Acute and Critical Care

Guideline

Meta-analysis
Early management of adult sepsis and septic shock: Korean clinical practice guidelines: Chul Park, Nam Su Ku, Dae Won Park, Joo Hyun Park, Tae Sun Ha, Do Wan Kim, So Young Park, Youjin Chang, Kwang Wook Jo, Moon Seong Baek, Yijun Seo, Tae Gun Shin, Gina Yu, Jongmin Lee, Yong Jun Choi, Ji Young Jang, Yun Tae Jung, Inseok Jeong, Hwa Jin Cho, Ala Woo, Sua Kim, Dae-Hwan Bae, Sung Wook Kang, Sun Hyo Park, Gee Young Suh, Sunghoon Park; Acute Crit Care. 2024;39(4):445-472. Published online November 18, 2024; DOI: https://doi.org/10.4266/acc.2024.00920

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Background
Despite recent advances and global improvements in sepsis recognition and supportive care, mortality rates remain high, and adherence to sepsis bundle components in Korea is low. To address this, the Korean Sepsis Alliance, affiliated with the Korean Society of Critical Care Medicine, developed the first sepsis treatment guidelines for Korea based on a comprehensive systematic review and meta-analysis.
Methods
A de novo method was used to develop the guidelines. Methodologies included determining key questions, conducting a literature search and selection, assessing the risk of bias, synthesizing evidence, and developing recommendations. The certainty of evidence and the strength of recommendations were determined using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Draft recommendations underwent internal and external review processes and public hearings. The development of these guidelines was supported by a research grant from the Korean Disease Control and Prevention Agency.
Results
In these guidelines, we focused on early treatments for adult patients with sepsis and septic shock. Through the guideline development process, 12 key questions and their respective recommendations were formulated. These include lactate measurement, fluid therapies, target blood pressure, antibiotic administration, use of vasopressors and dobutamine, extracorporeal membrane oxygenation, and echocardiography.
Conclusions
These guidelines aim to support medical professionals in making appropriate decisions about treating adult sepsis and septic shock. We hope these guidelines will increase awareness of sepsis and reduce its mortality rate.

Citations

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Care Pathway and Outcomes in Pediatric Septic Shock: A Narrative Review from Emergency Department Recognition to PICU Management
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Recommendations for the use of biomarkers for the management of adults with sepsis: a scoping review and critical appraisal
Miriam Mateos-Haro, Ana Garcia-Santa-Vinuela, Daniel Molano-Franco, Ivan Solà, Federico Gordo-Vidal, María Cruz Martín-Delgado, Jesus Lopez-Alcalde, Javier Zamora
BMJ Open.2025; 15(7): e090922. CrossRef
Regional Adherence to Early Sepsis Management Bundle and Associated Mortality in Hong Kong Between 2009–2018
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Association between emergency department–to–intensive care unit transfer time and mortality in patients with septic shock: a target trial emulation with septic shock in South Korea
Ji Hyun Cha, Danbee Kang, Ryoung-Eun Ko, Won Young Kim, Dong-gon Hyun, Yeon Joo Lee, Woo Hyun Cho, Sunghoon Park, Juhee Cho, Gee Young Suh
Acute and Critical Care.2025; 40(4): 548. CrossRef
Early Versus Delayed Norepinephrine Initiation in Septic Shock: A Systematic Review and Meta-Analysis of Randomized and Observational Studies
Chibuzo C Manafa, Oluwayemisi E Ekor, Akintunde C Akinboboye, Okelue E Okobi, Gift Ojukwu, Osemwegie O Ugbo, Michael U Mochu, Emasenyie Isikwei, Sergio Hernandez Borges, Miguel Diaz-Miret
Cureus.2025;[Epub] CrossRef
Quality assessment of clinical practice guidelines for sepsis and variations in recommendations
Hong-Yan Li, Shan-Ling Jiang, Jing Wang, Hai-Shan Wang, Li-Hong Wang
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Evidence-Based Interventions for Sepsis Management in Critically Ill Adults: A Systematic Review
Elsa Jardim Sousa, Michelle de Soresa Virissimo, Abel Mendonça Viveiros, Ana Alves, Valter Gonçalves
European Journal of Medical and Health Research.2025; 3(6): 232. CrossRef

Original Articles

Meta-analysis
Association of malnutrition status with 30-day mortality in patients with sepsis using objective nutritional indices: a multicenter retrospective study in South Korea: Moon Seong Baek, Young Suk Kwon, Sang Soo Kang, Daechul Shim, Youngsang Yoon, Jong Ho Kim; Acute Crit Care. 2024;39(1):127-137. Published online February 20, 2024; DOI: https://doi.org/10.4266/acc.2023.01613

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Background
The Controlling Nutritional Status (CONUT) score and the prognostic nutritional index (PNI) have emerged as important nutritional indices because they provide an objective assessment based on data. We aimed to investigate how these nutritional indices relate to outcomes in patients with sepsis.
Methods
Data were collected retrospectively at five hospitals for patients aged ≥18 years receiving treatment for sepsis between January 1, 2017, and December 31, 2021. Serum albumin and total cholesterol concentrations, and peripheral lymphocytes were used to calculate the CONUT score and PNI. To identify predictors correlated with 30-day mortality, analyses were conducted using univariate and multivariate Cox proportional hazards models.
Results
The 30-day mortality rate among 9,763 patients was 15.8% (n=1,546). The median CONUT score was 5 (interquartile range [IQR], 3–7) and the median PNI score was 39.6 (IQR, 33.846.4). Higher 30-day mortality rates were associated with individuals with moderate (CONUT score: 5–8; PNI: 35–38) or severe (CONUT: 9–12; PNI: <35) malnutrition compared with those with no malnutrition (CONUT: 0–1; PNI: >38). With CONUT scores, the hazard ratio (HR) associated with moderate malnutrition was 1.52 (95% confidence interval [CI], 1.24–1.87; P<0.001); for severe, HR=2.42 (95% CI, 1.95–3.02; P<0.001). With PNI scores, the HR for moderate malnutrition was 1.29 (95% CI, 1.09–1.53; P=0.003); for severe, HR=1.88 (95% CI, 1.67–2.12; P<0.001).
Conclusions
The nutritional indices CONUT score and PNI showed significant associations with mortality of sepsis patients within 30 days.

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Yameng Wang, Maosheng Wang, Ling Wang, Qi Tang, Yuanping Wang, Xiangyun Teng, Lili Jin
Journal of Acute Disease.2026;[Epub] CrossRef
Prognostic Value of Nutritional Risk Scores in Septic ICU Patients: A Survival Analysis Using mNUTRIC, PNI, and CONUT
Marius Bogdan Novac, Gabriel-Petre Gorecki, Alin Pătru, Anda Lorena Dijmărescu, Diana-Ruxandra Hădăreanu, Mohamed-Zakaria Assani, Lidia Boldeanu, Mihail Virgil Boldeanu, George Alin Stoica
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Prognostic nutritional index, Naples prognostic score and Osaka prognostic score as predictors of acute respiratory distress syndrome in non-diabetes mellitus patients with sepsis: a loss of predictive efficacy of NPS and OPS in diabetes mellitus cohorts
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Jhan S. Saavedra-Torres, Humberto Alejandro Nati-Castillo, Alice Gaibor-Pazmiño, Wilder Fernando Ortiz Erazo, María Alejandra Martínez Castaño, Cristhian Camilo Nieto Brandon, Diana Catalina Parra Ramos, Juan Villamil, Leonardo Sánchez S., Andrés López-Co
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Yujiao Jin, Tianyun Zhou, Chenshu Hou, Huihui Zhang, Binbin Xu
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Mingyuan Pan, Zheng Li, Shanfeng Sheng, Xiao Teng, Yuyang Li
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M. Ya. Yadgarov, L. B. Berikashvili, I. V. Kuznetsov, K. K. Kadantseva, A. A. Yakovlev, V. V. Likhvantsev
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Immunology
Patterns of inflammatory immune responses in patients with septic shock receiving vitamin C, hydrocortisone, and thiamine: clustering analysis in Korea: Seung-Hun You, Oh Joo Kweon, Sun-Young Jung, Moon Seong Baek, Won-Young Kim; Acute Crit Care. 2023;38(3):286-297. Published online August 21, 2023; DOI: https://doi.org/10.4266/acc.2023.00507

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Abstract PDF Supplementary Material

Background
Sepsis is characterized by heterogeneous immune responses that may evolve during the course of illness. This study identified inflammatory immune responses in septic patients receiving vitamin C, hydrocortisone, and thiamine.
Methods
This was a single-center, post-hoc analysis of 95 patients with septic shock who received the vitamin C protocol. Blood samples were drawn on days 1–2, 3–4, and 6–8 after shock onset. Group-based multi-trajectory modeling was used to identify immune trajectory groups.
Results
The median age was 78 years (interquartile range, 70–84 years), and 56% were male. Clustering analysis identified group 1 (n=41), which was characterized by lower interleukin (IL)-6, tumor necrosis factor (TNF)-α, and IL-10 levels, and these levels remained stationary or mildly increased until day 7. Conversely, group 2 (n=54) expressed initially higher IL-6, TNF-α, and IL-10 levels that decreased rapidly by day 4. There was a nonsignificant increase in lymphocyte count and a decrease in C-reactive protein level until day 7 in group 2. The intensive care unit mortality rate was significantly lower in group 2 (39.0% vs. 18.5%, P=0.03). Group 2 also had a significantly higher decrease in the mean (standard deviation) vasopressor dose (norepinephrine equivalent: –0.09±0.16 μg/kg/min vs. –0.23±0.31 μg/kg/min, P<0.001) and Sequential Organ Failure Assessment score (0±5 vs. –4±3, P=0.002) between days 1 and 4.
Conclusions
There may be different subphenotypes in septic patients receiving the vitamin C protocol.

Citations

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Systematic review, meta-analysis, and meta-regression of the association of serial leukocyte counts in critically ill patients and mortality
Nishkantha Arulkumaran, Fiona Dewar, Gareth Ambler, Maria Del Pilar Arias Lopez, Claudia Dos Santos, Jan J. De Waele, Jeffrey Lipman, José-Artur Paiva, Jean-Francois Timsit
Annals of Intensive Care.2026; 16: 100054. CrossRef
Vitamin C for sepsis: from mechanisms to individualized therapy
Yang Xiao, Fang Gong, Lina Zhang, Chunmei Gui
Frontiers in Medicine.2025;[Epub] CrossRef
Micronutrients as therapy in critical illness
Christian Stoppe, Ellen Dresen, Angelique de Man
Current Opinion in Critical Care.2024; 30(2): 178. CrossRef
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Critical Care.2024;[Epub] CrossRef

Infection
In-hospital mortality prediction using frailty scale and severity score in elderly patients with severe COVID-19: Yong Sub Na, Jin Hyoung Kim, Moon Seong Baek, Won-Young Kim, Ae-Rin Baek, Bo young Lee, Gil Myeong Seong, Song-I Lee; Acute Crit Care. 2022;37(3):303-311. Published online July 5, 2022; DOI: https://doi.org/10.4266/acc.2022.00017

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Abstract PDF

Background
Elderly patients with coronavirus disease 2019 (COVID-19) have a high disease severity and mortality. However, the use of the frailty scale and severity score to predict in-hospital mortality in the elderly is not well established. Therefore, in this study, we investigated the use of these scores in COVID-19 cases in the elderly.
Methods
This multicenter retrospective study included severe COVID-19 patients admitted to seven hospitals in Republic of Korea from February 2020 to February 2021. We evaluated patients’ Acute Physiology and Chronic Health Evaluation (APACHE) II score; confusion, urea nitrogen, respiratory rate, blood pressure, 65 years of age and older (CURB-65) score; modified early warning score (MEWS); Sequential Organ Failure Assessment (SOFA) score; clinical frailty scale (CFS) score; and Charlson comorbidity index (CCI). We evaluated the predictive value using receiver operating characteristic (ROC) curve analysis.
Results
The study included 318 elderly patients with severe COVID-19 of whom 237 (74.5%) were survivors and 81 (25.5%) were non-survivors. The non-survivor group was older and had more comorbidities than the survivor group. The CFS, CCI, APACHE II, SOFA, CURB-65, and MEWS scores were higher in the non-survivor group than in the survivor group. When analyzed using the ROC curve, SOFA score showed the best performance in predicting the prognosis of elderly patients (area under the curve=0.766, P<0.001). CFS and SOFA scores were associated with in-hospital mortality in the multivariate analysis.
Conclusions
The SOFA score is an efficient tool for assessing in-hospital mortality in elderly patients with severe COVID-19.

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Journal of Critical Care.2025; 85: 154930. CrossRef
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Jong Hwan Jeong, Manbong Heo, Sunghoon Park, Su Hwan Lee, Onyu Park, Taehwa Kim, Hye Ju Yeo, Jin Ho Jang, Woo Hyun Cho, Jung-Wan Yoo
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Evelyne Towair, Zeina Al Achkar, Romanos Haykal, Ahmad Kassar, Eric Bou Karam, Pascale Salameh, Toufic Chaaban
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Kyung-Eui Lee, Jinwoo Lee, Sang-Min Lee, Hong Yeul Lee
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Ethics
Effect of Timing of Do-Not-Resuscitate Orders on the Clinical Outcome of Critically Ill Patients: Moon Seong Baek, Younsuck Koh, Sang-Bum Hong, Chae-Man Lim, Jin Won Huh; Korean J Crit Care Med. 2016;31(3):229-235. Published online August 30, 2016; DOI: https://doi.org/10.4266/kjccm.2016.00178

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Abstract PDF

Background
Many physicians hesitate to discuss do-not-resuscitate (DNR) orders with patients or family members in critical situations. In the intensive care unit (ICU), delayed DNR decisions could cause unintentional cardiopulmonary resuscitation, patient distress, and substantial cost. We investigated whether the timing of DNR designation affects patient outcome in the medical ICU.
Methods
We enrolled retrospective patients with written DNR orders in a medical ICU (13 bed) from June 1, 2014 to May 31, 2015. The patients were divided into two groups: early DNR patients for whom DNR orders were implemented within 48 h of ICU admission, and late DNR patients for whom DNR orders were implemented more than 48 h after ICU admission.
Results
Herein, 354 patients were admitted to the medical ICU and among them, 80 (22.6%) patients had requested DNR orders. Of these patients, 37 (46.3%) had designated DNR orders within 48 hours of ICU admission and 43 (53.7%) patients had designated DNR orders more than 48 hours after ICU admission. Compared with early DNR patients, late DNR patients tended to withhold or withdraw life-sustaining management (18.9% vs. 37.2%, p = 0.072). DNR consent forms were signed by family members instead of the patients. Septic shock was the most common cause of medical ICU admission in both the early and late DNR patients (54.1% vs. 37.2%, p = 0.131). There was no difference in in-hospital mortality (83.8% vs. 81.4%, p = 0.779). Late DNR patients had longer ICU stays than early DNR patients (7.4 ± 8.1 vs. 19.7 ± 19.2, p < 0.001).
Conclusions
Clinical outcomes are not influenced by the time of DNR designation in the medical ICU. The late DNR group is associated with a longer length of ICU stay and a tendency of withholding or withdrawing life-sustaining treatment. However, further studies are needed to clarify the guideline for end-of-life care in critically ill patients.

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The Authors Reply
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