Cases reported "Shock, Septic"

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1/19. The application of immobilized polymyxin b fiber in the treatment of septic shock associated with severe acute pancreatitis: report of two cases.

    The elimination of endotoxin by direct hemoperfusion over immobilized polymyxin b fiber (PMX-F) was carried out in two patients who developed septic shock associated with severe acute pancreatitis. Parameters such as blood pressure, body temperature, and plasma endotoxin level improved after PMX-F treatment, and the infected lesions were successfully and safely removed by surgery. Although an aggressive operative strategy of debridement with ultimate closure over drains is generally associated with low mortality in patients with this devastating disease, we often hesitate to perform this operation due to the poor condition of the patient in the acute period, with multiple organ failure and/or septic shock status, and also because of the difficulty in diagnosing the pancreatic infection. In this situation, endotoxin elimination using PMX-F is a useful tool for treating secondary pancreatic infections to help the patient recover in preparation for surgery, or for treating perioperative endotoxemia.
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2/19. Invasive Group C streptococcus infection associated with rhabdomyolysis and disseminated intravascular coagulation in a previously healthy adult.

    Infections with Group C Streptococci can lead to severe disease, particularly in individuals with underlying illnesses such as cardiovascular disease, malignancy or immunosuppression. We report the first case of rhabdomyolysis and disseminated intravascular coagulation secondary to Group C streptococcus in a previous healthy male. A toxic shock-like syndrome associated with Group C and Group G Streptococci has been reported. However, unlike with Group A Streptococci, production of endotoxins by these organisms is less well defined. We tested the patient's isolate for its ability to produce superantigenic toxins and to induce a mitogenic response. Although it is not known whether Group C Streptococci require special growth conditions for the production of superantigens, we could not demonstrate either the production of exotoxins or the induction of a mitogenic response.
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keywords = endotoxin
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3/19. Recurrent pseudomembranous colitis as a cause of recurrent severe sepsis.

    clostridium difficile (C. difficile) colitis accounts for nearly 15-20 % of antibiotic-associated diarrhea. Manifestations include asymptomatic carriage, self-limited diarrhea, and pseudomembranous colitis, which is sometimes life-threatening. Despite effective therapy with metronidazole and vancomycin relapse rates are 15-33 %. Although colitis is seen in critically ill patients treated with combinations of broad-spectrum antibiotics, reports describing severe sepsis as a result of C. difficile infection are limited. We describe the case of recurrent severe sepsis due to recurrent local intestinal C. difficile infection as the only identifiable etiology. The mechanism of severe sepsis may be a derangement of the gastrointestinal barrier function. This could result in absorption of microbes or endotoxin or activation of inflammatory cascades in the submucosa of the intestine or liver. In general, for successful treatment of C. difficile infections other than anticlostridial antibiotics should be discontinued. However, in the present case bacterial translocation from the intestine is an attractive explanation for severe sepsis and therefore additional antibiotics had been administered.
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keywords = endotoxin
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4/19. Cardiac rescue with enoximone in volume and catecholamine refractory septic shock.

    In December 2000 and February 2001, two children with suspected meningococcal disease were admitted to our pediatric intensive unit. Their Glasgow Meningococcal Septicaemia Prognostic score was 12 points. General treatment including antibiotics, steroids in case of meningitis, and fluid replacement, was performed. Despite appropriate volume replacement, intubation and ventilation, noradrenaline and adrenaline continuous infusions < or =1.0 microg/kg/min, and additional bolus infusions, cardiac output deteriorated within minutes in both children. calcium and bicarbonate were given without sustained effect. echocardiography demonstrated no pericardial effusion and shortening fraction was <10%. External cardiac massage had to be performed immediately in one case for electromechanical uncoupling. Both patients received a bolus of enoximone 2 mg/kg and 5 mg/kg body weight, respectively, followed by a continuous infusion of 20-23 microg/kg/min. Thereafter, both children had an adequate blood pressure and their shortening fraction increased to >30%. Within minutes, the catecholamine infusion could be reduced in both patients. The children completely recovered from their life-threatening situations. In patients with severe prolonged catecholamine and volume refractory endotoxin shock in waterhouse-friderichsen syndrome, even with electromechanical uncoupling and complete myocardial arrest, enoximone can immediately restore myocardial contractility.
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5/19. polymyxin b-immobilized fiber hemoperfusion with low priming volume in an elderly septic shock patient with marked endotoxemia.

    An 84-year-old woman with septic shock caused by pyelonephritis is described herein. She was admitted for severe back pain and high fever. Her white blood cell (WBC) count and c-reactive protein (CRP) and endotoxin levels were elevated at 38,000/microl, 40.0 mg/dl, and 8,400 pg/ml, respectively. Her blood pressure was 80/34 mm Hg. urinalysis revealed occult blood with innumerable WBCs. Plain abdominal radiography showed calcium stones in both kidneys. Septic shock with endotoxemia was diagnosed, and the patient was treated with antibiotics, gamma-globulin, and dopamine. However, her plasma endotoxin level remained high for 3 days. We performed direct hemoperfusion twice using a polymyxin b-immobilized fiber (PMX-F) column with a low priming volume. After PMX-F treatment, the patient's temperature decreased to 36.8 degrees C; her WBC count and CRP level decreased to 9,200/microl and 3.8 mg/dl, respectively. Her plasma endotoxin level decreased to 840 pg/ml after the first treatment and to 188 pg/ml after the second treatment. The next day, her blood endotoxin level further decreased to 32 pg/ml. Her blood pressure increased to 92/60 mm Hg after the first treatment and to 118/76 mm Hg after the second treatment. The patient was discharged on day 26 after admission. Our experience in this case suggests that PMX-F treatment with a low priming volume may be beneficial in elderly patients with septic shock and marked endotoxemia.
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6/19. Effect of direct hemoperfusion with a polymyxin b immobilized fiber column on high mobility group box-1 (HMGB-1) in severe septic shock: report of a case.

    Because of the many difficult aspects in the treatment of septic shock and poor outcome of this condition, establishing the most appropriate therapeutic strategy is problematic. Recently, high mobility group box-1 (HMGB-1) has been shown to activate inflammatory responses and to be a late mediator in endotoxemia and sepsis. Therefore, we considered that it might be worthwhile to investigate the therapeutic potential of HMGB-1 blockade in cases of septic shock.Herein, we describe the case of a patient with septic shock with hepatic portal venous gas caused by intestinal obstruction. Hepatic portal venous gas is a rare condition associated with significant radiographic findings and a fatal outcome. Our patient, however, recovered from severe septic shock and was saved by the use of direct hemoperfusion with a polymyxin b immobilized fiber column (DHP-PMX). This treatment resulted in a decrease in the serum levels of endotoxin, interleukin-6 (IL-6), and HMGB-1.
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keywords = endotoxin
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7/19. sepsis associated with transfusion of red cells contaminated with yersinia enterocolitica.

    Between April 1987 and May 1989, the Centers for disease Control investigated seven cases of transfusion-associated yersinia enterocolitica sepsis; four were caused by organisms of serotype O:3, and one each was caused by organisms of serotype O:1,2,3; O:5,27; and O:20. All seven recipients developed septic shock after receiving units of red cells (RBCs) contaminated with Y. enterocolitica; five recipients died. The cases occurred in seven states and were unrelated. There was no evidence for contamination of the RBC units during processing. Six of the seven donors had serologic evidence of recent Y. enterocolitica infection, and it is hypothesized that these donors had asymptomatic bacteremia when they donated the implicated blood. Four of the seven donors reported gastrointestinal illness in the 4 weeks before blood donation, and one donor became ill on the day he donated blood. Y. enterocolitica grows well at 4 degrees C and in the presence of dextrose and iron. If blood is contaminated at the time of collection, storage of the RBCs at 4 degrees C provides an ideal environment for bacterial growth and endotoxin production. These cases demonstrate the need for careful evaluation of patients with transfusion reactions for possible sepsis and suggest a need to screen prospective blood donors for mild gastrointestinal illness, including those illnesses not requiring physician evaluation or medication.
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keywords = endotoxin
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8/19. The use of naloxone in treating endotoxic shock.

    The use of naloxone to reverse the hypotension caused by endotoxins and endogenous opiates is currently under investigation. This report provides a description of the pathophysiology of endotoxic shock and the therapeutic use of naloxone in order to provide the critical care nurse with the scientific rationale, research-based clinical trials, and the clinical implications for its use.
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keywords = endotoxin
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9/19. Changes in anti-endotoxin-IgG antibody and endotoxaemia in three cases of gram-negative septic shock.

    Circulating endotoxin levels and IgG antibodies to a range of Gram-negative bacterial lipopolysaccharides (LPS) (endotoxins) of different sizes and structures were measured daily in three cases of septic shock. There was an inverse relationship between endotoxin levels and cross-reactive antibodies to the core glycolipid (CGL) region of lipopolysaccharide. This suggests that antibody to LPS-CGL was initially consumed by a superabundance of endotoxin, and that a resurgence of intrinsic anti-LPS-CGL antibody levels may be associated with a reduction of circulating endotoxin. The implications of these findings for passive antibody therapy of septic shock are discussed.
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keywords = endotoxin
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10/19. Preliminary study on treatment of septic shock patients with antilipopolysaccharide IgG from blood donors.

    A novel intravenous therapy consisting of polyvalent IgG antibodies to lipopolysaccharide (LPS, endotoxin) obtained from screening of blood donors was used for treatment of patients with profound septic endotoxin shock. Investigation of the anti-LPS IgG pharmacokinetics in the 10 patients revealed time related changes in the plasma concentrations of anti-LPS IgG, endotoxin, tumour necrosis factor (TNF) and the clinical parameters. A decrease in serum concentrations of IgG and IgM antibodies to LPS was observed prior to the immunotherapy as well as in a clinical example of lethal septicemia without anti-LPS immunotherapy. Increasing serum concentrations of anti-LPS IgG during antibody infusion was followed by a decrease in the concentration of endotoxin and TNF. In survivors an IgM and IgG anti-LPS antibody response developed. Using clinical parameters and apache II clinical severity scores to measure the clinical condition, a beneficial effect was observed within 24 h corresponding to a decrease in the calculated expected mortality rate from more than 80% to about 50%. Five patients (55%) expired during the study. One patient died in the early septic shock phase. One patient expired due to superimposed hemorrhagic shock. Three immunosuppressed patients died 1-2 weeks after initial recovery, 1 with fungal sepsis and 2 patients due to pseudomonas infection.
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