Third International Symposium on Intensive Care and Emergency Medicine for Latin America plays a critical role in the inflammatory response and, potentially, a polymorphism in IRAK1 may alter the immune response impacting clinical outcome. P2 Gene expression and intracellular NF-κ κB activation after HMGB1 and LPS stimuli in neutrophils from septic patients

plays a critical role in the inflammatory response and, potentially, a polymorphism in IRAK1 may alter the immune response impacting clinical outcome. P2Gene expression and intracellular NF-κ κB activation after HMGB1 and LPS stimuli in neutrophils from septic patients E Silva, Introduction Neutrophils play a major role in sepsis-induced organ dysfunction, especially in the lung. HMGB1 has emerged as a late cytokine and is implicated in the perpetuation of inflammatory stimulus and organ dysfunction development as well. There are limited data about neutrophil response patterns to HMGB1 in septic patients, and whether those patterns could be different from those following LPS exposure. Objectives To evaluate the differences of gene expression and activation of NF-κB, Akt, and p38MAPK in blood neutrophils from septic patients exposed to HMGB1 and LPS; and to compare response patterns between blood neutrophils from patients and healthy volunteers. Methods Twenty-two sepsis-induced acute lung injury patients and 34 healthy volunteers were enrolled in this study. The primary clinical variables collected were the 28-day survival and the presence of shock at ICU admission. Peripheral blood was obtained and neutrophils were isolated by plasma-percoll gradients after dextran sedimentation of erythrocytes. Neutrophils were resuspended in RPMI and cultured with or without 1000 ng/ml rHMGB1 or with or without 100 ng/ml LPS for 15, 30, and 60 min. The electrophoretic mobility shift assay technique was used to measure the NF-κB translocation, while western blot analysis was used to determine Akt phosphorylation and an ELISA was used to determine p38MAPK phosphorylation. Microarray analysis was used to evaluate the neutrophil gene expression in unstimulated neutrophils and after either HMGB1 stimulus or LPS stimulus. P < 0.05 was considered significant. Results Although with some similarities, HMGB1 and LPS induced distinct patterns of gene expression in peripheral blood neutrophils from septic patients. A Venn diagram ( Fig. 1) displays genes upregulated greater than twofold that are both common and unique after both stimuli. Using functional ontology, the genes upregulated by both HMGB1 and LPS primarily consisted of cytokines, chemokines, coagulation-related proteins, phosphatases, and transcriptional regulators factors. Importantly, while HMGB1 induced an HMGB1-related gene downregulation, LPS did not induce any changes in HMGB1 gene expression in these patients. Regarding intracellular activation, both HMGB1 and LPS increased translocation of NF-κB and the phosphorylation of Akt and p38MAPK in neutrophils from septic patients. However, there were some differences in terms of the degree and kinetics of activation between neutrophils cultured with LPS and HMGB1 (Fig. 2). There are no important differences in terms of intracellular activation when we compared neutrophils from septic patients with those from volunteers. Finally, neither NF-κB translocation nor kinase phosphorylation was associated with sepsis severity. However...

IntrPrevious studies already showed a reduction in sepsis' mortality rates after the implementation of protocols based on the Surviving Sepsis Campaign (SSC) bundles, in high income countries. However, there is no similar study in emerging szettings. ObjectivesTo assess the impact of a national initiative in implementing sepsis protocols in Brazilian institutions, analyzing them according to the source of income (public or private). MethodsRetrospective analysis of the Latin America Sepsis Institute (LASI) database, from 2005 to 2014. Participation was voluntary. The implementation process was based on a multifaceted intervention including a local sepsis team, protocols, screening procedures, laboratory and antibiotics flowchart for emergency department (ED), wards and intensive care units (ICU), checklists, physicians and nurses training nd audit/feedback strategies. After the initial training, the institutions collect data on SSC bundles compliance and hospital outcome in patients with severe sepsis or septic shock in all hospital settings. We included only the institutions with at least 80 patients and at least one year of data collection, excluding patients admitted after the first four years of the campaign. All patients were followed until hospital discharge. We define public institutions as those with the major income coming from public sources and private as those coming from private insurances. ResultsWe included 21,103 patients from 65 institutions being 9,032 from public institutions and 12,071 from private ones. Comparing the 1 st semester with the 8 th semester, compliance with the 6-hours bundle increased from 13.5% to 58.2% in the private institutions while the public ones improved from 7.4% to 15.7%. Mortality rates significantly decreased throughout the program in private institutions (1st semester: 47.6%, 8 th semester: 27.2%; odds ratio (OR): 0.45; 95% confidence interval (CI): 0.32-0.64). However, there is no significant reduction in the public institutions throughout the semesters (1 st semester: 61.3%; 8 th semester: 54.5%, OR: 0.63; 95%CI: 0.39-1.02). The intervention reduced the mortality rates throughout the semesters in patients from all settings (1 st semester vs 8 th semester: ED -OR: 0.55; 95%CI: 0.38 -0.79; wards -OR: 0.59; 95%CI: 0.42-0.83; ICU -OR: 0.46; 95%CI: 0.39 -0.54) although the effect was less consistent in the ICU. In patients from private ED, mortality rates decreased from 38.1 to 21.2% (p < 0.001) while in the public institutions this reduction was not significant (56.3% to 49.8%, p = 0.057). ConclusionsThe implementation of sepsis protocols resulted in improved compliance to the quality indicators and reduction in mortality rates.