Effects of the timing of administration of IgM- and IgA-enriched intravenous polyclonal immunoglobulins on the outcome of septic shock patients

Background: The administration of endovenous immunoglobulins in patients with septic shock could be beneficial and preparations enriched with IgA and IgM (ivIgGAM) seem to be more effective than those containing only IgG. In a previous study Berlot et al. demonstrated that early administration of ivIgGAM was associated with lower mortality rate. We studied a larger population of similar patients aiming either to confirm or not this finding considering also the subgroup of patients with septic shock by multidrug-resistant (MDR) pathogens. Methods: Adult patients with septic shock in intensive care unit (ICU) treated with ivIgGAM from August 1999 to December 2016 were retrospectively examined. Collected data included the demographic characteristics of the patients, the diagnosis at admission, SOFA, SAPS II and Murray Lung Injury Score (LIS), characteristics of the primary infection, the adequacy of antimicrobial therapy, the delay of administration of ivIgGAM from the ICU admission and the outcome at the ICU discharge. Parametric and nonparametric tests and logistic regression were used for statistic analysis. Results: During the study period 107 (30%) of the 355 patients died in ICU. Survivors received the ivIgGAM earlier than nonsurvivors (median delay 12 vs 14 h), had significantly lower SAPS II, SOFA and LIS at admission and a lower rate of MDR- and fungal-related septic shock. The appropriateness of the administration of antibiotics was similar in survivors and nonsurvivors (84 vs 79%, respectively, p: n.s). The delay in the administration of ivIgGAM from the admission was associated with in-ICU mortality (odds ratio per 1-h increase = 1.0055, 95% CI 1.003\u20131.009, p < 0.001), independently of SAPS II, LIS, cultures positive for MDR pathogens or fungi and onset of septic shock. Only 46 patients (14%) had septic shock due to MDR pathogens; 21 of them (46%) died in ICU. Survivors had significantly lower SAPS II, SOFA at admission and delay in administration of ivIgGAM than nonsurvivors (median delay 18 vs 66 h). Even in this subgroup the delay in the administration of ivIgGAM from the admission was associated with an increased risk of in-ICU mortality (odds ratio 1.007, 95% CI 1.0006\u20131.014, p = 0.048), independently of SAPS II. Conclusions: Earlier administration of ivIgGAM was associated with decreased risk of in-ICU mortality both in patients with septic shock caused by any pathogens and in patients with MDR-related septic shock

Thromboelastographic predictors of venous thromboembolic events in critically ill patients: are we missing something?

Deep venous thromboembolism and pulmonary embolism are still underdiagnosed in the ICU. Thromboelastography (TEG) has shown considerable variability in sensitivity and specificity as a predictor of venous thromboembolism (VTE). We designed a prospective double-blind observational study to predict the risk of VTE using TEG in a cohort of critically ill patients. Seventy-two hours after admission in the ICU and consequent prophylaxis with low-molecular-weight heparin, we performed compressive color-Doppler ultrasound and diagnosed deep venous thrombosis. Computed tomography scan was performed for the diagnosis of pulmonary embolism if pulmonary embolism was suspected based on physical examination and transthoracic echocardiography. Whole blood samples were obtained from central venous lines 6-8\u200ah after subcutaneous administration of low-molecular-weight heparin. Native TEG and modified heparinase TEG were performed using a Thromboelastograph Coagulation Analyzer. Fifty-seven patients were consecutively enrolled of which six (10.5%) developed deep venous thrombosis; two (3.5%) also developed pulmonary embolism. The native thrombodynamic ratio (TDR) was an independent predictor of the odds of thrombosis (odds ratio 1.016, P\u200a<\u200a0.05, 95% confidence interval 1.008-1.047), with a 0.93 area under the ROC curve. Using 10.6 as the lower cut-off point, TDR showed 100% sensitivity and 0 negative likelihood ratio (95% confidence interval 0-0.4) in excluding the clinical diagnosis of VTE. Our results show that TDR predicts VTE in the ICU. Our findings are in agreement with those reported by other investigators, who demonstrated that a TDR less that 10 is associated with prophylactic levels of anti-Xa

Correction to: Effects of the timing of administration of IgM- and IgA-enriched intravenous polyclonal immunoglobulins on the outcome of septic shock patients

Following publication of the original article [1], we have been notified that the tagging of the author name was done incorrectly in the XML version of the paper. The correct given name is Michele Claudio, and the family name is Vassallo