• Antibiotics
• Corticosteroid
• Fluids
• Inotrope
• Norepinephrine
• Resuscitation
• SIRS
• SOFA
• Sepsis
• Septic shock
• Vasopressin
• Vasopressor
• qSOFA

• Humans
• Shock, Septic/therapy
• Shock, Septic/diagnosis
• Vasoconstrictor Agents/therapeutic use
• Fluid Therapy/methods
• Sepsis/therapy
• Sepsis/diagnosis
• Resuscitation/methods
• Emergency Medicine
• Anti-Bacterial Agents/therapeutic use
• Norepinephrine/therapeutic use
• Emergency Service, Hospital
• Vasopressins/therapeutic use

• Acute pancreatitis
• Choledocholithiasis
• biliary pancreatitis
• endoscopic retrograde cholangiopancreatography (ERCP)
• necrotizing pancreatitis
• recurrent acute pancreatitis

• biliary endoscopy
• emergency
• organization

• Humans
• Sepsis/therapy
• Anti-Bacterial Agents/therapeutic use
• Patient Care Bundles
• Fluid Therapy/methods
• Precision Medicine/methods
• Early Diagnosis
• Critical Illness/therapy
• Shock, Septic/therapy
• Practice Guidelines as Topic
• Vasoconstrictor Agents/therapeutic use
• Vasoconstrictor Agents/administration & dosage

• Emergency
• INTERVENTIONS
• mortality
• operative

• National Institutes of Health

• Adult
• Humans
• Shock, Septic/diagnosis
• Shock, Septic/therapy
• Retrospective Studies
• Hospital Mortality
• Sepsis/diagnosis
• Risk Factors
• Anti-Bacterial Agents/therapeutic use
• Intensive Care Units

• Emergency general surgery
• Patient preparation
• Perioperative management
• Resuscitation
• Sepsis

• Humans
• Resuscitation
• Emergency Medicine
• Surgical Procedures, Operative

• transfer
• interfacility
• system
• emergency general surgery
• air medical transport

• Humans
• United States
• Triage
• Consensus
• Outcome Assessment, Health Care

• T32 GM008516 NIGMS NIH HHS

• Acute cholangitis
• Apoptosis
• Choledocholithiasis
• Corisin
• Dysbiosis
• Microbiota

• 2023 Takeda Foundation
• 2023 Takeda Foundation
• Grant No 23K7651 Japan Science and Technology Agency

• Acute cholangitis
• Immune inflammatory responses
• Peripheral blood mononuclear cells
• Septic shock
• Single cell RNA sequencing

• Humans
• Shock, Septic
• Leukocytes, Mononuclear/metabolism
• Neutrophils/metabolism
• Cholangitis/genetics
• Sequence Analysis, RNA
• Neoplasm Proteins/metabolism
• Ribosomal Proteins/metabolism

• Humans
• Cholangiopancreatography, Endoscopic Retrograde
• Length of Stay
• Treatment Outcome
• Cholangitis/etiology
• Cholangitis/surgery
• Acute Disease
• Retrospective Studies

• acute cholangitis
• endoscopic retrograde cholangio-pancreatography (ERCP)
• intensive care unit
• sepsis

• Humans
• Female
• Aged
• Incidence
• Prospective Studies
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangitis/etiology
• Retrospective Studies
• Acute Disease
• Hospitals, University
• Sepsis/epidemiology
• Sepsis/complications

• Acute cholangitis
• Endoscopic retrograde cholangiopancreatography
• Length of hospital stay
• Thirty-day mortality
• Timing
• severity

• Humans
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Retrospective Studies
• Acute Disease
• Cholangitis/etiology
• Choledocholithiasis

Biliary decompression is well known to greatly decrease the risks of mortality in acute cholangitis (AC). Although early biliary drainage is recommended by the treatment guidelines for AC, the best time for performing this procedure is yet to be established. Furthermore, since the clinical outcomes of patients with severe AC vary dramatically, screening for patients that could benefit the most from early drainage would be more beneficial than the drainage performed based on the severity grade criteria.

To investigate the optimal drainage timing for AC patients with each disease severity grade and organ dysfunction.

In this retrospective monocenter cohort analysis, we reviewed 1305 patients who were diagnosed with AC according to the Tokyo guidelines 2018 at a Chinese tertiary hospital between July 2016 and December 2020. Demographic characteristics including age and sex, clinical and laboratory characteristics, and imaging findings of each patient were obtained from electronic medical records. We investigated the all-cause in-hospital mortality (IHM), hospital length of stay (LOS), and hospitalization costs associated with the timing of biliary drainage according to the severity grading and different dysfunctioning organs and predictors [age, white blood cell (WBC) count, total bilirubin, albumin, lactate, malignant obstruction, and Charlton comorbidity index (CCI)].

Biliary drainage within 24 or 48 h in Grade III AC patients could dramatically decrease IHM (3.9% vs 9.0%, P = 0.041; 4% vs 9.9%, P = 0.018, respectively), while increasing LOS and hospitalization costs. Multivariate logistic analysis revealed that neurological, respiratory, renal, and cardiovascular dysfunctions, hypoalbuminemia, and malignant obstruction were significantly associated with IHM (odds ratio = 5.32, 2.541, 6.356, 4.021, 5.655, and 7.522; P < 0.001, P = 0.016, P < 0.001, P = 0.012, P < 0.001, and P < 0.001; respectively). Biliary decompression performed within 12 h of admission significantly decreased the IHM in AC patients with neurological dysfunction (0% vs 17.3%, P = 0.041) or with serum lactate > 2 mmol/L (0% vs 5.4%, P = 0.016). In the subgroup of AC patients with renal dysfunction, abnormal WBC count, hyperbilirubinemia, or hypoalbuminemia, early drainage (< 24 h) reduced the IHM (3.6% vs 33.3%, P = 0.004; 1.9% vs 5.8%, P = 0.031; 1.7% vs 5.0%, P = 0.019; 0% vs 27%, P = 0.026; respectively). The IHM was lower in patients with AC combined with hepatic dysfunction, malignant obstruction, or a CCI > 3 who had undergone biliary drainage within 48 h (2.6% vs 20.5%, P = 0.016; 3.0% vs 13.5%, P = 0.006; 3.4% vs 9.6%, P = 0.021; respectively).

Biliary drainage within 12 h is beneficial for AC patients with neurological or cardiovascular dysfunction, while complete biliary decompression within 24 h of admission is recommended for treating patients with Grade III AC.

• Acute cholangitis
• Endoscopic retrograde cholangiopancreatography
• Mortality
• Biliary drainage
• Organ dysfunction

• Acute Disease
• Albumins
• Bilirubin
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangitis/complications
• Cholangitis/therapy
• Drainage/methods
• Humans
• Hypoalbuminemia/etiology
• Lactates
• Retrospective Studies

• acute cholangitis
• critically ill
• endoscopic biliary drainage
• percutaneous biliary drainage

• Anti-biotic agents
• Infection control
• Patient care bundles
• Sepsis
• Surgical source control
• Time-to-treatment

• antibiotics
• blood culture
• culture-negative
• culture-positive
• mortality
• sepsis

• Adults
• Evidence based medicine
• Guidelines
• Sepsis
• Septic shock

• Acute Disease
• Cholangiopancreatography, Endoscopic Retrograde
• Cholangitis/diagnosis
• Evidence-Based Medicine
• Humans
• Pancreatitis
• Prospective Studies
• Treatment Outcome

• Acute Disease
• Cholangitis/therapy
• Drainage
• Emergencies
• Humans
• United States

The guidelines recommend urgent biliary drainage (BD) for severe acute cholangitis, without a clear definition of “urgent”. To explore the optimal time, we identified the impact of timing of BD on clinical outcomes in severe acute cholangitis.

A retrospective study of patients with severe acute cholangitis was conducted based on the Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) database. Multivariable regressions were used to identified the effect of timing of BD on in-hospital mortality, 30-day mortality, and the length of stay (LOS) in hospital and the intensive care unit (ICU) with adjustment for confounding factors.

A total of 106 severe acute cholangitis patients underwent BD with a median time of 14.14 hours (IQR: 7.60–32.59). Among them, 67.9% were performed within 24 hours and 80.2% within 48 hours. Median length of stay was 2.65 days (IQR: 1.70–5.12) in the ICU and 7.54 days (IQR: 4.49–17.17) in hospital. The in-hospital and 30-day mortality rates were 13.2% and 14.2%, respectively. On multivariate analysis, every 1-day delay of BD increased 1.49 days of stay in hospital (P<0.0001). Delayed BD (>48 hours) was linked with 5.56 days longer ICU LOS (P = 0.0096), while urgent BD (<24 hours) did not significantly shorten the ICU stay (P = 0.0997). No significant increase was observed on in-hospital mortality (OR = 1.03; 95% CI 0.93–1.13) nor 30-day mortality (OR=1.01; 95% CI 0.87–1.14) with BD delay in this population.

In severe acute cholangitis patients, delay in BD increased in-hospital LOS. BD after 48 hours was associated with longer ICU LOS. Yet, BD within 24 hours did not significantly reduce the mortality nor shortened the ICU LOS.

• ERCP
• acute cholangitis
• biliary drainage
• endoscopic retrograde cholangiopancreatography
• length of stay LOS
• mortality

• Cholangitis
• ERCP
• Length of hospitalization
• Timing
• Tokyo score

Mortality and other clinical outcomes between culture-negative and culture-positive septic patients have been documented inconsistently and are very controversial. A systematic review and meta-analysis was performed to compare the clinical outcomes of culture-negative and culture-positive sepsis or septic shock.

We searched the PubMed, Cochrane and Embase databases for studies from inception to the 1st of January 2021. We included studies involving patients with sepsis or septic shock. All authors reported our primary outcome of all-cause mortality and clearly compared culture-negative versus culture-positive patients with clinically relevant secondary outcomes (ICU length of stay, hospital length of stay, mechanical ventilation requirements, mechanical ventilation duration and renal replacement requirements). Results were expressed as odds ratio (OR) and mean difference (MD) with accompanying 95% confidence interval (CI).

Seven studies including 22,655 patients were included. The primary outcome of this meta-analysis showed that there was no statistically significant difference in the all-cause mortality between two groups (OR = 0.95; 95% CI, 0.88 to 1.01; P = 0.12; Chi-² = 30.71; I² = 80%). Secondary outcomes demonstrated that there was no statistically significant difference in the ICU length of stay (MD = − 0.19;95% CI, − 0.42 to 0.04; P = 0.10;Chi-² = 5.73; I² = 48%), mechanical ventilation requirements (OR = 1.02; 95% CI, 0.94 to 1.11; P = 0.61; Chi² = 6.32; I² = 53%) and renal replacement requirements (OR = 0.82; 95% CI, 0.67 to 1.01; P = 0.06; Chi-² = 1.21; I² = 0%) between two groups. The hospital length of stay of culture-positive group was longer than that of the culture-negative group (MD = − 3.48;95% CI, − 4.34 to − 2.63; P < 0.00001;Chi-² = 1.03; I² = 0%). The mechanical ventilation duration of culture-positive group was longer than that of the culture-negative group (MD = − 0.64;95% CI, − 0.88 to − 0.4; P < 0.00001;Chi-² = 4.86; I² = 38%).

Culture positivity or negativity was not associated with mortality of sepsis or septic shock patients. Furthermore, culture-positive septic patients had similar ICU length of stay, mechanical ventilation requirements and renal replacement requirements as those culture-negative patients. The hospital length of stay and mechanical ventilation duration of culture-positive septic patients were both longer than that of the culture-negative patients. Further large-scale studies are still required to confirm these results.

• Clinical outcomes
• Culture-negative
• Culture-positive
• Meta-analysis
• Sepsis
• Septic shock

• Acute cholangitis
• antimicrobial resistance
• bacteremia
• endoscopic retrograde cholangiopancreatography
• mortality
• pathogens

• IDSA
• SEP-1
• sepsis
• septic shock
• severe sepsis

Little is known on the outcome and risk factors for mortality of patients admitted in Intensive Care units (ICUs) for Acute cholangitis (AC).

Retrospective multicenter study included adults admitted in eleven intensive care units for a proven AC from 2005 to 2018. Risk factors for in-hospital mortality were identified using multivariate analysis.

Overall, 382 patients were included, in-hospital mortality was 29%. SOFA score at admission was 8 [5–11]. Biliary obstruction was mainly related to gallstone (53%) and cancer (22%). Median total bilirubin and PCT were respectively 83 µmol/L [50–147] and 19.1 µg/L [5.3–54.8]. Sixty-three percent of patients (n  = 252) had positive blood culture, mainly Gram-negative bacilli (86%) and 14% produced extended spectrum beta lactamase bacteria. At ICU admission, persisting obstruction was frequent (79%) and biliary decompression was performed using therapeutic endoscopic retrograde cholangiopancreatography (76%) and percutaneous transhepatic biliary drainage (21%). Adjusted mortality significantly decreased overtime, adjusted OR for mortality per year was 0.72 [0.54–0.96] (p = 0.02). In a multivariate analysis, factors at admission associated with in-hospital mortality were: SOFA score (OR 1.14 [95% CI 1.05–1.24] by point, p = 0.001), lactate (OR 1.21 [95% CI 1.08–1.36], by 1 mmol/L, p < 0.001), total serum bilirubin (OR 1.26 [95% CI 1.12–1.41], by 50 μmol/L, p < 0.001), obstruction non-related to gallstones (p < 0.05) and AC complications (OR 2.74 [95% CI 1.45–5.17], p = 0.002). Time between ICU admission and biliary decompression > 48 h was associated with in-hospital mortality (adjusted OR 2.73 [95% CI 1.30–6.22], p = 0.02).

In this large retrospective multicenter study, we found that AC-associated mortality significantly decreased overtime. Severity of organ failure, cause of obstruction and local complications of AC are risk factors for mortality, as well as delayed biliary drainage > 48 h.

• Cholangitis
• Intensive care unit
• Microbiology
• Outcome
• Prognosis

• Culture
• Mortality
• Sepsis
• Septic shock
• Time to blood culture positivity

• Cholecystectomy
• Non-elective
• Postoperative complications
• Prediction
• Risk score

The difference in sequential organ failure assessment (SOFA) scores from the baseline to sepsis is a known predictor of sepsis-3 outcome, but the prognostic value of drug-resistant organisms for mortality is unexplained. We employed sepsis stewardship and herein report an observational study. Study subjects were patients admitted to the Departments of Surgery/Chest Surgery from 2011 through 2018 with a diagnosis of sepsis and a SOFA score of 2 or more. Our sepsis stewardship methods included antimicrobial and diagnostic stewardship and infection control. We determined the primary endpoint as in-hospital death and the secondary endpoint as the annual trend of the risk-adjusted mortality ratio (RAMR). For mortality, we performed logistic regression analysis based on SOFA score, age, sex, comorbid disease, and the presence of methicillin-resistant Staphylococcus aureus (MRSA) and extended-spectrum beta-lactamase inhibitor–producing bacteria. In a total of 457 patients, two factors were significant predictors for fatality, i.e., SOFA score of 9 or more with an odds ratio (OR) 4.921 and 95% confidence interval [95% CI] 1.968–12.302 (P = 0.001) and presence of MRSA with an OR 1.83 and 95% CI 1.003–3.338 (P = 0.049). RAMR showed a decrease during the study years (P < 0.05). Early detection of MRSA may help patients survive surgical sepsis-3. Thus, MRSA-oriented diagnosis may play a role in expediting treatment with anti-MRSA antimicrobials.

• Methicillin-resistant Staphylococcus aureus
• Sepsis
• Sequential organ failure assessment score

• antimicrobial resistance
• empiric antibiotics
• sepsis
• septic shock

• Anti-Bacterial Agents/administration & dosage
• Anti-Bacterial Agents/adverse effects
• Anti-Bacterial Agents/therapeutic use
• Antimicrobial Stewardship
• Drug Resistance, Bacterial
• Empirical Research
• Humans
• Inappropriate Prescribing
• Sepsis/drug therapy
• Shock, Septic/drug therapy

• National Institutes of Health Clinical Center

• maternal mortality
• maternal sepsis
• sepsis
• sequential organ failure assessment

• Female
• Humans
• Infant, Newborn
• Maternal Mortality
• Pre-Eclampsia
• Pregnancy
• Pregnancy Complications, Infectious/diagnosis
• Sepsis/diagnosis
• Shock, Septic/diagnosis

Bedside biliary drainage by endoscopic retrograde cholangiopancreatography (ERCP) without fluoroscopy for critically ill patients in the intensive care unit (ICU) remains challenging for endoscopists. The present study was to evaluate the efficacy and safety of radiation-free ERCP for these patients.

Consecutive ICU patients with severe pancreaticobiliary disorders who underwent bedside radiation-free ERCP were retrospectively analyzed.

Radiation-free ERCP was performed in 80 patients with acute physiology and chronic health evaluation (APACHE II) score of 24.1 ± 6.2. Cannulation was achieved in 75 (93.75%) patients. Biliary drainage was successfully conducted in 74 (92.5%) patients, including 54 (67.5%) and 20 (25.0%) cases of endoscopic retrograde biliary drainage (ERBD) and endoscopic nasobiliary drainage (ENBD), respectively. Adverse event (mild post-ERCP pancreatitis (PEP)) occurred only in 1 case. The 30-day mortality rate of these patients was 36.25% (29/80) and was much more higher in patients with ERBD in contrast to that of patients with ENBD, 40.7% (22/54) vs. 20% (4/20), OR = 2.750, 95%CI = 0.810 − 9.3405, P = 0.110. The APACHE II score in nonsurvivors was significantly higher than survivors, 27.6 ± 4.3 versus 22.2 ± 6.3, P = 0.009. The APACHE II score > 22 was an independent risk factor for mortality, 50% versus 10.7%, 95%CI = 2.148 − 31.569, P = 0.002.

Radiation-free ERCP guided bedside biliary drainage is effective and safe for critically ill patients, and ENBD may be an optimal procedure due to a low mortality in these patients.

• Appropriate antibiotic therapy
• Early antibiotic therapy
• Intra-abdominal infection
• Meningitis
• Mortality
• Respiratory tract infection
• Sepsis
• Septic shock
• Skin infection
• Urinary tract infection

• Bacteremia
• Lung abscess
• Septic pulmonary embolism

• Adolescent
• Adult
• Age Factors
• Aged
• Aged, 80 and over
• Anti-Bacterial Agents/therapeutic use
• Bronchoalveolar Lavage Fluid/microbiology
• Bronchoscopy
• China
• Critical Care
• Echocardiography
• Female
• Hospital Mortality
• Humans
• Male
• Middle Aged
• Pneumonia/diagnostic imaging
• Pneumonia/drug therapy
• Prognosis
• Pulmonary Embolism/diagnosis
• Pulmonary Embolism/drug therapy
• Pulmonary Embolism/microbiology
• Pulmonary Embolism/mortality
• Retrospective Studies
• Shock, Septic/diagnosis
• Shock, Septic/drug therapy
• Shock, Septic/microbiology
• Shock, Septic/mortality
• Staphylococcal Infections/diagnosis
• Staphylococcal Infections/drug therapy
• Staphylococcal Infections/microbiology
• Staphylococcal Infections/mortality
• Staphylococcus aureus/isolation & purification
• Tomography, X-Ray Computed
• Treatment Outcome
• Young Adult

• the Guangxi Natural Science Foundation
• the Talents Highland of Emergency and Medical Rescue of Guangxi Province in China

• Antibiotic
• critically ill
• individualized therapy
• pharmacodynamics
• pharmacokinetic
• procalcitonin
• sepsis

• bile ducts
• jaundice
• cholangitis
• referral and consultation
• tertiary care centers
• cholestasis
• biliary obstruction
• public health system
• obstructive jaundice
• main bile duct stones
• periampullary neoplasms

• Acute Disease
• Adult
• Aged
• Bilirubin/analysis
• Brazil/epidemiology
• Cholangiopancreatography, Endoscopic Retrograde/statistics & numerical data
• Cholangitis/diagnosis
• Cholangitis/epidemiology
• Cholangitis/surgery
• Cross-Sectional Studies
• Data Accuracy
• Drainage
• Female
• Hospitals, University
• Humans
• Jaundice, Obstructive/diagnosis
• Jaundice, Obstructive/epidemiology
• Jaundice, Obstructive/surgery
• Male
• Middle Aged
• Patient Acceptance of Health Care
• Patient Admission/statistics & numerical data
• Referral and Consultation/statistics & numerical data
• Retrospective Studies
• Sensitivity and Specificity
• Tertiary Care Centers
• Time-to-Treatment