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SCOPUS: er.j

An amendment to this paper has been published and can be accessed via the original article.

Introduction: Sepsis-related ARDS is a life-threatening complication in critically ill patients. Endothelial cell activation and dysfunction have key roles in the pathophysiology of ARDS. Circulating endothelial cell (CEC) count as a marker of endothelial damage has been poorly studied in this setting. Hypothesis: CEC count may be elevated in patients with sepsis-related ARDS compared to those with severe sepsis or septic shock without respiratory failure. Methods: CEC enumeration was performed by indirect immunofluorescence using CD146-driven immunomagnetic isolation and a subsequent confirmatory step with Ulex-Europaeus-Lectin-1 staining according to a consensus isolation methodology. Arterial blood samples were drawn in 27 ARDS patients, 12 septic control patients, 13 non-septic control patients and12 healthy volunteers. Of the ARDS patients, 63% were graded as moderate or severe according to the recent Berlin definition. Demographic data, hemodynamic variables and prognostic variables (PaO2/FiO2 [P/F] ratio, 28-day survival, blood lactate, APACHE II and SOFA scores) were also recorded. Measurements were performed between 12-24 h after ICU admission and onset of sepsis.Median values (interquartile range) were compared using a Mann-Whitney test and correlations between CEC count and prognostic variables were analyzed. All tests were bidirectional and a p < 0.05 was considered significant. Results: The median CEC count in patients with moderate and severe ARDS was significantly higher compared to that in septic patients without ARDS [27.2 (17.9-49.4) cells/ml vs 17.1 (9.6-21.9) cells/ml, p< 0.01]. Patients with severe sepsis or septic shock had elevated CEC counts compared to non-septic patients [19.6 (14.2-30.6) cells/ml vs 10.8 (5.7-13.2) cells/ml, p<0.01]. In healthy volunteers, the CEC count was significantly lower than in critically ill patients [1.8 (0.4–3.7) cells/ml vs 17.9 (10.7-28.5) cells/ml, p<0.01]. None of the prognostic variables was significantly correlated with CEC count. Conclusions: CEC count is significantly higher in patients with moderate and severe ARDS than in non-ARDS septic and non-septic ICU patients. This finding highlights the importance of endothelial damage in ARDS.

<title>Abstract</title> Purpose To generate consensus and provide expert clinical practice statements for the management of adult sepsis in resource-limited settings. Methods An international multidisciplinary Steering Committee with expertise in sepsis management and including a Delphi methodologist was convened by the Asia Pacific Sepsis Alliance (APSA). The committee selected an international panel of clinicians and researchers with expertise in sepsis management. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Results A stable consensus was achieved for 30 (94%) of the statements by 41 experts after four survey rounds. These include consensus on managing patients with sepsis outside a designated critical care area, triggers for escalating clinical management and criteria for safe transfer to another facility. The experts agreed on the following: in the absence of serum lactate, clinical parameters such as altered mental status, capillary refill time and urine output may be used to guide resuscitation; special considerations regarding the volume of fluid used for resuscitation, especially in tropical infections, including the use of simple tests to assess fluid responsiveness when facilities for advanced hemodynamic monitoring are limited; use of Ringer's lactate or Hartmann's solution as balanced salt solutions; epinephrine when norepinephrine or vasopressin are unavailable; and the administration of vasopressors via a peripheral vein if central venous access is unavailable or not feasible. Similarly, where facilities for investigation are unavailable, there was consensus for empirical antimicrobial administration without delay when sepsis was strongly suspected, as was the empirical use of antiparasitic agents in patients with suspicion of parasitic infections. Conclusion Using a Delphi method, international experts reached consensus to generate expert clinical practice statements providing guidance to clinicians worldwide on the management of sepsis in resource-limited settings. These statements complement existing guidelines where evidence is lacking and add relevant aspects of sepsis management that are not addressed by current international guidelines. Future studies are needed to assess the effects of these practice statements and address remaining uncertainties.