-changing rare
mutations have been identified in 14 of 92 SIDS cases among the PHOX2a,
RET, ECE1, TLX3, and EN1 genes, while only 1 of these mutations (TLX3)
has been identified in 2 of 92 control subjects. Black infants accounted
for 10 of these mutations in SIDS cases and 2 control subjects. 4 protein-changing
common polymorphisms were identified in BMP2, RET, ECE1, and EDN1, but
the allele frequency did not differ between SIDS cases and control subjects.
However, among SIDS cases, the allele frequency for the BMP2 common polymorphism
demonstrated ethnic differences; among control subjects, the allele frequency
for the BMP2 and the ECE1 common polymorphisms also demonstrated ethnic
differences : 71% of the SIDS cases that had the mutation were African-American
and both controls (healthy babies that had it) were African-Americanref
in pregnancy : as cigarette smoking has been demonstrated to lead to fetoplacental
insufficiency, which result in fetal hypoxia, it is concluded that hypoxia
is a precondition for the occurrence of SIDS. Prenatal exposure to cigarette
smoke decreases maternal RBC count, and concentrations of tyrosine and
selenium, reduces fetal and neonatal CBF, and increases maternal MCV, leukocytosis,
especially neutrophils, monocytes and lymphocytes, maternal and fetal heart
rate, systolic and diastolic blood pressure, resistance index in umbilical
artery, fetal hemoglobin, cytokine, serotonine, dopamine, catecholamine,
hypoxanthine, endorphin and IL-6. Maternal smoking and illness =>
uncontrolled inflammatory response to infection predominantly occurring
at night-time. The immature immune system may be altered by a primary infection,
preventing a protective response after secondary challenge,
an organophosphate (OP)ref
and Regolamento di Polizia Mortuaria
Copyright © 2001-2012 Daniele Focosi.
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