Hemodynamics and outcome of septic shock

Septic shock is a common killer in intensive care units (ICU). The most crucial issue concerning the outcome is the early and aggressive start of treatment aimed at normalization of hemodynamics and the early start of antibiotics during the very first hours. The optimal targets of hemodynamic treatment, or impact of hemodynamic treatment on survival after first resuscitation period are less known. The objective of this study was to evaluate different aspects of the hemodynamic pattern in septic shock with special attention to prediction of outcome. In particular components of early treatment and monitoring in the ICU were assessed. A total of 401 patients, 218 with septic shock and 192 with severe sepsis or septic shock were included in the study. The patients were treated in 24 Finnish ICUs during 1999-2005. 295 of the patients were included in the Finnish national epidemiologic Finnsepsis study. We found that the most important hemodynamic variables concerning the outcome were the mean arterial pressures (MAP) and lactate during the first six hours in ICU and the MAP and mixed venous oxygen saturation (SvO2) under 70% during first 48 hours. The MAP levels under 65 mmHg and SvO2 below 70% were the best predictive thresholds. Also the high central venous pressure (CVP) correlated to adverse outcome. We assessed the correlation and agreement of SvO2 and mean central venous oxygen saturation (ScvO2) in septic shock during first day in ICU. The mean SvO2 was below ScvO2 during early sepsis. Bias of difference was 4.2% (95% limits of agreement 8.1% to 16.5%) by Bland-Altman analysis. The difference between saturation values correlated significantly to cardiac index and oxygen delivery. Thus, the ScvO2 can not be used as a substitute of SvO2 in hemodynamic monitoring in ICU. Several biomarkers have been investigated for their ability to help in diagnosis or outcome prediction in sepsis. We assessed the predictive value of N-terminal pro brain natriuretic peptide (NT-proBNP) on mortality in severe sepsis or septic shock. The NT-proBNP levels were significantly higher in hospital nonsurvivors. The NT-proBNP 72 hrs after inclusion was independent predictor of hospital mortality. The acute cardiac load contributed to NTproBNP values at admission, but renal failure was the main confounding factor later. The accuracy of NT-proBNP, however, was not sufficient for clinical decision-making concerning the outcome prediction. The delays in start of treatment are associated to poorer prognosis in sepsis. We assessed how the early treatment guidelines were adopted, and what was the impact of early treatment on mortality in septic shock in Finland. We found that the early treatment was not optimal in Finnish hospitals and this reflected to mortality. A delayed initiation of antimicrobial agents was especially associated with unfavorable outcome.

Shock acceleration in the solar corona

In this thesis acceleration of energetic particles at collisionless shock waves in space plasmas is studied using numerical simulations, with an emphasis on physical conditions applicable to the solar corona. The thesis consists of four research articles and an introductory part that summarises the main findings reached in the articles and discusses them with respect to theory of diffusive shock acceleration and observations. This thesis gives a brief review of observational properties of solar energetic particles and discusses a few open questions that are currently under active research. For example, in a few large gradual solar energetic particle events the heavy ion abundance ratios and average charge states show characteristics at high energies that are typically associated with flare-accelerated particles, i.e. impulsive events. The role of flare-accelerated particles in these and other gradual events has been discussed a lot in the scientific community, and it has been questioned if and how the observed features can be explained in terms of diffusive shock acceleration at shock waves driven by coronal mass ejections. The most extreme solar energetic particle events are the so-called ground level enhancements where particle receive so high energies that they can penetrate all the way through Earth's atmosphere and increase radiation levels at the surface. It is not known what conditions are required for acceleration into GeV/nuc energies, and the presence of both very fast coronal mass ejections and X-class solar flares makes it difficult to determine what is the role of these two accelerators in ground level enhancements. The theory of diffusive shock acceleration is reviewed and its predictions discussed with respect to the observed particle characteristics. We discuss how shock waves can be modeled and describe in detail the numerical model developed by the author. The main part of this thesis consists of the four scientific articles that are based on results of the numerical shock acceleration model developed by the author. The novel feature of this model is that it can handle complex magnetic geometries which are found, for example, near active regions in the solar corona. We show that, according to our simulations, diffusive shock acceleration can explain the observed variations in abundance ratios and average charge states, provided that suitable seed particles and magnetic geometry are available for the acceleration process in the solar corona. We also derive an injection threshold for diffusive shock acceleration that agrees with our simulation results very well, and which is valid under weakly turbulent conditions. Finally, we show that diffusive shock acceleration can produce GeV/nuc energies under suitable coronal conditions, which include the presence of energetic seed particles, a favourable magnetic geometry, and an enhanced level of ambient turbulence.